Indian Journal of Medical Ethics


A multi-dimensional exploration of care extractivism in India

Vijayaprasad Gopichandran

Published online first on February 7, 2024. DOI:10.20529/IJME.2024.010

Maya John, Christa Wichterich, editors, Who Cares? Care extraction and the struggles of Indian health workers, Zubaan Academic, New Delhi, 330 pgs, Rs. 895, ISBN: 978 93 90514 03 8 (paperback)

Christa Wichterich coined the term “care extractivism” to describe the global phenomenon of intense commodification of social reproduction carried out by female healthcare workers in the health system without any acknowledgment or compensation for their contributions.

Why is care work provided by the female healthcare workers in India undervalued? What role does fragmentation of healthcare work into “voluntary”, “contractual” and “regular” work have to play in perpetuating this care extractivism? How are hierarchies constructed based on education, caste, class, gender within the highly fragmented and commodified care work? How does this hierarchisation contribute to care extractivism? What role does privatisation of nursing education have to play in deepening this hierarchisation? Did unionisation help mitigate the care extractivism? How active are nursing unions? How do they protect the interests of healthcare workers? These are important questions in understanding the political economy of care work in India. Who cares? Care extraction and the struggles of Indian health workers is an excellent volume crafted by Maya John and Christa Wichterich, which addresses these questions and attempts to clearly lay out the problem of the undervalued contribution of female workers in India. Christa Wichterich is a sociologist and feminist scholar who worked as a lecturer at the Jawaharlal Nehru University. As a journalist, she has written extensively on women’s work and feminist political economy. In the year 2018-19, she worked in New Delhi and researched care extractivism with respect to nurses in India. Maya John teaches history at Delhi University. Her area of work is the history of epidemics. She actively works with nurses’ unions, unions of domestic workers and teachers.

This book is built on excellent empirical and theoretical research by distinguished scholars in the field in India. It has 12 chapters divided into two sections with six chapters each. The symmetry of this distribution is alluring. The first section covers various aspects of nursing in India, including hospital-based nursing work and the community health work of Accredited Social Health Activists (ASHAs), Anganwadi Workers and Auxiliary Nurse Midwives (ANMs). The second section is a description of the state of nurses who migrate from India to various foreign countries including the Gulf countries, Germany, and Italy.

In the first chapter, Panchali Ray highlights how nursing labour has been split into “dirty” and “prestigious” jobs based on the existing social structures of caste, class, and gender. Ray observes that there are more upper caste women in the category of qualified and registered nurses and more women from scheduled castes among the casual unregistered nurses. This is based on an intensive field-study conducted in Kolkata hospitals. Hemantika Basu, in her chapter brings out the hierarchisation of nursing work in hospitals in Siliguri, West Bengal. As local Bengali nurses started getting empowered and asking questions, the private hospitals created hierarchies by hiring immigrant Nepali and Adivasi nurses who settled for poorer work conditions, given their vulnerable status in Siliguri. This creation of hierarchies among care workers, she argues, is a strong tool in the hands of the private healthcare system to perpetuate care extractivism. Sneha Makkad’s chapter on the unionisation of permanent and contract nurses in Punjab, traces the interesting history of the trade union movement of nurses in India. The informalisation of nursing jobs by creating a contractual work force, led to significant unrest and disparities between nurses within the same health facilities. The trade union movement helped organise and fight for some basic rights and pay increases for the contractual nurses. Maya John’s chapter on creation of educational hierarchies in nursing education throws light on how privatisation of nursing education led to poor quality as well as commodification of the care profession. There are Graduate Nurse Midwives and Bachelors of Science in Nursing graduates who are higher up in the hierarchy. Similarly, there is a hierarchy between nurses in private and public health facilities, and even within the public health facilities between permanent and contractual nurses.

Seemi Zafar’s chapter describes the various challenges faced by the ASHAs, ANMs and Anganwadi workers in India. Very low compensation, that too based on performance, inter-state variations in pay for the same work, delayed and irregular payments, no fixed work timings, and lack of respect among professional peers such as doctors and nurses, all affect their morale and performance. Ironically, these care workers who take maternity care to the community do not get any maternity benefits or social security benefits themselves. Christa Wichterich’s chapter focuses on the care extraction among the community health workers and healthcare providers, most evident during the Covid-19 pandemic and summarises all the problems of the undervaluing of care work in India.

The second half focuses on migrant nurses. Margaret Walton-Roberts and S Irudaya Rajan describe empirical research on migrant nurses from Kerala. While migrating to a foreign country to do nursing empowers a woman to earn money to save for her dowry during her wedding, it does not allow her to bargain for its eradication, thus perpetuating patriarchal norms. Nurse migration from Kerala has become a trap mechanism, wherein the high cost of private nursing education leads to indebtedness, and the care work in a foreign land becomes necessary to pay off this debt. Esther Gallo writes about three cohorts of nurses migrating to Italy through a Catholic religious institution. Urmila Goel’s description of an ethnographic research on the lives of Malayali women nurses who had migrated to Western Germany highlights the life of a migrant nurse. Another very interesting ethnographic work by Tanja Ahlin about the use of telephone calls as a means of providing care to their own elderly family members by young nurses who have migrated gives deep insights into their continued care-giving role within the family. Philomina Chakkalakkal describes the life of a migrant nurse from the point of view of her children, in a first-person narrative and her own mother’s story is narrated as the story of most Malayali nurses who migrate for work.

The editors have done an excellent job of putting together well researched and referenced material. What makes the book even more impactful is the colour painting photo plates titled “Salam, Chechi” (Malayalam for “Greetings, sister!“) by Nilima Sheikh and the photo essay of the first batch of nurses from Kerala who migrated to Germany, put together by Manoj Kurian Kallupurackal with texts translated by Christa Wichterich.

This book is a must-read for anyone interested in human resources for health, the nursing professions, community health workers and those interested in studying care work and labour in and from India.