By Amal Hlioui | Issue #22
The latest statements of Tunisian President Saied who warned against sub-Saharans’ presence in Tunisia as a ‘change of the demographic composition’, have been deemed xenophobic. During the outbreak of the Libyan Civil War in 2011, thousands of sub-Saharans fled to Tunisia. Ever since, a sub-Saharan diaspora was formed, yet the numbers, origins and social issues have long been neglected and “unknown”. Hiding in the shadows, sub-Saharans’ social vulnerability is accentuated by a general atmosphere of rejection and mistrust towards them in Tunisia.
Female sub-Saharans have precarious work and life conditions. Furthermore, they suffer from a double vulnerability as they have the burden to attend to their reproductive health, as well as that of their children and partners. In this article, I explore the treatment of sub-Saharan women by the Tunisian healthcare systems by interviewing two different stakeholders: a doctor, and a sub-Saharan migrant in first-line and third-line healthcare facilities.
Reproductive health: a satisfied need?
Officially referred to as ‘foreign residents in Tunisia’, sub-Saharans account for 21,466 immigrants, i.e. 36.4% of the total number, according to the National Survey on International Migration. This survey puts the total number of female immigrants at 7351, between 2020 and 2021, which is likely an underestimate of the total numbers. Dr. Syrine Trabelsi, a young Obstetrics and Gynecology resident at the University Hospital Mogi Slim in La Marsa, a region where the concentration of sub-Saharan migrants is high, believes that she has been seeing an increasing number of sub-Saharan women in the last two years.
At the Ariana Maternal and Infant Protection Center, the medical staff see sub-Saharan women every day for different purposes: family planning, contraception, STDs, pregnancy tests, and interruption of pregnancy. Indeed, medication abortion is available for free in all these centres. Tunisia is the only Arab country where abortion for non-medical reasons has been legal for all women since 1973, medication abortion has been available since the early 2000s. On average, 20 sub-Saharans are taken in by the Youth Space, within the Centre, for this pharmacological protocol every day. However, this number has fallen after the last controversial statement of the President as they are afraid of arrest, deportation or even attacks.
Contrary to the negative stereotypes that many Tunisians have about immigrants from sub-Saharan Africa, Dr. Trabelsi describes patients from sub-Saharan Africa as respectful and knowledgeable about their healthcare needs. For example, women from sub-Saharan Africa are more likely to develop uterine myomas than women from other populations. Dr. Trabelsi has found that most of the women she treats for this condition have a good understanding of their medical history and about care requirements for uterine myomas. Additionally, many of these women are proactive and knowledgeable about their reproductive health. For example, less than 2% of women who use contraception in sub-Saharan Africa use intrauterine devices (IUDs). However, Dr. Trabelsi noted that many of her patients from sub-Saharan Africa use the devices and come to her clinic to have them removed or for other purposes.
At public hospitals, sub-Saharan women are also taken in for pregnancy monitoring and childbirth. As any female citizen, they come into labour and are directly seen by midwives and doctors. They are treated with the same care as a Tunisian citizen would receive. Some of them, however, come with complications due to non-monitored pregnancies, which begs the question of whether or not they are able to access reproductive health structures.
Challenges: information, distance, money and fear
Luna, an undocumented Malian young woman, was sitting next to the Raoued community clinic, waiting in line. At first, she was reluctant to talk. Then, she expanded on the difficulty of going to the Ariana protection centre to access care or to take contraceptives. She ended up relying on non-medical methods for contraception and ‘hoping the worst does not happen’. For Luna, distance is the first challenge to easy access to reproductive health as state facilities are centralised and usually far away from neighbourhoods where she and other sub-Saharan immigrants live.
The second challenge, according to Dr. Trabelsi, is the lack of information. Most sub-Saharan women do not know how the Tunisian medical system works, legally or financially. They do not know that if they are not covered by state or private insurance, they must pay full fees. Some patients have even run away from healthcare facilities when confronted with the healthcare bill.
The “lucky” ones are paradoxically the very few sub-Saharans who were granted refugee status, in the absence thereof an immigrant cannot get reimbursement or coverage. In Tunisia, the UNHCR is in charge of the process of helping refugees to access healthcare. Dr. Trabelsi recalls the story of a refugee who could benefit from medical coverage for her breast cancer after a long process involving the patient, UNHCR and the hospital staff. She is, fortunately, undergoing chemotherapy after a delayed diagnosis because of the rare form of cancer and the slow response to her condition.
In addition to these issues, Dr. Trabelsi stated that the most challenging issue for sub-Saharan women is building rapport. Many sub-Saharan Africans have been poorly treated in the past by healthcare systems and other authority structures in Tunisia. This makes them reluctant to turn to health structures for help because they are afraid of rejection and/ or discrimination. When they receive adequate medical care, they seem puzzled and grateful at the hospital staff’s “nice” and professional treatment. ‘It seems that they do not receive such “normal” treatment elsewhere’, said Dr. Trabelsi. To mend the gap, she and her co-workers ‘have to listen to them, and get rid of prejudice’.
Amal Hlioui is an agrégée teacher at University Tunis El Manar. Holder of the Erasmus+ MIGRANTS project fellowship. PhD researcher in System Dynamics, DEMS, UNIPA. In her thesis, she works on the sub-Saharan representations in Tunisian media and the ramifications on migration policy.