Behavioral Failure and the Killer App: Reflections on Melancholy via AIDS Prophylaxis and the Indian Emergency

This post continues the last post’s brief speculation on the new figure of UID as a platform with “public health” as among its most effective “killer apps.”

Scary?

Several scholars have taken up this striking figure: here I want briefly to engage the critique of Usha Ramanathan in the journal Seminar. Her title, “The myth of the technology fix,” suggests the broad lines of the critique. Indeed it is hard not to be troubled by the promissary hype of UID boosters (suggesting a fruitful future engagement with the anthropology of technological hype and the varied arguments of Kaushik SunderrajanMike Fortun, Nik Brown, and many others).

Ramanathan begins with a diagnosis of public melancholy, to paraphrase the political theorist Wendy Brown, amid the apparent failure of the future-oriented progressivism of the development planning state: “The depths to which public morality has sunk evokes desperation, which seeks answers somewhere other than where the problem now abides, viz. in the human person. Technology and the machine can in the land of desperate optimism, seem relatively uncorruptible.”

The line of argument is familiar, from M.K. Gandhi’s Hind Swaraj to the critique of Nehruvian planned development. But if Gandhi could hold out for an ethic of the human and non-human set against certain extremes of machine life, by now Ramanathan suggests the human seems to have been altogether forfeited as a site of work.

If this melancholic condition holds, in which no movement at the level of the human is conceivable, in the context of the figure of duplication that haunts the entire moment and apparatus of UID, it is a condition of behavioral melancholy.  That is, persons, at least “public persons,” simply cannot be counted on to act morally. If behavior fails, tout court, then one needs a proxy for behavior: the machine.

I am moved to suggest this figure of a proxy for behavior given work from a very different context: that of the anthropologist Ryan Whitacre examining the emerging therapeutics of PrEP, pre-exposure prophylaxis for HIV as developed by the Gilead pharmaceutical corporation. At a UCLA conference organized by Mark McGrath to debate the impact of PrEP to which Ryan and I were invited, a dominant argument for the value of antiretroviral medication taken to prevent infection was that “behavior [i.e., condom use] has failed.” In the face of the utter failure of behavior, Gilead’s drug Truvada was offered as a proxy for behavior. [It is worth pointing out that these arguments were not made by Gilead representatives, who were not present at this conference. It may be worth pointing out that some of the activists making these claims were part of a welfare industry increasingly dependent on drug company funding.]

When behavior fails

One of Ryan’s several points, in the face of strenuous claims by several AIDS professionals that PrEP was necessitated by the failure of behavior, was that drug use is of course a behavior.

The point is neither to dismiss the power or utility of Truvada or PrEP nor to fail to acknowledge the experience of the activists that has led some to what I am calling behavioral melancholy.   Still, as scholars we note that PrEP may lead to a lifetime of the pharmaceuticalization of sex for many.  Truvada, used both to prevent as well as to treat infection, leads to a life course in which people who identify with particular terrains of risk consume the same drug both before and after seroconversion, a crucial clinical achievement but also brilliant corporate strategy and a validation of anthropologist Joe Dumit’s concept of the contemporary pharmaceutical capitalization of surplus health.

I mention this aside, on PrEP, as Ramanathan’s point similarly seemed to trouble an implicit or explicit claim for UID/Aadhaar as a proxy for behavior.

Ramanathan turns to the same and widely cited document on UID and Public Health I cited in the last post, and to the figure of the killer app. What is killer about the conception of public health as the “app” driving UID registration, as proposed in the document, is its coercive force. The ability to have access to more and more basic entitlements will be linked to the UID number: life will be inconceivable without it. Ramanathan challenges the “myth of voluntariness,” given the sheer force of the UID as it reorganizes the condition of life itself.

But in at least one sense, the form of coercion at stake works precisely through its “voluntary” quality. One is reminded of Emma Tarlo’s powerful reframing of the coercive sterilizations of the Indian 1970s’ Emergency. Unlike the powerful account in Rohinton Mistry’s novel A Fine Balance, when two poor men are literally dragged by goons into vehicles taking them to a surgical camp for forced operations, Tarlo shows through painstaking archival work in a Delhi resettlement colony how access to state-mediated land, food, employment, and minimal clinical care depended upon having the right identification papers, papers that marked one’s household as having given over a sufficient number of its members for the family-planning operation.

The state form under UID is not the state form under the Emergency. Increasingly, as Ramanathan points out, the state works not through operations but money. She cites the economist Jean Drèze: “The real game plan for social policy … seems to be a massive transition to ‘conditional cash transfers’ … If the backroom boys have their way, India’s public services as we know them will soon be history, and every citizen will just have a smart card – food stamps, health insurance, school vouchers.” Life will be conceived of as dependent on a series of apps, each associated with targeted cash transfer. The state is the platform for these apps. Health entitlement is the killer app as serious illness is, after all, a killer.

To return to the Jim Ferguson article cited in my last post: it is not clear that the shift to cash transfers is a priori a bad thing, or that its effects will represent the winnowing of a vibrant social state. It is not clear that the work of Jean Drèze is as contemptuous of the backroom boys as this particular citation suggests: a topic for another day. Next time, unless I am otherwise distracted, more on the Ramanathan article.

The ultimate proxy for behavior?

Advertisements

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