The Hidden Hierarchy of Illness, 2026, Gaber

[Dolphin]

Free fulltext:

https://journals.sagepub.com/doi/pdf/10.1177/27536351261431723

Gaber TAZK. The Hidden Hierarchy of Illness. Advances in Rehabilitation Science and Practice. 2026;15. doi:10.1177/27536351261431723

Keywords fatigue, legitimacy, hierarchy, post modernism, disability

Received: 23 January 2026; accepted: 17 February 2026

Medically Unexplained, Socially Unrecognised​

Modern medicine presents itself as a neutral arbiter of disease. Yet in conditions such as Functional Neurological Disorder (FND), Myalgic Encephalomyelitis / Chronic Fatigue Syndrome (ME/CFS), and other medically unexplained conditions, what is most visibly at stake is often not treatment, but legitimacy. Who is recognised as genuinely ill? Who is granted empathy? And who is quietly repositioned as difficult, weak, or morally suspect?

These questions expose an uncomfortable truth, societies operate with a largely unspoken hierarchy of suffering. At the top sit conditions with visible causes such as tumours or infections. Here, suffering is easily coded as misfortune. Empathy flows readily, responsibility is displaced onto an object, and the individual is preserved as fundamentally intact, a good person to whom a bad thing has happened.

Lower down the hierarchy sit disorders without stable, localisable pathology such as fatigue syndromes, functional neurological symptoms or chronic pain. Here, despite often profound disability, suffering becomes morally unstable. When causation cannot be pointed to, it collapses back onto the person. The clinical gaze quietly becomes a moral one.

Continues at link.

 

[Dolphin]

When Fatigue Has No Status​

Exactly the same structure governs the legitimacy of fatigue. Fatigue secondary to multiple sclerosis is readily recognised as real. Fatigue of equivalent severity in ME/CFS is contested and quietly downgraded. The lived experience may be indistinguishable. The social meaning is not. One story preserves the model ‘good person plus bad object equals illness’. The other destabilises it, and so suffering is reinterpreted as identity.

As a rehabilitation physician working closely with patients with long-standing ME/CFS and functional disorders, I have repeatedly been struck by a paradox that is difficult to forget. Several patients whom I had followed for years, disabled by profound fatigue, cognitive dysfunction, and loss of function, were later found to have incidental MRI findings that supported a diagnosis of multiple sclerosis. Each time, I expected devastation. Instead, more than one patient told me that the day they were given the diagnosis of MS was ‘the best day of my life’. Not because their suffering had changed, but because, for the first time, it had become legitimate. They were no longer exhausted without cause, disabled without explanation, or ill without status. They had crossed an invisible threshold from a condition that required justification into one that commanded recognition.

 

[Hutan]

Hmm, I read all of the brief article.

Their suffering is real, but its form does not map cleanly onto the objects our systems are designed to certify. The result is not neutral uncertainty, but delegitimisation and suspicion. This is not primarily a
failure of compassion. It is a category problem. We are asking a lesion-detection system to certify functional realities.

It may be necessary to confront a more unsettling possibility that orthodox medicine, shaped by centuries of anatomical localisation, and evidence hierarchies, may never be fully equipped to apprehend or legitimise conditions organised around instability of function rather than demonstrable damage. This is not a failure of clinicians nor a rejection of biomedical science, but a recognitionthat Knowledge like instruments, are selective. They illuminate some realities brilliantly and render others indis-tinct. In this context, rehabilitation medicine represents not a secondary service, but a different medical culture.

Disability and rehabilitation studies have already per-formed a quiet corrective. It relocated the centre of gravity from diagnosis to function, from cause to participation, from pathology to lived constraint. In doing so, it demon-strated that recognition need not wait for mechanisms. One can acknowledge suffering, protect dignity, and justify support without resolving ontology. This is not anti-scientific.
It is anti-monopoly of science over meaning.

The author seems to be suggesting that rehabilitation medicine is the natural home of conditions like ours.

My response involves swear words, but, for the sake of social niceties, basically I think the author can take his rehabilitation medicine and go find someone with a broken ankle or broken spine who might actually appreciate his skills, and stay far away from me.

I want science to give my illness meaning, not someone who is making things up as they go along. To quote:

Rehabilitation professionals are trained to work productively in uncertainty, to intervene without full mechanistic explanation, and to build clinical legitimacy around trajectories of function rather than lesions.

The core problem is that rehabilitationists on the whole seem not to work productively in uncertainty. They feel compelled to fill the uncertainty with 'mechanistic explanations', usually involving multiple circles. If there is no particular 'trajectory of function' possible to build their clinical legitimacy around, they become disappointed and look for someone to blame.

This places rehabilitation medicine in a uniquely qualified position not only to treat these patients, but to advocate for them, and to serve as a clinical home for forms of suffering that acute biomedical frameworks continue to struggle to recognise.

No, it really does not place rehabilitation medicine in a uniquely qualified position to do all of those things, including to advocate for me. Please, listen and then go away.

 

[Hutan]

Dr. Tarek Gaber
Consultant in Rehabilitation Medicine at Wrightington, Wigan & Leigh NHS Trust and NHS Bolton

In 2020 he started a Long Covid service.

 

[Hutan]

Who is recognised as genuinely ill? Who is granted empathy? And who is quietly repositioned as difficult, weak, or morally suspect?

When causation cannot be pointed to, it collapses back onto the person. The clinical gaze quietly becomes a moral one.

Fatigue of equivalent severity in ME/CFS is contested and quietly downgraded.

It asks not only what is wrong with bodies, but how certain forms of
malfunction are authorised as real while others are quietly moralised.

Disability and rehabilitation studies have already performed a quiet corrective. It relocated the centre of gravity from diagnosis to function, from cause to participation, from pathology to lived constraint.

There's an awful lot of things happening quietly in this brief article.

I'm sure the author means well. But my final impression is that he and his rehabilitation friends are quietly positioning themselves to run the 'holistic' clinics designed to keep people with ME/CFS and the like quiet and out of the real medical system with its tricky 'evidence hierarchies'.

 

[Trish]

First it was the psychiatrists, then it was the rehabilitationists wanting to own us and tell us how to manage our lives. What gives them the right? They have no more knowledge to help us than any random member of the public. It's BACME all over again - fill the gaps with false explanations and made up therapies.

 

[BrightCandle]

No one is very discerning about the process of buying treatments for ME/CFS. Rehab now seems like the model that will dominate for the next 20 years. GET/CBT is out, now exercising within your energy envelope is in with rehab movements and some other woo thrown in. Never mind people cant get out of bed and are exceeding their energy level eating.

 

[rvallee]

Several patients whom I had followed for years, disabled by profound fatigue, cognitive dysfunction, and loss of function, were later found to have incidental MRI findings that supported a diagnosis of multiple sclerosis. Each time, I expected devastation. Instead, more than one patient told me that the day they were given the diagnosis of MS was ‘the best day of my life’. Not because their suffering had changed, but because, for the first time, it had become legitimate.

This is something medicine massively struggles with, and it's exemplified by the common framing of how "X's life changed the day they got a diagnosis of Y". No, X's life changed the day they got Y, the diagnosis is not the beginning of the problem, it's only relevant in what it means socially, in what other people will do about it, or in our case whether anything will be done, and if it will make things better or worse.

No one should be surprised by this. It's actually shocking that anyone could ever expect otherwise. It takes a complete lack of reflection into the nature of illness, and a total lack of empathy, to fail to expect this. And yet it might as well be the Spanish inquisition, which no one ever expects.

Rehabilitation professionals are trained to work productively in uncertainty, to intervene without full mechanistic explanation, and to build clinical legitimacy around trajectories of function rather than lesions.

All I've ever seen of this in our case is that it has failed miserably, so I don't think they're actually trained at this, so much that they are trained to think so, which is one reason they never manage it, because there is no need to try to achieve something that already is. They can't help here anymore than they can handle infectious diseases. There are no exercises that will kill bacteria, no ritual self-affirmation mantras that will "top up" the immune system against a virus that has taken hold. All of this makes pissing in the wind productive by comparison.

This article also reveals a common reason why so much of this is messed up: no mention of mental illness, which is as low as us on the hierarchy, is not even considered real illness, just like us. Despite decades of mouthing pretend recognition of mental illness being just as significant as physical illness, no one disagrees with this more than the medical profession. It's also mainly why they think so little of us, because they think very little of mental illness, as something that isn't their responsibility. Two mutually aggravating problems that can't be fixed because the real people isn't with X, or Y, it's with medicine itself and its near total lack of meaningful introspection and accountability. Conformity is not accountability. They might be confused for one another, but they don't even overlap.

A system of rules cannot function through arbitrary exemptions. We have the worst of both worlds: we are bound by the rules and filtered out through arbitrary exemptions. What we see is the absolute worst case scenario for how to deal with this. There are millions of ways to do just as poorly, but there aren't legal ones that would hurt us more.

This continuously renewed call for the same solution to the problem is all the proof that's needed to show that this system cannot fix itself, is beyond redemption, or even minor correction. We haven't even seen minor correction yet.