From Angels to Fighters: Indian Nurses in Germany from the 1960s Till Today

Abstract

The article introduces global care chains as migrant labour regimes that represent transnational axes of social reproduction and supply chains in the wake of globalisation. Since the 1960s, attempts have been made to solve the nursing shortage in German hospitals with a spatial fix, the transnational commodification and extraction of care in a cross-border market. In addition to the push and pull factors for this international division of reproductive labour framed by global structures of inequality, the autonomy of migration and the agency of the subjects are also taken into account.

Based on biographical interviews, the empirical part compares the first generation of Indian nurses who came to Germany in the 1960s/1970s with those who have immigrated in the last 10 years. The categories analysed are their motivation, recognition, work and workplace, respect and discrimination, transnational family and, finally, their life perspective. The biographical narratives reflect ambivalences and contradictions, 50-year continuities, but also a growing autonomy. Despite massive constraints and marginalisation, they document great achievements in life, work and emancipation.

Introduction

Since the 1960s, labour migration and remittances have been a successful development strategy in the southern Indian state of Kerala. The emigration of nurses or young women to be trained as nurses played a significant role in this strategy and the feminisation of migration. This article explores the migration of Malayalam women to (West-)Germany as a case study to identify changes in the patterns of nurses’ migration in the past six decades. It refers to the first generation of young women who departed in the 1960s and 1970s from Kerala to get training as nurses in Germany and a recent generation of skilled nurses who came to Germany between 2014 and 2021. As an exploratory empirical study, biographical interviews were done with 10 nurses from this recent generation, while life stories and other documents by the first generation of Indian nurses are used as a background foil to outline changes and continuities, differences and commonalities, problems and achievements. This actor-centred research aims to make visible the agency and perceptions of the nurses themselves, their motivations and interests, their strengths and dreams.

The first part of the article contextualises the exploratory case study in a theoretical framework that compiles and interweaves concepts of global care chains and social reproduction, the autonomy of migration and border regimes, cultural political economy and care extractivism. These concepts provide some leading categories for the structuring and analysis of the biographical interviews, such as policies of recognition, valorisation and integration; the role of the informal network and the transnational family, border and boundary struggles.

This combination of primary data and secondary data allows investigating with a perspective of feminist-intersectional labour sociology whether and how the autonomy of migration and life planning has emerged, how the mechanisms of border and boundary regimes bring about the recognition and valorisation of migrant care work, which role informal networks, peer groups and the families of the nurses play and whether, finally, the migrant health care workers perceive this as a self-empowering process at the intersection of persisting inequalities.

Theoretical Outline

Global Care Chains as Gendered and Racialised Regime

Global care chains (Hochschild 2000; Parreñas, 2001) are the central axes of migration of care and health workers between low-income countries and countries of the Organisation of Economic Co-Operation and Development (OECD). While the initial focus of sociological and socio-geographical analyses of global care chains was on migrant domestic workers, Choy (2003) and Yeates (2010) extended the research focus to global nursing chains. Catherine Ceniza Choy has traced how the US colonial power built an ‘empire of care’ from the Philippines as part of the ‘culture of US imperialism’ and created ‘a racialised hierarchy with US-Americans at the top and Filipinas at the bottom’ by employing Filipinas as low-paid interns and nursing assistants in US hospitals (Choy, 2003, p. 5), a differential inclusion (Neuhauser & Birke, 2023).

Nicola Yeates analysed temporally and spatially how, in the context of global inequalities and neoliberal globalisation, nursing was increasingly organised into global nursing chains (Yeates, 2009, 2010). Beyond push and pull factors, she locates care by migrant professionals in the global political economy and transnational labour markets. In the meantime, care chains represent indispensable global axes of medical care and social reproduction, but also axes of sectoral accumulation fuelled by a market regime of supply through ‘labour brokerage states’ like the Philippines (Rodriguez, 2008) on the one hand and demand from OECD countries on the other. They are embedded in family, religious, commercial, state and digital networks that function as a transnational infrastructure of migration, organising recruitment, placement and employment of migrant workers, but also various forms of social and emotional support (Glick Schiller et al., 1992; Levitt, 2001).

Building on Evelyn Nakano Glenn’s concept of a long history of a ‘racial division of paid reproductive labor’ in colonial and post-colonial economies (Glenn, 1992), more recent theoretical framings place global care chains into racial capitalism (Neuhauser & Birke, 2023; Strauss, 2020). Apart from the focus on gender, they intersectionally highlight processes of racialisation in recruitment, migration and employment of health care workers and in valorisation and recognition of health care work. Value attribution refers to an intersecting patriarchal, colonial and capitalist logic of service which subordinates social reproduction to production processes. This rationale legitimises the persisting low valuation of care work and unequal exchange (Valiani 2012) in national and transnational labour markets. The gendered, racialised and class-induced mechanisms of segregation and othering, of inclusion and exclusion fragment the labour force and prepare the ground for a further devaluation and precarisation of migrant labour (Mezzadra & Neilson, 2012).

Stereotyping plays a significant role in the ‘cultural political economy’ of the valorisation of work (Sum & Jessop, 2013). The gendered profession of nurses and midwives is shaped in many cultures in an ambivalent way: on the one hand, as impure physical work, and at the same time, as an honourable altruistic activity (Nair & Healey, 2006). Because of the care of soldiers, night shifts and celibacy, nursing was also associated with the stereotype of liberal sexual morality—always linked to class, ethnicity and origin. Male fantasies of sexual availability mutated into an attribution of female frivolity or even sex work, which was reinforced depending on the distance of the nurses from patriarchal control at home, and even more so through migration (Walton-Roberts, 2012). Thus, the female body and the attributed female (im)morality were and are central to the discourses around the status of nurses. Sexist, ethnicised, racialised, class- and caste-based strategies of discrimination and devaluation of migrant health workers are intersectionally intertwined with material economic factors (van der Linden, 2020).

The stigma that nursing is impure is extremely pronounced in the Brahmanical caste system, where all impure work is assigned to the lower castes. To counter the stereotypes of impurity and sexual permissiveness, Christian missions ennobled nursing through concepts of discipline and ethos of care, self-sacrifice and nun-like desexualisation. This was symbolised in the white uniform and bonnet of the ‘sisters’, which also aimed to build a collective professional identity (Nair & Healey, 2006, p. 4).

In transnational health care chains, a new international division of reproductive labour materialises in an asymmetrical distribution of power based on class, gender and racialised or ethnicised differentiation of migrant workers, as well as an unequal distribution of gains and costs. Thanks to transnational migration, destination countries and the global middle classes can record a gain in terms of care capacities, skills and emotions to ensure their way of social reproduction as part of their imperial mode of living (Brand & Wissen, 2021). Problems are externalised from the Global North to the Global South when care providers, and with them training and knowledge, leave the countries of origin, and ease care and personnel deficits in wealthy countries. The care chain, which remedies a shortage in the West, creates a care drain, a brain drain and a supply gap at the other end, as well as a depletion of social capital (Isaksen et al., 2008; Lutz & Palenga-Möllenbeck, 2012).

The migration of care workers for the material well-being of the family not only causes high social costs in the households of origin in terms of gaps in household work and caring for the family but also painful experiences of deficit and emotional loss for the children left behind. Isaksen et al. (2008) have used the example of Malayalam families to show how care extraction depletes local social relations and care capacities as socio-emotional commons in the Global South. Even if income poverty is reduced in the households of origin, a social and emotional poverty of caring and provisioning is created (Lutz & Palenga-Möllenbeck, 2012). This ends up in a new stratification of social reproduction on a national and transnational level and a consolidation of inequalities under gender, class, post-colonial, ethnicised and racist auspices.

Interests and Struggles

Within the framework of push and pull factors, a sketchy mapping of interests in the migration of skilled nurses in transnational value chains points out that governments in the South became labour brokers. They use the export of cheap care workers as a development strategy that earns them foreign currency through remittances and is supposed to reduce problems of un(der)employment and poverty in their countries (Yeates, 2009). Countries and metropolitan cities of the Global North increasingly relied on migrant care labour to reconfigure their regime of social reproduction and manage the crisis of shortage of health professionals and care labour with the help of a ‘spatial fix’ (Harvey, 2001), the import of skilled people at low costs. As intermediaries, profit-oriented, commercial agencies in sending and receiving countries make money by facilitating the recruitment and placement; additionally, private hospitals are setting up their own agencies agencies to do targeted recruitment. The key actor, the care worker, has a right to mobility and often—beyond push and pull factors—a desire to migrate out of personal interests. While they want to escape often miserable pay and working conditions, lack of recognition and career chances, they land up in a vicious circle because the migration of nurses exacerbates the nursing crisis in their home country, and a conflict of rights emerges between the individual right to migration and the collective human right to health.

As migrants have long been understood as passive subjects and victims of these processes without agency, the concept of the autonomy of migration emerged as a counter-narrative focusing on subjects and their agency, against the structuralism of migration theories that reduce its complexity mainly to push and pull factors (Papadopoulos et al., 2008). The theorem highlights that within capitalist markets, migration and the corresponding spaces are constructed multidimensionally through structures, processes and discourses, as well as through the agency of migrants (Massey, 1994; Mezzadra, 2011).

The recruitment, migration and employment of care workers is a space for care extractivism (Wichterich, 2019), understood—analogous to resource extractivism—as the transnational commodification and appropriation of the social resource and common good of care in a power-asymmetric post-colonial market. Like any other resource overexploitation, it is paradigmatic for the reckless capitalist rationale that does not care about the exhaustion, depletion and erosion of natural and human resources or about vulnerabilities and precarities it constructs. The theorem of care extractivism interweaves care chain analyses with care drain analyses and thus adopts multiple perspectives on migration and labour processes, a structural economic, political and a socio-cultural as well as an everyday-life perspective, including their agency, desires and achievements, but also their physical and psychological vulnerability, precarity and exhaustion. (Wichterich, 2020, 2023). These perspectives highlight the market-based and the individual reproductive interlinkages between the two points of reference, the place of origin and the place of destination.

As in the context of the shortage of skilled labour, countries of the Global North ask for skilled healthcare personnel and thereby deepen the pattern of a spatial gap between skill training in the Global South and skill usage in the Global North is reaffirmed. In case governments finance education, this brain drain is a loss of return on investment. However, nowadays, due to the privatisation of nursing training, the costs of education are shifted to the individuals and their families. As they have to pay high fees to training institutions and placement agencies, they often accumulate a considerable debt burden. Debt becomes a driving force in the migration process and for the exploitation and care extraction of migrant workers, as it forces them to accept precarious working conditions. Furthermore, agencies offer to customise the education to the needs of the receiving country rather than to the country of origin of the nurses (Merz et al., 2024). Thus, global care chains are a paradigm of the unequal power relations between North and South, and the corresponding trade and financial interests in a post-colonial labour regime with racialised features. In addition to care extractivism, financial extraction from the Global South is taking place due to the financialisation of care, training and migration.

The initial motivation of migrant care wage labour is the reproduction of the family of origin through remittances. Therefore, paid care work in global care chains has to be valued as double reproductive work: the reproductive work done by care workers in the destination country, for example, as a nanny for the kids of the employer’s household or as a nurse for sick and elderly patients, is at the same time reproductive work for their family at home in the household of origin materialised in remittances. Paid care work has to be seen in its interwovenness with unpaid reproductive work, that is, from the perspective of the entire work of the workers (Bhattacharya, 2017).

After crossing borders, migrant workers face new internal boundaries and barriers through visa policies, residence and work permits, (non-)recognition of diplomas and allocation of precarious jobs in institutional and work hierarchies (Ghosh, 2018; Guild & Mantu, 2011). Furthermore, the above-mentioned socio-cultural attributions to nursing and nurses are effective as boundary and exclusionary mechanisms and as integral parts of the political economy. Not only the structures of economic valorisation of their work but also the border and boundary struggles in the country of destination can have important psychological ramifications on their identity and subjectivity.

Historical Context

Global Nursing Chains from Kerala

Margaret Walton-Roberts and Irudaya Rajan (2023b) have used the example of the migration of nurses from Kerala to link the migration–theoretical question of positive or negative development effects with the subject–theoretical question of the emancipation of health workers through migration or their being caught in a patriarchal trap. The high level of education in Kerala has been the backdrop for labour migration of Keralites and migration as a development strategy since the 1960s. The Marxist-oriented and anti-caste government of the state ensured good education for all, including girls. The more the migration of nurses proved to be a lucrative source of income, the more private training institutions for nurses mushroomed since the 1990s, and the more men entered the profession. According to the World Health Organization (WHO) in India (2021), 20% of trained nurses are nowadays male. Academic training provides medical expertise at high prices, although privatisation tends to cause a decline in the quality of training (Walton-Roberts, 2015). The fees for the privatised training, the costs for travel and placement agencies, in addition to the family obligation to pay a dowry to the future husband of the nurse, accumulate to a significant burden and driver of migration (Walton-Roberts & Irudaya Rajan, 2023a).

In order to introduce regulations for the largely unregulated transnational labour markets for nursing, the WHO adopted a Global Code of Practice on the International Recruitment of Health Personnel in 2010 (WHO, 2010). It initially listed 57 countries in the Global South, including India, that suffer from such a severe shortage of health workers that recruiting them is not feasible. The nurse-to-patient ratio in India is 1.7:1,000 inhabitants, deviating from the WHO standard of 3:1,000 (Chaudhary, 2022). This means that there is a shortage of about two million nurses in the country of 1.43 billion. The Indian states get caught in a dilemma between their strategy to benefit from the export of well-trained health workers and the need to improve public health care, in particular for poor and rural populations (Angenendt et al., 2014; Clemens & Dempster, 2021). Nevertheless, India was removed from the WHO red list, mainly due to the argument that it has a qualified pool of professionals in Kerala willing to emigrate, appearing as an oversupply of personnel (WHO India, 2022). In order to regulate emigration and meet domestic demand, trained nurses must first work in Indian hospitals, mostly for 2 years. Furthermore, often destination countries require specific work and time experience before employing a migrant nurse.

The Kerala–Germany Connection

A specific feature of the migration of malayalam nurses and trainees to West Germany in the 1960s/1970s was the recruitment and placement through Catholic networks, dioceses in Kerala and West Germany and church-related organisations such as Caritas and the sisterhood of the German Red Cross (Goel, 2002).

At that time in Germany, the labour migration paradigm was the guest worker model. Workers were recruited when there was an acute need in the labour market and were expected to leave the country when the need could be met otherwise. In this migration and labour regime, workers were not free in the sense that they could choose their jobs and employers. Between 1963 and 1977, in addition to 10,000 qualified nurses from South Korea, who were recruited under an agreement on technical development aid (Korea Verband et al., 2016), 6,000 very young Keralite women and nuns came to Germany through Catholic networks (Goel, 2002). When they were told in 1977 that they were no longer needed and should return home, the Koreans protested with slogans such as ‘We are not commodities’ and ‘We have provided development aid for you’ (Korea Verband et al., 2016). Many Indian nurses who had lived in Germany for years and built their own families there, quietly developed strategies to extend their stay (Goel, 2023).

Nowadays, the informal, initially primarily Catholic network, and the dispersed transnational family members, along with the four official agencies run by Indian states such as Non-Resident Keralites Affairs (NORKA) form a transnational (re)productive network for Keralese health care workers that helps them with placement, step-by-step and circular migration or return, as well as with covering costs and serving debt.

Referring to the WHO recruitment code that included India on the red list, the German government did not incorporate India in its Triple Win programme launched in 2013. However, immediately after the revision of the WHO recruitment code, Germany included Kerala in the Triple Win programme of the Gesellschaft für Internationale Zusammenarbeit (GIZ) and the German Federal Employment Agency at the end of 2021. The German state normalises through this programme the spatial fix of the crisis of social reproduction in Germany, as well as transnational care extractivism. Some of the German federal states offer 3,000 Euros in financial support for acquiring skills in the German language in Kerala, while the GIZ conducts 1- to 4-day seminars to prepare the candidates for life in Germany. The ‘Triple Win’ formula assumes equal opportunities in spite of global inequalities; thus it disguises care extraction and maintains globally stratified relations of reproduction between North and South, West and East, rich and poor. A transnational market with mushrooming recruitment and placement agencies promises to speed up the bureaucratic recognition and the learning of German. In Germany, commercial agencies now handle 80% of the government recruitment (Deutscher Bundestag, 2024).

Explorations Towards an Intergenerational Comparative Research

Actor-Centered Methods

There is only scarce literature on Indian migrant nurses in German-speaking countries and no research at all about the changes experienced since the initial phase of the 1960s and 1970s. The migration of the first generation of nurses is documented in a number of life stories and interviews (Goel, 2013b; John & Wichterich, 2023, pp. 267–284; Oommen, 2008) and in the documentary film ‘Brown Angels’ (2016) with many statements and observations, as well as an accompanying photo exhibition. While media and literature on Indian health workers in German-speaking countries mainly asked about integration or resumed integration deficits (Goel, 2013b), only recently a turn towards actor-centred and biographical research took place (Chakkalakkal, 2023; Goel, 2013a, 2013b). A lot of this recalling, remembering work and documentation is done by daughters and sons of the nurses, second-generation Indo-Germans, who want to give a voice to their mothers and make their life experiences and achievements visible (Chakkalakkal, 2023).

These documents and narratives, which present a rich repertoire of anecdotal evidence, are taken as background material and a starting point for the following exploratory study on changes in migration, life and work experiences in the past five decades. Along with a brief analysis of the secondary data on the first generation of Indian nurses in Germany, I conducted, in 2022 and 2023, 10 qualitative semi-structural biographical interviews with nine female nurses and one male nurse who arrived in Germany between 2014 and 2021, eight of them from Kerala. They organised their immigration and placement individually as the German state officially obtained from recruitment before 2022. At the time of the interviews, eight of them were employed as regular nurses, and two were still in their initial period as assistant nurses and lived in a nurses’ home on the hospital compound. One was working as a specialised surgical nurse.

Some interviews in six German cities were arranged by an elderly key figure in the Catholic Indian community in Cologne and Bonn; others were identified by a snowball system. As an icebreaker, I introduced myself as a bio-German scholar who is particularly interested in their life stories, as I had spent many years in India. I told them that they should stop the interview when they wanted to avoid an issue; this happened in one case. Each interview lasted around 1 h and was recorded and transcribed. Seven interviews were made online and three face-to-face, most of them in German, and only in two cases did we switch to English when the interviewees felt more convenient with it. Only one interviewee preferred to be anonymised.

Qualitative interviews are an appropriate feminist methodology in actor-centred research to give voice to interviewees whose voice normally does not reach the public and to explore their social realities and everyday experiences, giving space to their subjective assessments and reflections but also their physical and psychological conditions. Feminist-intersectional methods take into account that experiences and the production of knowledge are contextualised and situated within intersecting power dynamics. Situating qualitative semi-structured interviews in a historical perspective and in a structural and discursive context can do justice to the agency of migrant workers, and the autonomy of migration and of life planning.

For the structuring of the interviews, some categories were identified from the above-outlined theoretical and conceptual framework. These categories comprise (a) recognition, valorisation and integration; (b) the role of informal networks and the transnational family; and (c) border and boundary struggles. The aim of the interviews was to flesh out the three categories empirically.

Trajectories of Migration

Based on the secondary data from the first generation and the primary data from the younger generation, I would like to outline the most important differences and changes.

The 1960s/1970s generation travelled by ship or by plane in small groups, most of them as young as 16. They came from large families with up to 10 siblings, from poor and peasant backgrounds. Their travel, administrative formalities, education and accommodation were organised by Catholic networks. The peer group acted as a social safety net and collective shock absorber for the young migrant women. Daily life and residence in nurses’ homes next to the hospitals, training as nurses and learning the language integrated them into the German health and hospital system but demanded massive adaptation and assimilation, especially with regard to foreign food, clothing and the German weather. They wrote one letter per week to their family in Kerala and suffered from a culture shock and terrible homesickness. Later on, key experiences of separation, which still hurt them today, were that some young mothers had to leave their babies in Kerala while working in Germany, and that during their stay in Germany, relatives in Kerala passed away. Their struggle to adjust and integrate was a process of painful pioneering that constructed a new self, a new subjectivity in an alien socio-cultural environment, but at the same time, a kind of self-empowerment.

The generation that arrived after 2014 organised their migration individually and informally, mostly with the help of a network of family members in Europe. They were at least 22 years old when they left the country and came from small, middle-class families with two or three children. They got training as nurses at expensive private colleges and became indebted because of the high fees. Most of them have work experience in Indian hospitals, first as interns during their studies and after graduation as nurses. They learned German up to level B2 at a Goethe Institute in Kerala. They also sometimes suffer from homesickness in Germany but compensate for this with daily video calls to their family. In general, they believe they can easily adapt to German habits and culture. Nevertheless, they are tensed and feel challenged to constantly adapt and face barriers and boundaries.

Motivation and Agency

The 1960s generation had as its central reproductive motivation for migration to support the family in Kerala, initially by financing the education of siblings and later by building a house for their parents. The initiative for migration often came from a local priest who had connections to Catholic institutions or priests in Germany, selected young women from the parish and persuaded their fathers. The key desire to help the family is framed by a naturalising narrative of feminine service, self-sacrifice and a kind of fatalism that one ‘did what had to be done’. Migration was a family survival and support strategy. However, a first break in the patriarchal gender order took place by transferring a crucial breadwinner role in social reproduction from the male head of the family to the young departing daughter. In retrospect, the women do not see themselves as passive or even as victims, but they discovered and developed their own agency and subjectivity in this process while maintaining a strong family identity. Looking back, they are extremely proud of what they have achieved without questioning the authority of the father and parents despite the partial reversal of gendered and generational roles.

In contrast, the young generation stresses that it was their own decision and desire to emigrate in order to improve their individual reproductive conditions. They chose to be trained as nurses because of the excellent migration prospects for this profession. Against the backdrop of tremendous changes in the Malayalam society and economy in the past six decades, including Kerala’s migration culture, the parents also considered this life plan of their daughters to be the best option, while one or two siblings were often already working abroad. The migrants’ priority is to achieve a high quality of life—due to a good income—with personal freedom. The aim of earning money to pay off debts caused by educational fees in private colleges and migration costs is secondary. The topos of a ‘good life’ in Germany is the crucial reference point for most of the interviewees and replaces as an objective of migration the sending of remittances to the family. The two non-Malayalam nurses immigrated to Germany for a family reunion; one of them wanted to go to Canada for further education, but her parents refused to pay for that and recommended searching for a spouse in Germany and then migrating there. In one case, the separation from the husband was a reason to leave Kerala.

The preliminary comparison of the two generations thus shows a trend from migration as a family survival strategy to migration autonomy and an individualisation process in which the health professionals are conscious about their decisions and objectives from the beginning and develop a strong will to independence.

First Empirical Findings

Recognition and Integration

My parents paid for everything … An Indian priest in Germany functions like an agency, he contacts the hospital (Soji, 27 January 2023)

They delay recognition so that they don’t have to pay people (Santosh, 11 January 2023) bad, six months without a salary, I am very hardworking. During the Covid period we worked like hell. But they didn’t give us citizenship for that (Adi, 16 October 2022)

The foreign registration office is the worst, I call 1000 times, nobody answers, we get no answer. That takes so much time, whole days, nobody reachable, everybody from abroad says that (Gini, 14 March 2023)

Different from the first generation of nurses, the recent generation faces many administrative boundaries and barriers before entering Germany and within the country as well. This indicates that nowadays border regimes work much stricter and multidimensionally outside and inside of Germany. All migrant nurses report that they were confronted with many bureaucratic hurdles and requirements for 6–12 months and were asked to provide numerous documents and certificates before they could get their visas and permits. The difficult precondition for immigration into Germany, an employment opportunity at a German hospital, materialised with the help of an ‘aunt’, a priest or an agency in Kerala or Germany. While working with a contract in a German hospital, they are repeatedly confronted with this time- and energy-consuming bureaucratic power game when they have to renew their residence and work permits. They are relegated to the position of a petitioner who gets disciplined and controlled but also humiliated as non-citizens in these post-colonial power structures.

A crucial barrier to integration is the recognition as a professional in the German health system after the nurses have completed a good college education in India. After arriving at the destination hospital, they are first employed as nursing assistants with low pay, a form of integration with simultaneous devaluation and construction of cheap labour. After 6 months, they have to pass an ‘adaptation exam’ in a special medical field, for example, geriatrics. Failed exams have to be repeated after a few months. Only after passing, they get employed as ‘registered’ nurses according to collective wage agreements (Mahindrakar, 2024).

Both procedures for formal recognition by the border and migration authorities and in the hospital are tantamount to a rite of passage for migrant professionals and the systematic construction of precarity, meaning ascribing a subordinated status in the labour regime and society to them. The disregard for their high-quality education and for them as persons is perceived as unfair and harassing. In their perception, this struggle for recognition and permits is an integral part of their wage work and professional practice. Despite the uncertainty and precarity caused by the bureaucratic, non-transparent procedures, they develop a growing will to fight and resist these obstacles.

Work and Workplace

Basic care in Germany is easy but boring, no responsibility, but we studied medical stuff… The senior nurse also does care work, but I think it is unfair that when I have worked for 20 years and have a lot of experience that I have to keep doing basic care directly (Santosh, 11 January 2023)

Super respect in the ward, doctors come and ask politely ‘Can you please?’ (Ammu, 09 November 2022)

I can sit next to the senior doctor at lunch and talk to him (Leela, 10 March 2022)

For the current generation of nurses, the yardstick for assessing nursing work in German hospitals is work in Indian hospitals, where they have had practical experience (John & Wichterich, 2023). In Germany, they enjoy the regulation of work; they only work 8 h a day, overtime is paid, they have ‘a lot of free time’ and holidays and the feeling of earning well. They appreciate the option of flexible and part-time work as well as options for further education. While in India, they were aware of how poorly health workers are paid compared to other professions; in Germany, they do not compare their pay with other professions. What they praise most is the—compared to the steep hierarchy and multiple segmentation in India—flat hierarchy in German hospitals, the good teamwork, which also includes doctors, and the ‘equality’ in the team. This makes horizontal integration in work processes unproblematic. In their view, social equality shows when nurses are asked for their opinion, older nurses do the same work as the younger ones and doctors communicate with them normally. They also relate this narrative of social equality to the equal treatment of patients—those with private insurance and those with statutory insurance—while rich patients would always claim privileges in Indian hospitals.

Mostly, they feel overqualified with their medical knowledge and academic education because they have to do bodily care, which is considered impure and is done by unskilled ‘ayas’, helpers or family members in Indian hospitals. Since they are not allowed to make use of all the acquired skills and knowledge, for example, only doctors have permission to give intravenous injections in German hospitals, they find the work easy and sometimes boring. Compared to Indian hospitals, they feel less burdened and stressed, except when there are few nurses on the night shift or they have to deal with difficult patients in the emergency ward. However, it appears that the longer the health professionals work in Germany, the more they perceive the burdens and stress caused by neoliberal hospital management and staff shortages. Overall, however, their perception of work in German hospitals is marked ambivalently: good working conditions but de-skilling.

The singles among nurses enjoy their time off and vacations. However, the married women with children—similar to the narratives of the first generation—do not clearly separate their paid and unpaid care work: it is a flow of care work from the hospital to the household that shows how production and reproduction are intertwined and mutually dependent. In both generations, husbands take on shares of child care. This necessary change of roles was extraordinary in Germany in the 1970s and even more so in Kerala, while today it is considered normal.

Respect, Discrimination, Racism

Discrimination is more because of language than because of skin color, I didn’t experience that myself, but with many colleagues. Or I didn’t notice it at the beginning because I had to be friendly to everyone. It’s possible that you don’t hear it or don’t want to hear it (Ligi, 24 November 22)

Racism in Germany is 30-40 percent, but not in my situation, but in my husband’s company, especially against uneducated people. I get respect (Adi, 16 October 2022)

Here everyone is on the same level. I first thought I have to respect them but they told me, we are equal (Ammu, 9 November 2022)

Being respected in the hospital and by their colleagues is a major source of job satisfaction and a sense of well-being and belonging. The interviewees’ reaction to the question about discrimination is revealing. Initially, all of them denied being discriminated against but then acknowledged individual racist experiences, for example, by individual patients who did not want to be treated by foreigners or pretended not to understand them. Support by the team is essential to them in such conflict situations; that is, they construct the team as a peer group and a safety net and actively pursue their horizontal integration in the workplace.

However, they also report being assigned to stations or shifts where they do not like to work. One nurse who was several times infected with the COVID-19 virus was not transferred from the COVID ward despite requests; her infection was also not adequately medicated in the hospital. Another nurse who wanted to work night duty because of better remuneration was initially not included in the pool for the night shift.

Overall, the nurses tend to repress and reinterpret everyday racism based on their skin colour by attributing it to insufficient German language skills or externalising it, for example, to public transport. They strive to support other discriminated migrant workers whose German is poor. The aforementioned discourse of social equality is used as a counter-narrative to discrimination.

Over time, the nurses learn to manage and process their feelings and situations in which they feel humiliated due to discrimination and racism. This struggle for respect is integral to their work, and they increasingly develop strength and agency. The male interviewee, who is married to a German, is the only one who has filed a formal complaint at the hospital with the help of his wife. Others are not familiar with these official complaint mechanisms. Though some criticise neoliberal cost-cutting management in the hospital and support the demands of the German hospital movement against the industrialisation of health care, they are not planning to organise. The only male nurse in the sample who already was a health activist and organised in unions in India analyses labour relations most critically and plans to network with Indian nurses more closely with regard to labour rights. However, this observation suggesting a gendered labour agency, with female nurses tending to have great job satisfaction and a more critical stance among male nurses in this field, cannot be generalised at this point in time.

Nurses of the first generation downplay or reinterpret discrimination and racism in a similar way. They refer to their image of ‘brown angels’ as the counter-narrative to discrimination, an ascription that—in their view—made them popular and shows how they are valued in Germany.

Both generations of nurses are caught up in ambivalence between recognition and rejection, and construct their own subjectivity and the team as a safety net in these tensions and contradictions (Massey, 1994). They develop agency, while the permanent risk of discrimination remains a mental load and a stressful situation to be managed on a daily basis.

Transnational Families

My aunt and cousin did the paperwork for me (Anonyma, 19 October 2022)

I am totally different compared to back then, earlier I needed my parents for everything and didn’t think I could do it without my dad and mom… now I managed a lot, can do everything on my own (Ligi, 24 November 2022)

Today everyone is a bit modern and says ‘no dowry’, but we have to have something, gold or money, that’s why I put a little money aside every month…. My parents are looking for a partner for me (Ammu, 09 November 2022)

The embeddedness in the transnational family is the crucial lifeline for the current generation of nurses, not less than for earlier generations. They remain emotionally attached to their family and feel morally obligated to support the parents or the brother who has the duty of care for the elderly parents. Still, the parents, especially the fathers, make the final decision on when and where the daughter emigrates. Daughters accept parental authority as well as an arranged marriage. Though setting up their own nuclear family remains the most important goal in their life planning, the young generation describes itself as ‘modern,’ does not panic about marriage, dowry and motherhood, but postpones them when it becomes difficult to find a suitable husband willing to live in Germany. Each of the women is willing to pay dowry or has already paid it; all legitimise the system, saying it is for their own benefit and security.

Members of the transnational family in Europe, aunts and cousins who now form a support network of relatives in Europe, have also worked as nurses. They encourage young women to come to Germany and to stay while assisting with bureaucratic formalities and searching for jobs.

Social media is the central transnational field of action and family life. Daily video calls, sometimes several times a day and for over an hour, turn the long-distance relationship into an intimate bonding. They confirm their Malayali identity by speaking the language, feeling part of the culture and creating social intimacy between the children and the grandparents. They fulfil their duties to care for their elderly parents by giving them medical advice and monitoring medication intake.

Ironically, the elderly parents often live alone in an oversized house in Kerala, built from the remittances of their children working abroad, while most of their children (and grandchildren) settled permanently as migrant workers abroad. This hints at a social prize for migration and a lasting emotional dilemma that the parents are proud of their children who ‘made it’ but suffer from the separation and loneliness in Kerala.

Life Plans and Perspectives

Staying here is better. We get everything here (Anonyma, 19 October 2022)

Here I have good quality of life (Ammu, 9 November 2022)

There is a lot of freedom here… I can go somewhere alone and at night, I can do everything independently (Soji, 27 January 2023)

I definitely want to stay here. I don’t want to work as a nurse in India, maybe work as a German teacher, otherwise I wouldn’t find a job. I don’t want to sit at home as a housewife, I want to stay, but my husband wants to go back, he loves Indian culture… You can go there on vacation, but I don’t want to live there (Ligi, 24 November 2022)

The first generation wanted to return after they had achieved certain goals. When they were pressured by the German government to leave in 1977, most of them refused and found ways to stay. Later, they kept postponing the return when the children started school, when they finished school, when the children got married, when grandchildren were born in Germany and so on. Many became German citizens and today have more family members outside Kerala and more friends in Germany than in Kerala.

The young generation has a very conscious life plan. Only the male nurse interviewed and the Indian husband of a female nurse see an option to return. But the women cannot imagine being housewives in India or working there as nurses. They perceive migration as a boost for independence and self-empowerment, and want to see their children grow up and go to school in Germany. They intend to become German citizens and already consider their work, in particular during the COVID-19 pandemic, as an act of citizenship.

Conclusions

In India too little is paid in private hospitals, no money for our future. We have to go somewhere abroad. So many studied and migrate to another part of the world (Gini, 14 March 2023)

I can handle anything. I am strong. I fight my way through (Adi, 16 October 2022)

Even if the small sample is not representative and a larger sample is more heterogeneous, it can point to trends.

The everyday situation, state of mind and subjectivities of the current generation of nurses are characterised by many ambivalences and tensions. These must be interpreted in the continuum between constraints and surveillance, and ‘expansion of freedom and equality’ as outlined by Mezzadra and Neilson (2012). Obviously, their self-representation is dominated by a high level of job and life satisfaction, pride in their capacities and accomplishments, and a growing awareness of their abilities to cope with problems and struggle. While the first generation described financial support for their siblings and parents as the crucial achievement of their lives, the current generation understands personal independence and the ability to overcome difficult situations with the help of their network as their most important achievement. In contrast to the structural analysis of extractivism in transnational care chains, they see migration as an ultimately empowering process, downplaying the low valuation and extraction of care and the racialised discrimination against themselves. Additional to the growing autonomy of migration is the autonomy of life planning, although the migrant health professionals continue to leave important decisions to their parents.

Both generations use an expanded concept of work in their biographical narratives. The first generation remembers their difficult time of arrival and adaptation in Germany as hard work and pioneer struggle, while the second generation sees the strenuous bureaucratic procedures, the ‘paperwork’ to obtain recognition, visas and permits as a great burden in their everyday life and prolonged border struggles. For both generations, the permanent defence against disrespect and devaluation, as well as their own trivialisation of discrimination, are part of the normality of migrant work. Likewise, efforts to build a peer group, a safety net, a friendly work environment and a new self are ongoing invisible forms of work and struggle for self-empowerment. Therefore, the feminist labour sociology of migrant health care work must include three dimensions of work and struggle beyond the actual workplace: the internal construction of a new subjectivity with self-respect, the unpaid work in social reproduction in their local and transnational family, and the institutional struggle for formal recognition.

The assessments of the interviewed nurses are entirely informed by their personal experiences. Though they criticise a few structural conditions, such as the high fees charged by private training colleges, they do not address the fact that due to this transnational reorganisation of reproductive work through care chains, a new international division has emerged between care training in the less affluent country of origin and care use in the more affluent country of destination and that the exodus of care workers results in a staff shortage and thus poorer healthcare in the region of origin, which also affects their family. Paradigmatically, they construct themselves once again as actors in this problematic situation and assume that they can perform their reproductive duties and provide medical care for their parents through daily video calls, thus reversing the transnational chain of care by telephone.

Even if this exploration contributes to filling a gap in research on Indian nurses in Germany, it shows the need for deeper research on different—not only two—generations of nurses. Though this study points at ongoing trends, more similar explorations have to be made before generalising these findings.