the metablog

A new metajournal is coming

Wed, 27 May 2026 01:43:00 +0000

I'm excited to announce that a completely rebuilt metajournal will be (hopefully!) going live within the next week. More than just an update, the new platform is a ground-up rewrite, built on new infrastructure and servers, bringing big improvements across every part of the site.

The new metajournal has a fresh, redesigned interface that is faster and easier to navigate. Under the hood, the article recommendation algorithm has been further improved, and performance gains across the site mean a much smoother experience whether you're browsing on the web, or soon... on iOS or Android.

Because the new platform runs on entirely new infrastructure, your account will be migrated across automatically. However passwords cannot be transferred securely to the new system, so existing users will need to reset their password before logging in for the first time. You'll be able to do this easily via the login screen.

I'm working hard to make this transition as smooth as possible, and am very excited to share more new features in the coming weeks and months.

Let me know if you run into any problems!

Tylenol, Tyranny, and Misogyny

Fri, 26 Sep 2025 04:49:00 +0000

The Misogyny of MAHA and the Politics of Health

Wrapped up in the near-incoherent warning against the use of paracetamol (Tylenol/acetaminophen) in pregnancy reveals the real story of the Make America Healthy Again project: misogyny dressed up as health advice.

This is a broader project of bad science weaponised to undermine trust and weaken the very institutions that exist to support health and wellbeing.

Let's start with the evidence: while there has been more than a decade of concern about possible associations between paracetamol use in pregnancy and neurodevelopment consequences in children, particularly ADHD and autism spectrum disorder, the best and most recent evidence is reassuring:

"Acetaminophen use during pregnancy was not associated with children's risk of autism, ADHD, or intellectual disability in sibling control analysis." – Ahlqvist et al. 2024

Science as a punching bag

Despite this, we are treated to the absurd spectacle of a brain-wormed conspiracy peddler teaming up with a carnival barker unable to even pronounce acetaminophen. Together they issue sweeping advice in direct opposition to medical organisations across the world reaffirming the safety of appropriate paracetamol use in pregnancy.

What's revealing is not the bad science itself, but who bears the consequences of these pronouncements: this is not primarily about paracetamol. It’s about a particularly regressive worldview.

“If you’re telling parents or telling society that someone should be doing this work of keeping kids safe, what you’re really saying is women should be doing this work, especially mothers. ... RFK Jr is weaponizing the supermom myth – the false idea that moms are the only ones who can keep kids safe from harm.” – Prof. Jessica Calarco (2025)

Wrapped up together with the just-asking-questions bad faith anti-vax arguments, the distracting focus on food-dyes, fructose and food-purity¹, and now the "just tough it out" advice for pregnant women with pain and fever, is exposure of this movement's misogyny. The weight of navigating decisions on food, vaccines and now, paracetamol, falls disproportionately on women, and the consequences of making the wrong decision will be to be judged by MAHA as a bad mother.² Women bear all the responsibility and blame, but get little help and support.

The burden falls on women

The rhetoric is always the same: choices, responsibility, discipline. Pregnant women are told to carry the moral weight of every decision, bearing responsibility without support, risk without remedy, and blame without resources. The politics of American healthcare is quick to blame, slow to protect.

Condemning parents for childhood nutritional shortfalls while slashing $1 billion in funding for programs bringing fresh fruits and vegetables to schools and food banks; limiting vaccine access while fanning the flames of measles outbreaks; limiting reproductive health access while doing nothing for US maternal mortality rates more than double other wealthy countries; providing no mandated maternity leave (the only high-income country without such protection) or ready access to affordable childcare; and repeatedly refusing to address the scourge of childhood exposure to gun violence, are all unforgivable moral failings. Advising pregnant women to avoid paracetamol while offering no alternative is more of the same.

Misogyny, medicine, and power

The logic here is not accidental. By shifting responsibility onto the individual while dismantling institutions that help, MAHA’s ideology performs a double trick: it leaves people unsupported, and then discredits those institutions – medical, public health, government – that would normally step in.³ The state fails, blames the individual, and then demands more power. The moralistic thread tying these ideologies together both ignores the importance of institutions in addressing these issues, and then further disempowers them.

Anesthesiologists and other clinicians must defend access to safe and effective pain relief, a basic human right. Paracetamol is cheap, effective, and globally accessible. Pretending otherwise is not just bad science, it’s political theatre designed to keep women in pain, institutions weakened, and power concentrated. Beyond the drug, the real fight is recognising when science is being twisted to advance ideological goals, when those goals reinforce sexism and inequity, and then weaponise this sexism to hollow out the very institutions that sustain public health.

The misogyny of MAHA is not an accident. It’s the point.

Yes, some food dyes are harmful and yes, high-fructose corn syrup has helped fuel the obesity epidemic. But this simplistic, reductionist thinking ignores the many real social, cultural, economic and political causes of America's abysmal health outcomes. Switching Coke to cane sugar and using natural dye in Froot Loops is branding, not public health policy. ↩
Don't get me started on this essentialist obsession with the primary role of women in society, reducing them to wombs, caregivers, and homemakers, with little value beyond reproduction. Fifty percent of the population written off as support staff... ↩
Institutions are undermined in two ways: directly, through defunding, contradiction, and performative attacks; and indirectly, by corroding the very idea of expertise. When public figures spew bad science, it doesn’t just damage trust in them—it erodes trust in any medical authority. That’s the point: if no one believes experts, institutions themselves lose their power. ↩

Are Health Insurance Premiums the Only Healthcare Cost Keeping Up With Inflation in Australia?

Tue, 15 Apr 2025 06:28:00 +0000

Several questions remain unasked in the ongoing debate about healthcare affordability in Australia.

Why have only private health insurance premiums reliably kept up with inflation among all the major healthcare cost components: doctor’s fees, Medicare benefits, private insurance benefits, government health funding, and public hospital salaries?

Is this true?

Health Insurance Premiums: Always Rising

There’s no debate here: private health insurance premiums have risen almost every single year and nearly always at a rate above the Consumer Price Index (CPI). Over the last 28 years, there have only been six where inflation was higher than the average industry premium increase.

Between 2002 and 2024, private health insurance premiums increased by 5.1% annually, even as inflation averaged almost half that (2.74%) over the same 22-year period. Private insurers justify these increases by pointing to rising treatment costs, increased service use, and an ageing population. While these are all factors, the consistent premium increases have still allowed record profits among the biggest insurers: BUPA, one of Australia's Big Two with Medibank Private, recently reported over AU$ 900 million in profit in the Asia Pacific region.

✅ Conclusion:

Yes, health insurance premium increases have exceeded inflation.

Doctor's Fees and Medicare Benefits: A Growing Gap

Many Australians have noticed it’s getting harder to find a bulk-billing GP. The gap between fees charged and rebates paid continues to widen.

From 2014 to 2020, the Medicare rebate was frozen, despite rising costs.
While doctor’s fees may have risen, they are not indexed, and vary depending on practice location and cost pressures. In fact, most doctors recognise their patient's cost-of-living pressure and have worked hard to keep their fee increases below inflation even as their own practice costs track above the CPI.
The rebate freeze meant that more of the burden was passed on to patients.

❌ Conclusion:

Neither doctor’s fees nor Medicare rebates have reliably kept up with inflation.

Health Insurance Rebates and Benefits: A Two-Speed System

a) Government Health Insurance Rebate (for consumers)

Since 2012, this rebate has: - Been means-tested - Adjusted below inflation

This has reduced its value over time, increasing the cost of private health insurance for many Australians.

b) Private Health Insurance Benefits (payments to doctors/hospitals)

Despite rising premiums: - Benefits paid out by insurers have not kept pace. - Gap payments (out-of-pocket costs) for patients have increased, even as doctors have tried to keep these increases limited while maintaining the financial sustainability of their practices. - Insurers have applied greater scrutiny on what they reimburse.

In my specialty, anaesthesia, most doctors charge well below the AMA's recommended-retail-price for their services. Currently, two-thirds of my own patients receive no out-of-pocket for my anaesthetic care, mostly for high-volume procedures or social circumstances (advanced age, surgical emergencies & complications, miscarriages, financial stress, etc.). The other third of my patients receive a modest out-of-pocket cost, with my total fee still ~50% less than the AMA recommended fee. Because the health insurer benefits paid for anaesthesia services are so low, charging more would dramatically increase the out-of-pocket burden on my patients.

⚠️ Conclusion:

Premiums rise, but the benefits paid rarely match, leading to significant out-of-pocket charges.

Public Funding and Hospital Salaries: Falling Behind

Federal & State Government Funding

Although nominal government spending has increased: - It often lags behind demand growth, inflation, and the growing complexity of care. - Activity-based funding models are frequently criticised for underestimating real costs, although governments favour them because they incentivise efficiency, provide transparency in costs and services, encourage accountability, and align services with health system goals.

Public Hospital Salaries (Doctors & Nurses)

Governed by enterprise bargaining, although annual increases often below CPI.
Many jurisdictions implemented wage caps (e.g. 2.5% in NSW, Victoria) despite inflation above that rate. The current industrial action by NSW salaried doctors is a direct response to hospital wages lagging behind inflation.

❌ Conclusion:

Public hospital funding and salaries have not kept up with inflation or demand.

Australian Health Costs vs Inflation

Category	Kept Up With Inflation?
Health Insurance Premiums	✅ Yes	Often exceeded CPI
Medicare Benefits	❌ No	Frozen for 6 years
Doctor’s Fees	⚠️ Partially	Varies by provider; gaps rising
Government Health Insurance Rebate	❌ No	Adjusted below inflation
Private Health Insurance Benefits	❌ No	Benefits growth slower than premiums
Government Health Funding	❌ No	Not consistently CPI-indexed
Public Hospital Salaries (Doctors)	❌ No	Wage growth < CPI
Public Hospital Salaries (Nurses)	❌ No	Wage caps in place

In recent decades, Australia's healthcare funding landscape has become increasingly uneven. While health insurance premiums have steadily risen, outpacing inflation, other areas have failed to keep pace. As the crisis in maternity care has shown this has significant implications beyond the cost of care: access, equity, and workforce sustainability.

Patients today face a growing financial burden. Out-of-pocket expenses continue to climb in both the public and private systems. The value of Medicare rebates is diminished and bulk billing is less viable for general practitioners. Simultaneously, private health insurance is becoming harder to justify for many Australians. Annual premiums perpetually rise while perceived value is eroded due to coverage limitations and growing gaps between paid benefits and actual service costs.

On the provider side, the pressures are no less acute. Public hospital doctors and nurses have experienced years of effective wage stagnation, with pay increases often failing to match inflation. Coming off the tail of COVID trauma, this slow erosion in real income further affects morale, hampers recruitment and retention, and threatens the long-term stability of the health workforce. When healthcare professionals are underpaid and overstretched, the consequences ripple outward to affect patient care and system efficiency.

In Australia, among various healthcare cost components, health insurance premiums have most consistently increased at or above inflation. Meanwhile other areas, including Medicare and insurance rebates, public hospital funding, and frontline staff salaries, have lagged significantly behind.

What’s needed is healthcare funding that ensures inflation-adjusted support across the system, restores value for patients, and properly recognises the contribution of healthcare workers. We already have care models in Australia that are both lower-cost and higher-quality than the alternatives – this isn't rocket surgery! Only with more sustainable funding can the Australian health system continue to provide accessible, high-quality care into the future.

References

Average annual price changes in private health insurance premiums (Dep. of Health & Aged Care) https://www.health.gov.au/resources/publications/average-annual-price-changes-in-private-health-insurance-premiums
Australian Competition & Consumer Commission (ACCC). Private Health Insurance Reports
https://www.accc.gov.au/publications/private-health-insurance-reports
Australian Inflation Rates: 1949 to 2025 (rateinflation.com) https://www.rateinflation.com/inflation-rate/australia-historical-inflation-rate/
70 Years of Inflation in Australia (ABS) https://www.abs.gov.au/statistics/research/70-years-inflation-australia
Duckett, S., & Breadon, P. (Grattan Institute). Medicare’s Midlife Crisis (2016).
https://grattan.edu.au/report/medicares-mid-life-crisis
Australian Medical Association (AMA). General Practice in Crisis: Rebate Freeze Impact.
https://www.ama.com.au
Private Health Insurance Ombudsman. State of the Health Funds Report (2022).
https://www.privatehealth.gov.au
Australian Medical Association. The Impact of Health Fund Gaps and Policies.
https://www.ama.com.au/articles/gaps-and-value
Productivity Commission. Report on Government Services – Health Sector (2023).
https://www.pc.gov.au/research/ongoing/report-on-government-services
Australian Nursing and Midwifery Federation. Wage Campaigns and EBA Outcomes.
https://www.anmf.org.au
Grattan Institute. Budget Pressures on Public Hospitals.
https://grattan.edu.au
Morton, Rick. Walking wounded: Inside the NSW doctors’ strike. The Saturday Paper. 12 April, 2025. https://www.thesaturdaypaper.com.au/news/health/2025/04/12/walking-wounded-inside-the-nsw-doctors-strike

Australia's maternity crisis: the unasked question

Sat, 12 Apr 2025 08:02:00 +0000

The proposal

Private Healthcare Australia (PHA) CEO Rachel David advocates for a "bundled care" maternity costing model where midwives, GPs, and obstetricians offer fixed-cost maternity packages. This model promises low-cost, full-transparency care across antenatal visits, delivery, and postnatal care – supposedly providing affordable options by allowing private midwives and GPs to manage low-risk pregnancies independently, in parallel with specialist obstetricians funded by the same bundled care model.

The hidden agenda

The critical question remains unasked: Why is the PHA, representing Australia's largest health funds (98% of the market, predominantly for-profit insurers), pushing so aggressively for this model? What benefits do PHA members, such as BUPA, which recently reported over AUD$900 million in profit in the Asia Pacific, have in strongly advocating for this funding model?

David's argument hinges on the uncited claim that only 14% of deliveries require an obstetrician, contradicting the Australian government's own data. Official AIHW statistics show delivery mode alone dictates that over 50% of births require specialist obstetricians before even considering complications like haemorrhage, perineal trauma or retained placentas.

The inevitable sequela

This bundled care model would trigger devastating consequences. Private maternity hospitals will not accept the legal liability of allowing midwives or GPs to deliver independently in their facilities, especially when private midwives are unable to obtain commercial liability insurance for intrapartum care. Even ignoring legal liabilities, what happens when the majority of births require clinical intervention beyond what these practitioners can provide?

Private obstetricians will withdraw from this unsustainable model. Anaesthetists and paediatricians, apparently unpaid under this framework, will decline participation. Few of these specialists will be willing to become involved in these compromised cases.

Over 50% of women requiring obstetricians and the 33% needing epidural analgesia will instead transfer to public hospitals to become public patients in order to access specialist care – no longer costing their private insurer, and losing the continuity of care this model champions. (A continuity of care currently provided by private obstetricians!)

26% of Australian babies are delivered in private hospitals. Shifting even half of these deliveries to the public system will overwhelm already stretched public maternity services, creating a genuine national crisis.

The economic reality

This capped model is economically unviable for private obstetric practices. This is not about "insufficient profit" rather, it's about businesses forced to operate at losses. Obstetric fees represent revenue covering rent, staff, midwives, nurses, ultrasound machines, other equipment, and 24/7 on-call coverage – resources essential for quality care.

Private obstetricians will instead shift practice to gynaecology and fertility. Sadly, private obstetrics will survive only in a handful of capital cities for a wealthy few willing to pay tens of thousands in out-of-pocket fees.

The safest option dismantled

The greatest tragedy? This proposal will dismantle Australia's safest maternity care model. Recent Australian research shows that babies born in the public system suffer double the mortality rate compared with private obstetric care, along with significantly higher rates of maternal haemorrhage, birth trauma and emergency caesareans. Surprisingly, this higher-quality private care was actually AU$ 5,888 less expensive per pregnancy than care in the public system.

The endgame becomes clear: private obstetrics ends. Private midwifery and GP obstetrics will shift the costly part of maternity care – deliveries and emergencies – back to public hospitals paid for by state governments. Meanwhile, the private health funds will successfully rebate vastly smaller amounts while collecting ever-increasing premiums, protecting their record profits at our maternity system's expense.

As we consider changes, we must ask: who truly benefits, and at what cost to mothers and our health system?

Experts Embrace Uncertainty

Mon, 24 Feb 2025 08:37:12 +0000

As we witness the global consequences of expertise rejection, particularly in the United States, I've been considering what truly characterises expertise beyond just specialist domain knowledge and experience – a question at the heart of anaesthesia and critical care practice.

Many doctors are first drawn to anaesthesia as a specialty because we desire control. We imagine ourselves controlling airways, physiology, and pharmacological interactions – sometimes, we even fancy we have some control over our surgical colleagues.

Yet we don't actually control any of these things. Instead, we modify, ablate, and amplify, working within a complex interaction between the patient, physiology, surgery, and our interventions. Our expertise lies not in absolute control but in understanding and adapting to uncertainty.

As news from the US shows a country embracing the "find out" phase of cascading bad decisions (some people just need to touch the stove to learn it's hot), a culture of expertise rejection dominates. This rejection exposes itself in curious ways, including assumptions that success in one field, say, building electric cars or reusable rockets, represents translatable expertise to other specialist fields.

The world is one of shades of grey, and anaesthesia is no different. Embracing uncertainty requires being comfortable with the potential for change and then preparing for and adapting to this change. Anti-experts respond to uncertainty by asserting their will onto reality, mistaking their desired outcome for reality itself. We see this in anaesthesia when something is going very wrong, yet an overwhelmed anaesthetist is unwilling to accept the situation and continues to try the same futile intervention. Airway emergencies particularly highlight this risk.

While many of the world's biggest challenges require cross-discipline insights, humility is essential lest we mindlessly dismantle Chesterton's fences, letting the monsters inside escape. We must accept uncertainty when we lack expertise and learn why the bloody fences are there before we recklessly tear them down.

Aside from their casual callousness and banal cruelty, these anti-experts are dominated by their infallible certainty. In contrast, true experts are intellectually humble, even when they are sure—perhaps especially when they are sure.

Today, we find ourselves at a local maxima of peak uncertainty. Another pandemic is brewing in North America, spreading through poultry and dairy cows, with 15% of the US chicken population already culled. Global economic uncertainty is at a 30-year high, greater than the beginning of the COVID pandemic and now fuelled by wars in Europe and the Middle East. All this while the US toys with authoritarian descent, making me wonder whether the lasting legacy of the country of Washington and Lincoln will be to serve as a warning to future generations.

The expert's approach to uncertainty cannot be passive acceptance or paralysis. Instead, uncertainty demands preparation by considering possible outcomes, decision trees, and probabilistic thinking. Rather than falsely believing we can bend reality to our will, true expertise means adapting our responses and behaviour to reality. This combination of preparedness and humility in acknowledging uncertainty defines the expert's mindset and shows why expertise remains crucial for navigating our complex world.