In Dream Valley, the poor have many homes: duplication and tuberculosis in real time

A brief comment today riffing off of a set of lectures and seminars given by sociologist and anthropologist Veena Das at Berkeley a few weeks ago. Das and many colleagues have long worked in several slum areas in Greater Noida, an extensive area of urban development including large tracts of slum housing far to the southeast of the older urban core of Delhi.

A different kind of Greater Noida address

This work has long troubled the sufficiency of figures of “the poor” and “the slum” and their presumptive “everyday” reality, through long-term weekly and monthly inquiry by a team trained by Das into well-being and illness, income and expenditure, relations to politicians, brokers, bureaucrats, healers, and much more. Through “amplificatory techniques,” these weekly and monthly engagements have produced a dense and complex record challenging the adequacy of much urban slum ethnography that all too moves quickly from (1) single case studies, in or across widely separated moments in time, to (2) generalized accounts of “the poor,” of conditions and of processes in the slum. What Das has argued is needed is a very different form of research.

One of my concerns in this emerging project has been “duplication-from-below.” UID/Aadhaar is premised on ending “leakage,” regularizing and rationalizing state (and increasingly privatized) development and basic entitlements enabling life with an (allegedly) incorruptible ID card that uses biometrics and big data to eradicate all “duplicates” — that is, to end cheating with duplicate IDs. Duplication-from-above is the diversion of entitlements by a powerful “nexus” (usually named as politicians, parties, land mafia) that creates a phantom population in order to siphon benefits on a massive scale. Its opposite in formal terms is a duplication-from-below by which less empowered people get by with multiple (“duplicate”) ration cards, false (“duplicate”) addresses, and so forth.

De-duplication, the new order of information promised under Aadhaar/UID, is of course premised on ending both. If the new order threatens livability by depriving more marginal persons of the tactical resources of duplication, the benefit will be the legitimate flow of currently throttled entitlements and greater wealth and health for all. Or so the promise of the card is framed.

One could look at life in the areas studied by Das, her colleagues, and their research team as intensely “duplicated-from-below.” But the rigor of the amplificatory method they employ has allowed them to place what I term duplication in real time, as it were.

Let me give an example of duplication, from a paper by Das, and how it might conventionally be read. Then let me apply the discussion she offered during her Berkeley visit to rethink the problem of the duplicate in time.

Hospitalization through duplication

The example comes from an essay entitled “TB and Urban Poverty: An Essay Critical and Clinical” that can be found on the web. It centers on Meena, “a resident of a cluster of jhuggis (shanties) in the industrial area of Noida.” The cluster or slums is specific in several ways: (1) Waves of settlement: “The residents of the jhuggi settlement in our sample had arrived in waves – the earliest settlement can be traced to forty five years ago. Subsequent movements have followed networks of kinship and village affiliations.” (2) Complexity of the multiple norms structuring informal rights in land: “The settlement is an unrecognized colony which means that the residents do not have a legal right to the land but complicated customary norms have evolved here as in many other slums of this kind, so that people have ‘bought’ land and built jhuggis on this land.” I will return to this complexity as a particular condition of duplication: given the lack of a formal norm of occupation of land, provisional and contested norms proliferate. (3) Eviction stay, election cycles, and perennial hopes of formalization of rights in land: “The residents have also registered themselves as a scheduled caste association … [which] has enabled them to obtain a stay order … [forbidding] the government to take over their land unless alternate housing is provided to them. The government policy on this issue has vacillated over time but with each election, as residents are courted by candidates, they become hopeful of getting rights to pakka (i.e. built with bricks and cement) housing in a ‘recognized’ colony.”

Some initial context is offered on Meena: (1) Household: she lived “with her husband, two young sons and the husband’s father.” (2) Family tensions: “Her two sisters were married to the two brothers of her husband but relations between them were fraught with conflict.” (3) Employment and income:  “Meena’s husband and his father were both employed by a contractor in the U.P Water supply department as cleaners. Thus they had a stable but meager income throughout the period of our study which meant that small amounts of cash were available to the family, though this cash was never adequate for the many demands ranging from food, providing school supplies for the children, as well as money spent on alcohol and tobacco by Meena’s husband.” (4) Clinical expenditure: “there were regular expenditures incurred on medications, especially as the younger son suffered from a respiratory ailment.”

The fieldworkers’ account of Meena’s TB shifts. Initially in 2000, “Meena had reported that her first episode of TB occurred three to four years ago. At that time she said that she took medications for a long time – perhaps seven months, perhaps one year.” But later “she said to one of the fieldworkers that she had TB for the last eight years which had ‘never been cured.’ She described a complicated story in which first, she talked about a breast abscess after her child’s birth, a minor surgery as well as fever, cough and weakness.” The earlier period of TB occurred when she was still in the village. Meena took medication until she became asymptomatic or even remaining weak given the lack of money. After she went to a local BAMS [Ayurvedic Medicine] practitioner who gave her antibiotics, analgesics, and other medicines. Her need to get well was intensified by the fear that her husband was seeing another woman.

Their relation worsened, as did Meena’s health: her husband did not have enough money to get her admitted to a local private hospital but her cousin got her admitted to a government hospital at some distance “under another name in that hospital on the pretext that she was his dependent relative.” She stayed there 6 months. The research team could not find her for some time as her name had been changed: one of her sons also worried that his mother had died. When she returned home, “the hospital discharged her with instructions to complete the course of medications. She was required to go the hospital OPD to receive medication but her husband managed to get her name transferred to another DOTS center nearer their home.”

Meena’s health improved for two years. Her symptoms then worsened and the researchers took her to a clinic they knew at some distance again from the slum: the doctor there confided that he did not see much therapeutic benefit given likely MDR-TB [multi-drug resistant TB]. Again the distance was hard for Meena’s husband, he “did not want her to be admitted to a hospital so far away from home so they went to another DOTS center by providing a false address. Here again she was dispensed the anti TB regimen under the DOTS protocol but reported serious side effects such as continuous nausea. Her condition continued to worsen, so she stopped taking medications. She died in a private nursing home in December 2003 where she was rushed in the last two days of her life. The family at the end of her life was in debt to the order of several thousand rupees.”

Das’ essay uses Meena’s story to challenge the dominant account of much of the public health and anthropological literature: that stigmakeeps people from returning to clinics and adhering to an adequate course of anti-TB treatment. Rather: “what seems to emerge from the story, instead, is consistent institutional neglect and incoherence. This neglect exists in conjunction with the care and neglect built into Meena’s domestic relations. In the course of three and a half years, Meena took three rounds of TB medication, all under the protocols of TB management in DOTS centers. There was no consistent record of her illness with any of the practitioners. When she was admitted to hospital, she took an assumed name and did not show her previous medical records but even when she used her own name there was no attempt on the part of the DOTS center to ascertain her medical history. In each episode of the disease she completed the course of medications, and was declared to be sputum negative and thus ‘cured.'”

Das suggests that the particular practice used by Meena’s husband to get her into a DOTS program or treatment center closer to home, what I am terming in relation to the language of UID as “duplication,” is also not enough to explain why clinics never treated her in relation to her previous medical history.

Still, a pattern emerges: care from the wage-earning husband is inconstant and Meena depends both on him but on others (her relations, social welfare agencies [here the research team] who use their own connections to get her seen far from home. At some point when her husband becomes involved in her care he moves her back closer to home. These moves may involve a “duplicate” name or address change. Whether or not the care network resorts to duplication, the clinic seldom attends to Meena’s past history of TB in prescribing.

Duplication as access to care?

Duplication-from-below emerges here as a resource–for the relative who moves Meena to a government hospital and for her husband who on two occasions moves her care closer to home.

But Das and colleagues show that whether or not the care network “duplicates” Meena’s identity to get her admitted, her de-duplicated medical file is not utilized.

The context, in which the Government of India’s failure to organize effective DOTS treatment for drug resistant TB has led to calls for UID to be used to deterritorialize TB care and create incentives and demands for de-duplicated patient identity, is critical: in theory, allowing for the mobility of the patient file through UID/Aadhaar could lead to Meena’s information following her clinical trajectory. But the very structures of diagnosis and assessment have produced a body of knowledge which asserts that practitioners, most with substandard or nonexistent training, do not need such long-term mobile knowledge to treat people like Meena.

UID promises de-duplication, deterritorialization, and thus better care. The shifting availability of care from husband/husband’s family and her own family/outsider welfare have demanded that various persons in Meena’s world duplicate her in order to deterritorialize her care. And at some level, heretofore Meena’s duplication or de-duplication does not seem to change the quality of care as the clinic, despite the prevalence of MDR-TB, continues to treat each episode as a singularity.

Will a new demand for Aadhaar that makes duplication-from-below more challenging change the situation in terms of clinical norms of treatment?  The sense one gets from this paper is pessimistic.

The accusation of address

Finally, Das at her Berkeley talks made a point that echoed one with which I began discussing this paper. The complex conditions under which slum residents may make some kind of normative claims on state or corporate or NGO programs lead to the multiplication of addresses. Programs often mandate audits of the informal slum and may find previous systems of house-numbering to be inadequate or untrustworthy.  Numbering systems proliferate. Das described a given slum area that had some 4 or 5 parallel numbering systems each created by a specific agency of slum governance or welfare.

Subject to accusation and continual re-territorialization

At stake in the duplication, that is, may be an intensification of the accusation of untrustworthiness. Slum-dwellers are accused of cheating, of duplication, and are assigned new numbers, a presumptive de-duplication. But each effort to de-duplicate only intensifies the condition of duplication and the accusation.

Bodo-Muslim Violence and the Question of Identity Cards for Assam: Security as a Negative Condition

Some months ago I posted about the complexities of the UID/Aadhaar biometric program in India’s northeastern states, areas often marginal to Delhi-based national politics. Given that professional anthropology plays a large role in the institutions that organize and govern the racial and cultural presumptions of “tribal” identity across the Northeast, one could argue that the anthropology of the new biometrics bears a particular kind of responsibility to a different kind of engagement in relation to conditions of identity there. Meanwhile, time has not stood still and Assam again dominates the Indian news as a site of intense and upsetting “communal violence.”

Help: Charities in the new refugee camps

Months ago, my focus was threefold: (1) on concerns in the state of Assam that illegal Bangladeshi migrants would use the “residence”-based registration of UID to become citizens, de facto or de jure; (2) on efforts in the state of Tripura to rival the southern hi tech powerhouse Andhra Pradesh in number of persons registered, and how these might relate to the (legal) Bengali-migrant dominated state’s efforts to evade the peripheral condition of the tribalized Northeast; and (3) on reports in the state of Mizoram that some Christian pastors had been challenging the UID/Aadhaar “number” itself as the the apocalyptic “mark of the Beast,” raising both familiar and new questions about the occurrence of millenarian realities.

Even as I was writing those earlier posts, concerns over migration and their relation to the long apparent “instability” of Assam had led to the extraordinary move of shelving the entire project of UID in the state, or so reports (like the one I cite below) noted last January (2012). If so many minimal entitlements are to be tied to the card and number, then what it means for an entire state and its territory to be excluded from Aadhaar and its great promise (or, for its many critics, to escape the surveillance and exploitation of the program), is quite important to consider: both for Assam and its own out-migration, and more generally for its economic and political relations to the rest of India.

Over the summer of 2012, Assam has been daily in the news for intensifying waves of conflict over which groups have rights in land and legitimacy, joining debates over recent Bangladeshi migrants to relations between non-tribal and tribal communities to the many descendents of earlier, multiple migrations. Particularly at stake are relations between the Bodos, who were after longtime struggle granted certain rights over four districts in the state, and Bengali Muslims and Hindus, some of whom are and some are not “illegal” but whom a national political discourse at times identifies as illegal Bangladeshi Muslim migrants tout court.  Large numbers of killings have occurred, of Bodos and migrant Hindus but particularly of migrant Muslims (though I cringe as I write this for its vagueness is unacceptable: understanding where and how the killings have occurred and with what backing is critical. There are many scholars whose current work I will depend on, including Malini Sur and Garga Chatterjee). At present, camps for the large numbers, particularly  Muslims, who have fled for their lives have been set up in lower Assam, both local and religious charities and international humanitarian organizations appeal for needed resources to ensure food, clothing, water, and medication, and the state is trying to urge frightened and unwilling people to return to these contested villages with promises of secure if heretofore dodgy governance.

Even before the killings intensified and the refugee camps had to be established, UID/Aadhaar had not featured prominently in past months of the English-language press in Assam that is available via the Internet (but that admittedly is a restricted field). Given that what dominates the press are variant framings right now of Assam’s exceptional status, it seemed useful to return to the question of identity, particular amid the current moment in which a different form, the humanitarian camp and the basic emergency “kit” (see the work of Peter Redfield) dominate the organization of the minimal entitlement. So how do camps relate to Universal ID as forms of rationalized entitlement and control?

This at least is a question to gesture towards.

For today, I offer an earlier article from last January, announcing the exceptional status of Assam vis-à-vis the Aadhaar number, from the Assam Tribune of January 28, 2012.

Aadhaar cards unlikely to be issued in Assam
NEW DELHI, Jan 27 – The Aadhaar cards issued by the Unique Identification Authority of India (UIDAI) are unlikely to be rolled out in Assam and other North Eastern States, barring Tripura and Sikkim. A meeting of the Cabinet Committee on Unique Identification Authority of India related issues (CC-UIDAI) chaired by Prime Minister Dr Manmohan Singh decided to limit the issue of Aadhaar cards to 60 crore [ 600 million] population spread over 16 States and Union Territories. In the rest of the States, the national identity numbers would be issued on the basis of the National Population Register.

Briefing newsmen, Union Home Minister P Chidambaram and deputy chairman of Planning Commission Montek Singh Ahluwalia said that in all cases the NPR data base would prevail. However, Aadhaar numbers would prevail in those States where it has been issued. And in rest of the States, the NPR exercise would continue.

The States where the Aadhar cards have been rolled out included Andhra Pradesh, Goa, Haryana, Himachal Pradesh, Jharkhand, Karnataka, Kerala, Uttar Pradesh, Delhi, Maharashtra, Sikkim, Puducherry, Tripura and Rajasthan among others.

UIDAI uses information on five fields, while NPR seeks information on 15 fields. The entire exercise of issue of NPR is targeted for completion in 18 months by June 2013, said the Home Minister.

The Cabinet meeting called today to resolve the differences between the Home Ministry and the Planning Commission over the issue of Aadhaar cards and the national identity cards, worked out a compromise formula, under which the limit of the Aadhaar cards have been fixed. The Home Ministry has now been mandated to carry out the NPR project in rest of the States.

About the security concerns flagged by the Home Ministry, Chidambaram said that UIDAI has agreed to review all the information it has collected. At the moment they have agreed to review the entire process to address all the security concerns.

The security concerns included the possibility of the cards falling into the hands of the illegal migrants and subsequent misuse of the cards to avail of the government schemes. The infiltration prone North Eastern States including Assam, were particularly referred in this regard.

3 points.

(1) At stake, as noted in an earlier blog post, is the contest that had come to a head at the beginning of 2012 over the control of the national identity database between the security focus of the Home Ministry and the liberalization focus of the Finance Ministry. The Home Ministry, then under the powerful Chidambaram, officially won that battle with its census-driven “National Population Registry” [NPR] named as the ultimate arbiter of de-duplicated universal ID. But the article reveals that India is in effect divided into two: what I will term power zones and security zones. Power zones comprise the wealthier South and the politically powerful Hindi-heartland North. Security zones are insecure border states, though notably not Rajasthan, and insecure insurgency states, though notably not Jharkhand where several UID/Aadhaar programs targeting the elderly were first rolled out.
Assam and the north-east (minus the exception-to-the-exception Tripura) are here framed as the sine qua non of the insecure condition and the core of the NPR and its security zone.

(2) In the wake of the earlier massacres, and amid ongoing killings, local state and district government is trying to encourage the refugees from the Bodo districts to return, with promises of normalcy. What kind of normalcy is and can be expected in the security zone? Famed for the wealth of tea plantations, dependent upon the rationalized and secure labor of the Bengali migrants, one might imagine the Bodo lands economically as power zones: but the history of modern Assam and its racialized state governance and anti-state struggle belie that.

(3) Universal ID began as a Security measure: the conundrums of the liberal-security state led to its capture by the Planning and Finance people. The latter promised far more than Chidambaram, who really seemed to offer at best the status quo of security but not the neoliberal version of universal development. But Security as a state concern remains vital, and now despite the political efforts to commensurate the two data-gathering massive enterprises they seem to remain split, and perversely duplicated. That is, the very promise of the de-duplicated future has led to a massive duplication in the imaginary of the nation as database. If UIDAI/Aadhaar stands for the new conditions of the neoliberal social, that is of the promises of development in the aftermath of the failed planning state, Security has become the negative of that promise, and the two are kept distinct through the establishment of what are in effect two parallel zones of government by distinct ecologies of information.

Killer App: UID, Public Health Defaulters, and the Smartphone Theory of the State

Continuing on the theme of UID as public health tool, today I want to look briefly at a Working Paper on that topic available on the official UIDAI website. The paper makes a case for UID as enabling the expansion of varied welfare schemes using the metaphor of a smart phone.

Choose your metaphor, then…

I am particularly interested in the question of mobility, given the use of UID to address adherence failure due to mobility and migration.  And though I am cautious about overly relying on the logic of the metaphor, the conception of the state as a mobile smartphone is a productive one to work through.

Acknowledgements: I am grateful to Ian Harper and Bharat Venkat, both anthropologists and formidable scholars of TB treatment regimes, for comments they sent me on TB. Ian has critically studied and worked on DOTS [directly observed therapy] programs in Nepal and worldwide for many years; Bharat works in Chennai in a site critical for the formation of what would eventually become DOTS. And earlier comments and contributions by Jerome Whitington, Maria Ekstrand, Ashveer Singh, and Tulasi Srinivas addressed some of the issues at stake here.

The Excluded and the Defaulters: Ian points out: “the ‘migrant labourer’ and the issue of movement has been a particular problem with the DOTS programme from the start, and research in Delhi indicated that unless a patient could prove that they had a ‘permanent’ address, (even with staff visiting their address site to verify that they were there), then they could be denied treatment from the off through the public system… If started, then when they move, and given the lack of follow-up capacity in the government system, then they become categorised as ‘defaulters.’ High numbers of such ‘defaulters’ is one way through which programmes are evaluated by the WHO and described as poorly performing.”

Proof of permanent residency in the Delhi example Ian mentions becomes the basis for triage: a specific guarantee of territory, to continue the conceptual language of the preceding posts, is necessary for inclusion in the state’s pharmaceuticalization. If that guarantee may presume identification papers, it can extend as Ian suggests to a physical audit of their claims to proper residence. Improper or absent claims presumptively lead to abandonment. (These terms, developed by Joao Biehl, have generated intensive and productive debate). Types of claims on territory are used as proxies for knowledge of future patient mobility.

The flip side of the territorially excluded are the “defaulters” and here the audit at stake is not that of the state/corporate/multilateral organization/NGO apparatus of drug delivery auditing the prospective drug recipient but rather that of the multilateral organization (here WHO) assessing India and finding it wanting.

If the diagnosis offered in the Lancet cited in yesterday’s post framed the locus of failure at the nation state and its deficit of political will and regulatory capacity, here we see that the very privileged position of the European auditor (whether the medical journal of record or the WHO) is part of the feedback loop that leads the state TB administration to weed out the inadequately territorialized from the outset in order to improve its audits.

In such a context, UID makes a promise of transforming the reckoning of “adequate territorialization.” As will all such UID/Aadhaar promises, I want methodologically to avoid the hermeneutic of intense suspicion I and others are often drawn to produce. If I ended yesterday’s post with the suggestion that UID only addresses the minority of persons with MDR-TB [multi-drug resistant tuberculosis], one could argue that the point of the registration of the TB patient under UID will be to transform the ecology of multilateral audit and the logic of what I have called the feedback loop, leading to fewer disincentives against the exclusion of improperly territorialized persons diagnosed with MDR-TB (sorry for the quadruple negative in that last sentence, these blog posts are quick and dirty productions). In other words, if UID transforms the defaulter into an acceptably mobile drug recipient it might allow as well for the formerly abandoned to be included within the pharmaceuticalization regime.

Inclusion/abandonment: All this is speculation on my part at the level of the document or press report, at this point. But beyond TB, it points to tensions across the board in the imposition of UID that are framed in this binary of inclusion and abandonment: of elderly pensioners to be included in UID or whose fingerprints fail to register and whose motives are distrusted; of the Bangladeshi migrant who is to be more effectively surveyed as a Resident under UID or whose threat to the citizenship that differentiates Assam from the Bangladeshi prevents this inclusion and leads in due course to the entire state of Assam being temporally excluded from the UID program; and of transgender women whose community leaders have fought for inclusion under the census and other institutions of state identification but are divided and arguably deeply ambivalent about the value of inclusion under the surveillance of Aadhaar.

I am not satisfied with the conceptual payoff of this binary, but will let it stand for now.

Okay, why the smartphone?

I briefly cite the working paper I mentioned at the outset. It is symptomatic of all of the promise and confusion surrounding Aadhaar; as I pointed out much earlier on this blog, UIDAI officials seem as confused as anyone else about what UID is, does, and implicates. Here I break the document up into themes (ignore for now the many acronyms for particular state bureaucracies and entitlement schemes):

The unique and non-duplicated: “The Unique Identification (UID) project is a historic venture that seeks to provide a unique registration code to every Indian citizen. We surmise that the starting point would be to aggregate records from various population databases such as the census, the PDS system, voter identity systems, etc, while dealing with the challenge of duplication.”

The killer app as a figure of consumer/behavioral incentive: “Existing data bases would probably still leave a large percentage of the population uncovered. Therefore every citizen must have a strong incentive or a “killer application” to go and get herself a UID, which one could think of as a demand side pull. The demand pull for this needs to be created de novo or fostered on existing platforms by the respective ministries. Helping various ministries visualise key applications that leverage existing government entitlement schemes such as the NREGA and PDS will (1) get their buy-in into the project (2) help them roll out mechanisms that generate the demand pull and (3) can inform a flexible and future-proof design for the UID database. It will also build excitement and material support from the ministries for the UID project even as it gets off the ground.”

Public health will succeed if it can develop its own killer app: “Health, and health related development schemes could offer a killer application for the UID. After years of neglect, public health in India is seeing a revolution both in terms of (1) greater commitment towards government financing of public and primary healthcare (2) pressure to meet the MDG goals (3) consequent creation of large supply platforms at national levels such as the NRHM, RSBY and complementary state level initiatives such as the Rajiv Arogyasri insurance scheme in Andhra Pradesh. In health there is a cumulative historic gap both in terms of demand and supply. The UID could further help catalyse a revolution in India’s health outcomes.”

The participation of the new subject of UID (here termed a citizen by UIDAI, but as the official UIDAI website points out the subject of UID is a Resident and not a citizen: call this a constitutive confusion) is a matter of incentive, participation served by reforming governance as the promotion of self-interested participation in large-scale institutions, a broadly neoliberal figure for the condition of a scaled-up, arguably collective, social form. Jerome Whitington early on pointed me to Jim Ferguson’s very rewarding paper on this theme, “The Uses of Neoliberalism.”

Incentive is to be produced by each governmental agency. The new entitlement programs marking the last decade of Congress Party dominated rule, the extension of a prior development state electoral populism into a new form of state-corporate-NGO-multilateral governance, are here conceived of as killer apps for a generic platform, the UID.

Apps have become a powerful vehicle and metaphor. My Berkeley colleague Jim Holston is part of a collaboration thinking carefully about “social apps.”  Here I want to focus on the idea of a platform. What does it entail that UID is framed as a general platform for the “killer app”?

A real killer

De-duplicating migrant patients with tuberculosis: the dangers of “native place”

A set of articles recently sent me by friends have inspired the next several postings. This article was sent by Harris Solomon, from the DNA news website published today, 22 June.

Mycobacterium tuberculosis

UID numbers to record progress of TB patients

To keep track of the number of tuberculosis cases, a unique identification (UID) number was set to be issued to new TB patients from July 15, state health department sources revealed.

The scheme will be implemented across the country and will help doctors mete out the necessary treatment after referring to the digitised records to be available nationally. It will prove beneficial to migrant patients who often fail to avail the complete treatment after they move to their native places.

Dr Mini Khetarpal, TB officer, BMC, said, “This process will help us analyse the situation better. We will concentrate on prospective cases as per directions from the Centre, not old ones. Our officials underwent a day-long training in Pune about a month ago.”

She added that the digitisation program is currently being modified in Delhi after feedback from the World Health Organisation

The new system is specially designed to target migrant multi-drug resistant (MDR) TB patients and help doctors keep a tab on the treatment they have already received. It will also prevent duplication of UID numbers as their Aadhar card number will be mentioned as well.

The state has recorded 1,34,000 TB patients out of which 50% have contracted pulmonary TB for the first time. 25% cases are instances of recurrent TB while the remaining 25% have contracted extra pulmonary TB.

There is a lot here to think through, and as ever with this project one’s knowledge is limited and learning curve steep. For example, the article differentiates the “UID [universal identification database] number” from the “Aadhaar [identity card] number” (huh?) and argues that having both of these is necessarily to resist the threat that this blog has wrestled with from the beginning, that of duplication. So perhaps the next posting can clarify this doubling, assuming the article is correct, of the very number (Aadhaar/UID) whose uniqueness was to guarantee the promise of the de-duplicated nation. As with the earlier tussle between the Finance and Interior Ministries over who controls the national database, I want to suggest a familiar theme, that the Ur-database necessary to guarantee India’s de-duplicated, deterritorialized, de-corrupted promise is itself constantly being threatened with duplicates.

But let’s focus on three issues, as ever, for now.

(1) Biopolitics: at stake, first and foremost, appears to be a presumptively more effective means of health surveillance that can take account of the migrant status of persons taking medication for tuberculosis. TB patients will be registered for UID/Aadhaar. Registration will give doctors both aggregate information and patient-specific information. The latter will enable tracking patients as TB patients migrate.

The direction of migration noted is not rural-to-urban but rather urban-to-rural. Why only urban-to-rural migrants are a problem is not specified. Is there a presumption of less drug availability, less clinical knowledge, less data, or less effective adherence? Interesting that the return to the local “native place” becomes the clinical problem to be addressed.

Rural-to-urban migrants: not the clinical concern?

In my limited experience, patients in urban north India over the decades I have worked in clinical settings were far more likely than in the US to have control over their medical file, producing sections of it in doctors’ offices in order to create a range of desired clinical outcomes: files, that is, in theory migrated with patients anyway. TB differs, possibly for many reasons: adherence control in the face of drug resistance may mandate more intensive surveillance. Mobile medical knowledge, it would seem, can no longer depend upon patient-driven file mobility.

(2) Biopolitics and information failure: In the Maharashtrian case, the article implies that adherence failures and drug resistance may be due to a situation of information failure.

This is an idea worth thinking carefully about: that biopolitics is a matter of information adequacy in the face of certain forms of population migration. It develops the theme of deterritorialization: that UID/Aadhaar enables more flexible relations to place. Here surveillance is no longer a matter of the body fixed in its slum, repeatedly observed. The unit of analysis is now the ID number in a mobile trajectory. Somehow, the return to the village, to the native place, presents a particular clinical-informational deficit that the ID number must supplement.

What might it entail that fleshly conditions become digital conditions? I am not sure that there is much new here: surely the history of medicine long engages the relation of the sickness to the form of its representation.

Digital human lungs, for your consideration

(3) International informational standards: the WHO is positioned as an auditor here, and the Government of India must adjust its digitization accordingly. It would be interesting to think about the international governance of digitization, and how power here is organized and distributed.