Barrak Alahmad, Harvard University & Kuwait University
Workers are often exposed to harmful mixtures of chemical and physical exposures at the workplace that eventually leads to poor health. However, for migrant workers, stressors from many other levels cumulatively wear down their health. In this paper, I use Kuwait as an example. I highlight four key domains where risks can overlap for migrant workers: the individual, the community, the workplace and the environment. Then, I summarize the recent epidemiological evidence that describe key health disparities in migrant workers. In the hot desert climate of Kuwait, I focused especially on two key environmental exposures that are expected to be amplified in the future due to climate change: 1) extreme heat and 2) dust storms. I call for a disaggregated and intersectional data that allows epidemiologists in the region to further examine the adverse health impacts that climate change could bring to migrant workers. Finally, I argue for the inclusion of ‘health’ in the social justice and political conversations on migration.
At the population level, not all communities get the same degree of environmental protections, nor do they get equal access to the decision-making process that ensures a healthy environment. Nothing illustrates this more clearly than migrant workers. Migrant workers are usually left out from protections established by public policies, while facing precarious work conditions characterized by long hours, low pay, and suboptimal occupational safety and health training.(1) They work in conditions often called “3-D jobs”: dirty, dangerous, and demanding employment.(2) Migrant workers tend to take more risks on the job and cannot complain about unsafe working conditions because they always face the risk of losing their jobs or being deported. Often, there is no official unionization that would potentially give voice or provide additional protections for migrant workers. This power differential usually results in migrant workers’ unwillingness to assert their rights.
The Gulf countries – Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, and the United Arab Emirates (UAE) – host millions of migrant workers. In general, non-nationals constitute a very large percentage of the population (Figure. Panel A); more than 80% in Qatar and the UAE, two-thirds in Kuwait, nearly half in Bahrain and Oman, and one-third in Saudi Arabia.(3) The vast majority of the non-nationals are migrant workers. Usually, they are middle-aged males who come to the host country unaccompanied by their families.(4,5) (Figure. Panel B) This skew in the population pyramid introduces key vulnerabilities in population health that need to be explored and addressed.
The scientific consensus of the intergovernmental panel on climate change (IPCC) in its sixth assessment report in 2021 was ‘virtually certain’ that the magnitude and frequency of heat events have increased on the global scale since the last century. But the warming of our planet is not evenly distributed. In inherently hot and hyper-arid regions like the Gulf countries, temperatures are already soaring to unprecedented record-high levels, and climate change seems likely to have disproportionate impact on countries and specific populations in these regions. For example, extreme heat, beyond the body’s ability to regulate, is associated with increased risk of hospitalization and death. Under hot conditions, the capacity to do physical work and motor-cognitive performances are reduced, leading to serious occupational health concerns. Similarly, blown dust and associated fine air particles penetrate deep into the lungs and the blood stream which in turn can lead to major exacerbations of existing morbidities and other fatal and non-fatal health events.
In this paper, I use Kuwait as an example of how current and future environmental stressors impact the health of marginalized migrant workers. I summarize the recent epidemiological evidence that describes the health disparities seen in this subpopulation. Finally, I argue for the inclusion of ‘health’ in the social justice and political conversations and call on epidemiologists in the region to further explore the data on migrants, the environment and health.
Climate change and air pollution in Kuwait: History and future
The oil fires in 1991 following the Gulf war were among the most destructive environmental disasters in recent history. Kuwait recorded extremely high air pollution levels that prompted the country at that time to put serious efforts in assessing environmental exposures. The country has a harsh desert and hyper-arid environment. Frequent dramatic dust storms in Kuwait City deposit more than 270 tons of transported sand per km2 each year, one of the largest totals of any city in the world.(6) Kuwait is also one of the hottest countries in the world. In 2016, the temperature in Mitribah, Kuwait reached 54°C, which was the highest officially recognized temperature globally.(7)
There is little cause for optimism in future projections of these environmental exposures. If current global emissions remain the same (business-as-usual), Kuwait, and the rest of the Gulf region, will likely experience substantial increases in mortality risk due to extreme temperatures.(8) Some researchers suggested that these extreme temperatures will render the region uninhabitable by the end of the century.(9) It is estimated that by 2060 and under a moderately less extreme emissions scenario, Kuwait could see more than 1.8°C increase in average temperature compared to the early 2000s.(10)
For inherently hot regions like the Gulf, an increase in average temperature will bolster heat effects by frequency, magnitude, and duration of occurrence. This will translate into increased burdens of mortality and morbidity, especially among vulnerable subpopulations such as migrant workers who are at-risk from extended periods of exposure to these environmental stressors.
Health vulnerability of migrant workers in Kuwait
Workers are often exposed to harmful mixtures of chemical and physical exposures at the workplace that eventually result in poor health. These exposures, however, do not occur in isolation from other stressors.(11) More specifically, migrant workers are exposed to an array of stressors from what can be conceptualized as from four key risk domains: individual, community, occupation and environment.(12) In Kuwait, the stressors from all domains can overlap and increase the vulnerability of this marginalized subpopulation (Table 1). Looking at all these stressors, poor health of migrant workers is inevitable.
Table 1: Examples of stressors on migrant workers in Kuwait that contribute to poor health from four different risk domains
|Individual||– Lack of information and interpretation services
– Poor access to healthcare services
– High diagnostic and treatment costs
– Undiagnosed chronic conditions (e.g., blood pressure, heart diseases, etc.)
– Poor access to healthy diet or food choices
– Increased smoking prevalence
|Community||– Poorly maintained neighborhoods
– Cramped and unhygienic housing
– Lack of recreational facilities
– No physical activity options
– Overall community deprivation
|Occupational||– Limited occupational safety training
– Limited availability of personal protective equipment
– Exposure to toxicants and chemicals at the workplace
– Poorly regulated long hours
– Low pay
– Stressful demanding jobs
– Bullying at the workplace
– Job restriction and exploitation through the ‘Kafala’ system
|Environmental||– Extended exposure to outdoor air pollution
– Extended exposure to outdoor extreme heat
– Poor indoor thermal comfort (e.g. air conditioners)
– Poorly fitted housing with high infiltration of dust
– Water contamination
The Individual, the Community and the Workplace
At the individual level, non-Arab migrant workers in Kuwait do not usually have a serviceable command of the local language, and even Arab migrant workers may not have access to information on the health system and regulations. At the time of writing this paper, there are no programs of integration nor any mandatory interpretation services at public hospitals in the country. Access to healthcare services is free of charge for Kuwaitis but it is not for free for non-Kuwaitis, although some basic healthcare services can be covered by an annual health insurance fee.
At the community level, there are different segregated residential areas for Kuwaitis and non-Kuwaitis with striking differences in neighborhood deprivation. Strict family visa rules result in male migrant workers coming unaccompanied by their families and living in cramped houses that are solely populated by males. These neighborhoods are poorly maintained; they lack recreational facilities, healthy food choices and physical activity options.
At the workplace, there are limited occupational safety protections and training which likely results in increased risk of injuries and work-related diseases. There are systematic problems in the ‘Kafala’ visa-system that restricts the worker’s ability to change employers or change jobs. As a result, most of the jobs are demanding, with long hours and low pay. Migrant workers are often subject to workplace bullying and demeaning behaviors. Examples of bullying include social isolation or exclusion, devaluation of the subject’s work and efforts, and feeling threatened or frustrated. Evidence suggests that bullying at the workplace is associated with overall poor health.(13)
Environmental stressors further wear down the health of migrant workers. Especially in Kuwait, workers are at high risk of adverse health outcomes because they spend extended amount of time in a harsh outdoor setting. Only 4% of Kuwaitis take jobs that involve manual work(5); these physically demanding jobs are occupied by non-Kuwaitis. There are two environmental outdoor exposures that are amplified in Kuwait’s desert environment: 1) dust storms and 2) extreme heat.
Dust storms carry large quantities of fine particles that, when inhaled, can penetrate deep into the respiratory tract and the lungs. The evidence suggests that there is potentially a direct physical damage to the lung cells that could trigger an inflammatory response.(14) These fine particles can also travel in the blood stream and lead to exacerbations of existing heart diseases. Extended exposure to poor air quality from dust storms is linked to increases in morbidity and mortality rates.(15,16)
In Kuwait, where severe dust storms are frequently observed, our research group examined more than 17 years of mortality data stratified by nationality, age and gender.(17) The local context of this epidemiological investigation provided key insights into the impact of dust storms on mortality in the country. The risk of dying from dust exposure was significantly higher for non-Kuwaitis (total), non-Kuwaiti men and non-Kuwaiti adults aged 15 to 65 years. It was surprising to find that the risk of death for the non-Kuwaiti adults in working age was high from this environmental exposure. One would expect this young age group to be generally healthy. However, they are the ones who get extended outdoor exposure. Overall, we found a 4% increase in the risk of death for non-Kuwaitis during dust days compared to non-dust days. During the same period, there was no noticeable increase in death risk for Kuwaitis from dust storms.
The body has a complex mechanism in which its core temperature remains unchanged. This ‘thermo-regulatory’ biological process has a certain threshold that can be exceeded when the body is exposed to extreme hot temperatures over an extended period. The body will try to cool its core temperature by making changes to its blood vessels, blood pressure, heart rate and other physiological functions. The responsiveness to such cooling attempts may fail and this could lead to serious consequences, and potentially death.
Over the last couple of years, our research group conducted a number of health assessments related to extreme temperatures in Kuwait.(18–20) We found an alarming doubling to tripling of the risk of death for non-Kuwaitis and non-Kuwaiti males during extremely hot days as compared to days with optimal temperature. Similar to our dust findings, non-Kuwaitis despite their young age were still vulnerable to extreme heat. No significant increases in the risk of death were seen among Kuwaitis and Kuwaiti males for the heat exposure.
The data in these Kuwait studies was not stratified by work status but rather by nationality. The use of nationality as a proxy for migrant workers means that many affluent non-Kuwaitis are included in the same analysis group. In that case, however, the published results are even more worrying because they are underestimated due to the inclusion of affluent individuals who have socioeconomic resources and are not often exposed to outdoor dust and heat.
We used historical mortality data to study the risks of environmental exposures on migrant workers. The future health risks that are induced by climate change cannot be easily described due to the uncertainty associated with population dynamics, advances in technology, trajectories of weather patterns, global efforts to curb emissions and many others. However, some researchers attempted to investigate future mortality projections in the region. Studies revealed that in the near future, the risks of heat-related mortality are expected to sharply increase. By the end of the century, mortality rates are predicted to increase by a factor of 8 to 20 times the current rates in the Gulf countries.(8) We need local studies that utilize country-specific temperature and mortality data to project future climate change impacts on migrants in the Gulf.
Additionally, in arid regions, climate change is inducing droughts and desertification of lands. Increasing temperatures and reduced precipitation will lead to loss of cultivable land making the surface soil loose and prone to wind transportation and hence generation of dust storms. An analysis of the last 15 years of satellite data showed that loss of vegetation in Iraq and nearby countries was associated with increased dust storms in Kuwait.(21)
In addition to extreme heat and dust storms, climate change is associated with a number of other health risks (beyond the scope of this paper) such as vector-borne diseases, increased allergens, severe weather events, disruptions to food and water supplies, mental health disorders, and many others.
Other Epidemiological Studies
In recent years, an emerging body of epidemiological studies have investigated different health vulnerabilities of the migrant workers population in Kuwait. The storyline is similar. Young, otherwise healthy, migrant workers in Kuwait are systematically subject to adverse health outcomes. A summary of these studies is provided in Table 2. During COVID-19, migrant workers in Kuwait experienced higher transmission rates (22) and were more susceptible to severe COVID-19 than Kuwaitis.(23) There was a disproportionate increase of 72% in excess deaths among non-Kuwaitis in 2020 (vs. 32% for Kuwaitis).(24) In other non-fatal health outcomes, migrant workers in Kuwait also had a high prevalence of occupational-induced hearing loss.(25)
Table 2: Recent epidemiological evidence on the health vulnerabilities of Non-Kuwaiti migrant workers in Kuwait
|(A) Environmental Health Studies|
|Achilleos et al. (2019)(17)||Air pollution and dust storms||Mortality||4% and 5% increase in non-Kuwaitis and non-Kuwaiti males risk of mortality in dust days compared to non-dust days, respectively.
No significant increases were seen among Kuwaitis and Kuwaiti males
|Alahmad et al. (2020)(19)||Extreme temperatures||Mortality||The risk of dying for non-Kuwaitis and non-Kuwaiti males in extremely hot days is 2- and 3-times higher than optimal temperature days, respectively.
No significant increases were seen among Kuwaitis and Kuwaiti males
|(B) Other Epidemiological Studies|
|Buqammaz et al. (2021)(25)||Occupational noise||Hearing loss||20.4% of non-Kuwaiti workers who work in the Shuaiba area industries were medically diagnosed occupational-induced hearing loss
|Hamadah et al. (2021) (23)||COVID-19 infection||Needing intensive care and mortality||Non-Kuwaitis had a two-fold increase in the odds of death or being admitted to the intensive care unit compared to
|Khadadah et al. (2021)(22)||Nationality status||Spread of COVID-19||A partial lockdown in Kuwait reduced the effective reproduction number (Re; a transmission factor) of COVID-19 among Kuwaitis, but it nearly doubled for non-Kuwaitis who are typically clustered in certain areas.
|Alahmad et al. (2021)(24)||Nationality status||Excess mortality during the pandemic year of 2020||In 2020, deaths among non-Kuwaitis increased by 71.9% whereas deaths among Kuwaitis increased by 32.4%.|
Population health data is usually collected and analyzed for an aggregate estimate. For the Gulf countries, this carries a significant risk that marginalized migrant subpopulations are left unexamined. I call upon data analysts and epidemiologists in the region to examine the health disparities seen in migrant workers and recognize our responsibility towards the most vulnerable people in our society. Future climate change and health studies must be designed in a way that enables data collection and analysis among those that are marginalized, excluded, and discriminated against.
Many–if not all–determinants of health are centered around the environment in which the individual lives in and interacts with. Communities with low socio-economic resources and deprived neighborhoods are more vulnerable to environmental stressors compared to affluent communities. Beyond heat and dust storms, this environmental injustice observed in Kuwait can manifest in a range of other unhealthy exposures from worsened air pollution to poor water sanitation and exposure to chemical toxins and microbial agents. Early environmental justice movements in the western world grew out of areas that had a brutal legacy of slavery, political disenfranchisement, and racial minorities. I argue for the fair treatment and meaningful involvement of migrant workers to develop, implement, and enforce environmental health protections, especially in light of a changing climate that will amplify these environmental stressors. A changing climate is not felt equally by people, it is always the poor and the most vulnerable that are the worst hit.
Unfortunately, far too often I see social justice and human rights advocates and academics discuss migrants’ rights in isolation of public health. However, we continue to witness health disparities arising from systematic injustices that are closely linked with social, economic, and environmental disadvantages; and typically in communities that are historically excluded and discriminated against. I argue that health is inseparable from equal rights and opportunities; it is a fundamental human right that allows us to enjoy life and pursue our goals. ‘Health’ should be central to any social justice argument. ‘Health’ should also be central to any environmental policymaking.
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- Khadadah F, Al-Shammari AA, Alhashemi A, Alhuwail D, Al-Saif B, Alzaid SN, et al. The effects of non-pharmaceutical interventions on SARS-CoV-2 transmission in different socioeconomic populations in Kuwait: a modeling study. BMC Public Health. 2021 May 26;21(1):990.
- Hamadah H, Alahmad B, Behbehani M, Al-Youha S, Almazeedi S, Al-Haddad M, et al. COVID-19 clinical outcomes and nationality: results from a Nationwide registry in Kuwait. BMC Public Health. 2020 Sep 10;20(1):1384.
- Alahmad B, AlMekhled D, Odeh A, Albloushi D, Gasana J. Disparities in excess deaths from the COVID-19 pandemic among migrant workers in Kuwait. BMC Public Health. 2021 Sep 14;21(1):1668.
- Buqammaz M, Gasana J, Alahmad B, Shebl M, Albloushi D. Occupational Noise-Induced Hearing Loss among Migrant Workers in Kuwait. Int J Environ Res Public Health. 2021 May 16;18(10).