Frontline healthcare workers today are handling a disproportionate share of the pandemic’s burden while remaining poorly paid and outside the radar of attention. A new book titled Politics of Precarity , which studies nursing from the lens of labour politics and gendering, adds to our understanding of why a feminine workforce struggles on the margins of ‘respectability’ despite being indispensable to healthcare. Discussing the issue, author Panchali Ray, an independent researcher based in New Delhi, wonders if nursing can evolve into a mixed profession that respects both sexes equally.
The nursing profession has colonial roots. How did the Raj incorporate the figure of the ‘dai’ into the ‘Nightingale’ idea of nursing?
The demand for trained nurses arose with the emergence of Western medicine in colonial India. While middle-class, upper-caste men and some women were willing to train in Western medicine to become doctors, nursing had no takers. Historically, most women in Indian medicine were hereditary dais from lower-caste families who offered skilled services on female-related illness, including reproductive diseases, abortion, infertility, childbirth and postpartum care. Trained nurses, whether Indian or European, refused to offer bedside care that would identify them with the dai . Thus, even as the dai ’s knowledge practices were labelled as ‘primitive’ and ‘barbaric’, she had to be incorporated into colonial hospitals as the “inferior” helper to the trained nurse, who offered the bedside care the latter refused.
Can you tell us how the gendered cure-care binary plays out in the medical profession?
A WHO report (2019) records the adverse occupational gendering in healthcare: across countries, most physicians, dentists and pharmacists are men, while women are overrepresented in the ranks of nurses and midwives. The same report records that women health workers earn on an average 28% less than men. I argue that gendering of the healthcare sector reflects wider binaries of masculine/ feminine, cure/ care, science/ affect that lead to such occupational segregation. This hierarchical opposition reinforces a nurse’s secondary role within the medical field as subordinate to that of a doctor. The task of nursing is usually seen as more caring than curing, an extension of stereotypical feminine qualities. Thus, the relationship between doctor and nurse is not that of collaborators or equals but that of superiors and subordinates, further reflected in the gendered wage gap and adverse working conditions.
Despite attempts to project nursing in India as a noble, spiritual profession, it has stayed entrenched as low-end, feminine, domestic labour. Why is that?
Traditionally, nursing labour, similar to paid domestic work, was offered by women located on the margins of Hindu Brahminical society, partly because nursing was caste-based corporeal labour that included dealing with blood, fluids, and other bodily detritus, and partly because the existing sexual division of labour pegged nursing as women’s work.
Both gender and caste contributed to the devaluation of nursing. Professionalisation of the field has not led to a disassociation of caste stigma but has led instead to creation of newer hierarchies. Trained nurses, to escape the stigma associated with corporeal labour, have taken on more medical-administrative-supervisory roles leaving the hands-on care to ancillary nursing staff such as the attendants ( ayah ). However, the profession as a whole continues to struggle with the stigma associated with corporeal labour.
As healthcare became corporatised, nursing too should have become commoditised and therefore less discriminatory and more organised. Why hasn’t that happened?
Corporatisation and privatisation of healthcare has led to further exploitation of nurses and nursing ancillary staff. With international immigration, there has been a supply crunch in nursing labour and this scarcity of registered nurses, instead of valorising nursing labour, has led to an increase in the hiring of unregistered nurses, nursing aides and attendants. Whether it is the public or the private sector, there is a growing reliance on a pool of semi- or untrained labour that represents the most informal and casual end of the workforce. The nursing labour market is a pyramidal market with the bottom over-represented by female casual employees struggling with low wages and status, stigma, and no labour rights. What we are seeing is a growing precarity of frontline healthcare workers.
Quality medical education in India has focused on doctors to the exclusion of other healthcare categories. Are we seeing the fallout of this short-sighted policy now during the pandemic?
The scale has always been tipped against the nurse. Though nursing is a high-skill job that requires intensive education and training, it remains low-paid and stigmatised. The general understanding of the nature of work is of it being menial and unskilled. So, for instance, 3.5 years of GNM (General Nursing and Midwifery) training is not recognised as a degree but as a diploma. This devaluation of nurses and nursing training has led to the large-scale emigration of nurses. Policymakers and bureaucrats, instead of strengthening nursing education, have tried to further deskill the profession by encouraging employment of semi-trained contractual workers, who offer bedside nursing care. Thus, when a pandemic like the current one breaks out, we see a dearth of trained nurses.
Can equipment (like gloves and masks) and spatial inclusion (like separate clean toilets and resting rooms) help give dignity to the role?
We live in a deeply casteist society where any labour that brings you in touch with the body and its detritus is considered polluting. This reflects in the way we treat the domestic worker, the nursing attendant, or the manual scavenger. Work defines the worker and the caste-based division of labour prevalent in our society dictates that we devalue and stigmatise those who ensure the reproduction and continuity of life. Improving working conditions can go a long way in improving the worker’s status and bestowing dignity on the work.
A homogenised workforce could have demanded better working conditions and handled perception management. But hospitals have consciously reinforced hierarchies and differences. How can this be changed?
Contrary to common understanding, nursing service is not a homogenous sector but a deeply splintered one based on historically and socially produced structural inequalities. It is rigidly cleaved between ‘prestigious’ and ‘dirty’ work. With intensification of technology and emphasis on documentation, nurses have got more and more involved in administrative-supervisory roles leaving the everyday bedside care to less trained attendants. For hospitals and nursing homes, the lion’s share of nursing work can now be relegated to women hired casually, paid less than minimum wages, and easily laid off when there is no demand. The need of the day is to recognise these women who give actual hands-on care, ensure their visibility in health statistics, and lobby for their rights as frontline workers.
The affective or emotional labour of nursing has always been downgraded in a highly masculinised job market. With the entry of men into nursing, do you foresee prestige and pay gradually improving?
There is no doubt that the entry of men has also meant increased organisation. Thus, in recent years, we have witnessed nurses striking over low wages and exploitative work practices. However, male nurses also tend to be concentrated in prestigious departments such as psychiatric nursing. Given the internal stratification within the profession, how will this influence the gendering of the occupation? Will nursing be able to resist masculinisation and carry on to become a mixed profession of both sexes? Or will there now be an internal stratification of ‘dirty’ and ‘prestigious’ work, corresponding to a gender-based division of labour? The entry of men in large numbers will possibly trigger changes whereby women will continue to be employed in precarious conditions to perform menial-corporeal-affective labour required for healing, while medical-administrative-supervisory roles will become the responsibility of male nurses. So even if prestige and pay improves, women might be pushed out of the top echelons of nursing services.
vaishna.r@thehindu.co.in
