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For centuries, seeking a better life has presented major obstacles for those who have the need and the courage to relocate their lives. Recent media attention has focused on immigrant families escaping famine, war or other disastrous circumstances in their homelands. The popular media has written much less about migrant workers who travel abroad to earn a living not possible in their home settings. Commonly, family members who stay home are completely dependent on funds sent back while, in the host country, their migrant relatives are often employed in dirty, dangerous and demanding jobs and required to return to their country of origin after limited years. They cannot settle in the host country and cannot bring their family members with them. Regardless, all immigrants face immediate and long-term struggles as they attempt to interact with a new society. At minimum there are linguistic, cultural and economic challenges to face. Host countries can address these challenges in the way they welcome and assist immigrants and migrant workers to adjust. In the case of formal labour agreements between countries, as between Nepal and Qatar, they have an obligation to make the experience as safe and just as possible.
Public health professionals in host countries can help address the critical health needs of immigrants, but for migrant workers there is a particular need for the focused attention of the occupational health community. One case where that community must be more engaged was documented by Amnesty International: ‘In the prime of their lives’ Qatar’s failure to investigate, remedy and prevent migrant workers’ deaths. 1 There is good evidence that the plight of migrant workers is global in nature,2–4 but this case is a particularly vivid and upsetting wake-up call. It is one we should have seen coming from the time that Fédération Internationale de Football Association (FIFA) announced in 2010 that they had awarded Qatar the opportunity to host the 2022 World Cup football event.5 The decision was described by Sepp Blatter, the then FIFA president, as a ‘bold gamble’. Acknowledging this gamble, the Qatar leadership was quoted as saying: ‘We know it would be a bold gamble and an exciting prospect but with no risk…Heat is not and will not be an issue’.2 The Amnesty report documents the hubris of this statement. Surprisingly, international organisations such as WHO, International Labour Organization, FIFA and the global football stars have thus far chosen not to comment. Following on Amnesty’s earlier reports6–8 on the exploitation and abuse of migrant workers in Qatar, this newest report addresses the failures to appropriately investigate migrant worker fatalities and the environments that permitted them. ‘In the prime of their lives’ should be required reading for all those concerned with occupational health.
So, what led to the devastating findings in the report from Amnesty International? The answer is twofold. One part lies in the unstated belief that workers are expendable and migrant workers are easily replaced. It is highly likely that when officials indicated heat is ‘not an issue’ it was not because they were unaware of the hot weather in Qatar. Rather it was because they believed that heat could be managed for the footballers and that the World Cup competition would be produced in a manner safe for both athletes and spectators. Remarkably, the outdoor stadiums designed and built for the competitions will all be air-conditioned.9 10 No one appears to have considered the human cost of constructing these air-conditioned sites in such a hot environment—over a 10-year period—all for a 4-week event.
The other part of the answer lies in the naïve belief by many that establishing rules and regulations provides a safe and appropriate work environment. Time and again the occupational health community has seen the consequences of assuming rules are equivalent to preventive action.
Let us look for a moment at the data. Amnesty’s 2021 report points to the poor transparency and poor public health practice in Qatar’s surveillance of occupational disease among migrant workers. Cause of death is recorded inadequately, and routine information is not provided about occupation, activity at time of death or migration status. As one example, the report cites a study of Nepalese working in Qatar that found excess cardiovascular disease (CVD) mortality during hot periods—excesses associated with afternoon heat.11 The report suggests that at least 200 of the 571 CVD deaths could have been prevented had heat protection methods been in place. Another report from Nepal ‘found increased incidence of chronic kidney disease (CKD) among Nepali migrant workers returning from Gulf States and Malaysia’, >75% had unknown cause of CKD and 70% worked greater than 60 hours/week.12 Both studies point to inadequate data as limiting their analyses as to cause and conclusions about prevention. The Nepal Labour Migration Report 2020 calls for enhanced efforts to evaluate the health of all migrant workers returning from any country: ‘…to ensure early detection of health risks while broadening the understanding of common health issues faced by migrant workers that can inform policymaking’. Furthermore, if this information was coupled with the medical tests required prior to leaving Nepal the results should greatly inform and help target prevention efforts in collaboration with host countries.13
The Amnesty report goes on to present evidence that the established rules and regulations designed to protect migrant workers’ health are both inadequate and irregularly enforced. Earlier criticisms from Amnesty3 and other independent investigators14 15 were addressed in a Qatar-sponsored independent report published in 2014 by DLA Piper, an international law firm.16 While the report challenged the accuracy of the investigative reports, it concluded with recommendations for increased transparency and communication and for the adoption of a comprehensive set of worker welfare standards for all public contracting authority construction projects. Among the concerns it raised were with the kafala system of migrant–employer contracts. This system, common in the Persian Gulf countries, requires that a local company sponsor a foreign worker with tight restrictions on changing employers.17 Although the DLA Piper report refuses to indict the system as ‘forced labour’, it did conclude that the system ‘can result in a situation where migrant workers are ‘trapped’ in Qatar with an abusive employer, and without means of exit or the ability to legally transfer to another employer for months’.13 It took six more years before new laws addressing this system began to be adopted.
When it comes to direct attention to health and safety protection the promise that ‘heat will not be an issue’ has gone unfilled for thousands of workers due to inadequate and poorly enforced regulations. It took until 2007 for Qatar to prohibit working in areas exposed to the sun between 11:30 hours and 15:00 hours during the two hottest months of the year. Even by rule alone this calendar-based rather than heat-based regulation was inadequate. Not until 2021 did they expand the period and add a temperature limit along with the right for workers to self-pace. Even so, these improvements are inadequate. The law contains no risk-based tools (wet bulb globe temperature or heat index) to appropriately guide limits on work hours, it pays no attention to prescribed breaks in the shade, and it shows ignorance of the power differential that results in workers’ unwillingness to assert their rights.
Even if the improvements in protections were sufficient, their success would depend on adherence by employers and contractors, as well as enforcement by authorities. But authorities rarely have the resources or the power to monitor for, find and stop illegal activity, which permits the continuation of a grim status quo. The occupational health community must not only endorse the types of recommendations made by Amnesty International and other independent observers, but we must also use our knowledge and skills to shine bright lights on the plight of migrant workers. We must develop and publicise the evidence necessary to design effective protections. And we must openly advocate for their implementation using all available channels until real change is achieved.
Patient consent for publication
Contributors DHW drafted the editorial and DN, SS, and JG provided independent input and content in the revision of the final document.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Commissioned; internally peer reviewed.