This series was supported by the Pulitzer Center and produced in partnership with the nonprofit newsroom Type Investigations, with additional support from the Gertrude Blumenthal Kasbekar Fund and the Puffin Foundation.

When Maria landed in the United Kingdom in March 2022, she thought she knew what awaited her.

She knew she was bound for the Isle of Wight, a sunny rhombus of land lying just off England’s southern coast. She’d never been there before—or anywhere outside of India, for that matter. She also knew that she’d signed up with a private firm to be a domiciliary care worker, meant to tend to infirm or old patients in their own homes. 

It was a far cry from her experience as a nurse in India, where she’d assisted in neurology, urology, and cardiology wards. But she was prepared for that. It felt like a temporary hitch, given the larger reasons she was moving from India to England: an improved quality of life, finer schools for her children, and, eventually, a transition into the better-staffed, better-resourced hospitals of the National Health Service (NHS). 

What Maria wasn’t ready for was her work schedule: 20 home visits daily, driving from one house to the other, so that her workday stretched from 7 am to 10 pm, with lunch eaten hurriedly in the car. She wasn’t even ready to drive; in fact, she’d had no lessons on English roads. And, having mortgaged her house back home in the southern Indian city of Kochi, she was shocked to find that many of the promises by the Indian employment agency that recruited her never materialized. 

She’d already paid the agency around £5,835 ($7,265) to be placed in her job—a practice that is illegal in the UK, and legal if exploitative in India. Still, she was bullied on the phone for more money. Once, the agency uploaded a photo of her husband and her then 18-month-old child on a WhatsApp group, as part of its effort to intimidate her. “They deleted the photo after 10 minutes,” Maria said, “probably because someone advised them that it could count as abuse.”

Maria, a young nurse who asked not to be identified by her real name, is part of an army of nurses and care workers that has been arriving in the UK. After Brexit made it harder for Europeans to work in the UK, the pandemic further thinned out the ranks in social care for the aged or the unwell. As of October 2022, there were 165,000 vacancies across the sector. Some 42,000 care workers left their jobs from late April to late October 2021 alone. “And there just isn’t a domestic workforce ready to take their place,” said Nadra Ahmed, chairman of the UK’s National Care Association, an industry group.

The UK made more visas available to care workers

To fill the open positions, the British government made it easier for foreign care workers to get work visas, issuing 34,800 visas from mid-February through the end of 2022. Someone like Maria could expect an annual salary of at least £20,480 (around $25,000) and a visa valid for 12 months. She also could bring her family with her. Conceivably, they could stay on in the UK, in the long term. That was what Maria hoped. 

But while the new visa policy is helping to rebuild the care sector, it also has resulted in a spate of labor exploitation, according to interviews with more than a dozen nurses, care home officials, recruitment agency employees, and nursing union representatives in India and the UK. 

Agencies in the UK, India, and other countries collect thousands of pounds apiece from nurses to find them care jobs, provide training courses, and process their paperwork, Quartz and Type Investigations found. These fees often leave the nurses deeply in debt and bound to their contracts, a condition that the UK government terms “modern slavery.” Some agencies dupe their applicants, promising services that never materialize. Others, set up hurriedly over the past year and a half or so, have dubious credentials or opaque identities.  

A spokesperson for the British government’s Department of Health and Social Care said it was working with enforcement agencies “who can take action against those breaking the law.” Since December 2021, one of those agencies, the Gangmasters and Labour Abuse Authority (GLAA), has identified at least 70 Indian care workers as being potential victims of abuse and modern slavery, and offered them support.

Migrant workers are often unaware of the agency’s existence, however. Maria didn’t know about the GLAA, nor did the nurses who arrived with her. One of them even stopped making payments to her employment agency and returned home.

Maria decided to stick it out, knowing it was the only way to repay the loan she’d taken. “But sometimes,” she said, “I also wonder if I should even have come.”

From India’s cradle of hospital care work

In Kerala, Maria’s home state in southern India, nursing is a respected profession—a skilled career that offers steady employment, geographic mobility, and, for young women, an opportunity to work outside the home. India’s hospitals are filled with nurses from Kerala. So are hospitals in other countries—so much so, in fact, that the Kerala government runs its own agency to place nurses overseas. Tens of thousands of nurses emigrate from Kerala every year, heading to the Middle East, Canada, the US, and Europe. 

Maria, who grew up near the backwaters in the town of Alappuzha, finished her undergraduate degree in nursing in 2017. Then she worked at a hospital in Mumbai, before returning to Kerala—to Kochi, a city about a 90-minute drive north of Alappuzha. Maria planned to study for the International English Language Testing System, a key qualification for working for the NHS. 

The NHS has been hiring nurses from India and other countries for years. But demand for foreign nurses skyrocketed as the pandemic caused nurses to burn out and leave the profession, creating a staffing crisis in the UK.

The NHS’s process for hiring nurses from abroad is relatively watertight, and offers a glimpse of what principled recruitment looks like. “It’s free, and it’s well-regulated,” said Jibin Theerthakkuzhi Chalil, the national working secretary of the United Nurses Association, a professional organization in India.

The UK government stipulates that health and social care organizations should work only with agencies that appear on the nation’s official list of “ethical” recruiters. These agencies, based in the UK, India, the Philippines, and other countries, charge candidates no recruitment fees. Instead, the NHS pays the agencies and covers the cost of the nurses’ visas and airline tickets. Nurses know, up front, that they’ll pay nothing, said Ajinas A. M., an assistant secretary-general at the Trained Nurses Association of India, a professional organization.

But applying to the NHS through these agencies is fiercely competitive, and frequently, nurses like Maria find that their English skills or work experience aren’t quite good enough. For anyone able to pay an agency, however, the carer visa—which allows foreign nurses to staff private care companies and care homes—is an effective side entrance into working in the UK.

In January 2021, when Maria first went to a Kochi agency to ask about a carer visa, she was quoted a price of 600,000 rupees (around £5,835 or $7,265). “I came away without applying,” she said. But over the next few months, Maria saw more and more ads for the visas on social media, so early that summer, she went back to the agency. By now, she said, they were charging 1.2 million rupees as a fee to place a candidate in a care home. When she said she couldn’t pay that much, they offered a 900,000-rupee fee for a visa to work in domiciliary care. 

The agency broke it up for her in a contract: 600,000 rupees had to be paid in advance—half of that for visa fees and “relocation” expenses, and half for English language training that they promised she’d receive from a partner agency in the UK. She would have to pay the remaining 300,000 rupees after six months in the UK, she said, although she’s still unclear about what this money gets her. She was told it covered miscellaneous expenses—being picked up from Heathrow Airport, for instance—as well as the fee for the employer’s sponsorship of her visa. “But I asked my employer, and she said she had already paid for the sponsorship,” Maria said. “So why were they charging me again?”

A crop of new recruitment agencies

The demand for nurses globally has led to a surge in new agencies seeking to place nurses in jobs.

In the south Indian city of Chennai, one company, Nass Global Resources, was established in April 2022. Joseph Daniel, the founder, is originally from Kerala. He said he’d been a businessman in South Africa before getting into human resources. Nass’s offices in Chennai, on the first floor of a nondescript building, are compact—a small reception area, staffed by three employees, and a private office for Daniel.

Nass’s aim, Daniel said, was to make Indians more employable, and he happened to be starting with the healthcare sector because that was where it was easy to get jobs. In an August 2022 interview, Daniel said he charged candidates up to 500,000 rupees, ostensibly for 45 hours of English language training online, through an education company associated with Nass; classes to receive a nursing assistant certification ran to 140 hours, for an additional fee. Approximately 100 people had completed the nursing module, Daniel said—some would be bound eventually for the UK, others for the US.

In the UK, Daniel said, immigrant nurses would first be employed by a company called Get Care Angels, Nass’s partner, which would in turn place them in care homes. The credentials of recruitment agencies can be difficult for nurses and others to assess. Get Care Angels was set up in the UK in March 2022, founded jointly by Nass and an American Catholic group called Missionaries of Jesus the Savior. (The group did not respond to email inquiries about Get Care Angels or its partnership with Nass Global Resources.) Last year, before its website was suddenly taken offline, Get Care Angels listed a Danish phone number and an address on the planet Mars in its contact details. 

Daniel claimed that his trained nurses would be placed in NHS hospitals and clinics, but neither Nass Global Resources nor Get Care Angels are included in the UK’s official list of ethical recruiters. He said Nass would pay for the visas, insurance, and other expenses of the nurses it placed. But he added that the nurses’ contracts with Nass would obligate them to keep paying the company even after they find jobs: a pound for every hour they subsequently worked in the UK, up to a total of three years. (Recently, when asked subsequent questions about the relationship between Nass and Get Care Angels, Daniel claimed the recruitment work had stopped.)

Despite the uncertainties and pitfalls in the recruitment process, the pull of working in British care homes remains strong. Febin Cyriac, whose UK agency Envertiz is listed in the database of ethical recruiters, helps find candidates for both care homes and NHS hospitals. During a visit to India, he said, he was astonished by the clamor for care employment. “I had at least 50 people come by my house—my neighbors, my friends, someone who had just finished high school—who all wanted to know how to apply to be a care home worker,” he said. 

Part of the demand stems from labor conditions at home. Working as a nurse in an Indian hospital doesn’t pay very well. One nursing manager at the Maharaja Agrasen Hospital in Delhi, who asked not to be named, said he earns 45,000 rupees (about £438 or $545) a month after a 15-year career. “We’re under pressure all the time, because of staff shortages,” he said. “The working conditions just aren’t good.”

But nurses have also faced harsh working conditions in the UK as well.

Cleaning toilets, washing dishes

Maria’s first 10 days on the Isle of Wight were spent in a hotel room, with another nurse. They’d been picked up at the airport by local representatives of the company that recruited them. “They just dropped us here and left,” she said. “We couldn’t cook for ourselves. I had changed 50,000 rupees into pounds, but I didn’t know how much of it to spend on food, because I didn’t know if they would force us to pay for the hotel room or not.” 

Every day, the two nurses would go out, eat a cheap burger apiece, and return. Finally, when they were assigned a home to share, they were asked to pay half the hotel bill. “When we complained about that, saying that we’d already put down a relocation fee, they shouted at us. So we paid.”

The work itself was disconcerting as well. “We knew we’d have to feed bedridden patients, or clean them,” Maria said. “But after coming here, they said we’d have to clean their houses also—clean their toilets, wash their dishes.” All of this was work that lies outside the scope of her job, Maria said, and sometimes she found herself treated more as a maid than as a nurse.

Others had worse experiences. Chithra, who asked to be referred to by her first name, flew from India to the UK in January 2022. Unhappy with her domiciliary care employer, she found work at a care home last July, but said her first job still hasn’t paid her for the first two weeks or the last month that she worked there. 

She’d paid around 650,000 rupees to her agency in India, and then paid £2,800 once she was in the UK. Of that initial payment, 300,000 rupees were for English language classes promised to her in the UK, which never materialized. Then, she was asked to pay another £2,000. She refused.

“Now the agency is blackmailing me, saying: ‘We’ll get you deported,’” Chithra said. (Both Maria and Chithra were recruited not through Nass Global Resources but through another agency in the Kerala town of Kochi.) “They’d asked me to leave a blank check with them, and when I decided not to pay, I blocked that check.” 

On a WhatsApp group of nurses that the agency had created, the CEO of the agency left long, accusatory messages in English and Malayalam, the primary language spoken in Kerala. Chithra forwarded one to Quartz and Type Investigations, in which the speaker accused her of “living shamelessly on someone else’s money” and of being a cheat. She got plenty of messages in this vein, she said, so she blocked the number.

The Care Quality Commission, an independent regulator in the UK, declined to comment. The NHS referred questions to the Department of Health and Social Care. Ahmed, at the National Care Association, said the group hopes to work with the government to set up a helpline for workers who may be feeling vulnerable, and pointed out that “the majority of care providers” are keen to ensure their employees’ wellbeing. 

In late 2021, care home staff in Wales alerted authorities about some of their new Indian employees, who often turned up tired and “smelling,” and were seen eating leftovers from the meals served to residents. An investigation by the GLAA found nine such workers, from six care homes, had been housed in cramped quarters by a UK recruitment agency. The workers slept on mattresses on the floor, in cold and unsanitary houses; one of the two houses had a fire hazard. Five people associated with the agency have been arrested. In March, the GLAA rescued nine more Indian care home workers as potential victims of modern slavery. 

“The challenge will always be that when employed by agencies there is little providers can do as they will have no control,” Ahmed said. “The challenge of shortage of staff at the rates providers can pay makes it difficult to stop using agencies.”

Cyriac has heard of dozens of other cases where nurses have paid agencies thousands of pounds to come to the UK. He has first-hand knowledge of this, he said, because these nurses wind up contacting him to try to get better jobs or ask for his help when they get into financial distress. “I get phone calls every single day from these nurses in trouble,” Cyriac said. “It frustrates me and makes me sad.”

Maria stayed in her job with a domiciliary care provider on the Isle of Wight. But like Chithra, she saw no sign of the promised English classes, so she decided not to pay the recruitment agency the additional 300,000 rupees outlined in her contract. Her roommate did the same. “Her agency called her husband in Kerala and harassed him,” Maria said. “If you block one number or don’t pick it up, they call from another number. On the WhatsApp group, they send us threats and blackmail, and then quickly delete those messages.”