The Power of a Story

On a busy Friday night, I was paged for a consult for an 84-year-old with a right ovarian mass. RA was a lively, fashionable woman with a slight French accent. She had been in excellent health until she developed right lower quadrant pain one week ago. Her presentation and imaging were suspicious for a tubo-ovarian abscess, and RA was eventually admitted to the hospital. I lost touch with her, but one month later her name appeared on my clinic schedule. I perused her discharge summary and was stunned to realize that this woman who had previously been independent and healthy, had developed more medical problems during her hospitalization. The antibiotics to treat the abscess had led to acute renal failure and had ultimately not worked, requiring her to undergo drainage. She subsequently became so debilitated that after her 21 day stay in the hospital she was discharged to a rehab facility. When I saw her in clinic, she was wearing a hospital gown, and the brown hair that had been carefully coiffed at our initial meeting appeared limp. She had lost weight and required the aid of a wheelchair. An exam confirmed that the drainage site was healed and her abdomen was benign, but she was clearly deconditioned. She was disheartened by needing rehabilitation, but she pronounced that she had survived many things in her life and this was no different. Intrigued, I asked her where she was from; she was French but had immigrated to the US after World War II. I asked her why, and she slowly shared her story. Her family was Jewish, and when the Nazis invaded France, she was a little girl. One day, her mother sent her to the countryside for a trip, and when RA returned, she discovered that her entire family had been seized by the Nazis and sent to a concentration camp. Her neighbors took her in, hiding her Jewish origins at great personal risk. When the war ended, she left the country where she had only bitter memories of her family’s death and came to the US, where one of her uncles lived. His family was poor, and RA worked hard to win a scholarship to college and another one to graduate school for her PhD, and eventually became a French professor at a prestigious university. “So you see,” she told me sadly, “I have survived many things in my life.” I was moved by her strength and courage, and we sat in silence together. I had viewed her simply as a patient, never inquiring about her life, when that was possibly the most significant insight into her as a person. This is the danger of compartmentalizing work--that the patients I see will always be just that. I had let my patients’ interlude into medical care define them. RA upended that complacency, forcing me to reevaluate each patient as a person, with a unique story and vivid life. For that, I will always be grateful.

A Long Absence and Reflections on Burnout and Empathy

It is December 28, 2013.

The last time I posted anything in this blog was in July of 2009, 4.5 years ago. Where did those 4.5 years go? I could justify those years by saying: I finished my third year of medical school, discovered that I wanted to be an obstetrician/gynecologist, traveled abroad in my 4th year and confirmed my passion both for ob/gyn and for working abroad, got married, and started residency in ob/gyn...but those are just milestones. They don't explain the emotional changes I went through in those 4 years and certainly don't reflect my mental status. It just became easier to focus on milestones and goals and getting through things rather than on reflecting on my life, because sometimes those reflections were far too painful. If living life means living through each experience and gaining meaning and significance from those experiences, then it saddens me to think that I have merely been existing.

Outwardly, things appear perfect. I am happily married to my amazing husband, who puts up with my grumpiness, my love of shoes and Kate Spade bags, and tolerates me buying a 10 pound bag of sugar and 4 pounds of butter from Costco on a monthly basis because I bake so much. (I don't believe in "low-fat" baking. That is a lie that Hollywood celebrities want you to believe. Cookies need butter. Actually probably everything needs butter. Except for the best vegan muffins I made over Thanksgiving weekend.) I am a resident at my top choice residency program in ob/gyn and work at three phenomenal tertiary care hospitals. I love my co-residents (or indentured servants as one of my favorite Chief residents liked to call us and herself). I live in a great apartment in the heart of a pretty cool city and have a fearsome looking, excessively furry cat named Genghis who likes to sleep under radiators and eat flies.

Sounds TOTALLY great!
Is that for real?
Umm, no.

Reality check: I used to be a nice person. Now, I am just a raging bitch who eats my feelings and can only keep it together for my patients in the hospital. But just barely.

What happened?

As my education pulled me further and further into the sterile capsule of hospital life, I slowly let go of anything extraneous. As a third year medical student, I felt that these were temporary measures, even necessary measures, that would enable me to become a better doctor in the future, because how was I going to learn if I didn't make the hospital the center of my life? As a fourth year medical student, the hospital no longer was the center of my life, and instead, I was busy learning medical Spanish, traveling abroad, and getting married. I thought that the inordinate amount of time I spent in the hospital as a third year and the intense focus on medicine was a mere hiccup, a wrinkle in time, not the norm. Fourth year of medical school was so different from the previous year that I thought--being a doctor is great! I get to have fun and take care of my patients!

Now I realize that fourth year was actually a departure from the norm. I should have sensed that perhaps my relationship with medicine was not a healthy one. For example, for our honeymoon, I dragged my husband to Washington, D.C., where I was presenting a poster on my research at a national conference. Granted, both of us were broke and literally had no money to our name after renting our tiny apartment and couldn't go anywhere fancy for our honeymoon, but still, I left my husband for 4 hours alone on our honeymoon while I attended a medical conference. (Honestly, he was less trauamatized by that than the giant orphaned dogs who shared our breakfast space with us in our cute inn--he is not a dog person.)

To clarify: spending a LOT of time in the hospital is normal and actually necessary in order to learn how to practice medicine and to take care of patients. Patients need continuity in their providers, and to be fair, I am only working 80 hours a week, which is significantly less than my predecessors were working just 10 years ago. I am thankful that the regulations have changed, but in practical terms, does this mean anything at all?

A 2004 study titled "The Effect of the 80-hour workweek on resident burnout" published in the Archives of Surgery arrived at the following conclusion: "Despite successful reductions in resident work hours, measures of burnout were not significantly affected."

And burned out is what I feel. It is such a relief to be able to write this, so therapeutic to be able to verbalize it. I couldn't verbalize this even one year ago, but I came to the realization that this constant fatigue, this indulging in retail therapy or food therapy, the lack of reflection, everything I and my co-residents have felt--none of this is normal or healthy. And the only reason I could arrive at this conclusion was because as a third year in my program, I was able to take a research elective and leave the hospital for 6 weeks. Signing over my pager as "not available" with no end date was incredibly liberating. The 6 weeks allowed me to read, bake, cook, and travel. I felt like myself for the first time in years and even took my first spontaneous trip alone in 5 years(I ate my way through the city of Paris). For the first time in 3 years, I had enough free time that I felt bored! Boredom was a gift.

Then I returned to the hospital, and it was as though those 6 refreshing weeks had never existed. The problem is that it is not just the sheer number of hours you spend in the hospital--it's what happens there.

Bad things happen in hospitals. Even in my field, where people think we deliver bundles of joy, things can go wrong. There was a maternal death, and while it was not a patient I knew, the sadness among all of us was palpable for those next few days. A baby died before he could take his first breath. On the gyn wards, a patient died before she could ever go to the operating room. Another patient was discharged from the hospital to home hospice, and told us that all she really wanted was a fun funeral. I gave the diagnosis of metastatic cancer to one of my favorite patients.

These terrible events weigh on you. My first months of intern year, I was terrified of making a mistake and of my patients dying, so much so that I had nightmares and would wake up in the middle of the night frantically thinking that I had forgotten to write orders for my patients. The sadness of those cases made me cry, one time in front of my entire team when we were rounding in the morning. Yet there was no outlet--no one to ask me how I felt, no one to reassure me that my feelings were normal and ok.

Gradually, what happened is that those feelings began to shut down. It didn't do me any good to cry in front of my team--it just made me feel awkward and embarrassed. And by that point it was my second year of residency and I was spending so much time in the hospital that I never saw my husband or my friends. I became engrossed in being a resident, not by choice, but by default. My love of photography disappeared and my beautiful 1980s Canon camera sat on a dusty bookshelf. I stopped buying books and reading poetry. The only stamps/envelopes I used were to pay my rent. I stopped writing. I stopped doing yoga or exercising. In short, I became an automaton who arrived at the hospital, put in my hours, came home, ate, and slept. I was an efficient machine.

My marriage suffered. I thought I was going to get divorced. My parents complained that they never saw me and I never called home. I lost weight. Then I gained weight. I lived in scrubs, never wore real clothes, and never saw sunshine. I could deal with all of that. Worst of all was that my empathy was dying.

It was a subtle death. Every day as people asked me to do random things for which I never got thanks or acknowledgement, every day as I felt like a secretary who had spent far too many years in school than is sane or healthy, every day that I thought about residency as just a "job," chipped away at that empathy that I had so cherished. I became a doctor to take care of people. Instead, as I became more immersed in the world of medicine, I could barely take care of myself, never mind other people. Around Christmas time last year, I was working nights covering two different emergency departments for any gynecologic consults. I started to pray that I wouldn't get consults, because I just could not see any more patients. That was when I realized that I was in real danger of losing my empathy for patients, but I still couldn't change anything. The demands of being a resident were overwhelming, and I stayed afloat by not reflecting and by showing up to work, and it was one of the worst feelings to carry around with me--that if I felt too much, I would never be able to do my job.

Not all sense of self-reflection was lost, though. I did realize that I was losing the parts of myself that I cared about, but I was helpless in the onslaught that is the second year of ob/gyn residency. Now, as a third year resident, I am considered a senior, and the call schedule has improved. My life is more normal, and I am able to enjoy time with my husband and my family. I bake more often. I read more, and although I haven't started photographing yet, I have learned how to knit. Overall, I'm a happier person, and I'm kinder to my patients. However, this is something that I have thought about on my own. I have rarely talked to my co-residents about this. Our administration does not address burnout and there is no forum in which we can share our thoughts and feelings. However, there needs to be discussion and awareness about burnout. There also needs to be reflection around the bad things that happen in the hospital to our patients. Mortality and morbidity conferences are not sufficient to address poor outcomes as they presents cases with surgical precision and little emotion--there needs to be reflection around feelings of the providers, the patients, and their families, all of whom are deeply affected by poor outcomes. Doctors, especially ones who are just starting to practice medicine, need to be reassured that caring about patients is an essential part of their work, and that there is no greater gift that a doctor can give to her patient than that of empathy.

A Finite Reserve

Recently, I got together with two of my good friends from medical school for brunch, and as we shared our experiences, the three of us began reflecting on a specific characteristic that we had noticed among ourselves. All of us were able to establish rapport with many of our patients, and we expressed a genuine concern for our patients and a degree of empathy and patience that was appropriate to our call of duty. However, we realized that this empathy and patience was often not replicated in our personal relationships with friends and family. One of my friends had not had time to spend with her friends because she was so busy taking care of her patients, and another responded that she had a hard time conversing with people outside of medicine because they did not understand the exigencies of her life. I remembered the times when I ran out of patience with my family because they didn’t understand my life, and how difficult it was for me at times to explain what being a medical student entailed.

I still remember a phone conversation a few weeks ago with my mother when I was left sputtering with frustration. I had complained to her how exhausted I was, and she responded by saying that it was important to get 8 hours of sleep. “Of course I know that!” I had replied. But what was obvious to me was that it was mathematically impossible to get 8 hours of sleep when I came home from the hospital at 9pm and had to be awake at 4am the next morning. Of course, she was only trying to be helpful, but the solutions that my parents come up with often aren’t applicable to my life, primarily because they don’t understand my daily schedule. Yet I no longer have the patience to explain the minutiae of my time in the hospital.
As I relayed this story to my friends, the three of us puzzled over why it was so much easier to show kindness and to care for complete strangers who had little connection in our personal lives when it was so difficult to show the same level of generosity for those people who were most important in our lives.

In some ways, it’s easy to have a general love of humanity. The abstract ideas of kindness, generosity, and empathy sound quite agreeable on paper, and everyone would agree that they are all necessary in our interactions with others. Yet their practice is often difficult, and for my friends and me the difficulties were associated not with practicing those characteristics with our patients but with our families and friends. Our patients needed our help, and an element of a power dynamic existed in these relationships: we could afford to be generous because as physicians in training, we possessed a set of skills that our patients did not have but relied upon for the improvement of their health. This reality enabled us to show the best aspects of our characters, and furthermore, our patients’ gratitude and their responses to our kindness acted as positive reinforcement for us to give them even more of ourselves. Our relationships with our patients were established in only one context—that of the hospital—and we only had one role for them—the caretakers. It became easy to fulfill that role because we knew exactly what was expected of us and how to accomplish those expectations.

However, relationships with families and friends transverse the simplistic dynamics that can exist between doctors and patients. When I interact with my family or my friends, I do not have one coherent, clearly defined role. Rather, my relationship with them is fluid and dependent on their definition of my importance in their lives. Moreover, I am not interacting with them in a sterile environment (both literally and figuratively!)—they are real people, with real flaws that often approximate my own and impact our relationship. I also know that they have to love me unconditionally, and therefore, somewhat illogically, I am more willing to let my guard down, be more vulnerable, and show them the side of me that is grumpy after a long day at work, or sad because I didn’t do as good of a job as I expected on a case that I worked on, or angry because a surgeon was short-tempered with me. I don’t reign my flaws in—I allow them to see all aspects of me without wondering if they will allow me to take of them when they see the worst parts of me, as I do with my patients.

I am still struggling with how exactly to deal with this phenomenon; it’s almost as though I have a finite reserve of goodness that can get stretched thin. It’s obvious that a balance needs to be struck and can be achieved, and I hope that as I recover from the oft-brutal world of medical school, I will reestablish those relationships on a basis of kindness as well.

Writing Again

I cannot gauge whether anyone ever read the bimonthly columns I used to write for the Pakistan Post, or whether people just used them for wrapping fragile items that would then be stored in the remote reaches of cabinets (as my parents used to do with the paper before I started writing for it!), so I don’t know if anyone noticed my prolonged silence. Suffice it to say that I felt the burdens of being a second year in medical school, working for a student-run human rights organization, and being an adviser at my undergraduate alma mater were so overwhelming that I felt that I could not squeeze writing into my busy schedule. Now, months later, I am sitting at my desk, unable to read the chapter about trauma and surgical approaches to it because of my unbearable sensation of ennui. I fidgeted in my chair, played with Genghis Khan, my cat, and ate chocolate from Godiva’s before I realized what the problem was: for so many months, I had been reading other people’s writing, without having contributed anything remotely interesting or intellectual in the form of the written word.

Back in October, when I wrote my last column, I felt as though I didn’t have any interesting things to write about anymore, primarily because I was kept so busy that I had no time to think. The demands of medical school were making themselves fully felt, and the pressure to learn everything about medicine faster than humanly possible was building up. For so much of this past year, I felt like an inadequate student because of the sheer amount of information I needed to learn. I struggled both to maintain my sanity and my sense of balance in life, and also to learn the basic scientific material that would become my foundation as a physician. The resolve to maintain my sanity became stronger as I saw my classmates spending 24 hours a day in our medical education building (people actually began to sleep on the couches in the atrium instead of going home so that they could maximize on study time), or ignoring friends’ phone calls in order to cram. It was a whirlwind of a year, but luckily I survived without ever having to resort to sleeping on the couches in public…(except for that one time during Ramadan when I curled up on the couch, so hungry and sleep-deprived that I no longer cared if my professor saw my drooling onto the neuroscience textbook I was using as a pillow). That unfortunate episode aside, I felt a sense of relief as second year concluded without any mental breakdowns .

My initiation into my clerkship years as a third year medical student began this past May. Since then, it has been quite busy, especially because my first rotation is surgery, and so I spend an average of 15 hours a day in the hospital. Over this past month, I’ve seen and experienced things that I could never have imagined, and I’ve done things that probably only Jack the Ripper had done (such as the time when I had to hold a patient’s intestines against one side of his body while the surgeon operated on the opposite side, or when I removed someone’s rib with an instrument that resembled a large nutcracker, or when I used the sharpest surgical scalpel to cut through an infected toe). My intimate connections with the human body have left me puzzled as to how to respond, and I realize that part of this confusion lies in the fact that I have no outlet for my thoughts. The way I deal with all experiences in my life is to talk things through, or write things down, and I realized that I missed expressing the creative aspect of my nature.

So here I am—with a renewed enthusiasm for creativity and the magic of words, a sense of inspiration, and the desire to share those experiences that have left me alienated from the majority of mankind (unless of course you happen to be either a serial killer or a physician). What you desire to do with the written word is up to you, reader. I promise I won’t be offended if you continue to use this column to wrap your fine china for winter storage—I swear my mother still continues to use the paper for that purpose, despite the fact that this may be the only place where her daughter’s name appears in print. Recycle and reuse, she would defend herself if I were ever to confront her, so I grant you the same license.

Eid, a Celebration of the End of Ramadan

Eid in my house is always the same every year, but instead of being a monotonous affair, it’s become a much anticipated tradition. My father and brother attend the earliest Eid prayers, and my mother drags me out of bed because I refuse to be alert at the hideously early hour of 6am. I always take my time getting dressed in my newest pair of shalwar kameez while my mother puts the finishing touches on the halwa that she prepared the night before in anticipation of the holiday.

After prayers, my entire extended family gathers at my house and indulges in a delectable, traditional Pakistani breakfast of puris, halwa, aloo, chole, and sheer khorma. The kitchen floor is covered with plastic bags displaying raw puris that need to be deep fried, and my aunts prepare the rest of the breakfast with my mother while my cousins run around the house or play video games and my uncles watch Geo TV. Later, my cousins and I scheme about the best methods of extorting Eidi from our uncles, some of whom make it notoriously difficult. I always end up being the emissary for the rest of the group, because I am one of the few older cousins who is not ashamed to pander for money. It’s a loud, robust holiday for us, with its distinct rituals, flavors, and foods.

However, I believe that the last Eid I celebrated with my family was probably six years ago, in my freshman year of college when Eid coincided with Thanksgiving break. That was also a confusing one for me, as I was attending college in Boston, where the Muslim community had started its fast one day before my parents did, but I celebrated Eid with my family in New Jersey, where the community fasted for one day less than I had. This split was by no means atypical, and at times, the divide over Ramadan has had a clearly demarcated cultural and ethnic face, as the Arab Muslims followed Saudia Arabia’s declaration of the first day of Ramadan while the Pakistani Muslims followed Pakistan’s declaration. I had never been cognizant of these disputes because they had never really affected me, since when I lived at home, I just followed whatever my parents decided to do, and most of the Muslims in my community—many of whom were South Asian—tended to celebrate on the same day. Yet when I went to college, and the imam declared the beginning of Ramadan, I called home and wished my parents Ramadan Mubarak. Their confused reaction –“You’re one day early!” my mother told me—shocked me with the realization that now I was in a state of discordance with my parents. It was strange to be fasting when my parents, who had always been my guides in spirituality and religion, were not fasting, and I resented the semantic divides that cleaved the beginning of the holy month for my parents and me. The questions of moon sighting versus calculations, or whether we should follow Saudia Arabia considering that we would have to follow their calendar for Hajj, were not uniquely interesting to me, and at first, I wanted to follow the calendar to which my parents were adhering. Although I had to follow the local community, I felt a certain degree of sadness about this deviation from the norm.

Since then I have been fortunate enough that even though Ramadan has begun on multiple days—one year there were three “first” days of Ramadan from within different communities—and the controversy over the inception of the month has continued, my parents and I have miraculously followed the same calendar, even though I continue to live in Boston. Yet other issues have separated me from my family’s celebration of this month. Participating in family celebrations has become harder and harder as I become busier with school work, and now in medical school, it is virtually impossible to go home for Eid and celebrate it in the tradition that my parents established decades ago. My life is a whirlwind of exams, patient visits, and classes, and I cannot find the time to take time off from school to go home for Eid. This physical distance necessarily leads to some degree of emotional distance as well, and when I call home to wish everyone Eid Mubarak, I feel isolated, as though I am intruding on a celebration that I used to be a part of but no longer am. My generation in America is one that is highly mobile and lives in a society in constant flux, but this lifestyle can feel as though our home base is only the stuff of memories. Perhaps, in some way, it is—the memories of warm puris and gleeful children’s laughter, of playful haggling with my uncles for Eidi—and therefore can be wrapped up and taken with us wherever we happen to be.

Not My Representative

The nomination of Sarah Palin as the Republican Vice Presidential candidate has deeply angered me, and not only because I am an ardent supporter of Senator Barack Obama. To be honest, I probably would not have been as angry if McCain had chosen a man who was pro-life, whose only foreign policy experience was, as she so quaintly put it, living in Alaska, and whose solution to the oil crisis was not to think of more sustainable ways to live our lives but to further exploit our natural resources and environment by drilling in Alaska. In and of themselves, these issues are significant enough that I would not vote for such a candidate, but I would not be as angry as I am now. No, the reason I am angry is the fact that the Republicans chose Sarah Palin as the first female nominee for their party.

Their choice personifies the disregard that the party has for female intellect. The Republicans have their fair share of talented, intelligent, politically savvy and experienced women, and instead of choosing a woman who exemplified those qualities, they chose Palin. They sifted through their party, thought about picking a woman, and nominated the one who was the least qualified to run the country. Instead of picking someone who might actually be McCain's equal, they chose someone who would always be considered not only his junior in terms of experience and age, but also in terms of analytical and intellectual ability. Palin is by no means stupid—the former beauty queen knows how to package herself well enough to become governor of Alaska and then the Republican VP candidate--but she is also brash and ignorant of global affairs (since when can one see Russia from Alaska?). Her time in office has been marred by hints of political scandal that force me to question her ethical system. She promotes family values but lacks moral direction when it comes to firing people she does not like. For someone who represents the first woman on the Republican ticket, she is doing a pretty terrible job.

The Republicans and Sarah Palin herself claim that she is the typical American mom and represents the average American woman. As an American woman, I refuse to be represented by someone like her, who is so uncomfortable with her femininity that she claims to wear "school-marm glasses" to make herself look less attractive. Not only is that statement insulting to men (obviously they cannot think straight around attractive women), but it's also offensive to women (of course all bespectacled women are unattractive!). Her resume and educational level are less than impressive, but that did not seem to matter at the Republican National Convention where cameras focused on Palin sitting next to Cindy McCain cradling her five month old infant. Palin's image as a good mother was emphasized much more than her image as an experienced candidate. The message was clear: that was a woman's role, not going to Yale Law School and being a senator of one of the most populous states in the country and then running for president.

The contrast between Palin and Hillary Clinton could not be starker. Clinton is a woman who has achieved significant, tangible goals. She, too, has raised a family, yet no one is calling her the prototypical American woman. She is a highly educated woman with a formidable grasp of policies and global affairs, and even though I did not agree with her stances and vehemently oppose her decision to support the Iraq war, I still respect her, which is not something I can say of Palin. Palin has nothing to recommend her as a future VP, whereas Clinton would at least have been qualified for her position as president.

Palin now has the honor of being the first female nominee on a major party's ticket, and that rankles, because she is not a woman who is uniquely qualified for anything. To think that she represents an honor that shows how far women have advanced in American politics seems to be a travesty to me.

The Insinuations of Terror

Since I returned from Mumbai three weeks ago, I have had some time to reflect on my experiences there, especially as a Pakistani. While I was there this summer I noticed that the media, although not the ordinary people I came into contact with, was distinctly unfriendly towards Pakistan. About two months ago, , Pakistani and Indian border patrols got into a skirmish which each side blamed on the other for starting. The Hindustan Times, a prominent English-language newspaper, reported that of course the Pakistanis would claim innocence and implied that Pakistan had instigated the skirmish. This skirmish was followed by the bombing of the Indian embassy in Kabul, and again, rumors spread that the ISI was behind the bombings. In fact, India's national security advisor, M. K. Narayanan, advocated that the ISI "should be destroyed". Ajai Sahni, executive director of the Institute for Conflict Management, even proposed that the Taliban was being managed by the ISI as a tool of foreign policy. Apparently, he had conveniently forgotten the suicide bombings and violence that Taliban-trained fighters have wreaked on Pakistan.

The cycle of pointing fingers at Pakistan without substantive evidence continued with the bombings in Bangalore and Ahmedabad on July 25th and 26th. Almost immediately, the media accused Pakistan, or more specifically, the ISI, of having a hand in the bombings. Although a shadowy organization named the Indian Muhajideen claimed responsibility for the bombings via an email sent to the media, rumors arose of this organization being nothing more than a front for the ISI. In fact, just two hours after the last bomb exploded in Ahmedabad, a newscaster announced that Pakistan probably had a hand in the bombings.

The days following the attacks were tense. The multiple bombings in Bangalore and Ahmedabad had put the country on high alert, and the media kept showing sensationalistic images of streets running with blood after a bomb exploded outside of a hospital in Ahmedabad. Escalating violence between Pakistan and India only provided further circumstantial proof that Pakistan was involved in the recent terrorist attacks. On July 28th, at the Line of Control in Kashmir, Pakistani soldiers opened fire on Indian soldiers, killing one. In retaliation, Indian soldiers returned fire and killed four Pakistani soldiers.

The violence in India has been terrible, but I find the claims against Pakistan to be slightly absurd at times. Pakistan certainly is partly at fault for the situation in Kashmir, but of course the Indian troops also share the responsibility of the violence. The bombings in Bangalore and Ahmedabad to me definitely seem homegrown, but it seems that because the Indian government cannot find other culprits, it picks the target that has historically had many altercations and bloody disagreements with India: Pakistan. Pakistan has become a convenient scapegoat for the Indian government; instead of working to apprehend domestic terrorists, it blames Pakistan for infiltrating the country and seeding terror throughout India.

Yet the situation in Afghanistan certainly makes matters murkier by implicating the ISI; in fact, the Afghan government blamed the ISI for the bombing. Although the C.I.A. has not supported the Afghan government’s assertions that Pakistan had a hand in the bombing of the Indian embassy, the agency has complicated matters by presenting evidence to Pakistan suggesting that members of the ISI have cultivated ties with militant groups operating in Afghanistan. The nature of these relationships remains obscure, as does the exact involvement of the ISI in the escalating violence in Afghanistan. Yet the implications are tangible. As the US questions the ISI’s policies and its loyalties, this provides further room for conjecture on the part of the Indian press that perhaps Pakistan really has been behind all the terrorist attacks on India. It also makes it easier to believe that if the ISI has connections to the militants in Afghanistan, then it may also have connections to a group such as the Indian Muhajideen.

Where does the truth lie? The secretive ISI certainly commands a good portion of it. The recent C.I.A. evidence makes it obvious that the ISI has not been forthright about the extent of its dealings in Afghanistan, and the Pakistani government should increase the accountability of the ISI. Yet this does not mean that the next logical leap would be to blame the ISI for the attacks in India.

The relationship between India and Pakistan has a long way to go before the two countries are completely reconciled to each other. These past two months have been especially tense ones for the two countries, with multiple incidents of violence disrupting the ceasefire in Kashmir and the hesitant peace between the two countries, and do not bode well for the future. America’s most prominent South Asian allies have to work at becoming allies with each other as well.