There is the general view that the expansion of the nursing sector in Kerala is among the progressive results of the great social churning in Malayali society in the early 20th century. The Brahmin-centric value system that prevailed in the 19th century Malayali order of caste viewed touch with suspicion and stigmatized all labour involving touch-based care-giving as inferior.
But from the second half of the 19th century the new medical care system that expanded in Travancore and Kochi brought to prominence patient care outside the home. The practice of appointing men and women as nottakkaar for the aged and the sick was common not just in upper caste homes but also when they had to be nursed outside. But there is little evidence that these were trained workers — they were more likely to be regular house servants put on this special duty. There were traditional medical skills passed on through generations (an excellent example was that of the traditional dais) and some highly-remunerated, rather narrow, skills (such as the services of those who had gained immunity from small-pox, to nurse small-pox sufferers), but generally, this was not a valued role.
Modern nursing necessarily involved training and this skill could not be applied without overcoming the taboos on touch, of caste, community, and gender. Hence the first generation of modern nurses in Malayali society had to be mostly imported from outside. It was no surprise that the first generation of trained nurses in hospitals here were nuns or widows. As the medical sector grew, however, this became more and more impractical. They were lower down in a hierarchy in which the European nurses and the missionary women figured higher up. Even as late as the 1920s, nurses were often women past middle-age. Dr T H Somervel who practised in the Neyyur Mission remembers this clearly in his memoirs. He remembers that male patients were cared for by trained male nurses, mostly from the lower castes.
For female nurses, social life was a challenge in itself: the stigma was so debilitating. Dr Somervel recalls that these women who were past middle-age first lived in a house in a village where they were constantly harassed by women who considered them easy sexual prey. He remembers how one of these tormentors tried to slip into the house removing the tiles on the roof. After this incident, the nurses were moved into accommodation inside the Mission compound, where the European women nurses and the women missionaries lived — and a separate hostel had to be constructed. He further notes that young women could be recruited for training in nursing only after security was assured thus. Nurses were, however, stigmatized all over India: complaints about the slurs and sexual attacks they faced were heard everywhere.
In the 1930s, women in Travancore and Kochi actively sought paid work for a number of reasons: the disastrous effect of the Great Depression on family incomes, the first phase of the demographic transition here pushing up birth rates while depressing death rates, the huge thrust towards higher education in Travancore in the 1920s, the rising dowry system and the financial ruin of joint families in the time of legislation sanctioning partition, and so one. There is some evidence that indicates that there was a flow of female students towards the nursing course in the Vellore Medical School during the 1930s from areas hit hard by the Depression, as nursing seemed to be a skill with a relatively stable demand. Sujani K Reddy’s Nursing and Empire (2015) gives interesting details about this. She notes that the missionary Vera Pittman was particularly partial to Syrian Christian women students.
But the remuneration that the nurses, especially those who were trained in the Mission hospitals — was very poor, just around thirty to forty rupees, and this was barely half of what nurses employed in government hospitals were paid. This further exacerbated the idea that nurses were willing to perform sex work readily. This stigma was clearly carried into the 1940s and 1950s. In 1939, the Trained Nurses Association of India (which was the organization of Indian nurses) pointed out that some private hospitals were indulging in ‘immoral activities’ in a note of protest. They complained that many who were trained in Mission hospitals (who were likely to be poor and of the lower castes, suffering from social disadvantage) were being sexually exploited by their employers; that they were no better than brothels; that these were moral cesspools and dangerous for naive young women who were unfamiliar with the world.
In the 1930s and 40, Indian nurses were controlled by European nursing supervisors, who had been trained in nursing in England. The numbers of male and female nurses were also not hugely different. Soon the rule that nurses could not marry was also removed. But the stigma was disgustingly strong still. In the Kerala Legislative Assembly debates of the 1950s and 60s, legislators often raised this point, some even saying that in many parts of Travancore and Cochin, a young woman who trained to be a nurse would be inevitably treated as a sexually-available female. They asked, dramatically, why is it that a woman who chose nursing was thought of as some ‘cine-star’ (revealing yet another prejudice regarding women’s work).
In short, the first generation of trained Malayali nurses suffered great social stigma, and as nurses they had to submit to the dominance of European supervisors. The great churning of Malayali society did little to alleviate the stigma or improve greater recognition for their work in terms of better pay. Somervel is of the view that the stigma began to lift by the 1940s, but there is plentiful evidence to show that it continued.
An interesting question is this: men were quite numerous in this field right from the beginning in Kerala; then how did the impression that this is a specifically ‘feminine’ occupation come to be? It is common knowledge that those sectors in which women workers predominate are characterised by neglect and devaluation by authorities. If the sector had more of ‘male countenance’ then the nurses in Kerala might have earned fair wages long back. But the strong division of the world into ‘male’ and ‘female’ domains in the new order of gender in Kerala, and the identification of care work as essentially feminine made men reticent to call themselves ‘nurses’. Instead, they called themselves ‘compounders’.
The state’s discourse on nursing as a essentially feminine profession was also unrelenting as is evident, for example the legislative assembly debates and discussions in the press. Also, more women were chosen to be trained than men. In the 1950s, there was an outflow of more female than male nurses towards Europe during the post-War reconstruction.
From Sujani K Reddy’s book, it appears that though the fight for fair wages for nurses if still on, whatever gains they made are surely from their own struggles, especially of individual pioneers (for example, p. 127). One such name is of G Chandramathi who became the Assistant Director of the Nursing department. She completed her nursing education at the University of Columbia in New York supported by the Rockfeller Foundation. But this did not improve their wages or terms of service, which remained quite hierarchical and colonial. For example, in the 1940s, Mrs Rugmani Amma Iyengar who was study in Toronto with the support of the Rockfeller Foundation wrote to the later that she could not take this opportunity without active support from the Travancore government and that she suffered from serious economic difficulties (ibid. p. 123). The Travancore government agreed to bear the excess; however it extracted a 15-year bond for compulsory service and if she did not honour it, she would have to return the entire cost incurred by the government. The Nursing Advisor of the Rockfeller Foundation also complained about the hostel facilities available to the nurses in Travancore’s government hospitals too (ibid. pp 123-24).
After returning from her studies abroad, Rugmani Amma completed her bond period, becoming the Director of the Nursing School in the Thiruvananthapuram Medical College. Both she and Chandramathy made consistent efforts for equal wages and fairness in promotions. Rugmani Amma protested against the exclusion of the Director of the Nursing School from Gazetted Officer status; this was corrected. Chandramathy was one of the three Malayali nurses who protested against the pay hikes offered only to the European nurses who still continued in service even as Malayali nurses were paid only a pittance (ibid. p. 126).
Perhaps it is necessary to take into account this denial of a respectable wage, besides the persistence of stigma, in order to understand the migration of nurses from Kerala to other parts of the world post-1950.