The most unsettling feature of modern clinical medicine is the growing number of patients who are clearly unwell, yet do not fit the framework medicine still insists on using. I see this repeatedly now. Tests come back normal or only mildly abnormal. Scans are unrevealing. The usual pathways lead nowhere. And yet the patient in front of me is not imagining their symptoms. Something has shifted, both in how disease expresses itself and in the medical system’s ability to make sense of it.
That was one reason I wanted to speak again with Dr. Shankara Chetty. I have come to value his clinical reasoning because it is rooted in outcomes rather than ideology. He was one of the rare clinicians who looked carefully at what COVID was doing early on, acted on that pattern recognition, and saw results. What struck me in this follow-up was not simply that he still sees the same pathophysiology. It is that he sees it widening, diversifying, and increasingly evading the tools conventional medicine relies upon.
What I Am Seeing in the Data
Part of what shaped this conversation was the trajectory dashboard work I have been doing with NHS admissions data. Across age groups, I do not see stability. I see movement. I see admissions rising in categories that should not all be rising together if nothing fundamental had changed. That matters, because hospital admission is not the beginning of illness. It is the severe end of a much broader population curve.
If migraines are rising to the point of hospital admission, there must be a much larger burden of severe neurological dysregulation in the community. If toxic liver disease is rising across virtually every age group, including children and young adults, that should force a rethink of what is happening biologically. If cancers, hypertensive disease, renal complications, and inflammatory syndromes are all climbing together, the correct response is not to dismiss the pattern. It is to ask what common mechanism could plausibly sit beneath all of them.
That is where I think the profession is failing. Too many clinicians still want to argue each signal in isolation. But when you step back, the overall pattern is much harder to ignore.
FREE ACCESS - Explore the snapshot of age-stratified NHS admission analysis, including the top rising conditions in each cohort, trend trajectories, comparative controls, and detailed interpretation.
Why “Long COVID” Has Become Too Vague
One of the problems we now face is that the term long COVID has become too diluted to be useful. It has turned into a catch-all for almost anything that has gone wrong since the pandemic. That may be politically convenient, but it is not clinically precise.
Dr. Chetty’s point, and I agree with it, is that mechanism matters more than label. Whether someone deteriorated after infection, after vaccination, or after repeated exposures over time, the key issue is the individual immune response to spike protein and the downstream effects that follow. That response is highly variable. Some patients worsen immediately. Some deteriorate after reinfection. Some tolerate one exposure and not another. Some improve with an intervention and relapse when it is withdrawn.
That variability is exactly why a protocol mindset breaks down. We are not dealing with a single clean disease entity presenting uniformly. We are dealing with a biologic trigger interacting with an individual host, an individual inflammatory history, and an individual set of vulnerabilities.
The Fire Was Not the Same in Everyone
I often explain this in our Masterclass with a simple image. COVID infection or vaccination acts like petrol. But the petrol is not the whole story. What matters is where the ember already exists. If there is pre-existing inflammation, immune priming, silent tissue injury, allergic tendency, vascular vulnerability, or some other unresolved inflammatory spark, then exposure to spike protein can act like fuel poured onto that ember.
That helps explain why one person develops neurological symptoms, another myocarditis, another liver dysfunction, another gut inflammation, another a hypertensive crisis. The same broad insult does not produce the same phenotype in every individual. It amplifies what was already biologically susceptible.
That is also why the profession has become confused. It is still expecting a consistent pattern. That is no longer what is in front of us.
The New Clinical Presentation Is Much More Subtle
One of the most important points in my discussion with Dr. Chetty was how subtle the initiating illness has become. Many of these patients do not present with classic flu symptoms. They may have a brief headache, an odd period of fatigue, a transient sore throat, or a vague prodrome that would not even register as significant. Then, one to three weeks later, the real problem appears.
That delay is critical. By the time the patient develops palpitations, gut symptoms, severe fatigue, blood pressure dysregulation, neuropathic pain, or a flare of an old inflammatory site, neither they nor their doctor is still thinking about COVID. The initiating event has already been forgotten.
This is why the system is so poor at picking these cases up. The history is there, but you have to know how to ask for it. You have to think backwards. You have to ask what happened before the patient began to unravel, not just what happened when they finally crossed the threshold into illness severe enough to seek help.
Why the Old Testing Framework Is Failing
Many of these patients do not generate the objective findings doctors expect. That does not mean nothing is wrong. It means the pathology is occurring in a way conventional testing does not adequately capture.
Dr. Chetty made the point that in many of these cases there is no definitive test to confirm the diagnosis you are considering. That leaves clinicians in an uncomfortable position. But the answer to that discomfort cannot be denial. If the patient is clearly unwell and the current toolbox cannot explain it, the conclusion should not be that the illness is imaginary. The conclusion should be that our framework is incomplete.
That is where humility ought to begin. Instead, too often, ego steps in.
The Liver, the Gut, and the Systemic Pattern
One of the most striking findings in the data, even to me, was the rise in toxic liver disease across age groups. That should not be brushed aside. My reading is that the liver may be acting as both filter and victim. If gut dysbiosis, leaky gut, immune complexes, inflammatory products, and microvascular dysfunction are all part of the picture, the liver will inevitably sit in the path of that burden.
That fits what many of us are seeing clinically: gut disturbance is rarely peripheral now. It often looks central. The gut seems to be one of the major engines of persistence, and the liver may be one of the first organs forced to absorb the consequences.
A simple organ-based view of disease is no longer enough. The body is responding systemically, and unless we think systemically, we will keep missing the mechanism.
We May Be Dealing With an Adult Version of a Post-Infectious Syndrome
During the discussion, I found myself thinking about rheumatic fever and multisystem inflammatory syndromes in children. Not because the analogy is exact, but because the principle is familiar. A relatively minor trigger can produce a delayed, disproportionate immune reaction in a susceptible host. The initial illness may be barely memorable. The aftermath is not.
That may be much closer to what we are dealing with now in adults than many doctors realise. A person may not be particularly unwell during the initial infection, yet still be vulnerable to a significant inflammatory reactivation afterwards. Once that pattern is established, it may recur with even modest subsequent exposures.
That possibility has serious implications, because it means management cannot be limited to the acute infection itself. It requires recognising the patient’s pattern, anticipating recurrence, and intervening before dysregulation becomes entrenched.
Medicine Is Now Facing a Moral Test
The real issue is no longer just scientific. It is moral. Medicine has reached a point where it must decide whether it exists to defend guidelines or defend patients. Those are not always the same thing.
Protocol medicine is safe for institutions. It is safe for careers. It is safe for legal defensibility. It is not always safe for the patient in front of you. If a system creates conditions where a doctor is more protected by doing nothing than by thinking carefully and trying to help, that system is in serious trouble.
I do not think this can hold for much longer. The complexity of patients is increasing too fast. The volume of unexplained illness is too large. The fractures in trust are already visible.
What Comes Next
We are only at the beginning of a broader transition in how disease manifests. This is not a brief aberration. We are looking at the early stages of a decade-long shift in how chronic disease, vascular dysfunction, cancer risk, immune dysregulation, and inflammatory illness present across the population.
That is why I take these conversations seriously. Not because every answer is already known, but because the pattern is already visible. The greatest risk now is not that we ask difficult questions and are proven wrong. The greatest risk is that we refuse to ask them at all.
Medicine can survive being wrong. It cannot survive losing the courage to investigate.
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