Invitation to Contract: Assam, Aadhaar, How Governments Now Work

Continuing on a series of posts on the Government of India’s early 2012 decision to keep “insecure” zones of the country like most of the Northeast (particularly its largest state, Assam) out of the Aadhaar/UID biometrics program, to be monitored instead by the more territorialized, security-focused National Population Register (NPR):

Life in the Security Zone: protesters against state evictions, June 2012, Guwahati, Assam

What Is and Is Not in the News

Assam is daily in the news, though the retraction of Aadhaar from the region receives almost no press. Given that Aadhaar has become central to the promissary return of contemporary governance, the card’s appearing to give back secure entitlements to electoral supporters of the ruling coalition (and of the rationalized “corporate-ethical” sector [more on this concept soon] granted increasing control over specific state functions), the withdrawal of this promissary return would seem to generate its own press.  This is absent. I want to understand why.

The first answer is that Aadhaar has become so identified in Assam (and for many across India in relation to Assam in particular) with the “inflitration” of the Bangladeshi migrant into the citizenship and entitlement rolls that its removal generates little remorse among the dominant regional constiuencies of elite media, the media I at this point have access to via the Internet.

But one might expect the emergence of calls for a modified form of biometric registration, one that was not “universal” but separated citizens from mere residents in the dispensation of current entitlement and future promise. At this point I am going to argue that no such calls have emerged that are focused on the “proper” citizenry of Assam or at least no such calls seem to have been able to go public. I may well retract this claim if and when I can find substantial evidence to the contrary.

Such exclusive claims for rights in promissary citizenship in Assam are likely to be of two dominant kinds: rights in law [the Assamese resident and Indian citizen against the illegal migrant] and rights in nature [the Bodo autochthon against the non-Bodo stranger, the latter currently the illegal migrant]. But calls to redraft the form of Aadhaar to shore up these rights do not seem to have intensified with the state’s loss of easy access to UID.

The Assam-focused press is diverse, otherwise. It is devoted to registers of incivility and instability, of state violence and of state welfare in the face of civil violence. It seems both to support and to trouble the anti-migrant sentiment discussed in previous postings. Much national attention on Assam and its capital Guwahati has focused on the recent beating and forced-stripping of a girl in Guwahati this past July by a large group of jeering men, the event apparently captured on video. Many of the responses to the attack on this girl that I have seen on various media are complicit with a racialization of the Assamese as “backward” and somehow categorically unstable: in effect justifying the zonal distribution of modes of biometric control at stake in the division of the country between Security/NPR and Liberalization/UID.

There has been some press as well focused on resistance to government eviction drives against poor urban and rural slumdwellers occupying illegal “hutments.” The news photo above is of a piece with that genre.

None of these events are restricted to Assam–not communal killings, not sexualized violence against women, not the state policy of slum dispossession–but they form part of a mediascape affirming the state’s exceptional status and its exclusion, to use the first pass at a language I developed in the previous post, from the power zone of economic liberalization into the security zone [these terms are not conceptually adequate for many reasons, but for now the point is to focus on a zonal form of doubled or duplicated governance].

Two Orders of Contract?

Most of the documentation available online on Aadhaar in Assam is from the first, earlier moment, before January 2012, the moment when the biometric program’s promise for this marginal state had not been given over to the Security regime of NPR.

Information and reports at least via the Internet quickly dry up after January.

Perhaps the very nature of a security based enterprise like the NPR is that it produces a much smaller penumbra and far fewer traces of itself. Or to put it differently: both security interventions (like NPR) and liberalization interventions (like UID) now depend on a contractual relation between state agencies (like the ministries of home and of finance, respectively) and corporate sector companies to implement the new identity biometrics. But how contracts are established and entered into may differ between power zones and security zones. This post is a first effort to push myself to attend to the specificities of contract in the structuring of government: the emergent history of biometrics, in which twin national database regimes are being established in parallel, suggests that there is not a single pragmatics of contract, a single logic of governance, being crafted.

Having written this, I should note that I do not yet understand how the Interior Ministry’s NPR will work. It is tied to the Census, or has been, so part of the question is the organization of labor, capital, and control of the census over the next decade. I am in part assuming that security apparatuses, no less than other state functions, have throughout the world been given over to contract with privatized capital. But I should be cautious.

A second note of caution: the January 2012 entente between NPR and UID, between Security and Finance, between the Home Ministry and the Planning Commission, involved the powerful then Home Minister Chidambaram, who has recently again been given the Finance Ministry, a position he had earlier occupied. In other words, if the late 2011 struggle over the nation cum database focused on the tussle between these two ministries and presumably their distinct forms of governance over security and economy, how do we understand the movement back and forth of this powerful official?

Chidambaram aside, the very presence of two parallel such logics of governance and two parallel programs of biometric ID may suggest a second order of contract, not the contract between the state agency proposing and the private company executing one or the other mode of biometric inclusion but rather the contract governing the relation between two two orders or modes of registering people biometrically, of financial liberalization versus security.

What Was: Traces of the Earlier Promise of Aadhaar for Assam

The text for today is an RFQ, a Request for Quotation [that is a bid for contract] put out by the Government of Assam in the earlier phase of its relation to Aadhaar. For now I cite only a few small sections.

Invitation to Contract?

GOVERNMENT OF ASSAM DEPARTMENT OF PANCHAYAT & RURAL DEVELOPMENT
TENDER NO. – DPRD/P/183/09-10/127
REQUEST FOR QUOTATION: FOR SELECTION OF UID ENROLMENT AGENCIES FOR THE UID PROJECT (PHASE I) OF GOVT. OF ASSAM
Date of Release of RFQ: 24th Dec, 2010
Date of Pre bid meeting: 10th Jan, 2011, 1430 hrs
Last date of Submission of Bid: 21st Jan, 2011 (Up to 1500 hrs)
Date of Opening of Bid: 21st Jan, 2011 (1600 hrs)
TABLE OF CONTENTS:
Vol I: Instruction to Bidders
Vol II: Scope of Work
Vol III: Standard Contracts

Initially in the first phase, the UID project will be implemented in 5 (Five) districts of Assam, i.e Jorhat, Dibrugarh, Sonitpur, Sivasagar and Tinsukia. The Panchayat and Rural Development Deptt. will be Registrar for the districts of Sonitpur, Sivasagar and Tinsukia. Food and Civil supplies Deptt. would be Registrar for the project in Jorhat and Dibrugarh. Accordingly the districts have been clubbed in 2 schedules. The Registrar will implement the project in their districts block wise. Commissioner, P& RD as convener of the sub-committee for selection of Enrolment Agencies is inviting bids for both the schedules.

Under the project all KYR demographic and biometric data as per UIDAI standard would be captured from all residents. In addition data under KYR+ standard as detailed below would also be captured along with KYR data from residents.

The KYR + fields include –
1. Bank Account (which includes Post Office Account also)
2. Job Card No. under MGNREGA
3. RSBY No.
4. BPL (ID)
5. TIN No. (Census)
6. Ration Card No. (AAY/BPL/ FIC/ APL Card)
7. Profession (Service, Self Employed, Cultivator, Labour, Student etc.)
8. Panchayat Name.
N.B.: There might be addition of 4 to 6 more KYR+ fields in the data to be captured which will be notified later. The Project is expected to enroll around 69.26 lakhs residents [6.926 million] by 31st March 2012 (as per projected figure of 2010 population).

2.2 About UID Project
The Government of India (GoI) has embarked upon an ambitious initiative to provide a Unique Identification (UID) to every resident of India and has constituted the Unique Identification Authority of India (UIDAI) for this purpose. The timing of this initiative coincides with the increased focus of the GoI on social inclusion and development through massive investments in various social sector programs, and transformation in public services delivery through e-Governance programs. The UID has been envisioned as a means for residents to easily and effectively establish their identity, to any agency, anywhere in the country, without having to repeatedly produce identity documentation to agencies. The enrolment is voluntary, More details on the UIDAI and the strategy overview can be found on the website: http://www.uidai.gov.in

The widespread implementation of the UID project needs the reach and flexibility to enroll residents across the country. To achieve this, the UIDAI is following a multiple registrar approach and proposes to partner with a variety of agencies and service providers (acting as Registrars, Sub-registrars and Enrolling Agencies) to enroll residents for UID. By participating in enrolling residents, registrars and enrolment agencies across the country would be part of a truly historic exercise, one which can make our welfare systems far more accessible and inclusive of the poor, and also permanently transform service delivery in India.

In this context, the Registrars shall engage enrolment agencies empanelled by UIDAI for carrying out the various functions and activities related to UID enrolment such as setting up of enrolment centers, undertaking collection of demographic and biometric data for UID enrollment and any other data required by the Registrar for the effective implementation of their projects. This Request for Quotation document is intended to invite bids from only those agencies which are empanelled by UIDAI for undertaking demographic and biometric data collection for enrolment of residents.

That was the prefactory material in the RFQ. 3 quick points, bearing in mind that these suggestions about variant logics of contract are very tentative on my part and far from fleshed out as a conceptual field:

1) Throughout this blog, I have been fascinated by the diagnosis of corruption in history at the core of UID biometrics, that of duplication. The awarding of contracts is among the more important sites of corruption globally and marks many previous and still simmering Indian corruption cases. So the question of variant pragmatics or logics of contract with which I began also raises a question of the “corrupt” duplication of these. Putting it more baldly: when is the invitation within the form of the RFQ in bad faith? How in practice are contracts awarded, entered into, monitored, and broken? If as in many cases of state contracts, the RFQ is a formality and the decision as to which company is chosen is determined by other means (so-called cronyism or what in India is usually called “the nexus,” for example), might we speak of the actual contract as a “duplicate” of the fair and formal contract promised by the RFQ?

2) This particular Assamese invitation [pre-January 2012] to contract may be in bad faith in a second way. Presumably, the aggressive rolling out of UID noted in this document was later shelved with Assam being declared proper not to UID but to NPR: companies invited to bid, and in so doing to invest in becoming registrars, were thus left without a growing market of persons considered proper to UID registration.

3) The document refers to KYR and NYR+ as two sets of information fields that UIDAI-contracted companies collect. From the last post’s documentation, we know a primary difference of UIDAI and NPR is that the latter will collect far more information. In the terms of territorialization and deterritorialization used earlier, UIDAI has more of a deterritorializing imperative.

KYR often stands for Know Your Resident. It is one of a proliferating series in corporate jargon of what we might call the KYX imperatives: Know Your ——. Know Your Customer, Know Your Client, and so forth. The form has been taken to with a vengeance by both business and government agencies in Anglophone India. On the web, one finds sites devoted to Know Your Mobile India, Know Your Visa, Know Your Assessing Officer, and many dozen others. The many ID numbers one receives in moving through the Indian bureaucratic and financial landscape can be accessed through KYX sites: thus Know Your PAN, Know Your TAN, and so forth. There are a range of sites named as Know Your India.

Know Your Resident is an important component of Aadhaar’s relation to territory and its ability to minimize the number of locational fields in service of its vision of liberalization and labor and entitlement rationalization. One apparently non-official site notes: “The strong authentication that the UIDAI will offer, combined with its KYR standards, can remove the need for such individual KYC [Know Your Customer] by banks for basic, no-frills accounts. It will thus vastly reduce the documentation the poor are required to produce for a bank account, and significantly bring down KYC costs for banks. The UIDAI will ensure that the Know Your Resident (KYR) standards don’t become a barrier for enrolling the poor, and will devise suitable procedures to ensure their inclusion without compromising the integrity of the data.”

Again, “Resident” like “Citizen” is effectively placed under erasure by UID/Aadhaar. That is, Aadhaar uses the promise of biometrics to produce a political subject that is resists nomination either as citizen or non-citizen, and yet, the opposition does not go away but hovers in much of the positive and negative discussion of the program. Aadhaar promises both to deterritorialize entitlements, severing the link of access to state programs from the natal or family village and all of the regressive entailments of native place, and to create effective territorialization for Banking, in the sense that the biometric “Resident” will somehow provide the trustworthiness enabling banks to advance credit to marginal actors. How exactly a subject is produced both not in place and in place, both as citizen and as resident, is I think a matter for engaged observation, aka “fieldwork.”

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Marrying into the “banking fold”: Aadhaar, the Euro-chip, and the articulation of variant technologies of trust

More today on the use of Aadhaar to produce “financial inclusion” on the margin. I should note at the outset that the point cannot be only to (re) produce a critique of either financial “exclusion” or “inclusion.”

Proto Indo-European technology

Such critique is obviously important but perhaps difficult to sustain too quickly. In anthropology the broader debate may be to place the powerful critique of poverty capital in relation to the production of an unexpected “neoliberal social.” Barring a change in government, a radical curtailment of UID seems unlikely. UID/Aadhaar will continue to be rolled out.  Barring radical and perceptible failure of the program and its effective politicization, certainly possible, the card and number will attach themselves to the administration of more and more entitlements and institutions. The varied effects of UID will be assessed by many agencies and auditors, including (far down the queue) this researcher. Perhaps more than the current situation, of myriad arguably inflated promises of UID’s biometric design and regulation and myriad arguably premature critiques, the emerging field of audit will be critical to engage: what will constitute an event? An effect?

In anticipation of that work, the blog can only aid in the imagination of a research program and its own forms, sites, and constellations of evidence. Blah blah blah.

Today’s text is again from The Hindu, the edition of August 4, and an article posted from Hyderabad. At stake are security technologies for mobile card-based credit, the widespread European chip technology, or EMV [familiar to North Americans who find that their apparently backward and chipless credit cards often fail them in Europe], versus the biometric guarantee of Universal ID and the Aadhaar card. The first is seen as more secure and a proven technology; the second is much more affordable and would lead to the growth of poverty capital through financial inclusion, and with it the “social” promise of presumptively widespread microcredit.The solution may somehow be to “marry” security and inclusion in the production of a new form of trust-bearing identity and thus to bring in the poor to the formal sector financial “fold” while calming concerns about the trustworthiness of the new technology, its bureaucracy, and its economically marginal beneficiaries. This marriage of techniques and forms would somehow copy the effectiveness of the Euro-chip but bypass its prohibitive cost as banking’s potential seems to lie in producing cheaper norms of inclusion.

Choice is between EMV and Aadhaar: RBI Governor

While the chip and pin is a tested technology, Aadhaar based option is cheaper, says D. Subba Rao

Reserve Bank of India Governor D. Subba Rao has underlined the need for taking a decision on the choice between migrating to EMV (Europay-MasterCard-Visa) with chip and pin and an Aadhaar-based biometric authentication.

The chip and pin is an established and tested technology, but is relatively expensive. The Aadhaar based option is cheaper, but the robustness of the technology is as yet unproven. “If indeed we are finally able to marry Aadhaar into the cards, we will be achieving same level of security available in chip and pin model at a much lower cost,” he said.

Dr. Subba Rao was speaking on the topic “Indian Payment and Settlement Systems: Responsible Innovation and Regulation” at the Institute for Development and Research in Banking Technologies here on Friday. Aadhaar was recognised as an alternate authentication mechanism in payment systems and Aadhaar based payment products had already been designed and introduced.

Aadhaar Enabled Payment Systems was aligned with the UIDAI’s plan to utilise the UID number for routing all the Government benefit transfer payments to beneficiaries. AEPS was a bank-led model allowing online transaction through the business correspondent of the respective bank using the Aadhaar identification.

He said the Aadhaar Payment Bridge System was a centralised electronic benefit transfer facilitating disbursement of benefits to the bank accounts of the beneficiaries linked to their Aadhaar numbers. Such transfer would enable secure and efficient disbursal of benefits to intended beneficiaries which, in turn, help in reducing the administrative costs as well as leakages for the government.

This will also further financial inclusion by bringing the beneficiary households into the banking fold,” he said.

Will this Indo-European marriage make it?

For now, one notes the general form of the proposition: that as banking comes to drive Aadhaar, a form that had earlier if still recently migrated away from a territorialized, village or family-based defense model to a more deterritorialized and neoliberal form tied to a vision of rationalized population mobility and wealth creation, norms of “international” (here European) standard security must somehow be reintroduced. Aadhaar is to be “married” to a more secure technology and form, something like the chip and PIN number bank card but without the cost of the chip. What kind of marriage will be arranged is not yet clear. But if Aadhaar, under the ministry of finance, is perceived by security-focused industries and bureacracies as lacking in security, the idea here is that Aadhaar/UID must be combined with something else, not yet specified by these high-level officials.

Aadhaar and “Financial Inclusion” on the doorstep: Biometrics and the double expansion of poverty capital

A news item this week promises new “financial inclusion” of those previously too poor to be eligible for formal savings and credit instruments in the legal banking industry.

Intensified bank recruiting for “no frills” accounts

Reporting from the Union Territory of Puducherry [the former Pondicherry], the August 5 edition of the Hindu notes:

The State Level Bankers’ Committee (SLBC) has decided to step up campaign to lure people for opening bank accounts.

A meeting of SLBC, which held here recently, reviewed the progress of financial inclusion in the Union Territory.

A release said, the bankers were asked to give priority to those approaching banks for opening new accounts. The services of existing customers could be used for reaching out to others.

Simplification of norms

The norms for opening accounts were also simplified. They could open accounts with zero balance or low balance. Those, who had bank accounts, had been asked to hand over copies of ration card and “Aadhaar” card for including the details in their respective accounts immediately.

At the outset, some critics would understandably challenge the degree of inclusiveness of such publicity of inclusion. Thus Usha Ramanathan, whose article in Seminar I discussed in the previous blog post, compellingly challenges multiple “myths” promoted by the UIDAI and its boosters, including “the myth that this will be inclusive.” The enrollment structure of UID and Aadhaar formally parallels the typical enrollment structure of formal sector banking: one can only open a bank account, in many cases, through an introducer known to the bank, that is another account-holder. One’s access to banking presumes one maintains ties to others with the status of bank account-holders. Similarly, one registers for Aadhaar primarily in one of two ways: with sufficient formal documentation or, in the absence for many of the same [cf. the return of Jim Crow legislation in the ever more ugly United States] through an introducer.

Ramanathan does not in this short piece attend to the role of NGOs as introducers, discussed in the blog earlier in the context of debates over transgender inclusion under Aadhaar. But even if NGOs provide a different avenue of inclusion for variously marginal populations, they do so precisely through specific categories of humanitarian legibility producing their own terrain of limit and abandonment. One could both limit and extend her argument in reference to NGO “introducing.”

But here I want to support a claim opposite to that of Ramanathan, though not critical of or excluding her point. That is, how does inclusion itself become a ground of operations that might merit closer critical attention. The idea of inclusion as a form of subjectivization is not particularly novel, of course.  But it takes on a new range of relevance given the recent and ongoing powerful analysis of poverty capital and humanitarian goods by scholars like Ananya Roy, Vincanne Adams, Peter Redfield, and others. I had a recent and exciting conversation with William Stafford whose work rethinking the informality and extralegality of informal labor also engages the multiple ways in which “the poor” are being produced as forms of “potential value” and thus value.

At the outset, let me just note the following points, juxtaposing the brief Puducherri report with the photo above, referring to a different recent effort to include the previously excluded within formal sector banking through new “doorstep” enrollment programs linking humanitarian NGOs, corporate banks, and the state, a version of the expected current triumvirate.

(1) The expansion of banking to the poor, and thus of banking through the poor, operates in relation to Aadhaar in a double form, at least in reference to the limitations of the brief article. That is: new norms of simplified enrollment are to be offered as an inclusive measure. These norms parallel the design and rhetoric of UID/Aadhaar though the article does not state if Aadhaar will be used as a necessary or sufficient guarantor of the trustworthiness of the newly included marginal subject of finance. Given multiple previous articles splayed across the mediascape in which part of the promise of Aadhaar is its guarantee of financial inclusion, the use of Aadhaar in such new norms may be implied. But what is explicitly noted is something else, not that Aadhaar will be used to bring the marginal and excluded into the embrace of the included, but rather than Aadhaar will be demanded of the marginal and included: “Those, who had bank accounts, had been asked to hand over copies of ration card and ‘Aadhaar’ card for including the details in their respective accounts immediately.” In other words, not only is banking expanding in the sense of creating value through inclusion, given apparent recalibrations of trustworthiness through biometrics, but banking is expanding in the sense of creating value through intensifying its informational access to the already included by demanding of them new biometric links to their basic information. I will term this the double expansion, of persons included within the embrace of formal finance capital and of persons included within the economy of “basic information.”

(2) I lack as of yet adequate details of the “doorstep banking” programs that the photograph records. Of note is that this photo, part of a microfinance NGO’s self-audit and promotional materials, includes as obvious and necessary to the scene an act of biometric registration: a woman is having her fingerprints electronically taken through a mobile device “at the doorstep.” In a conversation we had at a conference at Berkeley organized by my colleagues Ananya Roy and Raka Ray, Ravi Sundaram of the Center for the Study of Developing Societies and Sarai pointed out that people’s lives are being saturated by a plethora of biometric demands, not only by UIDAI for the Aadhaar card. Here we have a microcredit program whose promise of total inclusion (“at the doorstep”) involves apparently parallel biometrics. From “a million mutinies now,” we seem to have slid into the age of a million biometrics. What remains in question, for me, is how this multiplicity of tracing will stand in relation to UID’s promise, or if you like threat, of universal de-duplication.

“The Mumbai Episode”: Big Data in the Wake of the Total Failure of Tuberculosis Treatment

This post continues the previous one’s focus on the just announced registering of all TB patients nationally through the UID/Aadhaar program, as a disease control measure for a national population increasingly conceived of as migratory or “deterritorialized.” It is also a response to Peggy Trawick’s comment on that earlier post suggesting that programs like UID miss the point and that tackling TB must focus on the fundamental conditions of the physical milieus in which people live.

Drug-resistant TB patient in Mumbai (Deccan Chronicle photo)

It begins by engaging a similar article to the one discussed yesterday, from the Asian Age newspaper of 7 July 2012. It then develops a reference to the disastrous “Mumbai episode,” reading a recent article in the Lancet.

TB patients to get UID number

Starting July 15, patients suffering from tuberculosis will be given a unique identification number by the state government, to keep tab on the spread of the disease.  A specialised software will connect all facilities treating tuberculosis patients, to avoid duplication of cases. Already 60 data entry operators working in the government, have been trained to use the specialised software, where the data of each and every TB patient in the state will be uploaded. “After the Mumbai episode, we had proposed a common software across all states. The government of India has already designed a common software for all states, in which the data of each TB patient will be uploaded,” said Dr Pradeep Gaikwad, joint director, tuberculosis and leprosy…

According to state health officials, the software will help the state trace the patient, even if he migrates to other states or other parts of the state. Having common data will also help avoid duplication of cases. “The major reason for the rise in resistant tuberculosis is because of defaulter patients, who stop their treatment mid-way. If a patient goes to another state, he/she can give his unique identification number to the doctor; this will help the doctor understand his/her case history and give the required medication to him/her,” Mr Gaikwad added. The patient’s contact number, Aadhar card number and other medical details will also be uploaded in the software, so that doctors can trace him/her, even if he/she stops coming to the hospital. Mr Gaikwad, however, warned that owing to the active case finding intervention, the number of tuberculosis cases in the state could rise.

According to the state health department records, of 1.35 lakh tuberculosis patients, 25 per cent fall under the multi-drug-resistant tuberculosis [MDR-TB] category.

This article offers a clearer rationale for the new program than the earlier article: centrally at stake is the tracing of TB patients to ensure that they complete the course of their medication. UID/Aadhaar becomes an extension of DOT, Directly Observed Therapy, a massive up-scaling of a surveillance intervention focused on local knowledge and intimate observation to ensure drug regime adherence. This tracing includes not only migration but also non-compliance in place, as it were.

Of note is the relation of the Aadhaar/UID number to residence information, a much debated feature of its data set. Like the banking and finance industries, the public health establishment requires location-specific data of Aadhaar. But one of the promises of UID early on was its deterritorialization, that is, its naming and characterizing an individual not through his or her native place or father’s village or town but through mobile biometrics. Implicit in the deterritorialization was an understanding of corruption (say, the cut a local official may exact of someone’s pension) that presumes that mobile identity allows individuals to evade this intimate and localized corruption.

With TB, as with finance, trust however depends on the ability to locate the registrant. UID promises the doctor that she or he can find the UID subject using the data encoded and linked to his or her UID number.  This spatial legibility is tied both to data and to use. For those who want UID to include spatial data, actual residence is included and available to those agencies with access to UID information. But UID number use itself produces a trace of location, much as a credit card would. To the extent more and more “minimal entitlements” from ration cards to employment guarantees to more and more state/private/NGO outlays are linked to UID, life itself becomes impossible without one showing up on a database somewhere in India or through its consular extensions.
That the public health state can trust locational data is critical as it must respond to its own massive failure, here the somewhat vague reference to the “Mumbai episode.”

For now, I am assuming that this episode is the much reported finding, early in 2012, that several cases of entirely multi-drug resistant tuberculosis had been found in Mumbai. Here is the Lancet of 21 January 2012:

India reports cases of totally drug-resistant tuberculosis

Samuel Loewenberg

Mismanagement of tuberculosis in Mumbai has led to the emergence of India’s first known cases of a totally drug-resistant form of the disease, say doctors. Samuel Loewenberg reports.

Researchers in Mumbai have identified 12 patients with a virulent strain of tuberculosis that seems to be resistant to all known treatments. The cases of so-called totally drug-resistant tuberculosis (TDR-TB) have been detected in the city in the past 3 months. Worldwide, the only other episodes of TDR-TB reported were in Iran in 2009 and Italy in 2007.

What then follows is a social diagnosis: a miserable state system drives persons to mostly untrained clinicians whose prescription patterns drive increased drug resistance: the state fails entirely either to regulate the latter or to address the failures of the state system.

“Basically, it is a failure of public health, and that has to be accepted in this country”, said Zarir F Udwadia, who has been treating the patients at the P D Hinduja National Hospital and Medical Research Centre, and who, along with colleagues, described four of the cases in a letter published online in Clinical Infectious Diseases. “The public doctors and private doctors are equally to blame”, he said. The city’s health officials reject these charges. “State TB care and health care in Mumbai is excellent”, Anil Bandiwadekar, the Executive Health Officer of the Public Health Department of the Municipal Corporation of Greater Mumbai, the city’s governing body told The Lancet.
Government health officials attribute the problems with drug-resistant tuberculosis to the city’s unregulated private doctors who prescribe inappropriate drugs. Privately, some senior officials acknowledge that much of the public have a negative perception of government-run health facilities, due to long waiting periods, rude treatment, and the stigma associated with tuberculosis. The result is that many infected people avoid the government tuberculosis programme and seek relief from private doctors, only some of whom have medical training. The government says that it is considering regulating tuberculosis drugs, but it has not yet taken action.
Mumbai would seem to be a prime breeding ground for drug-resistant infections. The city, home to more than 12 million people, is beset by poverty, overcrowding, and harsh living conditions.
Udwadia says that although the DOTS (Directly Observed Therapy, Short Course) programme has generally been successful for people with normal tuberculosis who do access it, for those with drug-resistant tuberculosis, it causes more than 8 months of delay as people are forced to go through standard treatments before they are diagnosed. All the time, they are generating further resistance.
The article concludes again stressing the failure of administrative capacity and political will, given the cost of treating MDR-TB, and uses the language of caste to characterize the forms of triage.
Presently, there are only 171 people enrolled in the DOTS-plus programme that has been in effect in Mumbai since 2010 to treat drug-resistant tuberculosis, according to the office of Bandiwadekar. Tuberculosis was estimated to have accounted for at least 15% of the deaths in Mumbai in 2010. India has one of the world’s highest burdens of drug-resistant tuberculosis, (around 100 000 people), according to WHO. The failure of the government to provide treatment for all of these patients is due to the cost—about US$4000 per patient, a high cost for India, which spends only $45 per head on health care. Udwadia says that the government passes its actions off as “health policy real politik”, which in effect means it ignores most of the patients with drug-resistant tuberculosis. “They have become the untouchables of the Indian medical system”, he said.
In fact, health centres and hospitals could be a contributor to the growth in resistance, said Nerges Mistry, the director of the Foundation for Medical Research in Mumbai. There is “poor infection control at most of these settings”, said Mistry, and people with resistant tuberculosis could well be infecting patients with a regular tuberculosis infection. A 5-year study done by the Foundation with the Wellcome Trust found that most patients were resistant to two or three of the first-line drugs, and some to all four. The city could have as many as 3500 cases of multidrug-resistant tuberculosis (MDR-TB) each year, but lacks the laboratory infrastructure in the public system to identify and confirm the diagnosis, said Mistry.
Exposure to MDR-TB is intensified in the city’s giant slums, described here as “notorious.”
Meanwhile, the patients with TDR-TB are walking the streets. Udwadia says that isolation is not practical due to cost and lack of hospital beds. He notes that four of the patients come from Dharavi, a notorious Mumbai slum with a population of 2·5 million people.
So far, three of the TDR-TB patients have died, one of them after lung surgery. One of the patients has passed on her infection to her daughter. Udwadia is trying any treatment he thinks might work. This includes a double-dose isoniazid, the harsh antibiotic linezolid, the anti-leprosy drug clofazamine, the anti-psychotic drug thioridazine, and meropenem and clavunate, which reportedly had some effect on tuberculosis in mice. “We are clutching at straws here”, he admits.

In this context, how to make sense of the turn to Aadhaar, to the new promise of Big Data? What is not addressed is the state’s failure, assuming the arguably inflationary language of the Lancet piece is acccurate, to enroll most persons with MDR-TB or to regulate the conditions of common treatment. Rather, those few persons already in the MDR-TB treatment pipline are to be more effectively surveilled through the UID number.
Or is there a more sustained argument to be made for the utility of UID. given this double failure, of routine TB treatment and of the enrollment of most persons with MDR-TB in treatment?