Bug's life: a woman tends to a shelf full of cockroaches in jars in a lab, c.1955. Photo: Getty
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The patient complained of insects crawling on her skin. Then she handed me a glass jar

The “matchbox sign” describes the tendency of a particular sort of patient to bring spurious evidence in a small container to show the doctor.

Erica was hugely frustrated. “I’ve had the council round several times, they’ve fumigated the whole place twice, and still I’m getting bitten.” I peered at her lower legs. There were scattered red lumps and lots of scratch marks. The pest control officer, having exhausted his insecticidal repertoire, had sent Erica along to me.

The commonest reason for someone being eaten alive in their own home is the death of a cat. Fleas live in carpets, hopping on to the resident pet when in need of food. As long as Tiddles remains hale and hearty, human beings are bitten only sporadically. But a few weeks after a feline departure, the now-starving fleas start to feast on the grieving owner. Erica, however, denied any previous pet ownership. And flea bites are typically clustered around the ankles and lower shins, whereas Erica said she was affected all over.

I scrutinised the skin of her wrist and the web spaces between her fingers. Infestation with scabies is surprisingly common, and those areas are favourite locations for the mites. There was nothing to see, though. And while most of her torso was scratched and bump-strewn, her mid-back was blemish-free. This pattern suggests something called prurigo. Incessant scratching of normal skin results in raised red prurigo lumps, which can easily be mistaken for insect bites. The area between the shoulder blades remains unaffected, though, because it is impossible to scratch there concertedly.

Numerous conditions can cause generalised itching, from iron deficiency to an underactive thyroid. I took blood samples and gave Erica a prescription for a bottle of Eurax – a fantastic lotion that will suppress itching, whatever the cause. A week later the blood tests were back, and normal. Erica was back, too. And this time she’d brought specimens of the offending insects to show me. “There!” she announced, handing me a little glass jar. Inside were a couple of wisps of dark fluff and some indeterminate bits of debris. Not even tapping the contents on to my palm for a sift-through could produce any evidence of life forms.

Something about the little glass jar rang a bell. The “matchbox sign” describes the tendency of a particular sort of patient to bring spurious evidence in a small container to show the doctor. I looked at Erica afresh: in her late fifties, a trifle eccentric, but absolutely no history or indication of any mental or physical illness. I wondered if she might have Ekbom syndrome, or delusional parasitosis.

Delusional parasitosis is a belief that one is infested with some sort of parasite. In all other respects the patient is functioning normally, and so presents a convincing account of his or her troubles to pest control personnel, doctors and veterinarians. A big problem with Ekbom’s is the characteristic refusal of the sufferer to accept that he or she is suffering from a mental illness. Antipsychotic drugs, more often used for treating schizophrenia, can be very effective, but most patients reject them out of hand.

“I’d like you to try these tablets,” I told Erica. “They’re usually used to treat schizophrenia, but bizarrely enough they’re also quite likely to reduce the itch and the rash you’re experiencing.” I smiled, hoping she wouldn’t probe my explanation. I wasn’t lying as such; just being careful which bits of the picture I painted.

She returned to the surgery a month later and, to my relief, had taken the tablets. “It’s amazing,” she told me, “it’s completely better.” She showed me a few areas of pristine skin, and then she fell silent for a few moments. When she spoke again her voice was lowered, embarrassed. “Doctor, was I psychotic?”

“Well, yes,” I told her, and explained about Ekbom syndrome. With recovery had come full insight, and she recounted, with something akin to awe, how she now looked at the specimens she’d collected and could see that they were nothing but fluff, but could clearly remember perceiving them as dead insects. And the persistent sensation of things crawling over her skin had been utterly real to her.

Ekbom’s is fascinating and rare; I doubt I’ll see another case. Pest control officers probably encounter it more often. I imagine they have a cut-off – perhaps two failed fumigations, or when the homeowner starts to present them with bits of debris in a matchbox – when they suggest that a doctor might be better placed to help with this particular infestation. 

This article first appeared in the 06 August 2014 issue of the New Statesman, Inside Gaza

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The Taliban's succession crisis will not diminish its resilience

Haibatullah Akhunzada's appointment as leader of the Taliban may put stress on the movement, but is unlikely to dampen its insurgency. 

After 19 years under the guidance of the Taliban’s supreme leader Mullah Omar, the group has now faced two succession crises in under a year. But although Haibatullah Akhunzada’s appointment as leader of the Taliban will likely put stress on the movement, it shows few signals of diminishing its renewed insurgency.

The news pretty much ends speculation about former leader Mullah Akhtar Mansour’s death in a US airstrike in Pakistan’s south-western Baluchistan province, which was criticised by Islamabad as a violation of its sovereignty.

The Taliban would have prepared extensively for this eventuality. The fast appointment, following days of intense council, appears to be a conspicuous act of decisiveness. It stands in contrast to the two-year delay the movement faced in announcing the death of the Mullah Omar. It will be not be lost on the Taliban that it was subterfuge around the death of Mullah Omar that caused the fracture within the movement which in turn led to the establishment of an ISIS presence in the country.

The appointment is a victory for the Taliban old guard. As former head of the Taliban's judiciary and Mullah Mansour’s deputy, in many ways, Haibatullah is a natural successor. Haibatullah, described by Afghanistan expert Sami Yousafzai as a “stone age Mullah,” demonstrates the Taliban’s inherent tendency to resort to tradition rather than innovation during times of internal crisis.

The decision taken by the Taliban to have an elder statesman of the group at the helm highlights the increasing marginalisation of the Haqqani network, a powerful subset within the Taliban that has been waging an offensive against the government and coalition forces in northwest Pakistan.

Sirajuddin Haqqani, the leader of the Haqqani network who already has a bounty of 5 million dollars on his head, was touted in some Taliban circles as a potential successor, however the decision to overlook him is a conservative move from the Taliban. 

The Taliban’s leadership of the jihad against the Afghan government is hinged on their claims to religious legitimacy, something the group will hope to affirm through the Haibatullah’s jurisprudential credentials. This assertion of authority has particular significance given the rise of ISIS elements in the country. The last two Taliban chiefs have both declared themselves to be amir ul-momineen or ‘leader of the faithful,’ providing a challenge to the parallel claims of ISIS’ Abu Bakr al-Baghdadi.

Any suggestions that Mansour’s death will lead to the unravelling of the Taliban are premature. The military targeting of prominent jihadi leaders within group structures has been seen in operations against the leadership of ISIS, al-Qaeda in the Arabian Peninsula, al-Qaeda in the Islamic Maghreb, and other groups.

In recent research for the Centre on Religion & Geopolitics, we found that it is often less prominent jihadis that play an integral role in keeping the movement alive. Targeted killings do create a void, but this often comes at the expense of addressing the wider support base and ideological draw of militant outfits. This is particularly relevant with a relatively decentralised movement like the Taliban.

Such operations can spur activity. If the example of the Taliban’s previous leadership succession is to be heeded, we might expect renewed attacks across Afghanistan, beyond the group’s strongholds near the eastern border with Pakistan. The brief capture of Kunduz, Afghanistan's fifth-largest city, at the end of September 2015, was a show of strength to answer the numerous internal critics of Mullah Mansour’s new leadership of the movement.

In a news cycle dominated by reports of ISIS, and to a diminishing extent al-Qaeda, atrocities, it is important to comprehend the renewed brutality of the Afghan insurgency.  Data from the Centre on Religion and Geopolitics Global Extremism Monitor found a seventeen per cent rise in fatalities from March to April, marking the start of the Taliban’s spring fighting season. A suicide attack in central Kabul on the headquarters of an elite military unit that killed 64 people was the single most deadly act of terror around the world in the month of April, and the group’s bloodiest attack in the Afghan capital for years. Reports this morning of a suicide attack on a bus killing 10 staff from an appeal court west of Kabul, suggests that the violence shows no sign of diminishing under the new leadership.

All these developments come during a period of renewed impetus behind international peace talks. Last week representatives from Pakistan were joined by delegates from Afghanistan, the United States, and China in an attempt to restart the stalled negotiation process with the Taliban.

Haibatullah Akhunzada’s early leadership moves will be watched closely by these countries, as well as dissonant voices within the movement, to ascertain what the Taliban does next, in a period of unprecedented challenge for the infamously resilient movement. 

Milo Comerford is a South and Central Asia Analyst for the Centre on Religion and Geopolitics