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Legacies of the Colonial Mission: French Medical Student Perspectives on Family Planning in Tunisia, 1978-1985

Author: Hannah Olsen (Michigan State University)

  • Legacies of the Colonial Mission: French Medical Student Perspectives on Family Planning in Tunisia, 1978-1985

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    Legacies of the Colonial Mission: French Medical Student Perspectives on Family Planning in Tunisia, 1978-1985

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Keywords: Tunisia, France, reproductive health, civilizing mission

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Olsen, H., (2024) “Legacies of the Colonial Mission: French Medical Student Perspectives on Family Planning in Tunisia, 1978-1985”, The Journal of the Western Society for French History 50: 4. doi: https://doi.org/10.3998/wsfh.5727

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2024-12-10

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According to David Arnold, “there is indeed a sense in which all modern medicine is engaged in a colonizing process.”1 This assertion neatly summarizes a plethora of historical scholarship on the relationship between medicine and colonization. Shula Marks even links colonial medicine, the practice of ridding poor regions of traditional “superstitious and dirty practices,” to biomedicine (laboratory-based medicine).2 Historians have examined how colonies have been spaces where this kind of laboratory-based medical experimentation has not been policed with the same ethical rigor as in the global North, often with disastrous and traumatic consequences for former colonial subjects.3 This was certainly true of medical practices in former French colonies.4 As historian Françoise Vergès elucidates, “regulating women’s bodies was the objective in both France and the overseas departments and territories (DOM-TOM), but it was not practiced in the same way in the two spaces.”5 Her work focuses on Reunion Island, a département d’outre-mer, but this was also the case in Tunisia, where Western countries continued to influence the political and medical landscape after its independence from France in 1956.

Though it was a protectorate rather than part of the DOM-TOM, Tunisia functioned much like a colony and France continued to carry influence in the region after the end of the French empire.6 After gaining independence, Tunisia’s first president, Habib Bourguiba, introduced sweeping reforms in education and health care. There was undoubtedly a direct connection between Bourguiba’s economic policies and the implementation of the family planning program in Tunisia. As historian Jennifer Johnson describes, “[Bourguiba’s] modernization campaigns and his commitment to reform and expanding education opportunities laid an important foundation for the introduction of larger social programs, including family planning.”7 This modernization process included transforming Tunisia’s economy from an agrarian based economy to an “extroverted,” industrialized one that exported goods like petroleum and attracted European tourists, according to historian Kenneth J. Perkins.8 Women joining the workforce was also a key change to Tunisia’s economic modernization.9

Although Johnson convincingly describes how Bourguiba was actively involved, emerging scholarship on the impact of Bourguiba’s policies begs further inquiry into the impact of Western influence on this modernization process. As historian Burleigh Hendrickson explains, “After independence in 1956, Tunisian president Habib Bourguiba’s pro-Western economic policies fractured a Tunisian population that was reconstructing a national identity in the wake of French colonialism.”10 Johnson, too, calls for additional research in this area stating that “much work remains to be done in this area, particularly on the development of national health industries, training and technical assistance, exchange programs and international humanitarian organizations.”11 Johnson’s commentary and existing scholarship on medicine and colonization invites us to question how the political motivations behind education on colonial history and family planning influenced exchange programs for medical students between France and its former colonies.

The foundations for establishing modern medical centers in North Africa reified ties between the West and its former colonies. Funds for the family planning project in Tunisia, the first of its kind in North Africa, came from the West. The Ford Foundation provided hundreds of thousands of dollars to fund the project and the Population Council, a “New York-based private organization that focused on managing population growth around the world, facilitated training for medical personnel and other equipment necessary to implement the family planning program.”12 In addition to monetary investments, France and other Western European countries also sent medical personnel to staff medical centers in Tunisia where they were trained in modern family planning practices. Historian Amy Kallander describes how this kind of practical training was crucial: “Even after independence, generations of elites from the former colonies who completed their higher education in France in the fields of medicine and public health were not likely to be exposed to family planning. Tunisia thus held ‘immense value’ for training, educating, and promoting birth control across a continent where French was the second language for over ninety million people.”13 As a result, by the 1960s only around half of all doctors in Tunisia were Tunisian and most were based in Tunis.14 This meant that there was a distinct lack of trained gynecologists in rural Tunisia, according to Kallander.15

As Johnson explains, “there was a constant interplay between European medical practitioners and the local populations over whom they ruled. These historical roots are essential to any study on the relationship between newly sovereign countries and their former European ruler.”16 To that end this article aims to better understand the perspectives of French medical students who worked in family planning centers funded by Western-based philanthropies. How did the interests of Western-based foundations influence French medical students’ perspectives on the role of family planning centers in Tunisia? And, perhaps most importantly, how did the doctor’s perspectives impact the kind of care that their patients received?

To attempt to answer these questions, I compare two studies conducted by French medical students in family planning centers in Tunisia.17 One such study was carried out by Dr. Catherine Leperlier (née Sautier), then a medical student at the faculté de médecine Pitié-Salpêtrière in Paris. Dr. Leperlier’s work was completed at the Hôpital de Moularès in Moularès, a mining town, in 1978. The second study, conducted by Dr. Yves Parent as part of his doctorat en médecine studies at l’Université de Paris VII, took place at the family planning center at Sfax in 1985. The goal of this article is not to place any moralistic judgement on the individual medical students who wrote these studies; rather, my argument places their professional assessments of the family planning program in Tunisia within the larger framework of colonial ideologies that permeated educational spaces both before and after the fall of the French empire, as scholars have shown in other contexts.18 As historian Matthew Connelly explains, rather than a global conspiracy, population control is made up of “networks of ideas, of individuals, and of institutions” that are “by their very nature resilient.”19

The ties between Bourguiba’s family planning program and the colonial ideologies in the medical field are evident in the way the doctors frame their research and the conclusions that they draw after a year or so of residency in family planning centers in Tunisia. As such, I will first analyze the ways the doctors frame their studies in economic and historical terms, emphasizing the comparisons both make between demographics in Tunisia and France. Then I will assess their references to concerns about immigration. Finally, I underline how the doctors’ perspectives impacted Tunisian women’s family planning experiences and how Tunisian women resisted Western influences on their family planning choices.

Ultimately, I find that the French doctors’ frames of thought align with the larger political goals of modernizing Tunisia and subtly curbing immigration to the Hexagon, instead of prioritizing care for their Tunisian patients. Their perspectives are characteristic of paternalistic mentalities that dictated the ways in which former colonies were described in France, particularly in educational settings, in the 20th century. This is an example of what Connelly calls “the politics of population”; “the regulation of public health, reproduction and migration” as “an alternative approach to policing a national border.”20 However, I also note evidence that Tunisian women played an important role in mitigating the impact of the continued colonial mission in family planning practices in Tunisia.

Colonial Frames of Thought after Independence

Following educational reforms brought on by student protests of May ’68, French medical students were required to spend six semesters training in teaching hospitals and their final year was dedicated to “clinical practice and examinations in medicine, surgery, and obstetrics and to defense of a thesis before a jury of professors.”21 Drs. Leperlier and Parent completed at least part of this training in Tunisia. Though family planning centers provided infant care, including vaccination and malnutrition prevention, their primary goal was lowering the birthing rate and slowing the population growth of Tunisia.22 This larger goal of population control is present in the way the two doctors frame their studies. Both studies begin by comparing birthing rates in Tunisia and France, which, as they both note, are remarkably low in comparison to Tunisia and other countries in North Africa. Whereas similar medical studies conducted in the Hexagon in the 70s and 80s emphasized the need for more doctors and medical staff willing to provide care and, most importantly, information about contraception and abortion to their patients, these studies from Tunisia emphasize a need for population control.23

Both doctors emphasize economic development, rather than improved reproductive health care for women, revealing the political discourse veiled by medical jargon. This is the kind of language that, according to Gilles Manceron, evolved from educational texts that glorified the colonial period. Manceron traces how “the discourse presented in school textbooks [in the 20th century] became less centered on war and more paternalistic and ‘developmentalistic.’ War and praise for colonization were replaced by ‘civilization’ and ‘humanitarianism’; these were more insidious, and probably more lasting, forms of ideology.”24 For example, Leperlier uses economic terms like production and consumption to speculate about Tunisia’s population growth, stating “L’explosion démographique, si elle n’est pas maîtrisée, rend aléatoire le développement économique du pays, du fait du déséquilibre inévitable entre l’augmentation de la population et celle de la production, aussi bien alimentaire que des biens de consommation.”25 As a result, Leperlier describes the family planning program as a necessity.26

Parent, too, notes that, traditionally, Tunisians preferred to have large families and he links this preference for large families with economic stagnation: “Cette explosion démographique rendait ainsi illusoire tout développement économique du fait du déséquilibre entre l’augmentation de la population et celle de la production…La tradition notamment exaltait une progéniture abondante. En effet, les enfants étaient considérés comme ‘des bras supplémentaires’ pour le travail et comme une source de sécurité pour les vieux jours des parents.”27 Although parents may have considered their children’s contributions to labor in the home or in industry as part of the family budget, the doctor reduces all forms of reproduction to an economic equation rather than considering other factors, like religion or local tradition, that could influence this preference for large families. It is also unlikely that Tunisian couples were planning their families with the national economy in mind. In other words, parents may have decided to have many children to increase their family’s income, but it is unlikely that they decided to have more children to increase the country’s overall production on the global market.

The doctors’ citations are also indicative of the influences on their worldviews and their understanding of medicine and family planning. In fact, both doctors cite very few texts on gynecological health and instead cite the Office nationale du planning familial et de la population based in Tunis, the Revue tunisienne des études de la population, Revue tunisienne des sciences sociales, The Population Council, and several articles on texts on emigration between Tunisia and France.28 Several of their citations reference economic development and socio-economic characteristics of women who chose to use contraception.29 This emphasis on economic development in the doctor’s analysis hints at the imperial ideologies behind these kinds of Western-backed modernization projects. As historian Leonard Smith argues, economic rationales, like that of Leperlier and Parent, often followed imperial conquest.30 What is more, these citations from primarily social science texts demonstrate the influence of population studies and anthropological work at the time. These works were certainly not immune to rhetoric that viewed Europe as more economically and scientifically advanced than the African continent. Even celebrated anthropologist Joseph Balandier, at the time, called into question Africa’s economic dependence on Europe, writing in A Dictionary of Black African Civilisation, “A pertinent question is: How much does African agriculture owe to local enterprise and how much to foreign imports?”31

Rather than purely humanitarian, economic reasoning, French intervention in the Tunisian family planning program is better explained by the legacy of the mission civilisatrice. As Smith explains, in 1885, Jules Ferry “sought to synthesize a new colonial doctrine, in which the French empire would do well by doing good. That synthesis became known as the mission civilisatrice, or civilizing mission. Historians now use the term mostly in an ironic sense. France, the theory went, would carry republican values wherever it brought the tricolor flag. French imperialists would intervene in the evolution of human progress, raising whole peoples to become worth of those values.”32 Sending medical students, like Leperlier and Parent, to rural Tunisia would have been seen as a kind of welfare program, bringing modern medicine to those in need. As Amelia Lyons explains, welfare programs were a way of rectifying France’s relationships with its former colonies, and its public facing image, after their independence.33 The French “framed imperialism in the ever-evolving concept of a civilizing mission. The basic principle that the French should be ‘leading people to civilization’ and ‘our superiority’ had been central to developing conceptions of universalism and racial thought since the eighteenth century.”34 According to Kallander, family planning “highlighted the importance of planning as a facet of modernization: using contraception was a rational decision made possible by scientific innovations, whereas unplanned families connoted underdevelopment, antimodernity, tradition, and even natural disaster.”35 Thus, Drs. Parent and Leperlier’s work was not simply a practical internship, it was part of a larger modernization program designed to bring French modern republican ideals, which now included reproductive freedom for women, to its former colony.

This kind of civilizing mission ideology becomes even more evident in Parent’s historical framework. He notes that “la population maghrébine a doublé en un quart de siècle” and that its population will pass that of France’s by 1986.36 Parent estimates that the population of Tunisia was roughly 2.5 million at the time of the Roman empire and that the population had decreased to 1.5 million by the time Tunisia was a French protectorate a millennia later. Parent attributes this decrease in population to the primitive demography that has governed the population for a millennium.37 Parent then notes that under its French protectorate status, the population of Tunisia grew again.

These comments also uncover a paradox in this colonial mentality; the Tunisian population, that had once thrived under the Roman empire, was reduced under “primitive” local rule, and now must be reduced again with modern medicine from yet another empire. The local population must be large enough to support the local industries, like phosphorus mining in Moularès, that could contribute to the global market, but it mustn’t grow so large that it surpasses that of its former colonizer. Furthermore, Parent’s historical framing implies that Tunisia requires an outside ruler or protector to maintain a delicate balance between over and under population, especially in comparison to that of France. The reasons for this fear of former colonies out-populating European countries becomes apparent in the doctors’ framing of their studies and in their conclusions.

Curbing Immigration to the Hexagon

According to Elisa Comiscioli, race, reproduction, and immigration are intricately linked, creating hierarchies of immigrants depending on their country of origin that prioritized “white immigration to France.”38 It is unsurprising, then, that Drs. Leperlier and Parent make note of the impact of their observations in family planning clinics in Tunisia may have had on immigration to France. This is apparent, for instance, in the way that Dr. Leperlier introduces her study. She begins by outlining global population growth, underscoring that in the decades to come, some regions of the world would see serious demographic and socio-economic problems as a result of this population growth rate.39 The doctor then gives statistics on birth rates, mortality rates, and population growth rate (the mortality rate deducted from the birth rate) for France all of which has resulted in an “aging” population with 13% of the population over the age of 65.40 Dr. Leperlier then juxtaposes these demographics of “developed” countries like France and Belgium with that of Tunisia. Though Dr. Leperlier credits changes in demographics in these developed countries to “progress in techniques and science” that have allowed people to live longer, marry later, and have less children, the same cannot be said for Tunisia, according to Dr. Leperlier. Tunisia is characterized as having a rapidly increasing life expectancy thanks to these same medical advances without any of the improvements of the quality of life that Europeans enjoyed, particularly in rural regions.41 Rather than exploring possibilities for attaining improved standards of living in Tunisia, Leperlier observes that most Tunisian workers that emigrate to Europe come from the rural south, where the mining industry was a primary source of employment.42

In his conclusion, Parent, too, hypothesizes that overpopulation in Tunisia will result in increased immigration from Tunisia to, as he describes, the industrialized Hexagon.43 He writes, “Les problèmes posés par l’immigration maghrébine sont pour l’avenir lourds de tensions et d’incompréhensions. Tout devrait porter la France à accorder un grand intérêt à l’évolution de la démographie maghrébines, serait-ce qu’en raison de la présence sur son territoire de plus d’un million de personnes des trois nationalités et de l’intense trafic de migrants d’une rive à l’autre de la méditerranée.”44 This fear is only solidified in the final thoughts included in his study, where he cites former president of Algeria, Houari Boumédiène: “Un jour des millions d’hommes quitteront la partie méridionale pauvre du monde pour faire irruption dans les espaces relativement accessibles de l’hémisphère nord à la recherche de leur survie.”45 By quoting President Boumédiène, second president of Algeria, Parent brings all of North Africa into the discussion of immigration to the Hexagon, as Algerian immigrants represented the largest population of North African immigrants in France.46 Instead of envisioning an economically independent Tunisia and an improved quality of living for Tunisians, both doctors assume that population growth in all of North Africa will lead to increased immigration to the Hexagon.

This assumption harks back to paternalistic colonial attitudes that the colonies depend socially and economically on their colonizer, when in fact workers from France’s former colonies in North Africa were recruited to work in France after the Second World War, filling a hole in the work force left after the devastation of the two wars. Historians have documented the role that immigrants have played in the French economy for hundreds of years.47 As professor of geography James McDonald, writing in 1969, describes, immigrants from Southern Europe and North Africa took on low paying, unskilled labor following the consecutive wars, stating that “In France, the necessity for importing labor became apparent almost immediately after the termination of hostilities in 1945…This was not a new problem for France, where a declining birth rate and the enormous losses of human life and demographic vitality produced by World War I made the maintenance of existing population levels problematic.”48 This acknowledgement of the essential role the North African immigrants played in the French economy, however, is absent from Dr. Parent and Dr. Leperlier’s assessments. Their historical and economic frames of reference are typical of rhetoric that excludes nuanced perspectives of former colonized people.

Increased population in the Hexagon due to immigration, however, was not seen as a means to repopulate following the demographic devastation of the two World Wars. As historian Elise Franklin explains, Algerian women in the Hexagon were denied the Medal of the French Family, a medal awarded to mothers of multiple children for service to the patrie as part of “a natalist initiative to counteract depopulation.”49 The growing Maghreb population was instead seen by many, including Dr. Parent, as a problem. In the mid-20th century, France faced a shrinking influence over its former empire and a growing immigrant population; “Rapid population growth – not gross political and economic inequality – was deemed the fundamental cause of unrest across North Africa. Like the British in the West Indies, only on a much larger scale, they feared increasing migration to the metropole. Bidonvilles, or shantytowns, started to sprout, not just in the cities of North Africa, but in France itself. As soon as authorities bulldozed them into the ground, they arose again in another neighborhood.”50 Calling to mind emigration from North Africa to France would have evoked images of these bidonvilles in the minds of the medical professors who assessed Parent and Leperlier’s studies.

These studies came shortly after an impactful shift in immigration policy in France. Prof emeritus Danièle Lochak describes how the Fontanet-Marcellin circulaire of 1972, authored by Minister of the Interior Raymond Marcelin and Minister of Labor Joseph Fontanet, marked a departure from previous immigration policy: “Les circulaires Marcellin-Fontanet sont bien annonciatrices d’un tournant de la politique migratoire puisque, deux ans plus tard, les pouvoirs publics décident la suspension officielle de l’immigration de travailleurs.”51 However, this stance did not endure. Immigration, albeit illegal immigration, continued. According to Alec Hargreaves, Tunisians, along with Turks and Moroccans, accounted “for almost two-thirds of those unregularized in the building industry” by the 1990s.52 The Maghreb population continued to grow, and by 1999 the number of Tunisian migrants in France numbered over 200,000.53 Just as efforts to stop immigration between Tunisia and France were unsuccessful, the family planning program in Tunisia was largely ineffective in slowing the growth of the Tunisian population. As Connelly notes, “programs to distribute contraceptives in poor countries have not had more than a marginal effect on population growth. Far more important is whether people actually want to have smaller families.”54 It seems that, according to the reports by Drs. Parent and Leperlier, these Tunisian women did not want to have smaller families.

Tunisian Women Resist Population Control Efforts

Just as the doctors frame their studies of family planning in Tunisia in relation to economics and emigration, both doctors’ concluding comments speak to the impact of these ideologies on Tunisian women. Their conclusions underscore the disconnect between the family planning program’s aims and Tunisian women’s needs. Dr. Leperlier’s conclusions show that the family planning project was difficult to implement in rural Tunisia. Typically, a doctor treats symptoms of illness or disease that the patient presents to them. Here, however, Western doctors were attempting to influence women’s family planning decisions. This begs the question: to what extent did these civilizing frames of thought impact their interactions with patients?

The aim of slowing population growth was largely incompatible with women’s individual goals for their desired family size. As a result, the family planning center in Moularès did not seen any significant impact on population growth since 1972; even though younger women were visiting the family planning center in greater numbers than in years previous, they were not continuing to take their birth control pills and the birth rate in the area was not decreasing.55 Furthermore, the family planning project’s aims did not sufficiently address women’s concerns with the new forms of contraception that were being presented to them. In Moualrès, most women preferred to use the pill because they feared unpleasant side effects of IUDs.56 As Johnson explains, medical infrastructure had been largely ignored during the French regime, especially in rural areas, and there were fewer medical staff available to address these concerns.57 As a result of their observations, juxtaposed with birthing rates from France, the doctors make recommendations for efficient family planning centers in Tunisia. Dr. Leperlier writes, for example, that an efficient Planning Familial should promote IUDs instead of birth control pills.58

Part of this recommendation is based on the fact that in Moularès, more women continued using IUDs after six months compared to women who chose the pill. Whereas 85% of women who chose an IUD continued using this form of contraception after six months, almost 50% of women who chose the pill stopped using this form of contraception after six months.59 However, as Dr. Leperlier notes, it is much easier to cease taking a pill in comparison to the medical intervention necessary to remove an IUD. Whereas Dr. Leperlier cites its efficacity and seemingly reliable nature as a long-term form of contraception, she also notes that women were fearful of this method of contraception and skeptical of the necessity of the medical intervention that it required.60 This was also the preferred method of Western organizations like the Ford Foundation and the Population Council that provided the funds, materials, training, and personnel needed to establish family planning centers in Tunisia.61 In an effort to promote modern medical family planning practices, press campaigns on birth control were initiated. As Kallander explains,

Presenting contraception as a practice already familiar to women masked the Western origins and colonial hierarchies of the population movement. Following the legalization of contraception, Faiza’s [a Tunisian women’s magazine] cover featured a smiling toddler with the caption ‘Tunisian women can now have happy children.’… Birth control became less a matter of choice than a means to implement a nationwide consensus on the benefits of the small, nuclear family. Whether evoking economic development or the modern family, birth control was incorporated into the national initiatives of economic planning and ideas of modern womanhood.62

The Tunisian women who discontinued their modern forms of birth control were, in a way, rejecting the notion that they must adapt to this form of modern womanhood.

However Tunisian women had good reason to be suspicious of new forms of contraception like IUDs. In fact, “Tunisian village women were rounded up for forced [IUD] insertion and that their husbands were sometimes threatened with loss of employment if they did not encourage their wives to accept it.”63 This preference for the IUD was likely due to the difficult nature of removal that Dr. Leperlier cites. To have those IUDs removed, these women would likely have had to return to the family planning center, an unlikely event given the violent manner in which the IUD insertion took place. Angel Foster’s 2001 dissertation documents one woman’s experience, a young woman named Roquia from Tunis, with forced IUD insertion in 1976, which later resulted in an ectopic pregnancy and an abortion.64

Dr. Leperlier again uses paternalistic language that characterizes Tunisia as underdeveloped in comparison to the “modern” (i.e. the global North) world. Leperlier describes the region in southern Tunisia as even less developed than the rest of the country and the implementation of the family planning program there as “lente et difficile.”65 As Dr. Leperlier explains, “On ne saurait demander à ces populations de modifier leurs attitudes traditionnelles sans qu’existent les conditions de vie et l’ouverture au monde moderne qui font du contrôle des naissance un choix conscient.”66 Indeed, it is unsurprising that women living in Moularès were resistant to these new forms of contraception, introduced to them by foreign or foreign-trained doctors, and instead they preferred to continue to have large families. Furthermore, Leperlier’s mention of choix calls to mind the rhetoric used by French feminist groups who advocated for the legalization of contraception and abortion. Whereas white, French women’s choice to have children, if and when they wanted to, was central to debates on family planning legislation in France, here Tunisian women’s choices are given little consideration in both doctors’ analyses.67

Unlike Dr. Leperlier, Dr. Parent fails to note the incompatibility between the family planning program goals and the needs of the patients who visited the centers. Instead, he concludes his study by making further comparisons between France, Tunisia, and the North African region in general. When comparing Tunisia to its neighbors Algeria and Morocco, Dr. Parent deduces that because Tunisia was quick to introduce a family planning program after its independence, the country is better armed to master its growing demographics.68 In comparing France and the Maghreb region, Dr. Parent reveals that the medical community in Tunisia was well aware of the potential consequences of allowing Tunisia’s population to grow, revealing a xenophobic line of thought that fuels the “need,” as these doctors describe it, to control the Tunisian population.

One would think that to better understand how to better implement family planning practices in Tunisia, perspectives of Tunisian women would be useful sources of information. However, neither Dr. Parent nor Dr. Leperlier include quotes from their patients, as some French medical students studying abortion and contraception at the time did.69 It is possible that the doctors and their patients were working around a language barrier, as it is not noted in either study if the doctor spoke Arabic. Even if they did, it’s unlikely that they spoke the correct dialect to be able to communicate with patients in these rural clinics without an interpreter.70 This underscores the differences between the way that family planning was perceived by French doctors in Tunisia and in France. Whereas in France, women’s voices were considered to be, in some cases, essential keys for doctors to understand their patients’ perspectives on contraception and abortion, in Tunisia this was not the case. This reiterates the notion that the family planning project was primarily a means to serving economic and modernization goals. As Foster’s field work elucidates, “The family planning program was a function of the state, which aimed at furthering state goals. It was not about individual women or their needs.”71 Unlike in France, in Tunisia there was no connection between the fight for women’s rights and the legalization of abortion, and contraception, rather, “took place in the framework of family planning policies.”72 While Tunisian voices are largely absent in these studies, there are hints at the work that Tunisian women contributed to gynecological health during this period throughout both studies.

Far from passive participants in family planning policies, Tunisian women were essential actors to introducing new forms of contraception and family planning services to communities across Tunisia. Sage femmes (midwives), in particular, played a key role in family planning centers. Both Drs. Parent and Leperlier acknowledge the work of sage femmes in their studies by thanking them in their acknowledgement sections. These sage femmes, Fatma Gargouri in Sfax and Hanifa Daoudi in Moularès, would have been able to prescribe birth control pills, insert IUDs, and assess gestational age prior to an abortion.73 This would have been particularly important in rural hospitals, like in Moularès, where a doctor was not always present. Parent also notes that there was no animatrice, a woman who would “motivate and instruct women and visit them in their homes,” at the hospital.74 This meant that the sage-femme had even more responsibilities. Fatma Gargouri is described in Dr. Parent’s study as la responsable of the family planning center, suggesting that she also undertook management or administrative duties at the center. Both women would have bridged the gap between Western biomedicine and local tradition, ensuring that women in their communities had access to family planning care.

Women also exchanged information between each other. Information about family planning circulated by word of mouth in Southern Tunisia, according to Dr. Leperlier. This certainly increased the population’s familiarity with the center and the services it provided. It was also a means for misinformation to spread. As Dr. Leperlier explains, sharing information in this manner did not allow for much detail to be communicated to every person who heard about the family planning center. Furthermore, the family planning center did not have enough personnel to adequately inform every person who visited the center; “des informations concernant le Planning Familial sont transmises de bouche à oreille, par les parents, amies ou voisines, les femmes étant pour la plupart illettrées et le personnel étant insuffisant pour donner de façon répétée, à chacune, les explications longues et précises qui seraient nécessaires, (en moyenne, soixante femmes se présentent à la consultation hebdomadaire).”75 However, this also indicates that Tunisian women reclaimed, in a way, some autonomy over their reproductive health by sharing information and, quite possibly, by warning other women to avoid unpleasant visits to the family planning center that so many other women, like the ones described in Angel Foster’s work, had experienced. It would be some time before Tunisian women had an opportunity to openly advocate for themselves. Most recently, Tunisian women worked together to integrate women’s rights protection into the new Tunisian constitution in 2014.76

Conclusion

Although there is a rich body of scholarship on Tunisia’s family planning project, particularly because it was the first of its kind in the region, this article has attempted to contribute to a key aspect of the legacy of Western influence in the medical field in North Africa. Many other studies have shown that the family planning project in Tunisia did not serve the interests of the local population and that the medical system in Tunisia instead continued to serve certain colonial functions, namely population growth and population control after its independence. My study demonstrates that this colonial mentality was even present in the minds of the French medical students that worked in hospitals in Tunisia in order to complete their thèse pour le doctorate en médecine.

Though this article is based on the writings of only two French medical students, their observations are indicative of the language that was used in medicinal education in France regarding former colonies and former colonial subjects. Both Dr. Parent and Dr. Leperlier’s studies were guided, edited, and approved by a team of medical professors based in France. Their analyses would have been guided with varying degrees of intervention by French doctors that were influenced by colonial ideologies that continued to exercise paternalistic and developmentalistic attitudes long after the end of the French empire. These professors would, in turn, have certainly been impacted by the reports of their students who had been sent abroad, thus reiterating the notion that French intervention in former colonies was necessary.

These theses were publicly defended in front of members of the university community and any members of the public who chose to attend their soutenances. The committees of professors that reviewed them and their colleagues at the faculté de médecine at Pitié-Salpêtrière and Xavier-Bichat are listed in the acknowledgment sections of the theses. Though they reflect the mentalities of only two medical students, these theses implicate a larger system that worked to continue the colonial mission into the late 20th century.

Notes

  1. David Arnold, Colonizing the Body: State Medicine and Epidemic Disease in Nineteenth Century India (University of California Press, 1993), 9-10. ⮭
  2. Shula Marks, “What is colonial about colonial medicine? And what has happened to imperialism and health?,” Social History of Medicine: the Journal of the Society for the Social History of Medicine 10, no. 2 (1997): 206-207. ⮭
  3. See, for example, Benedetta Calandra and Helen Rodriguez-Trias’ work on population control and birth control experiments on Puerto Rican women. Benedetta Calandra, “’100 million people reading and speaking Spanish are anxious to have your message’: Margaret Sanger in Puerto Rico (1925-1960),” Contemporanea, Rivista di storia dell’800 e del’900 no. 3 (2018,): 351-376; Barbara Bair and Susan E. Cayleff, (forward by Helen Rodriguez-Trias), Wings of Gauze: Women of Color and the Experience of Health and Illness (Wayne State University Press), 1993. ⮭
  4. In the Francophone context, Françoise Vergès’ research explains that overpopulation of former colonies was a national concern for French politicians and medical professionals. In the 1970s, French doctors had performed thousands of illegal abortions in the Reunion without patients’ consent while simultaneously collecting payments from the French Social Security, despite the fact that this, too, was illegal at the time. Vergès, The Wombs of Women: Race, Capital, Feminism. (Duke University Press, 2020), 2-3. ⮭
  5. Vergès, The Wombs of Women, 1. ⮭
  6. In Decolonizing 1968: Transnational Student Activism in Tunis, Paris, and Dakar, Burleigh Hendrickson outlines the international collaborative efforts of student activists in Tunisia, France, and Senegal that worked against Bourguiba’s one-party nation-building solution in the post-colonial era. Burleigh Hendrickson, Decolonizing 1968: Transnational Student Activism in Tunis, Paris, and Dakar (Cornell University Press, 2022). ⮭
  7. Jennifer Johnson, “The Origins of Family Planning in Tunisia: Reform, Public Health, and International Aid.” Bulletin of the History of Medicine 92, no. 4 (2018): 667. ⮭
  8. Kenneth J. Perkins, A History of Modern Tunisia (Cambridge University Press, 2004). ⮭
  9. Perkins, A History of Modern Tunisia, 161. ⮭
  10. Hendrickson, Decolonizing 1968, 8. ⮭
  11. Jennifer Johnson, “New Directions in the History of Medicine in European, Colonial and Transimperial Contexts.” Contemporary European History 25, no. 2 (2016): 399. ⮭
  12. Johnson, “The Origins of Family Planning in Tunisia,” 665, 680, 687. ⮭
  13. Amy Aisen Kallander, Tunisia’s Modern Woman: Nation-Building and State Feminism in the Global 1960s (Cambridge University Press, 2021), 87. ⮭
  14. Kallander, Tunisia’s Modern Woman, 101. ⮭
  15. Kallander, Tunisia’s Modern Woman, 114. ⮭
  16. Johnson, “New Directions,” 399. ⮭
  17. Medical students often wrote their theses based on their experiences working in hospitals and family planning centers in France and abroad as part of their medical training. ⮭
  18. See, for example, Nicolas Bancel, Pascal Blanchard, and Dominique Thomas, eds., The Colonial Legacy in France: Fracture, Rupture, and Apartheid, trans. Alexis Pernsteiner (Indiana University Press, 2017). ⮭
  19. Matthew Connelly, Fatal Misconception: The Struggle to Control World Population (The Belknap Press of Harvard University Press, 2008), 13-14. ⮭
  20. Connelly, Fatal Misconception, 5. ⮭
  21. Ivan Norman Mensh, “French Medical Education: Years of Change,” Journal of Medical Education, vol. 53 (September 1978): 742. ⮭
  22. M. Bouzidi and M. Jones describe how the family planning center in El Kef, another rural area of Tunisia, was established in 1970 and provided infant care but one of the primary goals of the Dutch-run center was to get half of women of childbearing age to use family planning services (in the form of intrauterine devices or birth control pills). M. Bouzidi, and M. Jones, “Family planning through child health: a case study of El Kef project in Tunisia,” JOICFP review no. 9 (1985): 12-17. ⮭
  23. I refer to the thèses de doctorat of Drs. Bittoun (1982), Burellier-Berthelot (1979), and Pitolet-Rabiller (1982), all of which are on contraception and abortion in France (mainland Europe), as points of comparison for Dr. Parent and Dr. Leperlier’s studies. ⮭
  24. Gilles Manceron and Alexis Pernsteiner, “School, Pedagogy, and the Colonies (1870–1914),” in Colonial Culture in France since the Revolution, eds. Pascal Blanchard et al. (Indiana University Press, 2014), 130. ⮭
  25. Catherine Leperlier (née Sautier) (médecin), “Planning familial dans le Sud tunisien” (Université Pierre et Marie Curie Paris VI : Faculté de Médecine Pitié-Salpêtrière, 1978), 10. ⮭
  26. Leperlier, “Planning familial dans le Sud tunisien,” 10. ⮭
  27. Yves Gérard Marie Parent, “Une expérience réussie de Planning familial : La Tunisie” (Université de Paris VII : Faculté de Médecine Xavier-Bichat, 1985), 122-123. ⮭
  28. Leperlier, “Planning familial dans le Sud tunisien,” i-iii; Parent, “Une expérience réussie de Planning familial : La Tunisie,” i-x. ⮭
  29. Leperlier, “Planning familial dans le Sud tunisien,” iii, and Parent, “Une expérience réussie de Planning familial : La Tunisie,” v, vii, viii. ⮭
  30. Leonard V. Smith, French Colonialism: From the Ancien Régime to the Present (Cambridge University Press, 2023), 1–5. ⮭
  31. Georges Balandier and Jacques Jérôme Pierre Maquet, Dictionary of Black African Civilization (Leon Amiel, 1974), 7. ⮭
  32. Smith, French Colonialism, 73. ⮭
  33. Amelia H. Lyons, The Civilizing Mission in the Metropole: Algerian Families and the French Welfare State During Decolonization (Stanford University Press, 2013), 17. ⮭
  34. Lyons, The Civilizing Mission in the Metropole, 19. ⮭
  35. Kallander, Tunisia’s Modern Woman, 91. ⮭
  36. Parent, “Une expérience réussie de Planning familial : La Tunisie,” 12. ⮭
  37. Parent, “Une expérience réussie de Planning familial : La Tunisie,” 15. ⮭
  38. Elisa Camiscioli, Reproducing the French Race: Immigration, Intimacy, and Embodiment in the Early Twentieth Century (Duke University Press, 2009), 19, 55. ⮭
  39. Leperlier, “Planning familial dans le Sud tunisien,” 8. ⮭
  40. Leperlier, “Planning familial dans le Sud tunisien,” 8. ⮭
  41. Leperlier, “Planning familial dans le Sud tunisien,” 10. ⮭
  42. Leperlier, “Planning familial dans le Sud tunisien,” 20. ⮭
  43. Parent, “Une expérience réussie de Planning familial : La Tunisie,” 120. ⮭
  44. Parent, “Une expérience réussie de Planning familial : La Tunisie,” 117-120. ⮭
  45. Parent, “Une expérience réussie de Planning familial : La Tunisie,” 120-121. ⮭
  46. Alec G. Hargreaves, Multi-Ethnic France: Immigration, Politics, Culture, and Society, Second Edition (Routledge, 2007), 21. ⮭
  47. Historian Jennifer Boittin describes interwar Paris as a colonial metropolis and historian Pap Ndiaye traces the hidden histories of Black people in Hexagonal France over several centuries, countering the national History that slavery never touched mainland France. Jennifer Anne Boittin, Colonial Metropolis: The Urban Grounds of Anti-imperialism and Feminism in Interwar Paris (University of Nebraska Press, 2010). ⮭
  48. James R. McDonald, “Labor Immigration in France, 1946-1965,” Annals of the Association of American Geographers 59, no. 1 (1969): 116–117.  ⮭
  49. Elise Franklin, “Defining Family, Delimiting Belonging: Algerian Migration after the End of Empire,” Gender & History 31, no. 3 (October 2019): 681. ⮭
  50. Connelly, Fatal Misconception, 181. ⮭
  51. Danièle Lochak, “Les circulaires Marcellin-Fontanet,” Hommes et migrations : Revue française de référence sur les dynamiques migratoires 1330 (2020): 15. ⮭
  52. Hargreaves, Multi-Enthnic France, 51. ⮭
  53. Hargreaves, Multi-Enthnic France, 21. ⮭
  54. Connelly, Fatal Misconception, xi. ⮭
  55. Leperlier, “Planning familial dans le Sud tunisien,” 53. ⮭
  56. Leperlier, “Planning familial dans le Sud tunisien,” 52. ⮭
  57. Johnson, “The Origins of Family Planning in Tunisia,” 672. ⮭
  58. Leperlier, “Planning familial dans le Sud tunisien,” 45. ⮭
  59. Leperlier, “Planning familial dans le Sud tunisien,” 44. ⮭
  60. Leperlier, “Planning familial dans le Sud tunisien,” 30. ⮭
  61. Johnson, “The Origins of Family Planning in Tunisia,” 680, 687. ⮭
  62. Kallander, Tunisia’s Modern Woman 100. ⮭
  63. Johnson, “The Origins of Family Planning in Tunisia,” 688-689. ⮭
  64. Angel M. Foster, “Women’s Comprehensive Health Care in Contemporary Tunisia” (doctoral thesis, St. Antony’s College, Oxford, 2001): 84-85. ⮭
  65. Leperlier, “Planning familial dans le Sud tunisien,” 53. ⮭
  66. Leperlier, “Planning familial dans le Sud tunisien,” 53. ⮭
  67. See, for example, Gisèle Halimi’s group Choisir and the often-cited rallying cry of “Si je veux, quand je veux” (“If I want, when I want”) used by French feminist groups in the 1960s and 1970s. ⮭
  68. Parent, “Une expérience réussie de Planning familial : La Tunisie,” 108. ⮭
  69. The theses of Drs. Bittoun, Bureillier-Berthelot, and Pitoilet-Rabiller all include direct quotes from their patients. Other studies, like that of Dr. Abdoul Carime-Nishat, include summaries or indirect quotes from patients. Nicole Jarrige Bittoun, “Contraception et adolescence : expérience vécue dans un centre de planification ou d’éducation familiale de la banlieue parisienne” (Paris V, Necker-Enfants malades, 1982), N° de thèse: 104; Marie-Josèphe Burellier-Berthelot, “L’Avortement thérapeutique : Une décision difficile – à propos de trente-six observations d’avortement thérapeutiques au CENTRE HOSPITALIERE de FIRMINY entre janvier 1978 et décembre 1979” (Université de Saint-Étienne U.E.R. de médecine, 1980); Brigitte Pitolet-Rabiller, “Enquête sur la contraception chez les adolescentes de moins de 18 ans: travail réalisé au centre du M.F.P.F. de St-Étienne, avril 1981-septembre 1981” (Méd.: Saint-Étienne, 1982), N° de thèse: 66; Abdoul Carime-Nishat, “Islam et pratique de l’avortement (I.V.G) à Paris” (Université Paris VII: Faculté de Médecine de Paris Lariboisière Saint-Louis, 1984). ⮭
  70. Kallander notes one example of an American Peace Corps volunteer who tried, and failed, to share information on contraception in cafés in Maktar but he did not speak the appropriate dialect of Arabic to achieve his goals (Kallander 98). ⮭
  71. Foster, “Women’s Comprehensive Health Care in Contemporary Tunisia,” 82. ⮭
  72. Irene Maffi, “Governing Reproduction in Post-revolutionary Tunisia: Contraception, Abortion and Infertility,” Medical Anthropology: Cross-Cultural Studies in Health and Illness 41, nos. 6-7 (2022): 690. ⮭
  73. Selma Hajri and Hedia Belhadj, “The role of midwives in first-trimester abortion care: A 40-year experience in Tunisia,” International Journal of Gynecology and Obstetrics 150, Suppl. 1 (2020): 46. ⮭
  74. Parent, “Une expérience réussie de Planning familial : La Tunisie,” 23. ⮭
  75. Leperlier, “Planning familial dans le Sud tunisien,” 30. ⮭
  76. See, for example, Imen Yacoubi, “Sovereignty from Below: State Feminism and Politics of Women against Women in Tunisia,” The Arab Studies Journal 24, no. 1 (2016): 254–74. ⮭

Hannah Olsen is a PhD candidate in French and Francophone Studies at Michigan State University. She also holds a Graduate Certificate in Women’s and Gender Studies from the Center for Gender in Global Context at Michigan State University. She is the 2023-2024 recipient of the Bourse Jeanne Marandon from the Société des professeurs français et francophone d’Amérique.