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.

Tripura, the opposite of Assam: on “success” in universal identification

This week’s focus, thanks to Malini Sur, is the Northeast: next week’s, thanks to Tulasi Srinivas, will be the question of failure haunting the publicity of UID since late 2011. Today’s and tomorrow’s posts bridge these. Tripura is positioned very differently in the Indian Northeast, in relation both to Bangladesh and to relations to Bengal more generally, than Assam, subject of the last 2 posts. This difference is something that at the moment I can discuss only anecdotally, and I would appreciate appropriate guidance. But in brief, Tripura has become one of the great success stories of UIDAI, if success is measured in the saturation of identity card registration. If Assam, as we saw, fears a double erasure–absent to national counts, and swamped by Bangladeshi migrants–Tripura is among the most present, counted, places in the Indian Union.

Tripura (in red) in India, Wikimedia Commons location map

Tripura leads in UID enrolment

Sep 26, 2011

UID

Tripura leads in enrolments for the the ambitious “Aadhaar” scheme, a 12-digit number being issued by the Unique Identification Authority of India (UIDAI) for all Indian residents, a minister said here Monday.

“In Tripura, 80 percent of the 3.7 million population have so far been enrolled in Aadhaar scheme followed by Andhra Pradesh (25 percent) and Maharashtra (20 percent),” Tripura Rural Development Minister Jitendra Choudhury told reporters.

Quoting a communique of the union rural development ministry, Choudhury said : “The central government, at a function in New Delhi on Thursday, would give awards to Tripura and other well performing states in implementation of the Aadhaar scheme.” Tripura was the first state in the northeast and the eighth in India where the Aadhaar scheme was launched on Dec 2 last year.

According to UIDAI director general and mission director Ram Sevak Sharma, in the next four years, 60 crore Indians would get the Aadhaar number. “Crores [tens of millions] of Indians do not have bank accounts. Once they get the Aadhaar number it would easily facilitate them to open a bank account and get banking services,” Sharma had told reporters here recently. The Aadhaar scheme, formally launched by Prime Minister Manmohan Singh on Sep 29 last year, is now in progress in many states. UIDAI has empanelled several enrolment agencies across the country.

“The Aadhaar number is an official confirmation of residency not the citizenship of any individual,” an official of the Tripura government clarified.

“The quality and speed of lots of government programmes and issue of official documents to people would be improved through this Aadhaar number,” he said, adding that the problems in getting government facilities and services would also be reduced. According to the official, the Aadhaar number would be stored in a centralised database and linked to the basic demographics and biometric information, including a person’s photographs, 10 fingerprints and iris impression. “The Aadhaar number and all details of an individual will be easily verifiable in an online and cost-effective way,” he added. “By March next year, the enrolment of all residents of Tripura would be completed. They would then get the Aadhaar number directly from UIDAI,” said the official.

Three things:

1) the “well-performing state”: Tripura, anthropomorphized, is to receive an award. Again, the index at stake seems to be one of “forwardness,” tied simultaneously to a developmental figure of command-polity effectiveness and (perhaps) a post-developmental figure of entrepreneurial efficiency. [If in the last post I posited two variably distributed and interrelating governmental regimes, developmental and neoliberal, I should note up front that such is an unsatisfactory conceptualization and will require work as I learn more]. But “performance,” not to make too strong a point where one is unwarranted, may pull us in some other directions. For now: what is developmentalism today? For whom does it perform? Here the figure is of a provincial entity performing its effectiveness for the Centre, a complex claim on the cosmopolitan as well as as the forward and modern.

2) not citizenship but residency: here, quite explicitly, is the claim that UID cannot stand for citizenship, even as UID is iteratively linked to (future) entitlement, within all the voluminous promise of the Kshirsagar [milk-ocean] of entitlement that will flow consequent upon mass de-duplication. Narrowly, the difference from Assam (if these contrastive articles I have posted can be used to entertain broader claims) is striking. The duplicate-migrant is not a palpable figure, at least not here. Tripura unlike Assam has not “disappeared.” On the contrary, it is an award-winning figure of presence and vitality, among the most counted polities in the nation. Understanding and disentangling the distinction here will take me some time, and again, help would be appreciated.

the future of entitlement?

Beyond the specific Northeast story, the claim of UID as a non-citizenship marker, and the question then of exactly what is Residency (a good old word redolent with colonial significance, not the least of which is the lurid literature of the Indian “Mutiny” and the fate of white Lucknow, if perhaps of dubious relevance here) looms. One way to think residency through will be to look, as Ashveer Singh has pointed out in a comment, at the NRI [Non-Resident Indian] as an included figure under Aadhaar: here, at first glance, UID seems to be offered in the opposite way: to citizens (some NRIs can now make such claims, in a way of relevance to my colleague Aihwa Ong’s classic work on flexible citizenship) but not to residents. So how the two are variably assembled seems a critical if obvious question.

3) Tripura as a figure of totality: Tripura promises to be the first “totally” counted state, and as such may stand as the elusive “Proof of Concept” [a bureaucratic term of self-audit that UIDAI has long used to argue for its commitment to effectiveness] that UIDAI has sought. The Central administration’s relation to Tripura is ritually elaborated: thus, the millionth person deemed to be a registrant for UID was from Tripura, a celebrated fact.