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The Mediterranean Region: A Hotspot of Inequalities in the Aftermath of COVID-19

Farah Al Shami

Research Fellow
Arab Reform Initiative (ARI)

The COVID-19 pandemic, which broke out in China in late 2019, reached the Mediterranean region by late winter 2020. While the impact of this crisis has been notorious on a global scale, it was remarkably more pronounced in the Mediterranean region as a result of economic fragility, exposure and transmissibility, and more importantly the quality of state and non-state responses which had a multidimensional multiplier effect on wealth distribution, access to health and education as well as other essential services, regional disparities and gender inequality, among others. Ever since its outbreak, COVID-19 has significantly exacerbated existing inequalities and has created new ones. It has also exacerbated vulnerabilities and created new forms of vulnerability, thus increasing the gaps on various levels between different social groups. These consequences were also more concentrated in the Mediterranean region as compared to the rest of the world, as the region had already been witnessing rising trends of inequality in the last decade, and especially before the pandemic hit, due to political instability, economic decay and inefficient public policies. While this reality has been experienced by both the northern and southern sides of the Mediterranean, it has been more intense in the latter. However, this is not to deny that constantly increasing inequalities in recent history has made both poles of the Basin much more susceptible to an enigmatic and acute shock such as COVID-19.

The impact of COVID-19 on multifaceted inequality in the Mediterranean is neither consistent nor linear. The region has witnessed declines in several forms of inequality and surges in several others. Yet, the overall impact in terms of the number and magnitude of increased inequalities versus reduced ones is negative, making the Mediterranean a hotspot of inequality in the aftermath of the sanitary crisis. Moreover, amplified inequalities have manifested in the Mediterranean Basin in the form of inter-country inequalities and intra-country inequalities – the former being mostly part driven by inter-sectoral imbalances. Inter-country inequalities have likely further cemented the north-south divide in the Basin.

This paper examines the different forms and faces of inequality in the region by trying to conceptualize the situations of different countries, despite their dissimilar and divergent contexts. It proves that COVID-19 has massively increased multidimensional inequality through various channels and at a relatively higher rate with respect to other regions. The paper also demonstrates that the Mediterranean is the microcosm of the north-south cleavage, as it is the closest place where the South meets the North, which makes it a natural starting point for dialogue concerning the north-south dichotomy and inequalities. As such, this paper highlights the need for tangible cooperation across borders, between sectors, and among citizens and their representatives, both within the region – between the North and the South – and with other regions, to advance reforms that address the factors of inequity and inequality in an already fragile and shaky regional context.

How Has COVID-19 Exacerbated Multidimensional Inequalities in the Mediterranean Region?

Income Inequality

It is well known in the literature that income and wealth inequalities are considered to be the most salient factors of inequality in human societies. The Mediterranean region, in particular, has been facing stark political instability and consecutive waves of protests and manifestations whereby deprivation and income inequality are noticeable in the nature of demands, the typology of social actors, their kind of activism and their geographic distribution. Waves of protests have swept across the Mediterranean countries since March 2019, from France to Algeria, Tunisia and Lebanon, and back to Italy. This not only marked a comeback ten years after the historic events related to the Arab uprising in the southern Mediterranean, but was also evidence of the growing discrepancies between these countries’ social groups and populations, over the last decade and especially since the outbreak of COVID-19. The aggravation of discrepancies also applies within the social groups and populations of northern countries, as well as between the nations of the North and the South. This multilayered increase of social differences was made perfectly clear, through, among other means, “non-social movements, social movements” or “everyday social movements,” despite the fact that the pandemic has attenuated physical and even digital activism of all sorts, particularly during the initial outbreak.

What accentuated the impact of the pandemic on income inequality in the Mediterranean is that, according to the World Inequality Database, there has been a trend of increasing the “pre-tax top 1% share of national income” and “pre-tax top 10% share of national income” in most of the region over the past ten years. As for the “pre-tax middle 40% share of national income” and “pre-tax bottom 50% share of national income,” they, on the contrary, have been constantly but gradually decreasing. Therefore, the relatively high GDP per capita for many Mediterranean countries before COVID-19 hit is linked to broad wealth inequality. Moreover, both shores of the Mediterranean, like the rest of the world, have seen a reduction in income and rising unemployment due to the pandemic, which had immediate impacts on food security and nutrition, education, health and other essential elements of decent life; yet, this has mostly affected the poorer and vulnerable segments of societies, and has occurred in low- and middle-income Mediterranean countries and those ‎affected by conflict (e.g. Libya, Syria and Palestine).

Furthermore, the gap between the informal and the formal sectors has considerably widened everywhere, including in the Mediterranean. In the North, the informal sector was badly hit because it mostly depends on mobility, and the transportation systems have stopped amid during the crisis. As for the South, it is the formal sector that was badly hit since this part of the region suffers from weak internet infrastructure, a key tool for formal businesses to keep operating during quarantine. This entails an asymmetry in the formality-informality relationships between the North and the South, thus deepening the north-south cleavage. Irrespective of the fissure between both sides of the region, the gap between the informal and formal sectors, which occurred everywhere, has widened socioeconomic inequalities. This is because informal workers are – on average – more vulnerable, have less job security, are more marginalized and have no access to social protection, and are poorer with lower, irregular or seasonal income, than their formal counterparts. While the size of the formal economy in the North is voluminous, that of the informal economy in the South is also not trivial.
In addition, on both shores of the Mediterranean, the gap between wage earners and rent earners has increased to the detriment of wage earners due to the pandemic, as businesses have started to close or slow down their operations. Such dynamics of income inequality have generated the issue of the “missing middle class,” as this social category is not eligible for aid, in the form of cash transfers for example, while it needs similar forms of assistance in crisis times, like the situation caused by COVID-19. Not receiving aid for the middle class and not being covered by social protection schemes for informal labour, has further impoverished the social groups in question, who also found themselves obliged to pay for additional COVID-19 related expenses, e.g. masks, hand sanitizers, medication and ventilators, out of their pockets.

On an intra-country level, the core-periphery and rural-urban dichotomies have become deeper. In fact, rural populations became better off compared to urban populations, as they mostly rely on the agricultural sector, which proved to be more resilient to the COVID-19 shock, being a flexible market with no barriers to entry, reliant on climate conditions and natural resources that were not altered by the pandemic, not subject to the restrictive labour market measures that were taken to contain the pandemic, and because it is a sector that meets its workers most basic needs of food, water and income, which remained essential throughout the confinements. Agriculture labour came in second place, behind workers in essential services, as it remained most intact during the pandemic. Agricultural and demographic imbalances between the countries of the South and those of the North have made the latter populations worse off relative to their counterparts on the opposite side of the Mediterranean. Finally, the majority of the countries of the South were forced into debt despite the problems they might have been facing, varying from economic stagnation or repression, to indebtedness and debt insolvency, and financial crises… As for northern countries, they either had enough financial resources to respond to the pandemic without borrowing or were in the position of lenders to the South. This not only widens the financial gap between both groups of countries, but also between their current and future populations, given that loans are in most cases intergenerational.

Educational Inequality

Quality education during COVID-19 is only made possible with access to decent telecommunication infrastructure. Therefore, due to low broadband internet penetration rates in the southern Mediterranean, students receiving remote learning in this area have been at a disadvantage, which is expected to increase the educational gap between the North and the South over the coming years. Similarly, the electrification rate needs to be high enough for remote learning to work, and while it is 100% in the northern Mediterranean, it can be less than 50% in many countries on the opposite side. These disparities also apply to the rural-urban divide, as rural areas on both shores of the region have relatively lower access to internet and electricity. This leads to high failure rates in the remote education system in southern countries and rural Mediterranean areas, especially considering the sudden rush into the experience of remote modalities of education, which caught almost everyone unprepared.

Nonetheless, educational inequality has always prevailed within and between the countries of the Mediterranean, regardless of COVID-19. This reflects the low levels in computer literacy, financial literacy and English literacy, all of which affect the ability to learn or access education, as well as the ability to access different forms of financial aid and development assistance. These issues are more intense in the South and in rural areas, making these geographic areas more prone to the negative repercussions of the pandemic on the educational sector. Apart from the differences in access to the infrastructure needed for a successful education and the intertwining between income and educational inequality, there is a consequent effect of these factors on the quality and ability of students and teachers, from which stems a layer of intergenerational inequality between youth and children. Southern and rural teachers are relatively less trained, and so are the teachers of kindergarten, primary and lower-secondary education, as compared to upper-secondary and tertiary education teachers. This is coupled with the fact that the younger the student is, the less their ability is to accommodate remote and self-learning, a form of learning widely imposed on all education systems during the pandemic. As a result, not only will there be an ensuing gap between students of the pre-COVID era and those of the post-COVID era, but also a subsequent gap between what the younger and the older students are getting in return for their school tuition and fees.

Health Inequality

The third most prominent form of inequality exposed during the COVID-19 pandemic has been health inequality, which also prevailed decades before the pandemic erupted. On both sides of the Basin, private healthcare outperforms public healthcare and is more available in terms of the number of medical and services centres and their distribution. This makes decent medical care more expensive and less accessible for underprivileged and vulnerable social groups, including people living in rural areas where medical centres are much less concentrated. Fortunate segments of society can access private healthcare and have the ability to purchase private insurance, whereas the poor cannot afford such means and have to rely on public healthcare, which is still not totally free in many contexts, and on national social security programmes, most of which have decided to exclude COVID-19 treatments because they are “related to a global health crisis,” just as they have long excluded many other forms of healthcare treatment in the past. Even private insurance programmes have excluded COVID-19 treatments, forcing patients to pay out of their pockets.

Not only does the private sector lack the needed corporate social responsibility to lead such a vital sector, but it has also been left by the states to operate without sufficient monitoring or organization. For instance, in Egypt, private health centres were allowed to conduct PCR tests, and there were major discrepancies in the pricing between these centres, one test costing between 1,000 and 2,000 EGPs, for example. And this, in any case, is not affordable for the vast majority of Egyptians, thereby engendering an additional factor of discrimination between the rich and the poor. This lack of coordination and cost-sharing between the private health sector and the government has led to citizens incurring heavy costs and caused more impoverishment and inequality, despite the fact that health is a fundamental right and should therefore be universal. On top of regional inequality between rural and urban areas is the fact that the hospitals in remote areas are mostly private. This geographic split is also more pronounced on the South shore, making the impact of the pandemic even more heterogeneous between the northern and southern Mediterranean.

Besides the interrelation between income inequality and health inequality, and the cross cutting public-private binary, the rural-urban binary can also be understood thanks to the fact that particulate matter pollution is higher in urban areas. This leads to greater health risks for people in cities, and puts those with respiratory problems, identified as one of the new most vulnerable groups post-COVID-19, at a major disadvantage. While this applies both in the North and South, it is more intense in the former, where there are more cities. Furthermore, the absence of urban planning on both shores, particularly on the southern one, has led to a highly significant number of misery belts and dire living conditions, thereby creating the nascent urban-urban inequality, which has likely worsened due to the pandemic. Both shores have also witnessed a new form of vulnerability, which is medical staff, especially nurses, who have joined the lower bound in all types of social inequality.

The fracture between the northern Mediterranean and the southern Mediterranean will also expand for two major reasons, which experts tend not to see: first, the northern societies are ageing whereas the southern populations are young, which is why the COVID-19 mortality rate in the North is much higher than it is in the South, since the elderly are more prone and susceptible to the virus. This increases the difference in the level of vulnerability between both sub-regions. However, the second reason is that poverty and food insecurity are relatively higher in the South, as is the number of anemic cases as a result. Since anemia weakens the immune system and increases vulnerability to the Coronavirus, then this situation represents a form of inequality between the populations of the opposite shores. This form of inequality also prevails between urban and rural areas of both poles of the Mediterranean, with rural areas being worse off.


Finally, health inequality due to COVID-19 stems from inequality in the access to vaccines, which mostly lies within a macro level between both shores of the Mediterranean, reflecting global inequality regarding the pandemic between the global North and the global South. Northern countries have access to patents and have resorted to bilateral agreements with big pharmaceutical companies to get vaccines, which have undermined multilateral agreements that can provide and aim at providing a more inclusive coverage, thus violating the WHO’s Equitable Allocations Framework and the Access to COVID-19 Tools Accelerator (COVAX ACT). As for countries of the South, most of them are being refused patents to produce the vaccines or do not have the ability for such productions. Some of them are part of the World Trade Organization (WTO) or the European Union Deep and Comprehensive Free Trade Agreements (EU DCFTAs), such as Tunisia and Morocco. These free trade agreements entail a binding TRIPS component on intellectual property rights, which has a degree of flexibility the whole world could benefit from to allow the production of the vaccines beyond the monopolizing pharmaceutical firms and to open space for more affordable generic production – like what was done with the therapeutics of HIV, Hepatitis C and Tuberculosis – to meet global needs at more affordable rates. However, this is being blocked by high-income countries, some of which belong to the northern Mediterranean. And let us not forget the lack of transparency and accountability due to the fact that civil society is not getting all the information about what is being planned, and is being neither consulted nor included in the entire process – on the global, regional and international levels.

Other Socioeconomic Inequalities

One of the most flagrant socioeconomic inequalities to have been exacerbated by the pandemic is gender inequality. This has been a major issue in the North and the South and especially in the sub-regions of the latter. Yet, the pandemic made it still more intense, as it imposed considerably more hours of unpaid care work at home, which is mostly borne by females. Mothers are now forced to juggle family life with work due to obligations that are enforced on them, and not on fathers, as a result of social norms, especially in the Mediterranean South. Additionally, gender-based violence has increased exponentially because of the social, psychological and economic tensions brought about by the pandemic, as well as the forced cohabitation between spouses.

It is true that COVID-19 responses in the Mediterranean have explicitly discriminated against women and other vulnerable and marginalized social groups, such as children, youth, the elderly, people with disabilities and migrants (migrant domestic workers and internally displaced people in the South versus refugees and asylum seekers in the North, in general), as well as among the new vulnerable and marginalized social groups as a result of the pandemic. It is also true that this explicit discrimination is due to inconsiderate and biased measures and laws. However, discrimination against these social segments is for the most part implicit as it stems from the fact that the social injustices of COVID-19 responses and interventions levy a heavier toll on already fragile populations that are much more susceptible to such a harmful shock. For example, daily workers, who are more mobile and need physical infrastructure to operate and take advantage of economic opportunities, were severely affected during the health crisis and especially during the lockdowns. The vulnerable groups among them, therefore, were the most affected among their peers due to their fragile predisposition. As for refugees, for instance, their exclusion from formal social protection systems and the prevailing loopholes in the frameworks that stipulate equity and inequality in their favour, makes them more exposed to the discrimination suffered by the whole population. This adds to “unconscious attitudes or stereotypes that impact people’s understanding, actions, behaviours and decisions” and thus negatively affect these social segments. Implicit as well as explicit discriminations are the result of a “continuity” instead of a “rupture” in countries’ public policies, despite the shock of the pandemic, thereby leading to accentuated social injustices.

Double and even triple vulnerabilities such as rural women, refugee women, women refugees with disabilities, are worthwhile mentioning in this context as well. Moreover, child labour has increased amid the pandemic, and related working conditions have worsened, children working as waste pickers and in other similar informal jobs. These scenes that have arisen as a result of COVID-19 are reflective of increased inequalities during the pandemic to the disadvantage of the underprivileged. While all of these types of socioeconomic inequalities apply to both the Mediterranean North and the Mediterranean South, they are definitely stronger in the latter where social injustices are more evident.

Conclusion and Policy Recommendations

The impact of COVID-19 on multidimensional inequality is very significant in the whole world, but is more pronounced in the Mediterranean region than in any other. The pandemic has exacerbated multifaceted inequality and has created new forms of inequality, including by creating new forms of vulnerability. This has manifested on an inter-country level and an intra-country level, thus deepening the cleavage between the North and South shores and proving that the Mediterranean is the microcosm of the North-South cleavage as it is the closest place where the South meets the North. However, this is not to deny that constantly increasing inequalities in recent history have made both poles of the Basin much more susceptible to an enigmatic and acute shock such as COVID-19. While both shores have actually witnessed exacerbated and new inequalities due to the pandemic, these inequalities have been more intense on the southern side of the Basin, as a consequence of its pre-pandemic socioeconomic and political landscapes, as well as the quality of public policies taken in response to the health crisis. The impact of COVID-19 on multifaceted inequality in the Mediterranean is not consistent and not linear, across and within countries. The region has witnessed declines in several faces of inequality and surges in others. Yet, the overall impact in terms of the number and magnitude of increased inequalities versus reduced ones is negative, making the Mediterranean a hotspot of inequality in the aftermath of the sanitary crisis.

This status quo of inequalities in the region, and especially in the southern part, is due to the fact that governments have been reactive to the pandemic and not proactive. They have also lacked a contingency plan. Instead, their actions were ad hoc and short-sighted. Mediterranean states have, on average, shown great inaction vis-à-vis inequalities, adopting an approach that represented a “continuity rather than a rupture” in their public policies when the pandemic hit, thus leveraging structural failures amid a hard socioeconomic shock. Even their measures in response to the health crisis were not inclusive and did not sufficiently consider the needs of vulnerable and marginalized social groups, thereby aggravating gaps between different social segments in Mediterranean societies. On top of this, states have prioritized economic parameters over health in their response, which has led to more social injustices, given that the pandemic has impacted the most essential and vital human needs (health, education, food, transportation, etc.).

Henceforth, to mitigate these structural and intergovernmental inequalities, the Mediterranean region and the world should come together to emerge from the global crisis stronger and more resilient; and so should the southern and northern countries of the Mediterranean. This will ensure partnerships and cooperation that bring together the resources of the global and Mediterranean North with those of the South, thus bridging the gap between both shores of the Basin and within the populations of each of them. On a country-level, each government should cater more to the social needs of its underprivileged and vulnerable social groups and should not discriminate against them. Instead, they should devise more inclusive public policies. Involving civil society organizations at the decision-making level by adopting a more participatory approach can help drive a shift from the inactivity or continuity in public policymaking to the generation of transformative policies that directly respond to the multidimensional impact of the pandemic, without marginalizing the needs of social groups to the advantage of others.

Notes

1 https://ufmsecretariat.org/covid-19-what-next-mediterranean/
2 https://erf.org.eg/events/inequality-trends-around-the-mediterranean/
3 https://revistaidees.cat/en/social-movements-and-revolutionary-episodes-in-the-mediterranean/
4 https://med.ispionline.it/from-protests-to-covid-19-understanding-how-2020-changed-the-mediterranean/
5 www.researchgate.net/publication/343482580_The_Pandemic_is_a_battlefield_Social_movements_in_the_COVID-19_lockdown
6 ibid
7 www.cbpp.org/research/poverty-and-inequality/a-guide-to-statistics-on-historical-trends-in-income-inequality
8 www.emro.who.int/emhj-volume-27-2021/volume-27-issue-3/covid-19-pandemic-a-unique-opportunity-to-build-back-fairer-and-reduce-healthinequities-in-the-eastern-mediterranean-region.html
9 https://ufmsecretariat.org/wp-content/uploads/2020/04/EMEA-EMNES_Study-Covid-19_in_the_Mediterranean_and_Africa.pdf
10 www.wiego.org/sites/default/files/publications/files/Arab-Watch-Background-Aita-2017.pdf
11 www.ilo.org/wcmsp5/groups/public/—arabstates/—ro-beirut/documents/publication/wcms_747070.pdf
12 https://ieg.worldbankgroup.org/blog/missing-middle-addressing-income-inequality-next-challenge-philippines-it-approaches-umic
13 www.imf.org/external/pubs/ft/fandd/2021/06/inequality-and-covid-19-ferreira.htm
14 https://assembly.coe.int/nw/xml/XRef/X2H-Xref-ViewHTML.asp?FileID=8089&lang=EN
15 www.afr.com/policy/economy/low-interest-rates-forever-will-be-the-legacy-of-this-virus-20200406-p54he6
16 www.imf.org/external/pubs/ft/fandd/2021/06/inequality-and-covid-19-ferreira.htm
17 www.bgca.org/news-stories/2020/July/Teacher-Shares-Eye-Opening-Effect-of-School-Changes-and-COVID-19-on-Americas-Youth?c_src=idm_cm_googleads&gclid=Cj0KCQjwraqHBhDsARIsAKuGZeGwWnmfKLbVdknMKCuJ_4JK4FUf15w3lHVsQtNU0RJULyZWEXm
lmI8aAuzlEALw_wcB
18 www.bgca.org/news-stories/2020/July/Teacher-Shares-Eye-Opening-Effect-of-School-Changes-and-COVID-19-on-Americas-Youth?
c_src=idm_cm_googleads&gclid=Cj0KCQjwraqHBhDsARIsAKuGZeGwWnmfKLbVdknMKCuJ_4JK4FUf15w3lHVsQtNU0RJULyZWEXmlmI8aAuzlEALw_wcB
19 https://openknowledge.worldbank.org/handle/10986/34238
20 ibid
21 An unpublished manuscript on “the impact of COVID-19 responses in Egypt,” by Mohamed Gad – Egyptian Initiative for Personal Rights, as a member of the Arab Hub for Social Protection from COVID.
22 https://reliefweb.int/report/world/build-back-fairer-achieving-health-equity-eastern-mediterranean-region
23 www.hsph.harvard.edu/c-change/subtopics/coronavirus-and-pollution/
24 www.frontiersin.org/articles/10.3389/frsc.2021.645914/full
25 An unpublished manuscript on “the impact of COVID-19 responses in Tunisia,” by Cyrine Ghannoushi – Tunisian Forum for Economic and
Social Rights, as a member of the Arab Hub for Social Protection from COVID.
26 www.imf.org/external/pubs/ft/fandd/2021/06/inequality-and-covid-19-ferreira.htm
27 https://jmhg.springeropen.com/articles/10.1186/s43042-020-00114-z
28 https://annd.org/english/itemId.php?itemId=873&cf_chl_managed_tk=pmd_72bf03ff5d18d1ed2198714a72982e0a37de920b-1626434903-0-gqNtZGzNAs2jcnBszQlO#sthash.wIOvNr5H.dpbs
29 www2.unwomen.org/-/media/field%20office%20arab%20states/attachments/publications/2020/04/impact%20of%20covid%20on%20gender%20equality%20-%20policy%20brief.pdfla=en&vs=4414
30 ibid
31 www.fhi.no/en/publ/2020/Social-and-economic-vulnerable-groups-during-the-COVID-19-pandemic/
32 https://nhchc.org/wp-content/uploads/2020/05/5-19-CCC-COVID-19-Implicit-Bias-Trauma-Informed-Principles-and-Social-Justice-Implications-1.pdf
33 A series of unpublished manuscripts (four national working papers) on “the impact of COVID-19 responses” in Egypt, Tunisia, Morocco and Jordan, by the Arab Hub for Social Protection from COVID.
34 www.arab-reform.net/publication/tunisia-covid-19-increases-vulnerability-of-rural-women/
35 www.arab-reform.net/publication/recycling-policies-from-the-bottom-up-waste-work-in-lebanon/
36 These statements which unveil the channels through which COVID-19 has exacerbated inequalities have been retrieved from a series of unpublished manuscripts (four national working papers) on “the impact of COVID-19 responses” in Egypt, Tunisia, Morocco and Jordan, by the Arab Hub for Social Protection from COVID.