In this week’s World of Genomics, we’re off to Tunisia. The northernmost country in Africa, Tunisia is one of the most popular tourist destinations on the continent and has a visibly rich history, complemented by ancient stone age ruins and historically significant temples and mosques. Today, the country is also famous for its place in the filmmaking world – for instance, large parts of the Star Wars films were shot in Tunisia.
Population of Tunisia
Tunisia is the northernmost country in Africa and has a long coastline along the Mediterranean Sea. It has land borders with Algeria to the west and Libya to the southeast. Tunisia has a varied landscape, with part of the Atlas Mountains situated in the country. Northern parts of the Sahara Desert also lie within its territory.
Tunisia has been an agricultural area since 5000 BC and settlers found a home in the country for precisely this reason. The earliest historical records imply that the first people in Tunisia were Berber tribes – indigenous north African individuals. However, Phoenicians settled in the region in the 12th century BC and founded the city of Carthage, one of the world’s most important historical trading hubs. Carthage eventually became a civilisation in its own right, before being conquered by the Roman Empire in 146 BC.
Over the centuries, the region now known as Tunisia underwent various conquests, including by Arab Muslims in the 8th century. This led to significant Arab immigration into the country; their influence on Tunisian culture remains to this day. Subsequent conquests were by the Ottomans and the French, the latter of which occurred after the nation declared itself bankrupt in the 19th century. In the later years of World War II and in the decade following, there was a struggle for autonomy in the region. The nation eventually declared its independence from the French in 1956.
Today, the country is a tourist hub and is also seen as a gateway for immigration from Africa to Europe.
Geographic and Population Statistics
- Land area: 163,610 km2
- Gross domestic product (GDP):
- Total: $49.8 billion (2022)
- Per capita: $4,071 (2022)
- Population size: 11.8 million (2020)
- Birth rate: 16 per 1000 (2021)
- Death rate: 8 per 1000 (2021)
- Infant mortality rate: 14 per 1000 (2021)
- Average life expectancy: 74 (2021)
- Male: 77 (2021)
- Female: 71 (2021)
- Ethnicity: 98% Arab, 1% Berber, 1% other.
Tunisia has provided its citizens with universal healthcare ever since its independence in 1956, although the system has been subject to various reforms since. In fact, healthcare remains a high priority in the country and was highlighted in the nation’s new constitution in 2014.
Tunisia operates a publicly funded health system known as CNAM. It is mostly centrally administrated and provides healthcare coverage to around 80% of the population. CNAM is funded through taxation and, since 2010, mandatory contributions equal 6.75% of an individual’s income – 2.75% from the employee and 4% from the employer. Through CNAM, patients can opt to obtain treatment through public or, for some treatments, private health providers, before applying for reimbursement. However, certain healthcare practices require the individual to make co-payments, which were increased to 20% in the late 1990s. These payments, alongside other out-of-pocket contributions including private insurance, now make up over a third of Tunisia’s overall health expenditure.
For individuals not covered by CNAM, including those with low income, financial provisions can be made. Moreover, some illnesses are covered for all patients regardless of their CNAM contributions. These provisions mean that around 88% of the nation have access to healthcare.
There is also relatively good hospital infrastructure in the nation. However, there is a discrepancy between the care available in rural versus urban areas, and many facilities are outdated and underfunded.
The private health sector operating in Tunisia is significant; around 50% of practitioners work in the private sector and 25% of the nation’s hospital beds are found in private facilities.
The leading causes of death in Tunisia are complications from diabetes, cerebrovascular diseases and, since 2020, COVID-19.
An ageing population and increasing rates of non-communicable diseases (NCDs) are at the forefront of Tunisian health priorities. As of 2017, NCDs accounted for nearly 90% of disability adjusted life rates. Among the causes of these NCDs are obesity and tobacco use.
Obesity has increased significantly over the last two decades, and in 2016 over a quarter of Tunisian adults and 8.5% of children were obese. 25% of children were overweight to some extent. However, the country has significantly decreased the rates of childhood wasting – that is, malnutrition and low weight – since the early 2000s, and now only 2.1% of children fall into this category.
Overall, around 25% of adults in Tunisia smoke, and this number rises to 50% when looking only at males. It is thought that tobacco use contributes to around 20% of Tunisian deaths. The World Health Organisation have worked with Tunisia to create and uphold Sustainable Development Goals that should see the use of tobacco and other harmful behaviours decrease, subsequently reducing the burden of NCDs by 2030. Part of the action plan includes the use of graphic images on cigarette packets.
Tunisia does not generally have problems with alcohol consumption given the religious and cultural views of most of the population. However, a 2019 study suggested that some adolescents may seek out alcohol as an impulsive and rebellious behaviour.
Certain cancers are highly prevalent in Tunisia, and a 2023 investigation by the World Health Organisation suggested that a high number of these diseases and related deaths could be attributed to low levels of physical activity in the population.
Genomic Medicine Capabilities
Genetic diseases are highly prevalent in Tunisia, attributed primarily to advanced maternal age and, historically, a high number of consanguineous marriages (that is, marriage between relatives). These include chromosomal abnormalities and metabolic disorders. Despite these problems, genomic medicine services can be difficult to access and are only available in a few Tunisian cities. Moreover, the true incidence of these diseases remains unknown due to deficiencies in screening programmes. A 2021 systematic review suggested that of the over 500 genetic diseases identified in Tunisia, less than 30 have reliable incidence records. Tunisia has patient registries for only three common ailments – Fanconi Anemia, Gaucher disease and bleeding disorders.
Some pre- and post-natal genetic screening tests are available through the public health service. These include amniocentesis for chromosomal disorders, an invasive test that is covered fully by CNAM. However, these tests are not mandatory. A robust newborn screening initiative to test for genetic disorders has not yet been introduced in Tunisia, but a number of infants have been involved in pilot studies for research purposes.
Due to the high rate of autosomal recessive disorders and consanguineous marriage in Tunisia, premarital genetic counselling is mandatory for those who have a family history of genetic disease. This has been the case since 1995 and it is fully covered by the national health insurance scheme.
To improve the genomic medicine landscape in the country, a genetics unit at Mongi Slim hospital has been established. Similarly, some universities and research institutes are also providing genetic medicine services.
ADAGE Project: This project was set up in response to the COVID-19 pandemic and aims to sequence both viral and human genomes, to understand host-pathogen interactions. The results will be used to inform precision medicine approaches.
European Genome-Phenome Archive – Tunisian and Moroccan dataset: A number of Tunisian and Moroccan genomes are held within the European Genome-Phenome Archive. The purpose of the archive is to allow access to genomic data for biomedical research purposes.
ITHANET: ITHANET is a Euro-Mediterranean project that explores thalassemia and haemoglobinopathies – a range of genetic diseases that are prevalent in Tunisia. The project is led by experts from Tunisia and 15 other European or Mediterranean countries.
SNP Genotyping Study in the Tunisian Population: This genome-wide SNP genotyping project aimed to identify breast cancer risk variants that are prevalent in the Tunisian population, combatting the lack of North African genomic data.
Notable Organisations and Institutions
Pan-African Bioinformatics Network: The network’s full name is the Pan-African Bioinformatics Network for Human Heredity and Health consortium, typically shortened to H3Africa. The network was set up to develop the bioinformatics and genomic research capabilities of African nations through extensive collaboration. They focus not only on infrastructure development but also training and education.
Institut Pasteur of Tunis (IPT): A branch of the infamous Institut Pasteur International Network, the IPT was founded in 1893. It was the research base of Nobel Prize winner Charles Nicolle, who won the 1928 prize for Medicine or Physiology for his work on parasitic infections. Today, the institute is part of H3Africa, and staff conduct research in a variety of biomedical and health-based topics.
Mongi Slim Hospital: Based in Al Marsa, Mongi Slim Hospital has a dedicated department for genetic diseases, opened in 2017. It is one of the only departments of its kind in Tunisia.
Habiba Bouhamed Chaabouni (1953-): Now a professor at Tunis University, Chaabouni was responsible for the introduction of genetic counselling services in Tunisia and has carried out significant research into genetic diseases in the nation. Her work was integral in realising the impact of consanguineous marriages in Tunisia. Since the 1990s, she has worked to encourage uptake of prenatal screening.
Sophien Kamoun (1965-): Tunisian-born Kamoun is now a professor at the University of East Anglia. His work has focused primarily on plant genetics, for which he has received numerous accolades and awards.
Charles Nicolle (1866-1936): Although Nicolle was French, his groundbreaking research was carried out primarily in Tunisia. He directed the IPT and solidified its place as a hub for biological research. He focused primarily on infectious disease and vaccine development, winning the 1928 Nobel Prize for his work on typhus.
Future Genomics Landscape
Healthcare is at the heart of Tunisia’s constitution yet has fallen short in many areas. However, with the development of facilities such as the genetics unit at Mongi Slim Hospital and the introduction of Sustainable Development Goals, the country is on track to improve its healthcare outlook significantly in the coming years.
Tunisia, alongside many other African nations, is making great progress in increasing its genomics output. Historically, little genetic data existed for those not of European descent, hindering the application of genomic medicine globally. However, initiatives such as H3Africa will lead to more tailored genetic evidence for use in African populations, including Tunisia, and will help to develop the skills of local scientists.
Precision medicine is also an up-and-coming field in Tunisia, not least because of the nation’s work on COVID-19 genomics. Additionally, the Columbia Global Center, Tunis (a branch of Columbia University, New York) is focused on increasing research output. Most recently, the Center has hosted a ‘Precision Medicine Academy’. With Tunisian scientists developing their own skills, alongside global assistance, Tunisia should be able to massively increase its genomic medicine capabilities in the not-too-distant future.
Elloumi-Zghal H, Chaabouni Bouhamed H. Genetics and genomic medicine in Tunisia. Mol Genet Genomic Med. 2018 Mar;6(2):134-159. doi: 10.1002/mgg3.392. PMID: 29663716; PMCID: PMC5902400.
Encyclopaedia Britannica. 2023. Tunisia. Available at: https://www.britannica.com/place/Tunisia
Mezzi N, Messaoud O, Mkaouar R, Zitouna N, Romdhane S, Abdessalem G, Charfeddine C, Maazoul F, Ouerteni I, Hamdi Y, Zaouak A, Mrad R, Abdelhak S, Romdhane L. Spectrum of genetic diseases in Tunisia: Current situation and main milestones achieved. Genes (Basel). 2021 Nov 19;12(11):1820. doi: 10.3390/genes12111820. PMID: 34828426; PMCID: PMC8617973.
UK Government. 2023. Health – Tunisia travel advice. Available at: https://www.gov.uk/foreign-travel-advice/tunisia/health
World Bank. 2023. Indicators. Available at: https://data.worldbank.org/indicator