Deathly Subsistence

Devendher Kasholla was set to return home in three weeks, to celebrate his older brother’s wedding. A native of Rampur, in the Nizamabad district of Telangana, Devendher had worked variously as a carpenter, mason and steel fixer at a labour-supply company in Saudi Arabia, since 2013. The earnings Devendher sent home, his mother, Rukmini Kasholla, used to build a new brick and cement home. He lived in a private dormitory that he shared with three other workers in the city of Dammam. Pradeep, Devendher’s roommate, described him as a hard-working and principled person.

On 9 March 2017, sometime just after midnight, Devendher gasped loudly in his sleep, raised one of his hands in the air and dropped back on his metal bed. He was declared dead by 1.40 am that morning, about an hour after he had been rushed to the Arawdha General Hospital. The death certificate said, “collapse of the heart and respiratory system due to hidden causes.” In medical terminology this means his heart had stopped beating but it was unclear to the doctor why. Devendher was 26 years old.

When I spoke to Rukmini in October last year, she sat through the entire interview with a photograph in her hand. The image was of her son posing in front of a white mini-van. It was the most recent photograph she had of him. Like countless Indian migrant labourers who move to other countries in the hope of a better livelihood, Devendher’s family had scraped together Rs 2,50,000 to send him to Saudi Arabia. His father had passed away a decade ago from a stroke and his brother worked as a daily-wage labourer in Hyderabad. Once in Saudi Arabia, Devendher worked twelve hours a day for six days a week, from 7 am to 7 pm, and was paid 12 riyals an hour—roughly Rs 240 as per today’s currency exchange rate. He made approximately 2000 riyals a month after rent, food and other expenses. Rukmini would tell me that to deal with the time difference, she stayed up until 11 pm each night to speak to Devendher who used to return to his dorm around 8.30 pm. “He never complained about his health or of any illness,” Rukmini told me, “He would have told me if he was suffering from something.”

As per government records, Devendher was one among 33,930 Indians who passed away between January 2014 and October 2019—a rate of roughly sixteen deaths each day—in the Arab Gulf, a group of nations including Bahrain, Kuwait, Oman, Qatar, Saudi Arabia and the United Arab Emirates. Data collated from various sources such as right to information applications, questions from Lok Sabha proceedings, websites and relevant departments in embassies, press releases and media investigations, show that a majority of deaths in the region were caused by cardiac arrests and related causes. For instance, in 2018, 59 percent of Indian deaths in the UAE were due to heart attacks.

The Indian government, however, appears to have no idea how seemingly healthy young and middle-aged workers were dying from heart and respiratory failures in the Gulf. Despite ministers declaring in Parliament that most deaths in the Gulf occur due to “natural causes,” the ministry of external affairs and Indian embassies in each of the Gulf countries had not conducted any research or investigations into the deaths of Indian nationals abroad. In the overwhelming majority of cases of workers who die from cardiac complications, autopsies are never performed to determine what caused their death.

New research, variously conducted by cardiologists, climatologists, journalists and academics shows that migrant labourers are being worked to the bone under blistering temperatures in the Gulf. The dangerous levels of heat exposure and stress put immense pressure on the cardiovascular system, which leads to heart attacks and other cardiovascular deaths.

Climate change is only exacerbating these risks. It will bring longer, hotter summers to workplaces around the world and men, women and children working on construction sites and farms in tropical countries are likely to be among those worst affected. Even where there are no deaths, excessive heat amplifies pre-existing health conditions including respiratory, cerebral, and cardiovascular diseases. High temperatures also make it difficult for people to work at full capacity or work at all, undermining their security, health and well-being. “Working on a Warmer Planet,” a 2019 International Labour Organization report, studying the impact of heat stress and labour productivity, estimated that the total financial loss due to heat stress would reach $2,400 billion by 2030.

Despite all of this, apart from the annual death toll, the Indian government has consistently denied any access to details about who these people were, how old they were, where they were employed and how they died.

Last November and December, I filed RTIs seeking details from the ministry of external affairs and Indian embassies in the Arab Gulf about Indian nationals who had died between 2014 and 2019, including their names, ages, sex, occupation and causes of death. The ministry provided some limited information, including a state-wise breakup of deaths based on the origin of the worker, between 2016 and 2018, for each Gulf country. They classified the total number of deaths each year under five broad categories: “natural causes,” “road accidents,” “occupational accidents,” “suicides” and “other causes.” But the government did not provide any demographic or employment information.

Indian embassies were even less forthcoming. Bahrain, Oman, Qatar and Saudi Arabia denied information under section 8 of the RTI Act 2005, noting the data sought is an “unreasonable invasion of privacy” or had “no relationship to any public activity or interest.” Missions in Saudi Arabia, United Arab Emirates and Qatar provided only the total number of deaths each year. The embassy of Kuwait provides some limited information about migrant deaths on their website. 

Clearly, I was not the only one to be faced with these obstacles. In August 2018, the Commonwealth Human Rights Initiative, an NGO based in Delhi, began their equally frustrating investigation into gathering information on the death of migrant workers abroad through official channels. It utilised the RTI law to seek information on the causes of deaths and individual information of deceased Indian workers from 2012 onwards. The ministry of external affairs transferred their application to the Indian embassies in the Gulf. In response, the embassies in Bahrain, Oman and Qatar provided annual figures of Indian deaths. The mission in Saudi Arabia provided data at the first appeal stage after the first request was rejected. The embassies’ rationale behind providing only annual death figures—either the data was in a disaggregate form or that any personal information about the workers would be in violation of the RTI Act. “What use is embassies providing the total numbers of deaths each year if they hide basic details about worker ages, their jobs and the causes of their deaths?” Venkatesh Nayak, programme head of the access to information programme at CHRI, asked me.

The embassy in Abu Dhabi has not provided the CHRI any data yet and the application is pending at the second appeal stage. The mission in Kuwait pointed CHRI to their website noting that the embassy uploaded a monthly list of Indian nationals who died in Kuwait. However, the monthly list contains names, ages, sex and causes of death of Indian nationals from July 2014 to December 2017. Even here, there are no details on workers’ occupations. Since then, the embassy has stopped uploading deceased worker lists, and now only death toll numbers are uploaded each month. 

Soon after CHRI sent their applications, the Indian embassies in Oman and Bahrain uploaded lists of deceased nationals on their website. Like Kuwait, the Bahrain mission provided the names, ages, sex and causes of deaths of deceased nationals between 2014 and 2018 but does not provide details of worker occupations. The mission has not provided any figures for 2019 or 2020. The embassy in Oman also provided information including the name, passport number and date of death of Indian nationals from June 2017 onwards but does not list the age, occupation and cause of death.

In August 2019, Gulf News, a newspaper published in the Emirates, reported the deaths of Indian nationals in Abu Dhabi based on numbers released by the Indian embassy in the Gulf state. In the first half of that year, the embassy noted that 131 out of 182 deaths of Indians in Abu Dhabi were caused by heart attacks. Of these heart attack victims, 43 percent were below 40 years of age. The embassy told the newspaper that the Indian mission had commissioned an analysis on deaths of Indian nationals “out of concern” and the results “came as a shock” to those involved.

Last December, three months after the information disclosure to the newspaper, I requested detailed information on migrant-worker deaths from the Indian mission in Abu Dhabi via an RTI application, but it said, “the information was not available in the format sought” and efforts to provide the data “would disproportionately divert the resources of the Indian mission.” Nayak said “The government is adopting an approach of secrecy and privacy over preventing unexplained deaths abroad.”

According to the information I received from another RTI application filed in November 2019, over sixty six percent of the Indian citizens who died in the Gulf between 2016 and 2018—11,874 out of 17,930—died from “natural causes.” Interestingly however, compared against the death certificates issued by the Gulf government, there are revealing discrepancies.

The cause of death is listed on the death certificates, which is usually determined by a physical examination of the body. The fragmented data from at least three embassies—Kuwait, Bahrain and the UAE—suggests that a vast majority of the death certificates may have listed the causes of deaths as “cardiac arrest” or other cardiovascular and respiratory conditions. It is not possible, however, to ascertain how many individuals were employed in the construction sector or in other physically demanding jobs because the Indian government does not categorise deaths by occupation. 

I found that in several instances, the Gulf governments classify deaths, including cardiac arrests, but it is registered by the Indian government as occurring due to “natural causes”—a broad spectrum of possible modes including cardiac arrest, respiratory failure and “sickness.” Five out the six death certificates I reviewed of migrants who had died from “natural causes” had ambiguous causes of deaths listed on their death certificates. These included reasons like “heart and breathing stopped,” “concealed illness,” “collapse of heart and respiratory systems due to hidden causes” and “cardiac arrest of unknown reason.” 

In all the Gulf countries, except Oman, autopsies or post-mortem examinations are carried out only to investigate deaths that are clearly suspicious such as murders, suicides or other “unnatural” deaths. In Oman, if the death did not occur in a hospital, family members can request for a post-mortem to be conducted. Deaths of workers caused by heart attacks are typically categorised under “natural causes” and their bodies are usually never investigated. 

“Under Islam, countries do not conduct autopsies unless it is absolutely necessary and usually related to a criminal or legal case,” Ray Jureidini, a research professor on migrant-worker rights, violations and reform in the Middle East at the Hamad Bin Khalifa University in Qatar, told me. “But this is an issue that must be explored.” 

 

In October last year, I travelled to Telangana to speak to migrant worker families who had lost loved ones in the Gulf from cardiovascular and respiratory causes. A local NGO helped put me in contact with these families. Apart from understanding more about who these workers were, I also wanted to know how the families found out about their deaths or if they knew the circumstances in which they had occurred. Because detailed investigations are not available, it is impossible to ascertain whether any of the men whose deaths I was revisiting died from exposure to heat stress, work stress, from pre-existing medical conditions or other causes. None of the family members, including mothers, fathers, sisters and wives had any reliable information about how their loved ones died.

One afternoon, I sat with Ponnam Vasantha in the front room of her house in Karimnagar. On the wall behind us was a photograph of her spouse adorned with a thin jasmine garland. She told me that she received her husband’s coffin and a parcel carrying his belongings between April and May 2017 from Saudi Arabia. The courier had listed the items Vasantha should expect to find in the package: two blankets, a shoulder bag, a bottle of hair oil, a Tang bottle, a pair of slippers, a bed sheet, thirteen T-shirts, a hair trimmer and a handbag. Her husband’s possessions, valued at a total of 120 dollars as per the currency exchange rate then.

Ponnam Satyanarayana, Vasantha’s husband, had died of a heart attack in March 2017. On the morning he died, Satyanarayana was painting a wall. According to his medical report, he felt dizzy, sat down, and, within minutes, lost consciousness. “48-year old Indian man brought by relatives from his work,” the report read. “No complaint of chest pain, no vomit, only dizzy.” His death certificate recorded the cause of death as “heart and breathing stopped.” Satyanarayana had not been paid in eight months and was owed over 20,000 riyals—approximately Rs 4,00,000—in wages and end-of-service benefits. His residence permit, an identity document that allows migrants to work and travel in Saudi Arabia, had expired and he was pursuing a wage claim against his employer in court.

Vasantha told me that her husband was stressed in the months leading to his death. “He had no medical history,” she said. “He had cavities and sometimes caught a cold or fever but otherwise he was healthy.” She added, “The court case wore him down.”

An estimated 8.5 million Indians live in the Gulf on short-term employment and visit visas. The majority of them work blue-collar jobs as drivers, labourers, domestic workers, cleaners, waiters and salespersons. They sweep streets, shovel dirt, push wheel barrows, level concrete and serve guests, all in an attempt to send their children to school, support their families and clear their debts back home in India. India is the world leader in remittances. It received over 257 billion dollars in receipts from six Gulf states between 2012 and 2018; more than half the global remittances of $488 billion received for the same period.

Gulf jobs have enabled poor and unemployed workers to find work, improve their skills, build new friendships and explore new cultures. For many workers, the Gulf countries are a second home. Unsurprisingly, many workers take huge financials risks to get a chance at improving the standard of living for their families. Balraju Karamkanti, from Dharmaraopet village in Kamareddy district, Telangana, is a case in point.

In 2017, Karamkanti paid Rs 65,000 to a recruiter for a job in Oman. To be able to afford his travel, Karamkanti borrowed the full sum from his relatives at a 36 percent annual interest rate. This was the third time Karamkanti was migrating to the Gulf, after two previous eighteen-month stints in the United Arab Emirates and Saudi Arabia. Every four months, Karamkanti sent Gangamani, his wife, Rs 50,000 to buy provisions and send their two boys to private school.  But when he died in 2019, Karamkanti had yet to clear Rs 15,000 of his recruitment loan and pending interest. “I found out when a friend of his in Muscat sent my mother-in-law a message and a photo of the body,” Gangamani told me.

The workers often make these journeys at great personal risk, only to face humiliation in a hostile work environment on the other end. The labour-rights record of the Gulf countries has been severely criticised by a number of independent human-rights organisations and the international media. According to various studies by international NGOs such as Human Rights Watch and Amnesty International, exploitative employers have abused many workers by charging them illegal recruitment fees, not paying them wages, working them long hours, denying them access to medical care, and trapping them in forced labour situations. Workers have also faced physical, and sometimes, sexual abuse.

The Indian government in the meantime seems blissfully ignorant about these conditions. Over the last five years, various members of parliament have asked the ministry of external affairs about migrant-worker fatalities in the Arab Gulf. When legislators probe for details, the MEA assuages legislators by providing the annual death count but withholds any relevant information about the workers. For instance, in 2016, VK Singh, a former minister of state in the ministry of external affairs told Parliament that, “no relation could be established between cases of demise of Indian migrant workers and employment in hazardous occupations.” He added, “The deaths of migrant workers are mostly due to natural causes and traffic accidents.” He was responding to a question by B Senguttuvan, a former Tamil Nadu legislator, who had asked whether the high mortality rate amongst Indians living in the Gulf was due to them being employed in hazardous occupations.

In December 2018, two Lok Sabha MPs, Malyadri Sriram, from the Telugu Desam Party, and Dharam Vira, of the Aam Aadmi Party, asked the MEA “whether an alarming number of Indians die in Gulf countries?” If deaths were alarming, they asked for details. In response, the Ministry of external affairs released annual figures on number of fatalities in each of the Gulf countries from 2014 to 2018. They did not clarify if deaths were alarming. 

 

To be fit for employment in the Gulf, workers must be certified healthy in medical screening tests prior to their departure. Migrants are examined again as a precondition for residency permits in the country of destination. Pre-departure medical tests require laboratory and clinical tests for HIV-AIDS, tuberculosis, hypertension, cardiac problems, cancer, diabetes, opiates and pregnancy.

However, research in recent years has revealed that migrant labourers employed in the Gulf heat can be at risk of extreme heat stress—a condition brought on by strenuous physical work in extremely hot and humid temperatures. This can cause heart attacks and other fatal cardiovascular complications.

There are regulations in all of the six Gulf countries prohibiting manual labour in unshaded locations in the summer months, usually for a few hours between 11 am and 4 pm from June to August each year—a measure that host countries claim reduce heat-related impacts. However, an investigation by the Guardian reported thousands of workers in Qatar and United Arab Emirates were exposed to potentially fatal levels of heat stress even outside the summer work ban period for up to four months each year.

A research study measuring heat stress exposure in Saudi Arabia, funded partly by the Saudi government, conducted on ten construction sites in the Al-Ahsa province between June and September 2016, found that the highest intensity of heat exposure on migrant labourers—all Indian origin—was felt between 9 am and 12 pm, hours not accounted for in the summer work ban. Saudi Arabia, Qatar and UAE share temperature conditions broadly similar to other Gulf states including Oman, Bahrain and Kuwait.

In 2019, the Cardiology Journal published a paper titled, “Heat Stress Impacts on Cardiac Mortality in Nepali Migrant Workers in Qatar.” The paper found evidence that extreme heat stress contributed to the deaths of hundreds of Nepali workers in Qatar. The authors, which included prominent climatologists and cardiologists, found it “likely that a large proportion’ of the cardiovascular deaths in the summer were caused by serious heat stroke.”

This phenomenon is not restricted to Indian or Nepali migrants. In 2018, nearly four thousand Bangladeshi workers died in the Gulf, more than any time previously, in fourteen years. The majority of them died from strokes and sudden heart attacks and were not over 35 years old. Like India, there have been no studies to determine the causes of migrant deaths. Sudden cardiac arrests and kidney health problems have also been reported among Nepali worker populations in Malaysia. Because post-mortems are not conducted and worker medical histories only poorly recorded, the causes of sudden cardiac arrests in Malaysia-bound workers were difficult to identify.

The climate crisis is expected to spur work-related heat stress, as both the number of hot work days and heat intensity are likely to escalate. I found that in 30 out of 32 Gulf cities the average temperature in 2019 was 1.65 Celsius warmer compared to historical temperatures averages between 1981 and 2010. “Based on rising heat conditions in the Gulf countries, it is clear that climate change is already contributing to these health risks and could in the future get worse,” Tord Kjellstrom, a professor and one of the co-authors of the Cardiology Journal study, told me. 

 

Laxmi Dandugula, from Raikal village in Jagtial district in Telangana, told me that Janardhan, her husband, employed for close to fourteen months in Qatar, died from “acute respiratory failure” in March 2018. Janardhan was 34 years old. Laxmi is a daily-wage worker and has two children. Since Janardhan’s death, she has found it difficult to support her family. “I make 150 to 200 rupees a day to roll beedis,” Laxmi said, adding, “but I don’t have work for weeks at a time.” Laxmi is paid Rs 2000 a month from a state widow pension scheme but it is not sufficient. “I have not paid my son’s school fees for months and the school has threatened to expel him if we don’t pay soon.”

Laxmi told me Janardhan worked on a construction site. This was all she knew. Both she and her husband’s mother and older brother, did not know which company he worked for, where he lived, and even what job he did. During my interview, the Dandugulas disputed amongst themselves regarding Janardhan’s occupation. Laxmi said he was a labourer, her in-laws maintained he was a security guard. They seemed to accept that Janardhan was employed on a construction site and worked long and irregular hours.

It wasn’t that that the families were not speaking to each other. In fact, Laxmi and her husband spoke almost every day on Whatsapp. “He would say, ‘I’m fine, how are you?’,” Laxmi said. “He asked about the kids and he asked me to take care of them.” But they never discussed his job or his life in Qatar. “Living away from your spouse and children is stressful. So, you won’t say anything that is likely to upset the family,” she told me.

When Laxmi found out about her husband’s demise, hours after she last spoke to him, she wrote a letter to the Telangana government asking for assistance with the repatriation of the body. On 7 March 2018, she wrote and explained that her husband had died of heart problem in Qatar. “Please we are very poor,” she pleaded, and urged the authorities to help transfer her husband’s body to India.

To repatriate the bodies, all the six widowed families I spoke to in India sent notarised power of attorneys authorising friends, relatives, neighbours or the worker’s colleagues to complete the paperwork on their behalf. To help register the death and transport the body, the family’s representatives were required to submit copies of death certificates, passport and visa copies of the deceased individual, a notarised consent letter, and an embalming certificate and clearance from the custom department to transport the body. 

“I did what I was told,” Laxmi said, “We wanted to bring the body back.” I asked her if she had thought about seeking a post-mortem. “At the time, nobody was talking about a post-mortem,” Laxmi replied, “I didn’t know what to do.”

Like Laxmi, all of the families I spoke to were stressed about completing paperwork and coordinating the return of the body. None of them recalled speaking to a representative from the Indian embassy either about the death or how it might have been caused. All of them had limited information about how their loved ones died.

For instance, on 10 May 2019, Karamkanti collapsed and died in a public bus in Oman. His death certificate states that he died from “cardiac arrest from unknown reason.” Gangamani, who now is dependent on a 200-rupee daily wage as an agriculture worker and a life insurance sum of Rs 250,000 rupees, told me his death was shocking and sudden. “He was fit and healthy,” she told me. “He left audio messages for us on Whatsapp everyday but never complained of being sick.” In the notarised affidavit, Gangamani sent the Indian embassy, she explicitly asked for a post-mortem to not be conducted.

“Desperate families are not in a position to make calculations about whether they want to submit the body for a post-mortem,” Bheem Reddy, president of the Emigrants Welfare Forum, a migrant-rights NGO in Telangana told me. “Some families may not know what a post-mortem is, and even if they do, may wish to preserve the body to commit last rites. A post-mortem can delay the repatriation of the body.”

This January, the Nepal Supreme Court ordered the Nepal government to investigate cases of its nationals dying abroad, including ensuring mandatory post-mortems for all deceased workers. The court directed the government to assist family members with the repatriation of the body, revise bilateral agreements between Nepal and Gulf countries to provide insurance and compensation to families and mitigate risks of worker deaths.

Bilateral labour agreements between India and each of the Gulf states provide only cursory protections for nationals abroad and lays out broad guidelines on recruitment and employment of Indian nationals abroad. These relate to fair recruitment processes, employment contracts, employment disputes and right to remit savings back to India.

“Like Nepal, the Indian government can push for mandatory post-mortem investigations in bilateral labour agreements,” Jureidini said. “They could also consider embedding these requirements into employment contracts such that if a worker dies, then there has to be a compulsory medical investigation. Something like organ donation notifications on drivers licences.” However, Jureidini was apprehensive about the Gulf response to such measures. “I am not certain that Gulf countries will appreciate formal requests from origin countries demanding post-mortems. Perhaps, if the request were to come from a member of the worker’s family, next of kin, then it may be considered more acceptable.”

I asked all Indian embassies in the Gulf about the number of deceased Indian nationals in the countries on whom a post-mortem was carried out. Except for the Indian embassies in Bahrain and Kuwait, none of the other embassies provided this information citing that the information was “not available in their records.”  Although post-mortems are conducted by the host country, it is worrying that the government of India does not maintain records of autopsies conducted on its own nationals.

The embassy of Kuwait said that a primary post-mortem is conducted on “all people who have died in Kuwait” but did not clarify what a primary post-mortem was, and if it was in fact, any different from an external examination by the coroner to determine the cause of the death.

The embassy in Bahrain provided annual figures on the number of post-mortems conducted in Bahrain for the years 2016 to 2019. Based on data available regarding the number of deaths in the country for those years, it appears that between 2016 and 2018, a post-mortem examination was conducted on a mere 3.5 percent of Indians who had died in Bahrain.

“Sometimes, if you do a post-mortem you may not find anything that is obvious because the effects of heat are not just on the heart but it’s also on the brain and also the whole control system of how the body functions,” Kjellstrom, who is also a consultant on environmental and occupational health for the United Nations, told me. “It may be more useful to understand from the deceased worker’s colleagues and supervisors the symptoms the deceased worker experienced on the day of the death and to check if the worker experienced symptoms associated with extreme heat stress.”

In the same set of RTIs, I asked the ministry of external affairs and the respective embassies in the Gulf if they had conducted any research related to the mortality of Indian workers in the region. Further, I specifically asked if the MEA or the Indian missions had conducted studies on deaths of Indians caused by heart attacks or other cardiovascular related diseases.

The Ministry of external affairs said it did not have any information about research or studies conducted on mortality of Indians abroad but noted that Indian embassies in the Gulf could possess more specific information. The embassies in Oman noted that it, “did not undertake any activities such as studies/research/analyses with regard to deaths of Indian workers.” The mission in Qatar said, “no study or research has been commissioned or conducted by the Embassy in this matter.” The embassy in Saudi Arabia said, “requested information is not available in the records of the embassy.” UAE and Bahrain said simply the information was “not available,” possibly denoting that no studies had been conducted. Kuwait refused to provide a response.

“What still needs to be confirmed is that these deaths are caused by occupational heat stress. This has not been established medically yet and the main problem is the lack of access to all the data on migrant worker deaths and the lack of a proper epidemiological study,” Jureidini told me. “We don’t have any demographic information about the ages of the deceased workers or details of their jobs or worksites. We don’t know if they died in their dormitories or collapsed at the workplace. We have no information about their medical histories. There’s so much we don’t know. And yet, what we do know is that there is no way a young man in his twenties or thirties who dies in his sleep can be classified as a natural death. Most importantly, we need to know why some men die but others, working alongside them, do not die. Maybe there is a genetic element involved.”

A 2015 survey on worker health among Bangladeshi, Pakistani and Indian men in the United Arab Emirates reported a high incidence of hypertension, obesity, diabetes and cardiac problems. Researchers noted that 76 percent of participants with hypertension and 44 percent with diabetes were not aware of their conditions. Blood pressure and diabetes peaked in drivers, shopkeepers, salesmen and construction workers with weight gains being attributed to refined carbohydrates, soft drinks and snacks—foods rich in both energy and fat. Men who lived longer in the UAE were more likely to be more overweight and obese than new migrants.

Based on the data supplied by the MEA, I analysed the number of fatalities in each of the six Gulf states against the Indian population in each Gulf state in 2018—the only year for which population estimates are available. The data I accessed revealed that the mortality rate of Indians in Saudi Arabia was over ninety per 100,000 people—50 percent higher than the regional average of 60.4. Oman, at 76.3, Bahrain, at 73.7, and Kuwait, at 70.9, had above average mortality rates. The UAE, at 56.7, and Qatar, at 41.2 had the lowest mortality rates among the six Gulf states. In the absence of any further data, it was not possible to estimate why Indians in Saudi Arabia were 50 percent more likely to die in the country than in the rest of the Gulf region.

“What is needed urgently is a comprehensive scientific epidemiological study into migrant worker deaths combining experts and medical doctors from countries like Qatar and India,” Kjellstrom said. “Workplaces in the Gulf are not very different from workplaces in many parts of India and these studies could help not only protect thousands and thousands of workers in the Gulf but also in India.” He added that “serious health problems like heat stress could be seriously reduced or eliminated with proper investigations.”

Last October, a study commissioned by the ILO and the Qatar government found workers employed outdoors are likely working under significant heat stress for at least four months of the year. The report which monitored 125 workers for 5500 work hours, on a World Cup Football Stadium and a farm in Qatar, found that enterprises in the country could significantly reduce the risk of heat stress by applying a comprehensive range of mitigation strategies. The Cardiology Journal study found that as many as 200 of the 571 cardiovascular deaths during 2009–2017 could have been prevented if an effective heat mitigation and protection measures had been enforced.

Women like Rukmini Kasholla then would not have lost their sons. The Kashollas migrated from Tirupur, in Tamil Nadu to Nizamabad in the 1950s to work as rock cutters on the Sriram Sagar dam on the Godavari river. Once the dam was completed, the Kashollas stayed on. Devendher was the third generation of Kashollas in Nizamabad, and used to work as an auto-driver before he moved to Saudi Arabia. As Rukimini walked through her village of Rampur, she could not help but mourn the cruel paradox. “When my son’s friends return from the Gulf, they come in cars,” Rukmini told me, “My son came in a coffin.”