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From Angels to Fighters: Transnational Nursing Chains from India to Germany 1960s to 2023

Published onApr 27, 2023
From Angels to Fighters: Transnational Nursing Chains from India to Germany 1960s to 2023
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Since the 1960s, transnational care chains have been established as a labour regime in a post-colonial context to overcome crisis situations in social reproduction and a severe shortage of health care personnel in the OECD world. Care workers, majority being women, migrate from poor to more wealthy households and countries, from the Global South to the Global North.

 Global care chains mark an intersection of a gender, a class and caste, and a racial international division of reproductive labour. Arlie Hochschild (2000) who coined the term „emotional“ labour used the notion of global care chains for the first time in 2000 based on the empirical research by Rhacel Parreñas (2000) with a focus on domestic workers. Catherine Choy (2003) unpacked the colonial rationale of care chains analyzing the “Empire of Care” created by the US colonial regime in the Philippines. They trained Filipinas as nurses, and constructed cheap health care and precarious labour relations by sending them as trainees to US American hospitals. Nicole Yeates (2010) took this analysis further and identified a „globalisation of nurse migration“.

My paper focuses on transnational nursing chains from India to Germany and compares the first generation of nurses who came in the 1960s/70s to the present generation who came in the past 10 years. Additional to the global care chain theory, this comparison is located in the conceptual framework of social reproduction theory (Bhattacharya 2017) which stresses the entanglement of social reproduction and production. And secondly it is located in the concept of autonomy of migration which was elaborated as a counternarrative against the perception of migrants as victims and passive subjects without agency, and embarks on an actor-centred analysis against the structuralism of the old migration theory of push and pull factors (Bojadžijev and Karakayali 2007; Papadopoulos, Stephenson and Tsianos 2008). Within capitalist markets, migratory space is constructed by structures, processes, discourses and migrants‘ agency (Massey 1994; Mezzadra 2011).

West Germany’s story of importing nurses began during the so-called post-war economic miracle. The “guestworker” model of migration reacted to a shortage of skilled workers and assumed that after some time, the shortage would be over and the guestworkers would return home. In 1963, the West German government entered into a contract of “technical aid” with South Korea and recruited 10 000 skilled nurses. On arrival in the hospitals they were told that their diploma and certificates were not recognised and initially they had to work as assistants, i.e. with little payment. The South Koreans were aware of the intertwined process of commodification and devaluation. And when they were told to return home in 1977, they protested saying that they provided development aid to Germany and that they didn’t want to be traded like “a commodity“.

During that time, 6000 young Indian women from Kerala, among them a number of catholic nuns, came to West Germany and got a nursing training (Goel 2013).  Their migration, training and placement in a hospital was facilitated by individual priests and nuns, Caritas and Red Cross. They created a narrative of self-sacrifice and of being perceived in Germany as “brown angels”.

Mapping various needs and interests in this transnational scenario of global inequalities and post-colonial power relations between the Global North and the Global South reveals a range of complementary interests in the migration of nurses. Since the 1970s, governments in the South became labour brokers and used the export of cheap care workers as a development strategy which earns them foreign currency through remittances and is supposed to reduce problems of un(der)employment and poverty in their countries (Rodriguez 2008; Yeates 2009). Countries and metropolitan cities of the Global North are keen to use this migrant labour force, namely skilled health workers, to fill the care gaps in their health system and thus manage a crisis of social reproduction at low costs. Older migration theories of pull and push factors identified wages and working conditions as decisive for recruitment and placement. In the middle of these driving forces stands the individual migrant health care worker as the key actor with firstly a right to mobility, and secondly often with a desire to migrate to what seem to be greener pastures. The migration processes between sending and receiving places get increasingly facilitated by a mushrooming commercial agency industry which asks for high fees and rolls off the costs to the migrant worker herself.

 Migration of health care workers results in a new international division of social reproduction with asymmetrical distribution of gains and costs. The receiving country can record a gain in terms of care capacities, energies and skills which means at the same time a loss for the sending country and household, a care drain, a depletion of social capital (Isaksen, Devi and Hochschild 2008). Furthermore, as countries of the Global North ask for skilled labour, the cost of training is born by or in the country of origin and due to the ongoing privatisation of the education system, they are passed on as fees to the individual student and her family. The debt burden on their shoulders results from the financialisation of education and the financialisation of the migration and placement process (Walton-Roberts 2015).

 The crucial point in transnational care chains is that nurses leave their home country although there exists a severe shortage of care workers. For this reason, WHO published a Code of Practice on Health Workforce Recruitment in 2010, which includes a list of countries where there are shortages of health workers and from which wealthier countries should not recruit workers (WHO 2010; Angenendt, Clemens and Merda 2014).

I suggested the concept of care extractivism (Wichterich 2019) – analogue to resource extractivism - to unpack this labour regime, its post-colonial rationale and power relations, the intensified commodification of care work and its normalization as an imperial mode of living by countries in the Global North (Brand and Wissen 2021). While David Harvey (2001) called this transnational strategy of crisis management a spatial fix in asymmetrical power relations, Germany’s GiZ sugarcoats its programme of transnational recruitment a “triple win programme”.

India was on the WHO no-go list in 2010, however it miraculously disappeared from the revised list of 2021 (Walton-Roberts and Rajan 2023). Between 2010 and 2022 only few nurses came to Germany. However, immediately after the announcement of the revised list, Germany entered into a Memorandum of Understanding on the recruitment of nurses with NORKA, the migration body in the south Indian state of Kerala (Express News Service 02.12.2021).

Biographical Interviews with Migrant Indian Nurses in Germany

Based on my biographical interviews with two generations of migrant Indian nurses in Germany, I would like to first highlight the main differences and changes.1 The 1960/70s generation came in small groups, most of them 16 years old only. Their trip, education and placement were organized by catholic networks. This initial peer groups functioned as social safety net and collective shock absorber for the young migrants. Being trained as nurses in Germany and learning the language integrated them into the German health and hospital system, while demanding from the young women to adjust and assimilate to German food habits, dress codes and cold weather. They came from large families with up to ten siblings and a poor and farmers’ class background. They wrote one letter per week to their Malayali family and found it extremely difficult to cope with the separation from their family, suffered from a culture shock and awful homesickness. Their struggle to adjust, to assimilate and later to integrate was a process of painful pioneering labour giving birth to a new self, a new subjectivity in a strange socio-cultural environment.

Brown Angels – Die Geschichte der indischen Krankenschwestern

The 2014plus generation organized their migration individually, mostly based on a network of family members in Europe, and were at least 22 years old when they left Kerala. The new generation originates from small families with two or three children and a middle class background. Most of them visited private colleges for their nurse training and had to pay a high fee which often caused a debt burden on their and their parents shoulder. They gained work experience in Indian hospitals, first as a practical part during their studies and for a year or two after graduation as wage workers. Most of them learned German up to B2 level at a Goethe Institute in Kerala. It was difficult for then to find a job in Germany; finally it was organised by an “aunt“, a priest or an agency in Kerala or Germany. They feel a bit homesick in Germany as well but compensate this with daily video calls to their family, sometimes several times per day and for more than an hour. Generally, they feel that they can easily adjust to German habits and culture. However, still they are tensed and feel they have to struggle.

I would like to go deeper into the six categories I used for the semi-structured biographical interviews with nurses of the recent generation and for the analysis of the interviews: motivation, recognition, labour and workplace, respect and discrimination, transnational family and finally their perspective.

Motivation

The 1960s generation had one distinct motivation to migrate: to help the family, in the beginning by financing the education of brothers and sisters, and later by building a house for the parents. Often it was difficult to convince the father to agree to the migration plans. The core motivation of supporting the family is framed by a narrative of service, self-sacrifice and a kind of fatalism that they “did what had to be done”. The overall goal was the social reproduction of the family in Kerala. However, they do not depict themselves as passive or even as victims in this scenario but they developed their own agency and subjectivity in the process.

Contrary to that, the young generation highlights that it was their own decision and desire to migrate in order to earn more money, have a better work place and a better life with more personal freedom. In the wake of a culture of migration in Kerala, the parents agreed and supported the daughters. Their goal is a good life for themselves. Thus, this comparison of the two generations points to a trend from migration as a family survival strategy to an autonomy of migration, and to an individualisation process with a strong agency and a will to independence.

Recognition

A crucial procedure in the migration process is to get recognition as skilled health care labour after they got a good and costly college training in India. All the migrant nurses report that for 6-12 months they faced many bureaucratic hurdles and harassment with never ending requests for documents and certificates before they got their visa and permits from the German embassy in India or the Foreigners’ Registration Office in Germany. After arrival at the destination hospital, they are first employed as assistant with little pay. After 6 months they have to take an “adjustment” exam in a special medical field e.g. geriatrics. If they don’t pass the exam they have to repeat it after a few months and only after passing they get employed as “examined“ nurse with full pay. These processes to get formal recognition imply a depreciation of their education and are perceived injust. They face this time and energy consuming bureaucratic power play again and again as they have to renew their stay and work permit every year. As this struggle for recognition is part and parcel of their labour experience, I suggest the use an extended notion of the migrant labour regime which includes the often humiliating and devaluating struggle for recognition and work permits in post-colonial power structures.

Labour and workplace

For the current generation of nurses, the basis to compare their labour in German hospitals are work places and labour relations in India where they gained practical experience (John and Wichterich 2023). In India, they are aware that health care workers are miserably paid compared to other professionals. In Germany they do not compare their health care work to other professionals, they enjoy the regulation of labour, they work only 8 hours per day, overtime is paid, they have a “lot of free time” and holidays, and feel that they get a good salary. They appreciate the option of flexible and part-time work. Most appreciated is the – compared to India – flat hierarchy, they praise the good team work which includes doctors and the equality in the team. Indicators for this assumed social equality are that they are asked for their opinion, that senior nurses do the same work they have to do, and that they can sit with and talk to doctors. This narrative of social equality is also transferred to the patients – rich patients enjoy many privileges in Indian hospitals.

However, they feel overqualified with their medical knowledge and academic training because they have to do bodily care which is done in Indian hospitals by unskilled care workers or family members. E.g. not being allowed in German hospitals to give intravenous injections, they perceive the work as simple and boring. Compared to Indian hospitals they feel less burdened and stressed, except when they are alone in nightshifts or have to cope with difficult patients in the emergency ward. Thus their perception of labour in German hospitals is ambivalent: good working conditions but a kind of deskilling.

The singles among the nurses feel that they have a lot of leisure time and leave. However – similar to the narratives of the first generation - the married women with kids don’t separate clearly between their paid and unpaid care work: it is one flow of labour and care from the hospital to the household showing how production and reproduction are intertwined and interdepending. In both generations, husbands share the task of taking care of the children what was exceptional in the 1970s, in Germany, but even more in Kerala. But they had no other option. Today it is seen as more common.

Respect, Discrimination, Racism

Their feeling to be respected in the hospital and by their colleagues is an essential source of their high job satisfaction and feeling of wellbeing and belonging. Revealing is their reaction to the question about discrimination. Initially, each of them denied to be discriminated against, but then they conceded that they experienced incidences of confrontation, sometimes by a patient who does not like to be treated by a foreigner or pretended not to understand them. What is most important for them is that they got support by their team in these conflict situations and that they can rely on the colleagues, meaning they construct the team as a peer group and safety net. However, they report that they have to work in wards or in shifts they don’t like. If discrimination happened, they insist that this is not racialised discrimination due to their skin colour but only because of their inadequate German language. They even support other discriminated migrant workers who don’t speak German well. But racism is downplayed, reinterpreted and externalised to public transport, into the company of the husband, etc. The above mentioned discourse of social equality is used as a counternarrative to discrimination. Their inner struggle against discrimination and humiliation and for recognition is part and parcel of their labour. They reject to be victims but show strength and agency though they feel insecure due to the permit procedures. The only male interviewee in my sample, married to a German, is the only one, who has filed a formal complaint in the hospital and is ready to enter a trade union. Others are not planning to get organised.

In the reports given by the first generation nurses, a similar downplaying or reframing of discrimination and racism was done. In their case, referring to the image of “brown angels” who were liked and appreciated in Germany is their counternarrative to existing discrimination.

In both generations, the nurses construct an ambivalent set-up of being acknowledged or refuse their own subjectivities, and the team as a safety net to protect them (Massey 1994). Both develop agency, while throughout the different generations and circumstances there are a lot of inner tensions and contradictions which on a day-to-day basis have to be handled by them.

Transnational Families and Independence

Their relation to the transnational family is the crucial lifeline for the present generation of nurses as well. They still are emotionally very much attached to their transnational family and feel morally obliged to support the parents or support the brother who has the duty to look after the aged parents. When migrating, the parents, in particular the fathers, agree nowadays but they take the ultimate decision when and where the daughter migrates to. The daughters accept the parental authority as much as an arranged marriage. Though their own social reproduction by setting up their own family is still a key driver in their life, the young generation calls itself “modern”, does not panic about the date of marriage, dowry and motherhood but postpone them if it gets difficult to find a suitable husband who is willing to live in Germany. At the same time they do not question the parents who still arrange these personal affairs. Each of the women paid dowry but legitimize the system and claim it is to their advantage.

Calling home every day is a way of bridging the geographical separation and feeling close, speaking Malayali, establishing a contact between the children and the grandparents. In Kerala, often only the elderly parents are left, living in an oversized house, while most of their children (and grandchildren) work as migrant workers or professionals abroad. Some aunts and cousins in Europe, who now form a support network of relatives in Europe, worked as nurses as well. They help with bureaucratic formalities and placement, and encourage newcomers to come to and stay in Germany.

Perspectives

The first generation was planning to go back after they achieved certain objectives. In 1977, when they were urged by the German government to leave, most of them refused and found ways to stay on. Later they postponed the return again and again, when children started school, when they finished school, when the children got married and got children in Germany, etc. Many became German citizens, and have now more family members outside of Kerala and more friends in Germany than in Kerala.

The young generation has a very conscious life planning. Only one of the interviewees, the male nurse, and the Indian husband of one nurse plan to eventually go back to India. But the women cannot imagine to be a housewife in India or to work there as a nurse. Migration is perceived by the women as a process of becoming independent. They want to see their children growing up and have their schooling in Germany. They intend to become German citizens and consider already now their work as an act of citizenship.

Conclusions

The situation of the current generation of nurses and their subjectivities are characterised by many ambivalences and tensions. However, the perception and self-perception of the nurses is dominated by a high degree of job and life satisfaction, a pride of their qualification and skills, and a growing awareness of their capacities to cope with problems and to fight. While the first generation identified the financial support given to siblings and parents as the pioneering achievement of their life, the present generation perceives the personal independence and the ability to manage difficult situations with the help of their network as their main achievement. Contrary to the structural analysis of care extractivism in transnational care chains, they see migration as an ultimately empowering process and downplay the care extraction as well as discrimination. Undoubtedly, they show indicators of the autonomy of migration and autonomy of life planning while still leaving some responsibilities of decision making to their parents.

Both generations suggest in their biographical narratives an extended notion of labour. The first generation remembers their difficult arrival and adjustment time in Germany as hard work and pioneering struggle; while the latter generation sees the strenuous bureaucratic procedures to get recognition, visa and permits as unpleasant part of the migrant labour regime in Germany. For both generations the permanent defence against disrespect and devaluation and the downplaying of discrimination are as well part and parcel of migrant labour. It is a permanent invisible form of groundbreaking and pioneering work, a subtle struggle of constructing a peer group, a network, a friendly work space and a new self.

While both generations stress the ethics of care as a foundation of nursing, the old narrative of self-sacrifice and angels does not turn up in the narratives of the young generation any more, but is substituted by a management and fighter mentality.

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