Medically Unexplained Symptoms

What do doctors do when their patients’ pattern of symptoms don’t appear in medical textbooks? The top ten complaints of patients to primary care physicians in UK include “tired all the time”, dizzy spells, headache and non-specific abdominal pain.

When I was working as a family doctor in Leicester, I could not make an accurate diagnosis based on pathophysiology (how a disease affects the workings of the body) in more than half my patients. “It’s probably just a virus,” I might have said. Or I could have been more honest, saying, “I don’t know what’s wrong but I’ve listened to your symptoms, checked you over, done some investigations and I can’t find anything seriously wrong. Come back if things get worse.”

Referring such patients to a hospital specialist rarely results in a diagnosis. The patients are subjected to more expensive and invasive tests, “just to make sure,” and they end up being sent back to their GPs, often more anxious and not reassured at all. “Maybe my condition is so rare that they haven’t done enough tests?” they might think. More than a third of patients referred to secondary care receive no precise diagnosis. On the other side of the coin, about a tenth of the patients, who were told nothing was wrong after seeing neurologists, were eventually diagnosed a decade later. And of course, neurotic patients are not immortal; we all have to die of something.

I don’t for a minute think that all these patients were fabricating their illness or malingering. With adequate time, good consultation skills and using a biological-psychological-social model of disease, health workers can often understand why these patients are unwell. Many have psycho-somatic disorders, when mental stress can provoke physical symptoms. As doctors, we can’t fix patients whose problems have social causes, such as lack of employment, loneliness or housing.

Being a glutton for punishment, I decided to specialise in this group of patients. I was assisted by an excellent psychotherapist, Lorraine Parker. My role was to have a long consultation with the patient after poring over their extensive medical records, looking for clues of a missed diagnosis or a clinical stone unturned. I would try to reframe the patient’s complaints so they would agree to have half a dozen therapy sessions with Lorraine. “We might not know what’s wrong, but we can try to help you cope with your symptoms.” Once therapy was over, the patient would consult me again to discuss future management. Rather than consulting any doctor, they would try to see the doctor who knew them best. Which was usually me.

Our plan was to assess how often these patients consulted GPs prior to the intervention, how often they saw specialists or were admitted to hospital, how much medication they were prescribed and investigations carried out, comparing this with what happened in the following year. We were hoping that the cost of the pilot would be vindicated by future reduction of health care costs.

Well, that was the plan. I didn’t mind taking on the “incurable” patients (one of whom gave me a talisman of St Jude, patron saint of lost causes), but I wilted under the strain of my wife’s final illness and left general practice a year after she died.

Are things different in Swaziland? Not much. Probably the most common complaints in our clinic are “sides pain”, pain all over the body, and headache. What on earth is sides pain? Backache which has migrated? I still don’t know. Most patients do not expect an explanation for their symptoms, just the medicine to cure it, preferably by injection. If you are a nurse seeing sixty patients a day, the temptation to dish out painkillers, vitamin pills, calcium tablets and other placebos, is irresistible.

As a doctor, I have the privilege of being able to spend more time with patients, so I can delve a bit deeper into their psychological and social situation. When I am using a translator, I am never quite sure how my strange questions and comments have been phrased or interpreted. Translators often feel uncomfortable asking non-medical questions on my behalf. They don’t like seeing patients become emotional and crying.

Virtually everyone will admit to being under stress. There is 40% unemployment here. Those lucky enough to have a job can find working conditions very tough. The massive loss of population from HIV/AIDS and tuberculosis over the past twenty years has disrupted family life. Marriage is less popular and many children are born to single mothers, often without support from absent fathers. The patients usually accept that their medically unexplained symptoms are the result of stress. But they still want medication. I might be able to resist this, using the “doctor as drug” for the treatment.

Patient narratives are often very similar to those in UK:

A middle aged man, who is the only bread winner supporting his extended family, has been sacked. He is desperate for any work so he can continue to fulfil his responsibilities.

An elderly gogo feels lonely and sad because her children no longer visit and support her. “They have their own lives now, but they have forgotten who brought them up.” No wonder she can’t cope with the pain of arthritic joints.

Another young man who has to pay child support from his meagre salary but despite this, his former girlfriend refuses to let him see his son.

The public servant who has got into such deep debt that interest payments swallow up most of her salary.

An old lady whose husband died, who is facing eviction from her home because of a dispute among members of the extended family over the inheritance.

A young lady with pain in her knee, who has visited the three biggest hospitals in the country, seen countless doctors and no one can find anything wrong. Neither can I, but I discover that her auntie had a pain in her knee and ended up in a wheelchair, unable to walk. She is understandably terrified that she is going to suffer the same fate. I’m not sure my long interpretation and explanation of her symptoms has made a difference, but she accepts it.

A nurse referred a man in his 40s to me after several consultations for general weakness and feeling tired all the time. He looked very pale and had a slow pulse of 50 beats per minute, so while we were waiting for the results of some blood tests, we had a chat. He revealed all the typical symptoms of depression, hopelessness, sleep disturbance, loss of weight, energy and appetite, low self esteem, early morning wakening, crying, social isolation, etc. He even admitted that he had tried to hang himself.

Just as I was thinking that ordering the blood tests had been a waste of time, I discovered his haemoglobin was just 5g/dl (about a third of the level it should have been). He was severely anaemic, requiring a blood transfusion. The psychosocial counsellor who saw him took a better physical history than I did, and he admitted that a hospital specialist had wanted to do a colonoscopy because of rectal bleeding. The patient had refused to have the test done, almost certainly because he was depressed. This medicine business can be tricky sometimes.

Very pale tongue, with an odd “map-like” appearance known as Geographical Tongue

Perhaps one of the most challenging patients was a man I met last month. He was in the treatment room, hooked up to a stuttering nebuliser, cloaked by vaporised salbutamol wafting from the mask over his face. He had been diagnosed with asthma by the nurse. He told her he had asthma, and his medical papers from other hospitals supported this assertion. Clearly, he was hyperventilating and about to keel over. I stopped the nebuliser, managed to get him up on the couch and examined him. No wheeze, plenty of air getting into his chest, in fact, too much air.

I tried to talk him down, explaining how his excessive breathing was making his symptoms worse. I wasn’t having much success so I asked the nurse for a paper bag, so he could rebreathe the expired air, correcting the low levels of carbon dioxide in his blood. All bags here are plastic. The nurse looked perplexed at my strange proposal. I had a thought, “Can you please bring me a large brown paper envelope from the office? A used one will do, it doesn’t have to be new.”

I folded the open end of the envelope over the man’s face and tried to get him to reduce his respiratory rate. After five minutes, the glue from the envelope flap had stuck it to his nose, but he still had muscle cramps in his chest and tingling “pins and needles” in his hands and feet. The queue of patients outside was building up and I wasn’t making much progress with my talking cure.

When in doubt, use drugs. I gave him 10mg of oral diazepam, a tranquilliser, and within a few minutes he was sleeping like a baby, with a normal respiratory rate.

While he was resting, I took the opportunity to read through the disorganised mass of papers which constituted his patient-held medical records. More than a year ago, he attended a hospital with a severe headache and managed to persuade the clinician to order a CT scan of his brain. This was essentially normal, though the radiologist had commented that his cerebral ventricles were slightly dilated. Usually, this is of no significance. He took the result of the brain scan to another doctor, who misread the report and thought it showed dilated heart ventricles, indicating a heart muscle problem or cardiomyopathy. This doctor referred him to a cardiologist. The unfortunate man had attended with a headache and then had been told he had a serious heart problem.

His panic attacks with hyperventilation started after this shock diagnosis and unfortunately health workers diagnosed this as asthma. The routine treatment for this here is thirty years out of date: oral salbutamol tablets for prevention. This medication is a heart stimulant and would cause his hands to shake. Inhaled corticosteroids, the standard preventive treatment in UK, are very expensive.

An hour later, he woke up and I had a long talk to him debunking his medical problems. Although he nodded in agreement, I wonder how much of my interpretation he would retain. He almost certainly doesn’t have asthma, cardiomyopathy or brain damage. Just like in UK, I offered to see him in future if his symptoms returned. Personal continuity of care is my most potent weapon. And diazepam.

Tops and Tees

I am always suspicious of tattoos of Chinese characters. “It means divine happiness,” the bearer might say. But I suspect the logogram might really say, “Stupid Westerner.”

Similarly, I would never buy a tee shirt which bore a slogan if I didn’t know what it said. Recently in clinic, I saw a lady wearing a top which said, “Love is the Answer”, with a smaller subtext, “It is the key to the gate of happiness”. As she spoke to my interpreter about her medical problems, I wondered whether love was the answer for her. She was a single mother with two children and was finding it difficult to cope.

Sometimes the tee shirts have a slogan which doesn’t quite match the wearer.

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A few weeks ago, I saw an older lady who looked strange because her face was a bit lopsided. She had a glass eye which was too big for the eye socket. She had also had a stroke some years ago, resulting in an arm which was flexed and useless. Her jacket had the word “Desire” picked out in diamante and sequins. She had no idea what the word meant.

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I took this photograph of a lady’s orange polo shirt which featured a photograph of her son who had gained a doctorate at university. Forget the obligatory photographs of the begowned graduate, clutching a scroll and wearing a tasselled mortar board. This was the ultimate advertisement of academic achievement. She was very proud.

Occasionally, young men attend the clinic wearing a tee shirt advertising, “World’s Greatest Lover” or “Sexy Beast”. I reckon that they know what is written on their chest. And I have a good idea of why they are seeing me at the clinic. Some of the baseball caps on sale here are rather tasteless and unSwazi. I can’t recall ever hearing a Swazi use a swear word.

Another young lad visited the clinic last week wearing a crimson tee shirt bearing the multi-coloured slogan, “I ain’t worried bout nothin’.” I know what it is trying to say, but taken literally, the double negative means he is worried about something. Which is presumably why he is seeking medical advice.

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PS A double negative indicates a positive, but there are no examples of a double positive meaning a negative…“Yerr-right!” (This quip comes from a FaceBook posting by Nigel Puttick, who shared a wrecked house in Coldharbour Lane, Brixton with me as a medical student in the winter of 1976-77.)

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Soka Uncobe: Male Circumcision in Swaziland

Soka Uncobe is the slogan of the Male Circumcision (MC) programme which began in 2008 in Swaziland. A Task Force led by the Ministry of Health aimed to integrate male circumcision into the services of all hospitals and health centres. Its ambitious target was to circumcise of 80% of men in the 18-49 age group by 2013. Another programme came on stream in 2011, aiming to circumcise 50% of all male babies born in hospitals by 2014.

Mass campaigns are very costly. After the initial push, health facilities were encouraged to integrate MC into their routine work, saving lots of money. The organisers naively thought that this could be done without disrupting normal health services. This thinking is very reminiscent of the NHS, where additional work is dumped into primary care on the assumption that its capacity is limitless.

To boost the flagging programme, MC champions were appointed in the Parliament, schools and Chiefdoms. Twenty-six doctors and 83 nurses have learned the new WHO-approved surgical method. Only 2% of operations resulted in significant adverse events, such as excessive bleeding, infection and damage to the penis. In South Africa, I read a newspaper article which claimed that 22 males had had their penis amputated following complications of circumcision, but I have not heard of any cases in Swaziland.

The programme didn’t work. After an initial rush to cut (the low hanging fruit?), the numbers have been falling recently. Only 70,000 men have had the operation, just 28% of the target of 80%. Barely 5,000 infants have been circumcised. As a result, the targets have been adjusted to 80% of males aged 10-29, and 55% of the 30-34 age group, by 2018.

Older men have not been excluded, but will not be priority cases. The circumcision of newborn males will continue after this “catch up phase”. Another cadre of health workers (45 doctors and 78 nurses) has been trained to circumcise babies using the Mogen Clamp.

P1010335I went to a Centre of HIV and AIDS Prevention Studies (CHAPS) event last month which was promoting MC in the private sector. Circumcision is free for the patient, but the private doctor collects a bounty of 700 Rand (£40 or US$60) for each case. The equipment is provided free of charge and there may be some assistance for private clinics to expand (staff, equipment, rooms) to take on more circumcisions. This is presented as a good business proposition, a money-making venture which will also improve the facilities and reputation of the private clinic. Private GPs must undergo rigorous training at an approved centre and perform at least ten circumcisions. USAID is providing most of the financial support.

The whole point of male circumcision is to reduce transmission of HIV to men. Removing the foreskin to expose the tender skin of the glans penis makes it tougher. The soft skin becomes keratinised, so it is less likely to get damaged during sex. Broken skin gives viruses a portal of entry. By my way of thinking, less broken skin should also reduce transmission of HIV from infected men to non-infected women during sex, but this has not been shown to be the case. Whilst men are recovering from the operation, they are more susceptible to HIV infection through the surgical wound. The official advice is “six weeks off games”, but most men I have spoken to would find that an impossible restriction on their sex life.

Unfortunately, MC does not protect men who have sex with men from HIV infection, but the reasons for this are unclear. Most American males are circumcised but the incidence of HIV infection is higher than in UK, where few males are circumcised. MC may provide some protection against herpes, but not against the commonest sexually transmitted infection I see in Matsapha – gonorrhoea. I have heard that some wily men who have HIV want to get circumcised as they think new girlfriends will regard them as low risk, and not insist on them using condoms.

In 2000, the London School of Hygiene and Tropical Medicine suggested that circumcision was associated with reduced risk of HIV infection. Three years later, the Cochrane Collaboration examined 35 studies and didn’t think the case was proven. To settle the matter, WHO/UNAIDS commissioned three randomised controlled trials in Africa. The trial at the Orange Farm district of Johannesburg in South Africa reported that circumcised men were 60% less likely to contract HIV. Trials in Kenya and Uganda showed similar findings, and were stopped on ethical grounds.

Even putting all the data from these three trials together (over 11,000 men were involved), the results are still not clear in my mind. The studies showed the risk of contracting HIV for circumcised men is at least half that of uncircumcised men over a year. But what about in ten years from now? One meta-analysis examined the trials and stated that to prevent one new infection of HIV, 72 males would need to be circumcised. WHO and UNAIDS mathematicians modelled the same data and came up with a different figure of between 5-15 circumcisions per HIV infection avoided. This is very cost effective compared with the price of anti-retroviral drug therapy. However, condom use is almost a hundred times more effective than male circumcision at preventing HIV infection. And of Circumcisioncourse, circumcised men would need to continue to have safer sex to maintain the protective benefit.

The local newspaper ran a story about circumcision interfering with an arrangement for warriors to collect urine (the imvunulo) when they are taking part in long ceremonies wearing traditional dress. I am not sure how this contraption works, but I doubt the foreskin is essential for its use. Circumcision used to be part of the rite of passage of becoming a warrior in Swaziland. I heard that the custom fell out of favour because the King needed as many warriors as he could muster and too many men were “on the sick”, recovering from the traditional procedure.

P1010690 On rare occasions, voluntary medical male circumcision (VMMC) turns out to be neither voluntary nor medical. In this newspaper article, a woman discovered her paramour taking a WhatsApp message from another woman. Was it his wife or another girlfriend? We will never know. Hell hath no fury like a woman scorned. She bit off his foreskin during oral sex. Ouch. No chewing gum jokes, please.

The slogan used toP1010496
promote MC in Swaziland translates as “Cut and Conquer (HIV)”. Perhaps this has given the wrong message to many young men who feel that once they have been circumcised, HIV has been defeated and they no longer need to use condoms. Our health counsellors blame the Americans for thinking up a snappy slogan and not consulting lots of Swazi men to find out what they understood by Soka Uncobe. “Cut and Reduce Your Risk Of HIV, But You Still Have To Wear Condoms” isn’t such a slick catchphrase.

Much better is Zambia’s slogan: “Shield and Spear”.

Statues

Some people in South Africa are getting angry about statues; there is a campaign to remove all symbols of colonialism.

The statue of Cecil Rhodes at Cape Town University had to be removed from its plinth because of protests from the Economic Freedom Fighters (EFF). This group objects to any symbol of colonialism which they view as the cause for the country’s present economic problems.

In Port Elizabeth, the Horse Memorial, erected in 1905 after the Second Anglo-Boer War, was damaged by the same group. The kneeling soldier holding a bucket of water for the horse to drink has been pulled off the base. They left the thirsty, bronze horse still standing, commemorating all the gallant animals that perished during the conflict. This inscription is written on the plinth:

“The greatness of a Nation consists not so much upon the number of its people or the extent of its territory as in the extent and justice of its compassion.”

The Boer War Memorial statue in Uitenhage’s Market Square was “necklaced” – activists set fire to a car tyre draped over the soldier’s shoulders. They used a sledge hammer, but could not bring down the statue. This triggered a newspaper cartoon showing a replacement statue, depicting the brutal necklacing and beating of a man.

Security guards have been trying to protect the statue of Paul Kruger (the President of the South African Republic from 1880 to 1900) in Church Square, Pretoria, after EFF activists splashed it with lime green paint. He fought against colonialism and the British imperialists.

Even the statue of Mahatma Gandhi was defaced with white paint in Johannesburg. And he was arguably the most famous freedom fighter of the twentieth century.

Is nothing sacred?

Jacob Zuma was also portrayed in the controversial painting, "The Spear"
Jacob Zuma was also portrayed in the controversial painting, “The Spear”

Apparently not. In Cape Town, a small statue resembling President Jacob Zuma was erected on the hill, Lion’s Head, overlooking the city. It depicted a short, fat, naked man, with a large pink sex toy in its hand. Zuma has a reputation as a philanderer. When he was on trial for alleged rape, Zuma stated that he protected himself from HIV infection by having a shower after sex. The statue was cut in half and destroyed.

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Gathering of the Clans

Her Excellency, Mrs Judith Macgregor CMG LVO, High Commissioner to the Republic of South Africa, and Mr Frank Pettit, Honorary Consul to Swaziland, held a reception last night for all Britons living in Swaziland at the Malkerns Country Club.

I was keen to go and broaden my social horizons. Social life in Manzini is not sparkling and I thought I might meet some interesting people. It is pleasant to chat with folks who will probably understand the subtleties of humour, cynicism, banter and references to “Blighty” (for example, Microsoft Word has underlined “Blighty” with a wavy red line, showing it has no idea what it means).

The reception was scheduled to start at 6pm. In Swaziland, this could mean as late as 7:30pm, but we Brits are sticklers for punctuality. I set off from Manzini at 5:30pm for a trip which should have taken 30 minutes. But it was raining, with poor visibility, and on the dual carriageway the out of town the rush hour traffic ground to a halt. There were three separate multi-vehicle pile ups, all in the fast lane. The speed limit on this stretch of road is 100 kph, but drivers rarely compensate for poor road conditions by slowing down. It is a holiday weekend (King Mswati III is 47 years old tomorrow and Monday is a Bank Holiday), so people were probably hurrying to get home.

I arrived at the Country Club an hour late. The speeches were over, the aluminium foil-lined trays of cucumber sandwiches (crusts still adherent), cocktail sausages, outsize vol-au-vents, cheese and cucumber strips and home-made paté with Ritz biscuits, had been plundered. But there was a tureen of delicious, hot, viscous vegetable soup, which I ladled out into a mug and sipped from a spoon.

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After work, I had changed into a fresh, white, short-sleeved shirt worn with a post-modern animal print tie, so I was feeling chilly. After warming up in front of the blazing log fire, set in a huge stone fireplace, I looked around and recognised no one among the seventy Brits.

Small talk isn’t my forté, and, apart from blogging, I don’t gossip. But I set out to get to know some people. Most of the group were semi-retired farmers living in and around the village of Malkerns. The village is named after Malcolm Kerns Stuart, who ran a trading store here in the early 1900s. The country club is the spiritual home of the British community and until recently, all the members had to “club in” and contribute to the running of the establishment.

I was impressed with these friendly people who arrived in Southern Africa almost half a century ago to live and have made Swaziland their home. Most were jacks-of-all-trades – farmers, mechanics, accountants – who bought a bit of land and built their houses in the hinterland. They are here for the duration. They talked to me about their lives, their families, local notables whom I should meet and invited me to the club amateur dramatic night next month, or to pop in one Sunday when I was feeling in need of good company.

I suppose they could be called “immigrants” rather than “expats”. Most had no intention of going back to UK (unless it was something special, such as to see their grandchildren singing in a choir in Canterbury Cathedral). I warmed to them while they got steadily plastered drinking Windhoek draft beer. Unfortunately, I missed the 70 year old resident GP, who left just before I arrived, who works half days in a private clinic close to MSF’s Matsapha Comprehensive Health Care Clinic. He sounded like a friendly, old fashioned GP who would really put himself out for his loyal patients.

I didn’t speak much to the younger Brits, some of whom had young children. They had ordered pizza on the verandah. I didn’t like to intrude on family groups.

Looking resplendent in viridian green, Her Excellency, the High Commissioner, worked the room, canvassing opinions. I was too busy collecting stories of the “olden days” to go and speak to her, but she was accessible and seemed interested. Following the closure of the British Consulate in Swaziland (Foreign Office efficiency savings), there had been delays in renewing passports, which had to be sent to Pretoria. This had now been sorted out, with the turnaround time falling from three months to three weeks. It seems odd that the Honorary Consul had no register of resident British citizens in Swaziland.

By 8:15pm, there were only a score of Brits left in the club. The couple I was talking to left, so I decided to call for a driver to pick me up. The cell phone reception wasn’t good, so I walked over to the fireplace and held my phone up to get a better signal. I sent a text and got a reply from the driver, accompanied by a religious text from the phone company, MTN.

I wandered over to join a garrulous group sitting around a table in the corner. I introduced myself and they all laughed. Apparently, they had noticed my strange behaviour holding up a cell phone (trying to get a signal) which they interpreted as my photographing the stragglers at the reception. One lady was trying to hum the James Bond theme tune (I think).

“With your white shirt and tie, we thought you were with the High Commission, security or something, taking pictures, casing the joint,” said one of the group. “Are you with MI5?”

“Not MI5, but MSF,” I quipped.

They all laughed uproariously, but I didn’t think it was that funny. There was a call for another round of beers, and soon the driver had arrived to take me home.

They seem like a good crowd. I’m definitely going to the amateur dramatics (“Gas, Giggle & Grub”) next month. Probably not nitrous oxide.

The Drop: Warning, Adult Content

I can always tell when men come into my consultation room with an embarrassing problem. They often hold their medical records over their groin, they avoid eye contact and take a while before telling me what’s wrong. It’s almost as though they are trying pluck up courage.

My next patient fit the bill perfectly. He was definitely looking sheepish. He rolled up his trouser leg to show me some abrasions on his knee. “I fell off my bike a week ago,” he said. “I’ve injured myself on the crossbar.” I asked what part of his anatomy had been affected, he said he didn’t know the correct word in English. “Perineum,” I thought to myself. “Let me have a look,” I asked him.

He undressed and I examined him. I couldn’t find any bruises, but I did see a classic case of gonorrhoea. I couldn’t resist passing an unprofessional comment that he had not just been riding bicycles…

“No, dokotela, I don’t do that, honest, really! I am a religious man,” he said.

“You’ve got the drop,” I told him. This is the local slang term for gonorrhoea.

I raised my eyebrows questioningly and turned to my Swazi nurse colleague who was observing my consultations. He spoke a few choice words to the patient and he reluctantly confessed that he had a bevy of girlfriends.

“I’ll have to give one of them the sack,” he said, “Once I have worked out who I caught this from.”

“I think you should contact all your girlfriends and persuade them to come here for treatment,” I said. “You could have passed the infection on to other girls, too. Perhaps you should hire a Kombi to ferry them all to the clinic.”

He didn’t seem impressed by this helpful advice.

“Look, if all your girlfriends don’t get treated, the infection will continue to get passed around between you, like ping pong,” I told him.

I don’t think he understood my point. “Ping pong?” he asked. “Do you mean I am going to have to masturbate?”

“Well, that would be safer, but I was trying to explain how people can catch the infection again just a few days after they have been treated for it. Everyone should be treated at the same time,” I said.

I prescribed the medication and wrote out some contact slips for him to give to his partners. “Have you had an HIV test? Do you know your status?” I asked him.

“Yes, I do. It’s a long story,” he replied.

“How long can it be?” I asked in exasperation.

But that’s another story.

Splat the Rat

How often have you tried to splat the rat? Usually at school fundraising events, the “Splat the Rat” stall is a popular attraction. For those of you who have never heard of this, the operator drops a toy rat down a length of drainpipe and the punter tries to whack it with a stick as it emerges. I can’t remember ever being able to time it right and hit the rodent.

The lady, who cooks the evening meal for expatriates in the project, pointed out the evidence in our kitchen. “Look, tooth marks in this chip,” she said. “And here in this apple. We have a rat in the house!”

I made a mental note to have a chat to my two flatmates about the need to keep the kitchen tidy and to store food in the refrigerator. They had left for the office a few minutes earlier. I was waiting for the vehicle to take me to the clinic when I heard a scream from the kitchen. “Rat!”

The cook called the cleaner to come into the kitchen and they shut the doors. They were obviously experienced at rat catching. They pulled the refrigerator and cooker out away from the walls. One pushed a mop down one side of the cooker and the other waited with a broom handle raised, ready to hit the rat as it was flushed from cover.

I went outside and looked in through the window, just in time to see the cleaner splat the rat. She gave it a few more thwacks with the broom handle until it stopped twitching.

“Ooh, it’s a big one!” said the cook.