Tuberculosis, Public Health, and Politics in Cuba, 1925–1965
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THE SICK REPUBLIC: TUBERCULOSIS, PUBLIC HEALTH, AND POLITICS IN CUBA, 1925–1965 by Kelly Lauren Urban Bachelor of Arts, Texas A&M University, 2007 Master of Arts, University of Pittsburgh, 2012 Submitted to the Graduate Faculty of The Kenneth P. Dietrich School of Arts and Sciences in partial fulfillment of the requirements for the degree of Doctor of Philosophy University of Pittsburgh 2017 UNIVERSITY OF PITTSBURGH THE KENNETH P. DIETRICH SCHOOL OF ARTS AND SCIENCES This dissertation was presented by Kelly Urban It was defended on March 16, 2017 and approved by Lara Putnam, Professor and Chair, Department of History Werner Troesken, Professor, Department of Economics Mari Webel, Assistant Professor, Department of History Co-Chair: George Reid Andrews, Distinguished Professor, Department of History Co-Chair: Alejandro de la Fuente, Robert Woods Bliss Professor of Latin American History and Economics, Department of History, Harvard University ii Copyright © by Kelly Urban 2017 iii THE SICK REPUBLIC: TUBERCULOSIS, PUBLIC HEALTH, AND POLITICS IN CUBA, 1925–1965 Kelly Urban, PhD University of Pittsburgh, 2017 This dissertation explores the politics of disease control in Cuba during the mid-twentieth century, and uses tuberculosis as a lens to understand citizenship, state-building, and populism. By analyzing the popular press, health reports, medical journals, and official correspondence in U.S. and Cuban archives, it argues that ordinary citizens, public intellectuals, and civic actors in the interwar era—not the revolutionary government of 1959—introduced the concept of a “right to health” and invoked it to demand an efficient state healthcare sector. In response to these claims and in his quest to strengthen the state, Fulgencio Batista created the Consejo Nacional de Tuberculosis in 1936. The heightened visibility of tuberculosis, achieved in part by the claims-making of citizens, channeled state attention towards a disease of the poor, but it also distorted the design of health projects, making them inefficient and openly political. Thus, although increased state attention to tuberculosis improved mortality rates and access to health services by the 1950s, the state proved unable to depoliticize the tuberculosis campaign and to uniformly implement the right to health care on the ground. The gap between the expectations of citizens and the performance of republican administrations influenced the growing de-legitimation of the state, the overthrow of Batista’s government, and the new regime’s priorities in health policy. Nonetheless, despite the revolutionary rhetoric of radical change, there were clear continuities in tuberculosis control policy before and after 1959, such as the new government’s reliance upon the resources and institutions developed by republican administrations. iv By complementing health outcomes and statistics with a social and political history of tuberculosis, and by balancing attention between state health efforts and grassroots definitions of medical success, this dissertation shifts the frame of a decades-long debate in Cuban historiography that has sought to establish the objective quality of state health care before and after the 1959 revolution. Furthermore, it challenges the assumption of a weak Cuban state and insists that health projects constituted a fundamental arm of state formation. Finally, “The Sick Republic” points to the agency of citizens as they became health activists, shaped state-building efforts, and defined citizenship rights. v TABLE OF CONTENTS ACKNOWLEDGMENTS ....................................................................................................... XIII 1.0 INTRODUCTION ........................................................................................................ 1 1.1 HISTORICAL OVERVIEW .............................................................................. 4 1.2 SCHOLARLY CONTEXT ................................................................................. 7 1.3 ARGUMENTS ................................................................................................... 17 1.4 CHAPTER OUTLINE ...................................................................................... 19 1.5 CUBA’S MEDICAL ORGANIZATION AND TERMINOLOGY ............... 23 2.0 TUBERCULOSIS AND CITIZENSHIP: COMPETING VISIONS OF HYGIENE AND HEALTH, 1925–1940 .................................................................................... 26 2.1 TUBERCULOSIS POLICY UNDER MACHADO ........................................ 31 2.2 CONTENDING NOTIONS OF HEALTH ...................................................... 36 2.3 CONCLUSION .................................................................................................. 55 3.0 “A WIDE BATTLEFRONT AGAINST TUBERCULOSIS”: STATE-BUILDING AND HEALTH CARE, 1936–1965 ........................................................................................... 57 3.1 THE REVOLUTION OF 1933 AND THE CONSEJO NACIONAL DE TUBERCULOSIS ............................................................................................................... 61 3.2 STATE GROWTH, STATE LIMITS .............................................................. 69 3.3 REVOLUTION .................................................................................................. 88 vi 3.4 CONCLUSION .................................................................................................. 96 4.0 “A SQUARE PEG IN A ROUND HOLE”: PATRONAGE, RIGHTS, AND REFORM IN THE HEALTH SECTOR .................................................................................. 98 4.1 THE RF IN CUBA, 1935–1942 ....................................................................... 102 4.2 THE NATIONAL PUSH FOR REFORM .................................................... 125 4.3 CONCLUSION ................................................................................................ 137 5.0 “A TEMPLE OF HEALTH”: THE TOPES DE COLLANTES NATIONAL SANATORIUM PROJECT, 1936–1964 ................................................................................. 139 5.1 CONTESTED CONSTRUCTION ................................................................. 141 5.2 ABANDONMENT OF THE PROJECT ....................................................... 155 5.3 THE GENERAL BATISTA SANATORIUM ............................................... 159 5.4 REVOLUTION AND REDEMPTION .......................................................... 168 5.5 CONCLUSION ................................................................................................ 174 6.0 “NO OTHER REMEDY”: STREPTOMYCIN AND THE POLITICAL ILLS OF THE CNT, 1945–1952 ............................................................................................................... 176 6.1 “THE MARVELOUS DRUG” ....................................................................... 179 6.2 GRASSROOTS MOBILIZATION ................................................................ 197 6.3 THE RETURN OF CHARITIES ................................................................... 212 6.4 CONCLUSION ................................................................................................ 216 7.0 “IN DEFENSE OF THE HEALTHY”: BCG VACCINATION IN CUBA, 1927– 1965 .................................................................................................................................... 219 7.1 FIRST STEPS, 1927–1951 .............................................................................. 222 7.2 NATIONAL VACCINATION, 1950S ........................................................... 230 vii 7.3 MASS VACCINATION .................................................................................. 245 7.4 CONCLUSION ................................................................................................ 253 8.0 CONCLUSION ......................................................................................................... 256 8.1 HEALTH & CITIZENSHIP ........................................................................... 260 8.2 STATE-BUILDING IN LATIN AMERICA & THE CARIBBEAN .......... 262 8.3 HEALTH IN CUBA ........................................................................................ 265 8.4 EPILOGUE ...................................................................................................... 267 APPENDIX A ............................................................................................................................ 270 BIBLIOGRAPHY ..................................................................................................................... 272 viii LIST OF TABLES Table 1. Bed Capacity of Tuberculosis Hospitals & Sanatoriums................................................ 71 Table 2. Number of State Tuberculosis Dispensaries .................................................................. 71 Table 3. X-ray Totals .................................................................................................................... 89 Table 4. Beds & Population, 1931–1968 ...................................................................................... 91 Table 5. American Production of Streptomycin ......................................................................... 183 Table 6. Grams of Streptomycin Imported into Cuba, 1947 ....................................................... 184 Table 7. Annual Number of Vaccines, 1943–1958..................................................................... 231 ix LIST OF FIGURES Figure 1. The First Lady