In October 2011, Beena Baby, a young Malayali nurse working in a private hospital in Mumbai, hanged herself from the ceiling fan in her quarter. It wasn’t the first such instance. But it moved the community like never before. Harassment at work, her colleagues alleged, drove Baby to take her life. The dreaded bond system, they cried, is a trap and inhuman. They went on strike to get justice for Baby and, through her, for themselves. It became a watershed moment; a community lauded to be angels laid bare the demons haunting them. The demons, though, were too many. The patient-nurse ratio in most private hospitals was nowhere near what the World Health Organisation (WHO) prescribed. Wages were low and not standardised. Duty hours stretched well beyond the stipulated time. Harassment by supervisors was all too common. Most of them were cooped up in hostels with few facilities.
Baby’s suicide was a reason why the Trained Nurses’ Association of India (TNAI), the oldest nurses’ body in the country, moved the Supreme Court (SC). “We did not believe in striking as patients are sacred to us,” says nun Gilbert, a former president of TNAI, in whose tenure the case was filed. The court was informed that the bond system — which forced nurses to surrender their original certificates to the hospital authorities, thereby binding them to the employer — has been scrapped in the intervening years. After over four years of hearing, the SC early this year ordered that a committee should study the grievances of nurses and recommend ways to improve their working conditions in private hospitals.
After decades of the mute endurance that characterised the community, nurses in the government and private sector have, over the past 10 years, scaled up their battle for better work and pay. The chasm in nurses’ pay between government and private hospitals widened in these years, leading to frequent strikes in private hospitals.
Gilbert brings up the Balaraman Committee report, which studied the plight of nurses in private hospitals in Kerala and recommended a basic pay of ₹12,900 for a staff nurse. Everywhere else in India, a nurse in a private hospital starts with anywhere from ₹4,000 to ₹16,000, according to TNAI officials.
Despite the growing collective clamour for better treatment, individually the nurses remain dogged by fear. Attempts to reach out to them, to simply share their stories, often drew a blank. Working nurses would speak only on condition of anonymity. Outspokenness, they explain, comes at a cost. The last thing they want is to be “targeted” or “blacklisted”.
Siju Thomas had taken up the fight, and also paid the price. He’s a plain-speaking man in his thirties. The plastic bag in his hand is a mini factfile on nursing in India. As he talks, he simultaneously brings out documents, legal papers, letters written to different commissions and pamphlets. Thomas is the general secretary of the Delhi Private Nurses’ Association, which has been highlighting the disproportionate patient-nurse ratio in hospitals.
In Thomas’s file is the answer to an RTI query on the prescribed nurse-patient ratio. The Indian Nursing Council and WHO norm for the ward, it says, is 1:3. “But here it often extends to 1:10 and more,” says Thomas. The skewed ratio, he points out, not only tires the nurse but also affects the patients. “When you’re burdened with patients, it’s difficult to give correct treatment,” he explains. The association had written to the National Human Rights Commission, but nothing came of it.
Thomas’s stints in private hospitals have been turbulent. In 2009, the Capital witnessed one of the first big strikes in a private hospital and Thomas was part of it.
Around 450 nurses were part of the weeklong strike, demanding the withdrawal of bonds and a better salary. A few months on, Thomas was suspended and eventually terminated for acting with the intention to “harm the reputation of the hospital”.
The only time Thomas goes quiet during our meeting is when I ask about his parents’ reaction to his job loss. He had come to Delhi after his three-year general nursing course in Karnataka. Unlike many of his peers, he didn’t have a loan to repay. In 2007, he had started with a salary of ₹7,000. “My mother was upset when I lost the job,” he says. After a short stint at another hospital, Thomas now largely makes a living from freelance nursing services. The rest of his time is reserved for association work. A significant achievement for the movement has been the scrapping of the bond system. “We are fighting for regularising the starting salary and parity with government pay,” says Thomas.
The neighbourhood in south Delhi where a few nurses live is like any other working-class locality in the Capital. A mesh of overhanging electric cables is part of the skyscape. The road is so narrow that a car coming in the opposite direction brings the traffic to a halt. Water leaking from an unknown source has made the alley swampy. Inside the window-less living room of a two-room apartment, it is eerily quiet.
It’s close to 11 in the morning. The pressure cooker in the kitchen whistles intermittently. A young woman rushes for a shower. The pick-up vehicle for her two o’clock shift will be here soon. The apartment is shared by a group of nurses working in a private hospital.
All of them are from Kerala, either the high ranges or a small town. Their stories too are similar. Young mothers have left toddlers behind with ageing parents and parents-in-law in Kerala. Some have followed a cousin or a distant relative to their job here in Delhi. They skimp on expenses to repay loans and send money home. Yet there is never enough.
Blessy* is over a decade-old in the profession and has worked in big and small hospitals in India and abroad. She initially completed a three-and-a-half-year general nursing course, only to realise it didn’t have much scope abroad. She quit the job she was in and took another loan to pursue BSc Nursing. She gets paid around ₹20,000 a month now, but her two loans eat up half of it. “It is not possible to live on my salary. And if I want to go abroad, I need to do additional courses, which my working hours don’t allow,” she says.
As we talk, a couple of her flatmates walk in. The girls are getting home after a night shift that technically winds up at 8 am. “If you have to hand over charge at three different levels, how can you finish on time?” asks Sheena*. At any given time in the ward, the nurse-patient ratio is 1:12 and even goes up to 1:15 sometimes, the women say. The filework required for each patient eats into their time and extends their duty hours. However, the paperwork is the least of their worries. What follows — the handing over of charge — is nothing short of a drill; the senior nurse accounts for every item in the inventory, and if anything is missing, be it a glove or a thermometer or an ice pack, it has to be replaced before the nurse can be relieved. Little surprise then that they routinely arrive home three hours past duty time.
The nurses speak cautiously, but the minute the conversation shifts to their mode of commuting they begin talking animatedly. The pick-up vehicle is an ambulance, they say wryly. And if that isn’t incongruous enough, more than 20 of them are cramped into it. Some of them swipe their cell phone to show pictures as evidence. Most of them travel seated on the ambulance floor. “The vehicle has broken down and we have pushed it. We’ve been caught by the traffic police, too,” says Shiju*.
Life for the junior nurses hinges greatly on what their nursing superintendent chooses to be — a headmistress-type or an associate. Bindu* works in a speciality institute. She recalls the time she was sick and her senior wanted her to travel to the other end of town to get a medical certificate from the hospital she works in.
When Sanjana* runs out of money, she skips meals. This young nurse has been working in a private hospital for three years. Her salary of ₹13,000 is spent on loan repayment, and lodging and other expenses. The hospital provides accommodation inside the campus as well as outside. Inside, the nurses are forced to eat at the hospital canteen, for which they have to pay ₹3,000 a month. Sanjana opted to stay outside where the nurses, four to a room, have to make their own arrangements. This way, when she doesn’t have money, she simply skips eating. “The hospital pays us a pittance as it knows we are more anxious to get an experience certificate. A certificate from an established hospital has a higher value when applying abroad,” she says.
In another part of the Capital, a similar story unfolds. Varghese* and his wife Daisy* are both nurses. Daisy works in the chemotherapy department of a cancer hospital and struggles to cope with the rush and demands of patients and their attendants. “Often we don’t even get the time to wear our gloves and apron and goggles. This means we are exposing ourselves to the risk of radiation... we forget about our own health and lives,” she says.
Varghese moved to Delhi a couple of years ago to work in a private hospital. The couple had hoped for a better life. Within a short time they realised they were chasing an illusion. “We get a little more money here, but once you account for rent and living expenses we save nothing. A daily-wage labourer in Kerala makes more money than us,” says Daisy.
Varghese says there is a huge gap between the actual salary and what is shown on paper. “A junior nurse would start at ₹14,000. But the basic is only ₹5,000 or ₹6,000. They cite all kinds of allowances and stretch it to ₹14,000.” After hostel and food bills, the amount in hand shrinks further. An experienced nurse may be in a better position to bargain, but here too the situation is tricky, says Varghese. Most of them hail from small towns and find it difficult to communicate in English. “These guys take advantage, and ask confusing questions during the interview. That is done deliberately to leave you in a weaker position while negotiating salary,” he says.
Though the plight of nurses is uniformly disheartening across the country, in the metro the workload is killing, says Varghese. “In Kerala, private hospitals have only two shifts. But the hospitals aren’t that crowded, so you get to sleep a little. Here we don’t even have time to sit,” he says.
Under these circumstances, a foreign job is highly coveted, but there are challenges aplenty. Daisy has witnessed it from close quarters. She was in the UK in 2010 for a nursing course. She had paid an agent ₹2 lakh for a seat in a college in Luton. But even before Daisy could finish her training, the college was de-recognised. She paid the agent again for admission in another college, only to lose it all. “We ran from pillar to post, but we lost the money and I returned to Kerala,” she recounts.
The story of agents cheating nurses is a familiar one for Evelyn Kannan, secretary general, TNAI. When she learnt of two girls who were cheated by an agent recently, she tried to get them to register a complaint, but they failed to turn up. TNAI officials also point out that finding a job abroad has become more difficult today as many countries are not as welcoming as they were before. “Migrating to the US has become more difficult, as also to other European countries like Ireland. The Gulf and Australia and New Zealand are among the places that still offer opportunities,” says Anita A Deodhar, president, TNAI.
That, however, hasn’t deterred Varghese in the least, as he continues to scout for overseas jobs. He is currently touching base with friends in New Zealand and Australia. The pay in those countries is a sure-shot lure, as a nurse gets paid almost as much as a doctor. Respect is equal too. “Doctors see the patient, give a diagnosis and recommend the treatment. The remaining work is done by nurses. They treat nurses at par with doctors,” Varghese explains. He knows of people who have gone to work in dangerous regions such as Yemen and Libya. They earn about $1,000 a month. “The temptation to go and earn that money for a few years is very strong,” he says, “in a way it’s better to be dead than spending a life working 12-14 hours just to pay off your loan and keep your head above water.”
Kannan, too, points to the lack of respect that nurses have endured for a long time. “They are the backbone of the health service. Yet they get so little credit,” she says.
BL ink sent e-mails to five prominent private hospitals in the Capital, seeking details on the conditions in which their nurses work. The only response came from Fortis Hospital, where the annual attrition rate among nurses is 45 per cent. The hospital stated that a grievance redress system and monthly townhalls were in place.
Nurses have been the subject of a decade-long study by Sreelekha Nair, a researcher at the Thiruvananthapuram-based Public Policy Research Institute. Nair says the series of strikes by nurses in Delhi in 2010 as well as Baby’s suicide had mobilised the community. “Nurses from Kerala who knew Baby formed a union,” she says. This was followed by strikes in Kerala, leading to the setting up of the Balaraman Committee and the Industrial Relations Committee. Despite these developments, Kerala still doesn’t have a uniform pattern of wages, says Nair. The focus, she says, should be on making innovative differences; allowing adequate rest-time and reducing the work burden. Until a decade ago, what was missing in the nursing community was a feeling of sisterhood. “It is important to keep the front united,” says Nair.
In the time BL ink was researching the story, three more nurses committed suicide. Baby was not an aberration, stories of desperation are now the norm. For Indians, who have long valorised nursing as a noble calling and idolised sacrifice as well as Florence Nightingale, this apathy is particularly shameful.
(*Names have been changed)
P Anima with inputs from Veena Venugopal