Note on AI usage: As is my norm, I use LLMs for proof reading, editing, feedback and research purposes. This essay started off as an entirely human written draft, and went through multiple cycles of iteration. The primary additions were citations, and I have done my best to personally verify every link and claim. All other observations are entirely autobiographical, albeit written in retrospect. If anyone insists, I can share the original, and intermediate forms, though my approach to version control is lacking. It's there if you really want it.​

If you want to map the trajectory of my medical career, you will need a large piece of paper, a pen, and a high tolerance for Brownian motion. It has been tortuous, albeit not quite to the point of varicosity.

Why, for instance, did I spend several months in 2023 working as a GP at a Qatari visa center in India? Mostly because my girlfriend at the time found a job listing that seemed to pay above market rate, and because I needed money for takeout. I am a simple creature, with even simpler needs: I require shelter, internet access, and enough disposable income to ensure a steady influx of complex carbohydrates and the various types of Vitamin B. For all practical purposes, this means biryani.

Why did a foreign branch of the Qatari immigration department require several doctors? Primarily, to process the enormous number of would-be Indian laborers who wished to take up jobs there. I would say they were 99% of the case load - low-skilled laborers working in construction, as domestic servants, as chauffeurs or truck drivers. There were the odd handful of students, or higher-skilled workers, but so few of them that I could still count them on my fingers even after several hundreds of hours of work.

Our job was to perform a quick medical examination and assess fitness for work. Odd chest sounds or a weird cough? Exclude tuberculosis. Weird rashes or bumps? The absolute last thing Qatari urban planners wanted was an outbreak of chickenpox or fungal infections tearing through a high-density labor dormitory. Could the applicant see and hear well enough to avoid being crushed by heavy machinery, or to avoid crushing others when operating heavy machinery? Were they carrying HIV? It was our job to exclude these possibilities before they got there in the first place. Otherwise, the government wasn't particularly picky - a warm body with mostly functional muscles and ligaments would suffice.

This required less cognitive effort than standard GP or Family Medicine. The causal arrow of the doctor-patient interaction was reversed. These people weren’t coming to us because they were sick and seeking healing; they were coming to us because they needed to prove they weren't sick enough to pose a public health hazard or suffer a catastrophic workplace failure.

We were able to provide some actual medical care. It's been several years, so I don't recall with confidence if the applicants were expected to pay for things, or if some or all of the expense was subsidized. But anti-tubercular meds, antifungal ointments and the like weren't that expensive. Worst case, if we identified something like a hernia, the poorest patients could still report to a government hospital for free treatment.

A rejection on medical grounds wasn't necessarily final. Plenty of applicants returned, after having sought treatment for whatever disqualified them the first time. It wasn't held against them.

While the workload was immense (there were a lot of patients to see, and not much time to see them given our quotas), I did regularly have the opportunity to chat with my patients when work was slow or while I was working on simple documentation. Some of that documentation included the kind of work they intended to do (we'd care more about poor vision for a person who had sought a job as a driver than we would for a sanitation worker), and I was initially quite curious about why they felt the need to become a migrant worker in the first place.

Then there was the fact that public perception in the West had soured on Qatari labor practices in the wake of the 2022 FIFA World Cup. Enormous numbers of migrant workers had been brought in to help build stadiums and infrastructure, and many had died.

Exact and reliable numbers are hard to find. The true number of deaths remains deeply contested. The Guardian reported that at least 6,500 South Asian migrant workers died in Qatar since the country was awarded the World Cup in 2010 - many were low-wage migrant workers, and a substantial share worked in construction and other physically demanding sectors exposed to extreme heat. However, this figure is disputed. Critics noted that the 6,500 figure refers to all deaths of migrant workers from Pakistan, Sri Lanka, Nepal, India, and Bangladesh regardless of cause, and that not all of those deaths were work-related or tied to World Cup projects.

Qatar's official position was far lower. Qatari authorities maintained there were three work-related deaths and 37 non-work-related deaths on World Cup-related projects within the Supreme Committee's scope. But in a striking on-camera admission, Hassan al-Thawadi, secretary general of Qatar's Supreme Committee for Delivery and Legacy, told a TV interviewer that there had been "between 400 and 500" migrant worker deaths connected to World Cup preparations over the preceding 12 years. His committee later walked the comment back, claiming it referred to nationwide work-related fatalities across all sectors. Human Rights Watch and Amnesty International both called even the 400-500 figure a vast undercount.

It is worth pausing here, because the statistics are genuinely confusing in ways that I think matter. The 6,500 figure, as several researchers have noted, covers all-cause mortality for a very large working-age male population over twelve years - a group that would have a non-trivial background death rate even if they stayed home and did nothing dangerous. Some analyses, including ILO-linked work on Nepali migrants, have argued that overall mortality was not obviously higher than among comparable same-age Nepali men, though other research found marked heat-linked cardiovascular mortality among Nepali workers in Qatar. The Nepal report also (correctly) notes that the migrants go through medical screening, and are mostly young men in better health on average. They try to adjust for this, at least for age.

I raise this not to minimize the deaths - dying of heat exhaustion in a foreign country, far from your family, in service of a football tournament, is a genuine tragedy regardless of the comparison group - but because I think precision matters. "Qatar killed 6,500 workers" and "Qatar had elevated occupational mortality in difficult-to-quantify ways" are meaningfully different claims, and conflating them makes it harder to know what we should actually want to change.

I am unsure if there was increased scrutiny on the health of incoming workers to avoid future deaths, or if the work I was doing was already standard. I do not recall any formal or informal pressure from my employers to turn a blind eye to disqualifying conditions - that came from the workers themselves. I will get to that.

I already felt some degree of innate sympathy for the applicants. Were we really that different, them and I?

At that exact moment in my life, I was furiously studying for the exams that would allow me to move to the UK and work in the NHS. We were both engaged in geographic arbitrage. We were both looking at the map of the global economy, identifying zones of massive capital accumulation, and jumping through burning bureaucratic hoops to transport our human capital there to capture the wage premium. Nobody really calls an Indian doctor moving to the UK a "migrant worker," but that is exactly what I am right now. The difference between me and the guy applying to drive forklifts in Doha is quantitative, not qualitative.

I could well understand the reasons why someone might leave their friends and family behind, go to a distant land across an ocean and then work long hours in suboptimal conditions, but I wanted to hear that for myself.

As I expected, the main reason was the incredibly attractive pay. If I'm being honest, the main reason I moved to the UK was the money too. "Incredibly attractive?" I imagine you thinking, perhaps recalling that by First World standards their salary was grossly lacking. To the point of regular accusation that the Qataris and other Middle Eastern petrostates are exploitative, preying on their workers.

First World standards are not Third World standards.

This is where Western intuition about labor often misfires, stumbling into a sort of well-intentioned but suffocating paternalism. The argument generally goes: This job involves intense heat, long hours, and low pay relative to Western minimum wages. Therefore, it is inherently exploitative, and anyone taking it must be a victim of coercion or deception.

This completely ignores the economic principle of revealed preferences: the idea that you can tell what a person actually values by observing what they choose to do under constraint. Western pundits sit in climate-controlled pods and declare that nobody should ever have to work in forty-degree heat for $300 a month. But for someone whose alternative is working in forty-degree heat in Bihar for $30 a month with no social safety net, banning Qatari labor practices doesn't save them. It just destroys their highest expected-value option.

You cannot legislate away grinding poverty and resource constraints.

The economic case for Gulf migration from South Asia is almost embarrassingly strong when you actually look at it. India received roughly $120 billion in remittances in 2023, making it the world's largest recipient, with Gulf states still accounting for a very large share, though the RBI's own survey data show that advanced economies now contribute more than half of India's remittances. For certain origin states - Kerala being the clearest case, alongside Maharashtra and Tamil Nadu - remittance income is not a rounding error in household economics; it is the household economy. The man sending money home from Doha is participating in a system that has done more for South Asian poverty alleviation than most bilateral aid programs combined. This is not a defense of every condition under which that labor is extracted. It is simply a fact that seems consistently underweighted in Western discourse.

Consider the following gentleman: he had shown up seeking to clear the medical examination so that he could carry sacks of concrete under the sweltering heat of a desert sun. Out of curiosity, I asked him why he hadn't looked for work around his place of birth.

He looked at me, quite forlorn, and explained that there was no work to be had there. He hailed from a small village, had no particular educational qualifications, and the kinds of odd jobs and day labor he had once done had dried up long ago. I noted that he had already traveled a distance equivalent to half the breadth of Europe to even show up here on the other end of India in the first place, and can only trust his judgment that he would not have done this without good reason.

Another man comes to mind (it is not a coincidence that the majority of applicants were men). He was a would-be returnee - he had completed a several year tour of duty in Qatar itself, for as long as his visa allowed, and then returned because he was forced to, immediately seeking reassessment so he could head right back. He had worked as a truck driver, and now wanted to become a personal chauffeur instead.

He had been away for several years and had not returned a moment before he was compelled to. He had family: a wife and a young son, as well as elderly parents. All of them relied on him as their primary breadwinner. I asked him if he missed them. Of course he did. But love would not put food on the table. Love would not put his son into a decent school and ensure that he picked up the educational qualifications that would break the cycle. Love would not ensure his elderly and increasingly frail parents would get beyond-basic medical care and not have to till marginal soil at the tiny plot of land they farmed.

But the labor he did out of love and duty would. He told me that he videocalled them every night, and showed me that he kept a picture of his family on his phone. He had a physical copy close at hand, tucked behind the transparent case. It was bleached by the sun to the point of illegibility and half-covered by what I think was a small-denomination Riyal note.

He said this all in an incredibly matter-of-fact way. I felt my eyes tear up, and I looked away so he wouldn't notice. My eyes are already tearing up as I write this passage, the memories no less vivid for the passage of many years. Now, you are at the point where my screen is blurry because of the moisture. Fortunately, I am a digital native, and I can touch-type on a touchscreen reasonably well with my eyes closed nonetheless. Autocorrect and a future editing pass will fix any errors.

(Yes, I do almost all my writing on a phone. I prefer it that way.)

There. Now they're drying up, and I'm slightly embarrassed for being maudlin. I am rarely given to sentiment, and I hope you will forgive me for this momentary lapse.

I asked him how well the job paid. Well enough to be worth it, he told me. He quoted a figure that was not very far from my then monthly salary of INR 76,000 (about $820 today). Whatever he made there, I noted that I had made about the same while working as an actual doctor in India in earlier jobs (as I've said, this gig paid well, better than previous jobs I'd had and many I had later).

He expected a decent bump - personal drivers seemed to be paid slightly better than commercial operators. I do not know if he was being hired by a well-off individual directly or through an agency. Probably the latter, if I had to guess, less hassle that way.

I asked him if he had ever worked similar roles in India. He said he had. He had made a tenth the money, in conditions far worse than what he would face in Qatar. He, like many other people I interviewed, viewed the life you have the luxury of considering inhumane and unpalatable, and deemed it a strict improvement to the status quo. He was eager to be back. He was saddened that his son would continue growing up in his absence, but he was optimistic that the boy would understand why his father did what he had to do.

One of the reasons this struck me so hard then, as it continues to do now, is that my own father had done much the same. I will beat myself with a rusty stick before I claim he was an absentee dad, but he was busy, only able to give his kids less time than he would have liked because he was busy working himself ragged to ensure our material prosperity. I love him, and hope this man's son - now probably in middle school - will also understand. I do not have to go back more than a single generation before hitting ancestors who were also rural peasants, albeit with more and better land than could be found in an impoverished corner of Bihar.

By moving to the Middle East, he was engaged in arbitrage that allowed him to make a salary comparable to the doctor seeing him in India. I look at how much more I make after working in the NHS and see a similar bump.

I just have the luxury of capturing my wage premium inside a climate-controlled hospital, sleeping in a comfortable bed, and making enough money to fly home on holidays. I try to be grateful for the privilege. I try to give the hedonic treadmill a good kick when it has the temerity to make me feel too bad for myself.

There are many other reasons that people decry the Kafala system other than the perceived poor pay and working conditions. The illegal seizure of passports, employer permission required to switch jobs, accusations of physical abuse and violence are all well-documented, though the link to the 2020 Reuters article claims the system was overhauled and “effectively dismantled”.

I make no firm claims on actual frequency; I have seen nothing with my own two eyes. Nor do I want to exonerate the Qatari government from all accusation. What I will say is that "exploitation" is a word with a definition, and that definition requires something more than "a transaction that takes place under conditions of inequality." If we define exploitation as taking unfair advantage of vulnerability, we need a story about how the worker is made worse off relative to the alternative - and the workers I spoke with, consistently and across months, told me the opposite story. They are not passive victims of false consciousness. They are adults making difficult tradeoffs under difficult constraints, the same tradeoffs that educated Westerners make constantly but with much less margin for error and no safety net.

The people who know best still queued up for hours in the hopes of returning, and I am willing to respect them as rational actors following their incentives. I will not dictate to them what labor conditions they are allowed to consider acceptable while sitting on a comfy armchair.

I do not recall ever outright rejecting an applicant for a cause that couldn't be fixed, but even the occasional instances where I had to turn them away and ask them to come back after treatment hurt. Both of us - there was often bargaining and disappointment that cut me to the bone. I do not enjoy making people sad, even if my job occasionally demands that of me. I regret making them spend even more of their very limited money and time on followups and significant travel expenses, even if I was duty-bound to do so on occasion. We quit that job soon; you might find it ironic that we did so because of poor working conditions and not moral indignation or bad pay. I do, though said irony only strikes me now, in retrospect.

Returning to the man I spoke about, I found nothing of concern, and I would have been willing to look the other way for anything that did not threaten to end his life or immediately terminate his employment. I stamped the necessary seals on his digital application form, accepted his profuse thanks, and wished him well. I meant it. I continue meaning it.

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