The Post-Mortem Mystery: Determining “Cause of Death” Among Migrant Workers

In the last few decades, SIDS, or sudden infant death syndrome, has entered the public lexicon and changed the way parents put their infants to bed. But a whole group of conditions known as sudden unexpected death syndrome (SUDS), sudden unexpected nocturnal death syndrome (SUNDS), sudden adult death syndrome (SADS) are far lesser known. These conditions are all used to describe sudden death, often at night, but in contrast to SIDS, SUDS typically occurs in otherwise healthy young men. After scientists noticed a mysteriously higher prevalence of this type of death in certain populations (while it has occurred in Filipino medical literature as early as 1917, SUDS was first officially documented by the CDC in Southeast Asian refugees in the 1970’s), they have spent the last few decades attempting to better understand its causes. They haven’t come to one definitive answer but have landed on several compelling theories involving possible genetic conditions that can lead to numerous problems including epilepsy, electrical failures in the heart, brain hemoraging, or pancreatitis. A genetic mutation would explain why particular groups are predisposed to higher rates of SUDS, but leaves fewer conclusions about the external forces that trigger the condition.

When it appears in the news, SUDS is typically replaced with terms like “sudden death, cause unknown,”heart attack,” or “dying in their sleep.” And most recently, SUDS has attracted concern for its occurrence not amongst refugees but amongst young male migrant workers in places like China, Malaysia and the Middle East. SUDS is reported to be the main cause of death amongst the top five migrant worker populations in Qatar, more than workplace and automobile accidents, and has accounted for more than half the deaths of Nepali workers between July 2014 and 2015. While groups like Amnesty International have gone to lengths to investigate the working and living conditions of migrant construction workers, these “cardiac” deaths remain shrouded in mystery and somewhat lost in the conversation.

Could the answer simply be that groups of men who tend to migrate to the Middle East for work happen to be from populations where SUDS is more prevalent? It’s certainly possible, although this doesn’t explain why more would die of SUDS while living abroad than at home. Could external factors like poor living conditions, lack of workplace training and safety, or psychological pressure be connected to SUDS? This is also a possibility. (This theory is tentatively supported by science – at least one study concluded that stress might be connected to SUDS in migrants.) But because the system of determining and reporting cause of death in countries like Qatar makes in-depth investigation of sudden, mysterious deaths next to impossible, SUDS has become a sort of default cover to avoid some more troubling questions about why workers are dying.

Builders at work in Qatar. From Boston's NPR News Station under CC License.

Builders at work in Qatar. Photo by Boston’s NPR News Station under CC License.

When a migrant worker dies in the Middle East, the process to determine cause of death is often complicated. An examination of this process in the case of Qatar makes it clear why a sudden or unexpected death is seldom investigated further than the initial findings. A 2014 DLA Piper report commissioned by Qatar explains that when a migrant worker dies, “the attending doctor at the hospital… will complete a notification of death, which will include a description of the cause of death.” The doctor might be given further insight into the worker’s death through information about previous medical conditions or treatments sought, but because most migrant workers lack access to quality healthcare while in the host country, they may have been unaware of any preexisting conditions.

In Qatar, a forensic pathologist issues a death certificate if he agrees with the notification, but if he disagrees or cannot observe a cause of death externally, he will recommend that the District Attorney order an autopsy. However, the DA can’t order an autopsy unless there are “suspicious circumstances surrounding the death” because autopsies are prohibited in Qatar unless there is suspicion that the death was the result of a crime or an illness was involved. So if the death does not appear to be immediately and externally suspicious, further investigation is highly unlikely.

Several factors could also prevent key information from reaching officials who investigate worker fatalities. Coworkers of the deceased may be fearful of retaliation for reporting workplace accidents and may not have access to the proper channels to lodge complaints or seek redress. The classification of “cardiac” death might also have financial implications for the employers. The DLA Piper study suggests that employers might “somehow be encouraging this classification with the effect that this prevents the deceased workers’ family in the State of Origin making claims on their insurance policies (death by cardiac arrest would fall outside of the scope of the employer’s insurance policy),” although the authors of the study conclude that they have no evidence to support or refute this allegation. Host countries often do not prioritize tracking of trends in migrant worker deaths, so the official data on SUDS deaths is inconsistent.

If the forensic pathologist can’t pinpoint a cause of death and there’s no visible possibility of crime or illness, “heart attack” or “cardiac arrest” is the official cause. The body is then flown to the worker’s home country, where grieving relatives come to the airport to retrieve it, “shrinkwrapped and stuffed into [a] plywood box,” along with minimal details about the circumstances surrounding the death. Some are even given completely conflicting information and many are shocked to hear that a young son or brother – seemingly healthy and vital upon his departure from home – could have died of a ‘heart attack” on his way to work. But because governments like Qatar’s are often defensive and refuse to open investigation into a migrant worker’s death once his body has been sent back, families who doubt the information they’re given are left with little recourse.

The home country government can also create obstacles to investigating suspicious deaths. While some governments have been motivated by high-profile cases to initiate policies limiting migration to certain countries (like Nepal’s ban on women under 30 migrating to the Middle East following cases of abuse and suicide), it is not uncommon for sending country governments to appear reluctant to investigate deaths that have already been officially attributed to natural causes. After all, migration is big business for many developing countries, and investigation into these mysterious deaths could send a message to the public that working abroad is dangerous. These governments are reluctant to act in a way that could discourage migration, thereby diminishing the remittances upon which their economies depend, or jeopardize already-precarious relationships with receiving countries.

Because some countries have never commissioned research into these sudden deaths and others have gone so far as to prohibit second autopsies, scientists are prevented from investigating troubling SUDS trends. In Indonesia, only one forensic pathologist is willing to reexamine bodies of dead migrants. After conducting many autopsies, he concluded that “reports issued by host governments listing suicide or illness as cause of death can be a smokescreen for the brutality suffered by workers at the hands of their employers.” But even when faced with these findings, governments are often inactive – perhaps because of the wide-reaching consequences should the allegations be true.

There is some hope that governments of countries like Qatar might acknowledge, if only on paper, the concerns around the system for investigating and reporting mysterious deaths of migrant workers. As the Washington Post reports, DLA Piper’s report to the Qatari government makes firm recommendations regarding the handling of sudden deaths among construction workers: “Going forward, it is crucial that the State of Qatar properly classifies causes of deaths. It is critical to collect and disseminate accurate statistics and data in relation to work-related injuries and deaths. If there are any sudden or unexpected deaths, autopsies or post-mortems should be performed in order to determine the cause of death. If there are any unusual trends in causes of deaths, such as high instances of cardiac arrest, then these ought to be properly studied in order to determine whether preventative measures need to be taken.” Whether or not such recommendations will result in substantive change is yet to be seen.

In many countries, migrant workers are an invisible majority, with little recourse against abusive employers and dangerous working conditions. Unless both the sending and receiving countries can introduce transparency into their treatment of worker fatality, the truth behind sudden death will remain a mystery.

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