As Suja, 24, nervously boarded the train her mobile phone rang. "It's Nimmi calling," she announced to her family — mother, father and brother — and friends, who were busy adjusting her luggage under her seat in the second class sleeper coach of the train. "So, she is already at the station," remarked her friend Bindu, a final year nursing student.

Just then the Kerala Express showed signs of pulling out from the small station of Thiruvalla, from where Suja had completed her diploma course in nursing and midwifery and from where her loved ones were now seeing her off.

As Suja bid goodbye and the train gathered speed, she was full of excitement. A trained nurse, she was on her way to Delhi to seek employment. Her friend, Nimmi, who had completed her diploma course from Ananthpur, Andhra Pradesh, was to board the train two stops later; while a senior, Susan, would pick them up at New Delhi to take them to their accommodation. Once settled, they would start looking for a job from the very next day.

More education

This is a regular sight in long distance express trains leaving any station in Kerala. Nurses from this state, also called 'Malayali nurses' after the language they speak, have become the epithet of care. There are 149 nursing schools and colleges in Kerala — the highest number of Indian Nursing Council (INC) recognised training institutions in the country. The INC is an autonomous body under the Government of India, Ministry of Health & Family Welfare that is responsible for establishing a uniform standard of training for nurses, midwives and health visitors.  The single largest category of skilled and unaccompanied women, nurses from Kerala have been migrating as workers within India and to places like Australia, West Asia and North America. Until recently, almost 80 per cent of nurses in Delhi hospitals were Malayalis, with a majority being Christian.

Researchers attribute the ubiquitous presence of Malayali nurses in the health care sector to various factors: Women's education having come early in Kerala; missionary and state efforts in developing service-oriented sectors, such as education and health; a well-established tradition of migration; and the existence of informal networks that expedite such migration.

When nursing was introduced as a feasible option for young women, who had completed their 12 years of education successfully, women from lower middle-class and poor backgrounds readily took it up as a career. In the 1960s, developments in the socio-economic life made women think of nursing as a possible livelihood option.

Preferred vocation

A symbol of single-women migrant workers, the Malayali nurse is omnipresent and virtually every patient in the world has been taken care of by her at least once in their lifetime. Whether it is in the barren lands of the Gulf — literally in the middle of nowhere, or a hospital in the US, or in a small clinic in Patna, Bihar, there will be at least a few Malayali nurses around. They are taken for granted as persons who 'naturally care', yet they are absent and invisible in discourses on women and work.

Underpaid and overworked

Although they are part of the minority of Indian women who have tertiary education, they have for long been considered uneducated workers whose skill is not recognised and labour not respected. Their work has been underpaid and their working conditions in Indian hospitals are pathetic. The nurse-patient ratio is often an alarming 1:30 or even 1:50 on in-patients' wards, although it is stipulated to be at 1:6.

Also, often in a city like Delhi they are vulnerable, as they are not fluent in Hindi, which considerably reduces their bargaining power and personal safety.

The ever-smiling nurses from Kerala are up for both criticism and competition. Ms Kora, a nursing superintendent at St. Stephen's, one of Delhi's oldest hospitals, narrated how she had a difficult time in May 2007 when around 40 nurses, from a staff of 150, resigned to leave for better prospects in West Asia.  In an attempt to counter the problems caused by the increasing migratory opportunities to the first world countries that Malayali nurses actively seek, hospitals have now begun to prefer those from other regions, such as north India, Manipur and even Nepal, to those hailing from the southern state.

As Ms Mattoo, the principal of a prestigious private nurse school, acerbically commented, "At least they will not run away at the first opportunity to go abroad!"