Kerala: Nursing profession
This is a collection of articles archived for the excellence of their content.
As in 2022
According to the World Health Organisation, almost two fifths of India's medically qualified nurses are from Kerala. The state, which accounts for only 2.76% of India’s population, has 38.4% of the country’s nurses. Over 8,500 nurses graduate in Kerala every year. The biggest reason for training so many nurses every year is migration. Kerala nurses are much in demand across the world, perhaps even more so since the pandemic struck.
In December 2021, the Kerala government signed an agreement with the Federal Employment Agency in Germany through which hundreds of positions are expected to become available for nurses from Kerala.
The peripatetic nurses of Kerala
The first generation of Malayalees migrated to Germany in the 1960s and were affectionately called Brown Angels there. The healthcare sectors of many European countries rely heavily on this army of nurses who not only provide care to patients, but also build a better life for themselves and their kin back home.
Sindhu says that there has been a spike in migration of Malayalee nurses to Ireland as there is a severe shortage of nurses. “We stay in an area called Swords in Dublin. There are around 800 houses in our residential area. When I moved, there were hardly a handful of Keralite families here. Now, there are over 200 Malayali families in this area alone,” she says.
Geo Jacob who works in Bayern, Germany says that there is a spike in inflow of Malayali nurses to Germany as well. “A large population of Keralites are already here, especially in the Northwest side. There is a high density of Malayalee migrants in regions like Frankfurt, Hamburg, Cologne etc. With more Malayalees migrating here, now we are everywhere. Many Keralites who had been working in Italy are also moving here for better financial security,” he says.
Then of course there’s the UAE, or the Gulf, which has traditionally attracted a high number of Malayalees. Nurses prefer to work in the Gulf because there is no requirement of a high IELTS score to work in the region.
Naveen J John, who has been working as a nurse in Kuwait for the past 13 years, says that there were at least 10,000 nurses from India here. “If you consider my ICU itself, out of the 70 nurses here, over 50 are Malayalees. Similarly, in most units the majority are Malayalee nurses,” he says.
Global challenges, cultural differences
Even as nursing helps many in achieving their dream life abroad, it comes at a cost. Moving to a whole new country is not easy especially when you know nothing about their culture and language.
Language is a definite problem, especially in European countries, where English is useful only in the larger cities. Geo says it’s necessary to achieve at least a B1 proficiency in German before entering the country; “without the language you simply can’t get by here,” he says. (B1 is a step above the elementary level, and requires students to be able to understand standard language in everyday situations.)
Getting used to a strange new city, a new geography, and a new language are all challenging. Jobin George in the UK says that it will take time to adjust to the strangeness of a new city. “We don’t have friends here nor do we have family. The main difficulty is staying this far away from home, away from family. But when we look at the career development and financial benefits, it is worth keeping aside our homesickness and working hard,” says Jobin. It’s not just cultural differences. Geo says it’s important to have certain life-skills including driving, before migrating. “Learning to drive after coming here would eat up your money and valuable time. So, it's ideal to learn driving before moving,” he says.
And what about racism? It is an issue, says Geo, but he doesn’t see it as a major concern. Like Jobin, most nurses are clear about why they are in a foreign land and try to shrug off the sting of racism.
Food, especially in recent years, isn’t a problem. Geo says most places have Indian grocery stores, so familiar ingredients can be had.
The importance of nurses Whether it’s the US or Ireland or most other countries, nurses are held in high regard. Raina Rock, who reached the US in 2005, qualified as a registered nurse (RN) after she moved. “Unlike home, here the opinion of an RN is held in high regard. If we tell a doctor that we don’t feel so good about giving a particular medicine to a particular patient, the doctor will give value to that opinion,” she says. She says that getting an RN licence is useful because these nurses have other opportunities like working with pharmaceutical companies, medical companies, as a patient advocate etc.
In Ireland, Sindhu says nurses are accountable for their patients, unlike in India, where the doctor is the one responsible. “We are encouraged to come out with our mistakes. Mistakes can happen and the only condition here is that it should be revealed at the earliest and rectification should be made as early as possible,” says Sindhu.
In India, patients are used to doctors telling them what medicine to take and when; in Ireland, says Sindhu, that’s the job of the nurses. Of course, the main job continues to be caring for patients. “Hospital nursing is different compared to homes. Here, there is no system of having a bystander. The entire care of the patient is with the nurse or carer. Some nurses like that type of work,” says Sindhu, adding that it is easier to start off at Nursing homes to learn the system here.
The role of the church
The Catholic Church had a big role to play in facilitating the migration of nurses to Europe. Fr Jerome Cherussery, now 86 and living a retired life in Thrissur, served as a priest in Germany from 1966 to 1986. He was the parish priest for the Indian community in North Rhine-Westphalia state in Germany.
“In 1960, the international Eucharist Congress was held in Munich which was attended by bishops from all over the world. This was a weeklong conference, and the Indian bishops became acquainted with their German counterparts. The bishops there informed our bishops that there was a shortage of people in the nursing sector. The Church there had strong influences in nursing homes, destitute homes, and orphanages etc and was running several such establishments. When this was communicated with the Indian bishops, they came to an agreement to send women to work there,” recalls Fr Jerome.
He said that there was a lack of proper preparation before sending the first few batches of nurses. “The culture, language, food etc was all very different and difficult for the girls from villages in Kerala to accept. Even the way of using the toilet was totally different. Hence, initially they had to face a lot of difficulty moving,” he says. But over time, those nurses settled down. “The children of the first generation of Malayalees who moved there are now engineers and doctors there. I personally know around 70 doctors whose parents had moved there and established themselves in Germany,” says Fr Jerome.
Raju E Raphael, director of ‘The Unknown Lives’, a documentary film on the life of Keralite teenage girls who migrated during 1962-70 to join Christian nunneries in Germany, says that this migration could be considered as a forerunner to the flow of manpower in the nursing sector from Kerala to Europe.
“In 1963 January, a batch of 20 teenage girls left for Germany to join the nunneries there. These were 15- or 16-year-old girls from the Changanacherry diocese who had completed matriculation. This migration went on till 1970 and hundreds of young girls reached Germany. This move came from the Church leadership due to the decline in vocation (religious calling) and dwindling numbers of nuns there. However, international, and Indian media had then alleged that this was in fact a type of human trafficking. Anyhow, many of these women who went there realised the opportunity in the nursing sector there and helped their relatives move to the country. This can be considered as the turning point that caused the great migration of Malayalee nurses to various corners of the world,” says Raphael.
Gulf or Europe?
The requirement of a high IELTS score in countries like the UK and Ireland and the need to learn local languages in countries like Germany are preventing many from pursuing their European dream. Many nurses see the Gulf countries as an alternate option even as Europe is any day the preferred destination for a variety of reasons.
In Kuwait, Naveen says that the chances of Indians securing supervisory roles are rare. “This is not the case in Europe. Financially, the advantage in the Middle East is that you don’t have to pay much tax. Bachelors can convert a major portion of earnings into savings. At the same time, for a family staying in the Middle East, there will be more expenses as education and healthcare are not free like in Europe.”
Sindhu worked in Saudi Arabia for three years before moving to Ireland. “The major difference with the Gulf is the permanent residency. After five years, I got my citizenship here. I have a house and my kids are studying here. When I say that I am from India and I have been here for 17 years, the residents here say that I am one among them. I don’t think such a situation will ever happen in the Gulf,” she says.
Naveen agrees that the most important difference is the opportunity for permanent residency. “In Gulf, we will not get nationality. Also, our children can only learn till 12th standard here. They will have to go back for higher studies as they will not be able to stay here anymore as our dependents,” he says. He says that since European countries are actively recruiting, many are resigning from their jobs in the Gulf region to move to Europe. “In fact, the Middle Eastern dream is almost over. Lots of recent recruits who joined around five years ago are resigning now to move to Europe, New Zealand, Canada, Australia etc,” he says.
Sindhu has a word of warning for nurses looking to move to Europe. The cost of living and taxes could take away a chunk of a nurse’s earnings. “Nurses in India are generally not getting a high amount of money as salary and hence don’t pay much tax. Hence, they are not used to the tax system,” she says.
Geo Jacob in Germany says something similar. Both he and his wife are nurses who moved to Germany three years ago. “There are six different tax slabs here,” he explains. “A different slab for single parents, married couples, bachelors etc. Also, the living expenses are high.” But, he says, there is free education and healthcare. “A much easier life awaits our younger generation,” he says.
The road ahead
Clearly, getting a nursing degree is only step one for those wanting to migrate. Since nurses are Kerala’s best export, perhaps it’s time the state began introducing language courses, IELTS, and training in cultural differences. Also, nurses generally go abroad through intermediaries, who charge exorbitant amounts. This practice can be stopped if the state steps in. Benoy Peter, executive director, Centre for Migration and Inclusive Development, says that if the government facilitates migration, it will ease the financial burden on students. “The deal with Germany is an example. When the government is directly facilitating recruitment, graduates from the marginalised sections of society would also get a chance to migrate and upgrade their lifestyle.”