Qatar 2022: An Unforgettable World Cup for Global Health

Gene Richardson & Smit Chitre

Abstract

Over one million migrant laborers in Qatar were subjected to conditions that could be characterized as best as apartheid, at worst as modern slavery, during the nation’s preparations to host the World Cup. Over 6,500 workers died due to the sheer physical toll of their forced labor; countless others were maimed. These deaths were attributed to natural causes, cardiac arrest, or respiratory distress by Qatari authorities, which obscures the exploitative structures of employment that these same authorities uphold. Such narrow explanations exemplify what Dr. Paul Farmer labels “immodest claims of causality,” adding insult to injury by shielding social arrangements that cause bodily harm from scrutiny and reform. Immodest claims of causality, however, are not unique to Qatar: they are widespread within the discipline of global health in Western academe. Rarely are histories of enslavement, colonial plunder, and neocolonial extraction—along with contemporary unfettered racial capitalism—considered factors that shape global dynamics of illness. By breaking these epistemic confines, global health professionals can expand the range of possibilities for global health interventions to encompass reparative and redistributive justice. Applying this approach to Qatar, one can appreciate that centuries of extractive colonial practices perpetrated by Great Britain on the Indian Subcontinent (which drained $45 trillion in wealth) resulted in the mass poverty that drives migration into the petrostate. Reparations for the colonized nations that are sources of migrant labor could ensure no individual needs to pursue precarious, often deadly, ‘employment’ as the only means of providing for their family.

Context: A Controversial World Cup from the Start

The 2022 FIFA World Cup amassed a total of 5.4 billion television viewers, making it the most watched sporting event in history; ¹ however, the world’s eyes were on more than just the footballers vying for glory on the pitch. This latest edition of the world’s most popular sporting tournament, hosted by the small petrostate of Qatar, was made possible by rampant corruption and lethal human rights abuses. Qatar and FIFA, football’s governing body, have been embroiled in controversy ever since the latter awarded the 2022 tournament to the former nearly twelve years ago. Red flags were raised as to how FIFA officials voted in favor of Qatar (over the U.S. or Japan—competitors in the 2022 World Cup bid) in spite of the country’s limited footballing history, outstanding record of intolerance towards LGBTQ+ community, scorching summer temperatures, and reliance on modern slavery through the kafala system. ² A lengthy investigation from the U.S. Department of Justice confirmed widespread suspicion, concluding that Qatar had bribed FIFA officials in exchange for votes, thereby surpassing concerns about Qatar’s suitability to host the fabled competition. ³

Despite over a decade of controversy and recent calls to relocate the 2022 World Cup, ⁴ it proceeded as planned in Qatar. FIFA crushed footballers’ attempts to speak out in protest, threatening to impose sanctions on players who chose to wear rainbow-colored armbands in support of LGBTQ+ rights. ⁵ Furthermore, in an unprecedented move, the tournament was rescheduled to start in November instead of the early summer, when average temperatures in Qatar fall within the 35-45ºC (95-113ºF) range. ⁶ This ensured that footballers and fans alike were not subjected to dangerous heat extremes, particularly in tightly-packed stadiums. However, no such concern was extended to the migrant workers who toiled in the sweltering summer heat, year after year, to construct the stadiums and infrastructure used for the 2022 World Cup.

When Qatar submitted its bid to host, only one of the eight stadiums that hosted matches had been built. ⁷ The bid proposed that the city of Lusail, which housed the World Cup final in a futuristic 80,000-capacity stadium, would be constructed from the ground up before the start of the tournament. To erect seven stadiums, renovate an eighth, build a new “smart city,” construct hundreds of hotels, and expand public infrastructure in little over a decade appeared to be a gargantuan undertaking. Nonetheless, Qatar has since harnessed the labor power of two million migrant workers, forcing them to work grueling shifts in inhumane conditions in exchange for little pay. ⁸

Building the World Cup - Blood, Sweat, and Tears

Most migrant workers in Qatar come from the Philippines, Kenya, and the Indian Subcontinent. Workers from the latter—which encompasses Bangladesh, Nepal, India, Pakistan, and Sri Lanka—are the backbone of Qatar’s construction industry. A recent analysis from The Guardian reveals that at least 6,500 South Asian migrant workers—who were generally healthy, middle-aged men assessed for fitness before leaving their homelands—have died in Qatar since the 2010 award of the World Cup. ⁹ Perhaps the driving force behind this shocking statistic is Qatar’s infamous kafala system: employers confiscate workers’ passports, setting the stage for relentless exploitation. ¹⁰ Employers withhold wages at will, sometimes for months at a time, leaving laborers with no pay. Workers cannot switch jobs—even if they could, they would likely encounter more kafala bosses—and cannot return home without their passports. They cannot protest shifts lasting over twelve hours in temperatures upwards of 35ºC and oppressive humidity during summer months. ¹¹ Further, safety precautions are minimal: workplace accidents account for seven percent of the staggering death toll among Indian, Nepali, and Bangladeshi migrant laborers. ¹⁰

A blatant disregard for laborers’ health and safety is also particularly evident in the camps in which they are housed. In one such example, reported by Pete Pattison for The Guardian, workers tirelessly maintaining the manicured parks that surround Al Bayt stadium are transported to a farm in the desert owned by their employer after their shifts end. ¹² Here, they are crammed into dingy, windowless cabins where five to six men will share small bunk beds. Further, in an episode of HBO’s “Real Sports with Bryant Gumbel,” journalists found workers preparing meals in filthy, unventilated kitchens where temperatures rival those endured outdoors. Nearly 150 men shared two bathrooms, with a handful of sinks and pit toilets. Those toilets frequently overflowed with sewage, but the workers had no choice but to take baths using buckets of water in the unhygienic toilet stalls. Documented scenes of workers’ living conditions were nothing short of nauseating, yet Khalid al-Sulaiteen—former CEO of one of Qatar’s leading sports organizations—insisted migrant workers inhabited a “comfortable, healthy environment.” When Gumbel insisted he had personally witnessed quite the contrary, al-Sulaiteen refused to comment and called for the interview to conclude. ¹³

Two key issues are apparent here. First, deplorable working and living conditions pose an enormous risk to the health of migrant laborers. Second, relevant FIFA and Qatari authorities are denying, downplaying, and even obscuring this risk, adding insult to injury. Heading into the World Cup, Qatar’s Supreme Committee for Delivery and Legacy—the organization responsible for orchestrating the tournament—put the official death toll of migrant workers at 40. ⁸ Of these, 37 were labeled non-work related deaths. However, Hassan al-Thawadi, head of the Supreme Committee, recently put forward a new figure of 400 to 500 deaths due to World Cup-related construction, but did not fail to add that “health and safety standards on the sites are improving, at least on our sites, the World Cup sites.” ¹⁴ This estimate pales in comparison to the figure of 6,500 South Asian migrant deaths produced by The Guardian, which is grounded in official death statistics from the countries-of-origin of the perished workers and is likely an underestimate. Al-Thawadi dismissed this analysis as fodder for a “sensational headline.” Other officials have criticized the report for passing off all South Asian migrant worker deaths in Qatar that occurred between 2010 and the present as necessarily linked to the World Cup. In reality, goes the argument, a small fraction of the Guardian-reported death toll occurred on stadium construction sites or other World Cup-related projects.

This claim rests on how one chooses to define World Cup-related projects. As Nick McGeehan tells The Guardian, “A very significant proportion of the migrant workers who have died…were only in the country because Qatar won the rights to host the World Cup.” ⁹ The cornucopia of construction projects—hotels, highways, an entire city—to supplement the creation of seven stadiums were all part and parcel of Qatar’s preparation to be the center of the world’s attention as 2022 draws to a close. There is, then, a conflict of representation with regards to the death toll in Qatar. A narrow understanding of what counts as a “World Cup-related death,” perhaps as one that occurs exclusively on stadium construction sites, favors a less damning picture of the human cost of Qatar’s hosting the quadrennial tournament. A broad–more just–interpretation makes evident how the ambitious project Qatar pitched to FIFA in 2010 was not limited to building new stadiums, but rather entailed a wholesale renovation of the country’s east coast. This project was designed to be predatory and exploitative, built upon the backs of one million migrant workers, who were robbed of their rights—and even their lives.

When workers die, interpretive politics inform what is written on their death certificates. Nearly 70% of Indian, Nepali, and Bangladeshi migrant laborer deaths have been attributed to “natural causes” or “cardiac arrest.” ⁹ Dr. David Bailey of the WHO tells Amnesty International: “Everyone dies of respiratory or cardiac failure in the end and these phrases are meaningless without an explanation of a reason why. ‘Natural causes’ is not a sufficient explanation.” ¹⁵ The issue with death certificate designations in Qatar lies less in blatant untruthfulness and more in providing an interpretation so narrow that it obscures broader socio-political realities. By failing to further investigate worker deaths and to produce a more comprehensive interpretation, Qatari officials obscure the relationship between the system of apartheid they govern and worker mortality. Strategically, this absolves employers of liability, which means workers’ families may not receive remittances for perished loved ones.

Illness and its Interpretations

Basic human pathophysiology and recent research from the International Labor Organization make evident that the sudden, premature deaths of thousands of migrant workers in Qatar are spurred by working long hours in oppressive heat and humidity. Interpreting the Qatar Meteorological Department’s data, the ILO claims that workers face “significant” heat stress risk for at least four months out of the year. ¹⁶ One out of three migrant workers in Qatar tested by the ILO had body temperatures exceeding 38ºC. At this point, heat syncope and heat exhaustion can occur; the latter can evolve into heat stroke if not properly treated with rest, hydration, and electrolyte recovery. During heat stroke, body temperatures can exceed 40.5ºC, which can cause multi-organ failure.

Even if the body does not reach the point of heat stroke, repeatedly experiencing internal body temperatures above the normal homeostatic range can lead to organ damage, compromising heart and kidney functionality. In a 2019 study published in Cardiology, nearly one out of every three cardiovascular disease deaths among Nepali migrant workers in Qatar could have been prevented with effective heat protection programs. ¹⁸ Another study in Kidney International Reports highlights that Nepali migrant workers have a higher rate of chronic kidney disease than the Nepali population at large. ¹⁹ Dr. Bishwa Raj Dawadi, who examines death certificates for Nepal’s labor ministry, tells the New York Times about an alarming trend: of the migrant laborers who return home alive, as opposed to in a coffin, many suffer from kidney failure, and die within a few months. ¹⁰ Migrant workers from the Indian Subcontinent are typically healthy men between 20 and 45 years old who pass inspections in their home countries that ensure they are fit for manual labor. Their deaths by the thousands are not a product of any pre-existing health issues, though their death certificates may insinuate so. Rather, sudden cardiac arrest and respiratory failure are inscriptions on the body etched by an exploitative system of labor that strips migrants of their legality (and therefore their rights), rendering them subject to employers’ every demand, no matter how dangerous.

The obfuscation of structural violence in Qatar through framing migrant worker deaths as “natural” exemplifies what Dr. Paul Farmer calls “immodest claims of causality”—interpretations of suffering that counterproductively perpetuate this very suffering by obscuring its roots in broader social and historical forces. ²⁰ However, immodest claims of causality are not limited to Qatar; as Dr. Farmer illustrates throughout his oeuvre, they permeate the study of global public health across universities in the United States and Europe. ²¹ Public health as a discipline has a history of setting epistemic confines around understandings of why some groups experience sicker lives than others, and these confines sustain unfettered racial capitalism rather than challenging it. ²²

For example, Ezekiel Emanuel, architect of the Affordable Care Act and founder of the NIH department of bioethics, published a notable editorial in 2012 effectively arguing that the President’s Emergency Fund for AIDS Relief was not “worth it.” ²³ Emmanuel wrote, “There are other highly effective and lower-cost interventions for the world’s poor”—a claim premised on his belief, conveyed as a sort of authoritative truth, that “health assistance will not, in any plausible scenario, meet the essential health needs of 2 billion people.” He reifies rampant inequality and widespread poverty, which have been sustained by centuries of extractive racial capitalism, ²⁴ as the natural state of the world; consequently, he shifts academic focus away from transforming the global socioeconomic order to guarantee basic human rights and towards pitting global health initiatives—vying for limited funding—against each other. In another such example, a study in PNAS claimed to provide a “complete overview of the transmission dynamics” of the 2014-15 Ebola outbreak in Sierra Leone. ²⁵ It found that living in a densely populated area, in villages with lower/higher average temperatures than its neighbors, near an Ebola treatment center, and/or near a setting with high cropland coverage were associated with a higher risk of contracting EVD. In this “complete overview,” there is no mention of how extraction–of humans and mineral resources–from Sierra Leone has predisposed the region to dire poverty and pressing threats to human health. How colonialism, neocolonialism, structural racism, illicit financial flows, and histories of enslavement have forged contemporary global dynamics of sickness and health remains conveniently unexplored by the disciplines purportedly charged with improving human health worldwide. ²²

In Qatar, the reality of migrant worker deaths is stated from the standpoint of dominant interests. The Supreme Committee for Delivery and Legacy has a not-so-vested interest in minimizing the official death toll of migrant workers in World Cup-related projects; they can do so by defining “World Cup-related” in a narrow manner so as to exclude many thousands of deaths from their jurisdiction. On the death certificates of these thousands of laborers, Qatari officials protect their nation’s elite developers through deliberate myopia, attributing deaths to “natural causes” and “cardiac arrest.” If we find this morally reprehensible, we must grapple with how dominant interpretations of realities in global health also obscure historical, social, political, and economic forces that, if uncovered, would challenge protected affluence. In fact, a limited focus on working conditions in Qatar may be one such example. Framing the authoritarian kafala system as a phenomenon confined within the natural gas-rich emirate ignores the transnational dynamics that it preys on. Without losing sight of the appalling atrocities in Qatar, it is also important to consider what factors have created a pool of migrant laborers for whom life-threatening jobs are paradoxically a lifeline.

More often than not, migrant workers come from dire poverty and are pursuing one of a very limited array of options to provide for their families. They put themselves in significant debt to pay recruitment fees to unscrupulous middlemen who connect laborers with risk-laden jobs thousands of miles away from home. ¹⁰ Their countries-of-origin are among the world’s poorest: well over 1.6 billion people earn less than $6.85 a day across the Indian subcontinent. ³⁹ Diarrheal diseases, neonatal disorders, lower respiratory infections, and tuberculosis—preventable in rich nations—remain leading causes of mortality. ²⁷

In India, nearly 97 million children between the ages of 0 and 17 live in poverty; for every 1,000 children born, 36 will not survive past age 5. ²⁸ One-fourth of the population of Nepal, whose economy is sustained by remittances,10 survive on less than $0.50 a day. Thirty-six percent of Nepalese children under-5 bear the marks of poverty in the form of stunting. ²⁹ Bangladesh and Pakistan face similarly dire realities.

It is worth considering how the redistribution of $45 trillion would impact the standard of living of communities across South Asia. This is the amount of wealth drained from India by the British Empire from 1739 to 1939, as calculated by renowned economist Utsa Patnaik. ²⁶ This figure stems largely from South Asians never having been credited with their gold and forex earnings; steep taxes on colonial subjects which were subsequently used to purchase Indian indigo, wheat, cotton, rice, and opium at low prices; and privatization of communal water sources and grazing land. Historian Mike Davis labels India the “greatest captive market in world history.” ³⁰

Nonetheless, a number of historians such as Niall Ferguson defend British colonialism as a system that brought prosperity to the world. ³¹ Recent research calculates the human toll of this so-called prosperity: nearly 100 million Indians died in entirely preventable famines brought on by the British Empire at the heyday of their dominion, from 1881-1920. ^32,33 During this period, Indian grain exports increased from 3 million to 10 million tons a year; the problem at hand was not that Indians lacked food to begin with, but rather that Britain extracted Indian grain for profit. ²⁴ A similar episode occurred during World War II, when three million more Indians starved to death in West Bengal due to food shortages created by British wartime policy. Winston Churchill allegedly blamed the famine on Indians for “breeding like rabbits,” but continues to be admired by many in the Global North. ³⁴ Indeed, nearly one-third of Britons today are “actively proud” of their nation’s imperial past. ³²

However, English footballers and fans were vocal about Qatar’s human rights abuses, despite FIFA’s resistance to protest.35 For example, the English men’s national team captain, Harry Kane, called for his fellow footballers to “help in any way we can” concerning “important issues” in Qatar. ³⁶ A meaningful start in this respect would be for England to grapple with how its bloody colonial past sustains its present prosperity. Perhaps populace and government alike can support Utsa Patnaik’s proposal that “the advanced capitalist world…set aside a portion of its GDP for unqualified annual transfers to developing countries, especially to the poorest among them.” ²⁶ This way, Global North powers would not simply be criticizing Qatar from a comfortable distance, but also reckoning with their own instrumental role in creating the migrant labor humanitarian crisis.

The goal of Patnaik’s proposal would not be to pit one nation against another—that should be reserved for the football pitch. Rather, reparative action is grounded in solidarity, in fellow-feeling for all human beings, particularly the most oppressed. Such radical empathy entails honest reckoning with history, which makes apparent how widespread deprivation is grounded in the same forces that create protected affluence: not only colonialism, but also—in the case of the Indian subcontinent—casteism, corruption, and ethno-religious conflict.

The human rights atrocities in Qatar hold a mirror up to public health students and practitioners in the Global North, evidencing the consequences of immodest claims of causality. Just like death certificates with minimal explanations of the causes of worker deaths perform ideological and material work that sustain exploitative systems of labor, so do our limited framings of these workers rights abuses, which often fail to look beyond Qatar to transnational and historical dynamics. In general, narrow interpretations of pathological phenomena often sustain the social forces responsible for the said phenomena. However, by expanding our understanding of the causes of ill-health to encompass large-scale predatory forces such as colonialism and extractive racial capitalism, we also embrace the necessity of large-scale interventions—such as reparations and redistributive justice—in constructing a healthy, equitable world.

About the authors

Dr. Gene Richardson is an Assistant Professor of Global Health and Social Medicine at Harvard Medical School. He received his MD from Cornell University Medical College and his Ph.D. in Anthropology from Stanford University; he has also completed his residency in Internal Medicine and a fellowship in Infectious Diseases and Geographic Medicine at Stanford University Medical Center.

Smit Chitre is a research assistant for Dr. Richardson and is currently working on research that focuses on climate change and global socioeconomic injustice and their effects on human health. He received his BA in Medical Anthropology from Harvard University (Class ‘21) and will be attending Harvard Medical School this coming fall to pursue his research interests further.

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