Second Illness Infects Meningitis Sufferers

Just when they might have thought they were in the clear, people recovering from meningitis in an outbreak caused by a contaminated steroid drug have been struck by a second illness.

The new problem, called an epidural abscess, is an infection near the spine at the site where the drug — contaminated by a fungus — was injected to treat back or neck pain. The abscesses are a localized infection, different from meningitis, which affects the membranes covering the brain and spinal cord. But in some cases, an untreated abscess can cause meningitis. The abscesses have formed even while patients were taking powerful antifungal medicines, putting them back in the hospital for more treatment, often with surgery.

The problem has just begun to emerge, so far mostly in Michigan, which has had more people sickened by the drug — 112 out of 404 nationwide — than any other state.

“We’re hearing about it in Michigan and other locations as well,” said Dr. Tom M. Chiller, the deputy chief of the mycotic diseases branch of the Centers for Disease Control and Prevention. “We don’t have a good handle on how many people are coming back.”

He added, “We are just learning about this and trying to assess how best to manage these patients. They’re very complicated.”

In the last few days, about a third of the 53 patients treated for meningitis at St. Joseph Mercy Hospital in Ann Arbor, Mich., have returned with abscesses, said Dr. Lakshmi K. Halasyamani, the chief medical officer.

“This is a significant shift in the presentation of this fungal infection, and quite concerning,” she said. “An epidural abscess is very serious. It’s not something we expected.”

She and other experts said they were especially puzzled that the infections could occur even though patients were taking drugs that, at least in tests, appeared to work against the fungus causing the infection, a type of black mold called Exserohilum.

The main symptom is severe pain near the injection site. But the abscesses are internal, with no visible signs on the skin, so it takes an M.R.I. scan to make the diagnosis. Some patients have more than one abscess. In some cases, the infection can be drained or cleaned out by a neurosurgeon.

But sometimes fungal strands and abnormal tissue are wrapped around nerves and cannot be surgically removed, said Dr. Carol A. Kauffman, an expert on fungal diseases at the University of Michigan. In such cases, all doctors can do is give a combination of antifungal drugs and hope for the best. They have very little experience with this type of infection.

Some patients have had epidural abscesses without meningitis; St. Joseph Mercy Hospital has had 34 such cases.

A spokesman for the health department in Tennessee, which has had 78 meningitis cases, said that a few cases of epidural abscess had also occurred there, and that the state was trying to assess the extent of the problem.

Dr. Chiller said doctors were also reporting that some patients exposed to the tainted drug had arachnoiditis, a nerve inflammation near the spine that can cause intense pain, bladder problems and numbness.

“Unfortunately, we know from the rare cases of fungal meningitis that occur, that you can have complicated courses for this disease, and it requires prolonged therapy and can have some devastating consequences,” he said.

The meningitis outbreak, first recognized in late September, is one of the worst public health disasters ever caused by a contaminated drug. So far, 29 people have died, often from strokes caused by the infection. The case count is continuing to rise. The drug was a steroid, methylprednisolone acetate, made by the New England Compounding Center in Framingham, Mass. Three contaminated lots of the drug, more than 17,000 vials, were shipped around the country, and about 14,000 people were injected with the drug, mostly for neck and back pain. But some received injections for arthritic joints and have developed joint infections.

Inspections of the compounding center have revealed extensive contamination. It has been shut down, as has another Massachusetts company, Ameridose, with some of the same owners. Both companies have had their products recalled.

Compounding pharmacies, which mix their own drugs, have had little regulation from either states or the federal government, and several others have been shut down recently after inspections found sanitation problems.

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Second Illness Infects Meningitis Sufferers

Just when they might have thought they were in the clear, people recovering from meningitis in an outbreak caused by a contaminated steroid drug have been struck by a second illness.

The new problem, called an epidural abscess, is an infection near the spine at the site where the drug — contaminated by a fungus — was injected to treat back or neck pain. The abscesses are a localized infection, different from meningitis, which affects the membranes covering the brain and spinal cord. But in some cases, an untreated abscess can cause meningitis. The abscesses have formed even while patients were taking powerful antifungal medicines, putting them back in the hospital for more treatment, often with surgery.

The problem has just begun to emerge, so far mostly in Michigan, which has had more people sickened by the drug — 112 out of 404 nationwide — than any other state.

“We’re hearing about it in Michigan and other locations as well,” said Dr. Tom M. Chiller, the deputy chief of the mycotic diseases branch of the Centers for Disease Control and Prevention. “We don’t have a good handle on how many people are coming back.”

He added, “We are just learning about this and trying to assess how best to manage these patients. They’re very complicated.”

In the last few days, about a third of the 53 patients treated for meningitis at St. Joseph Mercy Hospital in Ann Arbor, Mich., have returned with abscesses, said Dr. Lakshmi K. Halasyamani, the chief medical officer.

“This is a significant shift in the presentation of this fungal infection, and quite concerning,” she said. “An epidural abscess is very serious. It’s not something we expected.”

She and other experts said they were especially puzzled that the infections could occur even though patients were taking drugs that, at least in tests, appeared to work against the fungus causing the infection, a type of black mold called Exserohilum.

The main symptom is severe pain near the injection site. But the abscesses are internal, with no visible signs on the skin, so it takes an M.R.I. scan to make the diagnosis. Some patients have more than one abscess. In some cases, the infection can be drained or cleaned out by a neurosurgeon.

But sometimes fungal strands and abnormal tissue are wrapped around nerves and cannot be surgically removed, said Dr. Carol A. Kauffman, an expert on fungal diseases at the University of Michigan. In such cases, all doctors can do is give a combination of antifungal drugs and hope for the best. They have very little experience with this type of infection.

Some patients have had epidural abscesses without meningitis; St. Joseph Mercy Hospital has had 34 such cases.

A spokesman for the health department in Tennessee, which has had 78 meningitis cases, said that a few cases of epidural abscess had also occurred there, and that the state was trying to assess the extent of the problem.

Dr. Chiller said doctors were also reporting that some patients exposed to the tainted drug had arachnoiditis, a nerve inflammation near the spine that can cause intense pain, bladder problems and numbness.

“Unfortunately, we know from the rare cases of fungal meningitis that occur, that you can have complicated courses for this disease, and it requires prolonged therapy and can have some devastating consequences,” he said.

The meningitis outbreak, first recognized in late September, is one of the worst public health disasters ever caused by a contaminated drug. So far, 29 people have died, often from strokes caused by the infection. The case count is continuing to rise. The drug was a steroid, methylprednisolone acetate, made by the New England Compounding Center in Framingham, Mass. Three contaminated lots of the drug, more than 17,000 vials, were shipped around the country, and about 14,000 people were injected with the drug, mostly for neck and back pain. But some received injections for arthritic joints and have developed joint infections.

Inspections of the compounding center have revealed extensive contamination. It has been shut down, as has another Massachusetts company, Ameridose, with some of the same owners. Both companies have had their products recalled.

Compounding pharmacies, which mix their own drugs, have had little regulation from either states or the federal government, and several others have been shut down recently after inspections found sanitation problems.

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Cellphone Users Steaming at Hit-or-Miss Service

To wireless customers, cellphone networks might seem to be made out of thin air. But they are plenty vulnerable to catastrophic storms — and bringing service back can take an excruciatingly long time.

On Friday, four days after Hurricane Sandy, the major carriers — AT&T, Verizon Wireless, T-Mobile USA and Sprint — were still busily rebuilding their networks in the hardest-hit areas.

One-quarter of the cell towers in the storm zone were knocked out, according to the Federal Communications Commission. Many had no power, and their backup battery systems soon drained. The lines connecting those towers to the rest of the phone network were ripped out. Carriers deployed generators to provide power, but eventually those required more fuel — another limited resource.

In an emergency, a lack of cellphone reception can be dangerous, especially as more people have chosen to snip landlines out of their budgets. About 60 percent of American households have landlines, down from 78 percent four years ago, according to Chetan Sharma, an independent mobile analyst.

The carriers say they are trying their best to deal with an unusual disaster. But in the past, they have steadfastly objected to recommendations from regulators that they spend more money on robust emergency equipment, like longer-lasting backup batteries.

Neville Ray, chief technology officer of T-Mobile USA, said Hurricane Sandy was the biggest natural disaster he had ever dealt with and that service failures were inevitable.

“There’s an amount of preparation you can do, but depending on the size and scale and impact of the storm, it’s tough to anticipate every circumstance,” Mr. Ray said in an interview. “No degree of preparation can prevent some of those outages from happening.”

When networks fail, carriers deploy trucks, called C.O.W.’s, for cell on wheels, that act as temporary cell towers. But the companies say the challenge with deploying these trucks poststorm is connecting to power and to the wider phone network, which requires a microwave radio link to a working tower. Because of the density of the buildings in New York City, the trucks could serve only a small area, according to Mr. Ray.

The carriers have made other efforts to provide services while restoring their networks. AT&T wheeled out R.V.’s where customers could charge their phones. And it made an agreement to share networks with T-Mobile USA in the affected areas of New York and New Jersey. When customers of both companies place calls, they are carried by whichever network is available in the area.

But ultimately all of the carriers’ preparations and responses were not enough to get services running again in a hurry. Over the week the carriers reported gradual progress, and they declined to offer timelines indicating when customers could expect to have service again.

The unreliability of wireless networks may point to a bigger problem. Over the years, the phone companies have fought off regulators who want to treat them as utilities, arguing that if they are going to stay innovative, they cannot be burdened with the old rules that phone companies dealt with in the landline era. But as a consequence, there are almost no rules about what carriers have to do in an emergency, said Harold Feld, senior vice president for Public Knowledge, a nonprofit that focuses on information policy.

“With the new networks we’ve prized keeping costs down, we’ve prized flexibility and we’ve prized innovation,” said Mr. Feld, who wrote a blog post on Monday anticipating cell tower problems. “But we have not put stability as a value when we have been pushing to have these networks built out.”

Mr. Feld noted that after Hurricane Katrina in 2005, the F.C.C. recommended that carriers install backup batteries on their transmission towers that would last 24 hours, among other measures. But the carriers objected, presumably because they did not want to spend the money, he said. (Of course, 24 hours would not have been enough in many areas hit by the latest storm.)

In general, the carriers say it is in their own interest to fortify their networks for emergency situations, but Mr. Feld said this incentive was not enough.

“We ought to actually be doing this in the mind-set that there need to be actual rules, so that everybody knows how to behave when the crisis hits,” he said. “When I drive I have the best incentive in the world not to hit a telephone pole and not to slam into another car. But I still need speed limits, stop signs and stop lights.”

Debra Lewis, a spokeswoman for Verizon Wireless, said no amount of rules could have prepared carriers for the outcome of a storm like Hurricane Sandy.

“The fact is, regulation cannot anticipate the varied challenges that can arise in such situations, but we do learn from them and adapt accordingly to ensure we meet consumers’ needs,” Ms. Lewis said. She said the company prepared for natural disasters with generators and batteries that provided at least eight hours of power to cell sites.

Verizon Wireless said Friday evening that less than 3 percent of its network in the Northeast was still down. “In severely impacted areas, such as Lower Manhattan, while wireless service has yet to return to normal levels, coverage is good,” it said.

AT&T was the only major carrier that would not go into specifics about how much of its network was down. Anecdotally it seemed that in Manhattan at least, AT&T’s coverage was not as good as Verizon’s after the storm. One Twitter user directed this message at AT&T on Tuesday: “I live in lower manhattan. Vz has service u do not. You are ruining lives. I had to come midtown 2 call mom. Switching.”

Mark Siegel, a spokesman for AT&T, said the company would not comment because it was working on restoring its network.

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Petraeus’s Lower C.I.A. Profile Leaves Benghazi Void

WASHINGTON — In 14 months as C.I.A. director, David H. Petraeus has shunned the spotlight he once courted as America’s most famous general. His low-profile style has won the loyalty of the White House, easing old tensions with President Obama, and he has overcome some of the skepticism he faced from the agency’s work force, which is always wary of the military brass.

Brendan Smialowski/Getty Images

The low-profile style of David H. Petraeus, right, has won the loyalty of the White House, easing old tensions with President Obama.

Win Mcnamee/Getty Images

C.I.A. director, David H. Petraeus, right, appeared before the Senate Select Committee on Intelligence in Washington in January.

But since an attack killed four Americans seven weeks ago in Benghazi, Libya, his deliberately low profile, and the C.I.A.’s penchant for secrecy, have left a void that has been filled by a news media and Congressional furor over whether it could have been prevented. Rather than acknowledge the C.I.A.’s presence in Benghazi, Mr. Petraeus and other agency officials fought a losing battle to keep it secret, even as the events there became a point of contention in the presidential campaign.

Finally, on Thursday, with Mr. Petraeus away on a visit to the Middle East, pressure from critics prompted intelligence officials to give their own account of the chaotic night when two security officers died along with the American ambassador, J. Christopher Stevens, and another diplomat. The officials acknowledged for the first time that the security officers, both former members of the Navy SEALs, worked on contract for the C.I.A., which occupied one of the buildings that were attacked.

The Benghazi crisis is the biggest challenge so far in the first civilian job held by Mr. Petraeus, who retired from the Army and dropped the “General” when he went to the C.I.A. He gets mostly high marks from government colleagues and outside experts for his overall performance. But the transition has meant learning a markedly different culture, at an agency famously resistant to outsiders.

“I think he’s a brilliant man, but he’s also a four-star general,” said Senator Dianne Feinstein, the chairwoman of the Senate Intelligence Committee. “Four-stars are saluted, not questioned. He’s now running an agency where everything is questioned, whether you’re a four-star or a senator. It’s a culture change.”

Mr. Petraeus, who turns 60 next week, has had to learn that C.I.A. officers will not automatically defer to his judgments, as military subordinates often did. “The attitude at the agency is, ‘You may be the director, but I’m the Thailand analyst,’ ” said one C.I.A. veteran.

Long a media star as the most prominent military leader of his generation, Mr. Petraeus abruptly abandoned that style at the C.I.A. Operating amid widespread complaints about leaks of classified information, he has stopped giving interviews, speaks to Congress in closed sessions and travels the globe to consult with foreign spy services with little news media notice.

“He thinks he has to be very discreet and let others in the government do the talking,” said Michael E. O’Hanlon, a Brookings Institution scholar who is a friend of Mr. Petraeus’s and a member of the C.I.A.’s advisory board.

Mr. Petraeus’s no-news, no-nonsense style stands out especially starkly against that of his effusive predecessor, Leon E. Panetta, who is now the defense secretary.

Mr. Panetta, a gregarious politician by profession, was unusually open with Congress and sometimes with the public — to a fault, some might say, when he spoke candidly after leaving the C.I.A. about a Pakistani doctor’s role in helping hunt for Osama bin Laden, or about the agency’s drone operations.

Mr. Petraeus’s discretion and relentless work ethic have had a positive side for him: old tensions with Mr. Obama, which grew out of differing views on the wars in Iraq and Afghanistan, appear to be gone. Mr. Petraeus is at the White House several times a week, attending National Security Council sessions and meeting weekly with James R. Clapper Jr., the director of national intelligence, and Thomas E. Donilon, Mr. Obama’s national security adviser. Mr. Donilon said recently that the C.I.A. director “has done an exceptional job,” bringing “deep experience, intellectual rigor and enthusiasm” to his work.

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At Bellevue, a Desperate Fight to Ensure the Patients’ Safety

Uli Seit for The New York Times

Ralston Davis had a triple heart bypass operation at Bellevue, but when the hospital lost power, he walked down 10 flights of stairs and was moved to another medical center.

From the moment the water lapped above street level in Lower Manhattan, the doctors and nurses of Bellevue Hospital Center began a desperate struggle to keep patients safe. By 9 p.m. Monday, the hospital was on backup power, and an hour later, the basement was flooded.

Officials rushed to move the most critically ill patients closer to an emergency generator. After midnight, doctors heard shouts in the hallway. The basement fuel pumps had stopped working, and medical residents, nurses and administrators formed a bucket brigade to ferry fuel up 13 flights to the main backup generators.

By Tuesday, the elevator shafts at Bellevue, the country’s oldest public hospital, had flooded, so all 32 elevators stopped working. There was limited compressed air to run ventilators, so oxygen tanks were placed next to the beds of patients who needed them. Water faucets went dry, food ran low, and buckets of water had to be carried up to flush toilets.

Some doctors began urging evacuations, and on Tuesday, at least two dozen ambulances lined up around the block to pick up many of the 725 patients housed there. People carried babies down flights of stairs. The National Guard was called in to help. On Thursday afternoon, the last two patients were waiting to be taken out.

The evacuation went quickly only because Bellevue had planned for such a possibility before Hurricane Irene hit last year, several doctors said. But the city, which had evacuated two nearby hospitals before that storm, decided not to clear out Bellevue. In the wake of Hurricane Sandy, the consequences of bad calls, bad luck and equipment failures cascaded through the region’s health care system, as sleep-deprived health care workers and patients were confronted by a new kind of disarray.

A patient recovering from a triple bypass operation at Bellevue walked down 10 flights of stairs to a waiting ambulance, one of the dozens provided through the Federal Emergency Management Agency to speed patients across the metropolitan region.

Mount Sinai Medical Center, already dealing with the 2 a.m. arrival of a dozen psychiatric patients who spoke only Chinese, was struggling to identify the relatives of brain-injured traffic victims from Bellevue who arrived three hours later with only rudimentary medical records.

Maimonides Medical Center in Brooklyn was straining to meet a rising need for emergency dialysis for hundreds of people shut out of storm-crippled private dialysis centers. Patients who would normally get three hours of dialysis were getting only two, to ensure the maximum number of people received at least a minimal amount of care.

“The catastrophe is growing by the minute,” said Eileen Tynion, a Maimonides spokeswoman. “Here we thought we’d reached a quiet point after the storm.”

Every hospital maintains an elaborate disaster plan, but after Hurricane Sandy, the fact that many health care facilities are in low-lying areas proved to be something of an Achilles’ heel. Bellevue became the third hospital in the city to evacuate after the storm’s landfall, after NYU Langone Medical Center, just north of Bellevue, and Coney Island Hospital, another public hospital.

New York Downtown Hospital, the only hospital south of 14th Street in Manhattan, and the Veterans Affairs Hospital, just below Bellevue, had evacuated before the storm.

Hospital executives were reluctant to criticize their colleagues or city officials. But the sequence of events left them with many questions.

“All hospitals are required to do disaster planning and disaster drills,” Pamela Brier, the chief executive of Maimonides, noted. “All hospitals are required as a condition of being accredited, to have generators, backup generators.”

City health department and emergency officials have been particularly fervent about citywide disaster drills, she added, but “as prepared as we think we are we’ve never had a mock disaster drill where we carried patients downstairs. I’m shocked that we didn’t do that. Now we’re going to.”

The city’s health commissioner, Dr. Thomas Farley, defended the decision not to require evacuations of Bellevue, Coney Island and NYU Langone hospitals before the storm, which he said had been made in consultation with the state health commissioner, Dr. Nirav Shah.

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India Ink: A Conversation With: Lt. Gen.Baljit Singh Jaswal, Former Commander of Kashmir

After two decades of militancy, the Kashmir Valley has been relatively calm during the past two years. Tourists from India and around the world flooded into the scenic valley last summer, and the chief minister of Jammu and Kashmir, Omar Abdullah, has called for troop reductions and a repeal of the Armed Forces Special Powers Act.

But military officials say the peace remains fragile and that the infiltration of militants from Pakistan continues, albeit in smaller numbers. The army has said that Kashmir isn’t ready for any drastic dilution of security.

India Ink recently discussed the situation in Kashmir with Lt. Gen.Baljit Singh Jaswal, who from October 2009 to December 2010 led the Northern Command, which currently controls more than 300,000 troops in the state.  General Jaswal was in charge the last time violent protests swept the valley, in 2010.

 Decorated five times, General Jaswal has a family history of military service. His father was a British-commissioned officer who fought in North Africa and Burma during World War II. His brother was killed in the 1965 war with Pakistan. His son is currently serving in the Indian Army.

The retired general spent most of his career conducting counterinsurgency operations in Kashmir and the northeast. During a long conversation at the Assam Rifles Mess in Delhi Cantonment on Thursday, he discussed the challenges of guarding the Line of Control, the lingering threat from Pakistan, the Armed Forces Special Powers Act and the life of a soldier in Kashmir.

How much infiltration of militants from Pakistan is happening now?

Infiltration has come down a hell of a lot. This year, it has come down to just about 50-odd people. Earlier, it used to be 700 to 800 people. In 2010, there were 110.

But you see, it’s extremely, extremely difficult to stop. You have to be on ground to see how difficult it is.  To say that you can hermetically seal the borders – sorry, you can’t. People sitting in Delhi say, “Why can’t the army stop this?” You go and sit there, night after night, and see the psyche of a soldier. I mean, he is doing his best. But the strain is there. There is so much pressure on him. He will not like even the wind to go past him. It is very, very difficult.

We have now improved the fences, but you see what happens in the Gulmarg sector. There is 30 feet of snow. The fence gets covered. How do you then protect?

So the first thing we do is aerial rekkies [reconnaissance], or we see from the post if there are any footprints. We know that if someone has crossed at night, the travel time would have been this much, so we carry out an assessment that he will be in an area. So we cordon off that area and take appropriate action. It’s very difficult.

If you want to feel the heat, be in it. Then you will realize.

What threat do these militants still pose in Kashmir?

Even if there are five terrorists, well, they can do something — kill the chief minister, kill a cabinet minister. That itself is hell of a lot.

They have the potential. There are about 450 to 500 terrorists in the whole of Jammu and Kashmir, and a group of five, they can do anything.  A fedayeen [militant] attack can take place anywhere. It could be a fedayeen attack on the Jammu and Kashmir assembly.

What is your assessment of the recent murders of the sarpanches, or village heads, in Kashmir?

The assembly elections were held in 2007 and about 56 percent of voters turned out. In the 2008 general elections, 66 percent turned out. And now the Jammu and Kashmir government has decided to empower the panchayats [village councils] so that people have more power. In 2011 elections, 73 percent of people voted.

Now this does not auger well to Pakistan. For Pakistan, if governance is coming back again, well, their whole aim has been defeated. The sarpanches who were trying to once again to  revamp the state and make it surge forward, the best way to stop this is to go and kill them or threaten them so that the Panchayati Raj endeavor of the state is totally decimated. That’s why the killings took place.

There are about 30,000 sarpanches in the whole of Jammu and Kashmir. You can’t provide security to everyone. So the answer is that we should have village defense committees, which have been formed in a number of villages, and arm them.

There are ex-servicemen all over in Jammu and Kashmir. Otherwise, there are villagers –  train them. They will provide protection to the sarpanches.

When you say Pakistan — do you mean the government or the Inter Services Intelligence, the I.S.I.?

If I’m a general and something goes wrong in the Northern Command, I’m responsible. Similarly, if something is wrong in Pakistan, the government is to be blamed.

Its tools are the I.S.I. Whether they are all-pervasive over the Pakistan government or otherwise – they call the shots, we all know it. But the ultimate responsibility is that of the Pakistan government.

Why are they not being able to rein in the I.S.I?  Why are they so scared of the army?  Democracies don’t get scared of the army. Why are they so scared? It’s a democratic country. You can’t have the army dictating terms to the government.

What do you see happening after the U.S. troops withdraw from Afghanistan? Will Pakistan turn its attention to Kashmir again?

The first thing for Pakistan is to be able to have a major role to play in Afghanistan and that’s the reason they are not keen for India to come in, except for commercial ventures. And that too they object.

At one point in time, people were saying that Pakistan will turn Al Qaeda and some of these people from that area towards Kashmir. There were views that Al Qaeda people were operating in Srinagar and the valley. To my knowledge, there are none.

Initially, a lot of Afghans came in to Kashmir. The majority were Pakistanis who were trained in Afghanistan and they used to call themselves Afghans. That has died down for the time being.

But should Pakistan, in the long term, be able to have a hold on Afghanistan, they’re going to ready a kitty of insurgents available to them who can come down to Kashmir and carry on the job of fifth columnist in times of war.

Chief Minister Omar Abdullah is calling for a phased withdrawal of troops from Kashmir as well as the repealing the A.F.S.P.A. [the Armed Forces Special Powers Act]. But the army says it’s too early. Is Kashmir ready for these changes?

I’m the first proponent of saying that A.F.S.P.A. should not be removed.  Firstly, why are the terrorists not being able to operate? Because we’ve been able to provide ideal troop-to-ground density and restricted their space of operations.

Why did A.F.S.P.A. come in? It was because of the intent of Pakistan. Has the intent of Pakistan changed? If it has not changed, why change the provision?

Let the military realize where the situation is slightly improving, we could thin out troops from there, but a certain amount of troops will be there. The demonstration of the troops on the roads, that can be reduced and can be taken over slowly by the police and the paramilitary forces.

If you repeal A.F.S.P.A., for it to come back…you know, it’s an act of Parliament. You know the kind of difficulty which is there to pass in Parliament.

I have a lot of respect for Mr. Omar. He is a personal friend and we have a lot of professional respect for each other. I mean in his wisdom he has to make political statements, but I do hope he sees the ramifications.

The state government has made its position quite clear about the removal of A.F.S.P.A. and reduction in troops. Are the central government and the army divided on this?

No way. The Ministry of Defense is totally with us.

I remember a discussion with Mr. Chidambaram [the former home minister]. I said that if you  remove troops from here, you are creating voids. It will provide space for terrorists to be able to regroup once again.

And wisdom did prevail. And the Ministry of Defense just put its foot down.

Can militancy be eliminated entirely?

We are confusing the situation in Jammu and Kashmir. My wisdom as an army commander is to always say the situation in J. and K. is due to the non-resolution of the Kashmir issue. If the Kashmir issue is resolved at the diplomatic level and political level, insurgency will automatically come down.

Like I said, even if five terrorists are operating, well, they can create any strife anywhere. It happened in Bombay [Mumbai, in 2008].  The nation almost went to war. So the intent of Pakistan has to be decimated. And that can only be decimated when the Kashmir resolution takes place.

It has to be at the government level. We are just tools. We are controlling the situation, we are managing the situation, but to ultimately decimate the situation it has to be dealt with at the government level.

Has the number of troops in Kashmir decreased?

I wouldn’t like to give the figure because they are outside the public domain. Some troops have moved out.  It is not a continuous process.

In Srinagar, a lot of people express resentment when they see security forces posted on almost every street corner. How do you think the army has done in terms of winning the hearts and minds of the people?

We have an operation called Sadbhavna, and the Americans have copied us in Afghanistan. They are doing the same. It is empowerment of the women, providing education, integration of the population with India, providing goodwill schools.

I, in Northern Command, started a new venture providing free Service Selection Board coaching to anyone and everyone who wanted to join the army. In the first packet, 23 people got through. It’s a great achievement. In the valley some girls also wanted to come. There is a girl from Ladakh who is becoming an officer. So we are integrating them.

We have 51 goodwill schools there, providing free education. You go and ask any parents of these students, they will swear by the Indian Army.

Is it easier for a soldier to serve in Kashmir now that the situation is relatively peaceful?

No, the operations are still on. He still goes for his ambushes. He still goes for his convoys. He still guards the fence. Operationally, he actually in a week gets two nights to sleep on his bed. He still gets two nights of full sleep. And he has to go out with patrols.

You’re patrolling not just for the sake of measuring the length and breadth of the ground but you should be expecting an encounter. So the whole drill is the same.

(This interview has been lightly edited and condensed.)

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Live Coverage: Burdens of Storm’s Damage Ease Slightly

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State-by-State Guide

A look at the devastation caused in the aftermath of Hurricane Sandy from North Carolina to New England.

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