Radical Prescription: Citizenship and the Politics of Tuberculosis in Twentieth-Century Cuba

By Kelly Urban

Extinguishing a public health threat is difficult under any condition, let alone during a sweeping national revolution. In this first comprehensive study of tuberculosis in modern Cuba, Kelly Urban analyzes the medical, social, and governmental responses to the highly contagious disease as the island was heading into and emerging from the Revolution of 1959, providing a window onto broad questions of citizens' rights, biomedicine and public health, and political change.

Drawing on a diverse range of sources revealing the perspectives of those at the center of power and those on the margins, Urban finds that the Cuban republican state intervened to confront the tuberculosis problem only after coming under intense grassroots pressure. Cuban citizens forged an activist political subculture around tuberculosis, rejecting discourses that blamed the sick for their own illness. This loose coalition of sanatorium patients, tenement dwellers, black public intellectuals, labor organizers, and reform-minded physicians won entitlements to state health care and pressed for other social rights that influenced health. Their critiques of the state's politicized and inefficient tuberculosis program contributed to the declining legitimacy of the Batista government, helping to spur the Revolution and an innovative restructuring of the public health system.

• Language: English
• Publisher: The University of North Carolina Press
• Release date: Mar 16, 2023
• ISBN: 9781469673097

Kelly Urban

Kelly Urban is assistant professor of history at the University of South Alabama.

Book preview

Cover: Radical Prescription, Citizenship and the Politics of Tuberculosis in Twentieth-Century Cuba by Kelly Urban

Radical Prescription

ENVISIONING CUBA

Louis A. Pérez Jr., editor

Envisioning Cuba publishes outstanding, innovative works in Cuban studies, drawn from diverse subjects and disciplines in the humanities and social sciences, from the colonial period through the post–Cold War era. Featuring innovative scholarship engaged with theoretical approaches and interpretive frameworks informed by social, cultural, and intellectual perspectives, the series highlights the exploration of historical and cultural circumstances and conditions related to the development of Cuban self-definition and national identity.

A complete list of books published in Envisioning Cuba is available at https://uncpress.org/series/envisioning-cuba.

Radical Prescription

Citizenship and the Politics of Tuberculosis in Twentieth-Century Cuba

Kelly Urban

The University of North Carolina Press CHAPEL HILL

© 2023 The University of North Carolina Press

All rights reserved

Set in Merope Basic by Westchester Publishing Services

Manufactured in the United States of America

Library of Congress Cataloging-in-Publication Data

Names: Urban, Kelly, author.

Title: Radical prescription : citizenship and the politics of tuberculosis in twentieth-century Cuba / Kelly Urban.

Other titles: Envisioning Cuba.

Description: Chapel Hill : The University of North Carolina Press,

[2023]

| Series: Envisioning Cuba | Includes bibliographical references and index.

Identifiers: LCCN 2022033504 | ISBN 9781469673073 (cloth : alk. paper) | ISBN 9781469673080 (paperback : alk. paper) | ISBN 9781469673097 (ebook)

Subjects: LCSH: Tuberculosis—Cuba—History—20th century. | Public Health— Cuba—History—20th century. | Medical policy—Cuba—History—20th century. | Cuba—History—1895– | Cuba—Politics and government—1895–

Classification: LCC RA644.T7 U7769 2023 | DDC 362.19699/50097291—dc23/eng/20220729

LC record available at https://lccn.loc.gov/2022033504

Cover illustrations: Lung © iStock.com/3xy; syringe © iStock.com/MicrovOne.

Chapters 1 and 2 include material from the Rockefeller Foundation Archives. Those materials are used here with permission of the Rockefeller Foundation Archives.

To my family, for their generous support of my education,

and to my professors, who taught me a better world was—and still is—possible

Contents

List of Illustrations

Acknowledgments

INTRODUCTION

Politicosis

Tuberculosis in/as Cuban History

CHAPTER ONE

The Sick Republic

Forging Health Rights in an Era of Revolution

CHAPTER TWO

Tuberculosis as Statecraft

Fulgencio Batista and the National Tuberculosis Council

CHAPTER THREE

Striking for Streptomycin

Grassroots Health Activism under the Auténticos

CHAPTER FOUR

A Medical Monument

The General Batista Sanatorium

CHAPTER FIVE

A Shuttered Laboratory

Tuberculosis Policy Experiments in the Early Revolution

CHAPTER SIX

Therapeutic Revolution

The Boundaries of Health Citizenship under Socialism

CONCLUSION

The Battleground of Health

From the Special Period to COVID-19

Notes

Bibliography

Index

Illustrations

FIGURES

1.1 Damas Isabelinas raise awareness 28

1.2 A Havana tenement house 31

2.1 Batista’s new Cuba 45

2.2 Visiting nurse at a tubercular home 57

3.1 PAS advertisement 68

3.2 Sanatorium patient strike, 1948 77

3.3 Sanatorium patient strike, 1951 81

3.4 Anti-Tuberculosis League collects donations 86

4.1 Constructing Topes de Collantes Sanatorium 97

4.2 The General Batista Sanatorium lobby 104

4.3 Postcard, Topes de Collantes Sanatorium 105

5.1 Zapata Swamp free of tuberculosis 131

GRAPHS

5.1 Tuberculosis incidence and mortality rates, 1962–1969 134

6.1A Tuberculosis incidence and mortality rates, 1972–1989 158

6.1B New cases of tuberculosis, 1972–1989 158

MAP

4.1 National Tuberculosis Council dispensaries 108

Acknowledgments

As I sat down to write these acknowledgments, I glanced at my table. Layered in the soft wood were pen indentations, remnants of words piled on top of one another over the years. It was a stirring reminder of how long I have been crafting this history and how many people I have to thank for bringing it to fruition.

Alejandro de la Fuente tirelessly supported this project and, perhaps most importantly, never let me doubt my ability as a historian. Reid Andrews brought his incisive intellect to earlier versions of this manuscript; he also provided valuable encouragement and feedback as I applied for academic jobs, without which this book would probably not have been written. Lara Putnam changed the way I think by asking the most brilliant questions. Mari Webel and Werner Troesken provided valuable suggestions on how to make a dissertation into a better book. Mariola Espinosa frequently offered feedback, kind words, and letters of recommendation, despite not holding a formal position on my dissertation committee, and I appreciate her generosity. Andy Kirkendall introduced me to Latin American history when I was an undergraduate student at Texas A&M University, and I will always be grateful for the foundational knowledge he gave me about this fascinating part of the world.

Jesse Horst read countless drafts, shared primary sources, connected me with institutions in Havana, and provided a lot of laughs along the way. This book is immeasurably better because of his scholarship and his friendship.

Multiple scholarly communities pushed my research forward, and I’m thankful for mentors who invested in my development, senior scholars who provided encouragement at conferences and from afar, and peers who made the often difficult nature of research in Cuba less onerous. This list includes Lexi Baldacci, Manuel Barcia, Devyn Spence Benson, Anne-Emanuelle Birn, Mike Bustamante, Michelle Chase, Matt Davidson, Carlos Dimas, Reinaldo Funes, Cary García Yero, Pablo Gómez, Lillian Guerra, John Gutiérrez, Anasa Hicks, Rachel Hynson, Billy Kelly, Ariel Lambe, Jennifer Lambe, Raúl Necochea López, Elizabeth O’Brien, Raquel Otheguy, Nicole Pacino, Randall Packard, Daniel Rodríguez, Romy Sánchez, Rainer Schultz, Elizabeth Schwall, Emily Snyder, Gabriela Soto Laveaga, and Eyal Weinberg.

At Pitt, I enjoyed a kind cohort that included Andrew Behrendt, Lucy Behrendt, Matt Casey, John Galante, Aura Jirau Arroyo, Tasha Kimball, Mirelle Luecke, Stephanie Makin, Luke Martínez, Alex Mountain, Chris Myers, Katie Parker, Orlando Rivero, and Jon Sherry. To the entire History Department, but especially to Rob Ruck, Liann Tsoukas, and Molly Warsh, thank you for supporting my growth as a scholar.

In Mobile I received warm support from the Department of History at the University of South Alabama and useful feedback from a lively historical writing group, which included Claire Cage, Shane Dillingham, Tim Lombardo, Alex Ruble, and Nic Wood.

In the home stretch, Mike Bustamante, Jesse Horst, Rachel Hynson, Billy Kelly, Jenny Lambe, Alex Mountain, Nicole Pacino, Alex Ruble, Daniel Rodríguez, Elizabeth Schwall, and others answered panicked emails and provided feedback on drafts (often on inexcusably short notice). I owe you all a cafecito or a daiquiri, hopefully in Havana.

My research was facilitated by generous Cubans, including Antonio Álvarez Pitaluga, Enrique Beldarraín Chaple, Carmen Castillo, Yoel Cordoví, Milagros Martínez, Julita Piloto, Belkis Quesada Guerra, and Ricardo Quiza. To Lupe, Tania, Diego, Claudia, and Iván—thank you for providing a home away from home in Havana.

Historians cannot complete their projects without the vital assistance of librarians and archivists, and this book is no exception. Special thanks are owed to Gladys Gómez Rossié, Amanda Moreno, and Annie Sansone-Martínez at the Cuban Heritage Collection; Bethany Antos at the Rockefeller Archive Center; Graciela Guevara Benítez and Bárbara Jiménez at the Museo Finlay; and Debbie Cobb and the Interlibrary Loan staff at the University of South Alabama’s Marx Library, on whom I leaned heavily as institutions closed their doors to the public during the COVID-19 pandemic. My gratitude extends to the hardworking staff at the Archivo Nacional de la República de Cuba, the Archivo de la Oficina del Historiador del Ministerio de Salud Pública, the Biblioteca Nacional de Cuba José Martí, the Instituto de Historia de Cuba, the Museo Histórico de las Ciencias Carlos J. Finlay, the Cuban Heritage Collection, the Hillman Library, the Library of Congress, the National Library of Medicine, and the Rockefeller Archive Center.

Generous financial support came from the American Historical Association (Albert J. Beveridge Grant for Research in the History of the Western Hemisphere), the Cuban Heritage Collection (Goizueta Foundation Research Fellowship and Pre-prospectus Fellowship), Harvard University (Graduate School of Arts and Sciences Visiting Fellowship), the Kenneth P. Dietrich School of Arts & Sciences at the University of Pittsburgh (Social Science Doctoral Dissertation Fellowship), the Rockefeller Archive Center (Grant-in-Aid), and the University of South Alabama (Faculty Development Council Grant). Various awards also came from the Center for Latin American Studies at the University of Pittsburgh and the College of Arts and Sciences at the University of South Alabama.

Diego Armus and Jennifer Lambe served as kind and thoughtful readers of my manuscript. Their feedback was invaluable, fundamentally reshaping the final product. Any shortcomings are all my own.

Back when I was an undergraduate student, publishing with the Envisioning Cuba series at the University of North Carolina (UNC) Press was a dream I was never sure would come to pass. Elaine Maisner, Andreina Fernandez, and Lou Pérez at UNC Press helped smooth out the path to turning that dream into a reality.

To Paul and Diana Urban—your interest in supporting what I do has been a great source of encouragement.

To Dad—you are a historian, even if there isn’t a piece of paper that declares it; thank you for gifting me with a curiosity for the past.

To Mom—you are my biggest cheerleader; thank you for editing countless drafts and for always giving me a safe space I knew I could turn to.

And, finally, to Ryan—this book is the result of the decision we made to leave for Pittsburgh almost fifteen years ago. We certainly had no idea what that journey would hold. What I said before still stands: it has been my great fortune to grow up with you.

Radical Prescription

INTRODUCTION

Politicosis

Tuberculosis in/as Cuban History

In late 1926 a young soldier named Rubén took to the streets of Havana with his younger brother Juan in tow. Only twenty years old and driven by desperation, Juan had recently left the countryside for Cuba’s bustling metropolitan capital. He still nurtured illusions and dreamed of life, but he was engaged in a potentially fatal battle.¹ Juan had contracted tuberculosis.

By the early twentieth century, Cubans were well acquainted with this illness. Pamphlets distributed throughout Havana insisted that tuberculosis

"d[id]

not respect sex, age, or race."² Such well-intentioned propaganda was misleading, for the tuberculosis bacillus accumulated more intensely in certain spaces and infected certain bodies more successfully than others. Tuberculosis is a paradigmatic social ailment, tending to develop from latent infection to active disease predominantly among the marginalized. Their bodies bear the immunological consequences of inequality: living and laboring in unsanitary and cramped conditions, having inadequate access to nutritional food, and enduring uninterrupted periods of stress and overwork.

Although Rubén was only twenty-five, his steady income as a soldier and his posting in Havana made him the family member most capable of finding a solution for his brother. They set out on a pilgrimage familiar to Cuba’s poor, traveling from one hospital to the next to ask for admittance. When that failed, Rubén tried to use any connections he had as a soldier to secure a bed for Juan. He then contemplated sending him abroad for treatment, a hope quickly dashed by its prohibitive expense. Years later, Rubén bitterly recalled, There were no beds, there were no rooms, there were not even … sufficient medical specialists.… We turned to home remedies.³

The two brothers faced a public health system constrained by U.S. imperial prerogatives, which dictated an overwhelming focus on yellow fever. Complicating matters was the fact that no effective biomedical cure for tuberculosis existed; the most sought-after therapy was rest in a sanatorium, but there was never enough availability to satisfy demand. In the same year that Juan arrived in Havana, the government attributed more than 3,000 deaths on the island to tuberculosis but only provided approximately 300 beds for tuberculars in state hospitals.⁴

Despite the insufficient treatment network, Rubén’s efforts bore fruit after several weeks when Juan was admitted to Calixto García General Hospital. After a brief stay and release, Juan soon relapsed and returned, remaining in the hospital for almost two years. He sat in a bed as the bacilli multiplied and destroyed his lungs, slowly consuming his health. During frequent visits to provide company and food for Juan, Rubén became disgusted with the system of health care available for poor Cubans. Calixto García Hospital’s small tuberculosis ward was miserable … neglected and dilapidated. Rubén believed that more than devoting itself to the treatment of tuberculosis, it served as a warehouse to store the sick. One morning, Rubén arrived at the hospital and found Juan coughing up increasingly large amounts of blood, suffering a violent episode of hemoptysis. He helplessly bore witness to a gut-wrenching scene as Juan began to choke and suffocate. He died … in my own arms, Rubén recounted, bathing me in his … blood.⁵ Microscopic bacteria tragically claimed one more life and irrevocably altered another.

Rubén and Juan’s experience was far from unique. In Cuba in the 1920s, thousands died annually from tuberculosis, leaving untold suffering in their wake. But this tale also proved exceptional—in its cast of characters and its consequences. This bloody morning would haunt the young soldier, remaining never far from memory as he climbed the ranks to become Cuba’s ruling strongman in the 1930s. The elder brother was none other than Rubén Fulgencio Batista, the central political figure of Cuba’s Second Republic (1933–58). Soon after taking the reins of power, Batista founded the National Tuberculosis Council, dedicating an enormous amount of funding to eradicate the disease and publicly declaring that he would not allow a tragedy like Juan’s death to happen again in Cuba.⁶

Despite this proclamation, the history of tuberculosis on the island rests not only on the decisions of powerful figures, such as Batista when he was a military strongman, but also on the actions of a multitude of less powerful people, such as Rubén Fulgencio when he was a modest soldier. Beginning in the 1920s, ordinary Cubans denounced the government’s inadequate intervention in the tuberculosis problem. In response, the Cuban state expanded its antituberculosis campaign across the next several decades. As governments sought to control tuberculosis as a public health problem and foster political constituencies among those concerned with the disease, a varied group—sanatorium patients, peasants, the urban poor, black public intellectuals, labor organizers, Communists, crusading journalists, reform-minded physicians, and radical pulmonologists—became health activists, stringently demanding change. Some articulated new rights to health services, and others insisted that the state attack the socioeconomic conditions that allowed the disease to flourish. They all prescribed a radical expansion of the boundaries of social citizenship.

Bringing these two phenomena—state power and popular pressures—into conversation with one another is the central task of Radical Prescription, which centers grassroots activism, nuances our understanding of republican and revolutionary state formation, and questions traditional chronologies of health care in twentieth-century Cuba.

The Politics of Tuberculosis from the Turn of the Century

Tuberculosis is an ancient scourge, but it took centuries for the disease to gain visibility at a societal level. Consumption (or phthisis), as the disease was then known, developed cultural currency in Europe in the late eighteenth century. More than a few luminaries, such as John Keats and Robert Louis Stevenson, became consumptives, and their experiences influenced popular knowledge of the disease. Consumption was highly romanticized, with many believing that as sufferers took on a ghostly pallor (hence the moniker the white plague), their beauty and genius intensified. In Thomas Mann’s influential The Magic Mountain, published on the eve of war in 1914, a consumptive elite gathered at a sanatorium in the Alps, where they engaged in erudite conversation. The assumed privileged demographic profile of the sick informed physicians’ conceptualization of the disease as hereditary, noncontagious, and mostly limited to the white race. It followed, then, that they were neither to be blamed nor stigmatized for their condition.⁷

Across the late nineteenth and early twentieth centuries, however, scientific understandings of the disease shifted fundamentally, best illustrated by the ontological transition from consumption to tuberculosis. Concurrent medical and socioeconomic ruptures spurred this transformation. In 1882, German microbiologist Robert Koch identified the tuberculosis bacillus, further corroborating the germ theory of disease and establishing that tuberculosis was contagious and not hereditary. Urbanization in the cities of Europe and the Americas created the ideal conditions for a respiratory disease to spread, and eventually, civic groups pushed municipal governments to better control tuberculosis. As they gathered statistics, it became clear that tuberculosis was decidedly unromantic: the impoverished, many of them immigrants or rural migrants, were disproportionately dying of the disease.⁸ Tuberculosis no longer inspired visions of a noble cure in a Swiss sanatorium; instead, tuberculars were cast as a threat to the entire city, and the tenement houses in which they lived were denigrated as lung blocks.⁹ Tuberculophobia ran rampant from London to New York to Buenos Aires.¹⁰

In Cuba’s charged postcolonial context, the politics of tuberculosis took on a local cast. At the turn of the century, Cuba concluded thirty years of violent struggle, during which a racially diverse independence movement fought for freedom from Spain.¹¹ The feat proved incomplete—in 1898, as Cuban rebels drew nearer to victory, the United States intervened, declaring war on Spain. The United States brokered the peace, without allowing Cubans a seat at the negotiating table, and then occupied the island militarily for four years, until it deemed the fledging nation fit for self-rule. Its yardstick was undoubtedly self-serving: its priority was securing American economic interests.¹² U.S. congressmen believed this depended on extinguishing the threat of epidemic disease.

During the latter half of the nineteenth century, the yellow fever virus frequently traveled from the port of Havana to the U.S. Gulf Coast, circulating through the capillaries of railroads and rivers and sparking epidemics in cities and the surrounding countryside. Worried about the economic toll these events exacted, U.S. authorities began to keep a close eye on Cuba’s sanitary landscape. Worsening disease conditions in 1898 were one reason why the government intervened in the war. Under the U.S. occupation (1898–1902), American military authorities spearheaded a massive sanitation campaign in Cuban cities. They also made Cuban acceptance of the terms of the Platt Amendment a prerequisite for their departure in 1902.¹³ One of its eight clauses linked Cuban sovereignty to the absence of epidemic diseases—namely, yellow fever.¹⁴ If there was any doubt about the seriousness of the Americans in this matter, it dissipated in the first decade of independence when the United States occupied the island a second time (1906–9), which it justified in part by pointing to climbing yellow fever cases.¹⁵

The looming threat of U.S. intervention forced Cuban authorities to use public health resources to prevent yellow fever, primarily through maintaining clean streets and destroying mosquito-breeding sites. This redirecting of funding gutted Cuban medical research, which had previously attained a promising reputation in international scientific circles.¹⁶ In response, as historian Daniel Rodríguez has argued, physicians crafted a nationalist medical project, which

"[gave]

medicine outsized importance in postindependence Cuban politics and, conversely,

[gave]

the state outsized importance in the development of Cuban medicine."¹⁷ With a new national project stunted by the imperial meddling of the United States, a growing cohort of Cuban physicians no longer wanted to prioritize the study of tropical diseases like yellow fever. Instead, they argued, the Cuban state should attend to those health issues that most afflicted Cuban citizens, dubbing several of them national diseases.

While yellow fever targeted Spanish and American newcomers to the island, Cubans died from yellow fever in smaller numbers, as they had built up immunity from mild childhood infections. By contrast tuberculosis was a disease highly fatal to the native-born population, especially among mixed-race and black Cubans.¹⁸ While 900 Cubans died of tuberculosis in Havana in 1901, only eighteen died from yellow fever. Tuberculosis ranked as one of the top causes of mortality, outnumbered only by the expansive categories of diarrheal, digestive, and heart diseases. Approximately half of all tuberculosis deaths occurred among those in their twenties and thirties, a tragically early end for those in the prime of life. Two decades after independence, tuberculosis mortality in Havana had dropped only slightly and was still one of the leading causes of death.¹⁹

Due in part to the Platt Amendment, this epidemiological significance did not initially translate into public health funding. Concerned physicians formed the Cuban Anti-Tuberculosis League in 1901 to educate the public and push the government to act. Their first cause—launching a state tuberculosis sanatorium—languished in the Cuban Congress. Construction began only when the second U.S. military occupation government, satisfied with the state of yellow fever control, championed the project.²⁰ But for the next two decades, the state’s antituberculosis campaign advanced little. A small tuberculosis division within the Ministry of Sanitation and Charities conducted research, inspected homes, and attended to dispensary patients. The only facilities available for the tubercular poor were the Furbush Dispensary, La Esperanza Sanatorium, and the Romay Clinic at Calixto García General Hospital.²¹

In the 1920s, however, the politics of the disease shifted, and in the following decades, a steady expansion in the public health sector’s tuberculosis infrastructure replaced the slow progress of earlier years. By the 1950s, the Pan American Health Organization confirmed that Cuba possessed one of the highest tuberculosis-bed-to-population ratios in the Western Hemisphere, one roughly equivalent to that of the United States.²² Nonetheless, increased state attention brought a new set of problems. One public figure diagnosed the state’s antituberculosis campaign with politicosis, making a clever play on the word tuberculosis and suggesting an infection with the ills of Cuban politics.²³

Central to this book is a broader conceptualization of politicosis: in Cuba the disease was no longer simply a respiratory ailment or a reflection of the social hierarchies on the island; it had become a variable in national politics, a politicized disease with which students of Cuban history must contend. Such a task calls for more than dusting off timeworn medical texts; it requires a multiscalar analysis that starts, but does not end, at the microbiological level.

Tuberculosis as Historical Lens

Tuberculosis is an infectious bacterial disease. It is primarily spread through the air. When a person with an active case coughs or sneezes, small water droplets laden with Mycobacterium tuberculosis are emitted, which can be inhaled by others. Those in prolonged contact with a tubercular (a person with an active case of the disease) have a heightened chance of infection. This is one reason why tuberculosis was and is considered a social disease—those who live in crowded and poorly ventilated housing have increased exposure to a respiratory ailment like tuberculosis. Once inhaled, the droplets travel to the lungs, and the bacteria begin to multiply. The body’s immune system immediately launches an assault, and microphages (a type of immune cell) surround the bacteria. As they do so, nodular granulomas (tubercles) form to keep the bacteria contained. Even though this infected person has a latent case of tuberculosis, the body’s immune system works to keep the lung tissue safe. This person is asymptomatic and cannot transmit the disease.

An active case of tuberculosis develops when the immune system does not function properly. This might happen immediately following infection if microphages cannot surround the bacteria faster than they multiply. It can also develop years later, when a person’s immune system becomes compromised by any number of variables, such as the onset of an immunological condition like AIDS. Other social factors can intervene, such as stress to the immune system caused by inadequate nutrition and substandard wages. When the immune system falters, the granulomas break open, and bacteria begin to multiply and invade the alveoli, destroying the lung tissue. This accounts for the telltale sign of tuberculosis: a persistent and painful cough, often full of blood clots. Other symptoms include a chill-inducing fever, steady weight loss, and periodic night sweats. At this point, the individual has an active case of pulmonary tuberculosis, the most common form of the disease and therefore the focus of this book.

Holding the historical lens steady on one disease magnifies processes beyond the biological. There are, of course, limitations to a single-disease approach, including glossing over significant episodes in public health politics, ignoring the diversity of sociocultural narratives about disease, and flattening out nuances in the lived experience of other illnesses. However, as Nancy Leys Stepan argues, this method’s shortcomings can be countered to some extent by treating a single disease as a concentrated site in which all the possibilities and contradictions in public health and medical politics are sedimented.²⁴ In addition to sifting through these many sedimented medical topics, one must determine which broader sites of historical inquiry to excavate, a decision guided by the disease’s most essential characteristics.

Tuberculosis’s first salient trait is its social embeddedness. An individual’s contraction of tuberculosis, a classic social disease, is shaped not only by the mechanisms of the tubercle bacilli but also by social and economic factors.²⁵ As such, it evokes questions about the modern state. In his study of Italian history, Frank Snowden made a similar argument for malaria, another social disease. Because illnesses like malaria and tuberculosis are tied to poverty and societal neglect, their histories show the priorities … of statesmanship, of the relationship of the people to their environment, and of that overarching issue known to contemporaries as the ‘social question’—that is, poverty as revealed in the circumstances of ordinary people. In sum, Snowden contends that studying a social disease is not an exotic subspecialty, but rather a central part of understanding modern … history.²⁶ Exploring how tuberculosis gained a privileged place in the Cuban health apparatus can help unearth new revelations about the modern Cuban state.

This process was inextricably linked to the story of the end of the First Republic (1902–33), when authoritarianism and populism began to mark Cuban politics. Gerardo Machado’s election to the presidency in 1924 signaled a tremor of change, as he implemented nationalist policies and dabbled in populist measures. However, in 1928 he engineered an undemocratic extension of his rule, which triggered an explosion of violence as cross-ideological mass resistance developed against his dictatorship. The Revolution of 1933 finally unseated him from power, undermined traditional oligarchic politics, and abolished the Platt Amendment. However, it rested on an uneasy coalition of lower-rank soldiers, labor unions, middle-class professionals, and students.²⁷ Fulgencio Batista, a sergeant-turned-colonel in the Cuban army and a new player on the political scene, steadily consolidated the military’s power after 1933, constructing what scholars have categorized as an authoritarian populist regime.²⁸ Vacillations between dictatorship and democracy characterized the Second Republic (1933–58) and the first years following the Cuban Revolution of 1959. Throughout these periods, authoritarianism and populism proved durable in Cuban political culture.

Authoritarian signifies the relative absence of democratic processes and institutions, such as reasonably participatory, free, and fair elections, and the

"forcibl[e]

incorporat[ion of] more people into a … state system of rule."²⁹ Populism is a capacious analytical category, but most definitions reference a style of political leadership that is attuned to the people, in comparison to foreign or domestic elites.³⁰ In the case of mid-twentieth-century Latin America, scholars define populism by its reliance on mass support of a cross-class nature.³¹

Authoritarianism does not rely on coercion alone, as scholars of Latin American history have demonstrated.³² The foundations of despotism were paradoxical, with the exercise of violence existing alongside the extension of material benefits and the creation of culturally relevant exchanges.³³ In Cuba those material and cultural variables included public health policies. As a social disease, tuberculosis disproportionately afflicted the masses, those known in Cuba as the popular classes. They steadily carved out a place for themselves in politics from the late 1920s on.³⁴ Other Cubans bestowed cultural significance on tuberculosis, painting