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Migrant Health Professionals and the Global Labour Market: The dreams and traps of Nepali nurses, by Radha Adhikari

Tristan Bruslé
Bibliographical reference

Migrant Health Professionals and the Global Labour Market: The dreams and traps of Nepali nurses, by Radha Adhikari. London, New York: Routledge/Edinburgh South Asian studies series. 2019, 192 pages, ISBN 9780367344252

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1Radha Adhikari takes us on a journey initiated by Nepali nurses, from Nepali bureaucratic arcana to their own daily working and family lives in England or Scotland. A journey filled with expectations, rumours, daily imperatives, hurdles but also a sense of pride and accomplishment. Adhikari delves into the rationalities of migrant women who represent half of the global migrant population, by first focusing on the link between education and migration, and eventually talking about the diasporisation of the Nepal-born population.

2Over the course of more than ten years, thanks to her intimate knowledge of the issues related to nurses in the UK, the author delivers a compelling case-study of the globalisation of health professionals’ movements, from the South to the North. She describes a global phenomenon from below, that is from the point of view of women (and their families) to show us how imbalances in the global labour market and individual and family aspirations combine to create new economies of education based on hope.

3Associating notions of hope and aspirations is consubstantial with migration (eg Carling et al 2018), and in the case of Nepali migrants, there has been a growing corpus about the way aspirations – ideas about one’s own future – are achieved in migration (Zharkevich 2020; Kӧlbel 2020; Snellinger 2018; Korzenevica et al 2017). Migrant health professionals and the global labour market describes the motivations and paths followed by ‘the very first generation of professional women’ (p2) – why not call them pioneers? But ‘dreams of the West’ (p1), whether they are personal or a family matter (p3), sometimes translate into traps that women struggle to escape. The road to permanent residency in the UK and to the nuclear family settling there comfortably is paved with difficulties, ‘from one volatile labour market in Nepal to yet another in the UK’ (p7).

4In the introduction, Adhikari reminds us that this migration of nurses is a ‘catalyst of changing social and gender dynamics in Nepal’ (p5) – women become more mobile, marrying a nurse is now ‘socially acceptable’ (p5). These changing patterns in Nepal accompany the global market of nursing and care in the context of the privatisation of healthcare systems.

5The ethnography, based on Adhikari’s PhD fieldwork, was mostly done at the end of the 2000s among nurses, their family and the whole Nepali ‘migration infrastructure’ (Xiang and Lindquist 2014), from Nepal to the United Kingdom. The author, herself a nurse-turned-associate professor, continued to follow her interviewees, providing the reader with a welcome diachronic approach.

6Chapter one describes the history of the system for training nurses in Nepal and its growing professionalisation and privatisation since the 1990s. Adhikari demonstrates how the initially negative attitude towards nursing – the reluctance of parents to let their daughters out of the house, the polluting nature (jutho) of the job and even the white uniform too much like a widow’s dress – changed as nursing became a much sought-after occupation that is even prized on the marriage market. The development of nurses’ training, which first aimed at providing local hospitals with nurses and then turned towards meeting international standards, has seen huge investments from private groups that had seen the potential of this training. The health business, analysed here through the accreditation of colleges and training courses, gave rise to the rampant corruption that is often reported in the media. Institutions like the Council for Technical Education and Vocational Training (CTEVT) or the Nepal Nursing Council (NCC) are under pressure to approve the opening of nursing colleges. At the end of the 2000s, the continuous process of market liberalisation meant that ‘there are now more hospitals and nursing homes run by the private sector than by the government’ (p49). At the same time, the demand for nurses among international migrants leads to the creation of unaccountable institutes that facilitate nurse migration (the number of International Educational Consultancies (IECs) reached 1,000 in 2008 and 2,000 in 2018), thus depriving remote rural Nepali regions of qualified nurses.

7Chapter 2 analyses the international migration economy as seen from the vantage point of nurses. As a ‘culture of migration’ (Cohen et al 2011) settled in Nepal, many nurses or women studying at nursing college considered ‘an international career move [as] their best option and […] the most desirable career choice for professional women’ (p52). Adhikari skilfully shows how, in the early 2000s, the already established diaspora in the United Kingdom proved decisive in alerting Nepalis to the shortage of nurses in the UK National Health Service (NHS). Contrary to most migrant men heading for the Gulf states on a temporary basis, migrating to the UK, for nurses, meant ‘better professional opportunities and a better quality of life for themselves and their families in the UK’ (p53). The perspective for the latter is, from the outset, to settle abroad in the long term. Women are thus the driving force behind this family-based migration, which is often animated by ‘pride, linked to the desire to be modern and successful’ (p53). Adhikari stresses that the decision to migrate is not an individual one but a ‘collective one’ (p57) and part of a family’s inner dynamics: extended family members lend money, children are taken care of – the same could be said for most labour migration in Nepal. Nurses are subjected to a great deal of pressure from their families and peers, not to mention IECs or migration brokers who advertise ‘study abroad’ programmes everywhere in Kathmandu, in newspapers and on the radio. Once the decision is made – either to study nursing abroad or to work as a nurse after years of experiences in Nepal – the most difficult part is to obtain a UK visa. Once aspirant migrant nurses enter the stressful period of applying for a visa, lots of middlemen whose morality is often suspect hurry to grab their share of the money invested by future migrants.

8Chapter 3 follows those who managed to pass the hurdles of a visa application and all the shady ‘satellite businesses’ (p44) to arrive in England where they face ‘major challenges’ (p75) regarding accommodation, obtaining a UK nursing license and a valid visa or working permit in order to become both socially and professionally assimilated. ‘Difficulties’ is the word most commonly used to describe the settlement process: most women arrive alone and are joined by their family only later on.

9In 2018–2019 the Nursing and Midwifery Council (UK) counted 576 Nepal-educated nurses working in the United Kingdom. In the absence of a ‘direct agreement … between the Nepali and British governments as regards recruitment and work permit provision for Nepali nurses’ (p83), the nurses rely on the Home Office to provide them with a permanent residence visa. They often get lost in all the changes to regulations concerning the obtention of a work visa, with some even prolonging their student visa in order to stay in the United Kingdom. For most women, it’s a ‘never-ending chain of difficulties (kahilai nasakine samashyaharuko sikri)’ (p94), where the agents who sent them to the United Kingdom often suddenly disappear (this happens in the Gulf too), forcing nurses to turn towards private networks for support. The South Asian diasporic hotspots of Southall or Nepali-inhabited Aldershot are places where women can find proper accommodation within their own community.

10The first years are described as a struggle by nurses who have to fight on several fronts, the professional front being the most arduous because ‘there is no easy way for Nepali nurses to secure NHS jobs’ (p96).

11Chapter 4 shows how integration into professional life is not a straightforward procedure and gives rise to deskilling, thus to disenchantment. There is indeed a contrast between, on the one hand, the high expectations of women who dream of achieving top qualifications in the United Kingdom and wish to acquire further skills and, on the other hand, the reality of their job, at least in the first years of working in the United Kingdom. All nurses, as flexible manpower, begin working in private nursing homes – the NHS is not accessible at first due to the absence of a recognised training certificate – where they work long hours, describing their job as ‘BBC’: British Bottom Care (p107). They feel cheated by their agents, who failed to tell them the whole story about work in the United Kingdom, just as Nepali workers who venture to the Gulf do. To make ends meet – bearing in mind their ultimate goal of reuniting with their family in the United Kingdom – , they do not have much choice but to toil and juggle a number of jobs at the same time. Not fully mastering the English language, most of them experience difficulties in communicating, and face discrimination and racism. As a consequence, they do not socialise at work and, if working in remote areas, end up experiencing loneliness.

12However, all is not bleak, Adhikari reminds us. Thanks to interviews conducted ten years after the first ones among the same nurses, the author asserts that ‘some nurses have made reasonable progress in their professional careers’ (p119), some having integrated the NHS, others studying for a PhD. Only a small number have returned to Nepal.

13Chapter 5 delves into family and social life in the United Kingdom. As for work, the first years are full of delusions. There is a stark contrast between preconceived thoughts about migration and the actual reality of it. This hiatus between pre-departure images and post-arrival realities seems to be a constant in Nepali migrations. Once the difficult stage of long-distance mothering is over, once the family is reunited in the United Kingdom, the ordeal befalls the husbands whose status of dependent ‘challenges their family role and social position’ (p130). For them too, moving down the professional and social ladder is hard to bear. It’s a brand new life, in which they must accept an inversion of gender roles by taking care of the children and of household chores. The nurses’ spouses feel that the household is headed by a woman, just as the country is run by a woman: ‘yo raniko desh ho’ (p132). Though stuck in the ‘dream-trap’ (p133) for a period of time, all families encountered by Adhikari eventually managed to settle in the United Kingdom and obtained permanent residency visas that carry ‘a huge symbolic value in migrants’ social lives’ (p141). The family’s ijjet (‘honour’) is restored, it’s now possible for them to go back to Nepal for a holiday with ‘some achievements, after investing so much family money, time and emotion’ (p135).

14The conclusion sums up the major findings of the study, stressing the continuous overproduction of nurses in Nepal compared to the number of job openings in the country. In fact, the demand on the international market is such that, as of 2018, even men have begun to enrol in nursing schools. In the meantime, Adhikari points out that female nurses have gained more bargaining power and are still ‘seen as a license for the family to move abroad to affluent countries’ (p152).

15Adhikari’s study is a fascinating one. Thanks to long testimonies and the use of Nepali words and expressions (more would have been better), the reader enters the nurses’ world. The particular interest of the book is the diachronic approach, which could have been developed more in that it is a very novel way of reflecting on migration in the medium term. The study of family dynamics and of social changes of course benefits from this endeavour.

16From a theoretical perspective, the author does not actually compare writings about diaspora and writings about labour migration. This is unfortunate because her case study seems to be representative of the passage from transnational migration, when family members are scattered, to a diaspora where symbolic and social resources have to be found in the new country. These families now settled in the United Kingdom will not go back to Nepal and, as such, represent new forms of belonging. More generally, the author could have made more comparisons with labour migration as it takes place in Nepal.

17Theses few oversights left aside, Adhikari’s book is lively, pleasant to read and will no doubt be an important reference for understanding what is at stake in training and migrating within the global care market.

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Bibliography

Carling, J and Collins F. 2018. ‘Aspiration, Desire and Drivers of Migration’. Journal of Ethnic and Migration Studies 44 (6): 909–26. https://doi.org/10.1080/1369183X.2017.1384134

Cohen, J H and Sirkeci I. 2011. Cultures of Migration. The Global Nature of Contemporary Mobility. Austin: University of Texas Press.

Korzenevica, M and Agergaard J. 2017. ‘“The House Cannot Stay Empty”: A Case of Young Rural Nepalis Negotiating Multilocal Householding’. Asian Population Studies 13 (2): 124–39. https://doi.org/10.1080/17441730.2017.1303110

Kӧlbel, A. 2020. In Search of a Future: Youth, Aspiration, and Mobility in Nepal. Oxford: Oxford University Press.

Snellinger, A. 2018. ‘“Every Household Will Be a Micro-Enterprise”: A Youth Micro-Loan Scheme’s Role in Restructuring Nepal’. Children’s Geographies 16 (1): 66–79. https://doi.org/10.1080/14733285.2017.1399581

Xiang, B and Lindquist J. 2014. ‘Migration Infrastructure’. International Migration Review 48 (1): 122–48. https://doi.org/10.1111/imre.12141

Zharkevich, I. 2020. ‘“We Are in the Process”: The Exploitation of Hope and the Political Economy of Waiting among the Aspiring Irregular Migrants in Nepal’. Environment and Planning D: Society and Space 39(5): 827–843. https://doi.org/10.1177/0263775820954877

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References

Electronic reference

Tristan Bruslé, « Migrant Health Professionals and the Global Labour Market: The dreams and traps of Nepali nurses, by Radha Adhikari », European Bulletin of Himalayan Research [Online], 57 | 2021, Online since 15 December 2021, connection on 02 October 2022. URL : http://preo.u-bourgogne.fr/ebhr/index.php?id=421

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About the author

Tristan Bruslé

Tristan Bruslé is a researcher at the Centre for Himalayan Studies (CNRS, France).

By this author

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Copyright

Licence Creative Commons
Les contenus de la revue European Bulletin of Himalayan Research sont mis à disposition selon les termes de la Licence Creative Commons Attribution 4.0 International.

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