Tunisia’s experience coping with pandemic is worth West’s attention

Even allowing for the fact that Tunisia’s population is less than a third of its two North African neighbours and that Tunisians are worried by a recent spike in numbers this summer, the country’s comparative success in containing the pandemic is striking.
Tuesday 15/09/2020
A nurse checks a woman’s temperature before a covid-19 test at a military mobile hospital in the town of El-Hamma, in Tunisia’s southwestern Gabes governorate, on August 26. (AFP)
A nurse checks a woman’s temperature before a covid-19 test at a military mobile hospital in the town of El-Hamma, in Tunisia’s southwestern Gabes governorate, on August 26. (AFP)

The figures speak for themselves. COVID-19 has claimed the lives of 73 victims in Tunisia to date, 1,011 in Morocco and 1,475 in Algeria. A total of 3,323 Tunisians have been infected compared with over 43,000 in Algeria and over 57,000 in Morocco.

Even allowing for the fact that Tunisia’s population is less than a third of its two North African neighbours and that Tunisians are worried by a recent spike in numbers this summer, the country’s comparative success in containing the pandemic is striking. This success is even more noteworthy when set against the record of northern rim Mediterranean countries and the UK.

Three broad factors explain why Tunisia has come through the pandemic so far with flying colours compared to others, despite its political turmoil and sluggish growth, not to mention the threat of terrorism and widespread corruption that persists nine years after the overthrow of the authoritarian regime of longtime leader Zine el-Abidine Ben Ali. Tunisia has had twelve ministers of health since 2011, but as one senior businessman in Tunis quips, “the country is badly governed but it is well-administred.” Despite inflated numbers of recruits at the lower levels since 2011, the civil service remains professional. For decades after independence, it was the envy of the Arab world.

When news of what was only an epidemic reached Tunis at the start of the year, the medical establishment was quicker off the mark than its vis-a- vis in Europe, let alone neighbouring Algeria. Despite the loss of hundreds of doctors to Europe because of the turmoil of recent years and the decline in public hospital services and the corresponding growth in private clinics, which ordinary Tunisians can ill afford, the public health system’s early warning worked well. For all the weaknesses of a democracy which has yet to put down deep roots, freedom of expression allowed for a lively debate within the medical establishment and in the media.

Cardiologists like Faouzi Haddad, who practices at the Abderrahmane Mami teaching hospital in the Ariana suburb of Tunis, took to the air for the first time, warning older people with respiratory and other medical problems to confine themselves. “All my patients did so and my colleagues issued the same warning and the trust people showed in their doctors was remarkable, ” he told me. Tunisia is lucky to have a young population: the average age here is 31. But it is 26 in Morocco and 25 in Algeria, two countries that have recorded higher COVID-19 tolls. The over 65 year-olds represent 9% of the population and are usually cared for within the family. There are not many private old people’s homes here or the rest of North Africa.

Travellers embark on a ship at the port of La Goulette in the Tunisian capital Tunis. (AFP)
Travellers embark on a ship at the port of La Goulette in the Tunisian capital Tunis. (AFP)

In mid-January, the Tunisian health minister called her French counterpart. Then French Health Minister Agnes Buzyn told Tunisia’s Dr Sonia Bencheikh not to worry. “Do not panic” she urged her caller, who was quite nonplussed by the conversation. She had understood early on the seriousness of what was happening in China. But it was two senior civil servants who, in the view of well-informed Tunisians I spoke to, played the more important role: Dr Nissaf Ben Alaya is the director of the National Observatory of Novel and Emerging Diseases. She has headed the institution, which began operating in 2008 and has closely cooperated with Germany on developing a bio-security plan which includes humans, animals and the environment, since 2015. Dr Amel Ben Said is the director of basic healthcare at the health ministry. Ben Said has a distinguished career that includes working for UNICEF and the UNDP, but she resigned from her post late last year in protest of what she felt was political posturing by many ministers and political leaders. The team of senior doctors, which by February had morphed into a scientific committee advising the health minister, continued to play its role, however.

Earlier this week, Ben Said was recalled to her previous post by the outgoing prime minister, who was greatly concerned over the increase in COVID-19 cases since early August. Many Tunisians breathed a sigh of relief at the sacking of the controversial Dr Mohamed Chaouch, who had replaced Ben Said last year.

Tunisia boasts many well-trained doctors and specialists and an Institut Pasteur that was founded in 1893 by Charles Nicolle when the country was a French protectorate. For his discoveries on typhus, Nicolle was awarded the Nobel Prize in Physiology or Medicine in 1928. He died in Tunis in 1936 and his name was given to Tunisia’s main hospital in Tunis, a well-respected modern institution. Headed today by Professor Hechmi Louzir, its laboratories interact with research carried out by academic research organisations and pharmaceutical companies. In this small country, doctors know each other very well and interact professionally and socially with great ease. They also interact with the civil service. Many interlocutors in Tunis pointed out that the two groups whose freedom of expression was never restricted under Ben Ali’s rule were sports commentators and the medical corps. It is also worth noting that two thirds of the country’s healthcare professionals are women.

In 2012, Tunisia signed an agreement with the US National Centre for Disease Control (CDC) in Atlanta, which helped this country set up an early warning system for influenza epidemics. By 2019, it was in place and the necessary personnel had been fully trained. This came in handy eight months ago. Tunisia boasts regional health boards that function well, and all information from them is centralised at the health ministry. The authorities made sure suspect cases in the most remote towns were reported. When a small cluster was detected in the southern island of Djerba, a well know tourist region, the island was put under strict lockdown for weeks. Swift and localised confinement measures put a break on the epidemic. Passengers flying in from abroad had their temperatures checked and were required to fill in a medical form, which they handed to the police, allowing authorities from early April to trace them during their stay in Tunisia. I filled in one such form on February 26. Luckily winter is not the height of the tourist season: This country of about 12 million people received 9 million visitors last year.

During this pandemic, the commitment of healthcare personnel, scientists and researchers to interact and fight this scourge is tremendous. Louzir told me with pride: "This crisis has shown us that Tunisia has a huge human potential capable of anticipating, managing health emergencies and producing innovations."

Tunisia boasts a small but thriving pharmaceutical industry and laboratories, which are both public and private. They produce just over half the medicine the country consumes, one of the highest percentages in all of Africa. Fake pharmaceuticals here are unknown, as the Pharmacie Centrale has all of this well under control. Today it manufactures its own COVID-19 test-kits, though it imports some active ingredients from abroad. This medical and pharmaceutical ecosystem has proven invaluable, as has constant dialogue between the health ministry, the government, the private sector and the Institut Pasteur.

The reaction to the COVID-19 pandemic must be set in the context of a country where women enjoy more rights than in any other in the region, thanks to modern Tunisia’s founding father, former President Habib Bourguiba. Family planning was introduced here well before France, Italy and Spain. As a result, women play a key role in education, healthcare and increasingly politics. They are CEOs of pharmaceutical companies, such as Sara Masmoudi, the head of Teriak,  and Najla Hamdi, who is at the helm of SANOFI. The highly-skilled professionals like doctors Ben Alaya and Ben Said are, in a way, the true “daughters of Bourguiba.” Like professional woman in all walks of life in this country and more often than men, they are not afraid to speak their minds in front of government or foreign officials. Tunisians have been open to trade and the exchange of ideas and culture since the founding of Carthage more than 2,800 years ago. Politicians here followed the advice of doctors and do not regret it.

A Tunisian medical worker takes a blood sample  to test a student against the COVID-19. (AFP)
A Tunisian medical worker takes a blood sample  to test a student against the COVID-19. (AFP)

Although public investment in hospitals has been cut back since 2011, not least to finance the fight against terrorism that was spurred by the West’s ill-advised military intervention in Libya, this country has demonstrated that a key pillar of government, the health system, works in times of crises. As the EU’s foreign policy czar Josep Borrell encourages the re-shoring of some pharmaceutical manufacturing from Asia to countries closer to Europe, he and major European and US companies could do worse than to remember that Tunisia has the doctors and well-trained technicians and engineers necessary for an expansion of its young pharmaceutical industry. While some important reforms are essentially to make the business climate more friendly, being an hours flight from Europe and constituting no threat to the old continent matters. Tunisia’s economy is being battered by the crisis and desperately needs to create new value-added jobs.

The government and the private sector are currently finalising a plan to expand the production of pharmaceuticals. They hope the sector will account for 40% of exports by 2025, compared with 18% today. Locally produced pharmaceuticals should increase from 51% to 62%. This would create 4,000 mostly-skilled jobs. Other medical supplies, notably apparel, could be produced in the country, which has a thriving textile and electronics industry.

It does not therefore come as much of a surprise that a recently released poll shows that among the top four institutions that Tunisians trust is the healthcare corps. Those they trust the least include political parties and members of parliament. Recent months also offer a perfect demonstration that, contrary to what too many seem to think in the West, being “Arab” and “Muslim” does not condemn people to being incompetent. The COVID-19 pandemic has shown that being “Western” and “Christian” offers no guarantee of good governance in matters of healthcare. The word “underdeveloped country” might be past its sell-by date.