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Friday, August 8, 2003
Tunisia Wins Population Battle, And Others See a Policy Model
Women, Economy Gain With Lower Rate Of Birth, but Unemployment Figure Rises
By GAUTAM NAIK
Staff Reporter of THE WALL STREET JOURNAL

CISSEB, Tunisia -- When Habiba Khalfaoui inquired about contraception three years ago, she was frightened by a health worker's suggesting an intrauterine device. The term in Arabic translates as "uterus machine."

But after the 26-year-old, who has 10 siblings, conceived her third child, she began thinking seriously about not having more. So she recently came to this remote, dusty village not far from her home to attend a teaching session on family planning and saw how small and unobtrusive an IUD actually is. It helped make up her mind. After she delivers the child she is carrying, she said, "I'm going on contraception."

Birth rates have dropped in just about every developing country, but the decline in Tunisia has been especially sharp. Millions of Tunisian women have been persuaded by family-planning campaigners to have far fewer children than their parents and grandparents did. And the improvement in living standards for the country's 10 million citizens has been more pronounced than in most developing countries.

Tunisia now serves as a model for other countries that want to emulate its success and close the wealth gap with western nations. At a large center in Tunis, the capital, a team of midwives and doctors provide year-round reproductive-health training to local and foreign health workers. Family-planning experts from Tunisia have set up four mobile teams in Niger at the request of that country's government. In December, Tunisia will host about 1,000 delegates at a high-profile conference about population and poverty in Africa.

The prime agent of Tunisia's transformation was President Habib Bourguiba, who launched the campaign in the 1950s and established its focus on advocating birth control. And while many other countries have focused largely on reducing the number of children born, Tunisia also has actively pursued social change that enables its people to use the declining birth rate to gain personally and economically.

The government spends about $10 million each year to teach citizens about family planning and dispense birth-control devices to the remotest corners of a country nearly the size of Florida. Tunisia has gone a long way toward educating its women and bringing them into the work force. Men and schoolchildren learn about contraception. Mobile clinics offer free pap smears and breast exams. Tunisia has even persuaded its religious leaders to loosen their interpretation of the Koran to fit the cause.

As a result, the fertility rate -- or the number of children per woman -- has plunged to 2.08 today from 7.2 in the 1960s. In the developed world, that kind of decline happened over more than a century. Tunisia's per capita income has risen to about $2,070 today from $1,430 a decade ago and is one of the highest in Africa.

The country also is attracting foreign investors, which has helped it sustain a 5% annual growth rate in the past six years, compared with 2.6% a year for Morocco and 3.1% for Algeria. In those two similar countries, population-control efforts started later and social change hasn't been as pervasive.

"Without our program we would have been in the same situation as Algeria or Morocco," says Nabiha Gueddana, who heads Tunisia's family-planning and reproductive-health program.

Yet Tunisia's success in overcoming social and religious hurdles isn't easily emulated, especially in many Muslim countries. In addition, Tunisia's record on exploiting the so-called demographic dividend that can come with a lower birth rate isn't perfect. The country has done fine with one phase: As the rate drops, those born before the decline grow up to create a population bulge of working-age men and women with few children and proportionately fewer demands on the country's social and health systems.

But jobs must be available for those in the bulge or unemployment can soar -- which is where Tunisia has stumbled. Nearly two-thirds of its population today is now of working age, 15 to 59 years old, and many are unemployed. On workdays, the caf�s are crowded with educated young men lounging and smoking water pipes. The World Bank puts the unemployment rate at 16%.

Mr. Bourguiba emerged as a hero of the war to oust Tunisia's French colonial masters in the 1950s. When he became the country's first president, he was determined to create a society based on a modern interpretation of Islam. And he wanted to attack the high birth rate.

Under his direction, Tunisia became the first Arab and African country to adopt a specific population policy in the mid-1950s. It outlawed polygamy and raised the marriage age to 17 for women and 20 for men, from 16 and 18 respectively. Government subsidies to families were limited to the first four children. In 1966, Tunisia also legalized abortion, and it still stands alone among Islamic countries in legalizing the procedure.

Many thought that Tunisia's aggressive approach was misguided. At a 1974 population conference in Bucharest, Romania, various experts insisted that if a developing country could fix its economy, population would automatically decline. Initially, conservative political forces in Tunisia also opposed -- and tried to overturn -- Mr. Bourguiba's changes.

He overcame the challenge by using his freedom-fighting credentials to win over religious leaders, who then issued Koranic statements favorable to his cause. For example, the Koran says that a Muslim man may marry up to four wives, provided he can treat them equally. But a separate quotation suggests that it's quite difficult to treat several wives equally. The upshot for Mr. Bourguiba's purposes: Having just one wife isn't necessarily anti-Islam.

"It's all about interpretation," says Ms. Gueddana, the family-planning chief. Now, Friday sermons in mosques are often devoted to reproductive health and related subjects.

In 1987, physicians declared an elderly Mr. Bourguiba unfit for the presidency; born in 1903, he would live on until 2000. His campaign has been continued and expanded by his successor, Zine El Abidine Ben Ali, who rules the country with a strong hand and has little political opposition. Tunisia spends the equivalent of 18% of its gross domestic product of $21 billion on social programs, especially family planning and the expansion of women's rights, either through legislation or special projects.

Farouk Ben Mansour runs a reproductive-health clinic in Tunis focusing on younger patients. He visits college dormitories and talks to students about birth control and sexually transmitted diseases. He then provides his home number so they can contact him confidentially. Of the 4,500 students who attended his lectures last year, he says, more than 400 dropped by for a visit.

He made a separate entrance at the clinic (discreetly marked "Administration" in Arabic) so that young visitors can arrive and leave without being noticed. In a special area containing colorful charts and a large jar of condoms, he conducts teaching sessions for secondary-school students. In a back room, painted a shocking-pink color, nurses show older women how to examine their breasts with the help of a rubber device built to mimic a female torso. When the rubber breasts are pressed the right way, it's possible to feel a hard, unnatural lump, similar to an actual breast tumor.

"Without this, women don't really know what they're supposed to be looking for," Dr. Mansour says. Another clinic nearby has just acquired a mammogram machine. It has started a feasibility study on breast-screening and hopes to recruit 11,000 local women with a door-to-door campaign.

To bring the message to the one-third of Tunisians who live in rural areas, the government has relied partly on mobile teams -- a nurse, a social worker, a midwife and a driver -- that dispense family-planning and reproductive-health services. On a recent morning, one such team pulled up at a local clinic in Cisseb, which is part of a larger district known as Kairouan. A highly conservative area, it is home to Africa's oldest mosque, built in 671 AD.

Scores of women waited in the hot sun outside the clinic. They had come to take advantage of a range of free services, from breast exams and contraception, to referrals for abortions. Visits to reproduction-health clinics in Kairouan have jumped to 129,000 annually from 75,000 in 1997, according to official estimates. Contraceptive use in the district has nearly doubled in the past 15 years, while the fertility rate has fallen to 2.3 from 4.5 in 1996.

Acceptance hasn't been automatic. One midwife who works in a mobile clinic recalls a tribal woman who wanted to get fitted with an IUD. But her husband objected, possibly believing that it might interfere with their sex life. The woman resorted to taking birth-control pills secretly.

But two years ago, Tunisia's government began educating men, as well. It now conducts almost a dozen such teaching sessions each month, many in the country's underprivileged zones d'ombre, or "shadow zones," that remain largely untouched by modern life. One class was recently held in Tataouine in the Sahara desert. (Part of the Star Wars series was filmed in Tataouine's sandy wastes, the inspiration for a planet called Tatooine.)

In a makeshift classroom with a cement floor, nine participants, all from the Berber tribe, watched a video about sexually transmitted diseases. The teacher then explained the benefits of condoms, IUDs and birth-control pills. One man asked about AIDS. The disease is relatively rare in Tunisia. According to the World Health Organization, AIDS cases in Tunisia last year numbered 3,200, compared with 14,000 for Morocco and millions in sub-Saharan Africa.

Another man described how he used to worry about being infertile, but is now the father of two. Ali Khasraoui, a sunburned teenager, was attending for the first time. "I'm embarrassed," said the 16-year-old, squirming in his seat. "But my parents encouraged me to come."

Such changes have transformed Tunisian society. With fewer children to raise, women have become a big part of the work force. There are more women than men at local universities. If the population had continued to procreate at the original rate, Tunisia would have 15 million people today instead of 10 million.

Evidence of the declining birth rate is everywhere. Condoms are distributed free in all clinics and sold for a nominal price in shops. Birth-control pills and the morning-after pill are available free to almost anyone who needs them. The construction of primary schools stopped a decade ago as the average number of students in a primary-school class dropped to 28 in 2000 from 38 in 1985, according to Mahmoud Seklaui, a local demographer. In some schools, the first-grade has been eliminated because there aren't enough new students.

Foreign companies increasingly view Tunisia as an attractive place to do business. United Technologies Corp.'s automotive unit has a factory outside Tunis. Food company Groupe Danone and drug-maker Sanofi-Synthelabo SA, both of France, also have operations there. That has reduced the contribution of agriculture to Tunisia's GDP to about 12% from 14% during the past two decades, and has increased the contribution from manufacturing to almost 19% from 12%, according to the World Bank.

"We've found Tunisia to be stable, with low labor costs and high quality" of manufacturing, says a spokesman for Benetton Group SpA. The Italian fashion company is spending about $17 million on a second manufacturing facility scheduled to open in 2005. All of its products will be for export, mainly to Europe. About 10 million, or 10%, of the 100 million garments that Benetton produces each year are made in Tunisia; by 2005, Tunisia's contribution is expected to double to 20 million garments.

Tunisia's grand experiment is far from over. Women still don't have equal rights to inheritance. And the country desperately needs to create more jobs or risk a reversal in its economic fortunes. But barriers keep coming down. In June, the country adopted a new law that lets a woman transfer her maiden name to a child, if she is unmarried, or if the father is unknown.

With such moves, the country continues to assert that women hold the key to its transformation. In Tunisia, women are "taking on a modern lifestyle in terms of education and jobs," says Joseph Chamie, director of the United Nations Population Fund in New York. "Their behavior will affect everything."

Write to Gautam Naik at [email protected]

Updated August 8, 2003

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