If you’ve ever watched a game of Australian rules football, rugby league or basketball, you’ve probably seen it happen: a player lands awkwardly, grabs their knee, and doesn’t get back up.

An anterior cruciate ligament (ACL) injury is one of the most common and feared knee injuries in sport.

Every year, thousands of Australians rupture their ACL.

The ACL is a strong band of tissue that helps keep the knee stable, especially during quick turns, sudden stops and awkward landings.

At the time of injury, people often report feeling a “pop” in their knee with rapid swelling, acute pain and sometimes, the feeling the knee might buckle when trying to stand or walk.

So, what next? For most, it’s surgery.

But our recent research shows for most people, rehabilitation delivers similar results to surgery.

Read more: Injured your ACL? It’s more than just a knee injury

Are Australians too reliant on surgery?

Our team of physiotherapists and an orthopaedic surgeon recently researched the latest evidence from around the world on how best to treat ACL injuries, and particularly what happens when you do or don’t have surgery.

An estimated 90% of young active Australian adults with an ACL rupture choose to have surgery – an ACL reconstruction. We have the highest and also fastest growing rates of ACL reconstruction surgery in the world. This may be why most people assume surgery is the only treatment option.

But in Australia, no studies have compared surgery versus other treatments, such as physiotherapy rehabilitation.

However, other countries, such as Sweden, Norway and Denmark, more routinely offer a period of rehabilitation first before deciding on the need for surgery. Importantly, patients can still be deemed appropriate candidates for surgery after first trialling rehabilitation.

What we found

When our team reviewed all the evidence from robust studies (mostly from these countries), there was no difference in most short- and long-term outcomes between surgery first, rehabilitation without surgery, or rehabilitation first plus later surgery.

In simple terms, patients’ knee strength, ability to do daily activities and ability to return to sport was similar, regardless of treatment choice.

Importantly, at least half the patients who started with rehabilitation chose not to have surgery within the first two years after their injury, without compromising their outcomes.

This also matters because surgery comes with risks, including:

• infection: about 1%
• deep vein thrombosis (a blood clot): up to 8%
• graft failure (where the new ligament ruptures): up to 20%

These risks may not always be presented to patients or may sometimes be downplayed, which can lead to a lack of awareness when making treatment decisions.

Despite these risks, ACL reconstruction surgery may be the best option for some patients, especially those with concurrent injuries to the meniscus, cartilage and/or other knee ligaments.

Patients aiming to return to sports with lots of cutting and turning, like football or netball, and patients with a knee that still feels unstable even after extensive rehabilitation, may also be good candidates for surgery. For these reasons, surgery is the norm for treatment in professional sport, though with some exceptions.

Re-injury remains a big concern – re-rupture of the new ACL graft affects up to 20% of patients. About half of all patients with an ACL rupture will also develop knee osteoarthritis within 10 years of injury. This risk is mainly driven by the injury itself.

While surgery may make the knee feel more stable, it does not remove the long-term risk of osteoarthritis.

Rehab is crucial, with or without surgery

Regardless of the treatment pathway, rehabilitation is an important component of recovery.

A physiotherapist will guide patients in restoring knee stability by improving knee range of motion, muscle strength, balance and coordination.

Nine to 12 months of rehabilitation is recommended after surgery before returning to sport, with checkpoints along the way used to measure progress.

Exercising prior to surgery may also speed up recovery.

Nine to 12 months can feel like a long time, especially if you’re used to being active or playing sport.

Research tells us not meeting rehabilitation goals is related to a lower likelihood of returning to sport and increased risk of re-injury, highlighting the importance of seeing it through.

Talk to the experts

The bottom line is, not every ACL rupture needs immediate surgery – some people do just as well with a structured exercise-based rehabilitation program.

The right advice at the time of injury is crucial.

ACL injuries require a proper assessment by experts, such as physiotherapists and orthopaedic surgeons, who will help guide decisions about imaging, available treatment options and whether surgery is necessary or not.

Adam Culvenor receives funding from the National Health and Medical Research Council (NHMRC) of Australia.

Marc-Olivier Dubé receives funding from the Canadian Institutes of Health Research.

Dr Thomas West does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.

If you scroll through social media for long enough, you’ll probably find videos claiming that listening to songs tuned to “A 432Hz” can provide an amazing sense of calmness or healing.

It’s even claimed that listening to music tuned to this frequency can align your internal frequencies to those of the universe. It’s an alluring idea – that simply listening to music tuned in a specific way could improve your health.

But does it have any scientific basis?

An ancient idea

Firstly, what does it even mean if songs are tuned to A 432Hz?

Hertz (or Hz) is a measurement of frequency, or the number of times sound waves vibrate per second. Sounds are transmitted as waves through the air which hit our eardrums to create the sensation of hearing. The more quickly those sound waves are vibrating, the higher the pitch of the note.

In standard concert tuning, the note A above middle C is tuned to 440Hz. A 432Hz tuning simply means the pitch of that A and all the other notes in the music are tuned a little lower than normal.

Some argue 432Hz is closer to natural harmonic frequencies than 440Hz and that using this tuning is therefore better for wellbeing.

The idea that sounds or music can heal or even align us with the cosmos is not new. Long before social media, the ancient Greeks linked sound to the frequencies of the universe. Pythagoras proposed musical notes were governed by simple numerical ratios, the same ratios he believed underpinned the cosmos itself.

Later, medieval and Renaissance thinkers built on these ideas with the concept of “music of the spheres” – the idea that sound could be used to align us with the vibrations of the planets in a kind of cosmic harmony that influenced human emotions and wellbeing.

No magical effect

Although the concept of cosmic alignment is intriguing, there’s little scientific support for the idea that specific frequencies have any magical effect on wellbeing.

In one study from 2019, researchers played movie soundtracks tuned to 440 Hz to participants on one day and to 432 Hz on another day, finding that after listening to the 432 Hz tunings participants had slightly decreased heart rate and blood pressure. However, the study was limited by a very small sample and non-randomisation of participants, making it difficult to separate true frequency effects from expectancy or general relaxation responses.

Modern research suggests the effects of sound or music on wellbeing are less about any single special frequency, and more about how we perceive and interpret sound.

Some have theorised the use of frequencies that correspond to specific brainwave patterns such as delta waves (0.5–4Hz, associated with deep sleep), or alpha waves (8–12Hz, associated with relaxed wakefulness), can make the brain synchronise to those frequencies and achieve a relaxed state.

However, research in support of this theory is inconclusive. One study from 2017 found no changes in electrical activity in the brain after hearing such frequencies presented as binaural beats.

Binaural beats themselves are another form of sound that many claim can have miraculous effects on wellbeing. When two slightly different frequencies are played separately into each ear, the brain perceives a rhythmic pulse at a rate equal to the difference between the two frequencies. This is called a binaural beat.

There is some evidence that our physiological systems (such as breathing and heart rate) synchronise to any beat that we hear. This can help lower our levels of arousal or alertness.

That’s why most of us tend to be attracted to slower, calmer sounding music when we want to relax, for example, since the slower beat helps slow our breathing and heart rate and make us feel sleepier or calmer.

Focusing on your own response

Does that mean binaural beats have any special therapeutic effect? Not really.

A recent study found binaural beats can increase relaxation and alter brain activity. But crucially, similar effects were also observed with other types of moving or spatialised sounds. The authors concluded the benefits were likely driven by general auditory features rather than the binaural beats themselves.

It all comes down to individual preferences and perceptions. For example, binaural beats are frequently associated with meditation or mantras. And it could be this association which enhances the supposed wellbeing effects of binaural beats for some people.

Similarly with music tuned to A 432Hz.

Our brains tend to interpret sounds as expressions of emotional states. When humans are relaxed, our voices are usually lower in pitch than when we are excited or agitated.

Thus, notes of a lower pitch are sometimes perceived as more relaxing than notes that are higher pitched. Again, this doesn’t mean there is anything special or magical about 432Hz tunings – just that for many people, lower pitched notes seem calmer. The same effect could be achieved by listening to other music or frequencies with a lower pitch.

So while 432Hz might sound soothing to some ears, it’s not a shortcut to cosmic alignment. Rather than thinking about the numbers, focus on really becoming aware of your own response. Notice how different sounds make you feel, what slows your breathing, eases your body, or lifts your mood.

When it comes to wellbeing, what works is what works for you.

Sandra Garrido is the CEO of MoodyTunes, a music-based smartphone app for youth mental health.

This week, the Australian Bureau of Statistics released its refreshed General Social Survey. It tells a story economic indicators can’t capture.

On almost every measure of how Australians experience their lives – trust, connection, cultural openness, financial security, even how healthy we feel – things have gotten worse since the last survey in 2020, which was conducted during COVID.

What the data reveal

The survey results, collected in May and June 2025, show that many aspects of Australian life are shifting.

Compared to the previous General Social Survey in 2020, the new data reveal:

● Cultural tolerance is high, but dropping: 75% of people think it’s good for society to include different cultures, down from 85%.

● Trust in people and systems is falling: 50% agree others can be trusted (down from 61%), and 61% trust the healthcare system (down from 76%).

● Financial stress is rising: one in four households (25%) have at least one cash flow problem in the past year, up from one in five (21%). For single parents with dependents, it’s closer to one in two (48%).

● Fewer people feel healthy: 49% report their health as excellent or very good, down from 54%.

Almost one in ten Australians (9%) report very high mental distress. This is more common in women than men (10% vs 7%), especially in those aged 15–24 (17% of women vs 6% of men).

Although collected differently, mental distress rates are higher than previous ABS survey data from 2020–22, where only 6% reported very high levels.

How satisfied with life are we?

Overall life satisfaction, one of the most widely used measures of subjective wellbeing globally, sits at 7.1 out of 10 – similar to 2020 levels.

The annual Australian Unity Wellbeing Index data collected at the same time in 2025 was similar (6.9), but showed a small rise from its 2024 recording of 6.7.

Perhaps unsurprisingly, when we compare people with low life satisfaction to those with very high life satisfaction, big differences emerge. People with low life satisfaction are far more likely to:

● have very high mental distress (40% vs 1%)

● feel very lonely (47% vs 5%)

● have low trust in others (43% vs 19%)

● feel rushed for time (50% vs 20%)

● and feel they can’t have a say about important issues within their community (62% vs 24%).

Turning data into policy

Politicians talk about delivering a “good life” for more Australians. We now have ABS data on some important markers of a good life that go beyond traditional economic measures like GDP and productivity, or administrative measures like hospitalisations.

But the question remains: how will we use these data to deliver better lives for more Australians?

The Australian government formally acknowledged the limits of economic measurement by introducing its Measuring What Matters Framework in 2023.

The framework tracks 50 indicators of wellbeing across five themes: healthy, secure, sustainable, cohesive and prosperous.

The federal treasury has invested $14.8 million over five years to make the General Social Survey annual from this year onwards. This provides important regular data to help meet the goals of Measuring What Matters.

However, measurement alone changes nothing. A 2024 Australian National Audit Office report found treasury had no arrangements to monitor whether Measuring What Matters was actually being used in government decision-making.

Treasury accepted the recommendation to fix this – but until wellbeing measures are tied to budgets and championed by those in power, they remain a dashboard, not a lever. After all, budgets determine where resources flow, and resources drive outcomes.

States are already doing it

Several state and territory governments have moved beyond just measuring wellbeing and built it into how they make budget decisions.

The Australian Capital Territory government requires a “Wellbeing Impact Assessment” for all new budget proposals.

This involves identifying which areas of community wellbeing the funding will affect and how these impacts will be measured. It also specifically considers the effects on Aboriginal and Torres Strait Islander peoples, women and future generations.

Victoria’s Early Intervention Investment Framework takes a different approach. Through evidence-based budgeting, it invests early in social programs to improve outcomes and reduce long-term government costs, such as avoidable hospitalisations.

Sitting within the state’s treasury department, it also increases cross-collaboration across government departments and portfolios, enhancing coordinated efforts.

Without tools like these, budget processes will default to familiar patterns. Money flows towards addressing problems after they occur, rather than towards longer-term investments that prevent problems from happening in the first place.

Funding what we value

Internationally, many countries have redesigned budgeting systems to serve people and the planet, rather than economic growth. Where this has worked best, citizens have helped shape the journey.

Wales is a standout example where large-scale national conversations about the country’s future shaped the Wellbeing of Future Generations Act, whose seven goals are now embedded in government decision-making.

Community consultation was somewhat light for Measuring What Matters. Many Australians have no idea what it is. A national conversation would help everyday Australians shape the long-term direction of our country.

But we don’t have to wait for a national conversation to begin changing budget systems. Measuring What Matters and the General Social Survey are major steps in the right direction and provide the foundations to be embedded into budgetary decisions and adapted over time.

The five themes could become goals. If a policy proposal cannot demonstrate how it benefits these goals, it shouldn’t be funded. This would mean building wellbeing into how we allocate resources instead of just reporting on it.

What a nation measures signals what it values. What it funds builds on these values to shape better lives.

Kate Lycett receives funding from Australian Unity as part of the Deakin University and Australian Unity partnership to conduct the Australian Unity Wellbeing Index.

Georgie Frykberg received funding from Australian Unity as part of the Deakin University-Australian Unity industry partnership to conduct the annual survey of Australians' subjective wellbeing.

Warwick Smith is a Research Director at the Centre for Policy Development and a Director of the Castlemaine Institute, a charitable research hub.

Mozambique is not in total crisis – but it is faltering. There has been no currency crash, no hyperinflation, no bank run. But over the past decade the main indicators of the country’s economic health have severely eroded.

An IMF assessment in early 2026 was remarkably blunt: public debt is unsustainably high, the external balance of payments is weak, and policy makers have limited options. Since then, tensions in the Middle East have further disrupted supply chains and dramatically raised global fuel prices. This is a major shock for small import-dependent economies, like Mozambique.

My analysis draws on over two decades of experience supporting economic research and policy analysis in the country. Currently, my work under the Inclusive Growth in Mozambique programme involves tracking the country’s economic performance through surveys of firms, students, and households.

The picture that emerges from this evidence is troubling. For ordinary Mozambicans, the deterioration in conditions over the past decade shows up in higher poverty, unreliable public services and a labour market that offers few decent opportunities – especially for the young.

My central argument is that muddling through is not a safe option. Without careful adjustments now and a deliberate shift toward growth and job creation outside extractives – the part of the economy that actually employs most Mozambicans – today’s pressures will keep building until a large economic correction becomes unavoidable and under far worse conditions.

A slow squeeze

The country’s present condition is one of vulnerable stagnation. Since the hidden debt crisis of 2016, real GDP growth outside the extractive sector has hovered around 2%, barely matching population growth. In per capita terms, the non-extractive economy has flatlined for a decade. Average real incomes outside mining and gas (or the public sector) have gone essentially nowhere.

Fiscal deficits of 4%-6% of GDP have been financed increasingly by domestic banks. But as both the IMF and World Bank have warned, that model is now reaching a breaking point. Banks can only absorb so much government debt before they run out of willingness – or capacity – to lend. When that happens, the government faces a choice between defaulting, printing money, or slashing spending abruptly. None is painless.

Evidence of these pressures is plain to see. Over a year ago, the global rating agency S&P classified local-currency debt as “selective default”. This is a formal determination that the government had failed to meet its obligations to domestic creditors on the original terms, even if it continued paying.

By late 2025, arrears had extended to short-term treasury bills – government IOUs that mature within months and are supposed to be the safest instruments in the domestic financial system. When a government struggles to repay even these, it signals serious fiscal distress.

On top of this, a decade of crisis management has displaced any serious thinking about growth. The government’s wage bill and debt service dominate spending, leaving chronic underinvestment in infrastructure, education, and agriculture. Schools and health facilities lack supplies, roads deteriorate, and social protection has weakened sharply.

Payments under the basic social subsidy programme have become highly irregular. Many elderly beneficiaries receive only a fraction of what they are owed. Poverty has increased, with around two thirds of the population now below the poverty line.

Demographic pressures are intensifying. Mozambique needs to absorb roughly 500,000 new labour market entrants annually by 2030, yet the formal sector generates a small fraction of new jobs. Informal work dominates and without a step-change in growth, it will only expand. Each year of stagnation adds another youth cohort to an already strained labour market. Delay does not preserve stability – it makes eventual adjustment larger and more costly.

The exchange rate question

The metical has been held stable against the US dollar since 2021, but in real terms it has appreciated by over 20%, eroding export competitiveness. Foreign exchange shortages are now pervasive. The parallel market premium reached around 14% by late 2025. Firms report severe and lengthening delays in accessing foreign exchange through formal channels.

The policy response has been administrative: raising exporter surrender requirements, tightening banks’ foreign exchange position limits, restricting overseas card usage. These measures treat symptoms, but the underlying misalignment only deepens.

The overvalued exchange rate functions as a tax on the non-resource economy. Recent fuel shortages and panic buying – driven in part by importers’ inability to secure foreign exchange and price uncertainty – provide a visible demonstration of the mounting costs.

The politics of adjustment

In practice, public sector employment has come to serve as a form of social protection for the urban middle class. Our research shows roughly half of all university graduates find employment in the public sector, and having a public sector job is one of the best predictors of not being poor.

The public sector wage bill underpins political legitimacy, which is why attempts to cut discretionary 13th-month salary payments were quickly reversed once key workers threatened to strike.

Exchange rate adjustment poses a parallel dilemma. A depreciation would raise the cost of imported food and fuel, hitting urban households directly, and any price increase would spark calls to hike minimum wages. With the memory of popular violence from the 2024 elections still fresh, there is a strong bias toward the status quo.

But as pressures mount, there is a growing risk of compounding distortions. So far the temptation has been to respond with new administrative controls, including import restrictions, tighter capital controls, and preferential credit allocation.

The ongoing handling of the fuel price shock illustrates the pattern. Rather than adjust pump prices promptly, the government has held prices fixed, leaving distributors to manage a mounting shortfall through supply rationing.

Each temporary fix may ease immediate pressures, but tends to deepen the underlying misalignment, push activity into informal channels, and narrow future options.

Feasible pathways

Path 1: Muddle through and wait for the gas. This is the current trajectory. Fiscal adjustment occurs passively, driven by financing constraints rather than strategy. The hope is that LNG revenues could materialise from the early 2030s. Mozambique’s Rovuma Basin holds an estimated 100 trillion cubic feet of recoverable natural gas – among the largest discoveries globally in the past two decades. But only one offshore platform (Coral South) is currently producing. Even if the 2030 timeline holds, continued stagnation would further erode public services, weaken institutions, and deepen social frustration – and another general election must be managed. By the time resource revenues arrive, the state may lack the capacity and public trust to deploy them effectively.

Path 2: Gradual, growth-first adjustment. The most economically coherent path, though politically demanding. The central premise: restoring non-extractive growth must take priority, even at the cost of short-term macroeconomic discomfort. Key elements would include:

• a phased depreciation of the metical to restore competitiveness, supported by clear communication and strengthened social protection

• acceptance of temporarily higher inflation, with policy focused on preventing second-round effects rather than suppressing the initial price shift

• a fiscal framework centred on spending quality and revenue efficiency

• wage bill containment through hiring restraint, attrition, and systematic payroll audits to eliminate ghost workers and improper payments

• re-engagement with external partners under a credible IMF programme framework; and

• an evidence-based and financially viable medium-term growth strategy targeting agricultural productivity, labour-intensive exports and a predictable regulatory and macroeconomic environment.

Path 3: Forced correction. If external shocks bite deeper, a large adjustment may be imposed suddenly – involving disorderly exchange rate movement, abrupt fiscal contraction, and potential banking sector stress. The longer gradual adjustment is postponed, the higher this probability.

The narrow path

There is no easy option. Every adjustment has visible losers, while the benefits remain uncertain, delayed, and diffuse.

But one priority stands out: boosting growth beyond extractive sectors. Without it, fiscal consolidation is self-defeating, job creation will remain grossly inadequate, and social pressures will only intensify. Stabilisation pursued in isolation, or at the expense of growth, could be bad medicine.

This growth strategy must be grounded in data, evidence and honest debate. Mozambique has not lacked for projects or initiatives, but it has lacked consistent use of rigorous data to identify what drives productivity and job creation.

The window for a controlled, policy-driven adjustment is narrowing fast. The alternative is not stability. It is adjustment under far worse conditions, at higher cost.

Sam Jones does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.

China’s latest national accounts show the economy grew by about 5% through 2025 and into the first quarter of 2026, pointing to resilience despite ongoing trade tensions.

But the underlying picture is weaker: growth slowed last year and, while it has stabilised, it remains below pre-COVID levels.

China used to regularly report GDP growth rates above 10% before 2010 and around 6-8% after 2010. So, what’s behind the slowdown from those growth rates?

Weak consumption, uncertain exports

Household spending growth remains modest, while exports are growing more slowly amid global uncertainty and the Iran war.

Together, these trends point to softer growth, weak domestic demand and more fragile external support.

China has long been seen as an economy needing to shift from heavy reliance on exports and investment spending towards stronger domestic demand.

To understand whether this shift is actually happening and whether these recent patterns are temporary, or part of a deeper shift, we examined what has been driving China’s growth over the past decade or so. Our results do not suggest that consumer spending has yet become a stronger supporter of China’s growth.

A shift in the drivers of growth

In a recent paper, we compare the sources of growth across two periods: 2012–2017 and 2017–2022.

From 2012 to 2017, China’s growth was relatively strong, with real gross domestic product (GDP) rising by more than 40%, supported by solid consumption, robust investment and steady trade expansion.

Between 2017 and 2022, however, the picture weakened: GDP grew by about 30% – one quarter less than in the earlier period. While the pandemic played a role, trade tensions and deeper structural changes were also important, with slower import growth, weaker domestic demand, and a smaller contribution from exports.

At the same time, demographic trends turned less favourable, with slower population growth, fewer working-age people, and falling labour force participation and employment rates, all of which added further downward pressure on growth.

What has caused this change?

The charts above show a clear shift in China’s growth pattern after 2017. To understand why, we used an economy-wide model to identify the main drivers of growth in each period.

In both periods, productivity was the biggest contributor to China’s growth. But before 2017, foreign demand, a shift towards domestic sourcing and stronger business investment all supported growth. Together, these factors generated relatively balanced expansion.

After 2017, the picture became less favourable. The contribution from foreign demand fell, although it remained positive. The contribution from domestic consumption growth also turned slightly negative.

China’s workforce is shrinking as the population ages, and this demographic shift has become a more significant drag, reducing growth by 3.8 percentage points after 2017.

With demographic pressures intensifying and both household consumption and foreign demand weakening markedly, China’s growth has become increasingly reliant on productivity improvements.

A shrinking population and slowing productivity

This helps explain the slowdown in growth in recent Chinese data. Demographic change is a larger drag, and productivity growth has slowed.

Looking ahead, demographic pressures are set to intensify. China’s population began to decline in 2022, and the pace of decline is expected to accelerate. The working-age population is shrinking even faster than the total population.

Population projections suggest China’s working-age population could fall to less than one-third of its 2014 peak by the end of the century.

Other traditional supports for growth also look weaker. Total public and private investment growth has weakened in recent years, with fixed-asset investment turning negative in 2025.

At the same time, slowing global demand amid heightened geopolitical uncertainty is proving challenging for exports. Trade patterns are also shifting as higher US tariffs on Chinese goods have encouraged diversification to other markets.

What this means for the future

Our central finding is straightforward. China’s growth is now being increasingly shaped by two forces: slower productivity growth and a drag from demographic change.

This is not to say the demand side of the economy does not matter. But in our analysis, changes in consumer demand, investment and trade make only limited direct contributions to GDP growth. Their significance lies more in what they reveal about the broader structure of the Chinese economy.

In particular, both the 2017-2022 period and recent data show little evidence of a shift towards consumer spending playing a larger role in supporting growth.

What this means for the rest of the world

Looking ahead, the main question is whether productivity growth can remain strong enough to offset the effects of a shrinking workforce.

Our results suggest some caution on that front. The scope for continued rapid growth by adopting and adapting existing technologies from more advanced economies is narrowing. Population ageing is likely to place continuing downward pressure on the supply of workers. Although China is investing heavily in automation and robotics, these advances may not be sufficient to fully offset these headwinds.

The international implications are harder to predict. Slower growth in China would weaken demand for goods and services that are exported from countries like Australia.

But it could also create new opportunities for other developing economies. This is already evident in the shift of some manufacturing investment to Southeast Asia, partly in response to rising costs and trade tensions.

The effects are therefore likely to differ across countries and industries. What is clear is that the character of China’s growth is changing, and that change will matter well beyond China itself.

The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.

Planning summer holidays in Europe is beginning to involve more focus on avoiding high temperatures.

Destinations including the Greek islands and southern Italy have traditionally relied on warm, stable summers to attract tourists. But they have faced extreme temperatures causing mass evacuations, wildfires and putting lives in danger in recent summers.

Even without those conditions, high temperatures are changing the summer holiday experience. Tourists are often more exposed to heat risk than residents. They spend longer periods outdoors, take part in outdoor sports, and navigate unfamiliar environments without knowing where to find shade, or local healthcare. Yet despite this heightened exposure, tourists’ vulnerability to extreme heat remains relatively underexamined.

Recent summers have made these risks visible. During 2024, parts of southern Europe, including Greece, Italy, Spain and Cyprus, experienced temperatures exceeding 40°C. During Greece’s record-setting heatwave, several foreign visitors died or went missing including the British broadcaster Michael Mosley. Mosley went missing on the Greek island of Symi and a coroner found the cause of death could have been heatstroke. In response to these very high temperatures, countries including the UK, Germany, and Sweden issued travel advisories warning of extreme heat in popular destinations.

Heat is not just a safety issue; it is also reshaping the quality of the holiday itself. Extreme temperatures can shorten stays, reduce participation in outdoor activities, and lower overall satisfaction. Key tourist sites, such as the Acropolis in Greece, may close in extreme heat making trips less satisfying. As a result, rising temperatures are already influencing what tourists can do, when they travel, and how destinations function.

Shifting travel patterns

As heat intensifies, travel patterns are beginning to shift. A growing number of tourists are moving away from traditionally hot Mediterranean destinations towards cooler regions, a trend often described as “coolcations”. Emerging evidence points to declining tourist demand in parts of southern Europe during peak summer months, alongside increased interest in destinations with milder climates.

Elevated temperatures are also influencing when people take a trip. A recent report by the European Travel Commission found that 28% of travellers are planning to change the time of year that they travel. Avoiding extreme heat was cited as a key reason.

Extreme heat also interacts with other climate-related pressures. Wildfires, drought and water shortages can disrupt tourism activities and local economies. As one participant in ongoing research at the University of East London described: “Our reservoir was very low over the summer… boating, sailing, and water sports couldn’t run. The centre has now closed. You see those ripple effects.”

Climate is not the only factor shaping travel decisions this year. Geopolitical tensions, including the ongoing conflict involving the US, Israel and Iran, are contributing to rising fuel and travel costs. This is adding another layer of pressure, encouraging some travellers to reconsider long-distance or high-cost travel

These pressures can reinforce climate-driven trends. If southern destinations become both hotter and more expensive, travellers may be more likely to choose nearer, cooler alternatives.

Extreme heat is no longer a marginal issue for tourism; it is becoming a structural one. As heatwaves intensify and seasonal patterns shift, traditional peak holiday seasons may no longer align with safe or comfortable conditions.

Adapting will require more than incremental change. It means rethinking infrastructure, timing and visitor management, from providing shade and cool spaces, to redesigning tourism calendars. In some destinations, this is already happening, with attractions shifting opening hours to cooler periods of the day, a trend increasingly described as “noctourism”.

But adaptation is not only physical; it is also behavioural. A key part of this transition lies in how travellers perceive and respond to heat. Perception shapes behaviour: whether visitors adjust their plans, seek shade, stay hydrated, or recognise when conditions have become dangerous. This is particularly important for travellers from temperate countries, such as the UK, where awareness and experience of extreme heat remain relatively limited. Without a strong perception of risk, even well-designed warnings may fail to prompt action.

Clear and timely communication will therefore be essential. Travellers need support to interpret unfamiliar risks and take protective action when needed. This includes clearer public messaging, accessible guidance on heat safety, and better integration of tourists into national and local heat health alert systems.

At present, most heat alerts are designed with residents in mind. Yet tourists represent a highly exposed and often overlooked group. Integrating communication to visitors into heat action plans, through multilingual alerts and travel advisories, will be increasingly important as global travel continues. This kind of information needs to be developed for travellers and tour operators.

It is vital to improve our understanding of tourists perceptions of risk from heat, how to respond, and the effectiveness of communications.

Airlines, hotels, and travel websites could provide key ways to communicate in future. Providing heat-related guidance at the point of booking, before departure, and during the stay could help bridge the gap between awareness and action. In years ahead, if summer temperatures continue to intensify this could be vitally important.

Mehri Khosravi does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.

Consumption of ultra-processed foods – including soft drinks, snacks and ready meals – is growing worldwide, despite evidence they are unhealthy.

Ultra-processed foods (UPFs) make up about 70% of packaged food products on supermarket shelves, and even more in convenience stores.

In our new research, we explore how companies that produce these foods play on human nature to make such products seem the easiest, most rewarding and compelling option.

We show that UPFs are designed to make us crave them and eat more. They are marketed to all groups, particularly children, in a way that makes them seem the most delicious and convenient option, giving the best value-for-money, despite many health harms.

Our attraction to UPFs is no coincidence. UPF companies combine a range of tactics to drive up consumption. Many of these tactics exploit the ways we think, feel and behave.

Why we keep eating UPFs

UPFs are the most processed foods on the market. According to medical journal The Lancet, they are commercial formulations made from cheap ingredients extracted or derived from whole foods, combined with additives, but mostly containing little to no whole food in the end product.

UPFs are heavily branded and marketed, and most are produced by large international corporations.

But diets high in UPFs carry a risk of developing a wide range of serious health conditions, including excess weight or obesity, type 2 diabetes, hypertension, heart disease, cancer, chronic kidney disease and depression, as well as premature death.

Our research asked why we keep eating diets high in UPFs when we know how unhealthy they are. To answer this, we decided to zoom out and explore the system that develops, produces and markets UPFs, and investigate how human nature is caught up in it.

We reviewed a decade of published research on the food science and marketing of UPFs, and then worked with experts in these fields to create and refine system diagrams to visualise how it works.

These maps are called “causal loop diagrams”, and their power is in showing reinforcing (positive) feedback loops that drive the system towards its ultimate purpose: selling more UPFs.

We found the system is made up of many interconnected loops that capture parts of human behaviour and biology as key elements.

Products designed for maximum consumption

One feedback loop includes the use of addictive combinations of ingredients, particularly refined carbohydrates and fats. Biologically, carbohydrates (including but not limited to sugars) and fats activate different reward pathways between the gut and brain. When they are consumed together, their effects become addictive.

These ingredients can be combined in many different concentrations to hit sensory “sweet spots”. In other words, they maximise pleasure and craving responses while minimising negative responses.

Further strategies include processing methods that suppress peoples’ natural sense of being full or speed up digestion in order to give an immediate but quickly fading sense of “reward”, making us want more, sooner.

UPF marketing strategies

In terms of marketing, products are formulated to be easy and convenient to store and eat, and to appeal to our sense of getting good value.

Various promotional techniques aim to capture consumers’ attention and desire, as well as giving the illusion of healthiness. Strategies targeting children in particular employ popular culture associations with coolness or fun.

Another example of a feedback loop is how corporations collect large and complex data on our purchasing habits and our online lives, informing targeted digital marketing on social media platforms. This tends to be effective at driving purchases, providing more data to further refine these promotion strategies.

Overall we identified 11 different reinforcing feedback loops. Our research is the first study to show this web as part of the UPF system, designed to essentially trap people into buying and eating more and displacing healthier options in diets.

This product-level system also connects with feedback loops further up the supply chain in economic and financial spheres of the global UPF production.

This matters because unhealthy diets and excess body weight cause 18% of preventable premature death and disability in New Zealand. Both risk factors are linked to eating too much UPF.

Unfortunately, New Zealand hasn’t undertaken national nutrition surveys since the 2000s and we have to rely on data from similar countries such as Australia to estimate that UPFs make up about half of our energy intake.

What to do about it

Diets high in UPFs are not the result of people’s free personal choice or weak willpower, but of an intentionally designed system.

Our research shines light on how the UPF system is taking advantage, particularly of children. International experts have framed UPFs as a major global health issue, and advise strong government policy to regulate these products to counter some of these mechanisms.

Policy leadership already exists in other parts of the world, particularly in Latin America. New Zealand could follow other countries that have implemented taxes on UPFs and sugary drinks, regulations restricting advertising to children, strong front-of-pack labelling and transparency policies such as public disclosure of lobbying in government.

Complacency is not an option. The food system needs rebalancing so that it serves and nourishes people now and in the future.

The authors acknowledge the research contribution by Dr Joshua Clark.

Kelly Garton receives funding from the New Zealand Heart Foundation. She is affiliated with the advocacy group Health Coalition Aotearoa.

Boyd Swinburn is affiliated with the Health Coalition Aotearoa.

Mehmet Oz, the Centers for Medicare & Medicaid Services administrator, is ordering all states to step up their efforts to crack down on Medicaid fraud.

His April 21, 2026, announcement expanded on the Trump administration’s related enforcement actions, such as withholding Medicaid funds from Minnesota and threatening to do that for New York, California and Maine.

The Trump administration says there’s a big problem with fraud tied to government-funded care delivered in a person’s home or in the community, officially known as home and community-based services, along with nonmedical transportation, behavioral health and new or high billing providers.

The agency Oz leads is now asking states to immediately “revalidate” providers they claim are “high risk.” That is, states are supposed to require providers to prove that they remain eligible to participate in Medicaid and bill the program. The providers primarily offer at-home care, transportation, behavioral health and other services.

Related legislative initiatives, sponsored by Republicans, are also pending in Congress.

We are health services researchers who study the development and growth of the Medicaid home and community-based services program. One of us (Barkoff) previously served in the role of administrator and assistant secretary for aging of the Administration for Community Living.

We strongly believe that it is sensible and necessary for the government to take steps to prevent, root out and punish Medicaid fraud. But we are mindful that the government’s anti-fraud strategies and tactics could unnecessarily disrupt the very services that people depend on day to day.

We aren’t alone. Many researchers, advocates and policy experts are alarmed by this White House policy.

What’s at stake

All told, Medicaid provides health insurance coverage for about 75 million low-income Americans, including many who are at least 65 years old.

More than 5 million Americans benefit from government-funded home care, which is aimed at keeping low-income people with disabilities and frail older people living in their own homes and communities. Medicaid pays for most home care, covering nearly two-thirds of all such spending in 2023.

When home care works well, people become less likely to have to move into nursing homes or other assisted living facilities. If a home care aide doesn’t show up, the consequences are immediate and can be dire.

An older adult may be unable to get out of bed. A person with disabilities may miss meals or medications. A family caregiver may have to take time off without notifying their employer in advance and lose wages.

That’s why the federal government’s actions – particularly those targeting services provided in a person’s home or community – could endanger millions of people.

Supreme Court ruling

Home and community-based services include help with bathing, dressing, eating, medication management and mobility – services that allow people to remain in their homes rather than moving into nursing facilities. A shift toward home-based care has been underway for decades, driven by both costs and civil rights protections.

One reason for the shift was the 6-3 ruling in 1999 by the Supreme Court in the Olmstead v. L.C. case. The majority affirmed the right of people with disabilities to live in their own homes and communities when possible.

Today, most Medicaid long-term care spending covers the cost of services provided in a person’s home or local community, rather than in an institution. These services cost less and lead to better outcomes. Research and program data consistently show that fraud in these programs is relatively rare.

This is especially true due to safeguards like electronic visit verification, which ensures providers are actually providing services in the home.

Another safeguard in place is that most states contract with and approve fiscal intermediaries, which act as payroll, payment and compliance managers, to make sure that there are verifiable records, payment controls and audit trails in place for the Medicaid program.

Not all ‘improper payments’ are fraudulent

A central problem in the Trump administration’s strategy to root out alleged Medicaid fraud is a basic mischaracterization of many things as fraud that aren’t fraudulent.

Federal agencies are tracking “improper payments” and incorrectly equating them with fraud. The Centers for Medicare & Medicaid Services makes clear that most improper payments stem from documentation errors or administrative issues – not intentional wrongdoing.

The Government Accountability Office, a nonpartisan government agency that produces in-depth research, notes that while fraud does lead to improper payments, the reverse is not necessarily true. That is, improper payments can have a cause besides fraud, such as administrative errors and eligibility processing mistakes.

Blurring the distinction between improper payments and fraud can make it seem like providers are illegally taking advantage of the system. And when that happens, policymakers may turn to blunt solutions that do little to punish actual fraudsters, such as cutting or withholding funding, rather than fixing administrative problems.

Exaggerating the scope of Medicaid fraud

In our view, proposals to overhaul Medicaid’s enforcement methods should be grounded in strong and objective data. Yet much of the argument for structural reform relies on anecdotal examples, isolated cases and select audit findings without broader context.

One of the more egregious cases perpetrated by providers was a home care agency in Pennsylvania that billed fraudulent claims between 2020-2023 totaling US$1.8 million. Another was the Minnesota provider penalized in 2025 after billing for services not delivered.

But those infractions do not justify characterizing an entire category of services that helps tens of millions of Americans remain in their homes as rife with fraud and in need of dramatic changes.

By contrast, as we explained in Health Affairs ForeFront in March 2026, federal oversight bodies – including the Centers for Medicare & Medicaid Services, the Government Accountability Office and the Health and Human Services’ inspector general – produce systematic, data-driven analyses.

These sources consistently caution against equating improper payments with fraud and emphasize targeted approaches to program integrity.

The government designated some 6% of the annual payments by Medicaid as improper payments between 2022-2025, which were worth about $37 billion. Yet, more than 3 in 4 improper payments resulted from insufficient documentation, which usually doesn’t indicate fraud or abuse.

What’s more, Medicaid fraud is regularly subject to enforcement actions. In 2025, Medicaid fraud control units reported 1,185 convictions for fraud nationwide, and combined recoveries from criminal and civil cases totaled about $2 billion.

Emphasis on high-profile cases

Again, a few widely publicized fraud cases in Minnesota and a few other states do not prove that fraud is a chronic problem for Medicaid billing in home care programs.

In an agency as big as Medicaid, which spends nearly $1 trillion annually, some level of fraud will occur. The key question is whether fraud is widespread, systemic or goes unpunished.

Available evidence suggests Medicaid fraud is none of those things.

For example, large-scale home care programs serving hundreds of thousands of people report extremely low rates of confirmed fraud cases. Enforcement data from Medicaid Fraud Control Units, which investigate and prosecute Medicaid fraud, show that when fraud occurs, it is investigated and prosecuted.

In other words, the presence of enforcement activity is evidence that oversight systems are working – not that they’re failing.

A better approach

We believe that many strategies that are better than those that the Trump administration is embracing are readily available. Some examples include improved data analytics, stronger referral systems within managed care plans, enhanced provider screening and documentation standards, and continued support for Medicaid Fraud Control Units.

These approaches target fraud directly without jeopardizing access to the essential Medicaid services that help tens of millions of older adults and disabled people remain where they want to be: in their own homes instead of in more expensive nursing homes.

Given that the U.S. spends about $930 billion a year on the program, we don’t question the wisdom of engaging in its oversight.

But we are concerned that the policy response to alleged fraud could harm the very people that the Trump administration says its efforts are meant to protect.

Marc Cohen receives funding from the RRF Foundation for Aging.

Alison Barkoff receives funding from the Commonwealth Fund.

Jane Tavares receives funding from the RRF Foundation for Aging.

Sara Rosenbaum receives funding from the Commonwealth Fund.