It’s like an unspoken caste system. Signs of it can be seen littered casually across our everyday landscape—a clue was there just this week, in a Delhi government communique. News so routine that it disturbs nothing, angers no one, only confirms the order of things. But Urmila Bhadoria had encountered it back in the summer of 1978 itself, when she was still only at the cusp of it all. It came to her like a faint stigma, almost. Like an odour, it had arrived even before the real thing.
Just 17 then, she was on a train from Kanpur to Lucknow, chaperoned by her father. There was an interview waiting at the other end, for a diploma course in general nursing and midwifery (GNM). She remembers bits of the idle chatter in that compartment, rather vividly, to this day. Especially the disapproving words of a stray ‘uncleji’ in that motley group—rattling off almost like a high priest’s catechism.
“It’s not a very good job, you know. The girl will be working in a public place...she’ll be required to do night shifts. Why would you allow her do it?” went the unsolicited advice to her father. He could well have been speaking for all society, issuing a statutory warning considered normal within its order. The pyramid of values where one layer of human activity actually holds up the whole structure, but is perennially damned by that very fact—for being too ‘low’.
A nurse at a coronavirus sample collection centre in Delhi.
After 40 years into a career that’s been the central pillar of her life, Urmila can look back at it and laugh. There’s both a gritty pragmatism to her words, and a heroism worn lightly. “It was because I had this job that I was able to raise my two children and send them to a convent,” says the single mother. “We did night shifts. We dealt with HIV patients and Hepatitis B cases, knowing anything could happen to us. When we see COVID-19 patients, it feels we are inches away from death. Whether society recognised our role or not, we kept working silently all through.”
Suddenly, though, recognition has been instant. Nurses are no longer seen as that invisible human robot blending into white hospital walls—almost part of the apparatus. They are the vanguard…short only on protective gear. We know they are inhaling, as we speak, the acrid gunsmoke right on the frontline. In videos, we see them battling doubt and gloom like anyone else—the isolation ward is their trench. The words of an American nurse, a Black like the legendary Mary Seacole—speaking out her shattered soul, spiritually crushed by the ubiquity of death—have been all over. Everyone now sees them as an infantry marching right up front, without shields….
Nurses at a ward.
But even that recognition is accompanied by a touch of that older version of...shall we say, ‘social distancing’? At 11.30 pm on April 18, a five-star hotel in east Delhi told 15 nurses and technicians who had just begun their quarantine that they had to vacate their rooms—and those were meant “only for doctors”. They had been put up at Leela Ambience Convention Hotel in accordance with a Delhi government order—offering the COVID-19 warriors a 28-day stay at a premium hotel, while they spent half of that time on active duty, and half in quarantine. These nurses had finished their duty part, beginning April 2, when their lesser status was underlined. On April 20, Delhi duly amended its rules: “premium accommodation” would be offered only to doctors. It would be “hotels” for nurses, and dharamshalas for other service staff.
Put a face to them? At 8 am on a recent weekday, an Intensive Care Unit (ICU) nurse, emerged from her 12-hour COVID-19 shift at a government hospital in Delhi—one not notified as a COVID-19 hospital, which makes its staff ineligible for the government’s accommodation offer. We’ll call her Blessy Chacko, because her hospital has just put a ban on nurses speaking to media or on social media. “It was a tough night,” says Blessy, who saw six patients breathing their last, including a 13-year-old, at the isolation ICU. It’s a half-hour walk from the hospital to her rented one-room accommodation; she barely gets four hours to sleep before her next shift starts. The gruelling schedule will last through the week, after which she will be in a 14-day quarantine. For once, she’s relieved that her three-year-old daughter is far away, with her grandmother, though she misses her. Scores of nurses, she says, have stories to tell about being shunted out of flats by nervous landlords and not being given proper facilities in quarantine, including food. “We are being hailed as angels now, but will be forgotten soon. Nothing is going to change the situation,” says the 35-year-old who’s been a contractual staff nurse for the past 12 years. She prefers her one-room pad because the hostel option is much worse—one washroom for 25 nurses.
Egyptian pharaoh Tutankhamun’s wet-nurse Maia; Florence Nightingale, the founder of modern nursing—the world will celebrate her 200th birth anniversary this May and the British-Jamaican Mary Jane Seacole, another pioneering nurse like Nightingale and a contemporary during the Crimean War.
Premium stay? They can dream of at least not being reminded of their ‘status’ by government order in the middle of a pandemic. Or like when a top hotel started sending them their “stale” airline meals, which led to a huge uproar. It’s not pure class hierarchy either; there’s a shadow of caste here. In a traditional society, the bodily domain defines it—“girls who have to do night shift, who have to touch others”. Hence that early stigma. But wasn’t it, paradoxically, also the most vital of human activities always? One so sacred that all ancient cultures, from Greece to China to Egypt, embodied nurses as goddesses? Look at it frame by frame. From a delivery to the baby’s first vaccines, blood tests to wound dressings, the hand that checks the IV drip, the zero-error presence in a silent OT, the all-seeing eyes at a buzzing ICU—the nurse is central to all those snapshots. Then, the unseen side of things—the punishing schedules, the double duties, personal sacrifices.
In the mid-19th century, the Crimean War gave the world Florence Nightingale and nursing changed forever—what was once a profession for the working classes became more acceptable. Imbued in colours of Christian caring, a narrative of “service” enabled that shift. In India too, modern nursing as a profession had to create its niche with mental attitudes that were slow to change. And yet, social realities helped. The only three career options open to girls in Urmila’s time were teaching, banking and nursing. “Nursing had the maximum vacancies,” she says. Now, nursing colleges have mushroomed in India, even if service conditions haven’t kept pace. Not to mention ‘status’. It’s during this incomplete passage that—in 2020, the bicentennial year of the ‘Lady with the Lamp’—we see the burden of a pandemic fall on the nurse’s shoulders.
A US military ad for nurses during WW-II. A US Navy sailor hugs and kisses a nurse at Times Square, NYC, after WW-II. The cute coronavirus robot nurse Tommy in Italy.
“There has been change, but real change is yet to come,” says Prof Roy K. George, president of the Trained Nurses Association of India (TNAI). “It’s happening slowly in isolated corners, not everywhere.” He’s referring to the vast number of bedside nurses who struggle through poor pay and slow career progression. There are exceptions, especially at very senior levels where nurses even rise to become chief operating officers. “That’s a slow change coming in India, which was unthinkable 10 years back.” The sheer numbers are changing. Take Kerala, a state almost synonymous with nurses. Roy says when he enrolled in a nursing course in 1983, he knew of no nurses from his village. “Now every other home has a nurse.” There are other pockets where nursing has caught on, like in the Northeast. But not uniformly across India, he says.
“It should have happened 30 years ago, parallelly, when the medical community was getting established in India,” says Captain Usha Banerjee of Apollo Group. As nursing director overseeing a chain of 72 hospitals, she still speaks of the problem of attracting talent. “Nursing as a profession has not got a sheen around it,” she says. It doesn’t compare well with other professions of similar entry-level wages. “Nursing deserves much more attention than what it is getting.”
Actress Shikha Malhotra of Kaanchli Life in a Slough is working as a volunteer at a hospital in Mumbai to fight against coronavirus. Shikha has a degree in nursing from Delhi’s Vardhaman Mahavir Medical College and Safdarjung Hospital.
Some of the shackles go back a long way. First, it’s still seen as a woman’s job. It’s been an equally long, hard journey to shrug off the ‘menial’ job tag. Not to speak of the stereotypical depiction of nurses in popular culture, mostly risqué. Back in 1995, the nursing sorority even took out protests against a Bollywood film that showed them in poor taste; a few years ago, it was (then) AAP’s resident humorist-poet Kumar Vishwas who courted controversy by joking about them. Now, the 2019 Malayalam movie Virus has become the season’s must-watch—even for bureaucrats and medical staff—for its tense, superbly edited, blow-by-blow account of the Nipah outbreak in which the heart-rending story of nurse Lini Puthussery, who succumbed while treating the first Nipah patient, drives home the message of what a nurse actually faces.
And the incentives are next to nil. Promotions, many say, are few and far between in an entire career: someone like Blessy can look forward to endless, dreary hours slung on a bleak, static career graph. Usually, government jobs are sought after because pay in the private sector is comparatively low. Many, of course, are willing to work for lower wages. The TNAI went to the Supreme Court in 2011 over the matter. In 2016, a committee recommended that private hospitals link pay to state government salaries: those with under 50 beds paying a minimum of Rs 20,000, while salaries at hospitals with 200-plus beds were to be on par with government hospitals.
Nurses at Cooper Hospital, Mumbai, protest against an attack on colleagues by a patient’s relatives. Such attacks are happening frequently across India.
“But implementation is still lagging behind,” says Roy. Even in Kerala, it took months of protests by nurses’ unions in 2018 to get things moving. The reliance on contract staff allows some establishments a loophole, says TNAI. Even in the public sector, recruitment of nurses through outsourcing and contract basis is a sore point—in some states, like Gujarat and Tamil Nadu, nurses can get hired for as little as Rs 13,000 a month, says the association. “Nurses working in private hospitals are too scared to raise the salary issue because of the fear of losing their job. It’s difficult to sustain in a city like Delhi with a meagre 18-20k salary,” says Joldin Francis, general secretary and national coordinator of United Nurses Association.
COVID-19 has also brought new problems, while heightening old ones, says Francis. Many private hospitals are cutting the salary of nursing staff or giving it in instalments. “The spike in positive cases among healthcare professionals only goes to show the managements weren’t providing adequate protection,” says Francis. Altogether, this crisis has helped frame a mostly neglected part of healthcare, and bring a new focus on it. For, wages relate to one part of quality of outcomes. The other is the sheer workload. In most Indian hospitals, nurses handle far more patients than is optimal—nurse associations like TNAI demand a ratio of 1:1 in ICUs and 1:6 in the ward. But personnel shortages are rampant across India. The low social esteem, endemic to India, does not help at all. What it all adds up to: high attrition and, where possible, that outbound flight.
Aside from the Philippines, India is one of the top sources globally for nurses—even if we’ve tried ad-hoc measures to stem that flow, says Prof S. Irudaya Rajan of the Centre for Development Studies in Thrivunanthapuram. Of course, doctors migrate too. But for many nurses, it’s a more desperate bridge to a better life. “Even today, if you go to any nursing college in Kerala, 80 per cent students will say they want to migrate,” says Rajan. Typically, the first stop is the Gulf. From there, after a few years’ experience, some go to the UK, the US or Canada. That beeline to the Gulf has spawned a thriving local industry: an agency can charge a candidate about Rs 19,500. The going rates a few years ago were apparently as high as Rs 25 lakh, prompting the government in 2015 to ban all private agencies from recruiting to the Middle East in 2015. That led to a temporary stalemate, but some 30,000-50,000 nurses still go out of India every year, say experts.
AIIMS nurses bottle-feed an infant whose mother is a COVID-19 patient.
“It’s mostly the policies abroad that drive it,” adds Rajan. Last November, the UK decided to fast-track visas for medical professionals in a bid to plug the shortage in its National Health Service. Looking ahead, he reckons that will be the global scenario. “Because of coronavirus, high-skilled workers and especially experienced nurses will be in high demand in many countries,” he says. “Via-Gulf probably won’t necessarily be the main route any longer.”
There’s more to it than better pay. At the Royal Brompton and Harefield hospital in London, Sheeba Joseph is in charge of the heart and lung transplant and artificial heart service section. Every life-saving department has a specialised team of nurses, she explains. “Here, nurses are treated as equal with doctors,” says Joseph, who moved to the UK in 2002. “The treatment strategies are done in a coordinated way. In case of an emergency, junior doctors seek medical advice from the nurses on the next course of action.” Back in India, however, the public perception about nurses is still one of those who merely carry out the instruction of doctors, she rues. Cardiac surgeon Devi Shetty once wrote: “Ours is the only country where a nurse who has worked in the ICU for 20 years is legally not allowed to prescribe simple painkillers or give an injection without the presence of a doctor. Even in litigation-happy US, 67 per cent of anaesthesia is given by nurses, not doctors.”
That rigid hierarchy—throw in some patriarchy as well—is an oft-heard lament. Roy cites the example of how the MSc Nurse Practitioner course in critical care introduced in 2018—to fill a gap in ICUs—has run into opposition from doctors. Then, the long-standing plan for Directorates of Nursing in each state—again a non-starter. “With such a directorate, nursing will get more autonomy. We are not bargaining for power. More autonomy means a better-developed profession and better services for the public,” says Roy. As for now, even the country’s top representative post for nurses—the Nursing Advisor to the Government—has been lying vacant for the last four years, he points out.
India has around 21 lakh registered nurses and midwives and produces 3 lakh nursing personnel annually, but the actual count of available nurses (minus migration and retirements) isn’t clear. “Now, the Indian Nursing Council is in the process of making a live register. Maybe this year we’ll know how many nurses are actually in India and where they are working,” says Roy. First step, then, will be visibility.