[a version of this story appeared first on Outlookindia.com, the web product of Outlook Magazine, one of India’s premier weekly newsmagazines that sells more than 13 million copies a year, and later appeared on YaleGlobal Online.  It was also published on Immigration Here & There in June, 2006]

[to Profile “Male nurses of Rajasthan”]

“Male, 28: We are looking for nurses working in U.A.E. or in India. The girl should be god fearing. Our boy, who is handsome, is working as a supervisor in an electrical company in Sharjah having family status. He belongs to a renowned family in Central Travancore. Interested parties do contact us”. – Matrimonial website –

Beena Joseph

A nurse didn’t always have a young man’s family knocking at her door. Decades ago certain people whispered that she was dirty for handling the sick and the poor. Society questioned her purity knowing that she touched strange men unsupervised. That talk hasn’t completely silenced today, but Kerala’s nurses have persisted. They spread confidently across India, then to the Middle East and more recently to the West. They did a job others avoided.

These women traveled away from their country since the 1960s, when their fathers worried that it was inappropriate and unsafe. But they made good money doing it. Over time, their success got them attention and unexpected leverage. Today a woman can get more from nursing than a career – she can change life for her and her family.

‘Life is full of choices…choose carefully,’ reads the wall poster at New Delhi’s Fateh Institute – a nurse’s first stop on the way to work in the West. These nurses, the majority of whom are from Kerala, come here determined to score high on the English exam. Much of the pressure comes from parents, fiances or husbands, but none of them seem to mind. The promise of money and respect makes it all worthwhile. They have seen this promise come true for the drones of didis who have returned. And the respect isn’t just in their job, but also in their home.

These rewards fueled the more recent trend of nurses skipping a stint in the Middle East to go straight west. A phenomenon that may only get stronger with the May 25 U.S. Senate approval of immigration reform that would, among other things, eliminate the restrictions on the number of foreign nurses to help plug a spiraling nursing shortage over 100,000 deep.

With such opportunity around, the nurses may overlook the wise words on the wall. The decision to do nursing in America, the United Kingdom, Canada, Australia or the new hot spot, Ireland, hardly seems like one that needs to be made carefully – many nurses think it’s a no-brainer.

Beena Joseph never flinches from her plan to move to Philadelphia for the rest of her life. The 25 year-old woman heard from a friend that this historic U.S. city makes a good home. Anyway, if she is away from Kerala now while she works at a hospital and studies at Fateh, then she might as well be in America. Her point: If you are away from home, you are away from home.

Joseph’s pleasing warmth could never overshadow her persistent confidence – a manner that’s likely helpful for working in Intensive Care Units, where she requests to be stationed. The ICU is only as difficult as your mind allows, she says. Although her parents wanted her to become a nurse, she also states firmly that it was her idea and that she never considered doing any other job besides nursing since the tenth.

“Nursing is a noble profession, people get a chance to go abroad and do work, and visit many countries”, she says. “It is a good opportunity to serve the sick and poorer people.”

But it isn’t just respect and remuneration, Joseph is eager to learn new medical technologies and experience the adventure of a new country. She says, “Abroad there are many good working conditions and many good hospitals and also we can met many people. Iit’s a good living, it’s a foreign country.”

This unwavering certainty about the wonders of life abroad often worries Suneet Singh Kochar, Chief Executive Officer of Fateh. While he makes his money by helping nurses pass the English test, he tries to get them to think realistically about the choices they make. That’s why he made that poster to caution them. Many of the nurses return to tell him about their contracts, proud of the promised salary. Kochar laments that the salary looks deceivingly high in rupees. It’s good pay, no doubt, but those rupees can’t buy as much in the U.S. The recruiters never explain this to the nurses. Kochar does; he wants them to know all the facts before making their decisions

Kochar has also been researching a change for the nurses that is coming on the horizon. He predicts that language standards will get stricter because of a lesson learned by the United Kingdom.

“Patients can’t understand Indian nurses there,” he says. “And now they [in the U.K.] can more easily get nurses from Eastern European countries.”

Kochar’s institute specializes in the International English Language Testing System (IELTS) exam; every western country requires either this test or Test of English as a Foreign Language (TOEFL) as part of eligibility. He recently traveled the circuit of these countries as he plans to expand his business to include getting his clients jobs abroad – currently they have to go through recruiters after his institute helps them score high on the test. From his research, he saw that Australia had learned from the U.K.’s lesson and has high standards for allowing nurses into its hospitals. And Ireland may be soon to follow. Kochar saw articles all over Ireland talking about problems with the Indian nurses’ accents. He predicts, and other experts agree, that within the next two years Indian nurses will have to improve their language skills, accent and trained in the western way of nursing. But, he says, there will still be demand for Indian nurses.

“Filipino nursing skills are not up to the mark…and China has a language barrier,” he says. “The world needs nurses, and the biggest pocket is in India.” He adds that the aging population and increased life expectancy increases the need for nurses in the West.

Indian nurses, however, cannot yet count on the U.S. to let them help fill the nursing gap. The Senate approved the immigration legislation that favored opening its borders to foreign nurses, but the House of Representatives approved a different version back in December, which didn’t have this provision. Congress hasn’t focused on this part of the bill as they are distracted with the intense national debate on illegal immigration. As such, both houses will battle it out and that outcome will be important to nurses in India looking to work in the U.S. Until President George W. Bush signs the resultant bill, nothing is law.

According to the American Nurses Association (ANA), 3.5 per cent of U.S. nurses are foreign born – that was over 100,000 in 2004. And at that time the average earnings across all nurses was almost $60,000 (Rs 27 lakh) a year – a figure not always seen by Indian nurses, who’s recruiting agencies often take a cut. But satisfied enough to have a foot in the door, the nurses usually complete that first contract and renegotiate the next time.

Of the foreign born nurses, more than half are from the Philippines and 1.3 per cent of registered nurses have a diploma from India, according to the ANA. The U.S. Bureau of Labor Statistics puts nursing in the top 10 professions that will see the most growth by 2014. Yet, Americans, such as the ANA, are abuzz with concern that more foreign nurses means lower wages and worsened shortages in countries from which these nurses originate.

Joseph, however, has no doubts that she will be well received in the U.S. and she’s determined to succeed. She knows she will ace the test. She knows that she will easy acclimate, even though she hasn’t been there. Anyway, she must. It is all part of a grand plan. Joseph will first go to the U.S. – again, Philadelphia is ideal – she will try bring her parents after a couple of years. A task that is easier said than done in post-9/11 America. Her and her parents decided she shouldn’t get married now because she might not be able to give money to them.

Traditionally, once married, all the money goes to the man’s family. Some time before her parents move to her, she will marry a man from Kerala. Many nurses return home to marry, as the men from Kerala in the U.S. are in fields like engineering and may not want to wed a nurse; the stigma lingers. When Joseph’s parents look for her husband, one requirement will obviously be that he should want to move to the States. Whatever his profession, she’s sure he’ll have no problem finding a job there.

Researcher Marie Percot has seen Joseph’s story again and again – nurses with life -long plans all dependent on their career as a nurse. She says that Kerala’s nurses now create a “life strategy” based on the experience of the nurses who went before them. Percot, of France’s National Council for Scientific Research, spent ten months doing field research in India (Kerala and Mumbai), Oman and the United Arab Emirates, and she studied almost 300 migrant or to-be-migrant women. She went into her research thinking money was the nurse’s main drive, but found that over the decades their reasons became much more complex.

“There is an equation of money,” she says. But, “more and more I understood that it is more and more an individualistic need.”

She saw the women, especially the younger women, using nursing as a way to open doors for their whole family and to empower themselves to have more say in their life’s path. A nurse can reduce her family’s financial burden by giving them money and paying for some of her own dowry, which has a high price tag in Kerala. Nurses can find more prominent husbands with the attractiveness of a ticket abroad and, in some cases, bring a whole family to a new country. All of this power for change is in a woman’s hands.

“They are able to negotiate in the couple,” Percot says. The women had a say in where their salary went. Many of the women she studied were adamant that their money be spent on their own children, not a distant cousin. But Percot qualifies the findings of her research. “It is not a revolution,” she says. “I won’t say it is a revolution. But at least they are able to negotiate certain things”.

Nurse Smitha Chandran doesn’t hesitate to give some money to her own family for holidays or if someone is ill.

“If I am earning, I can ask him with courage to help my family. He did not object any time,” she says.

The 26 year-old came to Delhi several years ago with the intention of going abroad. She purposely studied nursing in Hyderabad so she would be taught in English and ensure her skills were ahead of the curve; if she went to school in Kerala, she would have learned in the official state language Malayalam. The expectant mother studies at Fateh from 5 p.m. to 7 p.m. after all her duties are done; her scores can change life for her family and her in-laws. She decided that they will settle in Florida because she has some friends there. She says that her ability to help her family and have a “good lifestyle” with her earnings gives her great confidence.

“If we have a job, we can stand on our own legs,” she says. “I am working so I’m getting respect. I can help my family and my husband. He can feel easy. I can reduce his headache.”

Although her and her husband would likely be able to live on her salary in Florida, he would work. Her friends in Florida told her it wouldn’t be that difficult for him to find a job. In reality, though, it would not be easy. She says nursing will be hard work in the U.S., but she’ll get paid for it. Anyway, her life in India is busy and her pay comparatively low. She must ensure that her home runs smoothly and her husband is well fed around working several shifts a week at the hospital and studying for the IELTS.

“If we are working, our emotion, our states everything will improve…If we sit at home, I don’t feel good,” she says. “We can get some respect.”

When Joseph made her choice to move to the U.S., it was an easy but well-researched decision for her. Nurses from Kerala naturally know many other nurses. She has many friends working in the Middle East and she emails with them about their experience.

“Arabic countries are very strict; there is a great difference between religions, especially Muslims, Christians and Hindus,” she says she heard of the region, particularly Saudi Arabia. “There is great discrimination between these religions.”

Joseph says that her friends went to the Middle East if they didn’t want to take the tests required for the western countries. She says, “Those who are in Saudi Arabia will try to come back and settle here or go to another place.”

Her friends are part of the decades-long trend that made the Middle East a stepping stone. No one went directly west, many times because of money. They needed to earn in the Middle East first to save money for moving west. Joseph says many of her friends do like it there, but it wouldn’t suit her.

Percot saw first-hand the discrimination Indians faced there. “It was complete segregation,” she says. Her research showed that one of the main reasons nurses didn’t stay in the Gulf was because they didn’t feel welcome to stay – not by the people or the law. Dubai is full of Indian migrants, but they don’t mingle much with the locals.

The lack of respect pushing many nurses away from the Middle East is also one of the reasons they continue to be pushed away from India. No one understands this better than G.K. Khurana, who pioneered the All India Government Nurses Federation in the late ’70s, early ’80s. First, Khurana highlights the advances.

“When I was getting married, some relatives of my husband said why are you getting married to a nurse – that was the situation,” Khurana says. “But now the time has changed. The people want to marry a nurse.”

Yet, still today nurses face discrimination. She says society likes to show respect by telling nurses their work is noble, but the tone may change once the nurse leaves the room.

“It doesn’t give anything just to say ‘noble’. The President of India will say ‘noble’, the Prime Minister of India will one day say ‘noble’…after that nothing”, says Khurana, who wants to see nurses get more respect and pay.

Khurana thinks that the treatment of nurses is related to traditional India’s second class treatment of women. She says, “I will tell you frankly…heart to heart, no man of India wants their wife to supersede him.” Khurana retired last year, but runs the union from the Ram Manohar Lohia Hospital where it began before it spread across the country. She sees that the nurses going abroad create high turnover in the hospitals. “And there is a shortage of nurses there,” she says. “India should have 9 lakh nurses according to the population, but we have 3 lakh and some went abroad.”

Of the 3 to 4 million total migrants abroad from India, nearly half are from Kerala and 10 percent are women, according to Percot. There are not reliable numbers on the migration of Kerala’s nurses, but tap an Indian nurse on the shoulder in any country and their dominance will be obvious. But why Kerala?

There are many push and pull factors that have made Kerala a breeding ground for migrants like these women nurses. Kerala has a concentration of Christians, which are 20 per cent of the state’s population according to the 2001 Census, and the majority of the Kerala’s nurses are from this minority. Historically many Hindus and Muslims saw nursing as low-level work, although Percot talked to about 25 nursing schools in 2003 that started to have slow increases in interest and enrollment – Chandran, a Hindu, may be an example of this trend. Many Christians, however, have always viewed nursing as a demonstration of their faith. Kerala also has a unique history of matri-lineage; all land and money passed through the women until the British outlawed the tradition. The women didn’t necessarily have the power, but everything went through their name. The state is also the most educated in India.

According to the United Nations Development Project’s research in 2001, Kerala has a 91 per cent literacy rate versus the 65 per cent in India overall. And the Census showed that the gender gap in literacy was only 6 per cent as opposed to 22 per cent in the rest of India. Yet, its average per person income is lower than the national per capita. Apparently, high literacy and education didn’t translate into a thriving economy. It has had a democratically elected communist state government since 1957 and is known for unions and high wages. Kerala finds it difficult to attract industry and is mainly an agrarian state. As such, nursing and many others sought work outside the state, sending enough money home to contribute more than 20 per cent of the State Domestic Product in 2002.

In Percot’s research she found that “migration has been a solution. In order to live the way they [Keralese] want to live.” Once the people of Kerala started moving out, going further became natural. Kochar notes “Once you move from your own state, own culture, it doesn’t matter where you go.”

He thinks that if the South Indians can handle the North Indian culture difference in food and language, they can probably make it abroad. The first area Kerala’s nurses ventured to was the Middle East because the requirements weren’t out of reach. But since the Western countries opened up to India’s nurses, Percot says it has become the preference.

“It’s easier to move to Christian countries,” Kochar adds. “Always when you are moving and unstable, you look for things to support – religion is one of the most stabilizing.” Yet, Percot found that the push from the Middle East was stronger than the pull of the Christian dominated west.

So many factors have contributed to the movement of nurses around the globe, including the influence of two heroines: Mother Theresa and Florence Nightingale. Many Keralese nurses told Percot they were an inspiration. Mother Theresa may have inspired the work itself, rising above any prejudices about helping the poor and the sick. And Florence Nightingale showed the way to traveling around the world, including India, to contribute to medicine and gain respect in a male-dominated world.

As Chandran says, “If we have knowledge and we are brave, we have confidence.”

June 2006