Praise be to God, in whose hands is weakness and strength, and the creation of sickness and medicine, who created bodies for atonement of sin, who brings recompense and averts disaster, who knows what is clear and what is hidden, and what is in all hearts. Peace be upon his noble Prophet, his great healer, Muhammad, especially God's beloved, but universal in his mission of call, root of remedy, pole of the circle of his wisdom, source of cure, free of whim in the eloquence of his word, as stated in Sura ‘al-Najma idha hawa’. Peace be upon his pure family and on his venerable companions, the stars of guidance and the base of piety.

When the chain of possibilities was linked to the presence of God, the Blessed and Almighty, thus order in every kingdom was organized by the presence of an amir [ruler] or khalifa as the base of power and security against the mishaps of time; thus God granted such an amir to the land of Tunis and Africa; a man from the select, shadow of justice who created for the multitudes kind deeds which he brought forth into being. He prevented by his policy the ruses of those of injustice and tyranny; he cleared the roads of fear and enmity with the awe of his policies, until men and boys, and women and girls, traveled upon them. How often he hit those who hit him with the accurate arrow of his bow.

Throughout the years of the plague and cholera epidemics, Muslim doctors continued to serve the majority of the population. Most were unlicensed empirics who had learned their trade from apprenticeships or experience. Until the early 1860s, however, the amin al-atibba’ continued to issue ijazas to applicants, usually in exchange for written proof of experience and a small fee. The amin continued in his role as head of the maristan, which remained the only Muslim hospital in Tunis. The authority of the Muslim amin diminished in the 1860s and 1870s until the last non-European-trained amin died in 1876. But the choice of medical systems had long become clear – European medicine was officially to prevail. The only questions were under whose authority and in what form. Were the reforms to take place under beylical authority or under a colonial government, and were the medical authorities to be European-trained Muslims or Europeans themselves? And if they were to be the latter, would they be Italian, British or French officials?

Transition from Muslim to European medical authority

The indigenous medical institutions continued to function until the middle of the nineteenth century. The bey's European doctor was still responsible only to the court while the Muslim amin al-atibba’ or the bey himself was in charge of licensing the indigenous doctors. Ijazas are preserved in the government archives issued by Ahmad Bey in 1840 to indigenous doctors; the last one is dated 1861 and was issued by Muhammad al-Sadiq Bey.

Social historians have seized upon epidemics and their effects on people's lives as fundamental causes or ‘motors of human history’ and as unique sources of historical insight. In the case of Tunisia from 1780 to 1900, epidemics were indeed of major significance, being barometers of social change, catalysts of medical reform, and even justification for political power. But contrary to the analyses of many contemporary observers and modern historians, the epidemics did not cause the economic destabilization that characterized the history of nineteenth-century Tunisia.

Mortality and history

Following the severe plague of 1785–6, the Tunisian economy apparently fared well, and there was no political instability that can be associated with the high mortality caused by the disease. The economic recession that followed the 1818–20 plague resulted from complex international commercial and political developments that reversed Tunisia's trade advantages. In the 1830s and 1840s, a succession of unequal trade treaties imposed by militarily superior European powers led the beys to instigate multifaceted reforms that stressed expansion of their own armed forces. Increased taxes to support the reforms and to redress public (governmental) loss of commercial revenue further distorted the indigenous economy. The agricultural recession that accompanied the 1849–50 cholera epidemic was largely a consequence of overtaxation and lack of investment capital. Immediately following the 1856 epidemic, agriculture prospered due to regularized taxation and favorable weather. In 1867–8, the cholera and typhus epidemics precipitated bankruptcy and foreign takeover of Tunisian finances.

In the 1860s economic, political, social, and ecological crises ricocheted off one another in ominous succession. In the past Tunisia had weathered epidemics but this time new outbreaks of diseases in the context of the existing economic imbalance resulted in permanent damage to the established political order.

The weakness of the economy was exacerbated by new, European-imposed laws that removed the few remaining protections available to Tunisian commercial enterprises. Despite Muhammad Bey's conservatism, European interests in 1857 had induced him to promulgate a new charter, the ‘ahd al-aman (Fundamental Pact). The pact was essentially a bill of rights that was to become the basis of the 1860 constitution. Written by the French consul and rewritten by Bin Diyaf, the document gave Europeans the right to own land, to establish factories, and to practice free commerce. It abolished all legal protection for local products and industries. Rural qadis yielded their customary authority to newly created central criminal and commercial tribunals patterned after those of French civil law. Europeans were henceforth subject to local law, which was rewritten to give equal rights to all religions and nationalities. The consuls retained their extraterritorial rights, however, and continued to grant asylum not only to their conationals but also to Tunisians they chose to protect. The laws were adaptations of the Hatti Humayun and Hatti Sharif (tanzimat) Ottoman reform laws. Muhammad Bey ceremonially signed the pact, encouraged by the presence of a squadron of French and British warships moored off Tunis and Malta.

From the slave of god…the living king, our lord, Husayn Basha Bey, master of the kingdom of Tunis…to our ally, Cavalier Mathieu de Lesseps, consul general of France in Tunis:

Your letter reached us on 2 Rabi ‘Ithani 1244 [12 December 1828]. In it you referred to a letter from your country concerning the ten days’ quarantine which we ordered for all merchant ships coming to our country to save the people from outbreaks of disease. Your request was to remove the quarantine from merchant ships coming from your Mediterranean ports. We have considered your request and the answer is that we have ordered the ten days to protect the people. God Almighty gave us the duty to take care of their welfare and to protect them from contagious diseases.

It came to us from many authoritative sources that plague, yellow fever, and other diseases are spreading. Yellow fever is severe in Gibraltar and elsewhere. We know that merchant ships have contact with other ships at sea and in port so we ordered these ten days to protect the land and the people. As for the corsair ships with their long stays at sea, we ordered any corsair ship to return to its port of origin for twenty days and to carry a patent in its language in the hand of its captain, who must prove the ship had no contact with another at sea and visited no other port.

Today, walking up the hill on the main street of the old city of Tunis, one passes former Ottoman barracks, stately Arab villas closed off from the narrow lane by wooden gates, shops selling hand-woven carpets, perfumes, and inlaid metalware. The street is full of jostling, milling crowds, pressing their way to work or to shops. The Great Mosque, built in its present form in the ninth century by the Aghlabid rulers, faces a row of herb shops where medicines are sold. The shops are colorful, with jars of spices, herbs collected in the countryside, camphor, and imported metallic compounds. Turning to the right, one crosses to another busy street, Nahj al-Qasaba, or rue de la Kasbah, where, at number 101, the old maristan (hospital) of Tunis is located. Continuing up the street, one suddenly enters a main square around which is the Dar al-Bey, or bey's palace, built by Hamuda Bey al-Husayni (1782–1814) and now the site of the prime ministry. Across the square is the newer Muslim hospital, the Mustashfa Sadiqi, and at the top the Kasbah (citadel).

Two hundred years ago Tunisia was ruled from the Kasbah by the Husayni dynasty of beys, who had become Arabized and who paid formal allegiance to the Ottoman sultan and ruled independently.

In 1830 France occupied Algiers and in the same year forced a new commercial treaty on the bey of Tunis. This treaty reinforced the ban on privateering and furthered the internationalization of the Tunisian economy. Under its provisions European governments with interests in Tunisia could establish consulates anywhere in the country regardless of the bey's wishes, government monopolies on indigenous industries were abolished, and European merchants were free to trade directly with Tunisian subjects, eliminating the necessity of purchasing export permits from the Tunisian government while European consuls retained the right to judge their own nationals. The treaty effectively nullified the advantages of Hamuda Bey's commercial policies that had stimulated and protected indigenous commerce during his reign. Furthermore, certain provisions in the treaty made France a ‘special commercial partner’ to the bey on highly advantageous terms to France, and rival Italian and English entrepreneurs were eager to join in such a partnership.

During this era of European commercial expansion, relationships between European and Tunisian authorities changed not only in political and economic spheres but in institutions of medicine and public health. In the eighteenth century, the beys had complete control over quarantining but by the 1830s, European consuls assumed management. This was a new trend of shifting responsibilities from Muslim to European hands. Later in the century European colonial historians were to claim that their consuls had to step in to guide Tunisia in quarantine procedures because of the beys’ heedlessness in the face of epidemic diseases.

Contemporary observers frequently offered the recurring epidemics of the nineteenth century as an explanation for Tunisia's increasing weakness. Close analysis suggests that the sharp demographic decline cited by contemporaries and later by historians did not in fact take place. Mortality rates, however, confirm the importance of the epidemics as major historical events that, because of the context of the times, did lead to new forms of medicine and public health.

Population size

Contemporary estimates of the population of Tunisia during the nineteenth century range from 800,000 (Pellissier de Reynaud in 1853) to 5,000,000 (Duveyier in 1881); most fall within a range of one to two million. Verification of such estimates is hazardous; the lack of systematic method in collecting the figures tends to disqualify them. Most were at best obtained after a quick journey on horseback through rural regions and quick tours through towns where dwellings were haphazardly counted. The depopulation that witnesses ascribed to epidemic crises can be understood in part as a result of temporary migrations. At times, the migrations were to the cities in search of famine relief from food distribution centers. Settled and seminomadic groups often sought escape from increasingly heavy taxation, government repression, or bad living conditions by migrating toward Libya or Algeria. In 1853 Pellissier de Reynaud observed that‘ settled peoples had shown a great tendency to emigrate toward the tribes and their relative autonomy…. If the government does not find a remedy for this, it will find itself in a very embarrassing situation.’

Method and approach

At the beginning of the nineteenth century, Louis Frank, a French doctor practicing in Tunis, found that he had to stay on good terms with the Muslim chief of physicians to practice European medicine without difficulties. At the end of the century, Hamda b. Kilani, a Muslim doctor and son of the former chief of physicians of Tunis, found that he had to be classed as médecin toléré (a second-class medical status) by the French medical authority to practice Arabic medicine at all. Why the change in power?

The answer emerges in the long struggle between Arabic and European medicine that accelerated with European economic expansion. The intricacies of the medical confrontation are best seen through the history of the major epidemics that struck the people of Tunisia between 1780 and 1900. The epidemics threatened the lives of vast numbers of people and called forth responses from all levels of society: ordinary people, medical personnel, religious authorities, and the political and commercial elite. The process of medical change revealed by the epidemics can only be studied meaningfully against the political, social, and economic realities of the times.

In Tunisia, the shift from Arabic to European medicine was a fundamental part of the colonial experience. The suspicion of the Muslim elite that European science contained superior sources of knowledge and therefore of temporal power led them to reconsider long-held medical concepts and to undertake a reform program with both enthusiasm and misgiving.