As droves of migrant workers sweat and die on construction sites and in homes in the wealthy countries of the Arabian Peninsula, a different army of expatriates is quietly laboring away in those countries’ hospitals and clinics. They are the main providers of health care to populations with blossoming rates of obesity, diabetes and other chronic medical problems.

Saudi Arabia, where 76 percent of physicians are expatriates, and other countries in the Persian Gulf region have few doctors and nurses of their own. A recent report described Middle Eastern countries as “heavily dependent on expatriate health care workers,” and as rates of chronic diseases in those countries continue rising, some worry that maintaining a medical workforce of expats will be unsustainable in an increasingly burdened health care system. These concerns are especially relevant in a region where at least 30 percent of the population is between the ages of 15 and 29 and leading lifestyles that are increasingly unhealthy, marked by high rates of smoking and growing levels of childhood obesity, all of which could lead to costly health conditions in the near future.

If Gulf countries want to lower their rates of chronic diseases, “you can’t address that alone by just bringing more people here, because there’s an issue of sustainability,” said Dr. William Hsu, who leads a team at the Joslin Diabetes Center. The Boston research center is addressing diabetes in the region by working with countries in the Gulf Cooperation Council (GCC), a bloc comprising Bahrain, Kuwait, Oman, Qatar, Saudi Arabia and United Arab Emirates. “You have to sustain a workforce in your country, incentivize, encourage the next generation.”

Unemployment in Saudi Arabia stood at 11.5 percent at the end of 2013, but for Saudi youth, or those between the ages of 16 and 29, it’s far higher, at 29 percent. “There are a lot of people who are not working but have the potential to be trained,” Hsu said, yet “they’re employing lots of expat workers, physicians and nurses.”

Dependency Issues

Over the past half century, countries in the Gulf region rapidly became wealthy with the discovery, production and exportation of oil. As money poured in, state economies developed and cities modernized. Mere generations ago, those in the region survived a harsh desert environment on little food; today, fast-food restaurants offer home delivery. But other sectors, like labor and health awareness, did not develop at the same pace.

“With the new wealth, everything changed,” Hsu said. From a biological standpoint, people who survived in truly sparse conditions had to be genetically predisposed to holding on to calories. “Now take those genes and put them in an environment of plenty, a virtually limitless amount of food and calories,” he said.

In Kuwait, 42.8 percent of the population is obese. Other Gulf nations are not far behind, with 35.2 percent of Saudis and 33.1 percent of Qataris also grappling with obesity. Regional obesity has been tied to greater consumption of fast foods and sugar-saturated beverages like soda, along with poor exercise habits. The region also is facing a diabetes epidemic, with an estimated 20 percent of the population suffering from the disease. Kuwait, Saudi Arabia and Qatar are among the top 10 nations with the highest rates of diabetes. By 2035, nearly 68 million people in the region are expected to have diabetes.

The six countries that make up the GCC have 10 times as many doctors and nurses per 1,000 people as some of the world’s most impoverished nations, like Afghanistan, Sudan or Yemen. But 75 percent of these physicians and 79 percent of nurses are not nationals from the countries in which they work, according to a policy brief on health worker migration in the GCC published by the Aspen Institute. These statistics are  in spite of nationalization programs aimed at injecting local, not expatriate, labor into the workforce. In 2001, after 20 years of “Saudization,” only 21.7 percent of physicians in Saudi Arabia were Saudi nationals.

Instead, health care workers come from just about everywhere else – Asia, Africa, Western Europe or North America. Eight hundred doctors emigrate from Sudan every year, the brief estimated, with 70 percent going to Saudi Arabia and 25 percent heading to other Gulf countries. The brief estimated that in 2020, Saudi Arabia will need to hire 32,660 doctors from outside the country.

Hiring And Development Sprees

Gulf nations have begun to acknowledge their medical challenges. In 1970, Oman, a sultanate hugging the southeastern end of the Arabian Peninsula, had 100 health care workers, 13 of whom were doctors. By 2003, it had 18,579 health care workers, 2,635 of them doctors. In 2013, it announced it would hire more than 3,200 doctors and nurses from outside Oman.

The United Arab Emirates announced last month it would build three medical colleges and five nursing schools over the next 10 years in order to meet a need for 8,000 more hospital beds, 7,300 more doctors and 8,500 more nurses. Training programs would aim to make nursing a more attractive profession for natives. 

In Saudi Arabia, 132 health care centers and hospitals are under construction, and the state plans to build 11 more hospitals, 11 medical centers and two medical complexes as well.

“Historically, GCC countries have not had the capacity to generate [a] skilled medical workforce, especially on the nursing side,” Siddharth Saha, a research director at Frost & Sullivan, a consulting firm, said by email. “There is also the fundamental social issue in GCC countries that citizens will not get involved in certain job sets, such as mid- to low-level construction, transportation and health care.” The wider issue, he said, "is for countries to develop and promote high-end skills at doctor and scientist levels to enhance its scientific pool."