FAMILY PLANNING IN TUNISIA AN EDUCATIONAL PROGRAM AND ITS IMPLEMENTATION- Disser’cation for the Degree of Ph. D MICHIGAN STATE UNIVERSITY ALICE AHEARNE 1977 . III!III!IIIZIIIIJIILIIIIIII"!IIqIIllclIl‘ItIlIIIIIJHILHIMI'I This is to certify that the thesis entitled FAMILY PLANNING IN TUNISIA: AN EDUCATIONAL PROGRAM AND ITS IMPLEMENTATION presented by Alice Ahearne has been accepted towards fulfillment of the requirements for Ph-D- degree in Secondarx Education and Curriculum (Comparative and International Education) I / ,v’ Major professor Date April 1, 1977 0-7639 It; \.-I' ‘ ‘J.L h 1'", \ _ . 111\‘44 L.. sin-A . 91¢“ 2'22} ‘9- 1 ..- . State 1‘31.\_v.~~u¢ UAAIVKifiI; v .. "i .T,’-.. Perm...“ i; 9.] b _ Mr; ABSTRACT FAMILY PLANNING IN TUNISIA AN EDUCATIONAL PROGRAM AND ITS IMPLEMENTATION By Alice Ahearne The purpose of this research was to determine the present status of the National Family Planning Pro- gram of Tunisia, and the importance of the role of edu- cation in achieving its goals. through the gathering of reliable, up-to-date information. The program is the first of its kind in an Arab culture, as well as the first African project in p0pulation control. It is. therefore, of great interest to those studying methods of demographic control in developing countries. As very little documentation on the subject is available in foreign libraries, the study was carried on in Tunisia, in the cities of Tunis and Sfax pri- marily, and in neighboring villages. Data was gathered during the summer of 1976, through the medium of interviews, and through partici- pation in two workshops.. The interviews consisted of conversations with national directors and personnel of the Ministry of Health, the National Office of Family Planning and Population. the United Nations Bureau at Tunis. the Office of the United States Agency in Inter- national Development, regional authorities, and the National Union of Tunisian Women. Recent government Alice Ahearne publications, as well as reports of seminars and meetings, both domestic and foreign, were also made available to the writer, and were of great value. The workshops, one in the region of Tunis, de- signed for young, unmarried adults, and one near Sfax, for regional cadres, were "Journées d'Information" or Information Days. One of these is described in detail. This study is concerned primarily with the origins, development, and implementation of the Family - Planning Program, and the educational effort which has sustained it. It is the account of the concerted effort of Tunisian leaders to establish a network of points of communication through which the entire population may one day be infiltrated by the philosoPhy of birth limitation. A variety of educational projects, both within and outside of the formal school system, that are striving to effect attitudinal change that will enable men and women to participate in voluntary contraceptive practices, are discussed and evaluated to some extent. The educational component receives major stress by those in authority. A second area of emphasis is the Tunisian woman herself. A major role of governmental responsibility is to educate woman to take her proper place in Tunisian society as not only wife and mother, but as an active participating citizen. Much of this study is therefore, concerned with her evolution and the degree to which Alice Ahearne her position has changed in contemporary society. In conclusion, the most recent data available gives evidence of some success in the realization of Family Planning objectives; recommendations are made by the writer that should make pr0posed achievement by the year 2001 more probable. FAMILY PLANNING IN TUNISIA AN EDUCATIONAL PROGRAM AND ITS IMPLEMENTATION BY Alice Ahearne A DISSERTATION Submitted to Michigan State University in partial fulfillment of the requirements for the degree of DOCTOR OF PHILOSOPHY Department of Comparative and International Education 1977 ACKNOWLEDGEMENTS It is a distinct pleasure to eXpress the writer's sincere appreciation for the help and encouragement that has made this study possible. She is greatly indebted to Dr. Carl H. Gross. Chairman of the doctoral committee, for his wise counsel and generous support; to Dr. David E. Stephenson, commit- tee member, upon whom rests the real reSponsibility for this document, as the writer's interest in Arab cultures dates from her participation in his course on the Maghreb and the Middle East; to Drs. Yvonne Waskin and Peggy Reithmiller, members of the doctoral committee, for their thoughtful comments and suggestions. Special thanks are due to the following whose efforts on the writer's behalf brought the research in Tunisia to a successful conclusion: Dr. Winton Lane. Coordinator of United Nations Papulation Programs in Tunisia, Dr. Benjamin Wallace. Family Planning Advisor for United States Agency for International DevelOpment at Tunis, Madame Fatma Gargouri, Regional Delegate of Family Planning in Sfax, and personnel of the National Office of Family Planning and Population and of the National Union of Tunisian Women. ' ii PREFACE A scant twenty years ago,1 Tunisia watched the departure of the French and set out upon its own pro- gram of socio—economic deveIOpment that has now touched the lives of most of its citizens. The major goal has been to bring the country into the twentieth century, and increase the life chances of its citizens and their right to human dignity through the improvement of living conditions. Medical facilities expanded rapidly; general health care improved, with a concomitant decrease in child mortality. As.a result, Tunisia, a poor country, found itself overwhelmed by a rapidly escalating p0pula- tion level. Where in the past only two or three child- ren of a family of ten had reached adulthood, now often all ten survived. This demographic expansion was incom- mensurate with the country's limited means of increasing productivity. The government's answer to the problem, a program of family planning, has been instituted, and is considered by many today to be outstanding and super- ior to those of other Arab states, a model program. For several reasons this program has been chosen as a worthy subject of research. To begin with, as the world starts upon the last quarter of the century, one of the most urgent questions to be answered is how lMarch, 1956. iii to bring the papulation and the world production of food into balance. Now that formerly fatal diseases, such as malaria, are being brought under control, are children to die instead of starvation? No one debates the ur- gency of this problem, and thus reasonable limitation of births must be achieved. The gathering of reliable, up-to-date information on a successful program appears to be a valid goal. Secondly, the writer has been in- terested in Africa and the Maghreb for several years as the result of cognate studies in anthr0pology and cul- tural geography. Reading, research projects, contacts with American researchers familiar with Tunisia, have all concentrated interest in this country. Finally a researcher must be able to communicate in the language of the country being investigated, if he is not to be limited to secondary sources and to not always reliable translations. The national language is Arabic, but all Tunisians having even rudimentary schooling Speak French; thus, the writer's fluency in the language has been an essential tool, and has enabled her to comprehend the nuances of conversations that are otherwise frequently lost, as well as to read with understanding the tracts, brochures and studies that are all written in French. This study is concerned primarily with the origins, develOpment, and implementation of the Family Planning Program, through a massive ubiquitous educa- tional effort. Tunisian citizens, in the Space of one iv generation, are being reached by a well organized net- work of points of communication. The entire country is in the process of being infiltrated by the philosophy of birth limitation, its necessity, and with its success the prOSpects of a better tomorrow, particularly for the children. By means of the active participation of unions, cadres of all kinds, commercial and industrial enterprises, political and governmental units. clinics and health facilities, and recently the public school system, Family Planning information and facilities are available to all. A massive publicity campaign through radio, television, billboards, and photographic and printed prOpaganda plays an important role in the edu- cational process. A second area of emphasis is the Tunisian woman herself. A major role of governmental reSponsibility is to educate woman to take her proper place in Tunisian society as not only wife and mother, but as an active participating citizen. Much of this study is therefore concerned with her evolution and the degree to which her position has changed in contemporary society. A serious attempt has been made also to point out the determining factors in Tunisian deveIOpment that have been crucial in the country's progress, particularly the leadership of its president, Habib Bourguiba. This study has been carried on during the summer of 1976, through the medium primarily of interviews, and participation in two worksh0ps. The interviews v consisted of conversations with national directors and employees of the Ministry of Health, the Ministry of Social Affairs, the Office of Family Planning and Popu- lation, all in Tunis, political heads of gouvernorats, as well as delegates of the Office National du Planning Familial et de la P0pulation within the gouvernorats? and United Nations Coordinator of Family Planning and other employees of the United Nations, the American direc- tor of USAID Family Planning projects, the Union of Tunisian Women, and finally two Tunisian families who most kindly received the writer into their homes. Pri- marily a descriptive study, the data could not have been gathered successfully outside the country. Reference is here made not only to the researcher's personal con— tacts, interviews and experiences with the Tunisian peOple within the country, which have been basic to this research, but also to most of the invaluable printed material put at the writer's disposal. Very little documentation is available in foreign libraries. M. Mourad Gachem, chef de service of the Division of Cooperation of the Office National du Planning Familial et de la Population, as well as head librarian, only librarian of the office for all practical purposes, 2Tunisia is divided into 18 gouvernorats. Each gouvernorat is divided into delegations, the head of each being a délégué'or delegate. The term, delegate, is also applied to those who are regional representatives of the Office of Family Planning. vi explained this lack. He stated that there has been a library for only two years, and that he who used to teach library science at the University of Tunis, has been forced to give up that part of his work to devote full time to the library. He stated also, that there is a great need for librarians who have been well trained, that there exists a wealth of information to be found throughout the country, but unfortunately to date there is a serious lack of trained personnel to catalogue it. Consequently, much important data in all areas of develOpment may be lost. This study is divided into five chapters. Chapter One is a brief account of Tunisian history, followed by a rather detailed analysis of political deve10pment before and during the French Protectorate. and from the moment of independence to the present. The first and to date, only president of the republic, Habib Bourguiba, and his unique role in his country's develOpment is discussed at some length. This chapter provides the background necessary to understand why Tunisia has become a model for transitional societies. Chapter Two focuses on the position of woman, past and present in this Arab society, and upon the legislative enactments that have provided the legal basis for her liberation. Chapter Three describes the inception of the Family Planning Program, its rationale, objectives, vii legislative and administrative infrastructure. Chapter Four is devoted to the implementation of the program through the Office National du Planning Familial et de la Population. The Office, its function, strategy, and structure is described in detail. Par- ticular emphasis is given to the all-pervasive educa- tional function of the Office, through the formal school system as well as through non-formal educational means. Chapter Five concludes the study with the most recent available data on the status and efficacy of the program, with a prognosis for the future direction and success of its efforts, based on the available data and the considered Opinion of the Specialists most closely involved. viii TABLE OF CONTENTS ACKNOWIJEDGEIVIENTS.IOOOOOOOOOOOIOOOOOOOO0.0.000... PREFACE...OOOOOOOOCOOOOOOOOOIOOOOOOOOOOOOOIOOIOO LIST OF TABLESOOOOOOOOOOOOOOOOOO0.00.0.0...CO... II. III. IV. ‘LIST OF ILLUSTRATIONS........................... Chapter I. TUNISIA: PAST AND PRESENToooooooooooooooo Historical and Political Development Contemporary Society: Culture and Government POSITION OF WOMAN WITHIN THE CULTURE...... Before Independence Modern Woman in Transition FAMILY PLANNING IN TUNISIA................ Demographic Situation: Need for Control Objectives of Program ~History of Program Legislation and Administration IMPLEMENTATION THROUGH OFFICE OF FAMILY PLANNINGAND POPUI‘ATIONOIOOOOOOOIOI0...... Mission Strategy Structure Educational Projects ix ii iii ix 23 38 54 RESULTS AND PERSPECTIVES OF NATIONAL FAMILY PLANNING EFFORTIIIIIIIIIIIIIIIIIIIIIIIIIII 101 Importance of Education in Context of P0pulation Control Demographic Statistics Social and Psychological Effects of the Program Recommendations for the Future GLOSSARYI I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I 125 APPENDIXI I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I 127 BIBLIOGRAPHYI I I I I I I I I I I I I I I I I I I I I I I I I I I I I I 137 LIST OF TABLES Structure of National Office of Family Planning and Population: Educational programs of Division of Promotion and Education............................ 68 Married Women of Age to Reproduce, Women Pro- tected by Family Planning and Level of Pro- tection by Gouvernorat............................. 103 Level of Protection in Percentages (l97h-l976)..... th Level of Protection in Total Numbers (1974—1976)... 105 Evolution of Contraception in Tunisia (196N-197h).. 113 xi LIST OF ILLUSTRATIONS Figure 1 & 2 Cartoon from E1 Mar'a................ 25 3 & N Cartoon from El Mar'a................ 59 5 & 6 Cartoon from El Mar'a................ 60 7 & 8 Cartoon from El Mar'a................ 61 9 & 10 Cartoon from El Mar'a................ 62 ll Mme. Masmoudi, M. Chekir and M. Mzali: Seminar on Secondary Education...... 88 12 M. Mzali talking with officials of the region before leaving the hotel. 88 13 El Hencha: Délégué and regional doctorIIIIIIIIIIIIIIIIIIIIIIIIIIIII 100 14 El Hencha: Village hall........... 100 15 Ministry of Public Health at Tunis. 100 xii CHAPTER I TUNISIA PAST AND PRESENT, AN OVERVIEW HISTORICAL AND POLITICAL BACKGROUND Host to Ancient Cultures If one goes back far enough in Tunisian history it merges with legend. According to Vergil in the Aeneid, Dido founded Carthage. It appears she was really the Queen Elissa, a Phoenician. AS Aeneas, on his way to found Rome, sailed away from the shores of Carthage, and looked back for one last look at his beloved, the flames of her funeral pyre lighted the sky. Little is known of the people who inhabited the land at that time. The Arabs called them Berbers, a corruption of the Latin, barbarus, stranger, and hence, barbarian. Archaeologists, in Spite of slim evidence, part legend, have accepted the date of 814-813 B.C., as the origin of this Phoenician colony. Carthage survived until lh6 B.C. when it was finally destroyed by the Romans in the Third Punic War, and the Phoenicians left as their legacy evidence of a written language, as well as some irrigation techniques. Roman occupation began in the second century A.D. This 2 was the period of greatest cohesion and most effective organization of the Roman Empire. The victory of Rome opened a new era in the region. Close contact with Europe was established which lasted for some five centuries. The Empire brought a period of political tranquillity. The security of the territory is evident in the remains of towns throughout the country, the testimony of a settled life. The Romans developed a system of sedentary agriculture in the area, and thus the region became important to them, supplying grain and foodstuffs. The towns and cities that deve10ped became wealthy and commercially prOSperous, and more importantly, benefited from the civic liberty of Roman law. There were no ethnic barriers in the African province, and any free man could become a full member of a Roman town. There is evidence that some Latin was still Spoken there in the fourteenth century. The Roman Empire in Africa collapsed in the fifth century, when the Vandal king, Genseric, esta- blished the seat of his government in Carthage. The Vandals never established their own civilization in Africa, even though they made a strong effort, using force and violence. Their dominion ended in 53h, when they were defeated by the Byzantine general, Belisarius. Byzantine rule was never very successful, and control of the Berbers was almost impossible. In the seventh century began the invasions of 3 the Arabs. They established cities that became centers for the diffusion of Islam and the Arabic language. In the eleventh century came the second expansion of Islam, coming along the coastal highway of Tunisia. So rapidly was Islam accepted by the native p0pulation, that today there is almost no evidence of Christianity in the regions that produced fathers Of the Church, as renowned as Augustine. The Turks established themselves in the coastal regions of North Africa in 1534. They encountered re- sistance from Charles V, the Holy Roman Emperor, and later from the Bey of Algeria, but they fought back and set up regencies in both Algeria and Tunisia in the seventeenth century. French Occupation French contact with Tunisia covers many centuries. In the late Middle Ages merchants of Marseilles imported silks, perfumes and products of the Sudan from Tunis. During the seventeenth and eighteenth centuries, France began to deveIOp good relationships in Tunisia deSpite Turkish control. Relations with the country took on new significance after France conquered Algeria in 1830. The Bey considered friendship with France his best pro- tection against Turkey, and therefore, French influence was generally strong. Finally in 1881, the period of the Protectorate began when the French invaded Tunisia on the pretext that some Tunisian tribesmen had been L, raiding Algeria. An agreement with the Bey was Signed giving France substantial powers in the administration of the country. In theory a protectorate establishes control for the mother country without destroying the dignity of the protected nation or stirring up hostility. Thus it is a delicate situation. The Tunisian government existed side by Side with that of the French Protectorate. One of the important results of this contact was the introduction of new ideas, both political and economic, into the phiIOSOphy of the protected state. Thus the cultural penetration begun long before was greatly strengthened. ‘ French officials moved Slowly, and were parti- cularly sensitive to Muslim customs. Problems of govern- ment were many for the French, but their work in apply- ing central power in the provinces, establishing muni- cipal administration, codifying laws, reforming the judicial system and prisons, drawing up and implementing a land law, prepared the country to, one day, with a minimum of difficulty, take over the political system from the French. Although the problems were somewhat complex, they were solved with relative facility during the Protectorate for several reasons, primarily because Muslim institutions were reSpected and because of the French policy of using Tunisian officials, thus of course, providing training in administration for the native element. These native officials were made up 5 of a small but elite group, many of whom had studied in French universities. For example, approximately half of the Ministry of Finance was Tunisian. Many of these officials were not merely pro-French, but actually French apologists. In addition to the work in the area of government and administration, the Protectorate set about systemati- cally transforming Tunisia to make it a safe and profitable base of French influence and activity. The groundwork for a modern civilization was laid in a relatively short time. The French built 1300 miles of railroads, as well as ports and other installations, such as municipal public works, roads, public buildings: medical services were develOped where there had been none, and a new system of education was introduced. All this provided a strong infrastructure, a rich legacy for the indigenous population at the moment of independence. In the period between 1900 and 1949, Tunisian nationalism had its beginning. French philos0phy of the Eighteenth Century Enlightenment, the rights of man, self-determination, and other democratic principles of which the French were so proud, had been taught to young Tunisians in French universities: now these students were an intellectual core of dissemination of this same philosophy in their own country. This same education had created in them a strongly deve10ped national sense. They had been brought into contact with the efficiency 6 of French institutions, socialist political concepts, progressive ideas and intellectual freedom. Thus French culture became the instrument of destruction of French colonial power in Tunisia. I A group of young Tunisians from the closeknit Tunisian aristocracy became the spokesmen to the French for their people, and interpreters of things French to the Tunisians. They provided a period of ideological formulation. With the first World War came the Destour or constitution party, organized in 1920. It was the major party of the twenties. It demanded independence, but at the same time was socially and politically con- servative. In the early 1930's, a new elite, closely allied to the worker, and the 'have-nots' in general then developed and the name of Habib Bourguiba came into prominence. This new movement, or the Nee-Destour,3 represented a new intensity of commitment. These men believed in the liberation of Tunisia from its own backwardness, and from foreign domination. In 1956, when Tunisia became independent, the nationalist movement had unchallenged leadership, a well organized and highly centralized party, the Neo-Destour. Independence Independence did not come easily. The new party led the Tunisian pe0ple in the fight for independence. 3Destour means constitution. 7 and after two decades of struggle and a series of in- cidents, bitter and bloody, success was achieved. The French had hoped for a co-sovereignty and internal autonomy, but these views became obsolete, outmoded doctrines for the Tunisians. Guerrilla warfare frequently became violent. There were gasoline fires, bombings, assassinations, general strikes and protest marches. At the same time, there were appeals to the United Nations. There were such atrocities as "operation 'Mars'" which was ordered as punishment for Tunisian nationalists. At seven A.M. one morning, trOOpS moved in, pillaging, wrecking, beating and raping.“ Habib Bourguiba, a rising young and verbal leader, was imprisoned three times during this period. France had an incoherent policy in North Africa, and if there is some justification for these atrocities, it lay in the serious problems at home. Frustration attended all efforts to be heard in the United Nations. The Korean situation and other world problems made the troubles of little Tunisia seem unimportant. It appeared that the only vocal Frenchman, sympathetic to the Tunisian cause, was Francois Mitterand,5 who strongly criticized the French position. Under Pierre MendeS-France negotiations “Charles A. MiCaud, Tunisia: The Politics of Modernization (New York: Frederick A. Praeger, 196E5. .89- 110. 5Mitterand was narrowly defeated by Giscard d' Estaing in presidential election of 1974. 8 between the two countries continued, the French premier granting so-called 'internal autonomy' to Tunisia. Bourguiba, after being held in Six different prisons since his arrest in 1952,6 returned to Tunis in 1955. Finally in March of 1956, a Franco-Tunisian Protocol of Agreement was signed by representatives of the two countries, calling for complete sovereignty instead of internal sovereignty. The protectorate was dead. Contemporarnyovernment: Destougian Socialist Party The story of Tunisia from this point on, is the story of Bourguiba and the Destour Socialist Party. Political develOpment and modernization of the state, and Bourguiba, are synonomous. Development in this context means socio-economic change. This kind of change has as its objective, in the case of Tunisia, moderni- zation. This term also can be interpreted in a variety of ways. Bourguiba believes in the dignity of man, and modernization to him means whatever change is neces- sary in the institutions of the country, to bring the land into the twentieth century, and this, he feels, improves the life chances of the individual. ....nationalism is only a necessary but far from sufficient condition to insure political develOpment. DevelOpment en— tails the translation of diffuse and *6 He was first held in several Tunisian prisons, Tabarka, Remada, la Galete. He was transferred to France when his 111 health became serious. 9 unorganized sentiments of nationalism into a Spirit of citizenship and, equally, the creation of state institutions which can translate into policy and programs the aSpirations of nationalism and citizen- ship. In brief, political development is nation-building. How is Tunisia going about its nation building? A comparison with European development is difficult and probably unproductive. The long evolutionary period the European states eXperienced does not exist for third world countries. Tunisia did have the advantage, however, of a long gestation period provided by the years of the Protectorate. A minority, it's true, but A still those with relative power, intelligence and pres- tige had contact with liberalism, and the political philos0phy that in time resulted in independence. This latency period allowed for limited participation by Tunisians in the government, a participation that became more meaningful as independence came closer to reality. The Neo—Destour is neither a constitutional mass party nor a totalitarian party. It is somewhat 8 like some organizations of French West Africa. It is 7Jason L. Finkle and Richard Gable, Political Deve10pment and Social Change, (New York: John Wiley and Sons, Inc., 1966), p. 86. 8Senegal, with its one party, strong president, and elected legislature seems to resemble , Tunisia. Sierra Leone, with a president, one strong party and an elected House of Repre- sentatives appears similar. 10 certainly a nationalist party: it has no effective constitutional Opposition. Bourguibism is the anti— thesis, however, of a totalitarian ideology. The mission of the Neo-Destour.... is the apparent paradox of maintaining its poli- tical mon0poly, in order to preserve Tunisian independence and to modernize the economy and the society, while working for the consolidation of a truly demo- cratic life in which reSponsibilities are limited and which guarantees for indivi- duals the enjoymeat of their rights and public liberties. This paradox is perhaps not as real as it appears. The Neo-Destour is representative: the new nation is embodied within it, through an elite formed by French education and united by years of resistance to French domination: it is an elite committed to the 10 It is a radical modernization of Tunisian society. political monOpoly, but one that does not use repression or foster a climate of mutual su8picion to stay in power. Its ideology is not rigid: it does not invade the privacy of the home. Obviously the regime is suffi- ciently secure that it does not need totalitarian methods. 11 According to C.H. Moore, the study of contemporary politics in Tunisia is of Special interest to students 9Jason L. Finkle and Richard Gable, Political Deve10pment and Social Change, (New York: John Wiley and Sons, Inc., 1966), p. 538. 10 Ibid. 11 Clement Henry Moore. Tunisia Since Inde endence (Berkeley: University of California Press, 1955). p. l. 11 of political science because it is the best example to date of modernization based on a single party system. He lists the following traits of such a system. 1. After winning independence, the party exercises a virtual monopoly of power, either directly or indirectly through the new state administration that it staffs, though weak Opposition parties may persist 2. While depending for its cohesion after independence mainly upon the personal power and prestige of a leader-hero, the party is a national symbol sharing its prestige as founder of the new state 3. The party is open to almost all na- tionals h. Its leaders and cadres are selected primarily on the basis of their loy- alty and political achievements rather than social positions 5. Its well-articulated structure, supple- mented by a network of ancillary organi- zations, actively sustains a mass fol- lowing and aims at integrating the soci- ety 6. Though the party does not have a total ideology, it communicates a broad mes- sage of social and economic moderni- zation Upon the advent of independence, Habib Bourguiba assumed leadership of Tunisia. He talked of a consti- tutional monarchy, but he was really consolidating his own power. At the same time the Neo-Destour decided that the power of the Bey should be limited until he became as innocuous as the English monarchy. A National Constituent Assembly was established by a decree of the Bey, and thus he was obligated to support a constitution he had never seen. At the insistence of the party he was weakening his own position. The party created a 12 national front list of 98 candidates, and exhorted the people to vote for them. The National Front received 597,813 votes to 7,352 for the Communists and 233 for an independent group. The monarchy was abolished and, Tunisia proclaimed a republic. Total unity through total organization was the goal. The Neo-Destour was organized into militant cells in different districts of the cities and the small villages. The cells educated the people and organized activities. These local cells formed regional federations in the principal centers of the country. The National Council is composed of delegates from the regional federations along with representatives from the national syndicates and the Political Bureau. The Political Bureau under the presidency of President Bourguiba consists of ten members, five of whom were ministers in the government. The Tunisian Constitution, published on June 1, 1959, is a presidential document giving almost complete power to Bourguiba. The Tunisian president appoints the members of his government, who are reSponsible directly to him, and makes all other civilian and military appointments. The president cannot nominate himself for more than three consecutive terms (of five years each) but the legislature can neither impeach him nor impede nor obstruct his wishes. When the legislature is not in session the president can rule by decree. There is no supreme court to decide 13 the constitutionality of legislation. In form at least, if not absolutely in practice, the power of Bourguiba is unlimited. Habip_Bourguiba: Leader This man is unique among modern political leaders. He was the director of his country's independence move- ment long before independence was achieved. He is honored and respected by his people. He is called and calls himself, the father of the nation. Orphans are called, "enfants de Bourguiba," expressing the American concept of Washington as father of his country. In the case of the latter, he had been dead a good long time before being awarded the distinction. Bourguiba was born at Monastir, one of the Sahel's most ancient cities. His family was a respectable one of low-ranking civil servants. His mother died when he was young and he was sent to Tunis to study, first at Sadiki's elemen- tary school annex, then at Sadiki College and the Lycée Carnot. In 1924 he left Tunis for Paris to study law and political science. His education in Tunis and Paris did much to form his personality and outlook. Away from his local surroundings he became familiar with the broader perSpective of history and European thought: no longer was he limited to the confines of Islam. He grew up as a humanist, and strongly rejected Marxism. He became sensitive to the ideals of a socialism that could provide individuals with a wider SCOpe for l# self-development. He made friends not only with North Africans, but With the French. He came to know the liberal and radical French tradition. Today he often appears to be more closely allied Spiritually to the eighteenth century of the French Enlightenment than to his Arab world. His political inSpiration comes from Rousseau, and Hugo, rather than from Karl Marx. For Bourguiba, Marxism was a theory for industrialized nations, not for Tunisia. He was introduced to politics at an early age. He joined the Destour in 1922; in Paris he had contacts with the French Left. He con- tributed to nationalist neWSpapers written in French, and formed his own paper, L'Action Tunisienne, with some university friends, who in l93h became a nucleus for the Neo-Destour party. He was thrown into prison in 1939 for the first time. He Spent ten of the next twenty years in prison. What is remarkable, is that no malice seems to have resulted from these experiences. He never shut the door to negotiation with France and the West. In 19h9, after four years of disenchantment with Egypt and Eastern Arabism, he became more con- ciliatory than he had been. He has a remarkably moderate political manner. This moderation is partly myth, however, for he could never have been successful in mobilizing a nation if he had been simply a moderate lawyer politician. 15 Politics to him is rational calculation, a Cartesian activity tempered with common sense, but the man is a fiery bundle of passion and theatrical gestures. It is not only intelligence, but determination and personal magnetism--so focused on politics that he addresses private in- dividuals as though they are public audiences--that make him an inSpirational leader. Like all great actors. Bourguiba, who seems always to be on stage, is able to calculate his gestures and to release the warm Spontaneity which draws audiences to him. 2 How important is the charisma factor in eval- uating Bourguiba's success? Horowitz states that: Nearly every nation in the Third World exhibits a strong principle, a Fuhrer— prinzip, in which power is seen to re- side first and foremost in the leader, since he contains within his person the sum and substance of the aSpirations and sentiments of the whole people. There is thus a significant tendency inlfihe direc- tion of charismatic authority. Bourguiba does not really have this charis— matic role, if charisma is viewed as in Max Weber,1u "a certain quality of an individual personality by which he is considered extraordinary and treated as endowed with supernatural, superhuman, or exceptional powers or qualities." He is however, very popular. He articulates his nation's values, but what he teaches lzIbid., p. 42. 13Irving Louis Horowitz, Three Worlds of Development (London: Oxford University Press, 1972), p. 318. 1h Max Weber, Econom and Societ (New York: Bedminister Press, 19 , p. 2&1. l6 and what he does are not unquestioned. Many, especially the young, agree with his modern ideas but rather often disagree with particular political measures. The un- educated also question much that does not agree with their traditional values. He is even thought by some to be a 'bad Muslim,‘ perhaps even an atheist. He is reSpected, but hardly charismatic. The cornerstone of his philoSOphy is the ad- vancement of man through modernization. He emphasizes man's intelligence, reason, and the virtue of free inquiry. He has reformed rather than attacked. He is willing to advance by gradual stages, and can accept compromises. The Destour is an instrument for im- pressing the wishes of the regime upon the p0pulation, but also for transmitting the aspirations and grievances of the masses to the leadership. Bourguiba's policy is one of accommodation and stability. He appeals to reason and common sense. He professes to believe in the individual and democracy, in spite of the highly centralized regime. He probably thinks of his government as a kind of tutelary democracy. The argument for this type of democracy is that it will provide a more disciplined and stable regime than political democracy during a transition period. It is felt by its advocates to be essential during a period when a country is not yet prepared for 'true' democracy. As Bourguiba stated in a speech to this effect, during 17 a visit to Bucharest in 1968: Democracy is the ultimate state of evolu- tion of every society. It is not given at the start, but comes about quite natu- rally once the necessary conditions have been fulfilled. These conditions, I think, are the following: a modern state that works, and enjoys the reSpect of the pOpu- lation because it is worthy of such reSpect: a nation which is held together by soli- darity and the coherence of its constituent parts: a people that has attained a high level of education and standard of living enabling it to receive democracy, not as a luxury with which one does not know what to do, or a toy which one breaks, but as a precious possession, a mark of maturity and a generator of progress. This, at any rate, islghe road we have been taking in Tunisia. Whether or not Bourguiba is sincere in his democratic aSpirations for his country at some distant point in time, is immaterial, at least for the purposes of this study. Deve10pmental progress toward moder- nization does not necessarily require a democratic political system. The polity essential is one that provides stability and capacity for purposeful and orderly change, and the Neo-Destour appears to be doing just that. The values growing out of the French Re- publican tradition that he accepted, he has adapted to what he believes to be the welfare of the state. 15Anthony Sylvester, Tunisia, (London: The Bodley Head, 1969), p. 7. 18 All Tunisians were to be equal as citizens having human dignity. They were to be bro- thers in the family of the Tunisian nation. They were to be free so far as their liberty did not conflict with the liberty of others or With the general interest. Human dignity required bread and possibilities of employ- ment, education, and health services: there- fore, the nation, existing as a good only so far as it furthered the dignity of its fgti- zens, had to be modern as well as free. The genius of Bourguiba has found its express- ion in his methods. He applied western ideas to a Muslim society through rational persuasion. He assumes that change can never really be forced: it can however, be 'nudged along' in the right direction. He is a pragmatic man. He has generally managed to have good relations with East and West. In 1968 he visited both Canada and the United States. He also has good relations with Russia. He walks a middle path between the old and the new, but when traditional ideas get in the way of modernization he has little patience with the forces of tradition. Contemporary Society: A Changing Culture The country is a poor one, poor in natural re- sources: it is overpOpulated: its peOple are lacking in skills: there is overcrowding in the cities: there is poverty, and in many rural areas still can be found ignorance, prejudice, and passivity in the face of 16 Clement Henry Moore, Tunisia Since Independence (Beakeley: University of California Press, 1965), p. 3. 19 misery. All this is true, yet there are many factors that are real assets in this tiny country's struggle for modernization. To begin with, its geographical position, facing the Mediterranean, at the crossroads of eastern and western civilizations, has exposed it to many civilizing influences. Tunisia has a rich heritage of art, for example, not only Moorish architecture, literature and handicrafts, but also the best preserved and most beautiful Roman mosaics to be found anywhere. The country has linguistic and religious unity. Except for small, isolated pockets of Berbers, one percent of the population, all people speak Arabic. French is also Spoken as a second language by all who have even very minimal education. Islam is another unifying force. The peOple are Muslims with the ex- ception of a small Jewish community. It is true that some tenets of Islam have been modified through re- interpretations to accommodate the needs of develOpment, particularly taboos and traditions relating primarily to women and marriage, but Islam remains a powerful force for unity. As would be expected, religion is a much stronger influence in small towns and rural areas than in Tunis. The traditional Muslim appetite for learning has supported to some extent tremendous changes in the educational system. Progress has been great indeed. The budget has been enormous, but by 1968 virtually 20 all of Tunisia's then one million or so children could be accommodated in schools. Efforts are continuing to improve the quality of instruction, and to gear it in the direction of the country's economic develOpment. Not only formal instruction, but many non-formal pro- grams outside the school system, have been established. A few of the latter are: Centers for Rural Girls, ages 12 - 18, in which illiterate girls are trained to provide better home and family life: Social Action Centers, that are the most coordinated systems of family training in Africa. These are under the Sponsor- ship of the National Union of Tunisian Women, and pro- vide a two-year literacy course. Pre-Apprenticeship Training Centers, for primary school leavers, develop Special Skills and attitudes necessary for productive employment or further vocational training. Doubtless the most dramatic social change that has occurred in the twenty years since independence is in the position of women. The first time visitor to Tunis is impressed by the uniformed police women directing traffic. Women frequently hold positions of authority in the ministries. Their numbers are increas- ing at the University of Tunis. They are employed in many enterprises. The enactment of a code of personal 17 statutes, replacing Koranic law, has attacked Tunisia's 17See Chapter II, p. 27 for fuller de- scription. 21 social structure at its roots. It encouraged the idea that marriage was more a relationship of two people than of two families. The principle of civic equality has given to women the right to full citizenship. In Tunis it is easy to forget that still a large number of women are illiterate, and that life for them in the little villages has not changed greatly as yet. The govern- ment has done much for them in a very short time, but much remains to be done. In relation to the economy, although the Neo- Destour and its president are aware of its importance, there has been less done in this area than in the others. The economy remained stagnant five years after inde- pendence. The government has encouraged private ini- tiative, but did little itself until 1961. The effort to transform attitudes and values and to reduce obstacles to progress has been, in contrast, enormous. The crea- tion of a strong, united national community took pre- cedence over economic expansion. Central develOpment and planning of economic develOpment began in 1961, when the withdrawal of French capital and trained personnel made it necessary. There was a ten year perSpective, with a three year and four year plan to follow. The broad objectives have been: reform of economic struc- ture including industrialization of the country, human development, and self-development. New industries have developed, among the most 22 important of them has been tourism. Existing industries have been expanded under government direction. The banks have been nationalized: the merchant marine has been developed so that Tunisian Ships carry the country's trade. The fishing industry has been greatly expanded. and immense progress has been made in the development and rational use of water resources. Progress toward the goal of modernization has been phenomenal. Serious problems remain to be solved, it's true, but a visitor from the West finds himself among likeable, basically friendly pe0ple, more Open, more oriented to the west than those of any other Muslim country. CHAPTER TWO POSITION OF WOMAN WITHIN THE CULTURE Traditional Society Tunisia, because of its geographical position, has had a unique history. It has politically bene- fited from an administrative training period under the French, and from wise leadership Since indepen- dence. It is considered a model transitional society. Much has been done to establish legal equality for women. President Bourguiba is much interested in their status. When he uses a frequently repeated expression, "the dignity of man" he includes both men and women in the term. He is convinced that develOp- ment of a nation can only be based on an improvement in the lot of all of its people. The Code of Personal Status reflects this conviction, and has given much legal recognition of women's rights. What has been the traditional position of women within this society? To what extent has reform been needed, and to what extent has it been accom- plished? Are Tunisian women enjoying a better life 23 24 today? What is their present situation in the culture? This chapter attempts to answer these questions. "It is unthinkable that half the population be cut off from life and hidden like a disgraceful thing." 18 He referred So said President Bourguiba in 1960. to the frightful conditions under which Muslim women lived for centuries. Woman was humble and obedient. She existed solely for the pleasure of her husband and to give him children. She was his prOperty and had no legal rights. As a child her father had absolute authority over her.19 He arranged her marriage, and frequently She met her husband-to-be for the first time at her marriage. The bride was often a child of ten to twelve years. The husband could divorce his wife for no better reason than that he had found a woman more attractive to him, and he could not afford two wives. A repudiated woman had to go back to her family, where she was considered disgraced. Her children, even the very young ones, were the prOperty of her husband, and therefore stayed with the husband's family. All women were excluded from outdoor social activities,‘ and also from those within the home when strangers were 18A Speech of Bourguiba' s in 1960. Quoted in La Femme Tunisienne, Secretariat d' Etat a 1' Information. Writer' s translation from the French. 19899 figures 1 & 2 cartoons taken from ElM Mar juin-juillet, 1975. p. 22. Succeeding cartoons in Chapter IV, from same source, pp. 20-23. Figure 2 25 26 present, eSpecially if they were men or foreigners. Women were secluded behind the walls of the female apartments of the house, and segregated from all contact with the outside world. In the cities and villages they were forced to cover themselves quite completely if they left the house. The only form of education open to them was instruction in household tasks, and sometimes in a craft such as weaving, through which they were able to supplement the family income. The Koran states that man is superior to woman: therefore, the birth of a male child has been a cause for rejoicing, whereas a girl child was only another mouth to feed. As late as 1965 Bourguiba expressed his horror at the case of a primary school teacher in Jerba, who was to marry a civil servant and was (to improve her beauty) shut up underground, smeared with clay, to give her a fairer complexion, and then stuffed with Spaghetti.20 Contemporary Woman: Twenty Years After Independence For many Tunisian women, life has changed dramatically Since their country became an indepen- dent nation in 1956. A land dedicated to secular moder— nization and cpen to western ideas could not afford to 20Wilfred Knap , Tunisia, (London: Thames and Hudson, 1970 , p. 13. It is still true in much of the country, that a well-rounded figure is much appreciated. 2? exclude half of its population from the process. The prestige of Bourguiba and his firm support of female emancipation was mainly responsible for an astonish- ing social revolution. In 1956, on August 13th, the Personal Status Code (Code du Statut Personnel), was introduced. It replaced Koranic law with a legal sys- tem. Its provisions, at one blow, established the legal framework for the complete emancipation of women, effective on January 1, 1957. Before the law, women became full citizens. Institutions particularly de- grading to women, such as polygamy, repudiation, and forced marriage were abolished. It is stated in Article III of the Code that a marriage can be contracted only by the consent of the two Spouses. Gone is the power of the father in this matter. Polygamy is declared unlawful under Article XIW1when an obstacle to marriage is stated to be the non-dissolution of an existing marriage. Repudiation is outlawed in Book II, the section on divorce. It states that a divorce can only take place in a court of law. Provision is also made for the welfare of children and for rights of inheritance. All in all, this Code is a startling document, a very daring one. The fact that it was accepted, and that no revolution ensued, indicates the power and prestige of Bourguiba and the Neo—Destour. The timing, of course, was on their side. Bourguiba was the national hero, and the Neo-Destour represented victory over the French- 28 and independence at long last. Now, twenty years after the Personal Status Code became effective, can it be said that the Tunisian woman is truly free? It is difficult, really impossible, to make a statement that applies to all women, as their relative Situations depend on many variables, chiefly the region of the country in which they live, and the economic and social status of their families. It can be said, however, that most women enjoy a much better life. Familiarity with the terrain of country and an understanding of its economy, facilitates understanding of the Tunisian woman. Tunisia is a very small country, with an overall area of l6h,OOO square kilometers, or 13,362 square miles, or about one quarter of the land surface of France, slightly larger than Georgia. It is rather consistently 150 miles wide, and about 500 miles in length. The country can be roughly divided into two parts: the northern coastal zone and the interior, meaning particularly the center and south. By far the heaviest pOpulation is found in the north, particularly in Tunis and urban areas. The north is also the richest and most varied part of the country. Because it is more heavily p0pulated, more industrialized and much more cosmOpolitan in appearance, as well as the home of the central government and the country's only university, it is also much more Open to European influences and is 29. more liberal in outlook. The central and southern sec- tions are subject to harsh natural conditions of climate. The average technical standard of these farmers is very low, and many live in abject poverty. The minimal popu- lation of this area results in isolation for many families even though they may live in small villages. Any life outside of their own is unreal. Some families living in caves,21 under the most primitive of conditions, are unaware that the modern world of the twentieth century exists. Thus any discussion of the position of the Tunisian woman in contemporary society must take into consideration the geographical region in which She lives with its concomitant orientations and resources. It is to be expected that the women living in the capital would be the most 'liberated.‘ It is easier to try out the new in the anonymity of a big city. It is, therefore, difficult to distinguish the women of Tunis from a western woman. The majority of them wear western dress, and appear as free and independent as their European counterparts. They are very visible. They are in the ShOpS, in taxis, on foot or driving their own cars. They are working-~in stores, offices, government institutions, and most surprising to many foreigners, they are directing traffic in the city, and doing it very efficiently in their very smart uniforms. 21 See page 35. . 30 Many women are employed in the ministries, often in a position of authority over men. There are, however, some vestiges of the past. Only in selected cafes, very few, do women stOp for some refreshment. Doubtless they would be served any place, but the cafe is still the preserve of men for the most part. A woman in the Ministry of Public Health, one who had several men as her subordinates, talked to the writer about her position. "There are no obvious difficulties, because Tunisian men are polite, but I am very aware they often make only a pretense of listening to me. On one occasion I had to tell them very expli-: citly that I had been chosen for the position because I had more education than they, that I knew better than they what had to be done, and that if they wished to continue working they would have to do as I asked them." She stated also that some men tended to make remarks about a pretty face in the office, but were slow to accept her seriously as an equal. As she was a very intelligent young lady She realized that culture changes slowly, and that what had been accomplished in twenty years had been remarkable. There is an easy relationship apparently between many young women university students and the male stu- dents. They are to be seen in friendly groups along the street, in the parks, and Sitting in the sidewalk cafes, (again only selected ones). They are the young 31 women who will some day be able to do much to bring their rural sisters into the twentieth century. Occasionally still, older women are seen wearing the safsari, the "odious rag."22 It is said that some cling to the old custom mainly because it hides poverty, and is therefore what the French call, a 'cache misére.‘ The atmOSphere in Sfax, the second largest city of the country, is noticeably different. PeOple here are considerably more conservative. Western clo— thing is still evident, but it's not the latest style. There are no pant-suits for women. Men and women would appear a bit dowdy to their brothers and Sisters of Tunis. The writer had the good fortune to be invited to stay in two homes in the city. Tunisian hOSpitality is not a myth. These peOple were exceedingly kind and thoughtful. The stranger was made one of the family. Elaborate, enormous meals were prepared, excursions to Sites of historical interest, visits to relatives and friends were a part of each day's activities. Each day the writer received a necklace of jasmin flowers that 22 Bourguiba urged women to take off their veils. In a Speech on December 5, 1957, he stated, "If we understand that middle-aged women are re- ticent about abandoning an old habit, we can only deplore the stubbornness of parents who continue to oblige their children to wear a veil in school. We even see civil servants going to work in that odious rag.... It has nothing to do with religion." In Sfax, Bourguiba prohibited the veil in the classroom. Ill.l{illi.‘l‘llll |‘ l' l.ll|ll1ll{lll 32 the grandmother of the family made for her. Each day she was embraced by each member of the family, and often by those she met for the first time. The family atmos- phere was warm and loving. Close contact was maintained with cousins, aunts, and uncles, and a stranger in their midst was accepted at once by everyone. The women of the family were excellent examples of women in transition. Two middle-aged mothers lived in beautiful houses that contained all the modern con- veniences, and in particular, very large television sets. Each day they watched a football game from Tunis, or a mystery story from Libya, their only two channels. One woman had her own car, the latest model Renault. Both women Spent their days in the house. They had each a bgnng, that is, a young girl who helped with the children and the housework. The bggng, the mother, and the older girls normally stayed home during the day, doing household chores and preparing meals, an all day process. Occasionally the women went in the car to visit other women, but the children and their husbands consumed almost all their time. Both women were illiterate and Spoke only Arabic. One day when the one woman had a minor automobile accident, she called upon her daughter, a student at the lycee, to read and fill out the neces- sary insurance papers. The writer was invited to visit a neighboring village that had a magnificent Roman amphitheatre. The 33 father and two high school girls accompanied her. The mothers stayed at home. The writer was invited to lunch at a good restaurant in the city. The mothers stayed at home. The men, the two fathers of the families, had been educated in the primary school for about three years until the death of their father, when they were apprenticed to construction contractors. The fathers, therefore, spoke rudimentary French, and could read and write sufficiently to carry on their enterprises. All the children old enough to be in school were able to communicate in French as well as Arabic. One daughter at the lycée was an excellent student, and was 'first' in most of her studies. She plans to be a doctor, and therefore, She will go to Tunis when she has the bacca— lauréat, and begin her medical training there. She would not be surprised to have to Spend some years in a foreign country if she decides to Specialize. Both parents appear very proud of her and are supportive of her plans. The daughter in the meantime is a dutiful Muslim daughter, Spending her days when there is no school, helping at home and doing little else. She feels that pants are not proper for girls or women to wear, and none of her friends would wear them. She isn't interested in religion, although a girl cousin with whom She spends much free time, is quite religious and prays everyday. Her father, although he dresses in 3h traditional clothing always, is considered a bit of a radical because he has wine each night with dinner. When the writer explained that She was doing research on family planning, the one mother stated that She was interested, because she felt her five child- ren were enough, but her husband didn't want her to go to the clinic. He explained that contraceptive methods were dangerous to a woman's health. He 'knew' Of women who had become very Sick, and some who had died: also the doctors always wanted to Operate. The mother Of the men talked of the younger brother studying in the States. They looked forward to the time when he would return to Tunisia and marry the girl that his mother had picked for him. This young man of whom they Spoke has Spent three years at an Amer— ican university. It is interesting to Speculate on the attitude of the young man when he faces this situation upon his return home. Sfax, therefore, is a city of contradictions, Where the old and the new exist Side by side. For the middle-aged and Older, the twentieth century is a superficial overlay of automobiles and indoor plumbing, but life has changed very little for them. The younger, however, primarily through their schooling, are becoming a part of a new Tunisia, which is a whole new world Of Opportunity for those prepared to meet its challenge. AS late as 1975 an article appeared in a 35 magazine, entitled, "Les Autres Tunisiennes"23 in which yet a third classification of Tunisian women is dis- cussed. These are the women of the rural areas that have not yet been reached by the program of moderniza- tion. The article describes the life of Mbarka, who with her family lives in a kind of grotto formed from rocks. In this cave live father, mother, and eight children, as well as a mare, a cow, and two dogs. The mother tries to nurse a baby, but obviously she has no milk for the baby and he cries from unsatisfied hunger. A four year Old boy lies on a stone bed. He's sick. Mbarka is 35 years Old, and has been married for twelve years. She finds it quite natural and normal to have SO many children, to see them almost always sick, undernourished, to give birth to her children without the help of a doctor, or even a mid-Wife. She feels the mid-wife of the village is too expensive. She charges one dinar for each delivery, about two dollars. Having had no instruction Mbarka is hardly aware that there is any life other than the one she has known. She accepts misery as inevitable?“ At a time when everywhere in the world and eSpecially in Tunisia the woman has become a free citizen, active, emancipated, parti- cipating in the social, economic and 23 Faiza Laalai, "Les Autres Tunisiennes" Dia- logue pour le Progrés, No.2l—(dfi_27—janvier au 1 1 fevrier, 1975), pp. 10—14. 24 Ibid. 36 political life, and taking upon herself the same rights and duties of all citizens, it is very disturbing to meet these 'other women' these thousands of Mbarkas, living in such conditions, in ignorance, deSpair, resignation, and eSpecially (is it dis- turbing to be ignorant) that this Situa- tion exgsts among those we call rural women. Not all rural women live in the same abject misery as Mbarka. There are some who have fled to the city and are now working as domestics. Some have benefited from rural development programs and are now working small plots of land that they own. The social assistant is also a rural woman, a woman who can scarcely find the necessary material to help her in her task Of helping the desolate. Little by little all these peOple are being helped, primarily by the program of social action Sponsored by the Ministry of . Social.Affairs, and by the Union Of Tunisian Women. The problems to be overcome are difficult and many. Transportation to centers, and lack of materials are real Obstacles, but the primary need is personnel, more doctors, more nurses, assistants, and instructors. Thus it is to be seen, that although much has been done to improve the lot Of woman, although she has legally gained full rights of citizenship and equa- lity before the law, much needs to be done as not all women have been reached by the programs of moderniza— tion. Twenty years is a very short time, and the 25 Translated from the French by the writer. 37 marvel is that so much has been done, and not that so much as yet has not been accomplished. Equality of women will be translated into reality only through education and employment Opportunities. CHAPTER THREE FAMILY PLANNING IN TUNISIA Its Origin and Development from Independence to the Institution Of The National Office of Family Planning and Population The Demographic Situation: Need for Control In the massive effort being made to improve the quality of life for the Tunisian woman, there are several aSpects tO be considered. First, she had to be legally granted equality before the law. Then she had to be given control over her own person, as a Single or married person, and thus respect for herself.26 Her mental and physical health had to be protected. Self-reSpect and psychological and physical well-being are important objectives of the Family Planning Program. TO protect the health of the mother, before, during, and after pregnancy, and to give her the means to limit the number of her children and thus insure that her mental and physical health will be 26* See Chapter II, pp. 27 & 28. Through the Personal Status Code and the enactment of laws, these needs have been met. Health protection has been improved, but much work is still to be done. , 38 39 adequate for her reSponsibility are primary goals. If the woman is to play her role as a responsible citi- zen, she cannot be burdened with an unreasonable number of children. This philosophy finds strong govern- ment support. Family Planning is without any doubt, a. physical liberation, eSpecially for the woman, for it assures protection of her physical and mental health.... Through its multiple services which it offers her, it Opens before her new horizons and permits her to haveza completely new concept of herself. And again, In our eyes, the Objective to attain is not only the limitation Of births, but also, and of equal importance, the pro- tection of the health of the mother and child, 323 improvement in the quality Of life. Of even greater importance probably in urging an efficient program of family planning, has been the demographic situation. Bourguiba, and many other govern- ment leaders make frequent reference to it. At this period in time, the demographic explosion has become SO great that it is truly absurd not tozgive it all the attention it deserves. 27- Mezri Chekir, préSident directeur général de l'Office National du Planning Familial et de la POpulation, July, 1975. 28 Hedi Nouira, Premier Ministre, September 24, 29 Mezri Chekir, July, 1975. All quotations are the writer's translation. 40 To the same extent that we must increase production in all areas, we must decrease the birth rate. We must be aware of the in- surmountable problems which arise from an uncontrolled demographic growth, which threa- tens to compromise all the develOpment plans that we gark out for the progress of our country. For the future is our supreme concern. We are working indefatigably to prepare for it. In this perSpective the essential considera- tion is the human multitude that will reach maturity in ten years, in twenty years. We must foresee and provide for it the means to live. We cannot imitate certain other coun- tries by seeking security in passive re- signation, hOping that God will help us, for- getting that God has given us the power to improve our situation. For ourselves, for our women, for the State, it is necessary that an exact accounting of our demographic evolution, and a rational, scientific plan- ning of our birthrate, spare uSthe miseries of families that are tOO large. This 'demographic explosion' started in Tuni- sia during the 'thirties'. In 1921 there were 1,875,000 inhabitants. In 1946 the national census recorded a pOpulation of 2,904,000 and in 1956, 3,442,000. According to the census of May 3, 1966, the pOpulation had reached 4,715,000. Today, in 1976, the population is 5,672,000. The explanation for this phenomenon is two-fold. First, the diseases that were once mainly re- Sponsible for the high death rate, have been either decreased considerably, or been entirely wiped out. Vaccination against smallpox, tuberculosis, diphtheria and tetanus has been practiced on a wide scale, and has 30 Bourguiba, La Maison du Parti, January 30, 1976. 31Bourguiba, Carthage, April 17, 1972. 41. assured the survival of most children. Such measures, as improved drinking water and better sanitation, protect the population against illness. Medical installa- tions have expanded their capacity, and are more effi- cient in their fight against disease and death. Thus we have more children surviving, and adults living longer: the mortality rate has been decreased at both ends of the life cycle. From a level of 20.9 percent in 1956, and 14 percent in 1966, the mortality rate has decreased to 10.3 in 1972, and 9.5 in 1974. Secondly, the fertility rate, because of the age structure Of the population, has been very high. The practice of very early marriage has added to the problem. Since the decree of February 20, 1964, fixing the minimum age of marriage for girls at the age of 17 years, and since the development of secon- dary and.university level educational Opportunities for girls, there has been some decrease in the birth- rate in the age group of 15 to 19 years. The largest number of marriages is at age 17 for girls, but age varies according to the region of the country. In Tunis the average age in 1970, was 23% years, and the average was the lowest in the gouvernorats of the center and south of the country. The overall fer- tility level has decreased generally an average of about five percent per year, since the rate has gone from 193 percent per thousand in 1965, to 163 percent in 1970, - )IIIIIIJ 42 and 149 percent in 1975.32 This decrease must continue at the rate of 2.5 births per thousand women annually, resulting in an average fertility rate in 1962 Of 131.5 percent of births per thousand. It is estimated that this decrease must be achieved, if the country is to have a maximum of 10,000,000 peOple in 2001. Ten million is the estimated maximum figure to achieve balance between economic production and population. It is likewise estimated that population would go over the thirteen million mark if family planning efforts were to be abandoned.33 In 1966, 43.2 percent of Tunisians were less than fifteen years Old. Today, 1966—1973, the pro- 34 portion is higher, 45 percent. In Spite of a lower fertility rate due to the efforts of a government pro- gram of family planning, this youngest group of Tunisians has increased in number. What must be taken 32 These fertility rates are Obtained by adding together percentages of births per thousand women of the age to procreate according to various age groupings. They may be 15-19 years, 20-24 years, 25-29 years, et cetera. The figure Obtained aS an overall fertility rate iS the sum of these age group figures. See Chapter III, p.1V7fOr goals relating to number of births to be avoided. 34 Comparable figures for France and Italy are reSpectively, 25% and 24% for those under 15 years of age. 43 into consideration is the decrease in the mortality rate - a fifty percent decrease within a Span of eighteen years. A large percentage of this figure is a decrease in infant mortality. Thus there is still today a large percentage of the pOpulation that does not produce. These very young peOple do not contribute, and are supported by the remainder of the pOpulace. They increase the expenses of the State, and place a heavy burden upon the active sector. Twenty-eight percent of the total population is of school age. Not until 1981 will this figure begin to come down. In that year, a decrease in the age group, O - 14 years, of 2.40 percent is expected. In 2001, a further de— crease Of 9.44 percent is predicted.35 It is estimated, that were there to be no family planning efforts, in the course of the period 1974-1982, the pOpulation would develOp thus: --Annual number of births: 250,000 --Annual increase in school pOpulation: 250,000 --An increase in the active sector of the pOpulation too large to be assimilated in totality into the labor force. --An increase in the number of children not being educated, and in the number of Tuni— sians unemployed and without income re- sulting in serious socio-economic problems 35 See Table, page 47. 44 which would upset the equilibrium of the society.36 These figures indicate clearly that family planning is necessary. It is obvious that vigorous measures must be taken to increase the services offered to couples, and to continue to encourage their parti— cipation so that projected birth rate decreases may be achieved within the next twenty-five years. Tunisia is not Opposed to rational growth of pOpulation, only to that which is incommensurate with growth of the economy. History of the Program Tunisia is the first African country and the first Arab country to undertake a national program of family planning. President Habib Bourguiba was one of the dozen chiefs of State who signed, in 1966, at the United Nations, the Declaration of Chiefs of State on the Population. From the very first years of independence, Tunisian leaders have realized the gravity of the demo- graphic Situation of the country. President Bourguiba, as early as the 25th Of December, 1962, addressing the third congress Of the Union of Tunisian Women, de- clared: 36 La Planification Familiale en Tunisie (Tunis: W1 7 q ‘ t' 45 We can't help but feel apprehension before the human tide that is irresistibly advanc- ing at a Speed that is much greater than that of our increase in essentials of life, for what good is it if both food production and our raw materials are Speeded up if the pOpulation continues to grow in such an uncontrolled and insane fashion. We will accomplish nothing, for we run a risk of finding ourselves reduced to a level of develOpment below that at which we started. Humanity, which through reason has dominated nature and progressively vanquished illness, which has invented the tool and has trans- formed the face of the world, can restrain itself and decrease the rate Of procreation. In another speech of November 2, 1970, he spoke thus: The key work for all social categories from this point on is to produce, always produce, and to produce more. It is also, to re- produce less, for we risk being swallowed up by the wave (of humanity). Since 1962, Tunisia has chosen a philosophy of develOpment planning in which the accent is on the importance of control of pOpulation growth, and its influence on economic and social development. The National Program Of Family Planning was adopted for the first time in 1964, and was limited to an experimental period of two years, (June, 1964 to May, 1966). Twelve Centers of Maternal and Child Protection (P.M.I.) were chosen for the diffusion of contraceptive products, and some months later, the number was increased to thirty-six. Three hOSpitals of the capital also began trial clinics for the IUD.37 Encouraging results from this experimental 37 Inter-uterine device. 46 phase influenced those in authority to extend the program to a national level, under the direction of the Secretariat d'Etat a la Santé Publique. Then as the result of a law of August 2, 1971, the National Institute of Family Planning and of Mother and Child Protection assumed the direction of the program.~ This institution of administrative character, after two years of activity, was replaced by the National Office of Family Planning and Population, today's ONPFP. The new organization was placed under the direction of the Ministry of Public Health. From the beginning this program has been helped financially by international organizations, such as, the Ford Foundation, the POpulation Council, the World Bank, USAID, FAO, and UNESCO. Objectives of the Program Tunisia presents a clear philOSOphy in the matter of pOpulation. Social progress is considered to be the key to develOpment, and its objectives are full employ- ment, a more equitable distribution of national income, or the opportunity for each individual to develOp his full potential and an improvement in the quality 01' life. The key to social develOpment is held to be pOpula- tion control, and thus the necessity of a program of family planning. The major Objective of the Family Planning Program is to bring the Tunisian rate of natural growth to the level of that of Italy today, by the year 2001. This 47 would represent a birth rate of 1.2 percent at that time. Quantitative Objectives for maximum allowable pOpulation increase are: 6,593,700.. ...... ............l981 9,783,000....................2001 To keep demographic growth within these figures, planned decrease in number of births would be: 1974....................22,5oo 1975. ...... .............26,250 1976....................3o,ooo 1977....................33,750 1981....................L+9,5oo38 The goal for 1974 has been reached, and that Of 1975 exceeded. POpulation structure by age would evolve in the following manner: Group by Age 1976 1981 2001 0-4 years ' 15-35% 15.11% 9.95% 5-14 years 27.72 25.57 22.29 15-64 years 52.69 55.02 63.13 65 years & more 4.23 4.30 4.63 The percentage of the pOpulation over sixty- five years of age appears very small. It is to be explained by the continued low life expectancy. In 1973, it was 52.5 years, an increase of 2.5 years over 38 La Planification Familiale en Tunisie, Tunis: ONPFP, March 1, 1976), p. 8. 48 1968. In 1946, however, life expectancy was only 38 years. Control of demographic growth is projected over a twenty-five year period. To determine that projected levels are being met, the sole indicators will be the account made of participation in the Family Planning Program and the number of births thus avoided. Family Planning must thus Operate in such a fashion that the demand for its services must be in the necessary volume to keep the pOpulation increase within projected limits. The problem Of family planning must not be considered only in economic terms. For Tunisian leaders, the problem is a problem of the quality of life,the liberation of the woman, and of the couple, the happiness of the family, and the psychological equilibrium of the children. Family Planning is an element Of cultural change, a change force particularly sensitive in countries in the process of development. It is a force that brings about a rupture with the Old way of life. Where traditional norms and the mores of a peOple represent the implementation of religious con- cepts, as is true in Muslim Tunisia, the acceptance of a new value system is especially difficult. Legislatigg Since 1956, legal reforms have been undertaken, on one hand to nullify certain texts from the period of the Protectorate, when large families were encouraged, 49 texts which were obstacles to the new political pro- grams, and to Family Planning in particular, and on the other hand, to institute some laws which would serve as a point Of departure for new programs. Thus, legis- lation played the role of catalyst for the demographic program, furnishing a legal foundation for it which was indispensable, and giving it new impetus. These legislative measures can be classified under two headings: Legislative Directives Indirectly Tiggto the Progggm of Family Planning Under this heading can be placed those measures relating to a system of special protection, such as social security, retirement, and regulation of the work Of women and children. Also in this category would be all measures that bear upon the equality of women, such as obligatory primary education, and the Opening of secondary schools and universities to them. Regulations bearing on the health of the pOpulation, infant mortality and length of life of all inhabitants, are indirectly supportive of a program of Family Planning. ngislative Digectives Directly Relatedjto Family Planning Most important of all decrees, and absolutely essential to the success of any program of family planning, is the Code of Personal Status, passed in 1956, four months after the formation of the first government of independent Tunisia. This code, in abolishing polygamy 50 and repudiation, and in instituting new regulations relating to divorce and marriage, has been the point of departure for the great social revolution undertaken by the country. Other decrees, laws, declarations and resolu- tions that have expedited the progress of family plan- ning, are as follows: --The law Of December 14, 1960, limits the government family allocations to the first four children. --The law Of January 9, 1961, authorizes the importation of contraceptive devices, and contraceptive progaganda. --The decree of February 20, 1966, establishes minimal marriage ages of seventeen for the woman, and twenty years for the man. --The law Of July 1, 1965, legalizes abortion in the first three months of pregnancy, after the birth of the sixth infant.39 --The law of March 23, 1973, instituted the National Office Of Family Planning and POpu- lation. 39 This law was considerably liberalized in 1973. At that time, abortion was authorized during the first three months of pregnancy in a hOSpi- tal or authorized clinic by a legally qualified physician. Abortion after three months autho- rized only when the mothers health is in danger or when the infant to be born may suffer from a severe illness or infirmity. 51 --The decree of January 31, 1974, established the structure relative to the organization and functioning of a Superior Council and Regional Councils of POpulation. The Super- ior Council, presided over by the prime mini— ster, defines the general orientation Of the activities of the ONPFP, and outlines the major thrusts of its programs and plans Of action. The Regional Council, established in each gouvernorat, and presided over by the gouverneur gives advice on projects and plans presented to it, after the approval of the Ministry of Health and it proposes any other action that it deems useful. --It was resolved that the contraceptive pill be largely diffused throughout the country beginning in January, 1976. This was to be accomplished by putting the pill at the dis- position Of everyone, in all the pharmacies, at a price of 50 millimes!+0 for a month's supply. This action was taken through the unified efforts Of the Office, the Central Pharmacy, and the Society of Pharmaceutical Sciences. From this time on, the sale of these pills would be made to anyone presenting a doctor's prescription. Hospitals and PF/PMI 40 There are 1000 millimes in one dinar, which is equal to about $2.20 today. 52 Centers would continue to distribute these contraceptives at no charge, as in the past. -—Three measures, at the international level, indicate the importance Tunisia gives to this struggle against an unreasonable increase in population. The first measure was the Declara- tion of Population made by world leaders in 1966 and 1967, and signed by President Habib Bourguiba that "an essential right of man (is) the possibility for him to determine freely the number of his children, and the spacing Of their births." The second resolution was the unanimous adOp- tion of the declaration that "couples have the essen- tial right to decide in a free and reSponsible manner the number of their children, the Spacing of their births, the right to an education for them, and to the information necessary to those ends." This resolu- tion was made at the Conference of the Rights of Man, held at Teheran in 1968. Finally, Tunisia supported the Declaration of the United Nations on the Progress and DevelOpment in the Social Domain, of 1969, which insisted again on the fact that the right to family planning included not only the knowledge necessary, but also the means essen- tial for the exercise of this right. Thus had been provided not only a legal, but 53 an attitudinal framework for a national program of family planning. Enormous obstacles to its acceptance were obvious when Bourguiba assumed the presidency. Muslim traditions of centuries, sanctioned by the Koran, or by what was generally accepted to be implied by Koranic teachings, seconded by strong societal attitudes, closed the door to any change in marital relationships, and to the establishment of protective practices for women and children. Many factors have played a part in preparing the country for this essen- tial component of national develOpment, family planning. It is not enough to be informed Of demographic pro- blems, and to lay out a plan of action. There must be catalysts, especially in countries where such power- ful impediments to progress exist. Thus it is evident that those reSponsible were not only fiercely determined to succeed, but were astute psychologists as well. Some of their strategies will be pointed out later in this study. I'll-ll [If I'll! III" 'III.’ (IIIII: CHAPTER FOUR IMPLEMENTATION THROUGH THE OFFICE OF FAMILY PLANNING AND POPULATION Mission With the way prepared legally and to some extent, psychologically, the newly established National Office of Family Planning and POpulation assumed the reSponsibility for the implementation of the National Program of Family Planning. "In virtue of the law 73-17 of March 23, 1973, a National Office of Family Planning and POpulation has been created and placed under the charge of the Ministry of Public Health." This organiza- tion has as its mission, in conformity with the philo- sophy defined by the government:l+1 --to undertake studies and research of social, technical, and economic nature to promote harmonious develOpment of the population and in order to make suggestions of a legislative nature to the government at this end. --tO establish and to put into effect, in _41 La Planification Familiale in Tunisia, Tunis: ONPFP, March 1, 197 ), p. 54 55 collaboration with all public and private organizations, the programs and plans of action to support family equilibrium and to protect the health Of its members. —-tO make available for the physical and mental health of the peOple, information and medical care Of all kinds, in hOSpi- tals and health centers, in medical of- fices, in pharmaceutical diSpensaries, in clinics and infirmaries, that they will be able to attain objectives of equilibrium ; and health in the family. -—to undertake educational programs necessary for the training in Family Planning of the School of Medicine, of various levels of social service, as well as workshOps and training programs in foreign countries. --to establish a permanent program Of in- formation and education of the pOpulace at the family, scholastic and professional levels. Strategy The strategy of Family Planning in Tunisia can be discussed under two headings: the psychological campaign waged to insure acceptance of the philOSOphy. and willingness of couples to participate actively in the program, and the strategy Of implementation devised 56 by the Office upon its inception in 1973. Strategy of Persuasion A particularly persistent and ubiquitous pro- gram of psychological persuasion has been going on Since independence. Every means possible has been utilized to prepare both men and women to accept a concept startlingly new and foreign tO their culture, a complete reversal Of the philOSOphy promoted during the protectorate. It is true that certain factors favored rapid dissemination of ideas. Tunisia is small: communication is relatively easy between the regions: there is no organized clergy to foment opposi- tion: the administrative and political organization of the country enables peOple to reSpond quickly to its leaders. These 'plus' factors are balanced, however, by ignorance, passivity in the face of misery and particularly in the rural areas, a ready credulity in reports of dreadful results from the utilization of contraceptive devices. This group needs personal contact outside the clinics with a trained educator in order to overcome their fears. This is the group, most numerous in the rural areas, which be- lieves the widely rumored misconceptions or exaggerations about contraception. One of the commonest-is that the IUD can migrate through the body and then cause disease where it lodgeS--headaches if in the brain, arthritis if in a joint, or heart disease if lodged there. Most of these misconceptions seem to be distor- tions of some factual problem. For instance, one vocal nurses' aide insisted that she knew the IUD "wandered around" inside the body be- cause she had seen one removed by Operation 57 from a woman's "stomach." This was obviously the surgical removal from the abdomen of a lOOp which had perforated the uterus at the time of insertion, a complication which occurs very rarely. Other misconceptions commonly cited by potential patients seem totally imagined and would seem to Spread by word of mouth simply because they are such interesting stories. ~ The writer heard some of these stories while visiting Tunisian families.’+3 Thus it is evident that a con- certed, continuing effort has been necessary in order to effect attitudinal change. 1. The National Union of Tunisian Women began a program of prOpaganda to fight against the inferior condition endured by Tunisian women, as far back as 1956. It worked within the party for the rights of women, establishing and 'manning' rural workshOps Offering literacy and homemaking courses, publishing a magazine devoted to women's interests, El Mar'a, organizing conferences, and generally being involved in whatever was supportive Of the cause of women. There was, and still is, a strong sense of responsibility among educated women toward less fortunate women and young girls.- The UNFT has waged a vigorous campaign for women's rights, and for family planning through car- toons that have appeared in El Mar'a, and that have 42 Melvyn Thorne and'Joel Montague, "Family Planning and the Problems of DevelOpment", Change in Tunisia, p. 209. 43 See Chapter II, p. 34. 58 been used elsewhere for publicity purposes. These cartoons present forcefully the new life open to Tunisia's women if they assert themselves and take advantage of Opportunities now Open to them. President Bourguiba demands continually more liberty and more rights for women, but in direct proportion to the degree of re- Sponsibility they take upon themselves. Figures and are particularly effective in illustrating the change in the feminine situation. Because the UNFT is cognizant of the fact that women who Spend their entire lives within the family confines, or even those who work outside the home and return each evening to the family, cannot alone effect much improvement in the quality Of their existence, it has set up a structure of clubs and professional groups. These groups have as their major Objective, to effect contact between the 'privileged women', that is, the intelligent, educated percentage, and those who are less fortunate. These organizations provide a meeting ground for young girls, working women, women in tOp level managerial positions, or in the professions, as well as the educated, 'westernized' women of affluent families, who perform aS full-time volunteer workers within the union. Meetings of these groups, which tend to be in- formal in nature, provide Opportunities for communica- tion within the various levels, where problems and possible solutions can be discussed, and where information 59 I‘ll", Ilw‘ Figure 7 Figure 8 61 ll“!lillll|,|1'||vllllll’ ,u y aux 9 prom-‘3" . ’ .~.'.:.~.3;.;.:.°.v.~.§w :W- amiss. Figure 10 62 63 can be freely disseminated. It is true that this struc- ture is found only in the urban sectors. Some projects 'Of the "Programme National de Developpement Rural" perform this function in a more limited fashion for the less populous and more isolated areas.“4 In a speech on the radio and television in Tunis, on the fifth of March, 1973, President Bourguiba expressed his respect for the women's organization, saying, "I praise the efforts of the National Union of Tunisian Women that with intelligence and efficiency is improving the condition of women and enlightening our sisters in respect to their rights and their re- Sponsibilities." 2. The President himself has had the greatest influence upon the attitudes Of his countrymen. He has been indefatigable in his efforts to change the mentality of his people, and to Open his country to the West. In respect to family planning, he has not only been supportive, but has been a leader of the move- ment. As he believes that more can be accomplished by ,persuasion than by force, he has been communicating with the peOple by every means at his diSposal. For twenty years, he has made speeches on the radio, on ‘television, at public festivals and at conferences, both ’44 These are workshops run in conjunction with the Ministry Of Social Affairs, mentioned on page 58 . 64 rural and urban. As frequently as possible, he has persuaded through personal contact. He knew that many Tunisians felt that birth limitation was somehow con- trary to the teachings of the Koran. To counteract this belief, he has frequently addressed himself to this point. Faithful to certain persistent traditions, couples hesitate to adOpt suitable means to limit births. These traditions have their origin in beliefs that have nothing to do with the Muslim religion. I hasten to remind you that interpreters of re- ligious law, in the different Muslim countries. are unanimous in affirming that family planning, source of strength and energy, 155not in contradiction with Muslim precepts. In 1970 he expressed his belief that some women, in spite of religion, were ready to take advantage Of birth control: Each family has six or seven children, very young. When I advise the women to be Oper- ated upon so that they will have no more children, they eagerly accept the idea.... It was not long ago that they thought that birth limifigtion was contrary to the di- vine will. In 1973, at Kairouan, he stated: There is no religious prohibition (of birth control), and we are not acting in Opposition to the recommendation of the Prophet "Procreate and you give me a rea- Son to be proud the day of the last judg- ment, in front Of the other nations," for '43 Extract of Speech delivered at the Opening of.L1_§sma1ne__u_Planning__am1lial April 3 1973 46 L'Action, 29 juillet, 1970. 65 in the eyes of theMuslims, what is right for one period of time is not necessarily right for another. It would be unreasonable to consider only the letter of this recommendation, and in- conceivable that Mohammed--May the blessings and God's salvation be with him!--can find pride only in the vast number of Muslims, even if they are totataly bare. if they are crawling in misery, if they are considered a negligible quantity in the world. I be- lieve, on the contrary, that to be a sub- ject of pride, a nation must use the means at hand to develop its power and invulner- ability to attack. And finally on that subject: Contraception has been authorized by the Pro- phet, since the military campaign against the Benou Mostalk. The companions of the Pro- phet, being unwilling to impregnate the slaves, preferred to use the contraceptive methods known at the time. Consulted in the matter, Mohammed replied, "There is nothing to forbid it." 3. There has been, and is today, much visual prOpa- ganda, as there is still a large percentage Of men and women illiterate. Billboards, and more frequently, posters, are used to good advantage. A frequent theme is education. The school house and the university are pictured with such captions as, "DO you want these Opportunities for your.children? Visit your nearest Family Planning Center." There is, of course, a large amount of coverage given to the varied, but interrelated themes, in newspapers and magazines, but this written material is only available to educated people, who tend to be already disposed to agree with the philosophy represented. 66 Sypategy Of_Implementatign The support of the president and government, in addition to a persistent campaign through the media of communication available today, has changed attitudes of urban dwellers, but has had little effect upon isolated, rural populations. In addition to this psychological battle, in which the Office plays a major role, the strategy of implementation has been carefully planned and organized. Since the guiding principle of the Office is that family planning is a fundamental right Of the individual, a two-fold strategy has been adOpted, to inform and educate the citizens, and to develOp an infrastructure sufficient to furnish edu- cational and health services to all citizens. These services are continually being improved, and are gradually being integrated into the established health facilities, particularly into the Centers of Mother and Child Pro- tection (PMI). In other words, the essential role of the Office will be to promote demand for its services and to provide adequate services and material to meet the demand. Structure9f_0ffice Divisions of Concern With the creation of the Office, administrative structure has been reviewed and modified. A simple and functional organization has been adopted. Outside of an administrative and financial bureau which assumes 67 the management of personnel and budget and a bureau of OOOperation to expedite the realization of progress. three major divisions have been created and put under the direction of trained personnel: 1. The Division of the Population. Directed by a demographic eXpert, it is responsi- ble for various studies, research programs and evaluation services that provide the data enabling the Office to control the ongoing programs and to achieve its Ob- jectives. 2. The Medical Division. Directed by a doc- tor, it is primarily concerned with the operation of clinics. Its function is to put at the diSposal of all peOple, in addition to the services continually being improved by Family Planning, all kinds of medical care, particularly gynecological. 3. The Division of Promotion and Education. Directed by a sociologist, it is reSponsible for the diSsemination of information, for the motivation of couples to participate in family planning, and for the develOpd ment of personnel. A The Office also maintains a Specialized library as well as a Bureau of Documentation, which are reSpon- sible for acquiring, claSSifying and synthesizing MINISTRYgOF PUBLIC HEALTH National Office of Family Other divisions of Nation- Planning and POpulation a1 Health & Medicine NATIONAL OFFICE OF FAMILY PLANNING AND POPULATION PreSident Directeur General (M. Mezri Chekir) Division of the Medical Division Division Of Pro- Population motion & Edu- (Research & Evalu- (Operation of Clinics) cation ation) (Dissemination of Information and education of the pOpulation: develOpment of personnel) DIVISION OF PROMOTION AND EDUCATION Secondary School Project (United Nations Support) Sfax oject (USAID Support) Media Programs Program for Industrial Workers Relevant Disciplines Workshops-Seminars of The University of of UNFT Tunis, and School of Medicine at Sfax Program for Agricultural Workers Table l 68 69 documents according to the needs and activities Of the different services.)+7 In the area of regional organization, there has been a restructuring: that has given birth to a rational, flexible and dynamic organization. The tasks of the Regional Director of Public Health, of the Medical Coordinator, the Supervisory Mid-Wife, as well as those of Educators and Regional Secretaries, have been clearly defined. The role of the pharmacist, although not one included specifically with the Office structure, is of increasing importance. He is essential in helping to solve population problems. As a man of science, and as a result of his position in the community, he has much influence in counseling couples, and in motivating them to plan their families. He is con- stantly available to furnish explanations, and to give the necessary information that is indiSpensable to the welfare of the community. Extensive efforts are being made throughout the regions to create extensive programs of information and education able to reach citizens where they are, and to Offer training Opportunities for medical cadres and paramedics, mobile teams for rural areas, and infOrmation and Family Planning Centers. These centers of infor- mation and Family Planning have been created in all the M See Chapter V, p.122 for information on libraries. 70 regions and they Offer medical care to all the citizens. Other services of Family Planning are installed in hos- pitals, maternity centers and dispensaries. The activities in rural areas are beginning to receive particular attention. It is in the country areas that the demographic explosion is the most threaten- ing. In these zones there are big families, often more than eight children. Parents live in misery, not knowing how to stop the flow of children. Mobile teams directed by doctors and mid-wives trained in family planning, have been formed to provide the help these families need. They go beyond the needs Of family planning in furnishing to all these citizens information on nutrition, care of children, and hygiene. Family Planning facilities available through the ONPFP, in 1976 are: 20 Principal and regional hospitals. Almost all abortions and sterilizations are per- formed here. 24 auxiliary hOSpitals 81 PMI Centers 15 Mobile Units. Thirty-two others are to be created 63 Community diSpensaries. They represent sixty percent of the active centers 89 Rural dispensaries 14 Family Planning Centers (free-standing clinics)";8 48 This information furnished by USAID Office at Tunis. 71 Division offEducation and Promotion As this study is particularly concerned with the educational aSpect of Family Planning, this division of the Office is of major interest for the writer's purpose and sOme of its programs are discussed in detail. The mission of the Office demands that its primary func- tion be one of education and information.“9 This is the basis upon which all other activities of the total program depend: therefore, a particularly heavy emphasis has been placed upon this division. Campaigns having as their goal to motivate and inform the pOpulace have been multiplied in all the regions. The role of educa- tion has been defined, strengthened, and enriched in the light of the experience and new demands of daily practice. Whatever may be the occasion, whether it be. during hospital services, or those of the clinics, and maternity centers, or during group meetings or home visits, information is transmitted, explained, detailed, and adapted to the Specific needs of each social class, and of each region. This action is as broad and inten- sive in SOOpe as it is because of the support of the administrative authority, of social agents, of the ‘49 Information in this usage refers to factual aspect of Family Planning, methods of contra- ception, procedures for use, etc. Education refers particularly to attitudinal components of programs. 72 personnel of Public Health, and that Of all the national organizations. Regional campaigns of education in family plan: ning last on an average of five to six days. Teams of educators from the Office move across the country. with their primary Objective to make available necessary information to social service and para-medical personnel. and to establish for them an educational program in the area, available to all. The organization of such programs is made always in collaboration with the Regional Administrator Of Public Health, and with the representatives of national organizations and of the Destourian Socialist Party. "Journées d'Information"5O or Information Days, were organized in the various administrations, in busi- nesses, and for journalists, so that nuclei of education can be formed within collectivities. Thus the Office organized fifteen campaigns and Information Days during the year 1974, which had allowed it to come into con- tact with 900 social service and para—medical groups. A vast program‘has been developed to integrate Family Planning information in programs for workers, for farm laborers, and for students in secondary public education. 50 See description of a Journée d'Information Chapter IV, p. 93-96. 73 Education for Agricultural Workers5l This program is primarily directed toward: --The integration of Family Planning curriculum into courses offered in agricultural lycees --The training of teachers in agricultural lycSes --The retraining of agricultural instructors and field service personnel --The education of rural populations through the efforts of said personnel related to agriculture A seminar was organized the 20th and 21st of November, 1974, at Tunis, for several administrative levels of public education and agricultural field ser- vice personnel. This seminar stressed the need to put into operation this project, not only for the purpose . of promoting family planning action in the rural zones, but also to improve the quality of life of the citizens of those areas. A technical committee, made up Of Officials of the Office and administrators of the Ministry of Agriculture, was created to supervise the implementation of this project. Education for Industrial Workers52 This program undertaken with the support and 51 ‘ Conseil Supérieur de lggPopulation May, 1975. Published by ONPFP, Tunis. pp. 16 & 17. 52 Ibid. 7., assistance of Tunisian unions, such as the UGTT (Union Générale des Travailleurs TunisienS), directs its efforts toward the extension of Family Planning education into the realm of commercial and industrial enterprises. It proposes to: -—promote the activities of Family Planning at the commercial level by establishing centers of information and Family Planning services within the enterprises --educate and motivate the workers by means of educators, social service personnel and the personnel of the workers' medical program (la Médécine de Travail) --to motivate and sensitize employers to the importance of the program --involve union organizations in educational activities. Journées d'Information have been organized at three large commercial organi— nations at Kasserine, which has enabled Family Planning to contact employees and managerial personnel of these enterprises, and to give them necessary information A National Colloquy of Family Planning for workers was organized the 27th and 28th of November, 1974, directed to the needs of heads Of enterprises, both industrial and commercial, as well as representa- tives of national organizations. The Objective of the 75 seminar was to draw the attention of the administration of those organizations to the importance of Family Planning and the necessity of promoting it within the enterprises. A technical committee made up of the Officials Of the Office, and of the various unions, including the National Union of Tunisian Women, was charged with overseeing the project, and studying methods for its realization. Education fop_Familerlanninggwithin the Secondary Public School System (The Secondary School Project)53 The program to integrate Family Planning into the secondary division of the public school system is one of particular interest to American educators in the light of their experiences with efforts 'pro and con' 4 the introduction of 'sex education' into the public schools. In Tunisia it is a program that appears to have the support of most educators, and most definitely that of the Ministry of Education. There are, of course, those opposed to the project. According to M. Driss Guiga, the Minister of Education: we must realize...that the Tunisian society has not as yet accomplished the change that permits it to understand Family Planning 53 Seminaire sur l'Intégration de l'Educatign en Population et Planning Familial dans l'En- geignement Secondaire, Sousse, January 7, 8, 9, 1975. This report provided major part Of information on this project. 76 and to graSp its importance. Certain factors can, however, contribute to this change, pri- marily the fact that Tunisian families con- sist of several generations. These genera- tions differ considerably in attitudes, and thus a dialectical relatiogghip results that can have positive effects. He continues: Tunisian families, or rather their adult members, in spite of their degree Of Openness, have reservations in respect to the integration of Family Education in school programs, fearing that the study of such a subject is contrary to morality, and that some disastrous results wilgsbe evi— dent in the coming generations. And again: The origin Of this situation goes back as much to the negative attitude of the father, who seems to ignore the problem, or who cannot resolve it, as to the incapacity Of the mother, through her very limited edu- cation that does not allow her to attack the problem. Thus an intellectual rupture develops, relative to serious, vital sub- jects which greatly interest the young, and wggch the adults avoid discussing with them. Thus, it appears that those of limited, or no education, as is to be expected, are often opposed to any Open approach to sex and its ramifications. Those in the government, and in professional occupations, are much more supportive. Even the professors of Islam philosophy at the secondary level state: 54 Ibid.. p. 11. 55 Ibid., p. 12. 56 Ibid,. p. 12. til-11151!“ 77 Existing programs don't treat in a direct fashion, the problems of Family Planning and POpulation. It is possible to revise certain parts of these programs in order to introduce texts that deal with questions related to different aSpects Of social attitudes, and to research done by contem- porary Muslim philOSOphers on Family Plan- ning,on relations between the family and society, economy,5§he health of the mother and Of the child. Two of the Muslim writers referred to are Cheikh Nefzaoui, and Professor Abdelwahab Bouhdiba, an anthrOpologist. The latter has written a dissertation on the subject of sexual education, entitled, "l'ISlam et la vie sexuelle."58 Interest in a secondary school project appears to have been first evident in March, 1969 when the Institute of the Sciences of Education established the first commission of educators to study the intro— duction of sexual education in the secondary school. The efforts Of this group, which included also the administration Of PF/PMI had limited results, but a rather important one: the introduction *Of a chapter on human reproduction, the reproductive organs of male and female ovulation and menstruation, and impregnation and con— ception.. This chapter was, from this point on, included. 57 Ibid., p. 64. 58 Information, and possible access to these publications would be through the University of Tunis, where Professor Bouhdiba is pre- sently director of research in Social Studies. 78 In January, 1972, a second commission was established to study the integration in secondary edu- cation Of Family Planning and Population. This commis- sion was made up of the educational inspectors of Natural Science, Muslim Philosophy, Religious and Civic Education, two women directors of lycees, and a secon- dary teacher. This group develOped an inter-disciplinary approach to infuse Family Planning into the various dis- ciplines taught. As a result Of participation in this commission, two women, Madame Masmoudi, Attachée of the Cabinet of the Ministry of Education, and Madame Becher, a teacher at the lycee, developed a pilot pro- gram at the Lycée de Montfleury. This was in 1972. Madame Becher, knowing of the interest of Madame Masmoudi in education for family living, invited her to attend a session devoted to the condition of women, as part of a civilization study of her class Of seven- teen year old girls. The session proved to be a very animated discussion of the education of girls, of marriage, of divorce, and of related tOpicS. Madame Masmoudi then suggested that she direct a similar session on the following Friday afternoon and on succeeding Fridays if sufficient interest develOpedS.9 This pro- ject was announced to the students, and received with a great deal Of enthusiasm. To prepare for the meeting, Madame Masmoudi asked the students to indicate'the.themes they particularly wanted to discuss, and the names of 59Mme. Masmoudi was acquainted with many students and staff. Her request Was a normal one. 79 the teachers they wanted to participate with them. The topics of discussions suggested by the students ranged from marriage to divorce, to homosexuality and impotency. The students evidenced great interest. The teachers selected by the students to participate in the sessions represented a wide variety Of disciplines. As for parent reaction} one third of the stu- dents indicated that their parents were favorably in- clined, (one of the students suggested that her mother be included in the session, but the other students were opposed to that idea): one third said that their parents wouldn't be Opposed but that they could not discuss the matter with them. The final third said their parents would probably be opposed to the idea, and that they had never supported, or understood what their children- were learning in school. These students, in fact all of them, were told that attendance at this seminar was completely voluntary. All students came to the first meeting, and there was never any protest from the parents.60 The number of adult participants grew, as the need for in- formation for Specialists became evident. Thus gyneco- logists and health service personnel among other eXpertS were invited from time to time. 60 It must be kept in mind that Tunisian schools are controlled by the Ministry of Education, and therefore, community reaction is much less important than in the United States. 80 Teachers and students not included in these informal seminars, requested information, and therefore, Madame Masmoudi set up a seminar for teachers in Decem- ber of 1973. As a result of this seminar, "Journees d'Information" were established for students of the Classe Terminale61 at Montfleury. and for two other lycees. At one of these 'Journées d'Information', M. Mezri Chekir, director Of the ONPFP was present. Impressed by the quality of work already done, and by the high level of interest and enthusiasm among both students and teachers, he resolved to launch seriously a program of integration of Family Planning in the secondary level of education. The result Of this determination was the Secondary School Project, now in operation. Officially in the records of the United Nations, it is Project Tunisia 1974/P02. It began on the eleventh day of January, 1974, and the support of the United Nations is to terminate the thirty-first of March, 1981. UNFPA (United Nations Family Planning Activities) is contributing thirty-six thousand dollars. In addition to this sun, $1,897,080 has been allotted to Project P05. This United Nations Project supplies various sums of money to cover all local cost components of UNFPA assisted programs in regard to activities in 61 .A kind of thirteenth year for lydee students. 81 62 which no external agency is directly involved. UNESCO has an advisory function. Tunisian counterparts to United Nations personnel, are Madame Dordana Masmoudi, from the Ministry of Education, Madame Rebha Bouslama, ONPFP, and M. Hamoudi Hanafi, ONPFP. For the year 1975—76, ten lycbes were Selected. Madame Masmoudi worked with relevant teachers through the year. The plan was to expand the program, if the pilot venture was successful. It was projected to bring thirty schools into the program over the course Of the three years, 1976-1978. In the summer of 1976, the Coordinator for Population of the United Nations, in Tunis, stated that the project was being eXpanded to twenty—four schools, and that he was satisfied that the program was going well. The rationale for the inclusion of such a pro- gram in the curriculum of the school system is stated thus by M. Hanafi, the Chief of the Division Of Promo- tion and Education of the Office: Whether we believe that we live in an over- pOpulated or underpopulated country, the family, the population and the evolution that they experience have repercussions on our own lives and their study touches uS in a direct manner. If it is educationally and intellectually accepted as valuable to study the animal population in the biology course, it should be equally as intellectually valu- able to include the study of human pOpulations 62 See Appendix, pp.13l-—l36, for Projects P04 and 5, as well as other pOpulation related United Nations projects. 82 in our sciences. The dynamism of the pOpu- lation can be seen particularly as a social phe- nomenon to understand, and not a problem to resolve. Knowing that one of the functions of the school is to infOrm the student and to prepare him in the areas which concern him the most and touch his life, it is justi- fied, even in the absence Of all demographic considerations, to develOp programs of family education and of pOpulation, especially when we note a great interest among students in ‘ questions of population and family life, and a very feeble level of knowledge in the sub— ject, and a lack Of maturity in their attitudes in relation to sexuality, family life, and life in society. Thus it is the education of the pupil first and his normal development within his family and within society that justifies the inclusion in educational programs of Family Planning and Population. To this need must be added the adaptation of this education to conditions of the society in which we live, and the search for solution 3 to whatever problem troubling our society. The objectives Of the program, as approved by the United Nations and UNESCO, are as follows: --to inform and motivate national and regional. authorities and personnel of higher education to support and help the introduction of Family Planning and POpulation material in education --to form a nucleus of teachers, researchers, inSpectors, instructors, and Specialists in education and communication to work for the realization of the project and its implemen- tation 63 Rapport Final, "Programme d'Action pour l'Integgation dans l'Enseignement Secondaire de l'Education en Planning Familial et Population", (Tunis, April, 1975) p. 25. 83 —-to develOp studies and research, along with curriculum --to give to inspectors, and those involved with evaluation of teaching personnel, information in the domain of pOpulation and Family Planning, and to define with them the methods and means of introducing these matters into education --to train teachers, eSpecially those in disci- plines most suitable to the objectives of the program, (Natural Science, Geography, Civic Education, Health Education) so that they can be prepared to handle these matters with their pupils in a competent and efficacious manner --to inform the teaching body in general in the domain of pOpulation SO that their relations~ with pupils, and their teaching will be favor- able to the establishment of positive attitudes in their students toward family planning --to study the curriculum at various levels of the secondary level in order to determine appropriate elements of Family Planning and Population to include and at what levels —-to produce curriculum for the training and in- formation of teaching personnel and for the school population, in order to obtain desired objectives A --to maintain a center Of documentation and 84 reference on the subject Of education in Family Planning in the schools to serve as a continual training tool for personnel. --to aid the Tunisian teaching body to participate in international meetings, and to go into training institutions relative to Family Plan- ning to improve their training. Each group or individual benefiting from a study trip will present at his return the fruits of his obser- vations to a seminar or meeting. Much dis- cussion and time has been devoted to content of the prOposed curricula, as well as to methods to be employed by the teaching body. M. Hanafi expresses the majority vieWpoint thus: We know that there are other needs (besides those Of demography) and problems to which our program needs to pay attention to create a healthier society. Among these problems we find venereal disease, attitudes toward the Opposite sex, a variety of emotional problems that the students experience, and which have their origin in family life and in the intimate life of the students. There is above all the need to not hide the child of a certain age from the knowledge of reality in regard to vital questions and the need to develOp in him the belief that man is master of his destiny and not a subject of fate. And again, later, in the same Speech: It (Family Planning) is thus an education in the global sense of the term that we want to offer the student, an education through which he can know the facts and the realities, and thanks to which he can form within himself strong moral values 85 and healthy attitudes. There is in this edu- cation the study Of sexuality in the sense that anatomy, physiology, human reproduction and contraception are studied objectively. That is information. There is however, a (real need also for the teacher to establish a relationship of trust SO that the student can discuss, reveal his ideas and his pro- blems, and relate what he receives as infor- mation to himself, to his own life, to his feelings and his fears. There must also be an element in the education of the student which inspires him with the importance of Family Planning as a national philOSOphy for the improvement of life of the Tunisian family. The study of contraception is very important for this result, but the same im- portance is attached to the study of social and economic problems and to others whigh result from an unreasonable birth rate. In Natural Science, even though the existing program devoted considerable time to human production, it was decided to introduce the idea of contraception, to strengthen the biology program in the early years of secondary school, and to add the study of venereal disease. In geography, demographic and economic infor- mation needs to be defined, and made more precise in order to teach the student a sense of responsibility in relation to problems of population.65 In civic education the accent must_be placed on the duties and rights of the citizen in relation to 64 Rapport Final, p. 25. 65 These are conclusions on content of course decided at the seminar of 1975. It is assumed that a major part of these recommen- dations has now been carried out. 86 the community and the law. Concepts of family welfare and the standard of living should result. As for re- ligious instruction, it should allow the student to understand the position of his religion in these matters, as that of birth regulation, a position which cannot be against the well-being of the individual or the community. In philOSOphy, in French, and in Arabic, Family Planning will not be studied as an independent theme, but will be closely related to the subjects studies. It will be very easy when the center of interest is, for example: family, liberty, under-develOpment, or responsibility, to sensitize students and motivate them for the questions Of Family Planning. Although the teacher is allowed some freedom, as how best he may incorporate Family Planning in his classes, certain ideas are constantly repeated in relation to recommended methods of instruction. I don't think that it is necessary that the programs of this discipline be defined in administrative fashion, rigid and con- forming to strict directives. It would be more effective to motivate the instructors so that they accord to the subject the seriousness and enthusiasm necessary to achieve an Open attitude 68 the schools to the social environment. If it (Family Planning) is a true education, that iS to say, if it is not limited to Simple information, and the enunciation of a line Of conduct to which the young must conform, if this education allows a complete and objec- tive as possible information, if this infor- mation is followed by a free and frank dialogue 66* Rapport Final, Guiga, p. 10. 87 then we can say that it meets the very intense need of all the adolescents that we have met. This education is received with enthusiasm, with seriousness, and with an immense gratitude. It is in striving toward a greater objec- tive that respects the liberty of the one educated, that we urge that the meetings Of family education be carried on, not by one person, but by several, differing in age, sex, and attitudes. Confronted by this diversity, the young learn to have a more 'nuancée' attitude relative to their parents, their friends, and their general environment. They no longer have the tendency to reject 'en bloc' and without appeal, the values Of their milieu. The 7 acquire a constructive, critical Spirit. ....the fact that the introduction of family education and pOpulation will not create a new discipline, but by the inte- gration in existing disciplines of the elements which makeup the subégct (will be infused into the program.) The commission suggests that (for the teaching of FP) the discussion method be applied, giving the students the Oppor- tunity to reflect on the themes, to ex- press tggir Opinion, and to formulate their choice. From all available information it appears that the interest among administrators and personnel in the Secondary School Project continues at a high level. The United Nations Coordinator eXpressed his satis- faction in the present status of the project. He felt that the increase of fourteen schools, after one half 67 Rapport Final, Masmoudi, p. 40. 68 Rapport Final, Hanafi, p. 29. 69 Recommendation Of Commission at Seminar, p. 57. i‘llilfllllllliiiii I‘ll i . n “fear; » Figure 11 Mme. Masmoudi, M. Chekir and M. Mzali: Seminar on Secondary Education - “J. ..z. .. ." M» 41.4 .13.. . . . . . , Figure 12 M. Mzali talking With offiCials of the region be ore leaving the hotel. 88 89 year beyond the pilot period of Operation, was en- couraging. Sfax Project Another Family Planning project, primarily of an educational nature, "Planning Familial a‘Domicile" or House-tO-House Family Planning Project, has been in operation since mid-April, 1976. This is primarily a United States Agency for International Development (USAID) Project. The Fertility Research Institute of the University of North Carolina has also been asso- ciated with it. For a period of one year, the budget is about $50,000.00: therefore, it is classified as one of the least expensive. } The area involved is rural, in the region of Bir Ali Khelifa, near Sfax. The project is carried on, as the title in- dicates, by house-to-house visitation. The interviewers, or Family Planning Aides, as they are also called, are young women from the area, who have had as a minimum, a secondary education,.plus a two week training period. The two-week training is directed by various medical personnel, social workers, medical doctors, health educators, and demographers. The Aides are bright young women, anxious to help other women, those with whose problems they are familiar, as they are working in their home region. They are happy to do this kind of work for several reasons. One important reason is that 90 it is one Of the few ways to earn a living, outside of agriculture, and still remain in the home region. They also are accorded a certain prestige by the inhabi- tants. They are paid forty dinars a month, which to them is a considerable sum. At today's rate Of ex- change, they earn about ninety dollars, which is an amount that represents a good income in the country areas. The purpose of the project is to inform married women, up to and including the age of forty—five years, primarily of Family Planning Services, and to induce them to visit the PMI centers. Information given to them will eventually include child care, nutrition and general health services, but in the summer of 1976 they had just completed the primary interview throughout Bir Aii.7O Because of timidity, women do not go on their own to the PMI centers. Personal contact is more effec- tive. Because of illiteracy and poverty, books and newspapers do not reach them. The AID coordinator stated that the women are receptive and are frequently very pleased to talk to the Aide, as for many it is the very first time that anyone has shown any interest in them individually. They are amazed to know that peOple are interested in the state of their health, and how they feel. The women are very attentive, and Often ask, 70 See Appendix,pp. 127e129 for questionnaire. 91 "Why didn't you come before and then I wouldn't be pregnant now?" There is a strong attitude component in the overall objective of the project. Women are be- ginning tO think for the first time about such questions as "Who am I? Who am I in relation to others? To my country? To my fellow man? What is my responsibility to myself? To my body? What control do I have over it? DO I have choices in life?" The coordinator stated also that it is possible to get more acceptors on a one-to-one basis, and that all in all it's a low cost delivery system. When interviewed, the women are asked to answer a questionnaire. The information that results gives valuable data to the Office; it also indicates whether return visits are to be made, and what particular pro-. blems exist, such as disease. If the woman is not being treated for diseases listed on the questionnaire, if she is not pregnant, if her husband is not absent at this time for a period of more than four months, the interviewer Offers her contraceptive pills, with an explanation of their uSe. If the woman desires a medi— cal consultation, she is given a coupon for a free ex- amination at either the nearest PMI center, or at the mobile clinic which is in the area one day a week. After some results have been determined, that is, that women are taking the pill consistently, and/or they are visiting the Centers to make use of their 92 services, the coordinator would like to persuade the government to renovate, and up—date the Centers in exis- tence. The government, however, wants to build more big centers. Using the facilities already available means that money badly needed for personnel, training and equipment will be there when needed. Before the establishment of the Office, there was really nothing to offer these women. There was a kind of curative, not preventative infra-structure under the French, and also during the first part of independence. Now the government is interested in prevention of malnutrition and disease. All these factors are related to the success of a Family Planning program. It is interesting to note that Thorne and Montague, before the institution of the Office of Family Planning, were cognizant of the fact that per- sonal contact is an essential component in a successful program involving attitudinal change. Face-to-face educators in the community, trained to discuss stories and give clear and credible explanations, would probably help a Significapt percentage of the women mentioned above to View contraception more realistically and to overcome their appre- hensions. This kind Of education, which 71 This reference is to the women believing the stories mentioned on pp. 56 &57 Chapter IV. 93 has been shown in other family planning programs to be the input most closely re- lated to utilization of existing facili- ties, remains one of the most striking deficiencies of t9? Tunisian family planning program. In 1976, many more Opportunities for information and service were available to the rural female popula— tion. It appears, however, that the AID program is a lone pioneer in activating a personal contact program. The main problems facing the AID office, and personnel Of Family Planning, in whatever capacity, seem to be the same, mainly personnel. In the Sfax program the Aides need more training. In all of Tunisia there are only 150 gynecologists, and many of these are foreigners. Nurses and mid-wives are still scarce. The AID Coordinator wants to upgrade the personnel already working, strengthen their services. He feels there is a huge reservoir that can be useful, once trained. The fall of 1976 was scheduled for a workshop for these peOple, which was to improve and expand their skills. Journees d'Infopmation. The Journee d'Information, mentioned several times in the course of this study, is an integral part of the educational program of the Office. It is a series Of 72 Melvyn Thorne and Joel Montague, Change in Tunisia: Studies in the Social Sciences, (SUNY Press, Albany, New York, 1976), p. 210. 94 day-long programs that have as their goal, the dissemina- tion of knowledge through lectures, discussions and ques- tion and answer periods. This educational series is set up in each delegation. A delegation is a division of one of the eighteen gouvernorats, and it is governed by a délegué, who is the political representative of the Socialist Destourian Party for his district. The Information Days are planned by the Regional Delegate of the Office of Family Planning, in conjunction with the Délégué. The participants of moSt importance to the program and therefore, the first to be invited, are representatives of the administrative, political and technical cadres of the delegation. By means of this structure, all of Tunisia is to be eventually infil- trated, as it is the reSponsibility of those instructed, that is, the top-level management, those in managerial positions, and union Officials, to disseminate in their turn, the information they have received to those under their jurisdiction or management. Other groups of citizens, also, as time permits, are participants in Information Days. These other groups can be agria cultural workers, union membership, university students, young unmarried men and women, artisans, et cetera. Speakers and discussion directors are often the Regional Delegates, Office personnel, particularly from the educational section, medical doctors, representatives of the Ministry of Public Health, and of course, the 95 Délégue’ . A description of a particular Journee d'Informa— tion in the summer of 1976 is here included, as the writer was a participant, and the personal experience for her was much more informative than the information received from the United Nations, AID, and Office personnel.” The Regional Office Delegate, a woman in her thirties, drove the writer to the village of El Hencha, the 'chef-lieu' of the delegation where the meeting was to be held. En route the delegate volunteered information of her personal history, as well as her evaluation Of the present effectiveness of the Family Planning Program within the region. Born during the French Protectorate, She was in her early teens when independence came. She was among the first of the Tunisian girls to pass the baccalauréat and go on to the University of Tunis. She now holds the 'licence' in psychology. The licence, which is roughly the equivalent of the American Masters Degree, is required for the posi- tion She holds. She indicated forcefully the strength of her conviction that hers was a most important post as the key to develOpment in her country was control of the pOpulation. Often, She indicated, She worked seven days a week, six days in the field and the seventh was occupied writing reports, answering letters, planning meetings, writing Speeches. She always felt pushed for time, as there was so much to do. She was hOpeful 96 of obtaining an "assistante" in the fall, but trained peOple were scarce. Another problem was equipment. It was very difficult to keep projectors, tape recorders, etc., in good repair, and most Of the repairing was her responsibility. “Parts were also scarce. It was market day at El Hencha. Stalls were set up in the village square, and a man was driving a herd of goats down the main street. A preliminary meeting was held in the Délégué's office. In addition to the Delegate of the Office, the Délégué, the chief of the Education Section of the Office, and two high school principals participated. The main meeting began at the village hall. Approximately eighty men were present. The Delegate and the writer were the only women. After the ubiquitous "cokes" were passed around to everyone, a four hour session began. It was devoted mainly to information relative to vasec- tomy and tying Of the tubes. The Delegate illustrated her comments with large charts that explained clearly the male or female anatomy involved, and exactly what was done, and how it was done. The question and answer period lasting almOst two hours was very animated, and indicated determination to understand, so that in their turn, the participants would be Well enough informed to conduct their own seminars, and would be able to diSpel many of the 'old wives' tales' so commonly circulated among the women. It was a serious group Of 97 men, involved in a very important learning experience. The program concluded with a film, that was easy to understand for the writer, even though the dialogue was in Arabic. The plot was a simple one showing how much better life was for the one woman who visited the Family Planning Center, and learned how to limit the number of children born to her. The three reel film took an unusually long time to Show, as the projector would grind to a stOp several times during each reel, and would then have to coaxed back into Operation again. The audience was remarkably patient. There was no evidence of annoyance. They simply waited for repairs to be made. When the meeting closed, dinner was Offered to the participants, courtesy Of the Office. In another small building, groups Of six, having left ‘ their shoes at the door, sat on the floor to share couscOus from a common pot. The writer was seated next to a principal of a lycée, who courteously addressed her in French. He wanted to eXplain to her that it was his impression that Americans had never understood Arabs, but that American presidents were beginning to have more comprehension of their problems; He mentioned no one by name, but doubtless the Kissinger policy seemed more reasonable to him than that of preceding administrations. He then turned to more important matters. He wondered if the writer understood that Tunisians were united in their determination to raise 98 the standard of living for all citizens, and that he was convinced that Family Planning was essential to development. He said that several of his teachers had participated in seminars for the introduction of Family Planning in the Secondary School, and that they were enthusiastic because they felt many of their students would be regional leaders in the near future, and therefore, it was essential that they be educated in matters of population control. On the return trip to Sfax, as a doctor shared the ride and obviously had many matters to discuss with the Delegate (for which they excused themselves re- peatedly), the writer had the Opportunity to review the day, and to consider its real value to her. It had certainly been pleasant to be with such gentle, courteous people, but there was much more than that. Several impressions were very strong. First, that a woman, only twenty years after independence, could address an assembly of men on a topic that was never even mentioned in mixed company a few years previously: Not only could she address such a group, but that she would be listened to seriously, and treated reSpect- fully, as someone who knew her subject, was incredible! As a participant, also, the writer was convinced of the dedication of the workers. The delegate herself does not have an easy job. Her work is mentally and physically exhausting. Her 99 responsibility in Speaking constantly to varied groups is demanding physically: she drives long miles almost every day, carrying projectors, films, tape recorders, and documentation. Her morale is excellent. AS she says, "Family Planning has infiltrated all of Tunisia. That does not mean that all people have been instructed in the means of contraception, but now the instrument exists SO that we can reach out and touch everyone." Figure 13 El Hencha: Delégue and regional doctor. I _. " 1:7 IF. El Hencha: Village hall .—:. \ ‘ xian III I III m . 'I- m Figure 15 Ministry of Public Health at Tunis. 100 CHAPTER FIVE RESULTS AND PERSEPCTIVES OF NATIONAL FAMILY PLANNING REPORT The Impprtance of Education in the Context Of POpulation Control Education is the core element of any program of social change. When the change is to occur in a country that has but recently committed itself to develOpment, and where a multiplicity of factors militate against innovation, any program is useless that does not have a well-organized, pervasive education component as its point Of departure, and as the heart Of its con- tinuing existence. The efficiency of the educational program in the domain of Family Planning is responsible for whatever success has been achieved to date and for whatever gains can be projected for the future. Family Planning in Tunisia is a voluntary program, as President Bourguiba believes that cultural changes are not realized through force. Any modification of traditional life patterns involves adjustments in the value system and is therefore a slow process. An all-pervasive, continuing, psycholog- ically-oriented effort to educate the peOple is thus lOl 102 essential. The Office of Family Planning and POpulation has three principal roles: study and research, educa- tion and information, and clinical services. The first two reflect the government's belief in the vital nature of education. Study and research are the supportive services for the educational prdgram. This department is responsible for the statistics which are becoming more detailed and complete, but are still somewhat elementary at this time. These are the data needed to evaluate what has been done, and to determine the needs Of the future. All data relative to medication, edu- cation, personnel, numbers of women or men who have accepted a means of contraception, are being recorded in the data bank. In addition, a study and research program is now in Operation. Information indicating the number of users Of the IUD, and Of the pill, research on the extent to which abortion and sterilization are accepted, studies on motivation and attitudes, all of these are examples of the kinds Of work done by this division of the Office. Tables 1, 2, and 3 record some of the information obtained relative to numbers of women now protected by some method of birth control. M. Mohamed Mzali, Minister of Public Health, reflects governmental concern and support for the edu- cational role of the Office: A particular emphaSiS is placed upon in— formation and basic education. In most MARRIED WOMEN OF AGE TO REPRODUCE, WOMEN PROTECTED BY FAMILY PLANNING AND LEVEL OF PROTECTION BY GOUVERNORAT January 1, 1976 Married Women Number of GOUVERNORATS of Age to Re- Women Pro- Percentage A Prodpce tecppdp Protected__ TUNIS-NORD 129,413 22,967 17.75 TUNIS-SUD 23,537 3,760 16.97 BIZERTE 50,822 7,267 14.30 BEJA 37,515 5,876 15.66 JENDOUBA 48,756 6,033 12.49 LE KEF 43,756 5,143 11.75 SILIANA 29,897 3,884 12,99 KASSERINE 40,452 1,270 3.14 SIDI BOU ZID 29,255 1,535 5.25 GAFSA 43,061 2,231 5.18 MEDENINE 46,019 2,137 4.64 GABES 38,378 2,735 7.13 SFAX 61,103 9,044 14.80 KAIROUAN 49,588 2,266 4.57 MAHDIA 24,747 3,414 13.80 MONASTIR 26,155 3,523 13.47 SOUSSE 28,466 3,884 13.64 NABEUL 47,221 7,315 15.49 TUNISIA AS A WHOLE 802,672 94,294 11.75% Table 2 103 LEVEL OF PROTECTION IN PERCENTAGES (12:24-12:26) Gouvernorats 1 l 1 .1/1/1975 171/1926 TUNIS—NORD 15.96 16.63 17.75 TUNIS-SUD 13.18 13.73 15.97 BIZERTE 10.35 12.21 14.30 BEJA 11.55 14.00 15.66 JENDOUBA 8.93 11.02 12.49 LE KEF 7.87 11.01 11.75 SILIANA 9.16 12.06 12.99 KASSERINE 1.13 2.17 3.14 SIDI BOU ZID 2.99 4.22 5.25 GAFSA 2.94 4.34 5.18 MEDENINE 3.28 4.12 4.64 GABES 4.80 5.75 7.13 SFAX 10.93 12.13 14.80 KAIROUAN 2.39 3.27 4.57 MAHDIA 8.44 9.98 13.80 MONASTIR 7.56 9.66 13.47 SOUSSE 8.07 9.66 13.64 NABEUL 8.51 12.14 15.49 TUNISIA AS A WHOLE 8.47% 10.06% 11.75% Table 3 104 LEVEL OF PROTECTION IN TOTAL NUMBE5§§1974-12761 GOUVERNORATS 1/111924 1/1/1975 11111976 TUNIS-NORD 18,415 20,313 22,967 TUNIS-SUD 3,250 3,585 3,760 BIZERTE 4,963 6,001 7,267 BEJA 4,095 5.100 5,876 JENDOUBA 4,097 5.191 6,033 LE KEF 3,108 4,461 5.143 SILIANA 2,472 3,339 3,884 KASSERINE 525 857 1,270 SIDI BOU 210 873 1,273 1,535 GAFSA 1,170 1,790 2.231 MEDENINE 1,490 1,852 2,137 GABES 1,746 2,149 2,735 SFAX 6,394 7,269 9,044 KAIROUAN 1,122 1.577 2,266 MAHDIA 1.988 2.421 3,414 MONASTIR 1,906 2,477 3,523 SOUSSE 2,214 2,703 3,884 NABEUL 3,818 5,596 7,315 TUNISIA AS A WHOLE 63,646 .77 959 94,294 Table 4 105 106 of the country. in reality, the demographic objectives are not very well known by the Tunisian public. We have felt the neces- sity to develOp programs of information for all classes of society. and for all areas of the country. But over and above the demographic objectives, it has been necessary to bring the pOpulation to the realization of the ad- vantages of family planning, and that can- not be done without offending certain menta- lities, certain traditions, certain myths that must be combatted. Our ambition today is to lead all citizens to choose family planning with a free conscience,7§n full knowledge of the reasons for it. The Office since its inception in 1973, has organized and develOped a large number of educational 7“ It recognized the need and/or training programs. to inform and train the medical, and para-medical per- sonnel. as well as social-educative kinds of workers. These people have been informed of the demographic. economic, social. cultural and psychological aSpects of family planning. The great majority of these peo- ple needed to be informed also of contraceptive methods. Numerous workshops, and seminars were organized through- out the country. In 1974, twelve workshops lasting from fifteen days to four months, were conducted. Forty-six nurses' aides, seventy-six mid-wives, nineteen social workers assigned to hospitals in Tunis, and 73 This quotation is from a speech given by the minister at the World Conference of POpulation at Bucharest, August, 19, 1974. Translation from French by writer. 7h Conseil Supkrieur depla.ngulation, May, 1975. Translation from French by writer. 107 seven doctors of general practice were participants. Thirteen other workshOps of short duration, two to six days. were organized in the gouvernorats of Tunis, Nabeul. Sfax, Gabes, Sidi Bouzid. Sousse and Kasserine. Three hundred workers in the medical, health and social fields participated, being prepared for the educational responsibilities they were assuming. along with their technical tasks. Scholarships have been granted to doctors and to those in positions of responsibility in the Office. to enable them to take part in foreign conferences, and specialized meetings of various kinds. Another area of enormous potential in the edu- cation of the public, that has been widely used, is mass-media. The national press has regularly published information on the activities of Family Planning, as well as interviews accorded to journalists by personnel of the Office. A vast program has been realized through the R.T.T. (Radio Television Tunisienne). Two work sessions were held in 1974, involving the Presidents of the Office and of the R.T.T., as well as those working closely with both organizations. Their goal was to decide upon methods of strengthening radio and television programs related to Family Planning. As a result of these meetings, television programs were presented in the center and south of Tunisia, and other programs concerning population control were offered to 108 secondary schools in the last months of the school year. Other promotional means have been utilized by the Office, such as posters, brochures, and films. All of these materials are available to the schools. Methods of informing, with a strong attitudinal component, the various cadres of administration, govern- ment, commerce and education have already been discussed in relation to 'JournEes d'Information'. This level of the society has also participated in many seminars and workshOps. Universities, in the disciplines that are rele- vant, such as economics, sociology, and the medical sciences, have incOrporated units on demography and the necessity for population control. The Office and the United Nations Bureau at Tunis are most Optimistic~ for the future of the Secondary School Project, be- lieving that the young are more Open to change, and as this section of the population is so large the effects of the program should be demonstrable. A most interesting effect of Family Planning upon education itself, and one that was doubtless not even considered, is the fact that the upper levels of the school system are becoming more responsive to the needs of the country. Until recently it has closely resembled its French model, and has been strongly intellectually oriented. It seems that the door has now been opened to a more service-oriented public school 109 philosophy. In discussing educational efforts of Family Planning, mention must be made of the National Union of Tunisian Women. Though the women's union-is not primarily involved in Family Planning educational pro- jects, it is highly supportive. Its representatives attend Office seminars, and workshOps of various kinds, and are very willing to help where needed. Their pri- mary function in attempting to improve the quality of life for women, has been in rural areas, in offering educational programs to combat illiteracy, to teach child care, home management, hygiene, and work skills for those wishing to work outside the home. In all these programs there is strong emphasis on attitude. Women are encouraged to develOp independence, to take advan-- tage of the new opportunities open to them, and to assume reSponsibility not only to be good mothers and wives, but to be effective citizens, and have respect for them- selves as worthy individuals. This kind of education, though not directly aimed at participation in Family Planning programs, definitely prepares women to be more receptive to them. Finally, information and attitudinal education is Open to all those who make use of the PMI and Family Planning Clinics now available in all areas. It is true, however, that availability does not guarantee their use. For many educational programs of Family Planning, 110 it is too early to determine the extent of their in- fluence. It can be said that most people in the country are aware that a program exists. It is not true as yet that most peOple are participating in the program. Attitudinal changes are difficult to measure. The most definitive information relative to results of the pro- gram, is to be observed in the statistics of the pre- sent demographic situation. The primary purpose of a Family Planning program is control of pOpulation growth. The major question to be answered is: Has growth of population decreased since the incidence of the program? Has the intensive educational program had an effect? The answer is a de- finite "yes". The rate of natural growth which was 3.2 percent in 1966, has decreased in 1974 to 2.5 per- cent. Without the educational program of pOpulation control, the rate, it is estimated, would have been 3.5 percent. This natural growth rate is determined through computation of births and deaths, and of such factors as migration where such information would be relevant. Two and a half percent is still a high rate of increase. It means that every ten years the pOpula- tion has increased by twenty-five percent. The present equivalent rate in the United States is about one percent. In eight years, the decrease from 3.2 to 2.5 per- cent in Tunisia, is encouraging and significant. A tremendous effort will have to be expended, however, 111 if Tunisia is to reach its objective for the year 2001, which is the present natural growth rate of Italy, or 1.2 percent, the 1976 figure. The crude birth rate in Tunisia which was #8 in 1956, 43 in 1966, and 38 in 1972, has gone down to 35.8 in 1974. Comparative figures are 14.9 in 1974 for the United States, and 06.3 in 1973 in Mexico. Crude birth rate is the number of births per thousand in relation to the total population. 35.8 is the lowest figure ever registered for Tunisia. Percentage figures for the number of women pro— tected, that is, the number of women using some form ‘ of contraceptive device, was 10.5 percent at the end of 1974. It has increased to 12 percent at the end of‘l975. This figure is 14 percent, if account is taken of con- traceptives distributed by the pharmacies. Equivalent figures for 1971, 1972, and 1973, are respectively, 5.77, 6.35, and 7.33 percent. These figures are cal— culated through the record of the number of women who have adopted a method of Family Planning in aTFamily Planning Center. This number does not include the women who practice contraception through obtaining pills, condoms, or contraceptive jellies from the pharmacies. This figure can be calculated, however, from the number of sales recorded by the Pharmacie Centrale in Tunis. To this figure also is added the number of women who have had the IUD inserted by private physicians. 112 It is expected that the importance of the pri- vate sector will increase in the future since official authorization has been given to private_physicians to perform IUD insertions in private offices, and since the pill is now on sale in all pharmacies at nominal prices. Since the beginning of Family Planning, abortions and tying of the tubes have remained relatively constant in number, that is, 2,525, and 1,857, per year, re- spectively, as an average. The new law of September, 1973, liberalizing abortion, and the campaign to publi- cize the tube tying method at Jendouba, in the last quarter of 1973, caused an abrupt increase in the prac- tice of these two surgical methods. In 1974, the number of women having the tubes tied rose to 10,757, and that of those having abortions rose to 12,#26.75 For the year, 1975, the number of abortions rose to 16,000, and that of the tying of the tubes decreased slightly to 9,896. At the end of 1975, 94,294 women were protected by four methods of family planning, IUD, pills, secon- dary methods, and tying of the tubes. tThus, in 1976, 23,578 births were avoided. If to this number the number of abortions is added, the figure of births avoided becomes 35,578 or 3.5 percent over the objective for the year. , 75 See Table 5 p. 113. EVOLUTION OF CONTRACEPTION IN TUNISIA Number of Women Involved 20,250 19,250 18,250 17,250 16,250 15,250 14,250 13,250 12,250 11,250 10,250 9.250 8,250 7,250 6,250 5.250 4,250 3.250 2,250 1,250 250 0 Table 5 Pill IUD Tying of Tubes Abortion 1969-197“ 113 114 It has always been true that the gouvernorat of Tunis-Nord has had the highest rate of women pro- tected by contraceptive methods, and that of Kasserine the lowest.76 During the years 1974 to 1976, however, the difference has become smaller. The two extremes are closer together. Four groups of gouvernorats remain distinct from each other, howeVer, in their rate of protection: 1. The gouvernorat of Tunis-Nord, which is still distinctly superior to the others The gouvernorats of the North and the North- East. These are Tunis-Sud, Bizerte, Beja, Nabeul, as well as Sfax. These regions have a level of protection well over the national average The three gouvernorats of the Sahel, that is, Sousse, Mahdia, and Monastir, as well as the three gouvernorats of the North-West, Jendouba, 1e Kef, and Siliana. These areas have a level of protection equal to or lightly superior to the national average Finally, the gouvernorats of the Center and of the South, Kairouan, Sidi Bou Zid, Kasserine, Gafsa, Gabes and Medinine, which 76 Famille gt POpulation, Office National du Planning Familial et de la POpulation, Tunis, MarCh, 1976: P0 3' 115 have protection rates much lower than the national average77 The Office states that the achievements of the years 1973 and 1974, that are particularly encouraging to Family Planning are: --the structural reform at the central and re- gional level, according to the decree that instituted the Office --a very close collaboration with the Ministry of Public Health --the decree liberalizing abortion --the installation in 1974 of the "Prix du Presi- dent Bourguiba," for the promotion of Family Planning. It is to be awarded to the three most active gouvernorats. This prize in in the form of a financial reward.78 All of these measures are thought to improve the action of the Office, qualitatively, as well as quantita- tively -—at the geographic level, there is a greater penetration in the regions only superficially contacted previously --at the level of services, the effort expended by the Office has permitted a Specialization within 77 See Tables 3 and 4, pp. 104-105. 78 First prize=10,000 dinars, Second prize=6,000 dinars, Third prize-4,000 dinars. 116 medical and para-medical personnel which has cut in half the number of patients served by each doctor or mid-wife. The number has gone from 6,855 to 3,023 for a doctor and from 5,998 to 2,470 for a mid-wife, during the period 1971-1974 79 Taking into account the present situation of the program, the future action of the Office will be based on the develOpment of preventative methods, a greater and still greater penetration into the rural areas, and a stronger emphasis upon the integration of family plan- ning into the services of family headth. Social angPsychological Effects of the Program Family Planning is today widely known and better understood in Tunisia. It has become part of the culé tural mentality of many peOple, in Spite of some re- servations due particularly to the persistence of an- cient attitudes and to a faulty interpretation of the Muslim religion. The continuing and systematic educa- tional process that the authorities are carrying on, will result in overcoming these difficulties, in enlightening the citizens, and in performing an in depth change in 79 Evaluation of the Office of achievements of 1973 and 1974, from Conseil Supérieur de la Population, mai, 1975, pp. 28-30. 117 attitudes and behavior. These changes will occur slowly, however, and they demand vigorous action and persistent effort. The considerable efforts already expended by those in charge have firmed up the foundations of the National Program of Family Planning. Some favorable results are becoming evident, as already noted. These results confirm the efficiency of the program and the interest and enthusiasm it arouses in the more urban areas of the country. Not less important than all the figures and projections....is the conscious and continually wider acceptance of the idea of birth regulation, which is a sign, not of blind submission to a law...or to an in- equitable social order, but rather the sign of maturity, of evolution, and of assimila- tion of this fundamental right recently proclaimed by the World Conference of Population, that is to say, the right to family social growth in a foyer where the need to safeguard the physical and mental health of the mother is a primary consider- ation; which will allow the mother to raise the desired number of children in a happy atmOSphere, and which will allow the head of the family to avoid the terréBle worries of insufficient material goods. In a young country like Tunisia, in full process of evolution and without great natural resources, a growing percentage of men and women together have accepted the challenge to bring their culture to the 80 Hedi Nouira, Premier Ministre at a meeting of the Superior Council of the Population, Tunis, May 27, 1975. 118 development level of western nations. Among those who have had the advantages of education, the dedication of both sexes to the task at hand is admirable. The women in this group, particularly, show remarkable cour- age. Not only are they engaged in new occupations, but they are often in positions equal to those of the men. and increasingly in positions of authority. The example of the young, attractive woman in the ministry office who has had to deal with the cultural problems of being the superior of three men in the office, as well as that of the rural delegate of the Office, who addressed a group of eighty men on the subject of vasectomy, are unforgettable instances of personal heroism. Cultural change is normally a very slow process. It is eaSy in Tunisia to forget that independence is only twenty years old. It is no wonder that in rural areas women, some of them, have not accepted methods of birth control. This is a voluntary program, which entails profound changes in attitudes for the participants. That a con- siderable number of women have participated attests to the determination and persistence of Family Planning personnel. It must be made clear that these women are still very much in the minority. Western clothing and hair styles do not necessarily indicate western modes of thinking. As this study has indicated, the extremes within the cultures are notable. Century old modes of life, untouched by the twentieth century, are to be 119 found in many rural areas. This is not surprising among the poor who still live by tending flocks, raising a little wheat, or selling fleece to meet their basic cash needs. What is very surprising to the foreigner is the middle-aged man or woman of affluence who lives in'a beautiful home, drives a late model car, dresses like a European, but is either completely illiterate. or has had but one or two years of elementary schooling. These are people who are caught between two cultures, and tend to be EurOpean in outward appearance only. They have all the 'trappings' but remain traditional in their habits and value systems.. The experience of sleeping in a quite luxurious bedroom of a very modern eight- room apartment, and being overcome by the stench of sewage coming from a drain in the bathroom, is one that will remain with the writer a very long time. It in- dicates so very clearly how thin, sometimes, is the veneer of 'progress'. Two major concerns today of the ONPFP, the UNFT, and of the supportive organizations, both national and international, are first, that the percentage of women participating in the upper levels of the public edu- cation system is still minimal, and that Family Planning is still not reaching rural women. Secondary and university education is the most powerful weapon in the struggle of women to improve all aspects of their lives. A vital one, of course, is 120 family living. Educated women are very receptive to the idea of controlling the number of children born to them. They are eager to find methods of providing better lives for themselves and their children. Of students receiving the baccalauréat, twenty— five percent are girls. This same twenty-five percent goes on to the university. All girls, rich or poor, married or not, if they receive the 'bachot' continue on to pursue higher level studies. Twenty-five per- cent is certainly an insufficient figure, even though in the twenty years that higher education has been available to them, tremendous gains in enrollment have 81 been made. The future demands that this percentage be doubled. At least that is the objective for the next twenty years. Again, schooling for girls, parti- cularly the upper levels of the educational system, is still considered unnatural. The idea of girls being independent and free, in complete control of their own lives, is a difficult concept to accept. Many parents feel that girls should be kept home and protected from the evils of the outside world.82 The second major concern of the Office is the ineffectiveness of the program in reaching rural women, 81 In 1955 there were only twenty-seven women enrolled in higher education, two percent of the total enrollment. 82 Information on education of girls taken from E1 Mar'a, March, 1976. 121 in spite of a considerable increase in the number of rural PMI/PF centers, and increasing number of mobile units. The majority of rural women are still not coming to the centers on their own volition. Recommendations for the Future Although good efforts have already been made, and some results have been achieved, it appears that Family Planning in Tunisia in order to achieve its goals for the year 2001, would find the following measures imperative: l. The allocation of a greater percentage of resources to the rural areas. Programs of this type often tend to concentrate personnel, funding and matériel in the urban areas. National statistics show that the isolated regions of the country are the lease affected by the philOSOphy of Family Planning, and have therefore the greatest need. Today, in 1976, there is at least one Family Planning Center in each gouvernorat and mobile units circulate at regular intervals. There is a need, however, for more of both kinds of units; personnel and equip- ment are often in short supply. 2. The intensification of the educational program in rural areas. The information offered to rural women is of a vital, functional nature. There is a good chance that it will be accepted, but only if the message gets to them. These women obviously do not visit 122 clinics of their own volition. They tend to be timid, perhaps scared by rumors that circulate about dreadful results of contraceptive methods, or sometimes afraid of their husband's reaction should they become involved in Family Planning. Women need the face-to—face, one-to- one contact, that the Sfax project has initiated. They need to be not only visited, but re-visited, counseled and encouraged. Obviously more Aides will be needed, girls from the region who understand the problems of the women they contact. Increase in personnel will entail more training workshops of the kinds Sponsored last fall by AID. 3. An increase in the number of trained librarians. Much valuable material is being lost, or at least is temporarily unavailable because of the lack of trained. cataloguers, and librarians of all kinds. Because it takes a long time to train effective personnel perhaps foreign personnel could fill the gap for the next three or four years. Progress has certainly been made in gathering data, but it tends to be incomplete, and sometimes vague, or difficult to locate. Accurate data are essential for future planning. 4. Addition of research and project develOpment Specialists to ONPFP. Experienced persons in this category can expedite programs of this kind, eliminating waste in both time and money. 5. More personal thrust to Family Planning 123 propaganda. Much logical demographic material is pre- sented by the media. Benefits to the individual, such as material comforts, and more robust health for example, would no doubt appeal to the pOpulace more effectively than birth and national production. statistics. 6. Involvement of parents in educational pro- grams. Family Planning instruction and education could be offered in conjunction with, or as a component of, rural workshOps in nutrition, child care, and home management that are now Sponsored by the Ministry of Social Affairs. This study has attempted to put one aSpect of the Tunisian developmental program, National Family Planning, into its cultural context, to see it in rela- tion to the political, religious, historical and social develOpment of the country. It is what it is, because of a multiplicity of factors, and therefore, could never be exactly replicated in another milieu. It has been, however, is now, and will continue probably to be for some time, a proving ground, an on-going experiement, a kind of nationwide laboratory for those interested in the study of population control. The Tunisian program--its successes and its few failures-—has been of considerable interest to both the Islamic and African worlds. It remains a critical test of a develOping nation's ability to deal with a burgeoning population utilizing non-coercive measures. As the first national family planning program in Africa, and one which was develOped as a result of purely indigenous 124 concern, its efforts are being watched very closely, particularly in the dev810p- ing nations of the francophone world. 83 Thorne and Montague, "Family Planning and the Problems of DevelOpment," Change in Tunisia: Studies in the Social Sciences, SUNY Press, Albany, 197 . p. 210. GLOSSARY I baccalaureat classe terminale Code of Personal Status Conseil superieur de la POpulation Délégation Delégué' FAO Gouvernorat IUD 1yc6e ONPFP RTT Sahel Social Assistant a diploma indicating that one has passed successfully an examination upon completion of studies at the lycée; also the examination itself the last year at the lycée, a thirteenth year legislation giving full legal equality to women administrative body of the National Office of Family Planning: members represent all branches of government political and administrative division of a gouvernorat chief officer of a delegation Food & Agricultural Organi- zation one of the eighteen major divisions of Tunisia Inter-uterine device secondary schools for those planning to attend the uni— versity Office National du Planning Familial et de la POpulation (National Office of Family Planning and Population) Protection Maternelle et Infantile Centers for Mother and Child Protection Radio et Television Tunisienne East coast of Tunisia person employed by the govern- ment to assist in rural pro- grams of the Ministry of So- cial Affairs 125 UGTT UNFPA UNFT USAID 126 o I / . Un1on Generale des Trava1l- leurs Tunisiens (Tunisian Workers' Union) United Nations Family Plan- ning Activities, a bureau of the United Nations at Tunis Union Nationale des Femmes Tunisiennes (National Union of Tunisian Women) United States Agency for International Development APPENDIX [l'lllllll I lulll‘lll.. ‘ l. 2. 3. 4. 5. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. QUESTIONNAIRE: FAMILY PLANNING AIDES REPUBLIC OF TUNISIA National Office of Family Planning and Population PROJECT: Family Planning House-to-House Visitations For the First Visit Identification Name of Head of Family Name of Interviewer Address Name of Womanflnterviewed I Identification number of the house . Identification number of the woman . Date of interview. Hour of the beginning of the interview. Are you at present married? No (stop interview) Yes What is your date of birth? If no answer, ask how old are you? If she is 45 years old or more, stOp interview. Are you menstruating regularly? Are you now pregnant? If yes, how many months? Have you been pregnant during the last three years? Are you breast-feeding a baby? If yes, how old is the baby? How many living births have you had? How many children do you now have? Do you want to have more children? The birthdate of your last living child? Is your husband now living with you? Are you or your husband now using a method of birth control? If yes, indicate the method used: 127 l7. Condom (during the last month) 18. 19. Pill (during the last three months) IUD (if yes, stop the interview) Tying of the Tubes? (if yes, stOp the interview) Vasectomy (if yes, stOp the interview) Abortion (during the past year) Other methods, jellies, foams, etc. Have you ever been treated for the following diseases? a. heart b. high blood pressure c. varicose veins d. diabetes e. yellow jaundice If the woman is not or has never been treated for one of these diseases, if She is not pregnant, if her husband has not been absent from the home for more than four months, offer the pills with an explanation of their use. The pills are accepted? Give her a supply. Indicate when you will return to visit her, and end the interview. If she refuses: For what reason has she refused? 20. a. desire to become pregnant? b. is nursing child? c. uses another method? d. harmful to the health? e. other? If she wants a medical consultation for another method of birth control, give her a coupon. 128 After the woman has accepted the coupon: 21. What method of control has the woman accepted after the consultation? a. no method b. IUD c. tying of tubes d. abortion e. condoms 22. Identification number of the study. 129 UNFPA/UNESCO PROJECT TUN/74/P02 - "INTEGRATION OF FAMILY PLANNING IN THE SECONDARY EDUCATION SYSTEM" Date of Commencement Termination Date 01/11/74 31/3/81 UNFPA Contribution: $36,000 (see also project TUN/74/PO5) Counterparts: Mrs. Dordana Masmoudi, Ministry of National Education Mrs. Rebha Bouslama, ONPFP Mr. Hamouda Hanafi, ONPFP BACKGROUND: Approximately 1/5 of the pOpulation of Tunisia attends schools, equivalent to about 80% of children of school- going age. The authorities concerned have agreed to introduce the subject of population and related matters in secondary schools to inform future citizens of the consequences of over pOpulation. The project will assist the "Office National du Planning Familial et de la POpulation" (ONPFP) to this effect. OBJECTIVES: By means of seminars, inform and motivate National and Regional authOrities of the importance of introducing Population Education in secondary schools and in support thereof, to train 1500 specialized educators. Simul- taneously to train suitable personnel, and, in due time, revise the curricula in order to accommodate population education as a subject. OBSERVATIONS: A UNESCO consultant from Paris has come to Tunis twice in 1975 to advise the authorities concerned. The pro- ject objectives have been rephased as follows: a) 1975-1976: 10 pilot chées have been selected. Work with the relevant teachers coordi— nated by Mrs. Masmoudi will be carried out throughout the year. b) 1976-1978: On the basis of the pilot effort, 30 schools will be brought into the pro- gramme annually over the next three years. Some Opposition to the project is said to have been voiced informally by representatives of the Party. 130 UNFPA PROJECT TON/74/PO5 - "TUNISIAN FAMILY PLANNING PROJECT LOCALVCOSTS" Date of Commencement Termination Date 01/10/74 31/10/77 UNFPA Contribution: $1,897,080 Counterparts: Mr. Abdelaziz, Chef de la Division de la Cooperation Internat., ONPFP Mlle Rafia Benlhabib, Chef du Sce de la COOperation Multilaterale, ONPFP Mr. Salah Messaoudi, Chef de la Division Financiere, ONPFP BACKGROUND: Financially, this is the most important, yet unortho- dox, project covered by the UNFPA country agreement signed on 10 April, 1975. The project covers all local cost components of the UNFPA assisted programme in regard to activities in which no external agency is directly involved, i.e. a) incentives, b) salary supple- ments, c) the entire salaries for medical MCH/FP staff in Gabes and Kasserine, and d) running costs of clinics. OBJECTIVES: To ensure the smooth disbursement of local costs from UNDP/UNFPA, retaining at the same time the right to receive semi-annual technical advice from Agencies. The Chief of UNFPA's administrative section has recent- ly visited Tunis when discussions were held with the 'Office' to harmonize prodecures. CorreSpondence with the 'Office' is currently underway about local cost disbursement for the second half of 1975. 131 UNFPA PROJECT TUN/74/PO3 - "LAW AND POPULATION" Date of Commencement Termination Date 01/06/74 30/06/76 UNFPA Contribution: $19,465 Counterpart: Mr. Mongi Bchir, Chief of Population Division, ONPFP BACKGROUND This project is one of a series being conducted in a number of countries along standard guidelines from the Law and Population Programme of the Fletcher School of Law and Diplomacy, Tufts University, USA. It is designed to assemble information about the statutory or customary laws of Tunisia which have a bearing on pOpulation and family planning. OBJECTIVES. A model code, based on the compilation of existing laws and a review of their origins, merits and de- merits, is to be drafted and eventually, a monograph "Law and Population in Tunisia" will be prepared and submitted to Tufts University Law and POpulation Pro- gramme. ‘ OBSERVATIONS: It is understood the project is developing satis- factorily and is progressing according to schedule. 132 UNFPA/FAG PROJECT TUN/74/PO8 - "INTEGRATION OF FAMILY PLANNING IN AGRICULTURAL EXTENSION TRAINING" Date of Commencement Termination Date 01/10/74 .30/06/76 UNFPA Contribution: $8,000 (see also project TUN/74/P05) Counterparts: Zacharia Ben MuStapha, Director "Direction de l'Enseignement, de la Recherche et de la Formation Professionnelle" (DERFP) BACKGROUND; It is estimated that agriculture provides half the employment in Tunisia. The need is felt to associate considerations of pOpulation growth with the increasing financial and other measures which are being pursued by the Government in favor of agricultural expansion, particularly through agricultural extension agents. OBJECTIVES: To provide expertise to develOp a curriculum and begin training agricultural extension agents in information and techniques relating to pOpulation and family planning. OBSERVATIONS: This project is not provided with full—time FAO ex- pertise, but provision exists for consultancy services. It has been agreed that project activities should con- centrate on the "Centres de Formation Professionnelle Agricole" (CFPA) and on the rural extension services. Introduction of pOpulation education in higher level "theoretical" agricultural schools (lycees techniques) will be undertaken within the framework of UNESCO project TUN/74/P02 (see separate sheet). 133 UNFPA/Netherlands Royal Tropical Institute PROJECT TUN/74/PO7 - "SUPPORT TO THE FAMILY PLANNING PROJECT IN LE KEF REGION" Date of Commencement Termination Date 01/01/7 5 31/12/ 77 UNFPA Contribution: $507,827 Counterparts: Dr. Habib Rejeb, Chef de la Division Medicale, ONPFP Mlle Rafia Benlhabib, Chef Service Coopera- tion Multilaterale, ONPFP Senior EXpert: Dr. Van Der Straaten, Chef d'Equipe Medicale, Le Kef BACKGROUND; In 1970 the Netherlands Government started the funding of MCH/FP (Mother and Child Health/Family Planning) activities in the Kef region. AS a result of the policy of that Government to channel pOpulation funds through multilateral sources, direct assistance to the project ended in 1974. UNFPA has now picked up the project. OBJECTIVES: ~ To provide services to the estimated 49,000 women of fertile age group in the Kef region. As the reduction in mortality and morbidity rates are considered to be a prerequisite for a successful programme, MCH services are made available by the Dutch team. OBSERVATIONS: During a recent visit of a representative of the Nether- lands Royal TrOpical Institute discussions were held with the ONPFP to iron out some problems which had arisen in the interpretation of the budget submitted by the Dutch team. Further information is awaited from the 'Office' and from Amsterdam. The team,comprising three doctors, two midwives and a dietician, performs excellent work. In.August, 1975, the team dealt with 5,666 cases (Nutrition 1,854: Pediatrics 1,562; Family Planning 1,343: Prenatal Advice 642: Gynecological Cases 265). 134 UNFPA/UNICEF PROJECT TUN/74/PO6 — "EQUIPMENT FOR FAMILY PLANNING CLINICS AND UNFPA SUPPORTED PROJECTS" Date of Commencement Termination Date 09/09/74 31/12/77 UNFPA Contribution: $1,446,050 Counterparts: Dr. Habib Rejec, Chef de la Div. Medicale, ONPFP Mr. Hamouda Hanafi, Chef de la Div. de la Promotion, ONPFP Mlle Rafia Benlhabib, Chef du Sce de la Cooperation Multilaterale, ONPFP BACKGROUND: Material assistance to the National Office for Family Planning in support of various projects. DDJECTIVES: To enable UNICEF to undertake all equipment procure- ment for all family planning related projects in Tunisia financed by UNFPA. DDSERVATIONS: UNICEF has the best capacity to order and ship pOpu- lation related equipment and supplies. There is however much room for closer cOOperation between UNICEF and the Coordinator to monitor more effectively the equipment delivered and its use by the ONPFP. 135 UNFPA/1L0 PROJECT TUN/74/PO4 - "INTEGRATION OF FAMILY PLANNING IN THE WORKER'S ENVIRONMENT" Date of Commencement Termination Date 01/10/74 31/10/ 78 UNFPA Contribution: $5,000 (see also roject TUN/74/ O 5 Counterparts: Mr. Habib Achour, Secretary General "Union Generale des Travailleurs Tunisiens" (UGTT) Mr. Hamouda Hanafi, Chef de la Division de la POpulation, ONPFP DACKQROUND; It is estimated that the population of Tunisia in- creased each year by 92,000 persons between the ages of 15 to 64. This means the creation of 500,000 new jobs during the current National Development Plan with another 200,000 required during the currency of the next Plan. OBJECTIVES; To make available information about family planning to industrial enterprises by involving social welfare and social security workers in this field and also making available to Trade Unions information regarding the dangers of uncontrolled pOpulation growth. OBSERVATIONS: A national seminar was held in March, 1975 follOwing one last year with the Employers' Organizations. Re- gional courses have also been held. ILO has provided consultancy services on two occasions in 1975. 136 [lu‘fllu' ll. 11 I'll . II... III: SELEC TED BIBLIOGRAPHY V'Illli I'..I‘ . I!!! I BIBLIOGRAPHY BOOKS Berelson, Bernard et a1. Family Planning and Population Programs: A Review of World Developments. Chicago, Illinois: The University of Chica o Press, 1966. Daly, Amor. "Tunisia", pp. 1511 Morsa, Jean. "The Tunisian Survey: 1A Preliminary Analysis", pp. 581-593. Berelson, Bernard. Family Planning Programs: An Inter- national Survgy. New York: BasicL Books, Inc., 1969. Daly, Amor.. "Tunisia: The Liberation of Women and the Improvement of Society", pp. 102-113. Finkle, Jason L. and Gable, Richard. Political Develops ment and ASocial Change. New York: John Wiley and Sons, Inc., 1966. Micaud, Charles A. Tunisia: The Politics of Moderniza- tion. New York: Frederick A. Praeger, 1964. Thorne, Melvyn and Montague, Joel. Change iQLTunisia: Studies in the Social Sciences. SUNY Press, Albany, 1976. PERIODICALS Boudiba, A. "Education Sociale et DevelOppement" Revue Tunisienne de Sciences Sociales 14. (Sept. 1968) pp.‘69491. Bouraoui, Abdelhamid. "Problémes psychosociologiques de Planning familial et de la Contraception en Tunisie". Revue Tunisienne de Sciences Sociales (juin-septembre, 1969), pp. 428-429. Daly, Amor. "Le Programme de Planning Familial en Tunisie". Revue Tunisienne de Sciences Sociales 17-18. (juin-septembre, l9 9). pp. 307-320. Vallin, Jacques et Lapham, Robert. "Place du Planning Familial dans 1' Evolution Recente de la Natalite en Tunisie". Revue Tunisienne de Sciences Sociales (juin-septembre, 1969). pp. 379-41 , Dialo e our 1e Pro res. "Les Autres Tunisiennes. (27-janvier-l er fevrier, 1975). pp. 10-14. 137 El Magia. "La Tunisienne". Union Nationale des Femmes de Tunisie. (juin-juillet, 1975). pp. 20-23. El Mar'a. "La Femme Rurale: Une Famille de Jendouba (juin-juillet, 1975). pp. 25-28. El'Mar'a. "Code du Statut Personnel". (juin- Roufou, Taoufik. "La Femme Tunisienne: l' Emploi" El Mar'a (mars, 1976). pp. 20-23. Lakhal-Ayat, Naziha. "Le Divorce et La Tunisienne". El Mayfa. (mars, 1976). pp. 36-40. REPORTS Tunisia. Office National du Planning Familial et de la Population. Famille et Po ulation. Bulletin Mensuel, 3 Annee, No. 3. Mars, 1976. La Planification Familiale en Tunisie.» l mars, 197 . Legislation Tunisienne en Matiere de Planning Familial. Mars, 1976. La Politique du Planning Familial en Tunisie. Mars. 1976: La Planification Familiale: Politique Humaniste. Mara. 1973a Conseil Superieur de la POpulation. Numéro SpéCial, mars, 1975. Les Centres de Plannin Familial en Actiyité de 1970 $1974. 1974. A La Démoggaphie Tunisienne: Situation et Perspec— tives de Population. No date. Séminaire sur 1'Int5ggation_ge l'Education en Population et Planning Familial dans 1' Enseiggement Secondaire: Rapport Final. Avril, 1975. UNFPA-UNESCO. Project Tunzz4ZP02. Integration of Family Planning in the Secondary Education System. Tunis: September 30, 1975. 138 OTHER SOURCES Office du Planning Familial et de la POpulation. Personal interview with the Chef de Service, Bureau of Cooperation, Tunis, Tunisia. June. July, 1976. Personal interview with the Coordinator for Bi- lateral Programs, Chief of Documentation and Libraries, Tunis, 1976. Personal interview with the Regional Delegate of Family Planning. Sfax, Tunisia. 1976. Personal Interview with the Chef de la Section de l'Education. Tunis, 1976. United Nations. Personal interviews with the Coordinator of Family Planning, FNUAP, (Fonds des Nations Unies pour 1eS Activités en Matiére de POpulation), Tunis, Tunisia. 1976. United States Agency for International DevelOpment. Personal interviews with DevelOpment Officer, and Family Planning Advisor. Tunis, Tunisia, 1976. SECONDARY,SOURCES BOOKS Ashford, Douglas E. Morocco-Tunisia: Politic§_and Planning. Syracuse, New York: Syracuse Uni- versity Press, 1965. Beal, George M. et al. Social PerSpectives of Domestic Development. Ames, Iowa: The Iowa State Uni- versity Press, 1971. Duwajo, Ghazi. Economic Develo ment in Tunisia. New York: Frederick A. Praeger. 1967. Horowitz, Irving Louis. Three Worlds of Development. London: Oxford University Press, 1972. Julien, Charles. Histoire de l'Afri ue du Nord. Paris: Presses Universitaires de France, 1941. Knapp, Wilfred. Tunisia. London: Thames and Hudson, 1970. Ling, Dwight L. Tunisia: From Protectorate to Republic. Bloomington, Indiana: Indiana University Press. 1967. 139 Moore, Clement Henry. Tunisia Since Independence. Berkeley: University of California Press, 1965. Poncet, Jean. Le Sous-develOppement Vaincu? Paris: Editions Sociales, 1970. Zartman, I. William, ed. Map, State and Society in the Contemporarngaghreb. New York: Frederick A. Praeger, 1973. MONOGRAPH Area Handbook for the Republic of Tunisia. Washington, D.C.: Systems Research Corporation, 1970. 140 ["ll..ll$‘i.{lllflr. 3'1. ICHIGAN sms UNIV. LIaRnRIEs IIHI Mill W W “I MI W ll mm W 1| “I” WI WWI 31293103043216