London Gatwick Airport, 11 July 2001. Nancy Wambui Itotia is making her way along the slowly coiling snake of a queue to get through Immigration Control. In her hand, a Kenyan passport. In that passport, crucially, a visa allowing her to enter Britain as a ‘student nurse’.
Student. It’s a curious description for a state registered nurse with over 20 years’ experience in a wide range of fields including midwifery, family planning, community health, immunization. A nurse, moreover, who has been a teacher of nurses.
But in order to work in Britain, she must become a student again and do a three-month ‘adaptation’ course before she can start practising.
Nancy with her cousin’s son, James. Nancy’s work in England helped pay for his mother's cancer treatment. Photo: Vanessa Baird There are many like her. Nancy is one of the three million medical workers from developing countries who have been recruited by wealthier nations.1 Hospitals and nursing homes in most Western countries and in Australasia would grind to a halt were it not for people like Nancy.
Today there are more doctors from Benin working in France than there are in Benin; more Ethiopian doctors in Washington DC than in the whole of Ethiopia.1 Some 40 per cent of nurses and over 30 per cent of doctors now entering the British health system were trained abroad. This trend is reflected in many other countries.2
You can see why. It’s a real bargain for the rich countries, saving them an average $184,000 in training costs for each of the three million recruits. That adds up to a saving of $552 billion – almost as much as the developing world owes in foreign debt.1
Health workers sending money home helps their families and communities. In many countries, such as the Philippines, remittances from foreign workers are the country’s biggest source of income.
But there is a debit side. Even hospitals in India and the Philippines – which train more doctors and nurses than they can employ – are beginning to suffer from staffing shortages due to the medical brain-drain.
And in impoverished sub-Saharan Africa, facing epidemics of hiv/aids, tuberculosis and malaria, it is quite simply a disaster. Some 23,000 medical staff emigrated last year, leaving ‘their own stretched health service in dire straits’ according to the International Office of Migration.
Though she does not have such statistics at her fingertips, Nancy is well aware that she is part of this brain-drain. But her reason for coming to work in the North is one that anyone could sympathize with.
‘In Kenya I could not make ends meet on a nurse’s salary,’ she says. With three offspring to support – and without any help from her estranged husband – going ‘out’ to work was the only way out of poverty that she could see.
This is the difference it makes: back in Kenya, Nancy – a nurse at the peak of her career – was earning a sixteenth of what she now earns in an Oxfordshire nursing home. With overtime she can sometimes earn 30 times more than in Kenya.
The money she has been able to send home has given her family hope where there was none; it has even helped save a cousin’s life. Who would not do that for those they love?
‘I suddenly felt very alone. I thought: if I die here no-one will know’
Preparing to work abroad was not simple. It took Nancy three years. She did not use an agent, but applied directly to the British Midwife and Nursing Council.
This was a wise move. All too often, behind stories of the most extreme abuse and exploitation lurks an agent.
On that summer’s day in 2001, as her plane landed in London, Nancy felt excited, anxious and sad. She had left behind a daughter and two sons – Ruth, then aged 15, Ayub aged 19 and 22-year-old Joel.
She also needed to come to terms with this strange northern land, so different from her equatorial home. ‘What kind of country is this,’ she thought that July evening, ‘where it does not get dark in the evening?’
Nancy did her ‘adaptation’ at a private nursing home in the northern English town of Scunthorpe. Like many international recruits she was disappointed that she would be employed not in a hospital but in a nursing home. ‘I was hoping I might learn some new technologies,’ she says.
She was also surprised to discover that during the three months ‘adaptation’ she would be largely unpaid, though she had to pay for food and accommodation. ‘For the first 35 hours a week you worked for nothing. After that you were paid for overtime.’
First winter in England: ‘I’d walk around with two hot-water bottles to keep me warm – one strapped to my front and one to my back.’ Photo: Vanessa Baird According to the nurses’ union, the Royal College of Nursing, this is unacceptable. But it is quite common for migrant workers to be exploited in this way – especially in the private sector – and it does not appear to be actually illegal.
There are many ways in which migrants are routinely fleeced in Western countries – including deductions by employers, agents and other third parties, debt bondage and pay levels far below the legal minimum. A recent report discovered an Indian nurse working within the British public health system living on $10 a week after such ‘deductions’.3
In terms of nursing, ‘adaptation’ taught Nancy nothing new apart from how to use state-of-the-art hoisting equipment. Once ‘adapted’ she moved to another nursing home in Staffordshire. By now it was November and very cold. ‘I’d walk around with two hot-water bottles to keep me warm – one strapped to my front and one to my back.’
She moved into a very small house that she shared with another nurse. Then one day, when the other nurse was away, Nancy slipped in the bathroom and injured her head.
‘I suddenly felt very alone. I thought: if I die here no-one will know.’
She was missing her family badly – and the African way of life.
But she could not give up at that stage. Instead she acted on the advice of a Kenyan friend and took a job in a nursing home in Oxfordshire.
Her daughter Ruth has now joined her in England and is studying sciences with the hope of pursuing a career in medicine. But Nancy’s sons Joel and Ayub, and her 90-year-old mother, remain in Kenya, along with a large extended family which she helps to support.
I first met Nancy in October 2004. I was curious to know the consequences of having a central figure in the family, a mother, living so far from home.
Was it worth it? At what point would a woman decide the price was just too high?
It seemed a cruel requirement of our globalized economy that for a mother to be a good one, in terms of providing for her children and giving them a chance in life, it was necessary for her to take herself far away from them. I wanted to explore the survival economics – but also the emotional economics – of this.
Was it worth it? At what point would a woman decide the price was just too high?
Was it really so necessary for her to be here, so far away, and doing in her words nothing but ‘work, work, work’? There was also the delicate matter of health demands in her own country. Was she not very much more needed there?
As we talked it did not take me long to realize that Nancy is a perceptive and thoughtful woman – who is also in possession of a robust and playful sense of humour.
Was the magazine going to argue that nurses from poor countries should be prohibited from coming to work in richer countries? she asked. In recent years the health ministries of developing countries have accused the rich countries of ‘poaching’. The World Health Organization is also critical. And in response some countries – including Britain, Canada and Australia – have signed up to weakly worded codes to limit direct recruitment from developing countries that are experiencing shortages themselves. But the codes are voluntary and the health workers still come – and keep the rich world’s health systems ticking over.4
The issues are complex, to be sure.
After a few hours’ discussion, Nancy agreed to accompany me on a trip to Kenya. ‘I will show you. I want you and the readers of this magazine to know what it is like for us. I have nothing to hide from you.’
A few months later she is back on the runway – but going the other way this time – and taking me to her homeland. She has an additional mission – in her absence her first grandchild had been born.
It is the Kenyan custom that the first-born baby girl should be named by and after her paternal grandmother. Nancy Wambui needs to see the child to give her her name – that is, the traditional Kikuyu part of her name: Wambui. And, as I am to discover, there are other wounds of family separation Nancy must heal.
I am interested to see what changes Nancy will find in her country. She last visited Kenya shortly after the brutal and corrupt 24-year regime of Daniel Arap Moi was ousted in elections that brought to power the National Rainbow Coalition (Narc) headed by President Mwai Kibaki in a landslide victory in December 2002.
He came in on a huge tide of hope and euphoria – and a pledge to tackle corruption.
Two years down the line, how is the clean-up going? Will it have any effect on Nancy’s decision to work abroad? And how are Nancy’s fellow nurses faring?
- 1 International Organization of Migration, quoted in Gdagi Kimani, ‘Brain Drain Robs Africa’s health sector of $552 bn’ The East African (Nairobi), 7 February 2005.
- 2 Nursing and Midwifery Council (NMC) UK figures for 2002/3.
- 3 Bridget Anderson and Ben Rogaly, ‘Forced Labour and Migration in the UK’, 2005, commissioned by the ILO and TUC.
- 4 Commonwealth Code of Practice for International Recruitment of Health Workers, 2002. UK Department of Health Code of Practice for the International Recruitment of Healthcare Professionals Guiding Principles, 2001, 2004.