In-Depth Ethical Analysis of the COVID-19 Vaccine Rollout for Migrant Workers in the Gulf Countries

Abstract

During the initial COVID-19 vaccine rollout, supplies were scarce, necessitating rationing. Gulf countries, hosting millions of migrant workers, prioritized nationals over migrants for vaccination. As it turned out, many migrant workers found themselves waiting behind nationals to get vaccinated for COVID-19. Here, we discuss the public health ethical concerns surrounding this approach and call for fair and inclusive vaccine allocation policies. First, we examine global justice through the lens of statism, where distributive justice applies only to sovereign state members, and cosmopolitanism, advocating equal justice distribution for all humans. We propose a cooperativist perspective, suggesting that new justice obligations can arise between people beyond national ties. In cases of mutually beneficial cooperation, such as migrant workers contributing to a nation's economy, equal concern for all parties is required. Second, the principle of reciprocity further supports this stance, as migrants significantly contribute to host countries’ societies and economies. Additional ethical principles—equity, utilitarianism, solidarity, and nondiscrimination—are essentially violated when excluding non-nationals in vaccine distribution. Finally, we argue that prioritizing nationals over migrants is not only ethically indefensible, but it also fails to ensure full protection for nationals and hampers efforts to curb COVID-19 community spread.

International migration is an integral part of global economic and social development. It is estimated that 3.3 percent of the world's population is living outside their home country. ¹ According to the International Labor Organization, a migrant worker is defined as any person who migrates from one country to another, with or without their family, in order to pursue employment or any other income-generating activity. ² Migrant workers provide the necessary labor and skills that are needed in the host countries. However, migrant workers are commonly identified as a vulnerable subpopulation in terms of their health status, as they face unique challenges that increase their susceptibility to health risks and adversities. ³ They have language and cultural barriers. They are usually left out from protections by public policies while facing precarious work conditions characterized by dirty and dangerous work conditions, long hours, less pay, and suboptimal occupational safety and health training. ⁴ They tend to take more risks on the job and cannot complain about unsafe working conditions due to job insecurities and threats of deportation. ⁵ Their health vulnerability stems from stressors that overlap from the workplace, the community, and the environment, making migrants more inclined to face additional adverse health issues not faced by non-migrants. ⁶

The Gulf countries—Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, and the United Arab Emirates—host millions of migrant workers. Due to the oil boom in the 1960s in these countries, many South Asian and other Arab migrants came to these Gulf countries to prosper in the newly found wealth. ⁷ To this day, migrants constitute a very large percentage of the population. In 2018, the Gulf Labor Markets, Migration and Population Program reported that the percentage of non-nationals in the Gulf countries varied widely. The country with the lowest percentage of non-nationals was Saudi Arabia at 37.8 percent, followed by Oman at 44 percent, Bahrain at 54.9 percent, Kuwait at 69.8 percent, and Qatar and the United Arab Emirates with the highest percentages at 87.3 percent and 87.4 percent, respectively. ⁸ The majority of migrant workers are middle-aged males who migrate unaccompanied to the host country.^9,10 Often, there is no official union nor a political party that would amplify the voice of migrant workers or provide additional protection in the Gulf countries.

The spread of coronavirus disease 2019 (COVID-19) has put migrant workers at even greater risks in the Gulf countries, unlike ever before. With ailing economies, a large proportion of migrant workers faced unemployment, income reduction, and furloughs. Many have defaulted on their rent and were unable to meet their daily needs. Uncontrolled outbreaks took place within spatially segregated clusters of migrant workers. This was attributed to poor housing conditions, ineffective public health messaging due to language barriers, and low turnout to testing stations and COVID-19 treatment centers. ⁶ Such outbreaks resulted in an overwhelmed health care systems and devastatingly significant increase in the numbers of deaths. In 2020, migrant workers in Kuwait saw a 72 percent increase in mortality compared to the historical mortality baseline. ¹¹ Furthermore, economic policies and stimulus packages to alleviate the financial impact COVID-19 has had on the livelihood of workers have largely excluded migrant workers. All these stressors triggered by the pandemic were extremely difficult to address, especially in the presence of a xenophobic political climate.

Once COVID-19 vaccines were authorized for use, vaccines were scarce initially due to the backlog of mass production and distribution. Due to the insufficient supply of vaccines, effective and ethical rationing would have been critical to ensuring equitable access to vaccines. Further, vaccine allocation guidelines grounded in ethical theory and distribution would have assisted in a fair rollout for all population groups, including migrant workers.

In this article, we first analyze the concept of global justice through the lens of statism and cosmopolitanism. Then, we examine the implications of ethical principles of reciprocity, equity, utilitarianism, solidarity, and nondiscrimination faced by the host countries in the wake of the COVID-19 vaccine rollout, specifically prioritizing nationals over non-nationals, which saw migrant workers being left behind in accessing preventative public health measures.

Vaccine Prioritization in the Gulf Countries

Like every country in the world, the Gulf governments and their health authorities have been confronted with the question of fair distribution of vaccines. Historically, official policies have favored nationals over non-national residents. Far too often, Gulf countries consider citizenship as a criterion for priority-setting in health care.

Under current health care systems, all Gulf nationals are provided health services that are free of cost by public hospitals. ¹² However, access and coverage for non-national residents vary across countries, ranging from emergency-only care to segregated outpatient clinics. In these clinics, non-national residents may be treated in separate facilities and at different times of day (eg, afternoon clinics only), which differs from the care provided to national residents. ¹³

In October 2020, Kuwait's Ministry of Health announced that it would initially be restricting influenza and pneumococcal winter vaccines to Kuwaitis only. ¹⁴ Subsequently, in the COVID-19 vaccine rollout of 2021, Kuwait also restricted eligibility to nationals in the initial phases of the distribution. While this was anecdotally reported and verified by a number of individual and media reports,^15–18 the Ministry of Health did not officially declare favoritism of the COVID-19 vaccines, nor did it cite the reasons behind this restriction.

Ethical Considerations

Global Justice: Cosmopolitanism versus Statism

The debate on vaccine allocation for migrant workers is underscored by a fundamental question: What standards of justice do nations owe their non-national residents? Our article is concerned with the concept of justice as it relates to the fair distribution of socially controllable factors that impact population health. ¹⁹ On the two polar ends of the spectrum lie the cosmopolitan and statist views. The cosmopolitan would contend that all human beings, regardless of nationality, are owed the same degree of consideration in the distribution of justice based on their shared humanity alone. ¹⁹ The arbitrary assignment of nationality at birth should have no bearing on rights to justice, and the failure to provide justice on a global scale stems from the absence of an instrument to enforce these norms.

The statist, on the other hand, maintains that only under the conditions of a sovereign state do requirements for distributive justice apply. This strong view by Nagel acknowledges that there are basic human rights owed to all people on the basis of shared humanity, such as freedom from torture and war. ²⁰ It contends, however, that norms of distributive justice beyond humanitarianism are only triggered in the context of a sovereign state and only apply to members of that state. The key criterion that distinguishes a nation state is that, with the exception of emigration, citizens are not able to opt out of participating. Because the norms of the sovereign state are coercively imposed while claiming to be imposed for the benefit of citizens, it is morally imperative that the state formulates these rules in a way that it is equitable to all of its members. Any inequities that could be avoided are deemed ethically unacceptable, but only for members of the state.

The implications of these two viewpoints on vaccine allocation for migrants are starkly different. The cosmopolitan would maintain that migrant workers would have been owed the same consideration as nationals based on their shared humanity alone. As such a system exists through which justice could be served, the governments of these states have a duty to include migrant workers. On the other hand, from the statist point of view, only citizens of the Gulf countries are owed distributive justice and while the state may choose to provide migrant workers with health care and other resources, this is done out of a sense of charity rather than moral obligation.

Cooperativism

Cohen and Sabel argue that framing global justice as a statist versus cosmopolitan debate represents a false dichotomy. ²¹ They reject Nagel's strong statist position. They argue that relationships between people not tied to a nation can arise that create new obligations of justice beyond basic humanitarianism. As associations between people become more complex, so too do demands of justice on a sliding scale.

They offer three conditions that trigger norms beyond basic humanitarian justice without meeting the definition of a state offered by Nagel. Institutionalism is the view that the existence of an institution tasked with distributing a good (ie, health) “is necessary and sufficient to require that the institution meet the obligation of equal concern”. ²¹ Interdependence is the view that any time the well-being of one group is dependent on decisions made by another, and vice versa, equal concern is due. The Cooperativist view is that any mutually beneficial cooperation guided by rules requires that equal concern for all parties be applied. When the organizing body has the power to set rules that improve the well-being of all parties involved, but instead chooses to set rules that fail to consider the needs of one group, it is shirking its ethical responsibilities.

The Cooperativist perspective presents a useful framework for the consideration of the inclusion of migrant workers in vaccine allocation strategies. If we argue that migrant workers have voluntarily entered into their work agreements and therefore lack claims to egalitarian justice, it is also true that they are active members in a cooperative system. The Gulf countries’ migration policies are not implemented for the sake of charity, but for mutual benefit. Migrants agree to this arrangement to enhance their own lot in life, but the countries also benefit greatly from their contributions to society. As the “rule setters” in this cooperative agreement, the Gulf states have had an ethical obligation to consider the needs of migrant workers when developing their policies, including vaccine allocation policy. However, once they failed to do so, they have shirked their ethical responsibilities in vaccine distribution. If the urgent needs of the less advantaged group could be addressed without significantly compromising the benefits to the more advantaged group, the cooperativist would argue that they ought to be. While achieving a completely egalitarian distribution to nationals and non-nationals may be hard, to exclude migrant workers entirely would be unjust. In other words, this viewpoint does not ethically encompass the duties ought to by the Gulf countries onto all residents as described by the cooperativist.

If you concede that migrant workers were owed some level of consideration of justice in the Gulf countries, the question remains of exactly what degree of consideration they should have been given in the vaccine allocation strategy.

Daniels and Ladin have argued that immigrants, as contributing members of society through their labor and other aspects of community membership, “ought to be eligible for the benefits their contributions make possible” under the principle of reciprocity. ²² Migrants should generally be credited not only for their contributions to the economy, but also more generally to their community by way of participation in various religious and civic activities, which add to the cultural aspects of host countries.

The case for reciprocity was and currently is even stronger for migrant workers in the Gulf states. There are no differences between nationals and non-nationals in terms of relevant contributions made to society and, in fact, migrant workers may even have a higher instrumental value as they comprise a majority of the health care workforce and are central to the fight against COVID-19.

If we agreed that migrant workers are owed full inclusion in vaccine allocation strategies, we should have also employed additional ethical principles to further support the stance (Table 1). Many have articulated several ethical principles when the issue of fair allocation of vaccines was considered.^23–26 First, the principle of equity entails the fair distribution of benefits and burdens. The prioritization of nationals has maximized their benefits but similarly has continued to make the disease burdensome on the migrant worker population. Second, the principle of utilitarianism involves maximizing welfare. Non-nationals comprise a large percentage of the Gulf populations and therefore more lives could have been saved if they were vaccinated alongside national residents. In fact, non-national migrant workers are generally younger, which potentially means more life-years could have been saved if they had been vaccinated.

Table 1.

Ethical Principles in Support of Full Inclusion of Migrant Workers in Vaccine Allocation Strategies in the Gulf Countries.

Ethical principle	Description	Argument against prioritizing COVID-19 vaccines based on nationality
Equity	Fair distribution of benefits and burdens	- Disease will be unfairly burdensome on non-nationals
Utilitarianism	Saving most lives (or life-years)	- Non-nationals represent a larger percentage, and more lives can be saved if they are vaccinated - Non-nationals are generally younger, and more life-years can be saved if they are vaccinated
Reciprocity and instrumental valuation	Respects contributions others have made in the past and could make in the future	- Both nationals and non-nationals contributed and continue to contribute to the society - Non-nationals who work in the health care sector should be prioritized based on their instrumental value in fighting the pandemic
Solidarity	Fellowship with other members of the society	- Non-nationals and migrant workers are among the worst off in the society due to systematic social, political, and economic exclusion
Non-discrimination	Individual characteristics such as gender or race must play no role	- Treating people unfavorably because they are from a particular country is discriminatory

The principle of solidarity is about fellowship with other members of society. Gulf nationals have better access to health care and have more socioeconomic resources that make them relatively less vulnerable to ill health, whereas migrant workers are affected by environmental and social exposures that would make them more vulnerable to ill health. There is always a moral argument for shielding the worst off in our society, especially systematically disadvantaged migrants. The Gulf States share a common social, economic, and political context that contributes to the systematic marginalization of non-national residents, and this context shapes the broader health issues faced by this population. The principle of solidarity has been overlooked in the vaccine schemes that prioritized nationals. Finally, the principle of nondiscrimination requires that certain individual characteristics such as gender or race must play no role in allocation. The prioritization of individuals on the sole basis of the color of the passport that they hold has violated the core principle of nondiscrimination.

An Argument of Self-Interest

Until this point, our argument for the inclusion of migrant workers has been made with an assumption of acceptance that some form of justice is owed to migrant workers in the Gulf countries. Our second argument, however, is not predicated on a rejection of the strong statist view. For the sake of argument, suppose we accept the premise that Gulf countries owed no special responsibility of justice toward migrant workers who have voluntarily chosen to live and work there. Because migrant workers are not subject to a coercively imposed system of rules, the Gulf governments, under a statist view, may have justified and continue justifying prioritizing the health and well-being of their citizens at the expense of migrant workers.

If the priority of the government is to maximize the well-being of its citizens, preferential vaccine access for nationals is not the path to achieving that goal. The COVID-19 vaccine does not provide complete protection for all recipients. As vaccines with near-perfect levels of effectiveness have been approved, vaccination of citizens would not guarantee their full protection. Strategically vaccinating portions of the population at the highest risk for infection and continued spread would be key in slowing community spread.

In order to have curbed community spread in the Gulf countries and potentially halt further waves of infection, even if for the benefit of nationals alone, the vaccination of migrant workers alongside that of nationals was an essential strategy. Two studies on disease transmission in Kuwait showed significant spreading and clustering events among areas populated by migrant workers due to cramped housing and large population density.^27,28 Another study, also in Kuwait, showed that non-Kuwaiti COVID-19 patients were more likely to die or get admitted to intensive care units compared to Kuwaitis, after adjustments for age, gender, body mass index, and comorbidities. ²⁹ The authors attributed this to several social and class reasons that disadvantaged overall health. Therefore, the argument for prioritizing migrant workers could have yielded substantial benefits to flatten the curve of the transmission, relieve exhausted health workers, and improve outcomes nationwide for both citizens and non-citizens.

There are hypothetical draconian measures, such as total separation and lockdown, that were put in place to protect nationals from community spread among the migrant worker population. However, migrants were and continue to be so strongly integrated into many sectors—health care, education, childcare, hospitality, food industry, and so forth—that complete isolation would shut down huge sectors of the economy. In complete lockdown for migrant workers, not even nationals would be able to maintain a semblance of normal life and would suffer economically. This is not even to mention the fact that extreme solutions such as complete lockdowns verged into the territory of human rights violations.

Conclusion

The preferential allocation of COVID-19 vaccines for nationals saw millions of migrant workers being left behind. This has been largely unsurprising since Gulf countries have given preferential treatment to citizens in various other health policies. We have argued against that stance in this article and maintain that prioritizing vaccine allocation based on nationality is ethically unacceptable on two grounds: an ethical basis for the practice of public health and a self-interest argument. First, migrant workers are important contributors to the society and, as such, are owed a certain degree of distributive justice that extends to vaccine rollouts. We argue unequivocally that exclusion of migrant workers from vaccination efforts is ethically indefensible from a public health standpoint. Second, regardless of one's stance, excluding migrant workers from the vaccination program will ultimately lead to worse outcomes for the nation as a whole, including citizens, for whose well-being the governments are unquestionably responsible. Whether they decide to take the vaccines or not, migrant workers should have been considered in each phase of vaccine allocation on the grounds we highlighted.

Limitations

This article, which served as a commentary on vaccine rollout in the Gulf countries, does not consider the cost-effectiveness of vaccine allocation nor does it rely on any mathematical simulation of disease transmission among different subpopulations under different vaccination scenarios. The guidance provided here is solely governed by the ethical basis of the practice of public health. Additionally, it is worth noting that while our article focuses on the Gulf states as a region, there may be significant differences in health care systems and policies across individual countries within this region, and further research is needed to fully capture this complexity. That said, we believe there are enough similarities across the region to warrant a large-scale discussion of health inequities for migrant workers.

Author Biographies

Barrak Alahmad is a physician from Kuwait and a research fellow at Harvard T.H. Chan School of Public Health who is extensively studying the effects of environmental exposures on the health of migrant workers.

Dawoud AlMekhled is a Kuwaiti medical student studying at the University of Melbourne with clinical interests in general medicine, neurophysiology, and hepatology. His public health interests are in race-based health disparities and health information systems.

Katie Busalacchi is public health professional with experience in American and global public health. She is a 2021 Presidential Management Fellow.

Wei-Chen Wang is a physician-epidemiologist and a research fellow at Harvard T.H. Chan School of Public Health.