Guest post by PANCHALI RAY
The COVID-19 crisis has laid bare some of the most significant and deep-rooted fault lines of society, whether it is attacks on Indians from the North-east part of the country including racial slurs, holding returning migrants responsible for the spread of the virus or even downright Islamophobia leading to a hashtag #CoronaJihad going viral on social media. Sections of the hyper-vocal, privileged Indian middle-class, along with frenzied nationalist media houses let no opportunity pass to demonize its minorities.
However, what came as a surprise was that along with the stigmatization of migrant workers, ethnic minorities and Muslims, health care workers too faced intense hostility worldwide. Already facing a severe lack of resources including no or few Personal Protection Equipment (PPE) making them even more vulnerable to infection, they are now facing the additional hazard of being labelled as agents of the pandemic.
While on the one hand, medical workers are being labelled as ‘warriors’ and ‘super heroes’ with orchestrated events to show gratitude, on the other hand, they are being hunted down, mobbed, and evicted from their homes. India went a step further, and did a grandiose display of felicitating health care workers by having the armed forces fly past fighter jets, shower flower petals aerially and have their military bands perform outside state hospitals.
This article focuses specifically on the gendering of the organization of the health care sector, which reflects wider binaries of masculine/feminine, cure/care, science/affect.
The Indian public health system has been systematically defunded over the decades, the process starting well before the famed liberalization decade of the 1990s. Currently a mere 1.28 per cent of the GDP is allocated to the public health-care system. It was also no surprise that given the nature of the health crisis and its epidemic proportion, private players closed shop and the National Disaster Management Act (NDM) Act of 2005 had to be invoked to compel some to continue plying. The crisis, also had the effect of forcefully bringing to notice that frontline workers— usually devalued, underpaid, and considered disposable— were crucial to fighting the calamity. Given that women consist of 70 per cent of the health care workforce worldwide, they are on the frontline with high risk of contracting the virus.
The health care industry is composed of both medical staff, as well as those, loosely termed as care workers: while the former is mostly male doctors and technicians, the latter is composed of the nursing ancillary workers, maternity assistants and women who give hands on nursing care. A WHO report (2019) records the adverse occupational gendering within the health care sector: across countries, the majority of physicians, dentists and pharmacists are men, while women are overrepresented in the ranks of nurses and midwives. The same report records that women health workers earned on an average 28 per cent less than men, which they attribute to occupational segregation, part-time employment, underrepresentation in senior positions, fewer opportunities for career advancement, and gender discrimination.
What most of these reports, however fail to capture, is the contractual/daily-waged (mostly women) workers who give hands on caring across hospitals and nursing homes. The rapid and unregulated expansion of the health care sector has had contradictory outcomes in terms of employment. While it is one of the few sectors that has not seen a masculinization, it has not created jobs that are regulated or protected. While it is almost impossible to fathom the casualisation of health care staff, there is enough evidence to point out that the bulk of health care workers work in precarious conditions with no job security. In fact, most bedside care has been delegated to Grade IV staff consisting of ayahs, ward boys, sweepers, and range of semi-trained and untrained women who pass off as nursing personnel and are employed in large numbers and in an ad hoc manner. A report by Public Service International (2016) notes that the period 2000–15 witnessed an increasing trend of hiring contractual staff in Group D levels, particularly as outsourced labour, discouraging any direct contract with the hospital. Group C workers, however, have been resisting casualization on the ground that it would lead to deskilling, and thus, adversely affect the quality of health care provided.
The over-representation of women in the lower ranks of health care is not just limited to India, but is a global phenomenon. In America, for instance, women belonging to the working class and racial minorities are concentrated in the ranks of ancillary nurses or lower levels of nursing rank, while middle-class, White women are concentrated in higher ranks and/or prestigious administrative roles. In India, we have no macro data on the social composition of women who work as daily-waged attendants and ancillary nurses in scores of nursing homes and hospitals across the country under different administrative headings, but some micro-studies do flag that most casual and menial end of the workforce is over represented by working class, lower caste women who work for pittance with no job security or legal protection. It is in this context that one must place the statistics on the impact of COVID -19 on health care workers and the glorification of doctors and nurses as ‘warriors.’
Health care workers are no strangers to the paradox of being glorified and simultaneously stigmatized and treated as outcastes, particularly women offering nursing care, whether a trained professional nurse or a bed-side care-giver, the latter often euphemistically termed as ‘ayah’. Historically, nursing was looked down upon by a caste-based society as it was essentially corporeal labour that included coming in contact with blood, fluids, and other bodily detritus. Additionally, the sexual division of labour pegged nursing as women’s work, and thus, both gender and caste contributed to its devaluation. In colonial India, nursing was perceived as low-status, menial labour offered by low-caste, plebeian or the outcaste Euro-Asian woman.
However, the hegemonic impulse of colonial medicine framed the nurse as an agent of purification. The colonial nurse had to embody the values of imperial femininity— the imagery of the white uniformed nurse, upholding high moral values, chastity, and purity and maintaining strict discipline, while catering to and nursing the sick and superstitious colonial subject was central to the expansion of colonial medicine. In practice, nurses found themselves in a profession with limited growth, no respect, overburdened, and ill paid, treated as mlecchas (outcastes) and menial workers by upper-caste patients. And it is precisely here, where the notion of seba (service) comes to play. This stigma meant that for nursing to be recast as respectable labour, it had to be framed as seba, rooted in religious and spiritual ethos.
The notion of seba/service/social work is a deeply feminine notion that is closely linked to bourgeoise ideology. The necessity of establishing nursing as a `noble’ profession, and re-signifying nursing labour as respectable work, implied that nursing care had to invested with the affective charge of seba. The various discourses surrounding nursing care foregrounded the affective and spiritual charge that nursing labour embodied; it was not just a professional service but a spiritual journey that transcended caste and class differences. Thus, nurses were not to perceive themselves as workers but rather as agents who would serve, nurture, and care for the sick, the poor, and the outcaste. Instead of focusing on low wages and exploitative working conditions, the emphasis was to draw women from middle-class communities who would take to professional nursing as an extension of social or religious services.
Women in their roles as mothers serving/caring for the household, community, and the nation are a common rhetoric and deeply gendered. And thus, investing nursing with a similar emotional charge that is embedded in seba, would draw deeply from tropes of self-sacrificing and spiritual femininity, which in turn would not question the various crisis faced by the nursing profession. However, professional nursing, over the years elevated its status by focusing on medical and administrative work, leaving the manual-menial affective labour to lesser trained women and attendants who continued to struggle with stigma, lack of recognition and less than minimum wages. As nursing continued to be stigmatized, despite draining it off all corporeal-menial labour, nurses took to international immigration, given the immense social and economic mobility.
This said, one would think that the deep crisis in care that the Covid-19 pandemic has precipitated would lead to larger discourse on service and spiritual and moral duty of care givers; rather, internationally we have witnessed a shrill battle-cry, with health workers being called warriors and super-heroes. Deeply gendered as well, its rhetoric is different from seba: no more a feminine spiritual service, it calls for a detached masculinity. While the underlying principle remains the same, constituting immediate sphere of work as a war implies that it goes beyond a profession but becomes a service to the nation, to the race. For instance, similar to soldiers who are penalized for questioning, doctors, too, have been threatened and intimidated for pointing out lack of infrastructure and government support.
Declaring the pandemic as a war and health care workers as warriors have the additional effect of invoking nationalism and racism, in a context where we are increasingly witnessing corona being declared a Chinese or a Tablighi Virus. An epidemic is, by nature, divisive. It fosters suspicion and xenophobia, mistrust of doctors and public health officials. The use the metaphor of war to describe responses to the epidemic fuels an environment of hostility and hatred and often leads to authoritarian means of social control. The idea of a heroic warrior with its emphasis on duty, obligation and compete obedience is grounded on notions of masculinity that acts as a signifier of national strength.
This has two effects: one, it casts the response to the epidemic as a battle between human and nature— a techno-curative war against the power unleashed by viruses to vanquish humanity— betraying an underlying Anthropocene anxiety. Thus, the grand narrative of the pandemic becomes one of a ‘wild’ viral strain that needs to be humbled and overpowered. This is exemplified in the various address the Prime Minister has made to the country. In one instance, Narendar Modi declares “The virus may be an invisible enemy. But our warriors, medical workers are invincible. In the battle of Invisible vs Invincible, our medical workers are sure to win.”
Secondly, it masculinizes healing, erasing the labour of women who offer bedside care— the backbone to cure— and thus invisibilizing the crisis in care, that most countries are undergoing. A quick look at the data generated by the government will tell us that while there are 9,27,000 government employed doctors and 1,53,656 MBBS students on Covid-19 duty, the number for trained nurses and students stand at 17,48,363. There is of course no mention of the scores of untrained/partially-trained women, hired casually, who give hands on bedside care and are most likely the first to contract the disease. It also comes across as no surprise that 10,07,045 ASHA workers and a stunning 25,43,113 Anganwadi workers have been mobilized to fight the pandemic. Officially labelled as sevikas and volunteers, aanganwadi workers have been struggling to be recognized as workers .
However, most reports on Covid-19 ‘warriors’ are restricted to hyper-vocal/visible doctors and more recently, with increasing unionization, nurses. Women who have been working in the frontlines as bed side care givers, hired casually and often labelled as ayahs and attendants are doubly marginalized: first their social locations as working-class, lower-caste women offering hands on care (no better than domestic workers) and secondly, their complete invisibility as health care workers. Similar to domestic workers, this invisibility stems from a complete lack of recognition of their contribution to the care economy. The metaphor of war and warrior, so closely linked to techno-curative understanding of healing and health, completely obliterates the real front-line worker in the health care industry.
Panchali Ray is the author of Politics of Precarity: Gendered Subjects and the Health Care Industry in Contemporary Kolkata (OUP 2019)