COVID-19 is revealing inequities between and within countries. Across the globe, poorer people tend to be more exposed to the risk of infection as they are more likely to have co-morbidities, less likely to be able to work from home, and more likely to live in multi-generational, large households in cramped conditions with limited access to clean water. Poorer population groups are less likely to receive the care they need once they are infected and have a lower survival from COVID-19.
The economic impact of COVID-19 is unequal, too. While no one has been spared the effects of the pandemic, a forthcoming report on the "Welfare Impacts of COVID-19 in the MENA Region" demonstrates how even within countries the consequences of the pandemic are felt differently. Poor people, refugees, or those engaged in the informal sector are more exposed to the risk of infection, have been harder-hit economically due to lockdowns, and have fewer means to cope with income losses.
As the world is grappling to reduce the impact of COVID through mass vaccinations, other inequities arise. The distribution of vaccines across countries is extremely unequal. In the United States for example, 60 out of every 100 people have been vaccinated with at least one dose. In the MENA region, by contrast, it is four times lower: 15 out of every 100. Across countries in the MENA region there exist sizeable vaccine inequalities with vaccination rates as high as 50 per 100 in Saudi Arabia and 37 in Morocco, to lows of less than 1 per 100 in Yemen and Syria, 2 in Iraq, and 4 in Egypt.
Obtaining up-to-date information about vaccine inequities within countries is challenging in the MENA region because nationally representative surveys are implemented irregularly and because vaccination rates remain low. Moreover, COVID-19 hinders face-to-face interviews. Targeted phone surveys among high-risk groups eligible for vaccination are a possibility, but have not been conducted to date. Anecdotal information, such as that of Lebanese politicians jumping the queue for vaccines, suggest prevailing inequities especially in the early phase of vaccination rollout, but the evidence we have is not systematic. Fortunately, in several countries, nationally representative phone surveys have been conducted to assess the impact of the pandemic on the well-being of respondents. While these surveys do not ask about vaccination status, there is much to be learned from their questions about COVID-19 testing.
Data from Iraq, for instance, collected in January 2021 shows how about 25% of the population has been tested for COVID-19. The data reveal that men are more likely to have been tested than women (27% versus 19%), that those with formal public-sector work (35%) are tested significantly more than those in the informal private sector and self-employment (24%), and that people with lower levels of education, or those who are food insecure are less likely to have been tested (see Figure). In summary, these results show that the poor and vulnerable are less likely to have been tested.
Unequal COVID-19 testing is not just an issue for Iraq. Phone surveys from other countries in the region expose the same issues. Of the respondents to the 4th round of the Djibouti phone survey, 29% indicated they were tested for COVID-19, yet only 22% of poor respondents were tested at least once for COVID-19 versus 30% of the non-poor. Those with greater exposure to the risk of infection, such as those working in the informal sector, were less likely to have been tested than those engaged in the public sector (25% versus 39%).
These findings raise important questions. COVID-19 testing is free in the public sector in MENA countries. Why are the poor not using these services? Is awareness lacking, are the opportunity costs too high, are there physical barriers, informal payments, or something else? More data is needed to shed light on questions.
Even if we get answers, providing equitable access to COVID-19 testing is very different from rolling out vaccinations fairly. Vaccine shelf-life is limited, some vaccines require ultracold storage, and those most at risk, the elderly and those with co-morbidities, should be vaccinated first. Still, these differences should not thwart efforts to avoid the inequities observed in so many other aspects of the pandemic.
COVID-19 related inequities systematically leave the poor behind. Unequal access to vaccines needs to be resolved at the global level, though pro-active governments can make a difference as the vaccination rate of Morocco illustrates. Within their own countries, governments can avoid compounding other COVID-19 related inequities through well targeted social protection programs, low-cost (even free) testing, and through transparently-run vaccination programs. As COVID-19 is likely to become endemic, we have to learn to do better and to invest in the evidence needed for learning.
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