The six states of the Gulf Cooperation Council (GCC)—Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, and the United Arab Emirates (UAE)—are affluent rentier states. Historically, the location of the Gulf at the nexus of Africa, Asia, and what is now called the Middle East made the region a hub for trade and migration. At the beginning of the 20th century, however, most people living in the Arabian Gulf region were poor, uneducated, and nomadic. Primary exports included pearls and dates (the desert’s most important crop); as a result, this region was not considered a significant player in the world economy. Yet within a few decades, the economic scene would change dramatically. As the pearl industry collapsed after the Great Depression of the 1930s, the early-mid 1900s brought the discovery of oil. GCC states learned to find and export this vital and lucrative commodity, in the process developing ties with western economies. These Gulf states, and especially Saudi Arabia, leveraged their resources for power on the global stage while enabling their relatively small native populations to pursue a high quality of life.
The migrant populations who build the modern, extravagant, and rapidly needed infrastructure of the growing Gulf states do not enjoy this same quality of life, despite making up a large percentage of the inhabitants of the region at present. After working long days, often in harsh outdoor conditions and sometimes in homes where they are subject to racist and derogatory treatment, they most often return to crowded work camps that are hidden away from the highways and skyscrapers that define the metropolitan areas presented to tourists and citizens. While native Arab populations are reporting the highest health risks from lifestyle-related ailments like cardiovascular disease and type 2 diabetes, migrant workers are at a higher risk for work-related injuries, mental health problems, and abuse by their employers. Their challenging social conditions have become even more difficult recently with the spread of the coronavirus into their communities and workplaces.
While native Arab populations are reporting the highest health risks from lifestyle-related ailments like cardiovascular disease and type 2 diabetes, migrant workers are at a higher risk for work-related injuries, mental health problems, and abuse by their employers.
Who Are the Migrants in the Gulf Arab States?
According to the International Labor Organization (ILO), the GCC states, along with Jordan and Lebanon, hosted 35 million international migrants in 2019, 69 percent of whom were men. While many were from Southeast Asia, others came from Egypt, Ethiopia, and other countries in Africa. All expatriates are admitted for employment in Gulf states under a kafala sponsorship system, which ties their presence in the respective countries to their employers. This gives employers enormous power over workers’ lives and work conditions, and in some circumstances, they may even bar workers from leaving the country. There is also a small group of expatriate workers who came from economically developed countries primarily to work in short-term, white collar, professional careers while living in protected compounds; they received health insurance coverage from their employers and, in general, accessed the benefits of living in a rich society. This paper will focus on most of the migrant labor in the Gulf that includes the construction workers, maids, nannies, drivers, and other service workers who do not have the same access to social amenities as others.
While the GCC states only host 10 percent of the world’s migrant population, the relatively small size of their populations means that migrants make up a significant proportion of their residents. In fact, according to the aforementioned ILO report, migrants make up most of the population in Bahrain and Kuwait, while in Qatar and the UAE, they comprise close to a staggering 90 percent of the population. Bahrain’s last census in 2015 found that 51 percent of the inhabitants were migrants. In Kuwait, migrants represented 70 percent of all residents, or 3.4 million out of a total of 4.8 million. The influx of South Asian workers started in the 1970s due to the oil boom in the region. In 2018, their remittances reached $78 billion and accounted for 60 percent of all remittances to South Asia.
Migrants make up most of the population in Bahrain and Kuwait, while in Qatar and the UAE, they comprise close to a staggering 90 percent of the population.
Health Care Delivery and Outcomes for Migrant Workers
Globally, migrant labor is often favored because states are willing to subject migrants to work conditions that would be considered unacceptable by native populations; in addition, the host governments do not embrace the responsibility of offering them the services that citizens receive, including government-provided health insurance. In the Gulf states, this often results in very long work days (sometimes with no rest breaks), no sick leave, payment disruptions and delays, and extremely low wages. It is noteworthy that some states have no minimum wage provision while others regulate a minimum wage of around $200 per month. This precarious economic status renders the migrant workers unable to pay for private health care, which is already limited in many of these countries.
Health care in the Gulf depends heavily on public funding, with states paying a high share of the health care burden to cover their citizens and, in the case of Saudi Arabia, the care of religious pilgrims. This poses a heavy financial burden on states, though it has been manageable due to their small populations of nationals. Providing even an inferior level of care—relative to what citizens enjoy—to the millions of migrants in the region would be a significant financial challenge in a period of newfound financial uncertainty. Moreover, there is no path for migrants to become citizens in their host countries, which would allow them to gain access to state benefits. At any rate, governments’ provision of health insurance has fluctuated, especially since the decline of oil prices that began in 2014, with varying policies across the Gulf for private sector employees. This shift is likely to persist as oil prices continue to decrease.
To be able to enter their host countries, migrants must pass a “Pre-departure Medical Check Up” to test for infectious disease, primarily because of the risk to the host population. Other basic health assessments include pregnancy tests, hearing and vision screenings, and evaluations for psychiatric illness and other ailments that would limit a worker’s ability to perform his or her job. In fact, it is reasonable to assume that the practice of recruiting only healthy migrants may inflate positive health trends in the Gulf states because the migrants make up such a large part of the population.
It is reasonable to assume that the practice of recruiting only healthy migrants may inflate positive health trends in the Gulf states because the migrants make up such a large part of the population.
Once workers enter the country, however, their health and well-being are not as much of a priority. Aside from the physical labor of most of their jobs, migrants are often driven to challenging lifestyles with little access to fresh and healthy foods, thus increasing their risk of cardiovascular ailments. For example, according to one study, Nepalese workers are exposed to environmental health hazards like pesticide exposure and experience injuries from falls and machinery/vehicular accidents while given little safety training and protective equipment. They also report higher rates of excessive drinking, drug use, and risky sexual behaviors, partially due to misinformation but also to the social isolation and stress of being away from their homes.
Basic health insurance is provided to migrant laborers, but many may not adequately understand its provisions. Language barriers between workers from the Global South and providers also limit the effectiveness of care, even for those with access. Lastly, while Gulf states have previously been criticized for lack of investment in public health, in recent years they have introduced health promotion efforts to educate their citizens about such topics as the risks of smoking, heart health, and safe driving. However, there are almost no similar efforts for migrant communities, who often do not receive this information in their home country either.
Migrant Labor and Gender
Because of the significant influx of male workers, the Gulf states report some of the largest gender imbalances in the world. Without external intervention, most states will have about a 1:1 ratio of male and female inhabitants. Yet the percentages of women in populations of the Gulf states ranges from 25 percent in Qatar to 42 percent in Saudi Arabia. Most male migrant workers are tasked with construction labor, which requires them to be young, healthy, and able. But working conditions and the hot climate have adversely affected even the able-bodied laborers. A recent report from Hyderabad News pointed out that almost 34,000 Indian migrant workers died in the Gulf from January 2014 to October 2019 from exhaustion and cardiac arrest due to the oppressive heat. Research findings published in The Economic Times in November 2018 stated that 10 Indians die in the Gulf countries every day and that 117 of them die for every $1 billion in remittances back to India.
The Guardian reported in October 2019 that thousands of migrants working on the Expo 2020 in Dubai, UAE, were exposed to dangerous levels of heat stress. The Indian government reported that almost 5,200 Indian workers died “natural deaths” (such as respiratory failure and cardiac arrest brought on by high temperature) in the UAE between 2012 and 2017. In another Guardian report about Qatar––where there is a high concentration of these workers due to construction for the 2022 World Cup, bringing extra scrutiny––hundreds of migrant workers die from sudden and unexplained cardiac issues away from their work site and their deaths are considered from “natural” causes. In Saudi Arabia, 90 of every 100,000 migrant Indian workers died in 2018 of the same causes, which is higher toll than all other GCC states. In Bahrain, workers can go without pay for months on end as they perform the same kind of work in unchanging conditions.
Advisedly, Qatar instituted new labor laws that addressed many concerns about migrant workers rights and conditions. The new laws allow the workers to freely change employment and leave the country without their employers’ permission. In essence, they ended the old kafala system instituted in the Emirate and other GCC states from which many expatriates complained. The International Labor Organization welcomed the changes which took effect last January, recognizing that they “support the rights of migrant workers.” Under pressure, other GCC states have also legislated new labor laws but none have instituted them or implemented their provisions.
Perceptions of an ethnic hierarchy, where Filipina and Indonesian women are more highly valued as “symbols” of social status, seem to temper the level of mistreatment women experience, yet these women are also not immune.
While men are tasked primarily with construction labor, women are much more involved with domestic work. Many of them arrive with the assurance that they will be principally tasked with childcare on a reasonable schedule, or with work in other industries altogether like computer programming. Instead, they often find that they are expected to perform a multitude of household tasks for more hours than contracted. Some women report being denied communication with their families back home, experiencing racism (especially toward women from African countries), and even suffering from not being given food. Perceptions of an ethnic hierarchy, where Filipina and Indonesian women are more highly valued as “symbols” of social status, seem to temper the level of mistreatment women experience, yet these women are also not immune. Women working in the domestic labor force make up 60 percent of all Filipino migrants in the Gulf. In January 2020, however, the Philippines banned migration to Kuwait after the highly publicized murder of a domestic worker by her employers, with evidence also suggesting that she was sexually abused before she died. In many Gulf states, there are few laws protecting women in general, and especially migrant women, from violence and sexual harassment, and the few women’s shelters that can be found may not be accessible to migrant workers. Those who do report rape or harassment may themselves be accused of engaging in unsanctioned relationships and punished.
Harsh work conditions, poverty, social isolation, and lack of screenings and treatments have led to higher rates of mental health conditions in migrants than in native Gulf populations. Very little recent empirical work exists on this topic, but wide-ranging reviews of the past several decades have demonstrated many more cases of mental illness in non-Arab expatriate populations. Dozens of suicides are reported among the Gulf’s migrant populations annually, and they have only increased due to the economic pressures brought by the coronavirus. When women domestic workers report contractual deception, movement restrictions, verbal or physical abuse, or months without payment to their recruitment agencies, they are often ignored or dismissed. Together, all these factors lead to high rates of depression, anxiety, and suicide in these women.
The Threat of COVID-19
The novel coronavirus has emphasized and exacerbated the preexisting disparities throughout the world, yet they have become even more present in the most vulnerable populations. Most migrants in the Gulf Arab countries already live in tight housing situations, often without adequate access to safe water and sanitation; they are unable to socially distance, creating “incubators” for disease spread. In fact, migrant workers in GCC states have become the most vulnerable communities during the COVID-19 pandemic. Additionally, as borders began to close in late March 2020, these migrants were unable to leave their host countries; but even if they could, their home countries were just as unable to help them. As economies shut down, so too did the companies and households that paid the workers, leaving them in dire economic straits. This confluence of factors poses a significant public health threat: a large population of impoverished and disenfranchised non-citizens living in what often amounts to poorly served slums.
Migrant workers in GCC states have become the most vulnerable communities during the COVID-19 pandemic. Additionally, as borders began to close in late March 2020, these migrants were unable to leave their host countries.
Not surprisingly, many of the first outbreaks in Gulf states occurred in these very compounds, leading states such as Qatar to lock down areas where migrants live. Access to health care for affected workers is highly dependent on their employers, and many migrants avoid seeking care because of previous negative experiences with the health care system or fear of repercussions if they are found to test positive for the virus. Already in some quarters of Gulf society, such as in Kuwait, migrant workers are being blamed for its spread. Some home countries, like India, were refusing repatriation of their citizens from the Gulf. As a result, while some have stayed by choice, many workers are involuntarily stranded. Recognizing the concerns, governments have begun moving in the direction of additional health services for migrants, but this newfound attention to migrant health, although welcome, should not end at infectious disease.
Human rights and labor advocacy groups have long called for more stringent protections for global workers on issues of exploitation, forced labor, and trafficking, with some success. Ultimately, however, these policies are either too weak or poorly enforced. Workers should always be guaranteed a regular and non-deceptive work schedule; safe, clean, and accessible accommodations with access to public transportation; nutritious and adequate food; regular access to clean water (especially for those who work outside); an environment free of abuse and discrimination; and access to necessary health care treatment. Employers who violate existing policies should face punitive consequences. Further, states with weak policies should be expected to change them to be in line with international labor standards, where treatment of migrants is to be “no less favourable” than that applying to nationals. If an expensive infrastructure project cannot be completed without the exploitation of foreign workers, then it is the project that should be reconsidered and not the health and dignity of the worker.
All states should offer a basic standard of medical care for the workers on whom they depend to build their infrastructure projects. Some states, like Kuwait, allow domestic workers to receive treatment at government hospitals, but whether or not a poorly paid migrant can afford health insurance, or whether their ailment directly affects their ability to do the work, should not be a factor in their right to be safe and healthy. Medical staff should be trained to recognize signs of abuse and be prepared to help migrant workers file a complaint or otherwise contact the authorities if necessary. The mental health needs of these populations should also be a priority, both for the health and well-being of the individual and the sustainability of the migrant workforce. Host countries should provide interpreters, psychologists, and social workers who are trained to support these populations when needed.
There is a paucity of research on the specific health needs of migrant labor in the Gulf. Most is focused on the specific factors of heat stress and dehydration, and there is also some advocacy work on the abuse of domestic workers. More efforts in this domain are needed, with the cooperation and funding of employers and governments. Additionally, finding accurate data on migrants—including on undocumented workers—is difficult. Aside from leaving a gap in our understanding of these populations and their needs, the coronavirus has shown that transparency and trust in health systems is a necessary component of effective public health.
Lastly, countries that provide significant numbers of laborers to this region should expect better treatment of their citizens and attach policies that reflect this perception with any labor negotiations. However, their reliance on the remittances of the migrants and on maintaining relations with wealthy and powerful countries creates a conflict in such talks. Prioritizing the health and human rights of their citizens should be the highest concern—but it cannot be solely the responsibility of the less developed and vulnerable states of origin to advocate for changes like mandated protections, higher living and working standards, and access to appropriate medical treatment. Host states should also guarantee that all their inhabitants, regardless of citizenship or country of origin, experience a life of opportunity, equality, and dignity. When human rights are prioritized, migration can and should be a positive experience for the host country, the home country, and the worker.
* Photo credit: flickr/Paull Keller