This article examines the significance of EMRs in enhancing care quality, highlighting ongoing initiatives in Tunisia to implement EMRs in public health facilities. It also addresses the challenges of EMR adoption and offers solutions for ensuring effective and responsible use of these crucial digital tools for improved patient care.

By Team Barr Al Aman

In today’s digital age, electronic health records (EHRs) [1] have become the cornerstone of modern healthcare systems. These systems go beyond merely digitizing patient files; they form the foundation of eHealth, fundamentally transforming the medical landscape. The World Health Organization (WHO) has underscored the numerous benefits of EHRs in its third global survey on eHealth, highlighting their critical role in enhancing healthcare service quality. As a result, many countries have implemented national eHealth strategies, particularly focusing on EHR deployment.

In Tunisia, the public health sector is embarking on a significant initiative to deploy Electronic Medical Records (EMRs) [2] across public health facilities. This project aims to reduce disparities in digitization among healthcare establishments and address the fragmentation of subsystems that generate patient data. In recent years, the implementation of Electronic Medical Records (EMR) has begun in several public hospitals, with Habib Thameur University Hospital leading the way, followed by other university hospitals. This initiative is steadily expanding to additional healthcare facilities, including six regional polyclinics, with the aim of establishing a unified patient file system. Pilot projects have also been launched in a district hospital and two primary health centers in the Hammamet region, as part of the “Essaha-Aziza” program, which focuses on digitizing primary healthcare services. Most recently, Jebiniana Regional Hospital [3] in Sfax has also adopted the EMR system.

At the heart of these efforts is the Ministry of Health’s IT Center (CIMS) [4], which plays a pivotal role in advancing eHealth in Tunisia. The center actively supports public health institutions in their digital transition while ensuring compliance with current security standards.

Enhancing Patient Care through EMRs

Electronic Medical Records (EMRs) are essential for establishing and organizing patient data governance, which encompasses the collection, sharing, storage, and security of medical information. Electronic Medical Records (EMRs) offer significant advantages over traditional paper-based systems by overcoming common limitations such as illegible handwriting, insufficient detail, the risk of document loss, and challenges in accessing patient information efficiently. The existence of multiple medical records across different departments and facilities often results in scattered and incomplete data, creating significant challenges during medical follow-ups.

The adoption of EMRs represents a transformative leap in medical data management. They streamline the identification and reporting of missing information through integrated alert systems that promptly notify users about data entry errors. By minimizing reliance on free text and employing standardized reference dictionaries, EMRs enhance data reliability and provide classification tools that allow healthcare providers to quickly retrieve information based on various criteria such as data type (clinical, biological, imaging), date, name, and condition type.

The integration and communication among various systems involved in a patient’s care pathway significantly enhance the comprehensiveness of patient data. This interconnection -known as interoperability- enables healthcare staff to collaborate effectively by providing seamless, real-time access to relevant information while ensuring confidentiality through customized access levels for providers.

As a result, clinicians gain a thorough and up-to-date view of a patient’s medical history, which is crucial for understanding their overall health status. This comprehensive perspective allows healthcare professionals to make more accurate diagnoses and informed decisions regarding treatments and care adjustments. Ultimately, improved care coordination minimizes disruptions in continuity of care.

EMRs serve as a holistic framework essential for both preventive care and chronic disease management. By facilitating better communication and data sharing, they contribute to improved patient outcomes [5].

For instance, EMRs are designed to minimize the risk of medical errors by providing alerts for potential mistakes based on medical histories, current treatments, and known allergies. This functionality helps prevent prescription errors and dangerous drug interactions while enhancing patient safety and reducing adverse events. Additionally, EMRs can flag critical values for clinical staff and detect duplicate tests or treatments, thereby reducing unnecessary healthcare costs and improving overall efficiency [6].

Major Obstacles to EMR Adoption in Public Healthcare Establishments

Despite their advantages, several obstacles hinder the widespread adoption of EMRs in public healthcare facilities. Budget constraints significantly slow down this process; high costs associated with procuring and maintaining EHR systems pose substantial financial challenges for many institutions striving to meet necessary technological infrastructure requirements.

Achieving seamless interoperability is one of the most significant technical challenges facing EMR adoption [7]. The diversity of information systems currently in use across healthcare facilities can impede progress towards this goal, making it difficult to integrate these disparate systems and ensuring that patient data can be easily shared across various settings. The integration process can be complex and time-consuming, often requiring significant technical expertise and resources. Healthcare organizations must navigate various data formats, protocols, and system architectures to facilitate effective data exchange between EMRs and other clinical information systems.

While there is consensus against reverting to paper records, transitioning from paper to digital records does not guarantee user acceptance [8][9].  This shift requires not only the adoption of new digital tools but also the transformation of long-standing practices, which can sometimes result in resistance from staff.

The adoption of EMRs is strongly influenced by users’ perceptions of the system’s expected performance and the effort required for its implementation. Various organizational factors [10] also play a critical role in shaping these perceptions- especially given the increasing workload on doctors. The situation is further complicated by healthcare professionals migrating to the private sector or abroad for better working conditions and higher salaries.

Additionally, a lack of awareness among stakeholders about the medical, ethical, and innovative challenges associated with data compromises commitment to addressing these issues.

Ensuring Responsible and Effective Engagement with EMRs

To foster responsible engagement with EMRs, careful planning and appropriate support are essential. This includes enhancing digital skills within the healthcare sector through targeted training programs tailored to various professionals’ specific needs. These programs should emphasize data governance issues and their ethical and medical implications, equipping healthcare providers to use digital tools responsibly and effectively.

Healthcare organizations should also conduct regular assessments of progress and challenges during EMR implementation. Evaluations should inform efforts aimed at improving on usability [11][12] and security within EMR systems. Thoroughly assessing the user experience [13] before making adjustments ensures that systems evolve according to healthcare professionals’ needs while incorporating user-friendly interfaces.

A user-centric approach to EMR design is essential to overcoming resistance [14] and ensuring successful implementation within healthcare organizations. By focusing on the needs of healthcare professionals and offering adequate support, organizations can create an environment that promotes effective engagement with EMRs. This approach not only enhances healthcare delivery efficiency but also improves patient outcomes.

Conclusion

As Tunisia embarks on the journey of healthcare modernization, the adoption of EMRs signifies more than a technological advancement; it represents a transformative step toward a more efficient and patient-centered healthcare system. By integrating these digital tools, Tunisia has the opportunity to improve the quality of care, achieve better patient outcomes, and align its healthcare standards with international best practices.

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References

[1] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8738989/#ref7
[2] http://www.santetunisie.rns.tn/fr/prestations/programme-de-d%C3%A9veloppement-de-la-%C2%ABsant%C3%A9-num%C3%A9rique%C2%BB-en-tunisie?start=3
[3] https://lapresse.tn/2024/12/14/tunisie-sante-lancement-du-dossier-medical-electronique-a-jebiniana/
[4] http://www.cims.tn/
[5] https://www.sciencedirect.com/science/article/abs/pii/S1386505619300255
[6] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8738989/
[7] https://www.ncbi.nlm.nih.gov/books/NBK551878/
[8] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4878018/
[9] Boonstra, Albert, and Manda Broekhuis. 2010. “Barriers to the Acceptance of Electronic Medical Records by Physicians from Systematic Review to Taxonomy and Interventions.” BMC health services research.
[10] https://pubmed.ncbi.nlm.nih.gov/20691097/
[11] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8068432/
[12] https://healthcare.utah.edu/press-releases/2023/09/when-electronic-health-records-are-hard-use-patient-safety-may-be-risk
[13] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8068432/
[14] Ben Hammouda, Seif, and Slim Hadoussa. 2018. “Projet e-santé Tunisie : étude des facteurs d’acceptation du Dossier Médical Informatisé (DMI) par les médecins auprès des hôpitaux.” Management & Avenir. https://www.cairn.info/revue-management-et-avenir-2018-4-page-15.htm

In this regard, it is crucial to consider territorial disparities in terms of both the characteristics of the populations and their health status, in addition to the geographical distribution of health services. For this purpose, a reliable and up-to-date data system providing precise geospatial information is required. This information will help produce the necessary indicators for analyzing disparities in access to care and identifying deficiencies.

Thus, public health authorities would have the ability to determine which areas require the most healthcare services and where resources should be allocated as a priority. This approach would effectively improve healthcare services management, with a focus on territorial planning and combating health inequalities.

Accessibility and utilization of healthcare services

Accessibility to healthcare is the ability of patients to obtain necessary care and medications from healthcare professionals when needed. In reality, access to healthcare remains constrained by various factors such as an insufficient healthcare supply and a shortage of healthcare personnel. Further, medical care costs are high and social coverage is limited. It is also important to note that disadvantaged populations frequently face mobility challenges that impede their access to healthcare.

The World Health Organization (WHO) has raised a major concern about limited healthcare access, affecting nearly half of the global population. This situation represents a crucial challenge for public health due to its complexity related to several critical aspects. On the one hand, it is essential to identify optimal locations for healthcare services. It is also essential to understand the correlation between current service locations and actual health needs. This analysis helps comprehend geographical disparities that may limit healthcare access, especially for rural and disadvantaged populations. On the other hand, it is crucial to identify the health needs of the population to efficiently allocate healthcare resources and meet population demands. This evaluation helps us recognize the most pressing health issues, and the most vulnerable population groups. In fact, targeted health policies ensure that resources are utilized efficiently while addressing the specific needs of a particular population.

Information management for healthcare access assessment 

Assessing healthcare access is essential to understand inequalities in healthcare provision and identify areas where healthcare is most needed. Any study of healthcare services accessibility and utilization must take into account several key factors, such as socio-economic variables, needs, supply, and demand.

A range of tools and methods are used to address healthcare planning issues. They provide management proposals that improve limited accessibility to healthcare service locations.

Health dashboards and health maps are highly useful tools for presenting health data in a simple and understandable manner. They provide general statistics on population health and well-being from different perspectives. They allow tracking the temporal evolution of various health indicators and highlighting disparities based on socio-economic levels, rural and urban environments, and local/regional health networks.

Combining these tools will provide a precise and comprehensive picture of healthcare accessibility in a particular country or region.

Often, a study of the available resources is conducted in order to characterize the service potential, both in terms of human and institutional resources, as well as material resources. An accurate count of healthcare facilities, healthcare equipment, and healthcare providers (general practitioners, specialists, nurses, etc.) can provide insight into healthcare distribution and disparities within it. This can be used to identify areas where healthcare is available and areas where it is scarce or insufficient.

In Tunisia, the national health service map “Carte sanitaire” provides statistics and a graphical representation of healthcare services distribution. This allows a clear visualization of their geographical spread at the level of each governorate.

In order to fully understand healthcare accessibility, we must look beyond healthcare provision evaluations and take into account inequities in access to care. It is therefore necessary to analyze the alignment between healthcare services and the served population, within the context of a healthcare system’s territorial planning policy. This approach facilitates the efficient planning and organization of material and human resources to improve healthcare access for all. This is regardless of geography or socioeconomic status.

However, to implement such analyses, having access to a robust and well-defined data system is crucial, allowing the collection of geolocated data related to socio-economic, environmental, epidemiological, and individual health factors. Statistical analysis must be conducted to identify all factors influencing the population’s healthcare needs. This will highlight the key factors contributing to healthcare access inequalities. It will enable the planning of effective interventions to address population health needs and ensure efficient resource distribution.

Recognizing the importance of data in assessing healthcare access is crucial. Organizations and public health authorities must integrate analytical approaches and rigorous statistical methods when considering strategies for healthcare service distribution. However, these approaches heavily rely on the availability of accurate data on the population, its health status, and environmental risks.

Data dependence poses a major challenge for specialists involved in in-depth surveys and spatial analyses. Therefore, it is essential to develop more comprehensive health information systems that efficiently collect, analyze, and share the necessary data. This will improve evaluation quality and develop more equitable and effective health policies.

The post Data challenges in healthcare access evaluation first appeared on Research Media.]]> https://www.researchmedia.org/data-challenges-in-healthcare-access-evaluation/feed/ 0 https://www.researchmedia.org/valueofhealthdata/ https://www.researchmedia.org/valueofhealthdata/#respond Fri, 28 Jul 2023 06:43:14 +0000 https://www.researchmedia.org/?p=5973   Manel Ben Fdilen, Meriem Ben Tarjem Several commonly observed pathologies in healthcare services, such as acute or…

 

Manel Ben Fdilen, Meriem Ben Tarjem

Several commonly observed pathologies in healthcare services, such as acute or chronic neurological and cardiovascular diseases, systemic diseases, and hereditary diseases, continue to present challenges in terms of diagnosis and patient orientation. These diseases have been extensively studied to constantly evolve management recommendations.

Despite advancements in prevention, diagnosis, treatment, and monitoring, these diseases still represent a public health problem due to their high frequency, multifactorial and clinical polymorphism, as well as their significant impact on morbi-mortality, and economic costs.

In Tunisia, the lack of national registries that establish the epidemiological profile of various diseases hinders our understanding and care protocol improvement. To address this, it is crucial to continuously update the data. This will enable the development of guidelines for diagnosis, treatment, and follow-up, while reducing healthcare burdens. By doing so, we can improve disease management and optimize healthcare resource allocation.

In this context, it is essential to emphasize the importance of health data in establishing national registries and their pivotal role in advancing scientific research and enhancing care quality. By doing so, we gain valuable insights that directly inform the development of effective health policies firmly rooted in current epidemiological information.

National Registries: An Essential Resource for Public Health Surveillance and Research in Tunisia

National registries are defined as “the continuous and comprehensive collection of individual-level data pertaining to one or more health events in a geographically defined population, for the purposes of surveillance, research, and evaluation in public health, by a team with appropriate expertise.”

The geographical definition of national registries encompasses several key aspects, such as the scope of diseases, medical specialty, population defined by age and sex, coding nomenclature, and data accessibility.

When determining the scope of diseases covered by the registry, consideration is given to the relevant medical specialties and domains pertinent to data collection. This ensures that the registry captures comprehensive information specific to the designated medical areas.

By defining the population in terms of age and sex, the registry provides precise demographic data. This allows for a better understanding of the characteristics of the population affected by recorded health events.

The registry’s coding nomenclature plays a vital role in organizing and analyzing recorded health events. It entails the use of a standardized classification system to assign specific codes. This facilitates data management, comparability, and interoperability across different registries and healthcare settings.

Lastly, data accessibility entails determining the appropriate access to recorded data, including the conditions and purposes for which it can be accessed. Striking the right balance is essential to sensitive data confidentiality and protection. It also enables authorized individuals and organizations to utilize the data for research, policy development, and initiatives aimed at improving healthcare.

In Tunisia, scientific societies play an essential role in managing registries by establishing the necessary policies and strategies for their implementation. These registries are specifically designed to address healthcare priorities, needs, and essential decision-making criteria. Furthermore, certain registries are part of national public health strategies, such as regional cancer registries. This demonstrates their importance in tackling major health challenges.

A concrete example is the Northern Tunisia Cancer Registry (NTCR), which was established by ministerial decree. The Epidemiology, Medical Informatics, and Biostatistics Department of the Salah Azaiz Institute was designated NTCR headquarters. These registries play a crucial role in providing a clear picture of cancer epidemiology in Tunisia. They allow for an accurate assessment, identifying existing disparities between genders and different regions of the country regarding cancer prevalence and access to care.

Furthermore, these registries play a crucial role in detecting epidemiological changes. They guide awareness strategies, individual or mass screenings, and cancer combat efforts. They also contribute to making well-informed decisions regarding patient management while fostering innovation in treatments, monitoring, and research.

However, despite progress, the epidemiological profile of many diseases is insufficiently covered by national health registries and remains unknown. It is in this context that the Tunisian Society of Cardiology and Cardiovascular Surgery initiated, for the first time in Tunisia, an international registry called “The Big 4 CVD Registry” (Africa and MENA). This registry aims to establish the epidemiological profile, improve management, and monitor therapeutic adherence for four major cardiovascular diseases: atrial fibrillation, heart failure, coronary insufficiency, and valvular heart diseases.

This ambitious initiative requires significant financial resources and expertise, but it promises to contribute significantly to scientific research by providing relevant data. It also highlights the fundamental role of coordination, both at the national and international levels, in developing health data for scientific research.

Data roles in health registry development

In order to ensure a comprehensive collection of information for registries, it is essential to draw upon different data sources. These sources include archives and hospital statistics, clinics, private practices, public or private analysis laboratories, autopsy reports and death certificates. The use of these diverse sources allows for a comprehensive and detailed view of health events in the population of interest. This increases the accuracy and relevance of established registries.

However, it is important that personnel responsible for data collection and registry creation receive adequate training and follow clear operational procedures. This is to ensure data quality. Meeting this requirement, however, necessitates the mobilization of significant human and financial resources.

To establish robust governance of this data, a national strategy for digital health development (e-health) is being developed. This strategy encompasses various initiatives, including medical records digitization. This modernization of the data management system will facilitate the collection of essential information for establishing registries. In addition, it reduces data loss risk.

Additionally, data protection is essential during registry development. A precise legal framework must govern the registry, ensuring information confidentiality, securing access to data, and regulating their use in other scientific research endeavors. It is also critical to control the distribution, dissemination, and sharing of this data. Certain registries are subject to legal obligations outlined in ministerial orders, with the primary objective of ensuring confidentiality, as is the case with the RCNT (Northern Tunisia Cancer Registry).

To ensure registry reliability, evaluation and certification committees are in place to guide researchers who wish to use the data. The National Health Evaluation and Accreditation Agency accredits several registries, ensuring compliance and reliability of collected information. This process aims to establish trust among users and promote ethical and responsible health data use.

The development of national and regional networks, as well as collaboration between scientific societies, healthcare institutions, the Ministry of Health, and the public and private sectors, plays a key role. On the one hand, this allows for quality and comparability standards for registries. On the other hand, it promotes collaboration among registries and facilitates data flow.

Therefore, institutes, healthcare organizations, and the Ministry of Health must commit to supporting and accrediting these registries. Their engagement is crucial to ensuring the success and sustainability of these initiatives, thus guaranteeing the reliability and value of the collected data.

 

In conclusion, it is highly advantageous to regularly update the national coverage of health registries in Tunisia. This would be done by assessing the range of pathologies they cover, and creating a national directory listing all accredited registries. This would guide researchers toward reliable data sources, facilitating research and analysis.

Moreover, it is essential to define and specify the data to be collected based on the specific missions of each registry. This approach rationalizes the budgetary, human, time, and effort resources invested in data collection. Interoperability between different databases and registries, as well as collaboration between the public and private sectors and national and international stakeholders, would be key factors in promoting registry data dissemination and utilization. This synergy would allow for optimal use of available resources and strengthen Tunisia’s role as a major actor in international research and scientific dissemination.

By implementing these measures, Tunisia could enhance its position as a key player in health data governance. This is while adhering to legislative and scientific quality standards. It would also become an indispensable reference in public health research, improving care quality and making informed decisions regarding national and international health strategies.

 

 

 

 

 

 

The post The value of health data in national registers: a scientific research and healthcare quality improvement tool first appeared on Research Media.]]>

Around a year ago we were reminiscing about how a decade had passed since the mass protests in Alexandria (Egypt) in June 2010 against the police murder of a young Egyptian, Khaled Mohamed Saeed,[1] and since the start of the third Saharawi intifada in Gdeim Izik[2] (Occupied Western Sahara) in October 2010. We talked about how for us that marked the beginning of a life-changing epoch.

In the year that followed (2011) a wave of revolt spread throughout the whole Middle East and North Africa region, in what came to be called the ‘Arab Spring’.[3] These uprisings were acknowledged as world-shaking events. The Tunisian and Egyptian revolutions ignited historic upheavals in North Africa and beyond. People there celebrated the toppling of the dictators, Ben Ali and Mubarak, and looked ahead towards meaningful change in their lives. These uprisings, like most revolutionary situations, released enormous energy – a collective effervescence, an unparalleled sense of renewal and a shift in political consciousness.

The peoples of the region are all too familiar with the racist stereotype and contemptuous cliché embodied in the facile falsehood that ‘Arabs and Muslims are not fit for democracy and they are incapable of governing themselves’. The imperial and colonial dominance over the region has led to it being seen in some quarters as a homogeneous entity that can be systematically reduced through negative tropes. Seen through this distorting lens, the region evokes images of conflict and wars, ruthless dictators and passive populations, terrorism and extremism, as well as rich oil reserves and expansive deserts. This orientalist imaginary and the rigid representation of ‘the other’, as well as having the power to ‘block narratives’, are hallmarks of a political and geographic violence that is produced by imperialism.[4]

The uprisings shattered many of these stereotypes and debunked many myths. The wind of revolution that began to blow in 2011 spread from Tunisia to Egypt, Libya, Syria, Yemen, Bahrain, Jordan, Morocco and Oman. The emancipatory experience was contagious, inspiring people all over the world: activists in Madrid, London and New York, whether calling themselves the Occupy Movement or the Indignados, were all proud to ‘Walk like an Egyptian’. Although the last three to four decades have seen attempts to delegitimize meaningful and radical change through revolution, following the shortcomings and defeat of decolonization efforts in various parts of the global South, and although counter-revolutionary onslaughts will always seek to crush the will of the people – revolutions and uprisings for emancipation continue (and will continue).

For both of us, as for many activists, the pride and hope that these events generated remains deeply personal and political. Our career paths, activism and world-views were shaped by this formative political experience. We participated in conferences/round-tables celebrating and analysing these historical events, we marched with our peoples in protests, and we were involved in various solidarity initiatives. We discussed, debated and disagreed with friends and comrades. Sometimes we felt hopeful, at others sad and dispirited. Above all, we learnt a great deal: engaging with revolutionary praxis offers a unique source of knowledge.

Nevertheless, we cannot deny that what started as inspiring uprisings against authoritarianism and oppressive socio-economic conditions, demanding bread, justice and dignity, morphed into violence and chaos, profound polarizations, counter-revolution and foreign intervention. The various people’s movements in the region found themselves pitted against entrenched authoritarian and counter-revolutionary forces bent on suppressing them. All were met with resistance from the state, often in conjunction with global capital and foreign interference. The military coup in Egypt ended up restoring a much more ruthless and repressive form of dictatorship. The brutal descent into civil wars in Syria, Libya and Yemen, and the series of crackdowns in Gulf countries like Bahrain, provide examples of the cruel logic of proxy war so reminiscent of the colonial schemes with which the region and its people are all too familiar. Tunisia, which had seemed to be the exception in this gloom and doom, is now in a very fragile position. Moreover, the deep polarizations (e.g. Islamists versus secularists) imposed on the masses have distracted them from the key socio-economic issues that were at the heart of the uprisings in the first place.

Some mainstream commentators have argued that the ‘Arab Spring’ gave way to an ‘Islamist winter’ (with Islamist forces coming to power in some countries). Some progressive voices have been less pessimistic and have presented a more historically nuanced perspective, arguing that these events should be seen as part of a long-term revolutionary process, with ups and downs, periods of radicalization and periods of setback and counter-revolution. This latter view received some vindication when, eight years after the 2010/11 events, an escalation of the revolutionary process took place, in the form of a second wave of uprisings in Sudan, Algeria, Iraq and Lebanon (2018–21), alongside the return to the spotlight in 2021 of the unending and heroic struggle of the Palestinians – all of which reveals people’s determination to continue fighting for their rights and sovereignty.

All of these momentous events between 2010 and 2021 have opened new horizons for people to express their discontent and demand radical change and reforms, forcing almost every government in the region to concede on issues – both political and economic.

Why a project to commemorate this decade of struggle in the region?

When we embarked on this project our guiding compass was the important role of memory in our movements for justice and freedom, and the crucial task of maintaining an archive. Our political memory is not an automatic process, like muscle memory; rather, it is shaped by the political and economic conditions in which we exist. The nurturing of political affinity and the maintenance of radical kinship does not occur in a vacuum – it must be fed, to be kept alive. To be archived and reflected upon. Anniversaries provide one occasion for such activities, and that is what this project represents. The project includes webinars [hyperlinks] and podcasts [links], together with the articles collected here, all of which can help us to look at the concrete within what are sometimes too-abstract debates, and to engage with some less visible cases.

One of our aims in this project has been to challenge a number of misconceptions about the region, its people and their revolts and uprisings. One such misconception was the attempt by the global and mainstream media, Western governments, as well as international financial institutions, like the World Bank, to portray the uprisings as merely revolts against authoritarianism and as demanding only political freedoms and democracy of the stunted kinds that exist in Western industrial countries. This framing steers away from any class analysis and tends to dissociate the political from the economic, ignoring the fundamental socio-economic demands of bread, social justice, dignity and popular sovereignty. But the misreading – or more accurately distortion – did not stop there. The Tunisian and Egyptian uprisings were dubbed by Western mainstream commentators ‘Facebook and Twitter revolutions’, exaggerating the role of social media in fomenting them. Another dominant – but no less superficial – framing was the demographic one, which interpreted the revolts as primarily youth uprisings against the older generation – the product of a ‘youth bulge’ in the affected countries.

A decade later, mainstream interpretations commemorating the tenth anniversary of the events have gained little by way of insight. Several media reports and articles talk of failed and lost revolutions and broken promises. But the dominant tone is captured by a title of one Guardian article published in December 2020, referring to Mohamed Bouazizi, the street fruit vendor who set himself on fire, catalysing the Arab uprisings: ‘He ruined us: 10 years on, Tunisians curse man who sparked Arab Spring’. The narrative advanced is one of despair and hopelessness: the uprising was not worthwhile, better to have remained in poverty and in chains. Such an interpretation needs to be strongly challenged and deconstructed in order to offer a more nuanced and less idealist (more materialist) reading of revolution and what it entails. Various critical progressive activists and researchers have emphasized the importance of acknowledging the complexities of revolutionary dynamics and their inevitable crises, shortcomings and even failings.[5] This necessitates seeing revolutions as being imbued with counter-revolutionary tendencies and encroached upon by reactionary forces. The fact that people in the region are continuing to revolt is testimony to this complexity. Ultimately, the ideas people hold about revolutions have a critical impact on the outcomes of such events when they actually occur; hence the necessity of reflecting and learning from past revolutions.

Throughout this project we have sought to make space for critical reflection: we prioritized an inclusive approach regarding different disciplinary views and political emphases, and in the process gave a platform to younger, female and local voices from the region – the least we can do. We hope we have eschewed rigid dichotomies, as well as self-righteousness as regards possession of ‘the truth’ – a desire that stems from our rejection of sectarian and polemical styles and behaviours, which can too easily morph into personal attacks. One outcome of this collaboration has been to learn to disagree and to work respectfully in a comradely fashion, and to continue the discussion in a constructive way. Anyone who is engaged in the issues presented in this project will be all too aware of how the nefarious effects of trench positions (campism) have weakened progressive possibilities for meaningful engagement over the years. So often we have seen debates about Syria or Libya, for example, turn into deeply polarizing (and often false) binaries – alienating participants and choking off productive debates regarding revolutionary strategies and international solidarity. Ultimately, how exactly we can reconcile certain positions (e.g. anti-authoritarian versus anti-imperialist) will be put to the test in our movements, but we should never absolve ourselves of our duty to argue against selective political positions. One case of freedom should be in the service of – not expendable in pursuit of – another. This was powerfully captured during one of our webinars between our Moroccan and Saharawi participants.

Summary of the articles

The contributors to this dossier are outstanding scholars and activists from, or having their roots in, the region.[6] They were given the choice to write either in Arabic or English. All pieces are offered to our readers in both languages.

In his piece, Adam Hanieh delves into the root causes of the regional uprisings through a historical and political economy approach. By describing in detail some of the lineages of the revolt that broke out in 2011, he deconstructs the mainstream liberal framing of the region and its uprisings. He argues that we must pay attention to the region’s centrality to the world economy, and how its political structures are directly reflective of the capitalist development that has taken place in the region over the last few decades.

Ghassen Ben Khelifa takes us back to 2010–2011, when Tunisian people who desired to live in dignity rose up to claim their rights. He takes a very critical look at the initial events that constituted Tunisia’s intifada and shows how it has now been contained, if not aborted. He cogently challenges the ‘exceptionalist’ framework around the Tunisian experience by showcasing a series of counter-revolutionary imperial and neoliberal measures designed to strangle the revolution and its economic demands.

Mostafa Bassiouny and Anne Alexander argue in their piece that any attempt to understand the course of the 2011 Egyptian revolution must necessarily grapple with the role of the workers’ movement. They show how workers’ struggles were an independent factor in the revolutionary process. They also underline the importance of ‘reciprocal action’ between the economic and the political aspects of the class struggle, and how this process played a pivotal role in the revolutionary developments in Egypt.

Fourate Chahal delivers beautiful and evocative illustrations for all the articles in this dossier. She also offers us some exquisite and powerful artistic collage, capturing the beauty, creativity and the energy released by various uprisings through graffiti, art, slogans and the recapturing of public spaces by people in revolt.

In his contribution, Ali Amouzai critically reflects on the historic February 20 Movement in Morocco, which arose in 2011, and details the balance of political and social forces that preceded it. Then, he describes and analyses the reaction of the monarchy to this threat to its rule, which took the form of repression, cooptation and containment. He also shines a light on Morocco’s role as an outpost of imperialist designs in the African continent, while continuing to resist the right to self-determination of the Saharawis.

Rafeef Ziadah argues that one of the major outcomes of the uprisings has been the increased role of regional players in multiple states, working to stabilize the political system to their advantage. With a focus on Libya and Yemen, she examines the various modes of intervention applied by the United Arab Emirates and Saudi Arabia, including direct military campaigns, the use of proxies, financial aid and humanitarian packages – all working in tandem to shape a regional outcome that has buttressed the status quo against the initial hopes of change offered by the uprisings.

Yasser Munif starts his article by examining bread as a central commodity in times of war and peace, offering an overview of the agrarian reform implemented by successive regimes in Syria from 1963 to 2000. He then focuses on the weaponization of bread as an important military strategy of the Assad regime during the revolt in Syria, while giving us a glimpse of the rebels’ grassroots resistance, using the city of Manbij in northern Syria as a case study.

Muzan Al Neel’s contribution focuses on the 2018–2019 Sudanese revolution and explains why the Sudanese rose up, and what it was they wanted to overthrow when they chanted ‘Just fall’. She analyses the current moment and the role of the transitional government, and its evolution vis à vis the uprising’s objectives. She ends by exploring the ways the Sudanese uprising could and should continue to achieve its goals in the face of the counter-revolution.

Zahra Ali puts forward a feminist analysis of the Iraqi uprising of 2019. Based on her in-depth fieldwork conducted with women and youth networks and social movements in Iraq, she takes the 2019 uprising as a framework for thinking about how massive protests allow for an understanding of emancipation that broadens our feminist imagination, paying particular attention to the spaces the uprising produced.

Hamza Hamouchene adopts a Fanonian lens to analyse the 2019–2021 Algerian uprising,  and argues for the rationality of rebellion in the context of the new popular movement (Hirak) in Algeria – a movement that he argues represents a continuation of the decolonization process. He also connects the uprising in Algeria with the Black Lives Matter movement in the United States and considers what Fanon’s thought has to offer to these and other struggles for economic and political justice.

And last, but not least, Rima Majed applies a comparative approach and asks what the Iraqi and Lebanese  uprisings of 2019 have in common beyond a regional/cultural proximity. She first discusses whether these uprisings can be termed ‘revolutions’ or ‘revolutionary’ in the first place. She then focuses on the internal contradictions of these revolutions, looking at the rhetoric of corruption, national unity, technocratic politics and individualism.

Looking back – looking forward

Anniversaries have a symbolic power and can be good opportunities for taking stock of what happened, and for reflecting on the positives and negatives. They can also be dynamic moments where we think about how to move forward. Our aim is not to reminisce about the beautiful times that are long gone, or to romanticize these great historical events. Instead, in this project we hope to get closer to the spirit of the revolutions, their creative energy, as well as their contradictions and shortcomings – and their enemies.

Obviously, this project has some lacunas – things that are not addressed. This is partly due to our own limits, in terms of our labour and time, and partly due to the limits of a project whose raison d’être is bound to a certain moment in time. In truth, revolutionary processes are always unfinished. The same goes for political praxis, which includes writing about revolutions. And although we would not pretend, or seek, to be fully comprehensive when discussing such a vast region, we hope we offer here an important glimpse, in the voice and the language of its people. What we have sought to present is a progressive analysis that can contribute to deepening our knowledge about the region – with the hope that this will allow us to learn from past mistakes and continue to push for long-sought change in the prevailing oppressive political and socio-economic conditions.

Our memories of the incredible events over the last decade have been foundational. We feel privileged to have witnessed people acting with a political stamina and bravery that can only be termed ‘historic’. Our minds have been enlightened and our spirits elevated by the countless ordinary men and women who dared to say ‘the people want’ [al sha’b yourid], and who rose up in unprecedented circumstances. We inherit their legacy, and the enormous price paid to arrive at a tipping point from which neither the friends nor the enemies of revolution can return. There are few things as powerful as ordinary working class people overcoming all the odds and shaking the very foundation of the status quo.

‘The personal is political’ proclaims the feminist maxim. ‘Nothing about us goes without us’ runs the motto of the disability struggle. In the spirit of these two messages we wholeheartedly thank all of the contributors to this project, who bring their perspectives as scholars and activists in and from the region. And we pay tribute to the fallen, the injured, the political prisoners and the ones who continue to struggle. We dedicate this work to them, and to all those who have sacrificed their lives for bread, justice and dignity.

Miriyam Aouragh is a Dutch-Moroccan anthropologist. She is a Reader at the Communication and Media Research Institute, University of Westminster. She is the author of the book Palestine Online and the forthcoming Mediating the Makhzan.  Her research and writings focus on cyber warfare, grassroots digital politics and (counter-) revolutions.

Hamza Hamouchene is a London-based Algerian researcher-activist, commentator and a founding member of Algeria Solidarity Campaign (ASC), Environmental Justice North Africa (EJNA) and the North African Food Sovereignty Network (NAFSN). He is currently the North Africa Programme Coordinator at the Transnational Institute (TNI).

Copy-edited by Ashley Inglis

References

[1] The murder by Egyptian police of Khaled Mohamed Saeed, and the outrage it provoked, contributed to the growing discontent in the weeks leading up to the Egyptian Revolution of 2011.

[2] Gdeim Izik was a protest camp in Western Sahara, established on 9 October 2010 and maintained till November that year. While protests were initially peaceful, they were later marked by clashes between Saharawi civilians and Moroccan security forces. Some have referred to the protests as the Third Saharawi Intifada, following the First (1999–2004) and Second (2005). Scholar and political activist Noam Chomsky has suggested that the month-long protest encampment at Gdeim Izik constituted the start of the Arab Spring.

[3] The term Arab Spring is an allusion to the Revolutions of 1848, which are sometimes referred to as the ‘Springtime of Nations’, and to the Prague Spring in 1968 , as well as later uprisings in Central and Eastern Europe in 1989. This term was been coined, and has been promoted by, Western media and pundits, and has been criticized by some scholars as part of a US strategy of controlling the movement’s aims and goals and directing it towards Western-style liberal democracy. However, it is important to acknowledge some positive uses of the term Arab Spring, and how it makes a link with earlier historic uprisings in the region, such as the Berber Spring of 1980 in Algeria and the Damascus spring of 2000.

[4] Said, E. (1984) ‘Permission to narrate’, Journal of Palestine Studies 13(3): 27–48.

[5] Bayat, A (2017) Revolution without Revolutionaries: Making sense of the Arab Spring. Stanford: Stanford University Press. See also Traboulsi, F (2014) Revolutions without Revolutionaries. Beirut: Reyad El-Rayyes Books.

[6] We note briefly here the various ways the authors in this dossier refer to the region that is the focus of this project. Some use ‘Middle East’ or ‘Middle East and North Africa (MENA)’. Others refer to the ‘Arab region’ or ‘Arab world’, while others go for the less-used coinages ‘North Africa and West Asia (NAWA)’ or ‘West Asia and North Africa (WANA)’. Our own view is that if we are committed to advancing counter-hegemonic narratives that challenge structures of power, and to decolonizing concepts and names, it is only fitting to call into question the colonial designation ‘Middle East’ – a construct of, and designed to sit in opposition to, the West; part of the legacy of Orientalism, of creating an ‘other’. We are sympathetic to the use of ‘Arabic region’, but without its ethnic connotations. We acknowledge that this naming can arouse feelings of exclusion and oppression among some. No naming is perfect, and each has its own limits. In our view, without trying to efface the rich shared cultural and political legacies in our region, a reference rooted in a geographic identification, such as North Africa and West Asia (NAWA), is a more apt description.

This dossier of articles is published in collaboration with the Transnational Institute (TNI) and Rosa Luxemburg Foundation – North Africa.

Why democratize? Every morning, men and women rise to serve those among us who are able to remain under quarantine. They keep watch through the night. The dignity of their jobs needs no other explanation than that eloquently simple term, ‘essential worker.’ That term also reveals a key fact that capitalism has always sought to render invisible with another term, ‘human resource.’ Human beings are not one resource among many. Without labor investors, there would be no production, no services, no businesses at all.

Every morning, quarantined men and women rise in their homes to fulfil from afar the missions of the organizations for which they work. They work into the night. To those who believe that employees cannot be trusted to do their jobs without supervision, that workers require surveillance and external discipline, these men and women are proving the contrary. They are demonstrating, day and night, that workers are not one type of stakeholder among many: they hold the keys to their employers’ success. They are the core constituency of the firm, but are, nonetheless, mostly excluded from participating in the government of their workplaces – a right monopolized by capital investors.

To the question of how firms and how society as a whole might recognize the contributions of their employees in times of crisis, democracy is the answer. Certainly, we must close the yawning chasm of income inequality and raise the income floor – but that alone is not enough. After the two World Wars, women’s undeniable contribution to society helped win them the right to vote. By the same token, it is time to enfranchise workers.

Representation of labor investors in the workplace has existed in Europe since the close of WWII, through institutions known as Work Councils. Yet, these representative bodies have a weak voice at best in the government of firms, and are subordinate to the choices of the executive management teams appointed by shareholders. They have been unable to stop or even slow the relentless momentum of self-serving capital accumulation, ever more powerful in its destruction of our environment. These bodies should now be granted similar rights to those exercised by boards. To do so, firm governments (that is, top management) could be required to obtain double majority approval, from chambers representing workers as well as shareholders. In Germany, the Netherlands, and Scandinavia, different forms of codetermination (mitbestimmung) put in place progressively after WWII were a crucial step toward giving a voice to workers – but they are still insufficient to create actual citizenship in firms. Even in the United States, where worker organizing and union rights have been considerably suppressed, there is now a growing call to give labor investors the right to elect representatives with a supermajority within boards. Issues such as the choice of a CEO, setting major strategies, and profit distribution are too important to be left to shareholders alone. A personal investment of labor; that is, of one’s mind and body, one’s health – one’s very life – ought to come with the collective right to validate or veto these decisions.

Why decommodify? This crisis also shows that work must not be treated as a commodity, that market mechanisms alone cannot be left in charge of the choices that affect our communities most deeply. For years now, jobs and supplies in the health sector have been subject to the guiding principle of profitability; today, the pandemic is revealing the extent to which this principle has led us blind. Certain strategic and collective needs must simply be made immune to such considerations. The rising body count across the globe is a terrible reminder that some things must never be treated as commodities. Those who continue arguing to the contrary are imperilling us with their dangerous ideology. Profitability is an intolerable yardstick when it comes to our health and our life on this planet.

Decommodifying work means preserving certain sectors from the laws of the so-called “free market;” it also means ensuring that all people have access to work and the dignity it brings. One way to do this is with the creation of a Job Guarantee. Article 23 of the Universal Declaration of Human Rights reminds us that everyone has the right to work. A Job Guarantee would not only offer each citizen access to work that allows them to live with dignity, it would also provide a crucial boost to our collective capability to meet the many pressing social and environmental challenges we currently face. Guaranteed employment would allow governments, working through local communities, to provide dignified work while contributing to the immense effort of fighting environmental collapse. Across the globe, as unemployment skyrockets, job guarantee programs can play a crucial role in assuring the social, economic, and environmental stability of our democratic societies.

Environmental remediation. We should not react now with the same innocence as in 2008, when we responded to the economic crisis with an unconditional bailout that swelled public debt while demanding nothing in return. If our governments step in to save businesses in the current crisis, then businesses must step in as well, and meet the general basic conditions of democracy. In the name of the democratic societies they serve, and which constitute them, in the name of their responsibility to ensure our survival on this planet, our governments must make their aid to firms conditional on certain changes to their behaviors. In addition to hewing to strict environmental standards, firms must be required to fulfil certain conditions of democratic internal government. A successful transition from environmental destruction to environmental recovery and regeneration will be best led by democratically governed firms, in which the voices of those who invest their labor carry the same weight as those who invest their capital when it comes to strategic decisions. We have had more than enough time to see what happens when labor, the planet, and capital gains are placed in the balance under the current system: labor and the planet always lose. Thanks to research from the University of Cambridge Department of Engineering (Cullen, Allwood, and Borgstein, Envir. Sci. & Tech. 2011 45, 1711–1718), we know that “achievable design changes” could reduce global energy consumption by 73%. But… those changes are labor intensive, and require choices that are often costlier over the short term. So long as firms are run in ways that seek to maximize profit for their capital investors, and in a world where energy is cheap, why make these changes? Despite the challenges of this transition, certain socially-minded or cooperatively run businesses — pursuing hybrid goals that take financial, social, and environmental considerations into account, and developing democratic internal governments– have already shown the potential of such positive impact.

Let us fool ourselves no longer:  left to their own devices, most capital investors will not care for the dignity of labor investors; nor will they lead the fight against environmental catastrophe. Another option is available. Democratize firms; decommodify work; stop treating human beings as resources so that we can focus together on sustaining life on this planet.

• The people of Tunisia invented new ways of a revolution in total respect of the legitimacy of laws and constitution and not against it.
• It is an unprecedented cultural revolution, it is not books of leaflets, it is the explosion of an awareness, that took shape after a long silence. It is the realization of the people that he can reorient his destiny.
• Tunisia transitioned from a Law-based-State to a Law-based Society. And Tunisian people genuinely embodied this spirit.
• It is a historical moment, and a revolution which will shake pr-set political conceptions.
• We thank all Tunisians that contributed their efforts to the campaign. 
• Our administration needs to be independent and impartial, and needs to respect  differences. 
• We will fight the threat of terrorism and a bullet from a terrorist will trigger bursts of bullets from our side. 
• Fighting poverty is a must and responsibility on our shoulders. 
• There is no way for unlawful, informal work.
• No one can steal the freedom that people reclaimed with blood. Not under any banner or circumstance. And those who are nostalgic for a old era are running after a mirage, against the history’s trajectory.
• No way for a setback in women’s rights. We need to expand them, especially social & economic rights, as the dignity of the people is in the dignity of women.
• We need to fulfill the hopes of the people for “Jobs, Freedom, and Dignity”
• The people are in need for a new trust relationship between rulers and citizens. 
• Those who gave their blood to liberate the country are ready to contribute their work and money to push it forward. And contribute to reduce and limit its debt. 

• He thank persons in the Tunisian diaspora abroad who said they were ready to donate one day of work to alleviate Tunisian public debt.
• We stand for just causes, and Palestine in the first place. It is not a position against Jews, we protected them and are ready to do it again, but it’s a position against racism and colonization. Our position is not negotiable under any deal.
• We carry the same commitment for our international obligations, but the cooperation between Peoples is the most important.
• We are looking to build a new history in which Humanism is the core value.
• Coming challenges and responsibilities are big. But the will of the people will help new rulers leave a better country for future generations. 
• The president is the symbol of unity and national independence. And no one is better than anyone, only in the love of the country. He shall rise beyond all conflicts. He invites everyone to rally together around national unity, for the benefit of Tunisia.

Find below the video of the full speech.

A new trade agreement between Tunisia and the European Union is at work and is raising crucial questions. The consequences on Tunisian sovereignty, its agricultural sector and its access to medicines might be at the core of this agreement. 

With over six years of discussion, two years of formal negotiations, 2019 – the deadline set by the European Union in order to adopt the DCFTA or Deep Comprehensive Free Trade Agreement – is now right around the corner. And yet, at the dawn of such a decision, it seems that the Tunisians are utterly unaware of the very content of the agreement. 

The issue is “sensitive”, according to a civil servant working at the Tunisian Minister of Investment and International Cooperation who suggested the journalists should consult the website “ALECA.tn” in order to get more substantial information on the matter.

It is a website with an official-like appearance, proudly displaying the European and the Tunisian flags with the motto “for a real partnership and a better integration of Tunisia within the global economy”. 

The Tunisian presidency is the domain name’s holder. However, no mention is made of the sources of funding for such a tool. No information sheet of the different topics being negotiated is available in Arabic, although they are partly so in English and completely so in French. 

The DCFTA’s topics

• Trade of agricultural and fishery products
• Sanitary and phytosanitary rules (SPS)
• Technical barriers to trade (TBT)
• Trade and sustainable development 
• Trade and investment in services 
• Investment jurisdictional system and dispute settlement 
• The protection of intellectual property
• Trade protection measures
• Public procurement
• Rules on Competition and State’s support
• Custom procedures
• Transparency rules
• Small and medium-sized businesses
• The measures related to trade in energy and raw materials

Source : Article “Les domaines concernés par l’ALECA” (01/01/2019)

A difficult access to information

In early October, the Tunisian Forum on Economic and Social Rights (FTDES) organized a two-day international conference on the DCFTA in Tunis. 

The organizers declared that the event was created, so as to connect people working in sectors that will be affected by the trade agreement.  The goal was to contextualize this agreement and, ultimately, to constitute a group of specialists capable of articulating an informed criticism regarding the DCFTA, in its current form. 

As the conference was running, the FTDES published a document analysing the DCFTA and exposing the perception of Tunisian experts, mostly from civil society and unions. Yet, among these specialists of the Tunisian key economic sectors, there was a tremendous lack of knowledge about the content. For instance, among the 13 experts interrogated in the document, only one knew the DCFTA’s mechanism for dispute settlements, whereas it allows the foreign investors to sue the Tunisian state more easily. 

The FTDES’ report observed that “none of the interviewed persons considers that they have an important influence on the negotiations. They consider the process opaque, the access to information inadequate and they blame the government for the absence of a real substantial discussion”. 

Furthermore, the Tunisian Forum on Economic and Social Rights’ report quotes a poll carried out by Sigma Conseil and presented during a conference organised by SynAgri (Farmers’ Syndicate) and the Konrad Adenauer Stiftung in Tunis on April 10th, 2018. 

The study shows that 90% of the agricultural workers were not aware of the existence of the DCFTA, currently being negotiated. 

The challenge of accessing negotiation

The Tunisian Forum on Economic and Social Rights (FTDES) thus offered to produce a thorough impact assessment on each sector of the economy in order to provide the Tunisian lawmakers with more data and thus allow a better balance of the agreement’s net positive – or negative – impact on the Tunisian economy. 

“We do have a few studies on this agreement, but what we are really missing is a better understanding of the agreement’s consequences”, this is what declared Marco Jonville, the author of the FTDES’s report on the DCFTA and a researcher at the economic department of the FTDES. “We also need to know what people think and what they would consider as positive for the country because, to date, the suggested texts come from the EU, Tunisians are only reacting to them, at best. What are the suggestions and ideas of Tunisian stakeholders, whether they come from the economic or the agricultural sector, whether they are a CEOs or union members? This report’s goal was to pay attention to the Tunisian citizens’ suggestions.” 

DC-FT-A, divide and conceal?

The negotiations between the Tunisians and the Europeans on the DCFTA’s layout are still ongoing. The third negotiation round – and most recent one – took place from December 10th to 14th 2018. Samir Bettaïeb, the Tunisian Minister of Agriculture asserted on Shems FM on December 21th 2018 that the primary sector wasn’t ready for the DCFTA yet.

Ministers, civil society stakeholders or professionals agree wholeheartedly with him. And yet, some of the treaty’s measures are already enforced by Tunisian law. 

The PPP “private-public-partnerships”, the validity of European patents in Tunisia and international dispute-settlement are already a reality. The process of alignment of the Tunisian legislation with the European “acquis communautaire” is continuous and de facto excluded from the negotiations. 

Simultaneously, the EU “exerts a pressure on the Tunisian legislator, through the conditions that accompany the loans it grants to Tunisia. This was the case for the Macro-Financial Assistance loans of 2014 and 2016”, according to Maha Ben Gadha working in the economic program of the Rosa Luxemburg Foundation – North Africa.

Trnaslation to English: An Hoang-Xuan