Imaginative geography,neoliberal globalization,and colonial distinctions: docile and dangerous bodies in medical transcription ‘outsourcing’

Introduction

It is imperative that we be the best global citizens that we can be – because in a flat world, if you don’t visit a bad neighborhood, it might visit you. (Thomas L. Friedman, The World is Flat, 2007)

Indian Data Theft ‘Exposed’: Britain Gripped by Fear of Keyboard-Wielding Foreigners. (Mark Ballard, The Register, 2006)

‘Imaginative geographies’ of neoliberal globalization often present ambivalences that are striking. ¹ Perhaps none is more glaring than the discursive construction of the world as ‘flat’ and yet marked by threat and fear. This ambivalence, if one were to follow Thomas Friedman’s argument, may seem understandable. ² The brave new flat world (which Friedman saw in Bangalore) seems to be under threat from, and also threatening to, those not wanting to be a part of it, particularly the terrorists. The resulting anxiety becomes acute because, as Friedman points out, ‘[t]he flat world – unfortunately – is a friend of both Infosys [an IT company based in Bangalore] and al-Qaeda.’ ³

Threat of terrorism notwithstanding, the figure of the terrorist remains deceptively ambiguous in Friedman’s analysis; particularly in its framing as the ‘other’ of IT ‘outsourcing.’ ⁴ Terrorists and IT ‘outsourcers’ (whose best exemplar for Friedman is Infosys) are represented as bearers of radically opposed worldviews. ⁵ However, they also seem to share a characteristic that makes them ‘successful’ within the flat world. Friedman writes:

Al-Qaeda has learned to use many of the same instruments for global collaboration that Infosys uses, but instead of producing products and profits with them, it has produced mayhem and murder. ⁶

Such juxtaposition of terrorism and IT outsourcing may be unique. Nevertheless, the imaginative geography that it displays is neither uncommon nor incidental. The ‘terrorist’ has become the present day idée fixe, which in the colonial discourse was symbolized by ‘despot, heathen, barbarian, chaos, violence.’ ⁷ This postcolonial and neoliberal idée fixe is not a fixed, pre-defined, and spatially containable ‘other,’ however. ⁸ S/he is seen as a fellow traveler in the ‘flat world,’ who not only can be anywhere and contaminate everywhere, but also be potentially anybody. ⁹

We argue that such a discursive construction represents an imaginative geography that is undergirded by a deeper ambivalence towards shifting transnational scape of technoscience. An ambivalence that is rooted in the ‘desire for a reformed, recognizable Other,’ who is expected to be ‘best global citizens,’ but could also easily slip into being a ‘terrorist.’ ¹⁰ This imaginative geography as Derek Gregory, following Edward Saïd, argues, ‘fold[s] distance into difference through a series of spatializations.’ ¹¹ Moreover, as Gregory further argues:

This space of potential [that is marked and also created by the imaginative geography] is always conditional, always precarious, but every repertory performance of the colonial present carries within it the twin possibilities of either reaffirming and even radicalizing the hold of the colonial past on the present or undoing its enclosures and approaching closer to the horizon of the postcolonial. ¹²

IT outsourcing, of which medical transcription is a part, is no different in this regard. ¹³ However, amidst the contingency and precariousness of the ‘colonial present’ there also exists an enduring ambivalence. We argue that such ambivalence, which is common within discourses of neoliberal globalization, is what makes transnational practices such as medical transcription ‘outsourcing’ seductive and yet the site for colonial desire. ¹⁴ Much like Homi Bhabha’s description of colonial mimicry, this ambivalence becomes the ‘sign of a double articulation.’ ¹⁵ On the one hand, it represents ‘a complex strategy of reform, regulation and discipline.’ ¹⁶ However, instead of appropriating the other (as is the case with colonial mimicry), it marks the other for continual vigilance lest s/he slips into being the other ‘other’ – the metaphorical avatars of the ‘terrorist,’ who cannot be best global citizens.

This neoliberal imaginative geography is not merely a representational practice. ¹⁷ It folds within itself a biopolitical strategy that is propelled by the anxiety inherent in the ambivalent desire for a reformed and recognizable ‘other.’ ¹⁸ The biopolitical strategy seeks to make the neoliberal worker engaged in ‘outsourcing’ services docile while continually marking him/her as dangerous (‘data thieves’ responsible for creating ‘fear of key-board wielding foreigners’). ¹⁹ We call this biopolitical strategy colonial governmentality to signify its forked operation as an art of government that operates through ‘conduct of conduct,’ but continually draws upon colonial practices. ²⁰ The recurrent anxiety of slippage between ‘best global citizen’ and the ‘terrorist’ allows, as we show in this article through an analysis of medical transcription ‘outsourcing,’ a folding of colonial strategies within the market-oriented neoliberal ‘governmental’ practice. Consequently, colonial practices become agenda/non-agenda of ‘government,’ rather than (explicit) strategies aimed at dividing population or people. ²¹

Neoliberal global economy of medical transcription

‘The world is flat.’ As soon as I wrote them, I realized that this was the underlying message of everything that I had seen and heard in Bangalore . . . The global competitive field was being leveled. The world was being flattened. (Thomas Friedman, The World is Flat, 2007)

Medical transcription is one of the most extensively outsourced services in the healthcare industry and is adopted as a part of easing the tedious process of medical record documentation. ²² (Prasanna Rege, S P Software Technologies [India] Pvt. Ltd, 2010)

Medical record keeping has a long history – often traced back to Hippocrates. ²³ Nevertheless, until recently, transcribing of medical records was largely a locally conducted exercise (within a clinic or a hospital). In the last few decades, as new medical technologies and procedures for the care of patients proliferated in the United States and some European nations so did the volume of patient records. The need for recording and archiving this fast growing patients’ medical data created the occupation of medical transcription. The US Department of Labor defines medical transcription work as:

Medical transcriptionists listen to dictated recordings made by physicians and other health care professionals and transcribe them into medical reports, correspondence, and other administrative material. The documents they produce include discharge summaries, history and physical examination reports, operative reports, autopsy reports, diagnostic imaging studies, progress notes, and referral letters. ²⁴

The Association for Healthcare Documentation Integrity, formerly the American Association for Medical Transcription, which was established in 1978, has striven hard to establish medical transcription as specialized work that requires a high degree of talent and qualification. ²⁵ It was, however, passed off as ‘medical secretary work’ and its practitioners were called ‘typists’ or ‘word processors’ until 1999, when the US Department of Labor gave this profession a separate job classification (under the Standard Occupational Classification). ²⁶ ‘Medical transcriptionists’ or ‘medical language specialists’ have become commonly accepted professional classifications these days. In the last decade, as the digitization of health records emerged as the new mantra for efficiency and cost-management in healthcare, medical transcription industry received a major boost.

The basic goal of medical transcription – linking of individual patients to the healthcare system – has not changed in the last 30 years. Nevertheless, parallel to the shift to digitization of health records, medical transcription has acquired a new urgency. The utility of such record keeping, according to medical transcription industry leaders, is very valuable. Glen Tullman, the CEO of the health records company Allscripts, argues:

Prescription errors . . . injure 1.5 million and kill 7,000 patients annually – and most mistakes could be avoided if scripts were written electronically. ‘Seven thousand deaths is the equivalent of one Boeing 737 crashing every week for a year’. ²⁷

Even though the importance of digitization of medical records is most often not being presented so starkly, there is an increasing belief that ‘digitization improves organization and efficiency’ and thereby leads to better and cheaper healthcare. Not surprisingly, the main goal of the Health Information Technology for Economic and Clinical Health (HITECH) Act, which was signed into law by President Obama in February 2009, is to ‘promote the adoption and meaningful use of health information technology.’ ²⁸

Increasing emphasis on electronic health records has resulted in phenomenal growth of the medical transcription industry. According to a recent report, the medical transcription market in North America alone is going to reach $30 billion by 2014. ²⁹ The demand for medical transcription services is expected to grow even further because of the aging population in the US and some other western nations. While this is good news for the medical transcription industry, hospitals and clinics have been concerned about burgeoning expenditure.

Outsourcing of medical transcription work was an outcome of the growing cost concern. Medical transcription work, in the first instance, has little to do with the socio-political, economic, and medical context of India. It emerged in India because of its ‘outsourcing’ largely from the US. Off-shoring of medical transcription work to India offered a lucrative cost advantage. While the median earnings of the medical transcriptionists in the US has been roughly $14 an hour, in India their counterparts are paid 5000 rupees or around $110 per month, which they can supplement by getting bonuses for faster turnarounds.

In spite of the significant cost advantage, medical transcription outsourcing would not have emerged without the possibility of electronic transmission of data. As broadband communication improved in the 1990s, medical data could be transmitted across the globe almost instantly. This data is then converted into electronic health records and transmitted back, allowing for a fast, cost-effective, and 24/7 operation. Rich Bagby describes the new socio-technical network nicely:

The physician phones a toll-free number, anytime, to record his or her transcription. Doctors can do this at home, since they don't have to deposit the recording at the hospital. If the service provider has an offshore office, say, in India, it's morning. Staff members retrieve the recording and type the transcript. On-site staff physicians review the transcription, so the American doctor doesn't need to review the record for accuracy. ³⁰

This techno-social transformation allowed profit extraction not only by cutting costs but also by stretching time. Medical transcription companies (whether of US origin, their Indian subsidiaries, or purely Indian-owned ones) stress the immense productivity that results from a speedy turnaround time and because the time difference between India and the US is around 12 hours, which allows a 24/7 operation. The other advantage that is highlighted by the medical transcription companies is the availability of a large body of trained personnel in India. In the last 10 years a large pool of IT professionals, most of whom are graduates with fluency in English, have formed the backbone of India’s human capital. ³¹ Medical transcription industry in India draws from this pool of human capital. ³²

It should, therefore, come as no surprise why medical transcription outsourcing is such a big and growing business. According to CBay Systems, one of the leading providers of healthcare outsourcing services, ‘internal trends, including budget cuts on capital expenses, staff reductions, and the shortage of qualified transcriptionists continue to mire the ability of hospitals and medical practices to provide timely and quality transcription’ in the US. ³³ CBay Systems, the third largest medical business process outsourcing (BPO) service provider, had thus aggressively started implementing its expansion plans based on its model of 95 percent outsourcing to India. ³⁴

The number of medical transcription companies has been growing very fast in India. In 2006, according to the Business Line, a business daily from the Hindu (a well known national daily), there were around 120–150 medical transcription companies in India. ³⁵ At present, it is believed that 10 percent of medical transcription in the US is handled by off-shore companies, but this figure is rapidly changing. Predictions are that this market is going to further develop with increasing healthcare costs in the US and because of ‘increasing regulatory emphasis on digitisation of medical records and documentation.’ ³⁶ In fact, medical transcription is being touted as a ‘recession proof’ career. ³⁷

Medical transcription outsourcing has offered new possibilities of making a living in India (as well as some other non-western nations such as the Philippines and Pakistan). The resulting transformation is not just economic. It has also made Indians a part of the ‘flat world’ of neoliberal globalization. Nuimuddin Chowdhury writes about the experience of one such ‘global citizen’:

Siva is about 36 years old, and — until the beginning of 2000 — was utterly ignorant of all aspects of computers. At the urging of a brother-in-law who practices medicine in the United States, he signed up for a medical transcription training course . . . After four months, Siva had mastered the production system . . . Siva’s gross income comes to about $350 a month – a comparative fortune in India . . . He prays fervently such good times should continue. ³⁸

Medical transcription industry in India evidently operates through ‘conduct of conduct’ or to use a Nikolas Rose’s phrase, through ‘powers of freedom.’ ³⁹ Medical transcription companies as well as individual transcribers commonly reflect willful embrace of a neoliberal identity. ⁴⁰ The key tenets of ‘neoliberal rationality of government’ such as ‘“competition”, “market”, “freedom”, “choice”, “customer orientation”, “efficiency”, and “flexibility”’ have become constitutive elements of the Indian medical transcription industry’s repertoire. ⁴¹ In short, medical transcribers in India are seeking to be Friedmanian ‘best global citizens’ – utilizing ‘instruments for global collaboration . . . [to produce] products and profits.’ ⁴²

Medical transcription providers in India have to be not just competitive and efficient, however. They should also be able to bring together two worlds – of American medical practices and medical transcribing by Indians. Bharthi MediScribe displays this upfront on its web page, juxtaposing images of a white male doctor holding a needle and an Indian woman transcribing on a computer. ⁴³ Nevertheless, cross-national ‘translation’ has not been easily subsumed within the logic of the market. Fear of data theft often disturbs medical transcription outsourcing’s ‘instruments for global collaboration.’ This is definitely because medical privacy in the US and some European nations is intimately tied to issues of identity and citizenship rights. Consequently, medical privacy is a deeply held belief and concerns over it are widespread. For example, in a Gallup poll in the US that was conducted in 2000:

78 percent of respondents said it is very important that their medical records be kept confidential, 82 percent opposed letting insurance companies see their medical records without permission, and 95 percent opposed access by banks. ⁴⁴

However, a closer look shows that there is something else going on as well. For example, an Ernst and Young survey showed that:

almost two thirds [of corporate managers in the ‘developed’ countries] expected to encounter more fraud in the emerging markets than at home . . . [even though] seventy five percent of the fraud occurred in the developed markets. ⁴⁵

That is to say, the commonly expressed anxiety towards medical transcription outsourcing may not be simply because of aggravated instances of data theft in the ‘outsourcing’ destination.

Global citizens in a transnational panopticon

India is a developing country, but it is a developed country as far as its intellectual infrastructure is concerned. We get the highest intellectual capital per dollar here. (John F. Welch, former Chief Operating Officer, General Electric, 2005)

This development [‘overinvestment in fiber-optic cable needed to carry all the new digital information’], in turn, wired the whole world together, and, without anyone really planning it, made Bangalore a suburb of Boston. (Thomas Friedman, The World is Flat, 2007)

In the new digital age, ‘Bangalore’ seems to have become ‘a suburb of Boston’ in more ways than one. Medical transcription industry in India, for example, operates in relation to American legal and medical concerns. Among the first things that Indian as well as multinational medical transcription companies with subsidiaries in India emphasize is that their work is Health Insurance Portability and Accountability Act (HIPAA) compliant. HIPAA, which was enacted by the US Congress in August 1996, makes disclosure of an individual’s medical information punishable under law. ⁴⁶ Department of Health and Human Services (DHHS) of the US has proposed four rules that define the privacy and security elements of HIPAA, two of which namely, Security and Privacy Standards are directly applicable to medical transcription outsourcing: ⁴⁷

As a result of these rules, covered entities are required to execute written business associate agreements with outsourcers that will have access to certain types of individually identifiable health information to ensure that specific privacy and security obligations are placed on the outsourcers. ⁴⁸

The final Security and Privacy rules came into effect from 14 April 2003 (14 April 2004 for small health plans). ⁴⁹

However, HIPAA cannot be legally enforced outside the US (except by sanctioning the US-based companies in case of violations). The effectiveness of HIPAA in the context of outsourcing, which is evident in the upfront display of its compliance by medical transcription companies in India, is largely a result of elaborate ‘disciplining’ mechanisms. ⁵⁰ Several of the American outsourcers have been using a variety of technologies to ensure security and privacy. Clarence Schmitz, Chairman and CEO of Outsource Partners International, Inc., a New York-based service provider with an Indian subsidiary, explained how his company maintained data security during an interview. The interview, interestingly, started with the question: ‘How can you be sure your employees in America and India are trustworthy?’ The questions that followed focused on concerns in relation to India, however. When asked, ‘[h]ow do you prevent someone in your Indian offices from copying the data?’ Schmitz replied:

None of our computers in India have removable media drives. None are wired to a printer. And we've disabled their email capabilities. We don't allow paper, pencils or pens at any workstation. Our offshore employees sit at a desk with two computer screens. The first screen shows the scanned data. They enter data into the second screen. ⁵¹

In other words, the disciplinary gaze in this case attempts to harness the Indian human capital through a transnational expansion of the ‘panopticon.’ ⁵² Michel Foucault’s analysis aptly resonates with the ‘disciplining’ of Indian medical transcribers through a set of technological controls far removed. According to Foucault, ‘discipline fixes; it arrests or regulates movements; it clears up confusion . . . it establishes calculated distributions.’ ⁵³

Nevertheless, slippages between best global citizen and its ‘other’ (the metaphorical avatars of terrorist) continue to disrupt the collaborative supply chains of the flat world. The University of California-San Francisco (UCSF) medical transcription outsourcing incident has been a much talked about case of such disruption. Medical transcription work of UCSF was outsourced to a Florida company, owned by Kim Kaneko, who sub-contracted it to Sonya Newburn, a Florida woman, who in turn outsourced it to a Texas man named Tom Spires, who further outsourced it to a woman in Pakistan named Lubna Baloch. ⁵⁴ Lubna Baloch, who was allegedly not paid by Tom Spires’ company for 18 months, threatened UCSF that she will post patient data on the world wide web. ⁵⁵

UCSF was not only confronted with a scenario that seriously damaged its reputation. It could have also faced legal problems in the US for medical privacy violations. After receiving the threat, UCSF reverted back to its ‘supply chain’ and the Florida subcontractor ‘Newburn agreed to pay a portion of the money Baloch claimed she was owed – about $500.’ ⁵⁶ In turn, Baloch wrote an email to UCSF stating, ‘“I verify that I do not have any intent to distribute/release any patient health information out and I have destroyed the said information”.’ ⁵⁷ On her part, ‘[a]n emotional Newburn said in an interview that she's as much a victim as Kaneko. “I feel violated”.’ ⁵⁸

It is relevant to note that this particular incident has not been seen either as an exception or as a case in which medical transcription outsourcing not only involved, but also implicated Americans as well as a ‘Pakistani woman.’ Rather, it has become a quintessential example of the dangers of medical transcription outsourcing to countries in Asia. An article in the Boston Herald titled, ‘Known Around the World: Private Records Might be at Risk,’ described this case in the following way:

The outsourcing industry was given a major scare recently when a Pakistani woman, who works in Asia and transcribes medical notes about Americans, threatened to post patients' records on the Internet unless she got a raise. Experts say such incidents will increasingly occur – and it's only a matter of time before a huge scandal erupts. (Emphasis added) ⁵⁹

Newspaper reports also highlighted that it was the greed for more money, rather than a possible claim for adequate compensation that may have led to the incident. David Lazarus wrote in the San Francisco Chronicle:

A woman in Pakistan doing cut-rate clerical work for UCSF Medical Center threatened to post patients' confidential files on the Internet unless she was paid more money . . . The Pakistani woman's threat was withdrawn only after she received hundreds of dollars from another person indirectly caught up in the extortion attempt. (Emphasis added) ⁶⁰

The other significant aspect of this portrayal is the reference to Lubna Baloch as the ‘Pakistani woman,’ even though the rest of those implicated are referred to by their proper names. Details of the person or the specifics of the case have been rendered secondary to her sole identification as the ‘Pakistani’ woman, ‘who worked in Asia.’ This generalized ‘other’ thus becomes the face of anything that is wrong within the whole system.

Interestingly, in such cases of privacy and security violations what is also forgotten is neoliberalism’s own logic of profit maximization. Within the market-oriented approach of neoliberalism, every individual is supposed to be maximizing his/her benefits by hedging the risks. Lubna Baloch may not have even been maximizing her benefits. She might have just wanted to get the remuneration that was due to her. To clarify, we are not defending violations of medical privacy. What we wish to point towards are the hierarchies and contradictions of neoliberal capitalism/globalization. More specifically, we argue that cases of data theft acquire a fetishized status because of the inherent ambivalence in the neoliberal/colonial desire for ‘best global citizens.’ This desire is articulated as a complex biopolitical strategy of reform and regulation and is ostensibly aimed at allowing unhindered operation of the global collaborative chains of the market.

Juridical measures such as HIPAA, as mentioned earlier, are only partially successful in this regard. The biopolitical strategy has been effective by resorting to a more elemental aspect of the law, namely delineation/constitution of the ‘normal’ and the ‘pathological.’ Normal and pathological are not extra-social and ahistorical categories. ⁶¹ Nevertheless, in the case of medical transcription outsourcing the ‘normal’ and the ‘pathological’ are being defined and understood in a unidirectional and fixed way – on the basis of laws and values of the outsourcing country and not the nation where the act may have taken place; for example, in Pakistan or India. ⁶² Moreover, the medical transcriber in the outsourced country is often identified as the prime and, most often, the sole site as well as the source of ‘pathology.’ ⁶³ An element of neoliberal citizenship of medical transcribers in countries such as India is, therefore, articulated like that of a colonial subject. ⁶⁴

It is relevant to highlight that the ambivalent desire for a reformed and regulated ‘other’ is not simply a post fact response to instances of data thefts, as it is often portrayed. In fact, the biopolitical strategy that this ambivalence propels is oriented towards preemptive action. ⁶⁵ Hence the response in India to privacy and security violations has not only been punishment of the violators. Broader self-disciplining mechanisms have also been put into place to exercise preemptive control. National Association of Software and Service Companies (NASSCOM) in India is well aware that privacy or security violations can easily be translated into discrediting of the Indian IT industry. Kiran Karnik, the President of NASSCOM in 2006, puts it succinctly: ‘We will leave no stone unturned to make India the “Fort Knox” of security, positioning ourselves as the gold standard for security as we are today for quality.’ ⁶⁶ Along with other security measures, NASSCOM has created a National Skill Registry to prepare an archive of biometric and social data of all IT professionals in India. ⁶⁷ Its website puts the goal upfront:

National Skills Registry is a NASSCOM initiative to have a robust, structured and credible information infrastructure about all persons working in the industry. This develops trusted and permanent fact sheet of information about each KP [Knowledge Professional] along-with background check reports. ⁶⁸

National Database Management Limited (NDML), which has set up National Skills Registry and manages it on behalf of NASSCOM, leaves even less to doubt about the purpose of this database:

This [National Skills Registry] can be used by the IT & ITeS / BPO industry and its clients as a credible source of information about the registered professionals who are being employed or put on client assignments. The system will also enhance the image of Indian IT & ITeS / BPO industry as one that has raised the bars on security standards in pursuit of excellence and client satisfaction. ⁶⁹

NASSCOM has also created the Data Security Council of India to serve ‘as a credible and committed body to uphold a high level of data privacy and security standards.’ ⁷⁰ These disciplinary mechanisms, which are evidently oriented towards the threat of data theft, have a much broader goal. They are aimed at ‘organizing all features of one’s national policy to enable market to exist, and to provide what it needs to function.’ ⁷¹ However, what they also signify is the furious anxiety that cannot abate because its site of origin, at one level, is the ambivalence inherent in the desire for ‘best global citizens.’

The deployment of disciplinary mechanisms such as National Skills Registry is also highly paradoxical, particularly in the case of medical transcription outsourcing. In order not to compromise the confidentiality and identity of the American patients, personal information of the Indian workers is being catalogued and monitored. In the articulations of power the panoptical gaze is evidently emanating from the US. Analogically, the tower of the prison in reference to which the panoptical gaze operates is located in the US.

Conclusion

Everyday, we come across a new report that confirms that India is coming into its own globally . . . Inspired by your generous and heartfelt support, we will work through the year to ensure that 2007 indeed turns out to be The Year of India. Because a take-off point comes very rarely – maybe once in several generations – in the life of a nation. And our time is now. (India Poised, The Times of India, 2007) ⁷²

As Nandan [erstwhile CEO of Infosys] explained to me how Infosys could get its global supply chain together at once for a virtual conference in that room, a thought popped into my head: Who else uses uploading and supply-chaining so imaginatively? The answer, of course, is al-Qaeda. (Thomas Friedman, The World is Flat, 2007)

There can be little doubt that a particular neoliberal governmentality has permeated the imaginary and practices of the ruling elite and to a large extent the middle class in India. Harnessing of human capital as a principle of ‘conduct of conduct’ is evident in government’s policy documents, in newspaper articles, and in the discourses of transnational corporations and international financial institutions such as the World Bank. Of course there are resistances and exceptions to neoliberalism’s growing reach. The resistances against neoliberal globalization in India, as elsewhere, exemplify the limits of the hegemony of neoliberal discourses. Nevertheless, their very existence also points towards neoliberal globalization’s reach. ⁷³

This neoliberal governmentality, very similar to Foucault’s description in the European context, seeks to constitute ‘the right disposition of things’ with the population as the target. ⁷⁴ It also operates largely through, to use Rose’s phrase, ‘powers of freedom.’ ⁷⁵ Even when disciplinary practices such as the National Skills Registry are instituted, they are ostensibly articulated as interventions in the ‘conduct of conduct’ in order to make India/Indians competitive and thus gain from outsourcing.

Nevertheless, Foucault’s analytics not only seem inadequate, but also in conflict with the biopolitical and geopolitical strategies of medical transcription outsourcing. ⁷⁶ In particular, colonial practices seem to be directly opposed to governmentality, which, according to Foucault, is articulated as a pastoral power. ⁷⁷ The issue here is not of hierarchical and unidirectional articulation of power. ‘Panopticon,’ as Foucault shows vividly, was designed for this very purpose. ⁷⁸ Foucault also alluded to the role of colonialism as a mechanism of power and government not only outside Europe, but also within it. ⁷⁹ To quote him:

It should never be forgotten that while colonization, with its techniques and its political and juridical weapons, obviously transported European models to other continents, it also had considerable boomerang effect on the mechanisms of power in the West, and on the apparatuses, institutions, and techniques of power. A whole series of colonial models was brought back to the West, and the result was that the West could practice something resembling colonization, or an internal colonialism, on itself. ⁸⁰

The problem in analyzing concatenations of colonial practices and governmentality is, in part, in relation to the role and place of the state (and thereby sovereignty). ⁸¹ In Foucault’s analysis, even though the state (in the plural) is the ‘mobile effect of governmentalities,’ it (through law) also defines the self-limitation of government. ⁸² Foucault put it succinctly:

In the new system we are dealing with a different problem: How can the necessary self-limitation of governmentality be formulated in law without government being paralyzed, and also . . . without stifling the site of truth which is exemplified by the market. ⁸³

Transnational expansion of governmentality makes this principle of self-limitation of government superfluous, or at least inherently contentious (since it is articulated at the conjunction of laws of two or more sovereign nation-states and transnational laws are few and largely ineffective). ⁸⁴ Consequently, transnational practices such as medical transcription outsourcing reflect a ‘global’ governmentalization of the state(s), which, nevertheless, is fraught with slippages between colonial control and ‘conduct of conduct.’ ⁸⁵ Such slippages remain deceptively ambiguous because they are ostensibly aimed at freeing the ‘market’ and avoiding disruptions in the global collaborative chains. However, as we have shown in this article, the colonial desire has much deeper roots. Such desire is evident in the imaginative geography that frames Friedman’s celebratory embrace of the ‘flat world’:

I had come to Bangalore, India’s Silicon Valley, on my own Columbus-like journey of exploration . . . Columbus was searching for hardware – precious metals, silk, and spices – the sources of wealth in his day. I was searching for software, brainpower, complex algorithms, knowledge workers, call centers, transmission protocols, break-throughs in optical engineering – the sources of wealth in our day. ⁸⁶

It is, therefore, useful to explore how imaginative geographies reflect (and allow) folding of apparently contradictory discourses as well as biopolitical strategies. We have argued that the biopolitical strategy within which transnational practices such as medical transcription ‘outsourcing’ are operating is rooted in the ambivalent desire for a reformed and regulated ‘other.’ We have called it colonial governmentality to emphasize its forked articulation through strategies of colonial difference and neoliberal rationality of human capital. We are certainly not claiming that the fear and threat that instances of data theft in an outsourced country generate are unfounded. However, we would like to argue that such fear is also an outcome of the ambivalence inherent in the neoliberal/colonial desire for ‘best global citizens.’