INTRODUCTION:

The incorporation of modern nursing emerged as an institution in the modern knowledge system, and traces the evolution of nursing. Health services developed in India in response to the interests of the British colonial rule. In this context it is important to understand that how modern nursing emerged in the West and its general nature. This is because in Kerala, it developed by a fusion between western modernity and an indigenous cultural superiority. Another important aspect which is explored here is the presence of women from the Christian community in great numbers in the nursing profession.

Nursing, as a profession, was long stigmatised in literature and cinema, and nurses were often condemned for being sexually decadent.

Indeed, in the 1960s, a prominent member of the Kerala Legislative Assembly, Prakkulam Bhasi, openly stated in the legislature that there were two sorts of women in Kerala who had to struggle against severe social stigma – stage artistes and nurses. Literature, cinema, and the print media have propagated this negative image. Popular novelists have represented this issue sensitively in their novels and short stories. The volume of the stigma attached was much more among nurses in the military services. Most of the women nurses have admitted the problems which they face during their service in the military. Another dominant version of society’s exclusion of women nurses is the poor demand they have in the marriage market. Most of the men are not ready to marry a woman nurse. The only men who were willing to marry them belonged to the category of the police.

Nursing Care through the Ages:

Nursing care has been mentioned in the Indian culture from the times of the Vedas. Only a few scattered records of the nursing profession in India are available, but although the science and art of nursing has not reached the stage of development as in most other countries. It is interesting to note that, provisions were made for the sick and attendants for them were employed, even long before the Christian era. These attendants were placed under the direction of skilled physicians and surgeons like Charaka and Sushruta. Massage was one of the old practices in use as a health measure and there were women practitioners of massage for attending on the females and men practioners for men¹.

Buddha elevated, care of the sick to the level of social service and ordained it as the primary duty of the coenobites. Initially confined to the members of the fraternity, this service logically extended to the laity in general as a part of service to humanity. The early Buddhism gave a stimulus to the emergence of the monastic infirmaries which may be considered as the forerunner of the hospital system. Usually the monks and nuns were medically treated in their own cells but the early Pali texts categorically suggest existence of ‘Gilanasala’ or house of the sick highlighting the process of institutionalization of medical care².

When the British Colonial rulers opened their hospitals in India, the attendance of women was almost negligible because of the seclusion observed by women in many parts of India. Since there were no women among the hospital staff, women resented being treated by men and stayed away from the hospitals. The pathetic condition during childbirth because of the lack of medical attendance and the large scale infant- mortality disturbed many women missionaries who decided to do something to reduce the sufferings of these women. Because of the educational endeavours of the lady missionaries, women got their economic independence. The educational endeavours of the missionaries created a sense of social awakening in the minds of the people. The barriers to social identities were shattered into pieces. The missionaries introduced hospital nurses into Indian homes and persuaded Indian women to take part in public life and health service³.

Under the British rule India had well trained European and Indigenous Midwives and training in nursing used to be conducted under the initiative of nuns belonging to the Christian Missions. In the 1890s, the missionaries received requests from the upper caste educated Hindus to expand their activities in new localities. Dr. Fells, a (LMS: London Missionary Society) medical missionary, with the help of European nurses made elaborate arrangements for the training of Indian nurses and midwives. The medical missionaries also maintained a European nursing homes to attract funds from the European plantation industries⁴. The Martandapuram Hospital in Quilon also served as a training centre for the Indian dressers. Eight Swiss nuns began work as nurses in Trivandrum in 1906, and formal nursing courses were established in hospitals in Trivandrum and Ernakulam in the 1920s⁵.

Women have not only contributed to the development and success of Public Health and medicine as mothers and home-makers, they were also employees in the health departments. Before the end of the nineteenth century, having recognized the dangerous and unsanitary habits of the dai, a traditional midwife, the governments and the missionaries began to train midwives. By 1914, in Cochin, there were sixteen trained midwives affiliated with the medical department. In a single year, these women attended 1,475 labor cases. This picture improved continually. Three years later, twenty four more indigenous midwives were trained⁶. In 1934/35, 50 midwives were affiliated with the department and attended 3,499 labor cases. Moreover, by 1934, female medical subordinates treated 75,196 women and 58,418 children. Similarly, in Travancore by 1901 there were thirty two licenses mid-wives, six nurses affiliated with the Medical Department and eight female vaccinators attached to the Sanitary Department. In the same year, the state of Baroda had only four trained midwives and nurses. By 1943-44, there were 106 trained midwives affiliated with the Travancore Medical Department. They attended 11,222 deliveries. Finally, in 1951, two years after Travancore and Cochin had combined to form the state of Travancore-Cochin, there were 106 midwives attached to Public Health Establishments and 231 employed in the medical institutions. In most major hospitals, furthermore, women were trained for the position of nurses and female medical subordinates⁷.

The advantage of Kerala women for taking to nursing lay in readiness of their families, demonstrated since the 1920s, to send their young women to salaried jobs. Once nursing opened up as a sure avenue of employment, many families, mostly but not exclusively, belonging to the Christian Community willingly sent their daughters to the nursing training programmes. The two-year programme which was initially introduced, in 1920, was found to be inadequate to cope with the needs of the developing medical sciences. Hence a revised certificate course in nursing consisting of 3 years general nursing and one year of midwifery was started in 1943 in the school attached to the General Hospital, Trivandrum. A similar programme was in existence in the Cochin State since 1924. Apprenticeship was the main feature of this programme. Malabar had no formal training for nurses until 1958, when Kerala’s second medical college was started at Calicut. Kerala’s first medical college came up at Trivandrum in 1950, aided by grants from the Rockefeller Foundation⁸.

The rising demand in Kerala for medical services has led the incumbent governments to start medical and health care institutions including nursing schools in the different regions of the State. The seats in the nursing schools began to be filled with young women looking for regular salaried employment. The princely states of Kerala always welcomed the welfare activities of missionaries from the beginning itself. They promoted educational and health care activities of missionaries in the state. Today, the impact of this emphasis on nursing education by the missionaries is being felt all over the world-Keralite nurses are found practicing in many major cities.

Medical Missionaries and Nursing Training:

In the beginning of the 19^th Century, the Christian Missionaries started their health care service to the Kerala people. Later they decided to give some training to assist the medical Doctors in their works. Various Missionary groups like London Missionary Society, Salvation Army, and Church Missionary Society voluntarily took care of the people of Kerala especially they were more active in Travancore. The first medical mission hospital that was started by London Missionary was in Neyyoor in 1838. There they started to give training in the hospital to assist the Doctors. In the earlier period before the coming of the missionaries the nursing was in the beginning stage and the nursing of patients was done by the relatives of patients and by the menial staff. The modern Nursing was started after the coming of the Women medical missionaries. By the passage of time, caring the sick was done by the ward – aids. Dressing the wounds and admission of medicine etc. were done by the doctors themselves. When medical work became more advanced and complicated doctors found it difficult to attend these duties. So they decided to train the nurses for these works.

In the earlier period, in the rural parts, the low caste women played the role of midwives due to communal economic and social reasons. Therefore persons who came forward to the nursing were from low caste and ost of them were widows, who had no other source of living. The progress of nursing was hindered by many difficulties such as the low social status of women, caste system, illiteracy, poverty, superstition and the fact that nursing was looked down upon as a disgraceful work. Those poor widows played the role of midwives and helped a mother during the delivery of her child. A low caste woman who helped a mother during the child birth was called ‘Marthuvachi’⁹.

The earliest attempt to get midwives was made by Dr. T. S. Thomson. When they tried to get candidates for this purpose suitable people were not available because the young girls were strictly confined to their houses. According to the social customs, unmarried girls would not go as nurses even for women patients. Therefore, he selected some Bible women working in the mission and gave them some training in the midwifery. In 1892, with the arraival of Miss Margaret Elisa Maccdonnel the first missionary nurse to Neyyoor, South Travancore. She was the first fully qualified nurse to send as missionary by L.M.S. to Travancore¹⁰. There had been no professional nursing at Neyyoor. Realising the great need for trained nurses and midwives both in the central and branch dispensary, she began to organise the nursing section of medical mission and she became its first medical trainer¹¹.

The candidate for nursing was expected to read and write in atleast in one vernacular language but English language was also desirable. Intelligent well educated women were encouraged to take up nursing as a profession. But there was an understanding that no one should be accepted for training before she is seventeen year of age¹². When a medical trainee was appointed in the service of medical mission, he/ she was usually asked to be an assistant to a senior European Missionary. Dr. John Low called them dressers because at first they had been given responsibility to dress the wounds of the patients. Later they were used to assist in surgical cases. These medical assistants were highly respected by the people. Inspite of the caste prejudice which prevailed in those days they had free to the homes of both upper and lower castes¹³.

Christian Women in Health Care:

It is significant to not that in the earlier period the women of Christian community mainly preferred Nursing care and teaching as their means of livelihood. Why the Christian women are more in this field is because of their willingness to do such kind of menial job which society considered as ‘worthless’ and ‘impure’. The Christian women saw it as the part of charity and voluntarily came to this field. The Hindu, Muslim women came to this field very late only¹⁴.

Before the 19th century, the individuals trained to care for the sick were nuns, but their space was only within the religious institutes. When secular hospitals first came into being in Europe, the moral character of any woman nurse who did not belong to the upper or middle class was automatically suspect. And the media attention on nurses is indicative of a general anxiety that held sway about the poor conditions in hospitals. To improve the quality of hospital care, cleanliness and the presence of trained nurses were seen as an essential precondition. These notions created conditions favourable for the appearance of trained nurses and their acceptance in society.

The available data indicate the over representation of the Christian community in the nursing service. In an all India survey of nurses conducted in 1974, it was found that 65 percent of the nurses were Christians and 30 percent were Hindus, the representation of the rest of the communities being extremely low. Oommen cites the following factors for the predominance of Christians in nursing: 1. Nursing being an exclusively female occupation and since many women from Hindu, Muslim, and other communities were not available for the profession until about the last 1920 to 30 years, Christian women might have been over-represented in all predominantly female occupations. 2. Nursing profession might have been considered ritually ‘unclean’ by Hindus and other communities. 3. The low prestige associated with nursing as an occupation in the eyes of the community, emanating partially from the fact that the female nurse has to handle male patients, might have been a disincentive to women in general to enter this profession. 4. The family and caste background of converted Christians might also have been a reason for them to enter into this less prestigious profession which, they found, an easier one to enter, with minimum education and free training¹⁵.

The end of the Nineteenth century is often seen as a major period of transition in the history of Kerala. Modernity was mainly characterised by the emergence of various institutions like the school, the hospital, and the print media. The training in the nursing profession, religiously and rigorously piloted by the Missionaries, must have spurred the spirit of the Kerala women from Christian community, to enter in to the nursing service. In the gendered public sphere of colonial Kerala, ‘women’s inborn capacities’ or ‘natural qualities’ like love, patience, and care happened to be reiterated in all discussions¹⁶. Literature of various forms and popular journalistic writings, especially those of community magazines and leading newspapers, give glimpses into the mentality which led to the large scale presence of the Christian women from Kerala, in the nursing profession.

Kerala Women in Health Care:

‘Kerala women are ahead of their all-India counterparts in many areas. Educated women have benefited from the expansion of the social service sector. They enter jobs such as teaching, nursing, social work and related fields’. Education and salaried employment have been regarded by all these scholars as the important indicators of women’s ‘status’. Women in Kerala have been among the most literate women in India. Much has been written about the ‘high status’ of women in Kerala and their central role in social development¹⁷. Prolonged periods of institution-building have preceded the attainment of the present stage of well-being in Kerala. For example, medical care had, like education, a double attraction for the Keralite. The number of allopathic hospitals and health care centres began to multiply rapidly in Travancore and Cochin since the 1930s. Opportunities for employment in medical care institutions also increased simultaneously. The number of patients treated in hospitals and dispensaries doubled between 1951 and 1961. By the 1970s, Kerala’s medical facilities showed the highest rate of use in India¹⁸.

There is no specific study to explain why nursing has become such a monopoly of the Keralite women, but a few hypotheses may clarify this fact. First of all, nurses in India in the context of colonisation, were mainly Christian nuns engaged in the charitable institutions. By around the 1930s, they started to enrol local nuns. So when, first nursing schools were open to women, the choice of candidates was surely done on the basis of religious origin. A second reason is that nursing is seen by young Christian women as a charitable duty and they quickly stressed the example of Florence Nightingale or Mother Theresa. Doctors in the missionaries opened up large areas for accommodation of women as emancipators of their women and for those women whose lands they visited. A third reason is that in the Hindu context, nursing was, on the contrary, seen as a very impure job. As a result nursing carried a stigma which has lasted till very recently. In the case of the Muslim community, the women were not allowed to go out of their home. They were denied education and they had to sit inside their home and do all kinds of works in the home. On the contrary, Christians in Kerala were among the first to have a different approach to the study and work of their women. Nevertheless, for a long time nursing was considered as a low status job in Indian and Keralite society¹⁹.

Indeed the intertwining of the images of ‘progressive Malayalee womanhood’ and the participation of Malayalee women in the nursing profession appeared in popular discourse long before the idea of Kerala Model was proposed. Dr. Susheela Nayyar, Health Minister of India, stated in 1967 about the progressiveness of Malayalee women. She found that progressive women in Kerala are engaged in nursing service even outside Kerala and that it was the matrilineal system which had prevailed in Kerala that helped them in choosing this profession as a service²⁰. In the mid-Twentieth century Malayalee public sphere, most of the women leaders argued that teaching is the most suitable job for women while some of them agreed with the suitability of nursing too. At the same time they agreed that women have the capacity to do most of the public jobs on a par with men but such jobs should be undertaken only with the consent and the support of the family. Here one finds that both women and men were in agreement about the concept of ‘womanly’ qualities or capabilities. Women leaders of the mid-Twentieth realised the importance of both womanly and manly duties for the development of the community or society²¹.

Another important sphere was modern medical institutions. Here ‘womanly’ qualities pushed women into the profession of ‘nursing’ which was a womanly’ service. It was thought that nursing would come naturally to women. These women were thus the products of a gender- based division of labour that evolved over time in modern medicine. This institution was linked, right from the beginning, to the spirit of caring, compassion and charity, which had come early to Kerala and has flourished ever since. The establishment of medical institutions was part of the effort to redefine the Tiruvitamkoor’s (Travancore) image as a Dharmarajayam, a land of equity²².

By publishing the biography of Florence Nightingale in women’s magazines repeatedly during the early Twentieth century, some public men of moderate views advised Malayalee women, especially those who were in the field of charity and nursing to accept her life as a role model and to practise nursing by taking inspiration from her life. Likewise, magazines published biographies of those women who had spent their life for charity and patient care in hospitals. During the 1970s, magazines produced articles which suggested that Malayalee women took great interest in doing such kinds of services as nursing eminently suitable for display of feminine qualities. Thus modern nursing emerged as a gendered profession through, and around the debates and discussions of, a gendered Kerala society²³.

Economic security enables women to take family responsibility, and sometimes, it helps to take independent decisions also. Instances of nurses securing overseas employment have brightened the prospects of nursing as a career in recent times. The profession has increasingly come to be viewed as a profitable and rewarding job drawing more aspirants into the field. There is a growing demand in the marriage market for nurses employed overseas or who are likely to go abroad in search of employment. Thus a new type of ‘hypergamous’ marriage has come into vogue augmenting the social status of the lower middle class families to which nurses usually belong²⁴.

CONCLUSION:

The development of nursing in India reflects the country’s history and complex socio-cultural composition. From the old records we can understand that the attendants or the helpers for the sick had an important role and their job considered a reputed job but later it degraded and this profession came to be thought only for women of low repute. The health care services of medical missionaries influenced the native women to come to this field of nursing and take care of the sick and the bedridden. As in many other countries, nursing is now seen as a potentially lucrative career choice, a stepping stone to work overseas and towards greater social mobility for the entire family. The activities of the medical missionaries among women created a new spirit and power in the society. The awakened women made revolutionary changes in the health care.

One of the major tasks of the medical missions was to build up an efficient nursing service because of the cultural constraints of the country. The missionaries were trying to create a favourable condition for the women to enter in to this field. In the earlier times, the missionaries and other native Christian women did this health service as a part of the charity. The medical missionaries started to take care of the Hindu and Muslim, upper and lower caste, Christian and Non-Christian in a same manner. Their activities in the health care opened the eyes of the caste Hindus. The people started to recognize their services and accepted women in this field. The government also took initiative to promote women in the nursing field. The empowered Kerala woman in the nursing field all over the world is the result of the efforts of the medical missionaries and rulers of the princely state in the colonial period. The high demand of Kerala nurses by the western and other parts of the world shows the quality of health care providing by the Kerala women. The well talented and skilled nurses of India raising the prestigious of the country and becomes an example to all other women of the world.

REFERENCES:

1. O.P. Jaggi, History of Science Technology and Medicine, Ayurveda: Indian System of Medicine, Vol.4, Atma Ram & Sons, Delhi, 1981, p.318.

2. Sukla Das, ‘Institutional Care for the Sick: Concept of Hospital in Early India’, Nupur Dasgupta, (ed.), Essays in History of Science, Technology and Medicine, Sethu Prakashani, Kolkata, 2014.

3. Mita Bhadra, ‘Indian Women in Medicine: An Enquiry since 1880’, Indian Anthropologist, Vol.41, No.1, January- June 2011, P. 20.

4. Marie Percot, S. Irudaya Rajan, ‘Female Emigration from India- Case Study of Nurses’, Economic and Political Weekly, Vol.42, No.4, 2007, pp. 318.

5. Robin Jeffrey, Politics, Women and Well-being: How Kerala Became a Model, Macmillan, Delhi, 1992, p.108.

6. Government of Cochin, Reoprt on the Administration of the Mediacl Vaccination and Santation Department in Cochin State, Ernakulam, 1916-17.

7. V.Nagam Aiyah, The Travancore State Manual, Travancore Government, Trivandrum, 1906, p.541.

8. Ibid, p. 548.

9. Martin Daniel Dhas, N., Missionary Medical work in Travancore, South Indian Press, Marthandam, 1981, p. 96.

10. Ibid., p.38.

11. Ibid., p.97.

12. Rport of the 4^th Decemnial Indian Missionary Confrence, 1902, p.129.

13. Missionary Conference, South India and Ceylon, Vol.II, 1879, p.107.

14. Kumar, Deepak; Sekhar, Basu Raj(eds.), Medical Encounters in British India, Oxford University Press, New Delhi, 2013.

15. T. K. Oommen, ‘Vedana Mattunnavarude Vedhana’ (Pain of Pain Removers), Malayala Monorama, 25 October 1964.

16. Kumar Pragya, Medical Education in India, Deep and Deep Publications, New Delhi, 1987, p.134.

17. Binumol Abraham, Women Nurses and the Notion of Their “Empowerment”, Kerala Research Programme on Local Level Development, Thiruvananthapuram, 2004, p.7.

18. Ibid, p.9.

19. T. H. Somerwell, Op.cit. p.234.

20. Meera Abraham, ‘Religion, Cast and Gender: Missionaries and Nursing History in South India’, B.I. Publications Pvt. Ltd., 1996.

21. J. Devika, Imaging Women’s Social Space in Early Modern Keralam, CDS Working Paper 329, Trivandrum: CDS. 2002.

22. Koji Kawashima, Missionaries and Hindu State Travancore 1858- 1936, Oxford University Press, New Delhi, 1998, p.128.

23. Stephan Timmons, Catrin Evans, Sreelekha Nair, ‘The Development of Nursing Profession in a Globalised Context: A Qualitative Case Study in Kerala, India’, Social Science and Medicine, Vol.166, 2016, pp.41-48.

24. Sreelekha Nair, S. Irudaya Rajan, ‘Nursing Education in India: Changing Facets and Emerging Trends’, Economic and Political Weekily, Vol. 52, No. 24, 17 June 2017. p.48.

Received on 04.05.2019 Modified on 27.06.2019

Res. J. Humanities and Social Sciences. 2019; 10(4): 1006-1010.

DOI: 10.5958/2321-5828.2019.00165.7