Ageing in the Mediterranean 9781447301073

Table of contents :
Ageing in the Mediterranen_4Helen_NoBackCover
Ageing inthe Mediterranean
Contents
List of tables and figures
Tables
Figures
Preface: Working for future ageing societies: ambivalent realities in the Mediterranean region
The present agenda of population ageing
Focusing on the Mediterranean region
Notes on contributors
Part I. The Mediterranean region: its social fabric
1. Squaring the circle: demographic outlook and social development as determinants of ageing in the Mediterranean
Entering a contested terrain
What is ‘the Mediterranean’?
Ambivalences in contrast
Modernisation as a critical reference for researching ageing
The ageing complex in the Mediterranean: challenges and developments
Consequences and perspectives
2. Demographic outlook of ageing in the Mediterranean, 1950–2050
Introduction
Socioeconomic consequences
Demographic data and population ageing
Population ageing in the Mediterranean region
Determinants of population ageing
Trends in population ageing
Demographic characteristics of the elderly population
Conclusion
3. An ageing population, institutional context and family values in Southern Europe
What is so special about the Mediterranean?
Historical study of Mediterranean family patterns and its contemporary relevance
European divides
Structure, culture and the role of the family as welfare agency on the two Mediterranean shores
Conclusion
4. Becoming conscious of the ‘whole Mediterranean’: old cleavages and recent developments
Surprising experiences and new directions
Sudden ruptures and traditional divisions
Landscape and environment as elementary conditions
Crisis in this maritime world
New lines of reasoning about ‘the Mediterranean’
The ‘southern welfare states’ and the southern shore countries
‘Le noir et le bleu: un rêve méditerranéen?’
Part II. Comparisons and diversity inemployment, health and care: ageingin the Mediterranean
5. Ageing and employment in the Mediterranean: old and new challenges
The age divide
Some economic consequences of an ageing population
Market selection, age-related discrimination and policy disincentives
Setting the incentives right: an overview of macro and micro policies
What can MENA countries learn from their northern shore partners?
6. The present and future health status of older people in the Mediterranean region
Introduction
Measuring health
Health and quality of life
Disability and the need for care
Improving health and quality of life among older people in the Mediterranean region
Conclusion
7. The new risk of dependency in old age and (missed) employment opportunities: the Southern Europe model in a comparative perspective
Introduction
Care policies and female employment in European countries
The Southern European trajectory in a comparative perspective: problems and prospects in Italy and Spain
Conclusion
8. Migration, retirement and transnationalism in the Mediterranean region
Description of the Immigrants and Retirement Survey
Results of the survey
Life choices for retirement
Preferred place of burial
Conclusion
9. The future of demographic regimes in the Southern Mediterranean
The end of the population explosion
Ageing societies in the Mediterranean: similarities and differences
Solidarity and intergenerational dynamics in the Southern Mediterranean
Benefits of the new demography of the southern shore countries
Controversial perspectives: exit, voice and loyalty?
Part III. Mobilising care support:transnational dynamics inMediterranean welfare societies
10. New approaches to familism in the management of social policy for old age in Portugal
Introduction
Background: familism and social policy development in South Europe
Long-term care reform in Portugal
Long-term care reform and familism: challenges and lessons from the Portuguese experience
Conclusion
11. Migrant care work for elderly households in Italy
Introduction
Migrant care work in ageing societies: the phenomenon in a global and Mediterranean perspective
The Italian case: current trends in the demand and supply of elder care in Europe’s oldest country
The Italian case: migrant care work as a crucial ‘pillar’ of long-term care provision
The care experience through the eyes of migrant workers
Conclusion
12. Caring for frail older people in Israel
Introduction
Population ageing
Changes in family structure and roles
Meeting the needs of frail older people
Provision of home care services
The interface between formal and informal care
Facing the future
13. ‘Ageing in place’ in the Maltese islands
Population ageing in Malta
The changing traditional caring role of the family
Government policies and programmes
Future policy challenges
Conclusion
Part IV. Constraints and complexities inageing societies of the SouthernMediterranean
14. Ageing in Turkey: the Peter Pan syndrome?
Introduction
Population trends in Turkey: a demographic transition?
Images and representations of older people in Turkish society
The Peter Pan syndrome: a reality check for the state?
15. Ageing in Lebanon: evidence and challenges
Introduction
Demographic trends
Social and economic conditions
Structural support channels
Health profile of older Lebanese people
Use of health services
Nursing homes and non-governmental organisations
Governance
Capacity development and research
Conclusion
16 Ageing in Tunisia
Introduction
Demographic indicators
Social and economic position of older people in Tunisia: a gender equality perspective
Conclusion
17. Conclusion and themes for further discussion
Options for the methodology
Problem of culture: between empirical and ideological domains
The imagined family and its contradictions
Life course regimes and ageing perspectives
Governance perspectives and the European challenge
Index
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Edited by Joseph Troisi and Hans-Joachim von Kondratowitz

Ageing in the Mediterranean Edited by Joseph Troisi and Hans-Joachim von Kondratowitz

First published in Great Britain in 2013 by Policy Press North American office: University of Bristol Policy Press 6th Floor c/o The University of Chicago Press Howard House 1427 East 60th Street Queen’s Avenue Chicago, IL 60637, USA Clifton t: +1 773 702 7700 Bristol BS8 1SD f: +1 773 702 9756 UK e:[email protected] Tel +44 (0)117 331 5020 www.press.uchicago.edu Fax +44 (0)117 331 5369 e-mail [email protected] www.policypress.co.uk © Policy Press 2013 British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging-in-Publication Data A catalog record for this book has been requested ISBN 978 1 44730 106 6 hardcover The right of Joseph Troisi and Hans-Joachim von Kondratowitz to be identified as editors of this work has been asserted by them in accordance with the 1988 Copyright, Designs and Patents Act. All rights reserved: no part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise without the prior permission of Policy Press. The statements and opinions contained within this publication are solely those of the editors and contributors and not of The University of Bristol or Policy Press. The University of Bristol and Policy Press disclaim responsibility for any injury to persons or property resulting from any material published in this publication. Policy Press works to counter discrimination on grounds of gender, race, disability, age and sexuality. Cover design by Policy Press Front cover image: Billy Alexander Printed and bound in Great Britain by Berforts Information Press Policy Press uses environmentally responsible print partners

Contents List of tables and figures Preface Working for future ageing societies: ambivalent realities in the Mediterranean region Notes on contributors Part I: The Mediterranean region: its social fabric one Squaring the circle: demographic outlook and social development Hans-Joachim von Kondratowitz two Demographic outlook of ageing in the Mediterranean, 1950–2050 Joseph Troisi three An ageing population: institutional context and family values in Southern Europe Pier Paolo Viazzo four Becoming conscious of the ‘whole Mediterranean’: old cleavages and recent developments Hans-Joachim von Kondratowitz Part II Comparisons and diversity in employment, health and care: ageing in the Mediterranean five Ageing and employment in the Mediterranean: old and new challenges Annamaria Simonazzi and Fiorenza Deriu six The present and future health status of older people in the Mediterranean region Judy Triantafillou and Elizabeth Mestheneos seven The new risk of dependency in old age and (missed) employment opportunities: the Southern Europe model in a comparative perspective Barbara Da Roit, Amparo González Ferrer and Francisco Javier Moreno Fuentes eight Migration, retirement and transnationalism in the Mediterranean region Claudine Attias-Donfut nine The future of demographic regimes in the Southern Mediterranean Youssef Courbage

v ix xv 1 3 33 57

75

99 101

123

151

173

197

Part III Mobilising care support: transnational dynamics in 213 Mediterranean welfare societies ten New approaches to familism in the management of social policy for 215 old age in Portugal Alexandra Lopes iii

Ageing in the Mediterranean eleven

twelve thirteen

Migrant care work for elderly households in Italy Carlos Chiatti, Mirko Di Rosa, Francesco Barbabella, Cosetta Greco, Maria Gabriella Melchiorre, Andrea Principi, Sara Santini and  Giovanni Lamura Caring for frail older people in Israel Esther Iecovich ‘Ageing in place’ in the Maltese islands Joseph Troisi

235

257 273

Part IV Constraints and complexities in ageing societies of the Southern Mediterranean fourteen Ageing in Turkey: the Peter Pan syndrome? Özgür Arun fifteen Ageing in Lebanon: evidence and challenges Nabil Kronfol and Abla Mehio Sibai sixteen Ageing in Tunisia Radhouane Gouiaa and Abla Mehio Sibai seventeen Conclusion and themes for further discussion Joseph Troisi and Hans-Joachim von Kondratowitz

295

Index

375

iv

297 325 345 359

Contents

List of tables and figures Tables 1.1 1.2 2.1

2.2

2.3 2.4 2.5 2.6

2.7

2.8

3.1 3.2 5.1 5.2 5.3 5.4 6.1 6.2

Adjusted values of the Human Development Index, for all countries 16 of the Mediterranean region, 2000, 2005–11 Number of Arab countries by life expectancy at birth and year of 16 estimate/projection Estimated and projected size and percentage of the elderly 34 population out of the total population in the Mediterranean countries, 2007, 2025, 2050 (000s) Total fertility rate (per female) and infant mortality rate 38 (per 1,000 births) in the Mediterranean countries, 1970–75, 1990–95, 2005–10 Estimated and projected life expectancy at birth by gender in the 40 Mediterranean countries, 2005–10, 2025–30, 2045–50 Estimated and projected percentage of total population of the 44 Mediterranean countries by age group, 2007, 2025, 2050 Estimated and projected median age of total population of the 45 Mediterranean countries, 2007, 2025, 2050 Estimated and projected age dependency ratio (number of people 47 aged 60+ for every 100 aged 15–59) in the Mediterranean countries, 2007, 2025, 2050 Estimated and projected percentage of ‘young old’ and ‘old old’ 50 out of the total elderly population in the Mediterranean countries, by age group, 2007, 2025, 2050 Estimated and projected sex ratios (males per hundred females) 52 of the total and of the elderly population in the Mediterranean countries, 2007, 2025, 2050 Life expectancy at birth in selected European countries, 1910–2000 58 Proximity to nearest living child and frequency of contacts with most 63 contacted child in 10 European countries (men and women aged 80+) Dependency ratios in selected European countries 104 Employment rate, employment rate of older workers (aged 55–64) 105 and average exit age from the labour market, by gender, 2010 Dependency ratios, countries of the Mediterranean region, 2010 113 Indicators of labour market participation of the youngest and the 114 elderly population in the Mediterranean region, 2010 Life expectancy at birth in Mediterranean countries, 1990, 2000 125 and 2007 Healthy Life Years at birth, at age 50 and at age 65, for men and 131 women in EU Mediterranean countries in 2011 v

Ageing in the Mediterranean 7.1 7.2 7.3 7.4 7.5 7.6 8.1 8.2 8.3 8.4 8.5 8.6 11.1 11.2 14.1 14.2 14.3 14.4 14.5 14.6 14.7 14.8 14.9 14.10 14.11 15.1 15.2 15.3

vi

Proportion of people aged 65+ receiving residential and home care 156 services, selected countries, early 1990s and mid-2000s Employment rate of women aged 25–49 and 50–64, in several 158 European countries, every five years since 1985, and 2007 Employment rate of women aged 25–49 and 50–64 in the health 159 and social services, in several European countries, 1992–2007 Percentage of women’s employment in health and care services, 159 in several European countries, 1992–2007 Domestic workers and foreign domestic workers registered with 165 the National Institute for Social Security in Italy, 1991–2009 Domestic workers and foreign domestic workers in Spain, 166 1987–2008 The proportion of immigrants in France by age and country of origin 176 Frequency of going back to country of origin 177 Proportion of transfers and migration transfers by country of origin 180 Motives of gifts and loans among migrants in France 184 Desired place of retirement for migrants in France 185 Burial preferencesof migrants in France, by nationality and religion 189 Profile of migrant care workers in selected Mediterranean countries 237 according to gender, age, main country of origin and working conditions Home and domestic care workers in Italy, 1991–2007 243 Distribution of the older populations in Turkey 299 Distribution of the population according to residential area in Turkey 302 Distribution of the older population according to gender in Turkey 304 Marital status of older people according to gender in Turkey (%) 306 Educational levels of older and total populations in Turkey, according 309 to gender (%) Gainful employment status of older people according to gender 310 in Turkey Cumulative annual income (US$) of older populations in Turkey, 312 according to gender Distribution of social security insurance among older populations in 314 Turkey (%) Distribution of older populations according to ethnic background in 316 Turkey (%) Distribution of older populations according to ethnic background in 317 Turkey (%) Quality of life among the older populations according to ethnic 319 background in Turkey (%) Trends in selected demographic indicators, Lebanon, 1970–2050 327 Basic socioeconomic characteristics of older adults aged 65+ 329 in Lebanon (%) Retirement provision for beneficiaries in Lebanon, 2008 331

Contents List of tables and figures 15.4 15.5 15.6 16.1 16.2 16.3 16.4 17.1

Older adults as recipients of support from and as a resource to family members (%) Health characteristics of older adults aged 65+ in Lebanon (%) National health accounts for older adults aged 65+, measured in billions of Lebanese pounds Demographic indicators, Tunisia 1980–2040 Selected socioeconomic characteristics in Tunisia (%) Functional impairments and self-rated health among older women and men in Tunisia (%) Percentage distribution of men and women aged >60 by type of intergenerational co-residence in Tunisia (%) Demographic dividend

332 335 337 346 350 352 353 369

Figures 1.1 5.1 5.2 5.3 7.1 9.1 9.2 9.3 9.4 9.5 9.6 9.7 10.1 10.2 10.3 12.1 12.2 13.1 14.1

Countries that border the Mediterranean Sea 7 Employment rates of older workers (aged 55–64), by country 106 and gender, 2010 (%) Employment rates of older workers, by country, 2010 (%) 115 Employment rates in the Mediterranean region by gender, 2010 (%) 117 Expenditure for cash and in-kind benefits in the long-term care sector 157 Total fertility rate by educational level, Morocco, 1975–2030 198 Projection of educational level, women aged 15–49, Morocco, 198 2005–30 Ageing as a rate of increase (%) of those aged 65+, 2010–50 200 Ageing as a gap between the rate of increase (%) of those aged 65+ 201 and total population Entries, exit and net entries in some countries of the southern 204 shore, 2005–30 Projection of female activity rates according to ILO, 1985–2025 206 Annual number of potential new entrants, 1st grade primary, 211 selected countries, 1950–2050 Evolution of public expenditure in care for older people as a 219 percentage of GDP, 1990–2008 Best care option for own parents if dependent 221 (% in national samples), 2007 Agents and referral circuit of the Portuguese RNCCI 224 Changes in activities of daily living tasks performed by primary 266 caregivers Changes in instrumental activities of daily living tasks performed 266 by primary caregivers Total Maltese population for 2009, divided according to age group 273 Transformation of the population according to age groups in 299 Turkey, 1935–2023 vii

Ageing in the Mediterranean 14.2 14.3 14.4 14.5 16.1

viii

Transformation in the rural and urban population in Turkey, 1927–2008 Life expectancy at birth in Turkey, 2004–25 Average annual income of older people according to marital status in Turkey (US$) Educational attainment of older populations in Turkey according to ethnicity Population pyramids, 1980–2040

302 305 308 318 347

Preface: Working for future ageing societies: ambivalent realities in the Mediterranean region The present agenda of population ageing A broad public discourse about the societal impact of population ageing has now emerged in a growing number of discussion groups, symposia, conferences and publications. In its components of continuous fertility decline, lowering mortality and increasing life expectancies at birth, thereby giving contours of new societies of longevity, its effects and consequences are now being debated beyond merely the experts in the field of public health, demography and life course research. After being treated for too long as a topic of only secondary importance, the negotiations about this epochal development have now become a frequent, if not already dominant, concern for most governments, media and scientific councils, not only on a national, but even more so on a global, level. However, depending on the respective stage of demographic transition of each country, the response and perspectives to develop potential strategies to deal productively with these consequences of an ageing society will vary accordingly. Moreover, considering and debating demographic changes not only concerns the present and immediate future, but also requires an engagement in patterns and periods of long-term development of the respective demographic regime of each country. Therefore, a necessary and inevitable challenge for social strategies in all of these countries is to calculate the different time horizons, different compositions and needs of their sociodemographic settings. However, if this is done sensitively to each situation of sociodemographic changes, it should also provide opportunities for social forecasts, for action perspectives and for social planning. For a long time, the sustained fertility decline (in the words of demographical expertise), together with an extended period of decreasing ‘dependency ratios’, was described as a ‘window of opportunity’. As a limited time period, it has been characterised (in the terminology of the UN Population Division) as the ‘demographic dividend’, about which much has been published. But, by using such economically inspired terminology, this seems to automatically imply an inevitable benefit for society. In fact, there are two dimensions in this ‘dividend’ situation: a strong increase in the size of the working-age population, and a relatively slow increase in the ‘dependent’ groups – children and older people. In other words, due to the decline in fertility, the number of children will increase more slowly than the number of people of working age. In contrast, the number of older people will grow faster than the number of working-age individuals, but this increase will not balance out a sustained fertility decline.

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However, whether this constellation turns out to be a benefit remains a matter of concrete political and economical evaluation in order to assess to what degree countries can still calculate with these ‘dividend’ dimensions. Most observers agree that such a demographic situation requires strong investments in education and a serious expansion in job opportunities. However, to implement this ambitious programme also requires a comprehensive capability for change and a powerful engagement that is very much dependent on the political and socioeconomic situation of a country. The present situation of a serious financial crisis in many European countries makes such an engagement even more difficult as the examples in the whole Mediterranean region currently demonstrate. Beyond these difficulties, certainly the term ‘opportunity’ ought to be understood in a wider, rather long-term societal perspective that directs attention to new areas of concern. Leaving the discussion about the limits of a ‘demographic dividend’ behind and turning away from overstrained crisis scenarios, this allows us to see the still hidden, but often overlooked, potentials of an ageing society: of stimulating new productivity by technology investment in the immediate household economy, by developing and implementing electronic health and care designs and by transforming the whole work environment in a way that would be sensitive to position in the life course. Moreover, the even more complex social dimensions of such a society are also apparent: to further expand the female workforce and to advance new models of social engagement, by structuring activities of civil society to integrate and support those in a dependent situation, as well as generally enhancing and intensifying the activity rate of older people.

Focusing on the Mediterranean region In order to specify and differentiate such ambivalences in more detail, this book concentrates on a special entity for analysis, the Mediterranean region. As a major ‘civilisational zone’ (Inglehart and Baker, 2000) of extraordinary importance, which has been the source of numerous cultural connections and achievements, this Mediterranean region has exposed an enormous richness in cooperative structures and networks. And it could be expected that these affiliations and contacts would be mobilised and transformed for a common strategy of policy formation in the field of ageing. Such expectation would be even more justified, as, with the introduction of the ‘new Mediterranean policy’ in 1989 by the European Union (EU) and its further political developments up to 2008 with the establishment of the ‘Union for the Mediterranean Region’, a vision has been presented that could be seen as strong encouragement for such reflections. Therefore, in a number of contributions to this work, such concern about the social fabric of the whole of Europe is taken up by comparing different policy fields and outcomes in ageing from Northern and Central European countries with those of the Mediterranean countries. But the main objective of this collection remains to concentrate on the interregional differences and similarities between the northern and southern shore countries of the Mediterranean. x

Preface:Working for future ageing societies: ambivalent realities in the MediterraneanPreface region

Following a research perspective with cross-border explorations is not without problems, however. And to select a whole region as a research subject is not selfevident but a rather rare decision in comparative work due to its considerable methodological difficulties. Mobilising information and expertise about several countries in such a region with all its necessary differentiations, to develop a comparative research strategy which will be flexible enough to include their respective historical and cultural conditions, while at the same time emphasising cross-national and global similarities, such a programme asks for a broad and multiprofessional perspective with a wide variety of social science approaches and field experiences to be used.Therefore, the first part of this book aims to deliver a detailed overview about the whole social fabric of what is described and implied when ‘the Mediterranean’ has been defined as a unit of analysis. It is therefore the objective of Chapter One, the introduction to the volume, to elaborate a comprehensive framework by confronting competing approaches to define the Mediterranean, reconstructing unity visions that have resulted from terrestrial conditions and the historical heritage of sea power dominance, of highlighting the diversities and cultural variations in this region, and finally, by critically discussing the promise of modernisation as an interpretational tool to differentiate the ageing phenomenon. Chapter Two describes in detail the demographic developments longitudinally, in respect to many differentiating dimensions, and for all countries regarded in this volume as parts of the Mediterranean region. By comparing the historical family regimes in Central and Northern European countries with the northern shore countries of the Mediterranean, Chapter Three reconstructs another line of analysis, of longevity and the institutional impact of such family regimes in historical and comparative perspectives. Finally, in the closing contribution to this part, images and symbolic representations for the ‘North’ and the ‘South’ in its historical and present confrontations are followed and described as a long-lasting heritage of disarray and misperception which has made potential cooperation in Europe always irksome and additionally burdened by neglect and disinterest towards the Muslim countries of the Mediterranean (Chapter Four). The second part is devoted to a more detailed account of the existing diversities of the ageing experience in the Mediterranean region.An important step in giving this account is the comparison between some of the northern shore countries with a number of Central and Northern European welfare states. Several aspects are under observation, for example, the ambivalent policy options that the ageing imperatives create, particularly in the field of employment strategies and labour market dynamics. In particular, several policy reforms, that is, those reforms that are designed to increase the employment rate of older people and originally recommended on the European level, are again under discussion (Chapter Five). Another aspect concerns trends and patterns in the long-term development of health in Northern and Central European as well as in the Mediterranean countries. By giving a detailed overview about the health situation in different Mediterranean countries (including the southern shore), and by arguing along xi

Ageing in the Mediterranean

several individual and population-based indicators, disease profiles and care situations, Chapter Six considers social inequalities and cultural differences together with ongoing changes towards the dominance of chronic disease and preventive policies. Speaking about health trends in adult and old age leads inevitably to the subject of provision of care. Here there are clear differences between Northern and Central European countries and the Mediterranean but there is also an emergent dynamic of working on new policy options for support arrangements. Of central importance is the role and development of female employment in this field of care. Several contributors also point to the formation of a new care labour market. While formal employment rates among adult women in the care sector are still low, long-term care tends now to be organised often by migrant care workers in shadow work constellations (see Chapter Seven).The recent ambivalences of such reform strategies among the northern shore countries have given the opportunity to argue about given options. One later contribution (see Chapter Ten) discusses these effects by using the example of Portugal. Traditionally labelled a classic example of a familist welfare state, Portugal has undergone substantial reforms in its social care system during the last few years, namely with the implementation of a new long-term care integrated system in 2006, which comprises an integrated network of health and social care services for those in need of long-term care. It is based on a new approach to familism that may ultimately be of some interest in discussing the available paths for the development of long-term care solutions in familist social policy settings. Migration work will be of a dramatically increasing relevance for future ageing societies in the whole of Europe. In the 1990s, ‘the old continent’ became migrants’ number-one destination, ahead of the US, due to the convergence of several trends. Political and economic change has been especially dramatic in Southern Europe, turning them from former suppliers of migrants into countries of immigration themselves. Despite the restrictive immigration policies of the European Community, population ageing in the southern shore countries seems to encourage immigration to the whole of Europe, and also to other regions and continents, often also to the Arab Peninsula. This geographically spreading out of migration flows is occurring simultaneously with changes in the forms of migration and migrants’ characteristics, motivations and migration behaviour. Rich empirical material about ageing migrants in France that came originally mostly from the Maghreb show today the effects of modern transnational migration (see Chapter Eight). This gives an opportunity to shed the light on comparisons between the southern shore countries in contrast to the Northern European welfare states. Reporting in particular on data from Morocco, the central message of this contribution is that arguing with a demographic rift between the northern and the southern and southeastern part of the Mediterranean distracts attention from the really important changes that materialise as demographic modernisation not only in Morocco but also in a wide variety of Arab countries. Several developments are critically discussed: a dramatic increase in educational levels, resulting from a xii

Preface:Working for future ageing societies: ambivalent realities in the MediterraneanPreface region

growing number of primary and secondary institutions, particularly for women; the changing position and intergenerational dynamic of the family; and the impact of demographic change on entry into the labour force where women are also entering in larger numbers (see Chapter Nine). The third part focuses on the central topic of developing care policies in a situation of an increase in old-age care needs, alongside decreasing fertility rates and a reduction in family care. Besides the already mentioned example of Portugal, this part presents other actual models in order to demonstrate the various ways of arranging care by today’s Mediterranean welfare states. The dynamic of the Italian model stands for a systematic approach: the urgency in helping to establish a more equitable and internationally oriented perspective to solve staff shortages in elder care. With the traditionally ‘cash-oriented’ profile of the Italian welfare system being low on social services, this has resulted in perpetuating familistic tendencies by stimulating the employment of foreign migrant care workers, often on a live-in, undeclared basis. Chapter Eleven identifies important advantages of migrant care work in increasing ‘ageing in place’ opportunities (thereby reducing institutionalisation), and by providing a more personalised home care system at reasonable cost. But the authors also discuss the consequences of such migration for the sending countries, and their respective qualification profile. Chapter Twelve explores the same problem of migrant care under different and more favourable conditions, namely, the Israeli welfare state, with long-term care insurance and a wide offer of social services in which migrant care is conceptualised as an officially accepted offer of care provision. Moreover, empirical research demonstrates here that to render social services and to employ migrant care work does not have to be seen as mutually exclusive but rather complementary, notwithstanding difficulties in connecting them in practice. Studies show that family caregivers still play a key role in care work when there is a paid live-in homecare worker who is available around the clock.The islands of Malta present another developed welfare society in the Mediterranean (see Chapter Thirteen). Here sociopolitical influences and gerontological discourses from Northern European countries have helped to develop a society in which not only retirement policies, but also public family support, the provision of social services and the engagement of voluntary work initiatives are combined to help dependent and frail older people. Reviewed in the light of the country’s rapid population ageing, this chapter gives a careful reconstruction of government activities and programmes in order to guarantee a strategy of ‘ageing in place’ as the dominant perspective for older people in Malta. The last part of this volume shifts attention to the emerging welfare societies of the southern shore of the Mediterranean. In Chapter Fourteen the ageing situation of Turkey is discussed in more detail. While Turkey, at the present time, has a predominantly young population, this will change in the near future due to declining fertility rates combined with increasing numbers of people living into old age.Turkey will need to accept that it, too, will become part of the worldwide trend towards population ageing. This chapter presents data on the conditions of adult and older people based on sociological factors such as daily life, gender, xiii

Ageing in the Mediterranean

marital status, education, work and income, health, religion and ethnicity. It ends with a discussion about the state’s activities towards ageing in the realm of social policy. In Chapter Fifteen the situation of Lebanon as an increasingly ageing society in the Southern Mediterranean is critically discussed. Past and present fertility levels are among the lowest in the region, and the country has the highest percentage of older people. Mortality rates have dramatically decreased during the last few decades and cardiovascular disease has, for some time, been the leading cause of death.This is reason enough to respond with appropriate social-political policies and by designing and implementing supportive measures for economic and social security. However, research activities and funding resources continue to be heavily geared towards the health of children and young people, adults of working age and women of reproductive age, thereby following the urgent political pressures of priority setting. Chapter Sixteen deals with the post-revolutionary situation in Tunisia. This country has one of the highest percentages of older people aged 65+ among the Arab countries, and is distinctive by being one of the few countries in the world that has incorporated the word ‘elderly’ into the name of its Ministry entrusted with ageing and older people’s issues. Chapter Sixteen explores the conditions and situations of older people in Tunisia, their demographics, socioeconomic characteristics, and health and geriatric care within existing governmental institutional arrangements that provide care and support for older people. Again, a crucial problem remains the role and situation of the family as a central agency for support for older people. While still a cornerstone for organising support for older people, the degree of family cohesion is under severe pressure in this new, rather insecure, societal situation. Finally, it should be noted that this publication is, by and large, the outcome of a European conference entitled ‘Ageing in the Mediterranean world’, which was held in Malta between 12–14 March 2009. It was organised by the International Association of Gerontology and Geriatrics (IAGG) European Social Research Section, and by the European Centre for Gerontology and Geriatrics, University of Malta. Thirty experts from different Mediterranean countries participated. Reference Inglehart, R. and Baker, W. (2000) ‘Modernization, cultural change, and the persistence of traditional values’, American Sociological Review, vol 65, pp 19-51.

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Notes on contributors Özgür Arun was educated at the Middle East Technical University (METU). In 2001, he moved to Berlin, Germany, continuing his research through 2002. On his return home he taught at the Department of Sociology, METU (2004–11), during which time he completed an MA and a PhD. He is presently a full-time faculty member in the Department of Gerontology, Akdeniz University. He has conducted research on higher education, rural development, income, welfare, youth and unemployment, child labour and disability. His most recent research and writings are on ageing, culture and intergenerational relationships. Claudine Attias-Donfut is a sociologist. She is Director of the Ageing Research Department of CNAV (National Retirement Fund of Public Social Security) in France, and senior researcher at the Edgar Morin Center at EHESS (Ecole des Hautes Etudes en Sciences Sociales). Her research interests include ageing, relations between generations and immigration. She is the founder of the peer-reviewed journal Retraite et Société and was editor in chief until 2011. She has published numerous academic articles and books. Her last book, Citizenship, belonging and intergenerational relations in African Migration, is coedited with Joanne Cook, Jaco Hoffman and Louise Waite. Francesco Barbabella currently works at the Italian National Institute of Health and Science on Ageing (INRCA) in Ancona, Italy as a research fellow. In previous years he has worked on several international projects, such as FUTURAGE,ASPA, CARICT and AIDA. He has been visiting doctoral student at the European Centre for Social Welfare Policy and Research in Vienna, Austria, a United Nationsaffiliated organisation, for one year (2011). His research interests include: the role of information and communication technologies (ICTs) in improving care and support services; the impact of migrant care workers’ employment; and the ongoing trends of social policies at international level in long-term care. Carlos Chiatti is a researcher at the Italian National Institute of Health and Science on Ageing (INRCA), and a post-doctoral researcher at Lund Universitet (Sweden). He recently worked on the project FUTURAGE, aimed at defining the roadmap for future ageing research in Europe. He is now working on a large community trial (the UP-TECH project), funded by the Ministry of Health, aimed at improving the provision of health and social care for patients affected by Alzheimer’s disease and their caregivers, through a better integration of existing services and the use of new technologies. Youssef Courbage is Research Director at the National Institute of Demographic Studies in Paris, of which he has been a member since 1990. Between 2003-05 he headed the Department of Contemporary Studies at the French Institute xv

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of the Near East in Beirut (IFPO). His research covers the study of the world’s populations, the old and new minorities and the political, social and economic correlates of population dynamics. His publications include various books printed by well-known publishing companies. His work, A convergence of civilizations, has been translated into French, Arabic, Persian, Japanese, German, Spanish, Italian, Polish, Korean and Hungarian. Barbara Da Roit is Assistant Professor in Social Policy and Interventions Studies at Utrecht University, the Netherlands. Her research interests focus on care policies and practices with a comparative perspective. She recently published Strategies of care: Changing elderly care in Italy and the Netherlands (Amsterdam University Press, 2010) as well as several articles on the transformation of care systems in Europe in international journals (Current Sociology, South European Society and Politics, The Milbank Quarterly, Ageing & Society, Health & Social Care in the Community, Quality & Quantity, Social Politics and the Journal of European Social Politics). Fiorenza Deriu is Assistant Professor of Sociology at the Department of Statistics of Sapienza University of Rome, Italy. Her research fields range from population ageing and social policies for older people to the impact of labour market changes on the transition to adulthood of young generations, poverty and social exclusion. She is currently focusing her research studies on the relationships between the theory on social investment and housing policies, trying to identify a new model of social housing for older people. Mirko Di Rosa, an economist, has collaborated since 2009 with the Italian National Institute of Health and Science on Ageing (INRCA), where his main tasks are related to data analysis through the use of quantitative research methods, mainly microeconometrics, parametric and non-parametric techniques, but also panel and longitudinal studies. During his experience at INRCA he took part in several international research projects in the following fields: family care of older people; reconciliation of professional and caring responsibilities; migrant care workers; prevention of elder abuse and neglect; role of technology for improving the quality of life of older people; and active ageing and work. Amparo González Ferrer is a research fellow at the Research Group on Demographic Dynamics of the Spanish National Research Council (CSIC). Her interests lie, in particular, in the areas of social demography, international migration, integration and immigration policies. Two of her most recent publications are ‘Sampling international migrants with origin-based snowballing method. New evidence on biases and limitations’ (with Cris Beauchemin, Demographic Research, 2011) and ‘Explaining the labour performance of immigrant women in Spain: the interplay between family, migration and legal trajectories’ (International Journal of Comparative Sociology, 2011).

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Radhouane Gouiaa is a medical doctor, specialising in Internal Medicine and Geriatrics. He completed an advanced postgraduate programme in Geriatrics at the European Academy for Medicine of Ageing, and is a member of its network. In collaboration with the International Institute on Ageing, United Nations-Malta (INIA) he organised five training programmes in Gerontology for Tunisian medical doctors. He is a founder member and to-date President of the Tunisian Association of Gerontology (ATUGER), which is a full member of the International Association of Gerontology and Geriatrics and AIFGG. He is member of the African Research on Ageing Network (AFRAN). Cosetta Greco, a social worker, collaborated on several international and national projects in the field of ageing and healthcare services. Since 2006 she has collaborated as a junior researcher at the Department of Socio-Economic Gerontological Research of the Italian National Research Centre on Ageing (INRCA). She participated in the following European Projects: EURHOMAP: Mapping professional home care in Europe (European Agency for Health and Consumers); 2008–10: ABUEL: Elder abuse: A multinational prevalence study (European Agency for Health and Consumers); 2008–11: WEDO, European Partnership for the Wellbeing and Dignity of Older People (European Unionfunded, submitted by AGE Platform Europe). Esther Iecovich is one of the leading social gerontologists in Israel. She was Head of the Master’s programme in Gerontology at the Faculty of Health Sciences, Ben-Gurion University of Negev in Israel, where she is a researcher and lecturer. Her fields of research interest include formal and informal caregiving, including care provided by migrant care workers. She occupied various senior management positions in the field of elder care in both community-based and institutional longterm care services in Israel. She is currently the chair of the board of a non-profit organisation that supplies domiciliary services to older adults with a disability. Nabil Kronfol is Professor of Health Policy and Management, President of the Lebanese Healthcare Management Association, and co-founder of the Center for Studies on Aging. Dr Kronfol received a medical degree from the American University of Beirut (AUB) in 1969, became a diplomat of the American Board of Pediatrics in 1972 and then joined the Harvard School of Public Health, pursuing a doctorate in Health Services Administration (1979). He continues to be a frequent consultant to the World Health Organization, The World Bank, UNICEF, the United Nations Development Programme, the UN Economic and Social Commission for Western Asia (in health systems design, human resource development), and the health of the older populations. Giovanni Lamura has gained experience in international research projects mainly focused on family and the long-term care of older people; work–life balance; migrant care work; prevention of elder abuse; and information and xvii

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communication technology-based solutions for a sustainable informal care. In 2011 he coordinated the four-country research project CARICT (‘Assessing the impact of ICT-based solutions for informal caregivers’). In the last few years he has participated, among others, in the following projects: EUROFAMCARE – Support Services for Family Carers of Older People; ABUEL – A multinational prevalence study on elder abuse; ASPA – Activating senior potential in an ageing Europe; and FUTURAGE – a road-map for future ageing research in Europe. Alexandra Lopes holds a PhD in Social Policy from the London School of Economics and Political Science for a thesis on living arrangements and the wellbeing of older people in familist social policy settings. Up until early 2010 she was Director of the Department of Sociology at the University of Porto, where she works as a senior lecturer. Her research interests and experience include the analysis of long-term care systems and reforms from and the interface between formal and informal care provision in familist social policy settings, topics on which she has several publications. Maria Gabriella Melchiorre, an economist, worked from 1989 to 1997 at Ancona University, Italy, on several research projects on family care policies and migrants. In 2006 she taught Sociology at Ancona University. Since 1997 she has been a researcher at the Italian National Institute of Health and Science on Ageing (INRCA), working on the social aspects of caregiving as well as on social policy for older people. She has been involved in several projects on caregiving (COPE, ESAW, EUROFAMCARE), on home care (EURHOMAP) and on elder abuse (PHASE, ABUEL, WEDO). She also has experience in studies on migrant care workers and in the field of quantitative data sampling, collection and analysis. Elizabeth Mestheneos, a UK-trained sociologist, has worked in Greece since 1988, mainly at Sextant Co, undertaking a range of predominantly European Union-funded research projects including family care, older workers, elder abuse, home care services, older women and long-term care systems, with publications on these subjects. She is a founder member of the Greek non-governmental organisation, 50plus Hellas, that promotes the wellbeing of all older people through information, advocacy and research, and served as the elected President of AGE Platform Europe during 2008–11, representing 160 member organisations and 28 million members. She is currently Director of the International Federation of Ageing. Francisco Javier Moreno Fuentes is a research fellow at the Institute of Public Goods and Policies of the Spanish National Research Council (CSIC). His research is centred on the comparative analysis of public policies within the European region, with a focus on welfare regimes’ transformation, immigration and urban policies. He published his doctoral thesis in the Colección Documentos of the Consejo Económico y Social, and has written several chapters in edited books, xviii

Notes on contributors

as well as articles in Spanish (Política y Sociedad, Documentación Social and Revista Española del Tercer Sector) and international journals (Politics & Society, International Migration Review, Hagar and Pôle Sud). Andrea Principi, a sociologist, has been a researcher at the Italian National Institute of Health and Science on Ageing (INRCA) since 2000. His main research interests relate to active ageing, that is, work and volunteering in older age, working carers’ reconciliation of work for the labour market with informal care to older family members and informal caregiving to older family members. He has participated in several European projects, including ‘Income from work after retirement: A national report, Italy’, funded by the European Foundation for the Improvement of Living and Working Conditions;‘Carers@work’, funded by the Volkswagen Foundation; and ‘ASPA: Activating senior potential in ageing Europe’, funded by the European Commission. Sara Santini has collaborated with the Italian National Institute of Health and Science on Ageing (INRCA) from 2000 in numerous surveys and European research projects on ageing, the reconciliation of care and work, caregivers’ quality of life and incontinence. She deals with social and health policies for older people and support measurements for caregivers, focusing on the incontinence issue and the integration of health and sociological aspects of care. She is in charge of information and communication technology-based initiatives for caregivers. She is skilled in qualitative research and content analysis and expert in the use of the Max-Qda (Plus) software for the management of qualitative data. Abla Sibai is Professor of Epidemiology and Population Health at the Faculty of Health Sciences, American University of Beirut (AUB) and co-founder of the AUB University for Seniors and the Center for Studies on Aging in Lebanon. During the past 15 years she has led the way in placing older adult issues at the forefront of the national agenda and in the region. She is the author of over 150 scholarly articles in prestigious journals, book chapters and reports. Dr Sibai holds an MSc from the AUB and a PhD from the London School of Hygiene and Tropical Medicine. Annamaria Simonazzi is Professor of Economics at Sapienza University of Rome, Italy. Her main areas of expertise include social policy and the economics of the welfare state, labour and gender economics and international macroeconomics. She has coordinated several national and European research projects in these fields, and has published widely on population ageing and long-term care, female employment and international female migration, as well as the economic analysis of European Union monetary integration, with a special focus on the problems of competitiveness and growth in Southern European countries.

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Judy Triantafillou is a UK-trained medical practitioner working in Greece in primary care, and researches at both national and European levels into healthy ageing, services and family care for older people. Recent projects include INTERLINKS – health and long-term care systems for older people in 14 European countries (2008–11) (http://interlinks.euro.centre.org/project) and EUROFAMCARE – Services for Supporting Family Carers of Elderly People in Europe (2003–05) (www.uke.uni-hamburg.de/extern/eurofamcare/). She is a founder member of the first Greek non-governmental organisation for older people, 50plus Hellas, and has served on the Administrative Council of AGE Platform Europe, as well as in the Health Expert Group. Joseph Troisi is Professor of Sociology in the Department of Sociology and of Social Gerontology at the European Centre of Gerontology and Geriatrics, University of Malta, which he directs. For the last eight years he has been nominated by the United Nations (UN) Secretary General as Director of the International Institute on Ageing, UN-Malta. He is a member of the UN Economic Commission for Europe Working Group on Ageing and of a number of UN international bodies. He has taught social gerontology in a number of foreign universities throughout the world, and has served as a consultant in the field of ageing to governments in developing countries. Pier Paolo Viazzo is Professor of Social Anthropology at the University of Turin, Italy. Formerly a Research Associate of the Cambridge Group for the History of Population at the University of Cambridge, UK, he has specialised on the historical and anthropological study of household structures in Mediterranean Europe, and has published extensively on the role of kinship and family as welfare agencies. He was Lead Researcher for Italy in the project ‘Kinship and social security’, coordinated by the Max Planck Institute for Social Anthropology (2004–07). Hans-Joachim von Kondratowitz is Senior Adviser at the German Centre of Gerontology, Berlin. He carried out his studies in Berlin, Saarbrücken and St Louis (Washington University); he has been Assistant Professor in Sociology at the Technical University of Munich; Interuniversity Consortium for Political and Social Research (ICPSR) participant at the Survey Research Center, University of Michigan, Ann Arbor in 1980; Scientific Researcher at the German Centre of Gerontology from 1981 to 2010;Visiting Professor for Social Gerontology at the University of Kassel from 1997 to 1999; and President of the European Social and Behavioural Science Section (EBSSRS) of the International Association of Gerontology and Geriatrics for the European Region from 1999 to 2011. His fields of interest include welfare state research; life course research; medical sociology; care research; and communal social policy.

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Part I The Mediterranean region: its social fabric

1

one

Squaring the circle: demographic outlook and social development as determinants of ageing in the Mediterranean Hans-Joachim von Kondratowitz

Entering a contested terrain The central subject of this book is to follow the ageing process by addressing a variety of its implicit social dimensions, and to do this by concentrating on a particular geographical region, the Mediterranean basin. At first, to study the demographic and social developments in such a large geographical unit seems to cause no specific difficulties in mobilising detailed and continuous projections as well as analysing its far-reaching sociopolitical dimensions. The immediate importance of this subject of ageing is even more apparent today. Considerations can start from some essential and undisputed observations about the general situation of ageing societies and particular constraints and specialities affecting the Mediterranean region. Such observations can be summed up as follows: population ageing and the onset of a decline in the working-age population has today undoubtedly become an increasing concern for most governments. Across the Mediterranean, this phenomenon has exposed a great variation in its level and pace, mainly determined by a country’s stage in the second demographic transition and by the scope and timing of the country’s fertility decline. Such a development has important and far-reaching implications across all spheres of society.And since these processes are without any historical precedent, in order to meet these challenges, new policies and programmes are urgently required. At first this task appears easy in having only to deal with an obviously welldefined geographical area to which our comparative social research is directed. However, we should not expect a straightforward way to approach the topic of ageing in the Mediterranean – it is characterised by a variety of cultural conceptions, persistent images and long-term powerful visions that are inseparably bound to a comprehensive and differentiated understanding of this area.To prove how and in which ways such a heritage will affect and influence the present situation of the differently ageing Mediterranean societies is, therefore, a useful and enlightening perspective for comparison. 3

Ageing in the Mediterranean

• The first step into this broad field of research can be made by simply asking the obvious question, what is meant by ‘the Mediterranean’, and how is the area more exactly defined? • I then elaborate on the various ways of conceptualising the Mediterranean, in terms of perceiving its environmental and ecological conditions as unifying dimensions. But at the same time, I also perceive the cultural differentiation of the Mediterranean as a means of self-interpretation and important image production for this region. • Looking for the appropriate theoretical framework to explain the interlocking demographic and economic development, I discuss the modernisation effects in some present forecasts for ageing and employment, care, health, migration and religion. This is particularly relevant for connecting to the discourse of life course research. • Finally, I give critical comments on comparing recent ageing developments in the countries of the northern and southern shores of the Mediterranean. This gives the opportunity to look at the generational images and power implications of these processes.

What is ‘the Mediterranean’? Inquiring about the meaning of ‘the Mediterranean’ is more than simply deciding about the scope and boundaries of this geographical unit. First, it is obvious that, for comparative purposes, one has to deal with already institutionally prearranged settings which are structured by the modern nation state and respective information packages of national statistical data sets using a variety of social and economic indicators as well as additional quantitative, publicly available information coming from comparative data sets from international organisations.

Arbitrary lists of countries After checking the research perspectives of several comparative projects on how they described ‘the Mediterranean’, an instructive but nevertheless surprising impression emerges. Most of these studies do not even bother to clarify the use of the concept of ‘Mediterranean’; they just assume it as a matter of course and believe that every reader would know what is meant. There is a core complex of nation states included in a list of ‘Mediterranean countries’, which usually consists of countries of the northern shore of the Mediterranean Sea: Spain, Italy, Yugoslavia and Greece, often also, but not always, France, and sometimes even Portugal (although it is on the Atlantic coast) is added..

Politically defined lists of countries Another layer of countries attributed to ‘the Mediterranean’ is formed in connection with a political definition. For example, during the 1980s there 4

Squaring the circle

was intensive discussion about possible discrimination in trade between the European Economic Community (EEC) and non-member countries from the Mediterranean (Shlaim and Yannopoulos, 2008). The list coming out of these debates (and omitting the two founding countries of the European Union [EU], France and Italy) includes: Albania, Algeria, Cyprus, Egypt, Greece, Israel, Jordan, Lebanon, Libya, Malta, Morocco, Portugal, Spain, Syria, Tunisia, Turkey and Yugoslavia. But any listing also depends on actual historical developments. Yugoslavia has dissolved into several new political entities and the political ruptures in Albania have contributed to move this country into public and political attention after a phase of ideologically induced self-isolation.

Countries per direct coastal line By now adding Slovenia, Croatia, Bosnia-Hercegovina and Montenegro, it is becoming clear that this whole list is based on a common but rather simple denominator.All these countries hold a direct coastal line with the Mediterranean Sea. And more importantly, the scope of this list has been extended from the countries of the northern shore to also include those of the southern and southeastern shore of the Mediterranean basin. However, the coastal line criterion alone may not be sufficient in order to mirror the variety of characteristics of physical and social factors influencing the countries of the Mediterranean basin.

Controversial cases: Portugal and the Black Sea countries This scepticism is highlighted by the positioning of Portugal.Although bordering the Atlantic Ocean, there are similarities with Spain in the historical traditions of their colonialist adventures and authoritarian regimes, in their engagement in securing a fishing and shipyard industry as well as in their development of wide international maritime commerce relations. Nevertheless, although Portugal has distinguished itself in its language, mentality, popular images and customs from the rest of the Iberian mainland, despite these internal differences, it is most often included into this group of Mediterranean countries because the Iberian Peninsula has always been considered a mutually shared cultural entity, possessing common characteristics such as religious affiliations, certain traditions as well as family and household models. This demonstrates that the Mediterranean cannot be conceived as a mere geographical complex defined by certain markers (as a shared coastal line with its immediate coastland), but rather it should be interpreted as a unique and multifaceted cultural area or as a ‘civilisational zone’ (cf Inglehart and Baker, 2000). Another problem of inclusion is addressed by pointing to the countries bordering on the area of the Black Sea.This region is generally considered to be an area with comparably low population density (except for the Marmara Sea and Bosporus area), a rather stable continental climate and in many respects (coastal configurations, risk of crop failures, topography, non-agricultural resources), 5

Ageing in the Mediterranean

quite different from the rest of the Mediterranean (Özveren, 2001; King, 2004). Moreover, several countries around the Black Sea also demonstrate the impact of Islamic culture.The Turkish minority in Bulgaria, and also the Turkish population of the southern coast of the Black Sea, represent this influence, which has been in continuous conflict with a Christian heritage: the Orthodox traditions of Russia and Ukraine, Bulgaria and Georgia, as well as the influence of the independent Armenian church, which all connect to the impact of the Byzantine empire having been dominant in the northern and eastern part of the Black Sea.

Circum-Mediterranean countries: African and Arab extensions To expand the scope of countries of the Mediterranean into the ‘CircumMediterranean’ countries, as for example, the southern and southeastern areas, has given much stimulation to extend this list further by including more countries from North Africa that are adjacent to the southern shore countries (for example, Mauretania and Sudan). Even more important have been the suggestions to follow the connections into the larger Arabian Peninsula, for example, Jordan, Yemen, Saudi Arabia, the Emirates and Oman.

MENA countries: the alternative option for comparative analyses In the 1980s, The World Bank proposed a new approach to group country specifications and research orientations along regional lines and across continents. So they introduced the MENA countries, the Arab countries of the Middle East and North Africa, as a unit for analysis and evaluation in international comparisons, assuming that they shared similar social characteristics such as religion, ethnicity, demography and culture (The World Bank, 2005). Meanwhile, several international organisations have adopted this approach, reshuffled their indicator systems accordingly and remodelled their political bodies. In 1985 the United Nations (UN) established an Economic and Social Commission for Western Asia with its headquarters in Beirut in order to intensify relations in the Asian and South Arab regions. But it separates the Arab southern and southeastern shore countries from European reference and reduces the vision of ‘the Mediterranean’ to a merely historical quotation which, in an area of globalisation, can be dissolved and replaced by more actual political definitions (see Figure 1.1) . But does this shift in attention imply that asking questions about the unity and differences in the whole Mediterranean basin must cease to be a challenging topic for the social sciences? Not at all. Studying this culturally rich and ecologically diverse unit of the Mediterranean basin, with its century-long connections and conflicts, has been a continuous subject of research for very good reasons. The richness of material presented here demonstrates the complexities when this basin and its two shores are approached, both in present time and as a historical subject. The subject of ageing and its social consequences is the central guiding element here within this process of exploration. Its material basis can be found 6

Squaring the circle Figure 1.1: Countries that border the Mediterranean Sea

Note: Portugal and the Occupied Palestinian Territories are not included here. Source: www.worldatlas.com

in all those countries that have a common coastal line with the Mediterranean Sea (Portugal and the Occupied Palestinian Territories included) (see Figure 1.1). Not all of these countries will be analysed and discussed in this book, however: some will be presented as single-country pictures, while others will be analysed in comparative studies centring on certain fields of thematic attention.

Ambivalences in contrast These experiences question the language that talks about ‘the’ Mediterranean. They point to an intensive debate among social scientists and historians about how to approach this Mediterranean basin. A long tradition in social sciences and policy formulation to visualise a basic unity of the Mediterranean, to perceive the Mediterranean as a construct of unifying similar geographical, social and cultural conditions, is called into question. Now there is an increasing tendency to point to differentiation, to diversity in the physical and social dimensions of this region. Therefore, such an implicit tension between unity and variety is characteristic of any assessment of the Mediterranean landscape today. I work with this tension, but concentrate mostly on the side of the discursive production of meaning and images with respect to the Mediterranean as a framework for the comparison work. This will be shown for some selected aspects in the following paragraphs. It is useful to clarify in which way the comparisons will operate:

7

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• large-scale comparisons of areas going beyond one country, including comparisons of the whole or some Mediterranean countries and referring to the North European welfare states; • geographically vertical comparisons between the northern shore and southern and southeastern shore countries, all within the Mediterranean basin; • comparisons between the northern and the southern shore countries and in a geographically horizontal line.

Unity visions of the Mediterranean: dominance of landscape and sea power For the historian Fernand Braudel, the idea of unity of the Mediterranean was central for designing the method of his huge and well-known study on the Mediterranean (Braudel, 1966, 1999). Such a perspective assumes that there is a general comparability across a variety of historical periods and places in this world under observation.‘Unity’ describes more than just a collection of attributes being present simultaneously in different countries of this area. It implies that there is a deep-rooted consistency in integration, in commonly shared values and visions emerging among all these countries beyond their separate existence. To document this, he situated his perspective within a geological, terrestrial and ecological basis of analysis that was meant to serve as a continuous and stable ground in a longue durée. In his words: The Mediterranean as a unit, with its creative space, the amazing freedom of its sea-routes ... with its many regions, so different yet so alike, its cities born of movement, its complementary populations, its congenital enmities, is the unceasing work of human hands; but those hands have had to build with unpromising material, a natural environment far from fertile and often cruel, one that has imposed its own long lasting limitations and obstacles.... I have, therefore, sought out within the framework of a geographical study, those local, permanent, unchanging and much repeated features which are the ‘constants’ of Mediterranean history. (Braudel, 1966, vol II, p 1239) And he has been ever active in defending this theoretical decision. In the preface to the English edition of his work in 1966 he emphasised again the unity and coherence of the Mediterranean region: I retain the firm conviction that the Turkish Mediterranean lived and breathed with the same rhythms as the Christian, that the whole sea shared a common destiny, a heavy one indeed, with identical problems and general trends if not identical consequences. (Braudel, 1966, vol I, p 14)

8

Squaring the circle

Arguing with natural rhythms in the physical unit of the Mediterranean justified his reason to look at the distribution patterns of vine growing, of olive trees and the implantation of palm groves reaching from the Atlantic to the Indus as such unifying features (Braudel, 1966, vol I, pp 232, 172; Matvejević, 1987, pp 19, 64). However, the sea as a medium of exchange remained the most dominant feature of the Mediterranean. It made communication, cooperation and conflict possible among its different political, social and religious inhabitants and acted, even in times of severe discord and mutual hostilities, as an essential element of unity (Goitein, 1960; Grove and Rackham, 2001). The unity perspectives of the Mediterranean have also been negotiated on a level of imagery, of social constructions and circulating myths, often transmitted from the northern part of Europe into this region. Stereotypes as well as sympathetic narratives about alleged traits of the inhabitants have been produced and found their place in a wider public (cf Matvejević, 1987, 2005; for the North–South divide see Chapter Four, this volume). And even in tourism today one can find the continuous spreading and reformulation of such images (Gordon, 2003). Using the term ‘Mediterranean’ itself seems to be of rather modern origin, and its impact can be traced back to the imperialistic forces of the early 19th century of Northern and Central European countries to intrude and remodel, and forcefully modernise the Mediterranean.They expected that these changes would serve the realisation of their own political and economical interests. France and Britain, Russia, later also Germany, then systematically mobilised archaeological, geological and geographical expertise to qualify the most efficient explorations of these conquests (Fischer, 1906; Storch and Meiring, 2000). This grip of the imperial forces produced a persistent vision of being able to completely restructure the Mediterranean region for securing and enlarging the influence of these powers (Aboulafia, 2011). Clearly, the most successful project was the successful construction of the Suez Canal in the late 19th century (Karabell, 2003).

The Mediterranean: emphasising difference and culture Such trust in the benefit of transforming whole landscapes remains the heritage of a vivid philosophy of progress that, in its megalomania, has been dominant during the turn to the 20th century. With this colonialist burden, it is no surprise that looking at the Mediterranean from a line of unity has been widely discussed for years and has increasingly been critically reassessed. In the social sciences, above all in geography, anthropology and history, many contributors have become irritated with these propagators of unity, such as Braudel, Goitein and others (cf de PinaCabral, 1989; Shaw, 2001; Harris, 2005). Horden and Purcell (2000) formulated the most explicit and radical rejection of such a unity vision.They broke with the determinism of Braudel, and emphasised that they would rather look at the Mediterranean as a network of micro-regions, of ‘micro-ecologies’, seen as an arrangement of loosely connected but quite diverse entities that have to be regarded as constituting a rather fragmented landscape 9

Ageing in the Mediterranean

with a profoundly uncertain environment and an unpredictable climate. And in order to balance and to cope productively with these differences, such networks have to show a considerable degree of ‘connectivity’. Economic exchange in commerce and interactions in and between several micro-ecologies are the means to demonstrate this quality by coping with the risks of an ecologically fragmented world (cf Matvejević and Klakocar, 2011). However, to argue with a region-related connectivity means going beyond the diverse ecological dimensions of the Mediterranean basin. It has to widen the view to those social and cultural processes that would serve as an embedding fabric for differentiation. Pointing to cultural definitions of distinction opens the prospect of looking at variations in cultural settings in the Mediterranean. To be aware of these varieties in cultural expressions has not prevented the introduction and frequent use of a term such as ‘Mediterranean culture’ in scientific and public discourse that again promised to signal a certain degree of cultural homogeneity in the Mediterranean basin despite existing differences in its countries and regions. Usually, some essential elements are mentioned, which would constitute such a ‘culture’: • A central element of value affirmation consists in the existence and attribution of certain strict codes for regulating everyday life: the dominance of genderbased conceptions of male honour and its equivalent in female shame has been researched and studied intensively (Peristiany, 1966; Lisón Tolosana, 2001; Albera, 2006). But critical anthropologists have questioned the validity of honour–shame codes as a defining feature of the Mediterranean (Gilmore, 1987). Nevertheless, even today, the honour–shame concept and its gender dimensions remain a central topic for public discussion. • Another dominant element of such a culture is strong familism: the highly regulated social fabric of positioning family and kin members hierarchically; of following marriage strategies along relatives, kin and with early marriages for women with large age differences between spouses, as well as high levels of endogamy; of maintaining and transferring collectivistic values by making individualist options of privacy difficult; of granting emotional and economical security to intergenerational and wider community networks of villages and neighbourhoods; and the existence of patronymic associations of patron–client, non-kin relationships which have the tendency to develop into local clientelism, acting as patron–client relations making use of direct access to public means for private aims. But here again, anthropologists object: widespread and different forms of clientelism are also embedded in other cultural settings (Pitt-Rivers, 1963; Georgas, 1989; Inglehart and Baker, 2000; see also Chapter Three, this volume). • The other side of this dominance of smaller networks and their informal capacities for support is a lack of ‘public spirit’, and furthermore, a rather stable feeling of distrust against anonymous institutions and large-scale bureaucracies, foremost against a dominant power position of the Catholic or Orthodox 10

Squaring the circle

Church, but most of all against the regulating impact of a central or local state agency (Stavrou, 1995; Woolf, 2003; Sotiropoulos, 2004). • Some other observers want to give this pattern of distrust and scepticism an additional twist: this may result in a high presence of self-centred attitudes of those living close to each other in the Mediterranean basin (Matvejević, 1987). Moreover, Matvejević suspects that the inhabitants of the Mediterranean countries do not show any interest in learning from the experiences of neighbouring countries (cf p 103). Whether such generalised evaluations are empirically justified is left to comparative studies in cultural psychology and cultural anthropology (Davis, 1977). There has been intensive discussion among many anthropologists, historians and sociologists about the empirical validity of such a concept of ‘Mediterranean culture’. Moreover, cultural psychologists have tried to trace back the impact of this type of culture on processes of human development. For the group of MENA countries, Gregg maintains that there are several ‘layers’ of impact to be taken into account. These countries: … constitute a ‘culture area’ with distinctive influences on psychological development. This culture area is not defined by a clear boundary separating it from its neighbors but by the intersection of patterns it historically has shared with them: peasant agriculture with all Eurasia; nomadic pastoralism with the arid and semiarid zones surrounding the Sahara and stretching into Central Asia; a pediatric (and ‘slingcarrying’) model of infant care with much of sub-Saharan Africa and South Asia; the honor-modesty system with the preindustrial Mediterranean; Islam with societies now stretching from Nigeria to the Philippines. (Gregg, 2005, p 359) The continuous discourse about such a culture has mesmerised several intellectual observers and politicians in the Mediterranean, and has resulted in contradictory commentaries.When Taha Hussein published his book about culture in Egypt in 1938, it caused an enormous reaction among the British colonial forces as well as among his Arabian compatriots (Hussein, 1938). Hussein wanted explicitly to emphasise the shared heritage of a common Mediterranean culture, and advocated an intensive connection of Egypt with a European lifestyle.As a fervent nationalist he voted in favour of establishing secular institutions in his country, but refused to follow the very popular vision of a unification of Arab nations. To interpret the ‘Mediterranean culture’ as a productive means of helping to organise political change demonstrates the enormous force of this category for the intellectual and political life of the Mediterranean basin. Particularly for the Arab elites, it remains a highly questionable concept. However, it is not sufficient to intellectually question its validity from a social sciences standpoint, but rather to be aware of the fascination it has transported for many discourses of the educated 11

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elites from both shores until recent times.And this fascination has been intensified by the image production coming from North Europe: arguing with deep-rooted divisions between the ‘North’ and the ‘South’ and its mutual ascriptions.This has resulted again in an intellectual counter-movement of insisting on a unity vision for the Mediterranean (see Chapter Four, this volume).

Modernisation as a critical reference for researching ageing Emphasising differences and variety by pointing to different regional culture productions, but at the same time re-establishing and arguing with a unity orientation – this has been the ambivalent message of discussing the possible impact of a ‘Mediterranean culture’. Tension between unity and difference has also been a quality of discourses influential for a critical discussion of social and economical life in the Mediterranean, among them the modernisation theory. Concepts in the tradition of modernisation theory have been a decisive element in explaining the dynamic of social and political relations on a global scale. And it has materialised in the increasing impact of industrialisation and the crisis of the traditional rural world. It has received a worldwide importance in modelling the process of social and economic development in developing countries in the 20th century (Parsons, 1965; Rostow, 1967; Lepsius, 1977).The starting point for many reflections has been to describe and explain the formation of a ‘modern society’ by tracing it back to deep-rooted changes of ‘traditional’ features of a ‘premodern’ society, and by distinguishing new elements of developing modernity. For ageing and life course research, this view on modernisation has been particularly relevant. Representatives of this approach came to the conclusion that the societal status of older people in modern (that is, European) societies is clearly disadvantaged and in crisis. Several historical indicators have been offered to support this: the marginalisation of older workers in the internal relations of companies and on the societal level of labour markets; the pushing of older family members into a separate form of existence at the edge or even outside of a dominant nuclear family; remarkable general decline in reputation and power for older people on the societal level due to these marginalisations; and a loss of influence of older people in everyday life due to the disappearance of oral traditions in which stories and experiences have previously been transmitted and its replacement by modern technologies of reproduction (Cowgill and Holmes, 1992). This picture of a strict marginalisation of older people in present modernity has been criticised by historical demography, historical family research and anthropology. Some observers suspected an indirect transfiguration of a golden era for old age in pre-modern times in reverse, a vision that would be quite contradictory to the historical record. Several research results have shown that, arguing with clear-cut phases in the modernisation process tends to straighten quite diverse developments defined by class, status, religion and gender within the ageing process of modernising societies. It overlooks the variety of non-mobilised 12

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competences and abilities which have been, and are still apparent today, in an ageing population. Also, the promise of modernisation to challenge societal authority relations has not been redeemed in modern European societies. At least on the level of decisive elite positions, a form of (male) gerontocracy has obstinately survived. Moreover, modernisation has imposed new performance criteria and introduced new and institution-based inequalities: a split between a larger group of still ‘healthy’ older people and a smaller group of those in need of permanent social and medical care. However, the development of a modern welfare state with its programmes has achieved – despite continuous class, health and gender differences – a historically unheard of level of stability and accountability for the majority of older people. This has led some observers to speak directly about a ‘welfare state for older people’, established after the Second World War in Europe, but developed under the dominance of longevity into a crisis of self-legitimation today. Recent extensions of the classical modernisation concepts as, for example, the world systems approach and reflexive modernisation (Giddens, 1990; Beck et al, 1996), has resulted in a process of diversification and enrichment of perspectives. Despite a growing complexity, it is possible to summarise some of these observations and to reformulate them as attributes of a potentially postmodern society. The following trends can be observed for such a society: • rationalisation and orientation toward effectiveness in work and work-related conditions.This rationalisation, acceleration and performance pressure extends into private life, and also to other social and economic spheres of society; • professionalisation of procedures and administrations in a modern society as well as the creation of new professional and educational settings of institutions; • a shift of control and security assurance away from personally defined networks and face-to-face relations to newly created organisational features being more anonymous and impersonal; • transnational migration of female employment in services and of (young) male employment in different international production and service contexts; of whole families as victims and refugees due to political upheavals and civil wars; • a weakening of traditional religious affiliations and also the formation of new groups, which are more oriented towards spiritual feelings in everyday life; • changes in fertility, more strategies of reproductive control and self-control, also of counselling and planning of reproductive behaviour. Fertility decisions are negotiated depending on life conditions with a reduction in fertility; • dissolution of traditional female role conceptions, concentration on equal education of women, increasing female employment and representations in public life; • an increasing impact of the media, telecommunications and of the internet on professional and everyday life, creating new domains in the public representation of life cycle transitions;

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• a democratisation of this society, a radical questioning of traditional authority relations, an increase in self-organised activities and in civil engagement as well as a development of participatory mechanisms in decision-making. It remains an open question as to which cultural elements from a traditional background will lose its impact in a ‘modern society’, and in which way such traditions may buffer postmodern developments. Moreover, arguing with these society models presupposes a linear progress and an imminent unity and connectedness of intensifying changes in the process of developing into modernity. On a global scale, the promises of modernisation have been just as unfulfilled. Contrary to expectations, there has been no convergence or generalisation of modernised societies. Processes of a mutual rapprochement have not happened, not even between societies that seem to have been quite similar to each other as, for example, Western Europe and the US. Instead, there seems to exist an increasing degree of diversity in institutional arrangements, in family, in education, religious affiliations, political movements and so on, in different societies and independently from each other. And this applies not only to those societies that have been called ‘industrialised’, but is also apparent on a global level. In other words, modernity seems to create quite different dynamics of distinction and it favours divergent formations of civilisations. But this does not mean denying the challenge it still poses for a balanced comparative analysis of societal development today. Therefore, a strategy of open approaches seems to be the only appropriate way to study countries of the Mediterranean basin and their ageing processes. The following section should help clarify the dimensions of such undertaking.

The ageing complex in the Mediterranean: challenges and developments Ageing will result not only in challenges to the social fabric of societies, but might even intensify existing inequalities. An older observation about migration processes into the EU described characteristic modernisation deficits for its southern shore countries: The Mediterranean Sea marks one of the sharpest demographic and economic divides currently to be found on the world map. To the north lie countries whose demographic growth is extremely low and whose standard of living is among the highest in the world. To the south of the Mediterranean lie the countries of North Africa with rates of natural increase which are extremely high and whose economies, while not uniformly weak, provide their populations on average with incomes worth only 6 per cent of the values of incomes in Western Europe. (Rees et al, 1996, p 3)

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Squaring the circle

Based on the Human Development Index (HDI) of the annually published UN Human development report, data since 2004 demonstrate that this general impression of a discrepancy in development still shows some validity today (World Bank, 2006). The HDI, as quite a controversial index (cf Sagar and Najam, 1998), is formed by per capita income, but also by life expectancy and degree of educational attainment, with the help of the number of years in school and the prospective duration of education for a child being in an age of enrolment. Looking at the unfolding of its values over time for a first inter-country comparison might give helpful insights (see Table 1.1).Therefore, looking at the data longitudinally, they seem to indicate that this rift in the socioeconomic conditions between the northern and southern shore countries was still existent in 2011.There are some differences within the northern shore countries. Greece, as well as Montenegro, and in part Croatia, Italy and Malta, show a certain unsteadiness in their values, while some countries expose either a clear increase (France, Spain, Portugal and Slovenia) or a slow growth (Albania and Bosnia-Herzegovina). In the southern and southeastern shore countries only Israel stands out with a very high value; the rest of the countries show a steady but quite slow increase in values. The contours of longevity in the countries of the southern and southeastern shores of the Mediterranean have been already discussed among demographers (see Tabutin and Schoumaker, 2005). In Table 1.2, which is taken from an excellent review of demography in the Arabian countries, one can see the slow decrease for the younger age groups (60 by type of intergenerational co-residence in Tunisia (%) No children co-residence Parent head, biological children only Parent head, any children in-law Child head, biological children only Child head, any children in-law

Total 10 44 22  4 20

Men 10 58 22  1  9

Women 10 29 22  7 32

Source: Yount (2009)

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partner selection, major purchases and relocation (ranging from 44 to 83 per cent) as well as in other less important affairs such as decisions that have to do with food selection and recreation, albeit at lower rates (ranging from 31 to 69 per cent). As a whole, these percentages show an active participation of older people in family decisions fostering an environment for active and healthy ageing.

Image of old age in society There are some contradictory aspects, positive and negative, regarding the portrayed image of older people in Tunisian society. For the most part, they are valued as ‘guardians of the collective memory’,‘conservers of intergenerational relationships’ and ‘transmitters of authentic ideals’, and are also seen as contributing indirectly to the national economy through their caregiving role to grandchildren. However, once they lose their autonomy and become frail and dependent, older people are then seen as incapable of making their own decisions and tend to become a social and financial burden on the family and on society. While mistreatment of older people is majorly frowned upon, many people who reach the age of 60+ still unfortunately experience social marginalisation, economic insecurity and sometimes even abuse. From their own perspective, older adults fear loneliness, illness and dependence as well as being a burden on others. The feeling of loneliness is common despite living with others; 6.5 per cent of those aged 65+ do actually live alone, and 40 per cent of them feel lonely (Hajem, 1996). Tunisian older people often pray to live as long as their spouses and not longer, and to die without suffering and without being dependent on others: ‘One day in bed, and the next in the grave’. Owing to cultural norms, it is dishonourable to place an older parent in an elderly home, as this is socially perceived as a relegation of the role and duty of the family. At present, there are 11 public homes for older people in Tunisia, and while accurate data are not available, it is estimated that these accommodate around 0.07 per cent of Tunisian older people. This is much lower than the prevalence rates of institutionalisation in Europe and the Western world (5.5 per cent in the UK, 4 per cent in France, 9 per cent in the Netherlands and 6.5 per cent in the US) (Ribbe et al, 1997).

Governance Among its neighbouring Arab countries,Tunisia has been a pioneer in formulating policies, legislation and plans of action in support of its older people. It is one of few countries worldwide that has the word ‘elderly’ in the title of its Ministry (Ministry of Women’s Affairs, Family, Children and the Elderly). One of the fundamental principles of Tunisian policies in the field of ageing revolves around the premise ‘ageing in place’, helping older people to stay at home and in their natural environment for as long as possible. Tunisia stressed this principle in the Law of Protection of the Elderly Persons as early as October 1994, reinforcing 354

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primarily the role of the family and the duty of society and state in providing care and protection for its older people. In this regard, Tunisia introduced the concept of volunteer hosting families whereby legislation authorised families to host an older person within their homes, granting them decent living conditions in exchange for a modest monthly allowance contracted by the state. The National Committee on Ageing was set up within the High Population Council and is entrusted with an in-depth exploration of the direct impact of demographic developments in Tunisia. A decennial (2003–12) plan of action for older people was adopted in 2004 according to the guidelines of the Madrid International Plan of Action on Ageing 2002, The Arab plan of action on ageing to the year 2012 (ESCWA, 2002), and the specific needs and values of Tunisian society and culture. It stressed the following principles and activities: (1) ageing in the home environment; (2) poverty reduction; (3) active participation in society and family; (4) lifelong learning; and (5) health and social interventions. In response, Tunisia invested in several programmes that aim to bring these policies to fruition.Among these are the National Programme to Assist the Elderly within their families, state-funded facilities to accommodate those in need, financial assistance for selected poor older people and the expansion of Tunisia’s health infrastructure providing healthcare that responds to the emergence of chronic disease and disabilities and the growing needs of the older population. Tunisia also passed a law that defines the conditions under which private institutions and homes for older people can be set up. It also prescribes and monitors the services they are required to provide in terms of health, social and cultural services as well as leisure (Robalino et al, 2005). As part of its effort to preserve the purchasing power of pensioners, the state has ratified the law that links old-age pensions to standards of living. Pensions are thus automatically revised when there are wage increases (Sibai and Kronfol, 2007). In March 2010, concrete measures were taken at the highest political level to further develop quality services offered to seniors in all regions. These measures include increasing the number of mobile multidisciplinary health and social protection teams reaching older people in their home environment, boosting the services and interventions of non-governmental associations (NGOs) and associations of older people, and encouraging the creation of clubs that are tailored to the needs of older people while encouraging businesses to build institutions for the accommodation of older people without any family support.The amount of monthly allowance given for hosting an older person in a surrogate family was raised by 50 per cent, training in geriatrics was enhanced and plans made to create new geriatric units in public hospitals. In 2003, the Ministry entrusted with the affairs of older people created a national register of qualified professional seniors, encouraging retired and older people to engage in voluntary activities for the community, thus helping them to maintain an active and productive life (www. kafaet-mousenine.nat.tn).

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Conclusion The Tunisian population is ageing rapidly, and older people have always been given special attention at the highest levels of the state.Tunisian policies for older people focus on helping them to remain in their home environment for as long as possible, promoting their values in family and society, enhancing their contribution to the country’s development and consolidating intergenerational relations. Yet Tunisia has a long way to go. Recent political changes, as well as the more precise data about older people to be generated by the population census planned for 2014, are expected to lead to modifications and adjustments to Tunisian policies in the field of ageing, notably a reform in its pensions system.The policy agenda needs to have a culturally sensitive understanding of issues affecting older people and similarly, a culturally sensitive application of government action on ageing. References Beard, J.R., Biggs, S., Bloom, D.R., Fried, L.P., Hogan, P., Kalache,A. and Olshansky, S.J. (2012) Global population ageing: Peril or promise?, PGDA Working Paper No 89, Program on the Global Demography of Aging (www.hsph.harvard.edu/ pgda/WorkingPapers/2012/PGDA_WP_89.pdf). Ben Braham M. (2008) Pension systems generosity in North Africa, Working Paper, June, Terre Haute, IN: Networks Financial Institute, Indiana State University. Charrad, M.M. (2011) ‘Gender in the Middle East: Islam, state, agency’, Annual Review of Sociology, vol 37, pp 417-37. ESCWA (Economic and Social Commission for Western Asia) (2002) The Arab plan of action on ageing to the year 2012, February, Beirut, Lebanon. Ghannem, H. and Hadj Fredj,A. (1997) ‘Epidemiology of hypertension and other cardiovascular disease risk factors in the urban population of Soussa, Tunisia’, East Mediterranean Health Journal, vol 3, no 3,pp 472-9. Hajem, S. (1996) Tunisian survey about the health and conditions of life of the elderly aged 65 and over living at home, National Institute of Public Health, National Office of Family Planning, Ministry of Health and World Health Organization (unpublished article). Hamza, N. (2006) Socio-demographic mutation of the Tunisian family, Tunisia: The National Board for Family and Population. [in French] INS Tunisia (National Institute of Statistics, Republic of Tunisia) (2007) Population projection 2004-2034, Ministry of Development and International Cooperation, pp 108-10 (www.ins.nat.tn/publication/prjpop_2007.pdf). [in Arabic] INS Tunisia (2008) Statistical yearbook of Tunisia, Ministry of Development and International Cooperation, p 51. Jawadi, A. (2012) ‘Tunisia’s ageing population faces challenges’, Tunisialive (www. tunisia-live.net/2012/04/07/tunisias-aging-population-faces-challenges). Laouani, K.C., Hmouda, H., Ben Naceur, M.H., Ghannem, H., Toumi, S. and Ajmi, F. (2004) ‘High blood pressure for people aged more than 60 years in the district of Sousse’, Tunisie Medicale, vol 82, no 11, pp 1001-5. 356

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NBFP (National Board for Family and Population) (2002) The Tunisian Survey for Family Health: Principal report, September, Office National de la Familie et de la Population. Ribbe, M.W., Ljunggren, G., Steel, K., Topinkova, E., Hawes, C., Ikegami, N., Henrard, J.C. and Jonnson, P.V. (1997) ‘Nursing homes in 10 nations: a comparison between countries and settings’, Age & Ageing, vol 26-S2, pp 3-12. Robalino, D.A., Whitehouse, E., Mataoanu, A.N., Musalem, A.R., Sherwood, E. and Sluchynsky, O. (2005) Pensions in the Middle East and North Africa: Time for change, Washington, DC: The World Bank. Saxena, P.C. (2008) ‘Ageing and age-structural transition in the Arab countries: regional variations, socioeconomic consequences and social security’, Genus, vol 64, nos 1-2, pp 37-74. Sibai, A.M. and Kronfol, N. (2007) Situation analysis of population ageing in the Arab countries: The way forward towards implementation of MIPAA, for UN ESCWA (www.globalaging.org/elderrights/world/2008/situation.pdf). Tunisia (2010) ‘Tunisia: State acts to strengthen integration of older people in society’, Seniors World Chronicle (www.seniorsworldchronicle.com/2010/10/ tunisia-state-acts-tp-strengthen.html). UNDESA (United Nations, Department of Economic and Social Affairs) (2010) Population ageing chart, Population Division. World Bank, various years, databank (http://databank.worldbank.org). Yount, K. (2009) ‘Gender and intergenerational co-residence in Egypt and Tunisia’, Population Research and Policy Review, vol 28, no 5, pp 615-40, October. Yount, K.M. and Agree, E.M. (2004) ‘The power of older women and men in Egyptian and Tunisian families’, Journal of Marriage and Family, vol 66, pp 126-46. Yount, K.M. and Agree, E.M. (2005) ‘Differences in disability between older women and men in Egypt and Tunisia’, Demography, vol 42, no 1, pp 169-87. Yount, K.M. and Sibai, A.M. (2009) ‘The demography of aging in Arab societies’, in P. Uhlenberg (ed) International handbook of population aging, Dordrecht, The Netherlands: Springer, pp 277-315. Yount, K.M., Agree, E.M. and Rebellon, C. (2004) ‘Gender and use of health care among older adults in Egypt and Tunisia’, Social Science & Medicine, vol 59, pp 2479-97.

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Conclusion and themes for further discussion Joseph Troisi and Hans-Joachim von Kondratowitz Editorial work for this collection was based on a few, but essential, premises. To deal with the ageing phenomenon it is important to be aware of present and future demographic changes and shifts. It is also necessary to make visible and comprehensible the social consequences of these processes for individuals and social settings. Moreover, it is imperative to discuss critically the manifestations and developments of ageing in their effects for whole societies as well as for the programmes and policy options of welfare states responding to this new challenge. In this book the whole Mediterranean region was chosen as the central unit of research. It has therefore also been indispensable to become aware of long-lasting traditions and cultural traits whose possible impact on the ageing phenomenon must be discussed and evaluated. With such a programme, formulating central conclusions is complicated, for several reasons. First, often non-harmonised theoretical and disciplinary approaches about the ageing dynamic of the Mediterranean make it difficult, as well as the social heterogeneity in this whole Mediterranean region being its dominant characteristic. Balancing out the weight of differences and complexity against the strengths of similarities requires careful assessment of the evidence about the social effects of ageing in all of the Mediterranean countries. Altogether, five main fields for discussion emerged as essential to stimulate further reflections and dispute: first, a discussion about methodological implications regarding the development of appropriate concepts, of establishing instruments and indicators for a comparative framework; second, becoming aware of the given ambivalences regarding the concept of culture for an analysis of this region; third, discussing again the crucial position of the family in this region and pointing in particular at the ongoing changes and reforms for the care of older people there; fourth, recalling some sociological approaches to life course analysis and discussing and using their explanatory power for the comparison work; and finally, evaluating the ongoing policy strategies and patterns of governance in respect to ageing in this region, and taking into consideration support from the European institutions.

Options for the methodology First, we look at some methodological and theoretical ideas and consequences aimed at suggesting new research perspectives. It was mentioned in the introduction 359

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to this volume that there are today several data-enriched alternatives to analyse countries from the Mediterranean region in a comparative way, for example, the model of MENA (Middle East North Africa) countries (or other similar options). Its objective is to develop a comparative framework for concentrating on the southern and southeastern shore countries of the Mediterranean by attributing them to the African and/or Asian continent, and focusing on the Arab and mostly Muslim background. Several contributions as well as our own editorial texts have repeatedly taken advantage of these datasets. Using the MENA strategy has meant separating the southern countries from the northern shore countries of the Mediterranean, and to systematically cut connections to a European reference.To focus deliberately on the special cultural and social dimensions of this whole Mediterranean region in a comparative manner requires the production of new instruments and strategies for data collection. For future empirical research it will be advisable to qualify this model by constructing an ‘indicator grid’ or a systematic data and information package in order to characterise countries or sub-regions if they are conceptualised as cross-border units. The only initiative working on such an instrument has been the Mediterranean Prospects Consortium (MEDPRO), coordinated in the EU’s 7th framework programme by the Centre for European Policy Studies in Brussels (www.medpro-foresight.eu). Moreover, such analyses should also be qualified by mobilising ethnological and cultural-scientific expertise and by integrating small-scale studies about certain areas and units within this Mediterranean region. The concept of ‘connectivity’, originating in Horden and Purcell’s (2000) work and discussed in the introduction, might serve here as a guiding general idea. Its perspective would be to first balance out the interaction of quantitative and qualitative aspects and data; second, to insist on the strength of a variety of social as well terrestrial bonds as central factors of forming the self-understanding of local communities and networks; and finally, it might also allow a pointing to the mutual dependence of people for integrating and connecting to their complex social environment with the help of communities and social networks.To develop out of this process a specific local self-definition and culture will be important. Ageing research has already used concepts that promise to be supportive of this orientation and offer intellectual linkages to such an understanding of cultures. It is particularly true for the analysis of social networks and their function for the wellbeing of older people. Life course research has worked successfully with the ‘convoy model’ of social networks which ‘suggests that people maintain distinctive personal social network structures that accompany them over time but also that these structures change in response to different situations’ (Litwin, 2009, p 599). These social network structures are also conditioned by the social and cultural context to which a person belongs. Results of the research about religious identities and ageing from Lebanon have confirmed this perspective (Ajrouch et al, 2011). In his comparative analysis using the SHARE datasets, Litwin wanted to inquire about the differences between networks of older people in the Mediterranean 360

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(here, France, Greece, Israel, Italy and Spain) and non-Mediterranean countries (Austria, Belgium, Denmark, Germany, the Netherlands, Switzerland and Sweden). He found remarkable differences in network conceptions between families in Northern and in Southern European countries. In the Mediterranean countries families indeed had larger households, but defined their boundaries as much less wide and more in respect to their contacts in their immediate spatial vicinity. This stands in clear contrast to the Northern European families, whose network exchanges extend over great distances (Litwin, 2009, p 605).

Problem of culture: between empirical and ideological domains The preceding remarks give sufficient reason to look at ‘culture’ as a much more influential point of reference for future analyses of the Mediterranean region, but several contributions in this volume have shown the risk of such association.The message of the introduction was clear about the theme of ‘culture’ – there have been several discussions about working with a somewhat homogeneous ‘culture of the Mediterranean’, but there have also been good reasons to challenge such a wide and generalised outreach. It would be preferable instead to speak about different ‘cultures’ in order to characterise rather small-scale or micro-political social settings shaped by specific dominating norms and values with a wide social impact, as, for example, in the case of ‘family cultures’.Therefore, cultural analysis would focus on the study and inquiry about the interlocking and interweaving of several cultures of different quality and on different levels of analysis. In contrast, arguing with ‘culture’ has often meant transporting quite a global understanding. Research in cultural psychology by Hofsteede,Triandis and others has developed the dichotomy of cultural syndromes of ‘individualism–collectivism’ in order to distinguish whole societies by looking along this dichotomy for the dominance of one of these central value orientations in different groups and social settings (see, for example, Triandis, 1995; Hofsteede, 2001). Recent research, in this line, has focused more on the interface between the development of selfconcepts and individualistic and collectivistic cultural mindsets. Such a research perspective also has relevance for comparing collective ‘cultures of honour’, as maintained to be characteristic of the Mediterranean, with collective cultures of modesty, contrasting them with individualistic cultures that could be termed ‘cultures of self-enhancement’. However, there is another heritage to be kept in mind when ‘culture’ is used in public debates, coming from an ideological background. Here the topic of ‘culture’ has quite often been radicalised to a perspective of an inherent value convergence in all these countries, by speaking about a ‘unity’ of the whole region. It has now occupied several cultural historians and philosophers, mostly from the northern shore countries, with the idea of giving the whole Mediterranean a new value position and also recognition in international affairs. Using a concept of unity

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is supposed to trace in these differences essential degrees of interconnectedness between northern and southern shore countries. But whether such a concept of culture in the Mediterranean will be convincing remains controversial. Policy-makers shape the public arena with progressoriented strategies and with their eagerness in trying to stimulate economic growth along industrialisation in a crisis-ridden zone threatened by disarray and diminishing economic capacities. Apart from this list of potential problems, the ageing of these countries is often added as another important factor of insecurity, but also of promising societal gains in the future. Homogeneity visions for these societies are under scrutiny, and to evocate long traditions and cultural roots of the whole Europe, founded in the Mediterranean civilisation model, is losing public recognition. Using ‘culture’ here is an empty phrase or, even worse, a term that is used to cover up unwelcome irrationalities and habits in the political acquaintances, work and everyday life of this region. Additionally, tendencies of an intensifying regionalism and of fractional dynamisms are reaffirmed between the countries of the Mediterranean that will necessarily work against any unity aspirations. Whether the European Union (EU) and their policy structures could act as a mediator is questionable since, at the moment, they are themselves taken up with the renegotiating of their own concord (Ayadi and Sesso, 2011; Coutinho, 2012).Therefore, at the moment, the allegation of a ‘unity of the Mediterranean’ has been transformed into an oftenused formula for advertising ambitious cultural projects as exhibitions or literary meetings (as in the symposium ‘The white sea’; see http://www.euromedp.org/ profile/our-white-sea-conference/).

The imagined family and its contradictions It is remarkable that the Mediterranean region is still characterised by the dominance of the model of a larger extended family environment, with a clear gender-specific division of labour, and often also connected to certain ethnic and religious communities. Particularly for the southern and southeastern shore countries, the contributions have again underlined such dominance. And this, despite several influences coming from everyday life, which has set the normative strength of this model under pressure of unfavourable life circumstances, as strenuous formal and informal work conditions, unemployment, and also of civil war experiences and political oppression. These reports show a certain degree of ambivalence concerning the position of older people in their families. Veneration and respect towards older people are still reported, and are continuously flanked by extensive references to the Islamic traditions. However, at the same time, arguments are raised reflecting a potential weakness of such normative codes under strain. Further research with regard to the continuous relations of intergenerational solidarity and the position of social networks in these southern shore Mediterranean countries will be necessary (Jurado Guerrero and Naldini, 1997). 362

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Really remarkable developments seem to materialise in the critical case of care of older people. The relative attention given to this subject is manifested in the growing impact of an internationalised gerontological expertise. However, it also seems to reflect a general trend, particularly in the southern shore countries, to look at old age predominantly under the aspect of health and dependency. This gives the medical profession a particularly strong position. In the field of care, the Mediterranean countries from both shores seem to experiment with several options to provide help and support in the case of old-age dependency. First of all, the range of variations in these arrangements reflects characteristic welfare traditions applying especially in the northern shore countries. The Long-Term Care Insurance and its principles in Israel (and recently Spain) as well as the universality principles of the tax-financed health service in Malta and Italy are such traditions. But they are now complemented with new arrangements: connecting with informal migrant care workers (as in Israel and Italy) or with communityoriented home care services (as in Portugal).All these different options, connected to this traditional background, take into account the increasing number of older people, the decreasing availability of family (that is, mostly female) carers and the crisis in the mobilisation of professional care personnel in these countries. But experimenting with care provision also seems to be a topic in the southern and southeastern shore countries. Home care, as opposed to a socially strongly disapproved institutionalisation, is here still a product of informal connections, of neighbourhood relations, social networks and of kin support. But these care constellations can also be further enriched by professional qualifications from a public health or geriatric perspective. Such flexible informal–formal mixes in direct personal care seem to be a sign of a new understanding of support and help for dependent older people in these southern societies. But to what degree these mixes are already characterising the care reality in different social classes needs to be documented. And these supportive trends stand in contrast to a still increasingly negative image of old age in the case of frailty and dependency in these societies (as in Tunisia and Lebanon). Despite such ambivalences, it is worthwhile investigating how and in which way these countries will develop a new model of a special welfare state for elder care. This may be defined by different degrees of obligations and by mixes of informal and formal work.Yet, at the same time, it will reach beyond a mere state responsibility for care, of which its political elites will not be capable or willing to take over such a binding task. In the present situation of public unrest in most of the Arab Southern Mediterranean countries, the development of such careoriented policies will certainly carry only secondary importance for policy-makers. The urgency of offering job opportunities for the unemployed and educated as well as the less educated youth will overpower the discussions aimed at preparing programmes of job maintenance and work–life extensions for the still smaller group of those adults and older people who are in formal employment (albeit in societal minority).

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At the moment, the promise of improving the social situation for a widely suffering urban and rural majority seems to be the only credible solution for securing the legitimacy of a still unstable political leadership in the Southern Mediterranean countries. At least, with respect to mobilising the planning activities for an ageing society, there will, for some time, be a difference between the northern and the southern and southeastern shore countries. However, in the end, there will only be a short delay to also bring these countries into the arena of the discourse on ageing societies and its variety of political consequences.

Life course regimes and ageing perspectives We now contrast the northern shore countries (Portugal, Spain, Italy, Greece, Cyprus, Malta, also France and Israel) with those of the southern and southeastern shore (Morocco, Algeria, Libya, Tunisia, Egypt, Occupied Palestine Territories, Lebanon, Syria and Turkey) regarding existing differences and similarities in respect to the ageing phenomenon. But while a full information base for the northern countries is already available, it is necessary to devote particular room to the southern countries.Three macro-sociological approaches, which have been proven to be successful in analysing long-term societal developments for modern ageing societies, could be tested in their explanatory power for the two parts of the whole Mediterranean. These are the model of the institutionalisation of the life course, the typologies of welfare states and the life course and institutional analysis in a global economy. They all exposed a critical perspective on the modernisation processes that would give prominence to diversities and varieties between different country spectrums. An influential model of looking at changes within the ageing process has been the idea of an institutionalisation of the life course (see Kohli, 1986; Dannefer, 1988). This process has emerged over a long time period and has structured the existing welfare systems with increasingly standardised life courses in the 20th century, particularly after the Second World War. Focusing on the society-wide implementation of the formal employment system as an institution, with its processes of gradual standardisation of life forms, the essence of this model has been well described by Kohli (2007, p 255). It refers ‘to the evolution, during the last two centuries, of an institutional programme regulating one’s movement through life both in terms of a sequence of positions and in terms of a set of biographical orientations by which to organise one’s experiences and plans.’ Several indicators for this process have been presented and ought to be tested: temporalisation, when life time develops into a central structural characteristic; chronologicalisation as a mechanism to use chronological markers for structuring life time passages; individualisation for focusing on individuals as units for social life; and systems of work based on wages, labour and a tri-partition of the life course. The southern and southeastern shore countries of the Mediterranean show conflicting evidence: signs of a temporalisation and measures of chronologicalisation are already visible in all of these societies. In a comparative study about ageing 364

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in Arab countries (Yount and Sibai, 2009, Table 13, pp  285-7), most of these Middle East countries with contribution-based security systems expose retirement solutions by using clear chronological age limits. All these retirement schemes are aimed at the public sector, at different professions, at employees in hazardous work conditions, sometimes in self-employment, at civil service employees and at the armed forces. By using chronological markers in retirement, administrative traditions from the former colonial rule of Britain and France might have been adopted. Empirical research has still to show how these age limits are implemented or negotiated in the practice of these countries. In addition, other differences are obvious, by deviating from the institutionalisation model: the informal and/or poorly insured work structures with several flexibilities in performance and work organisation, as well as the often poorly or uninsured rural work which are still prevailing in all these societies, although with different intensity. The processes of individualisation are already somewhat apparent, particularly in the well-off middle classes, resulting from the use of technology and media, as well as from everyday life experiences being exposed to global commodities. But they seem to also reach into the poorer segments of these societies in urban and rural environments. And here women seem to be an important source for formulating and acting out such processes of selfdetermination. Nevertheless, individualisation is not yet a widely shared quality of these societies. In other words, there are first contours, but no domination by an institutionalisation of the life course in these southern countries. Two further options can be useful to help enrich comparative perspectives. First, the intensive discussion about adequate criteria to identify and to argue with typologies of welfare states. This has been inspired by Esping-Andersen’s work and the ensuing controversies about his suggested typologies (EspingAndersen, 1990, 1999). He concentrated on the Central, Nordic and AngloAmerican countries, but had also included Italy in his study, and attributed it to his type of a conservative-corporatist model of welfare state. To associate Italy with the conservative type has incited further debate, and the answer was the development of a special model of the Southern European welfare state. It was also an appropriate response to the previous neglect of this region by welfare state theoreticians (see Ferrera, 1996; Martin, 1997; Rhodes, 1998;Andreotti et al, 2001). Without being able to go into many details here, some dominant characteristics of this southern state model are apparent: a clear weight of insurance- and contribution-based welfare provisions in which nearly two thirds of welfare resources are distributed. If they could look back at such a contribution-based working career, older people, mostly males, are fairly well secured by this welfare state, even if pensions turn out to be unequal in benefit size. Data from SHARE have shown that there is a common transfer pattern between generations in Europe, a net downward flow from the older to the younger generations in respect of inter vivo financial transfers, but also of social support. And those transfers are more frequent and intense than those going from the children to their older parents. This also applies to most of the northern shore countries of the Mediterranean 365

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(see Albertini et al, 2007). Moreover, it stands in difference to the options of older people in most southern and southeastern shore countries, where the direction of economic means of support goes mostly in the opposite direction, from the middle generation to older people (see Daatland and Herlofson, 2003). Another characteristic of welfare state organisation in the northern shore countries is the existence of several inherent deficits that work simultaneously together. These welfare states aim to be legitimised in a divided and socially fragmented society in which informal and parallel economies work against a realisation of universal principles and solidarity mechanisms. This deficit allows the heterogeneity of interest groups to follow corporate policies and to help developing structures of clientelism and corruption to balance deficiencies of state provision (Rhodes, 1998). Partial compensation takes place through the mobilisation of solidarity networks based on kinship and community ties and by the third and voluntary sector. Observers summarise a particular combination of a weak state, strong primary networks and segmented labour markets as clear indicators for this type of welfare state (Andreotti et al, 2001, pp 49-50). ‘Family’ refers here not only to being able to count on wider reciprocity networks, but it also defines the domestic sphere as the realm of female work activities which, in turn, means stabilising a breadwinner position for males within the labour market. To consider under these conditions the development of the life course in both parts of the Mediterranean means also consulting the second theoretical option. This approach opens a view on the conduct of the human life course under the condition of an increasingly globalised economy. It looks at other institutional settings beyond the employment sector, how they are linked together and influence the life course, particularly of adult and older people in the Mediterranean. Here one needs to give due importance to the impact of education, the dynamics and value orientations and the transfers within the family, to potential career offers and the special omnipresent risks of life course regimes as, for example, the organisation of care of older people (Mayer and Müller, 1986; Mayer, 2001; Buchholz et al, 2011). Unfortunately, countries originating from the former Yugoslavia and Albania could not be analysed in detail here, although they have been part of the report about the demographic dynamics of the region. All of the northeastern shore of the Mediterranean are representatives of a post-socialist welfare state that had a peculiar development in their immediate transition to capitalism (Hoff, 2011). They have been characterised by remarkable decreases in fertility rates and mounting pressure for migration (especially in Albania, but also in some of the former Yugoslavian states). And they all experienced rapid rationalisation, a high degree of unemployment and forced the early retirement of older workers in manufacturing and agricultural sectors and of low qualified employees, together with a wide increase in deep social inequalities. Several of these welfare states later followed quite diverse routes of economic improvement and ageing policies that need to be studied in more detail. Moreover, the countries of the former Yugoslavia had to cope with extreme social ruptures and the destructive long-term 366

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consequences of civil war.Therefore, to look at the transitional passages and policy shifts of these countries as well as their internal connections to the Mediterranean paradigm would be a better subject of a contribution to be published separately. An impression at first sight renders a surprising presence of similarities and, therefore, it associates a high degree of immediate comparability within this whole Mediterranean region. Even if apparent and valid at quite different points in time, several of such similarities appear as dominant characteristics. Conditions for the ageing phase of the human life course in both contexts of this region are: • predominance of formal employment in the state and wider public sector; • high presence and utilisation of informal and, often precarious, work connections; • ‘insider-outsider’ constellations of social security in old age due to the effects of the existing insurance systems; • slow development of more extensive labour market participation of women (outside the sphere of domestic work); • high degree of unemployment, particularly youth unemployment, but also of the long-term unemployment of older people, with pressure to get active in informal work as a survival strategy; • intensive family obligations, processes of cohesion and support in times of crisis, together with a buffering potential by social and immediate community connections; • complementary strategies of well-off families to secure care for dependent older family members (for example, by mobilising migrant care work); • apparent disparities and inequalities in respect to economic and social security in old age; • marginalisation of special groups among older people, for example, along ethnic origin and status of impairment; • strong pressures for individuals and families to try the way out by investing in transnational migration of family members or groups of families; • normative dominance of religious world interpretations – Christian (catholic and orthodox) or Muslim (Sunnite and Shi’ite) – in forming the evaluation of adult and old age. This clear prominence of similarities raises doubts in regard to the calling in question of modernisation that has been formulated in the introduction to this volume. Obviously the framework of modernisation still has a remarkable explanatory power for shedding light on social processes in the whole Mediterranean region. Indeed, one might be tempted to use a formula, often criticised as being too valueladen.This refers to the formula of a ‘catch-up modernisation’ in order to describe intensified industrialisation as the dynamic factor of the whole developmental patterns of the southern and southeastern shore countries in comparison to the northern countries. But while it is important to see all the common dimensions of the two contexts, it is also necessary to look for the characteristic differences 367

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between them, and to describe their potential impact for different development routes (Buchholz et al, 2011; Groth and Sousa-Poza, 2012; Lloyd-Sherlock, 2010). Therefore, the northern shore countries are interpreted here as already exposing developments toward postmodern contours. In contrast, the southern and southeastern shore countries can be seen as quite ambivalent and potentially contradictory environments with several lines of development crossing each other – in some respects in the case of those modern societies with some industrial structures, but in several cases with still large and traditional areas of rural work, normatively strong family impact and in the process of coming to terms with long-lasting and religiously inspired value orientations and social characteristics. But, at the same time, several southern countries are already additionally exposed to influences and consequences of a post-industrial development. In view of these dispersing trends in the southern shore countries, it is, therefore, too narrow to approach this context with the formula of mere ‘catchup modernisation’. In contrast, the future development of these countries with respect to the ageing impact is by far more multifaceted and less clear to project. It might even be possible that, in the southern and southeastern shore countries of the Mediterranean, a historically new model of an ageing society will emerge, evolving under their specific conditions. In order to follow such a long-term vision in more detail, it will be useful to look at the whole evidence for comparison under a fresh point of view.

Governance perspectives and the European challenge In order to better understand the activities and strategies directed at ageing in both contexts of the Mediterranean, it is useful to follow the specific dynamic of demographic projections. For the northern shore countries, the situation is clear. Fertility decline is already fully present, life expectancy at birth is steadily increasing and the longevity societies of the future are in the making. In all the northern shore countries there is now a continuous discussion about the consequences of an ageing society for the labour market, for social insurance systems and for securing the care situation for the ‘oldest old’ in these countries. This debate took a considerable time to materialise, with some countries (as in Albania, several countries from the former Yugoslavia, with the exception of Slovenia) still ‘relative latecomers’ in discussing the effects of an ageing social environment (Hoff, 2011). Despite such slight discrepancies in the timing of societal awareness about ageing, the large majority of the northern shore countries have now developed an extensive political discourse about reform strategies and policy options. Therefore, a discussion of governance perspectives is now able to concentrate on the southern and southeastern shore countries. This allows us to go back to the topic of the ‘demographic dividend’ that has already been described as the period in which the proportion of children under the age of 15 drops below 30 per cent, and the proportion of people beyond 65 is still below 15 per cent.This connection between a fast increase of the working-age 368

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population with a ‘youth bulge’ (aged 24–30) of young adults (resulting from a former high fertility rate), a very slow increase or even decline in the number of new-born children and a still slower increase of older people has the advantage of being projectable in an accurate way.This opportunity might offer the possibility of concentrating investments on important development positions (for example, education) if such a road is recognised, politically decided and used productively (Jones, 2012). As can be seen in Table 17.1, these constellations will affect the southern and southeastern shore countries in a temporal sequence up to 2030. Moreover, it clarifies the undeniable time pressure in which to make the best of this opportunity will play the decisive role for active governance. It also proves that Algeria,Tunisia, Lebanon, Morocco and Turkey would have the utmost reason to engage in ageing policies in order to respond to the coming constellations of an ageing society (cf Abdih, 2001; Lloyd, 2005; Dhillon and Yousef, 2009). First, we look at some similarities. In both countries of the southern shore, Tunisia and Lebanon, the first step consists of opting for scientific expertise by organising cooperation between disciplines such as demography, medicine (including geriatrics), epidemiology, psychology and social work, and by concentrating them in national councils on ageing. These are linked, on the one hand, to ministerial administrations and, on the other, to several civic organisations, non-governmental organisations (NGOs) and other professional representations. It is obvious that such an organisational arrangement is influenced by standards coming from the professional background of international gerontology following theVienna and Madrid World Assemblies on Ageing in 1982 and 2002. In Lebanon, already in 1999, following the recommendations of the Vienna World Assembly on Ageing, such a national council was established. In Tunisia, which, since 1994, has followed an ageing policy orientation towards the recommendation of ‘ageing in place’, the expertise has been concentrated in a national committee on ageing and Tunisia has indeed been a pioneer in many respects of ageing policy. Such commissions, with consultative and advisory status, are generally linked to direct political decision-making and, by incorporating the exchange between different associations and civil society organisations, the ongoing conceptual work in several ministries is expected to be shaped by such contacts. However, in various countries that have a massive unemployment rate for the younger age groups, priority is given to labour market policies, resulting in the planning of policies and programmes to meet the challenges of population Table 17.1: Demographic dividend Category Have already reached or will reach the peak of the demographic dividend before 2020 Reaching their peak in 2020-30 Reaching their peak after 2030

Arab southern and southeastern countries of the Mediterranean Algeria, Lebanon, Morocco, Tunisia and Turkey Egypt, Libya and Syria Occupied Palestinian Territories

Source: Kronfol (2012, p 251, Table 15.3) 369

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‘ageing’ being considered less important. In contrast to this, at least in professional circles, ageing is recognised as a coming but rather distant ‘problem’. Some have therefore interpreted it as a ‘demographic catastrophe’, with several policies and programmes often showing only uncoordinated plans, activities and projects to target old age. In general, it seems to be a characteristic of the activities of the southern shore countries by providing care for older people to adopt a welfarebased and service-oriented approach without actively trying to involve the older people themselves in the planning process. In the future it will be necessary to develop a broader strategic framework for promoting ageing research and policy development for the southern and southeastern countries. First of all, an account is needed of what has been researched in all disciplines concerned and systematically differentiated according to specified research fields and in all the spoken languages (in particular, Arabic, English and French).Yount and Sibai’s (2009) study of the demography of ageing in the Arab countries has been a first and valuable document in which all southern shore countries have been included (except Turkey). It will also be helpful to conceptually and intellectually widen the domain of the life course research in these countries into the whole field of the social sciences. To go beyond the often-exclusive reliance on the medicalisation of ageing and to complement and enrich their results with solid research from a social science perspective would be a valuable perspective (see, for example, Jabbour et al, 2012). It will be equally important to engage in comparative work initiatives in order to evaluate variable ways of research and policy formulation in the ageing field and life course analysis. How important such realistic research will be has been demonstrated by some recent journalistic reports from several, now more transparent, southern shore countries which show apparent deficiencies in health provision; this also raises questions about the successful implementation of ageing policies in these countries (see, for example, von Randow, 2012). The continuous support and active engagement of the European institutions and, in particular, expertise from the northern shore countries, would be of great benefit. Such an engagement, which would also require sufficient funding, could be embedded in those support structures that are already present and active (as, for example, ESCWA [the United Nations Economic and Social Commission for Western Asia] in Beirut, INIA [the International Institute on Ageing] in Malta and the American Universities in Beirut and Cairo).At the moment, due to the current fiscal crisis, public attention has been somewhat distracted away from the ageing complex and has produced more urgent priorities. But for meaningful cooperation between the North and Central European and the Mediterranean countries from both shores, these quite special conditions do not have to be an insurmountable barrier for discussing and planning such cooperation in the future. The most important element for structuring such cooperation will be to have a clear focus on themes from the ageing and life course agenda that can serve as a conjoining link for a successful comparative venture. Hence, to put the whole Mediterranean into the centre

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of analysis could serve as a stimulating experience to generate new research perspectives in ageing across the Mediterranean Sea. References Abdih,Y. (2011) ‘Closing the jobs gap’, Finance & Development, vol 48, no 2, pp 36-9. Ajrouch, K.,Abdulrahim, S. and Antonucci,T. (2011) ‘Social networks in Lebanon. The interaction between religion and age’, Presented at the ‘Aging and health in the Eastern Mediterranean region’ Conference, Nicosia, Cyprus, 18-20 September. Albertini, M., Kohli, M. and Vogel, C. (2007) ‘Intergenerational transfers of time and money in European families: common patterns – different regimes?’, Journal of European Social Policy, vol 17, pp 319-34. Andreotti, A., Garcia, S.M., Gomez, A., Hespanha, P., Kazepov,Y. and Mingione, E. (2001) ‘Does a Southern European model exist?’, Journal of European Area Studies, vol 9, no 1, pp 43-62. Ayadi, R. and Sesso, C. (2011) What scenarios for the Euro-Mediterranean in 2030 in the wake of the post-Arab spring?, MEDPRO Policy Paper No 2, October. Buchholz, S., Rinklake, A., Schilling, J., Kurz, K., Schmelzer, P. and Blossfeld, H.P. (2011) ‘Aging populations, globalization and the labor market: Comparing late working life and retirement in modern societies’, in H.P. Blossfeld, S. Buchholz and K. Kurz (eds) Aging populations, globalization and the labor market. Comparing late working life and retirement in modern societies, Cheltenham and Northampton, MA: Edward Elgar, pp 3-32. Coutinho, L. (2012) Determinants of growth and inflation in Southern Mediterranean countries, MEDPRO Technical Report No 10/March. Daatland, S.O. and Herlofson, K. (2003) ‘“Lost solidarity” or “changed solidarity”: a comparative European view of normative family solidarity’, Ageing & Society, vol 23, pp 537-60. Dannefer, D. (1988) ‘Differential aging and the stratified life course: Conceptual and methodological issues’, in G.L. Maddox and M.P. Lawton (eds) Annual review of gerontology, vol 8, New York: Springer, pp 3-36. Dhillon, N. and Yousef,T. (eds) (2009) Generation in waiting:The unfulfilled promise of young people in the Middle East, Washington, DC: Brookings Institution. Esping-Andersen, G. (1990) The three worlds of welfare capitalism, Cambridge: Polity Press. Esping-Andersen, G. (1999) Social foundations of postindustrial economies, Oxford: Oxford University Press. Ferrera, M. (1996) ‘The southern model of welfare in Social Europe’, Journal of European Social Policy, vol 6, no 1, pp 17-37. Groth, H. and Sousa-Poza, A. (eds) (2012) Population dynamics in Muslim countries: Assembling the jigsaw, Heidelberg, Dordrecht, London and New York: Springer. Hoff, A. (ed) (2011) Population ageing in Central and Eastern Europe: Societal and policy implications, Farnham: Ashgate.

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Hofsteede, G. (2001) Culture’s consequences: Comparing values, behaviors, institutions and organizations across nations, Thousand Oaks, CA: Sage Publications. Horden, P. and Purcell, N. (2000) The corrupting sea.A study of Mediterranean history, Oxford, MA: Blackwell. Jabbour, S., Giacaman, R., Khawaja, M. and Nuwayhid, I. (eds) (2012) Public health in the Arab world, Cambridge: Cambridge University Press. Jones, G.W. (2012) ‘Where all the jobs? Capturing the demographic dividend in Islamic countries’, in H. Groth and A. Souza-Poza (eds) Population dynamics in Muslim countries: Assembling the jigsaw, Heidelberg, Dordrecht, London and New York: Springer, pp 31-42. Jurado Guerrero, T. and Naldini, N. (1997) ‘Is the South so different? Italian and Spanish families in comparative perspective’, in M. Rhodes (ed) Southern European welfare states: Between crisis and reform, London: Frank Cass, pp 42-66. Kohli, M. (1986) ‘The world we forgot: A historical review of the life course’, in V. Marshall (ed) Later life: The social psychology of ageing, Beverly Hills, CA: Sage Publications, pp 271-303. Kohli, M. (2007) ‘The institutionalization of the life course: Looking back to look ahead’, Research in Human Development, vol 4, nos 3-4, pp 253-71. Kronfol, N.M. (2012) ‘Changing demographies in the MENA region: The need for social policies to drive opportunities’, in H. Groth and A. Souza-Poza (eds) Population dynamics in Muslim countries: Assembling the jigsaw, Heidelberg, Dordrecht, London and New York: Springer, pp 247-62. Litwin, H. (2009) ‘Social networks and well-being: a comparison of older people in Mediterranean and non-Mediterranean countries’, Journal of Gerontology: Social Sciences, vol 65B, no 5, pp 599-608. Lloyd, C. (ed) (2005) Growing up global: The changing transitions to adulthood in developing countries, Washington, DC: National Academies Press. Lloyd-Sherlock, P. (2010) Population aging and international development, Bristol: The Policy Press. Martin, C. (1997) ‘Social welfare and the family in Southern Europe: are there any specificities?’, in B. Palier (ed) Comparing social welfare systems in Southern Europe, vol 3: Florence Conference, Paris: MIRE, pp 315-35. Mayer, K.U. (2001) ‘The paradox of global social change and national path dependencies: life course patterns in advanced societies’, in A. Woodward and M. Kohli (eds) Inclusions and exclusions in European societies, London: Routledge, pp 89-110. Mayer, K.U. and Müller,W. (1086) ‘The state and the structure of the life course’, in A. Sorensen, F.Weinert and L.R. Sherrod (eds) Human development and the life course: Multidisciplinary perspectives, Hillsdale, NJ and London: Lawrence Erlbaum Associates, pp 217-45. Rhodes, M. (1998) ‘Southern European welfare states: Identity, problems and prospects for reform’, South European Society and Politics, vol 1, no 3, pp 1-22. Triandis, H. (1995) Individualism and collectivism, Boulder, CO: Westview.

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von Randow, G. (2012) ‘Alles wartet auf ein Ereignis. Die Tunesier sind Pioniere des Arabischen Frühlings – sie suchen immer noch nach einem Weg’ [‘Everyone is waiting for action. The Tunisians are pioneers of the Arab Spring – they are still looking for a path’], Die Zeit, no 50, pp 12-13. Yount, K. and Sibai, A. (2009) ‘Demography of aging in Arab countries’, in P. Uhlenberg (ed) International handbook of population aging, New York: Springer, pp 277-315.

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Index

a accessibility of services 132, 139-41, 153, 155, 303 see also inequalities in society ‘active ageing’ 23 ADL (Activities of Daily Living) measures 127-8 Agamben, Giorgio 91 age dependency ratios 47, 48-9 age-friendly cities 139 age-related discrimination, employment opportunities 108-11 ageing, modernisation theory 12-14 ‘ageing in place’ care 22, 283-91, 354-5 ageing populations 33, 35-7 demographic characteristics 49-53 the ‘old old’ 49-51 sex ratios 51-3 demographic data 34, 35 dependency ratios 114 estimates and projections 34 importance of understanding 359 key indicators 43-9 reliability concerns 35 trends 43-9 determinants 37-42 fertility rates 20, 37, 38 infant mortality 37-9 life expectancy 15-16, 39-42, 40-1, 57-8, 125-7 employment challenges 101-18, 310-13 discrimination and disincentives 108-11 North–South divisions 102-5 socioeconomic consequences 33, 46-8, 105-8 see also analysis of ageing populations and care needs Albera, D and Tozy, M. 66 Alzheimer-type dementia 140 analysis of ageing populations and care needs 359-71 governance perspectives and challenges 368-71 life course discourses and regimes 82, 364-8 methodology options 359-61

Anna Lindh Foundation 78 Arab nations 11 family obligations 66-7, 332-3, 352-4 life expectancies 16, 39-42 ‘MENA (Middle East North Africa)’ classification 6-7, 360 see also individual Arab countries; Mediterranean countries; North–South divide Arab plan for the older population (2002– 12) 339, 355 Arab revolts implications for Mediterranean identities 90-2 polarisation tendencies 26-7

b badanti (family assistants) 164 see also migrant care workers Barbagli, M. 62 Barcelona process (1995) 77-8 benefits and allowances 135, 140, 161 social assistance packages 285 see also ‘cash-for-care’ arrangements Billari, F.C. and Dalla Zuanna, G. 58-9, 65-6 Braudel, Fernand 8-9, 78-80 burial choices, migrant workers 188-9

C

cancer 126, 133 cardiovascular disease 126-7, 132-3 care for the elderly 21-2 community-based provisions 283-90 ‘ageing in place’ care 22, 283-91, 354-5 comparisons of care options by country 221 disability care needs 126-9, 133-5 family-based 134-5, 152-3 cf. state welfare 62-5 changing nature of 65-7, 68-9, 141, 1523, 279-82 structural cf. cultural explanations 65-7 increasing costs of 133 institutional care 22, 141, 245

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Ageing in the Mediterranean integrated health and social care models 222-31, 282-91 means-testing 155, 157, 162, 225, 228, 242, 277 self-help initiatives 288-90 sustainability concerns 65-7, 68-9, 140-1, 152-3 use of migrant workers 22, 65, 134-5, 153, 163-7, 235-52 care services 135 employment opportunities for women 151-68 in Israel 261-9 in Malta 286-7 in Portugal 225 in Southern Europe (overview) 161-2 see also institutional care; migrant care workers; welfare schemes (state) care workers improving status and conditions 141 policy towards female employment 15160 see also carers (family); migrant care workers caregiving equality legislation 285 carers (family) support measures 134-5 financial payments 135, 140 integrated health and social provisions 222-31 pension provisions 285 respite provisions 134, 140, 286 well-being 134 emotional and physical costs of caring 333 see also family care provisions Caritas Malta 287-8 ‘cash-for-care’ arrangements 135, 140, 162, 223 Italy 241-2 see also financial transfers Cassano, F. 87-9 Catholicism, perceptions of 82-3, 91 Chesnut, Mary 87 Chevalier, Michel 85 childminding roles 67 chronic diseases 21, 126-7, 132-3, 137 see also individual diseases civil society voluntary care 287-8 clientelism 10, 25 climate considerations, North–South divide 81-2 co-residence arrangements cultural cf. structural explanations 66-7

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North–South divisions 152, 221 Portugal 221-2 Tunisia 352-3 see also family care provisions cognitive disorders 21 cohabitation trends 69 colonialism 79-80 community care 267, 283-5 housing provisions 285-6 neighbourhood schemes for the elderly 287-8 policies for ‘ageing in place’ 22, 283-91, 354-5 see also home care services ‘connectivity’ concepts 10, 360 costs of care, increases in 133 cultural discourses European divisions over family forms 64-5 over family as welfare agency 65-7 regional divides 87-9 religious divides 82-4 ‘Mediterranean’ concepts 9-12, 361-2 problems with ideological and empirical domains 361-2 negative consequences of 362 North–South divisions 76-89, 90-2 Orientalism 85-7 West–East divisions 86-7 Cunedioglu, E. and Yucel, E. 91

d day centres 284 dementia care needs 140, 338 support for carers 268-9 democratisation trends 24-5 demographic data on ageing 33, 35-7 data reliability 35 estimates and projections 34, 44, 45, 47, 50 key characteristics 49-53 median age of elderly 43-6 relative weight of elderly 43 trends 43-9 see also ageing populations demographic indicators for ageing 43-9 dependency ratios 101, 113, 114 depression 126, 128-9, 338 diets Mediterranean 58-9, 126-7, 132 rise in obesity prevalence 132 traditional vs. fast food 132, 138

Conclusion and themes for further discussion Index disability care needs 133-5 classification and measurement 127-9 rates and trends 21-2, 124, 129, 313-14, 351-2 see also health status of older people disease burden 126-7, 132, 137 divorce rates 135

e e-health 139 early retirement disincentives 288-9 masking discriminatory practices 109 education access for older people 139-40 skill deficits and age-related discrimination 109 in Lebanon 328 in Tunisia 349-50 in Turkey 308-10 Egyptian revolution (2011) 75-6 elder care see care for the elderly EMP see Euro-Mediterranean Partnership (EMP); Union for the Mediterranean Region employment challenges 101-18, 310-13 market selection and discrimination 10811 participation and opportunities rates 17, 310-11 for women in care services 153-68 policy frameworks 111-16 EU 111-12 for job creation 113, 154, 160, 168 lessons from Northern countries 116-18 national models 112-16 women in care services 151-60, 167-8 productivity concerns 108-11 work performance 15-17, 108-11 employment rates migrant care workers 163-4, 165-6 older workers 105-8, 114-15 women 158 women care workers 159 youths 114 empowerment agendas 140 environmental dimensions, North–South divide 78-9 equality legislation for caregiving 285 Esping-Andersen, G. 89, 365

Euro-Mediterranean Partnership (EMP) 77-8 EUROFAMCARE study (2006) 134 EUROMED 78 Europe 2020 Strategy (COM 2010) 101 European Economic Community (EEC) INTERLINK long-term care study 135 North–South prosperity gaps 76-8 European Foundation for the Improvement of Living and Working Conditions (2008) 118 European Union (EU), employment policy frameworks 111-12 expenditure on elder care 219

f familism 10, 20-1, 65-7, 216-17 Italy 240-1 Lebanon 332-3 Tunisia 352-4 see also cultural discourses; family care provisions; social networks family care provisions 134-5, 152-3 cultural influences 10, 20-1, 65-7, 216-17, 240-1, 332-3, 352-4 financial transfers 63-4, 161 functional and structural changes to 27982 long-term outlook 65-7, 68-9, 141, 152-3 legal responsibilities 161, 240 as moral obligations 67, 352-3 policy orientations 161-2 development and convergence 217-20 Italy 240-1 Lebanon 332-3, 339, 341 Malta 283-5 Portugal 215-31 Tunisia 352-4 roles 65-7, 68-9 sociological and structural perspectives 216-17 cf. state welfare provisions 62-5, 65-7, 68-9 sustainability of 65-7, 68-9, 141, 152-3 see also carers (family) family dynamics 20-1 family forms background and history 59-62 changes and challenges 362-4 altered values 281-2 reduction in size 280, 333, 353 European divisions 62-5, 68-9

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Ageing in the Mediterranean intergenerational co-residency 352-3 relationships with welfare systems 62-5, 65-7, 68-9 capacity to maintain care roles 65-7, 68-9, 152-3 family functions 67 family values changes in 281-2 see also cultural discourses fertility rates 20, 37, 38 Malta 274 financial kinship rights (Italy) 240 financial transfers by migrant workers and retirees 179-85 intergenerational 63-4 national allowances 161 to domicilary migrant workers 163-4 flexible working arrangements 113 ‘flexicurity’ 112 formal care services see care services France, migrant retirees and transnationalism 173-92 A fresh map of life (Laslett, 1989) 57-8 further education 139-40 FUTURAGE project 252

g GAFTA (Greater Arab Free Trade Area) 77 gender caregiving equality changing role of women 22-3 legislation 285 in policy making 68 cultural codes 10 care obligations 68 employment challenges for older workers 119 employment rates for older workers 117 migration trends 19, 237, 247 of care workers 151-68 population ageing demographics 52 imbalances 303-4 life expectancy differentials 39-42 geographical proximity see residential proximity (parent–child) geopolitical dimensions, North–South divide 78-9 Germania (Tacitus) 81 Ginsborg, P. 62 Goddard,Victoria 66 governance perspectives on elder care see policies on long-term care

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government policies on elder care see policies on long-term care Grand Tour 83-4 Green Card schemes 313-14 Gregg, G.S. 11

h Hajnal, J. 60 handyman services 285 health expenditure, Turkey 315 health indicators 127-9 health inequalities 132 health insurance systems Turkey 313-14 see also social insurance schemes health promotion, importance and advocacy for 138-9, 140 health services in Malta 276-7 in Turkey 313-15 see also care services health status of older people 123-41 disability trends 21-2, 129, 313-14, 351-2 inequalities between populations 132 life expectancy 15-16, 39-42, 125-7 by gender 40-1 Mediterranean countries 39-42, 58-9, 125-7 measurement 124-5 need for care 133-5 need for strategic interventions 137-41 healthy life expectancy 130-2 ‘help-at-home’ services, Spain 140 Herlihy, D. and Klapisch-Zuber, C. 60 historical perspectives North–South divisions 81-2 ‘Orientalism’ 85-7 romanticisation discourses 83-5 trade and maritime dimensions 79-80 home care services in Israel 261-9 in Lebanon 338 in Malta 284, 286-7 in Portugal 225 in Southern Europe 161 ‘honour’ concepts 10, 21, 66 Horden, P. and Purcell, N. 9-10 hospital care, employment of supplementary migrant workers 246-7 hospital discharges, intermediate interventions 226-7 hosting families 355 house maintenance services 285

Conclusion and themes for further discussion Index housing provisions, Malta 285-6 Human Development Index (HDI) 15-16 human rights, and health needs 138-9 Hussein, Taha 11 Hyperboreans 81

i illegal care workers 135, 244-5, 250 images of old age 23, 354 ‘in-kind’ benefits, Israel 261 in-patient care services, Portugal 225 income inequalities 14-15, 139 individualism–collectivism discourses 220, 361 inequalities in society 14-15, 124-5, 132, 139 Mediterranean countries cf. Western Europe 14-15 unemployment trends amongst older workers 25-6, 310-13 infant mortality rates 37-9 informal care 134-5 sustainability concerns 65-7, 68-9, 140-1, 141, 152-3 see also family care provisions; migrant care workers information technologies 109 institutional care 22 costs, Italy 245 increasing use of 141 low availability 161, 354 and stigma 338, 354 see also residential care insurance-based benefit schemes 18 Turkey 313-14 integrated health and social care models Israel 261-9 Portugal 222-31 intergenerational transfers, financial 63-4 INTERLINKS project (2008–11) 135 Internet 23-4 Islamic traditions 19-20 burial wishes 190 child–parent relations 20-1, 352-3 see also cultural discourses Israel family structures and roles 259-60 Long-Term Care Insurance (LTCI) (Israel) 238, 261-2, 363 policies on elder care 261-2 future directions 267-9 population ageing 258-9 provision of home care services 262-4

supplementing informal care provisions 264-7 Italy co-residency rates 152 life expectancy 58-9 long-term care policies 154-5, 161-2 migrant care workers 235-52 regional divisions 87-9

j job creation opportunities, care sector 113, 154, 160, 168

k KASS (Kinship and Social Security) project 62-3 Kertzer, David 61 Kurdish populations 315-19

l ‘la leyenda negra’ (the black legend) 82-3 labour market participation rates 114-15, 117 in Lebanon 328-9 in Malta 288-9 in Tunisia 349 in Turkey 310-13 see also employment landscape of the Mediterranean 8-9, 78-9 Laslett, Peter 57-8, 60-1, 67 ‘Le noir et le bleu’ (Lepenies, 2011) 90-1 Lebanon demographic trends and population ageing 325-7 economic and social conditions 327-30 family-based care 332-3 health profiles of older people 334-6 pension systems and insurance schemes 330-1, 339 policy directions and governance arrangements 339 capacity development 340 research studies 340 role of NGOs 338 structural support channels 330-4 use of health services 336-8 use of institutional care 338 Lepenies, W. 90 life course discourses and regimes 82, 364-8 life expectancy 15-16, 39-42, 125-7 by gender 40-1

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Ageing in the Mediterranean ‘healthy life’ and compression of morbidity 130-2 international comparisons 57-8, 126-7 Mediterranean countries 39-42, 58-9, 125-7, 275, 305 lifelong learning 139-40 lifestyle and disease 126-7, 132, 138 Linton, Ralph 67 Lisbon Strategy (EC 2000) 101, 134 living with elderly parents see co-residence arrangements; family care provisions loneliness fears 354 Long-Term Care Insurance (LTCI) (Israel) 238, 261-2, 363 long-term care policies see policies on longterm care longevity see life expectancy

m Macfarlane, Alan 59-60 Madrid International Plans of Action on Ageing (2002) (MIPAA) 35, 136, 139 Malta population ageing 273-4 feminisation trends 276 fertility and mortality rates 274 life expectancy 275 migration patterns 275 provision of pensions 277-9 social and health services 276-7 socioeconomic implications 276-9 programmes and policies 282-90 future challenges 290-1 housing provisions 285-6 residential care 286-7 role of voluntary sector 287-8 self-help initiatives 288-90 traditional family care for elders 279-82 changing role of women 280-1 changing values 281-2 impact of reduced family size 280 marital status changing patterns 135, 306-8, 330 key trends 69 ‘maritime’ concepts 8-9, 79-80 Matvejevic, P. 9, 11 means-tested care 155, 157, 162, 225, 228, 242, 277 cash allowances 162 measurement tools 127-8 media influences and portrayals 23-4, 354 median age demographics 43-6 medical advances 133

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Mediterranean countries concepts of 4-12, 76-92, 123 categorisations and definitions 4-7 as ‘coastal’ countries 5 ‘connectivity’ perspectives 10, 360 as cultural entity 9-12 as political voice 4-5 differentiation and diversity 7-12 unity visions 8-9, 12, 89, 90-2 see also individual countries; North–South divide Mediterranean diet 58-9, 126-7 decline of 132 Mediterranean Prospects Consortium (MEDPRO) 360 ‘Mediterranean Sea’ 88 La Méditerranée des anthropologues (Albera and Tozy, 2005) 66 ‘Mediterranean thinking’ 87-9 on cooperation processes 87-9 post-Arab uprisings 91 MEDPRO see Mediterranean Prospects Consortium (MEDPRO) MENA (Middle East North Africa) countries 6-7, 360 see also Arab nations; individual countries; Mediterranean countries mental health illness prevalence 128-9 measurement tools 128-9 migrant care workers 22, 65, 134-5, 153, 235-52 benefits and drawbacks 245-6 impact on sustainable policy developments 167, 168, 251 ‘care models’ 163 characteristics 236-8, 247 costs and tax incentives 244-5 countries of origin 242-3 demand for 238 difficulties 248-9 experiences of 247-9 in Israel 263-4 in Italy and Spain 163-7, 238-52 non-family care settings 246-7 prevalence 164, 236-7 reasons for hiring 244-5 registration 164, 165-6 regulation of 134-5, 164-7 types of activities undertaken 247-8 migrant retirees 173-92, 251 characteristics 175-6 permanent return vs. continuing transmigration 187-8, 191

Conclusion and themes for further discussion Index preferred place of burial 188-90 retirement life choices 185-8 transmigration experiences 176-8 financial transfers 179-85 personal savings 182-3 migration trends 18-19, 65 in Malta 275 youth unemployment 25-6 MIPAA see Madrid International Plans of Action on Ageing (2002) modernisation theory and ageing 12-14 and family support 220 moral obligations (intergenerational) 67 weak ties 60-1 musclo-skeletal conditions 126 Muslim immigrants, returning to country of origin 189, 190

n national surveys, attitudes towards elder care options 220-2 neighbourhood schemes for the elderly 287-8 networks see social networks NGOs health advocacy work 139 as health service providers 139 role in North–South engagement 91 supporting older populations in Lebanon 338 non-communicable disease see chronic diseases Nordic countries see Northern countries North–South divide 76-8 efforts to establish connections 76-7 employment rates 103-5, 106 historical images and ambivalences 81-2 new perspectives 87-9 post-Arab uprisings 90-2 the paradigm of Orientalism 85-7 population ageing 102-5 traditional divisions and sudden ruptures 77-8 landscape and environment influences 78-9 maritime and trade crisis 79-87 transformation and solidification of the divide 82-5 Northern countries long-term care policies 151-60 attitudes towards care options 220-2 unifying cultures and history 81-5

Enlightenment 83-4 Protestantism 83 ‘nuclear hardship’ (Laslett) 60-1, 67 nuclear households 67 nursing homes Lebanon 338 see also institutional care; residential homes nutrition see diets

o obesity 132 ‘old old’ (80+) population demographics 49-51 older people health status 123-41 life expectancies 15-16, 39-42, 57-8, 125-7 media portrayals 23, 354 participation agendas 139, 288-9 population demographics 33, 35-7, 49-53 historical data 80 as percentage of total population 34 projections 34 power and distrust issues 75 roles, childminding 67 self-help initiatives 288-90 Orientalism 85-7 out-patient care services Portugal 225 see also rehabilitation interventions

p palliative care, in Portugal 225 participation agendas 139 older workers 288-9 women as care workers 151-68 employment rates of women 158-60 see also employment; labour market participation rates patron–client relations 10 pension systems 18 for carers 285 flexible options 110 in Lebanon 330-1, 339 in Malta 277-9, 285 MENA coverage 116 need for structural reforms 116 in Tunisia 351, 355 performance see work performance and ageing pharmaceutical costs 133 policies on long-term care

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Ageing in the Mediterranean key challenges and priorities 368-71 in Europe (overview) 153-60 in Israel 261-2, 267-9 in Italy 154-5, 161-2 in Lebanon 330-1, 339-41 in Malta 282-91 in Portugal 222-8 in ‘Southern’ countries 161-7 in Tunisia 354-5 in Turkey 320-1 and ‘job creation’ 154, 160, 167-8 weaknesses and challenges 320-1 see also analysis of ageing populations and care needs population demographics 33, 35 data reliability 35 estimates and projections 34, 44, 45, 47, 50 indicators for ‘ageing’ 43-9 key characteristics 49-53 structural changes 46-8 see also ageing populations Portugal, long-term care policies and familism 215-31 poverty trends and employment status 310-13 gender-related inequities 110, 312-13 and pension shortfalls 117 primary health care policy directives 138, 140 see also rehabilitation interventions productivity concerns (older workers) 10811 professionalisation of ageing 17-18 Protestantism 83-4

q quality of life ethnic backgrounds (Turkey) 319 improvement strategies 136-7, 283-90 trends 132-3

r radicalisation trends 20 Rees, P. 14 regionalism concepts 26-7 rehabilitation interventions, hospital discharge measures 226-7 Reher, David 61-2, 67 religious affiliations 19-20 North–South rifts 82-3 see also Catholicism; Islamic traditions

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religious organisations, role in charitable activities 68, 286, 287 research studies on ageing in the Mediterranean 359-71 governance perspectives and challenges 368-71 life course regimes and perspectives 364-8 methodology options 359-61 residential care availability 155-6 employment of migrant workers 247 increasing use of 141 in Malta 286-7 see also institutional care residential proximity (parent–child) 63, 67, 152 see also co-residence arrangements respect and veneration concepts, familism vs. media portrayals 23 respite care 134, 140 in community-based houses 286 ‘right to alimony’ (Italy) 240 right to health 139-40 RNCCI (National Network for LongTerm Integrated Care)(Portugal) 215, 223-9 romanticisation discourses 83-5

S Said, E. 85-6 satellite television 23-4 secularisation trends 19-20 security assurance 18 self-centred attitudes 11 self-employment 17 self-harm rates 128 self-help groups 288-90 service provisions see care services sex ratios 51-3 ‘shame’ concepts 10, 66 SHARE (Survey of Health, Ageing and Retirement in Europe) project 62-4, 365 sheltered housing 286 Shi’ite networks 20 skills acquisition, new technologies 109-10 ‘slowness’ values 88 Smith, Richard 60, 66 social housing provisions 286 social inclusion policies 283-90 social insurance schemes Israel 238, 261-2, 363 Malta 276 Turkey 314

Conclusion and themes for further discussion Index see also health insurance systems social networks 360-1 cultural codes and associations 10-11 importance of 283, 289 Islamic traditions 20 social policy development see policies on long-term care social service provisions for the elderly see care services social welfare see welfare schemes (state) socialisation factors 283 socioeconomic consequences of ageing populations 33, 46-8, 105-8 socioeconomic differentials see inequalities in society ‘southern welfare states’ 89-90 see also Mediterranean countries; North– South divide Spain co-residency rates 152 historical perceptions of 82-3 long-term care policies 155, 161-2 new ‘dependency’ legislation 140 ‘stairs of life’ characterisations 82 state-led policies on elder care see policies on long-term care Stewart, F. 116 stigma, and institutional care 338, 354 suicide rates 128 Sunnite networks 20

t technology changes impact on care costs 133 impact for older workers 109-10 telecommunications 23-4 ‘third age’ (Laslett) 61 Tocci, N. 26-7 training opportunities 109-10 transmigration 176-8 Tunisia demographic indicators 345-9 gender equality and socioeconomic characteristics 349-55 family-based care 352-4 governance 354-5 health status and geriatric care 351-2 media portrayals 354 pension systems 351 Turkey population trends 298-301 portrayals and characteristics of older people 301-19

education 308-10 gender 303-5 health 313-15 marital status 306-8 religion and ethnicity 315-19 urbanisation 301-3 work and incomes 310-13 policy directions and challenges 320-1

u unemployment trends 25-6 amongst older workers 310-13 Union for the Mediterranean Region 77-8 unity visions (Mediterranean countries) 8-9, 12, 89, 90-2 universalism 153-4, 155, 162 urban cultures 79 urbanisation trends 138

v voluntary organisations hosting families 355 neighbourhood schemes for the elderly 287-8

w Warwick Report (2006) 112 welfare schemes (state) 18, 135 cf. family forms 62-5 expenditure on elder care 219 institutional development 67 southern state models 89-90, 135 typology of 89 see also care services; policies on long-term care West–East divides 86-7 WHO definitions of health 123-4 Millennium Goals 124 widowhood 307-8 women changing roles 22-3, 280-1 equality in caregiving legislation 285 demographic data on ageing 51-3 life expectancy differentials 39-42 education and inequality 308-9 elderly care 134-5 cultural obligations 68 employment in care services 151-68 employment rates 158-60 as migrant workers 19, 237, 247

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Ageing in the Mediterranean providing family-based care 67-8, 134-5, 152-3, 240-1, 280-2 employment challenges for older workers 110 labour force participation rates 329 work performance and ageing 15-17, 10811 world population data 33

y Yount, K.M. and Sibai, A.M. 66-7 youth unemployment 25-6, 113-14, 117-18

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Joseph Troisi is Professor of Social Gerontology and Director of the European Centre for Gerontology, University of Malta. He directs the International Institute on Ageing, United Nations-Malta and serves on a number of UN expert groups in the field of ageing. He is a member of the European Masters in Gerontology. Hans-Joachim von Kondratowitz is Senior Advisor/Researcher at the German Centre of Gerontology (DZA) in Berlin, and an affiliated lecturer at FU Berlin in the Department of Social and Political Sciences. He has wide international research experience in social gerontology and life course research.

AGEING / Social studies

ISBN 978-1-44730-106-6

AGEING IN THE MEDITERRANEAN • Edited by Troisi and von Kondratowitz

At a time of extreme globalisation Ageing in the Mediterranean fills a key void in international literature on ageing societies. This important and timely volume brings together a distinguished set of international scholars who provide rich information about the social, economic, political and historical factors responsible for shaping ageing policy in the Mediterranean region. It is a regional handbook that highlights the idiosyncrasies of overlapping ageing issues in one particular territory and presents a range of key issues and concerns, including migration, caregiving, employment and health care, amongst others, while providing rich data from various countries such as Israel, Italy, Lebanon, Malta, Portugal, Tunisia and Turkey. Ageing in the Mediterranean will be warmly welcomed by researchers in social and public policy, gerontology and geriatrics, welfare economics and health care. It will also be of interest to policy makers and non-governmental organisations involved in welfare and social care services.

Edited by Joseph Troisi and Hans-Joachim von Kondratowitz

9 781447 301066

www.policypress.co.uk

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