Before 1959, Cuba possessed one of the most advanced medical civilizations in the hemisphere: a democratically elected National Medical College, a physicians’ retirement law, private and mutualist hospitals covering the majority of the population, and an intellectual tradition reaching back to the sixteenth century. All of it was systematically destroyed in less than six years. Before the Fall reconstructs, with documentary rigor, what Cuba had before the revolutionary regime dismantled it, from Tomás Romay and the first scientific dissertation on yellow fever, to Carlos Juan Finlay and the discovery of the Aedes vector, to the exodus of three thousand physicians and the last free assembly of Cuban medicine in Santiago in December 1959. Written by family physician Enrique C. Fernández, MD, great-nephew of the last president of the National Medical College, this is not a nostalgic chronicle nor a family memoir, but the rigorous documentation of a medical civilization that existed, that contributed to universal medical thought, and whose destruction was not inevitable.
Before 1959, Cuba possessed one of the most advanced medical civilizations in the hemisphere: a democratically elected National Medical College, a physicians’ retirement law, private and mutualist hospitals covering the majority of the population, and an intellectual tradition reaching back to the sixteenth century. All of it was systematically destroyed in less than six years. Before the Fall reconstructs, with documentary rigor, what Cuba had before the revolutionary regime dismantled it, from Tomás Romay and the first scientific dissertation on yellow fever, to Carlos Juan Finlay and the discovery of the Aedes vector, to the exodus of three thousand physicians and the last free assembly of Cuban medicine in Santiago in December 1959. Written by family physician Enrique C. Fernández, MD, great-nephew of the last president of the National Medical College, this is not a nostalgic chronicle nor a family memoir, but the rigorous documentation of a medical civilization that existed, that contributed to universal medical thought, and whose destruction was not inevitable.
Santiago de Cuba. December 20, 1959.
The man at the front of the room had been elected to be there. That was the point — the point that was about to be disputed, and then dismantled, and then remembered for the rest of his life, which he would spend in a country that was not his own.
His name was Augusto Fernández Conde. He was forty-six years old, a pulmonologist who had trained in Havana and Philadelphia, a specialist in diseases of the chest who had subordinated two decades of potential private practice to institutional service. He was the elected president of the Colegio Médico Nacional de Cuba — the autonomous national body of Cuban physicians, built across thirty-four years by men and women who believed that Cuban civil society possessed the right to govern itself. He was presiding, on this Saturday morning in December, over what would prove to be the last democratically elected National Assembly in the institution’s history.
The Club San Carlos stood in the heart of Santiago de Cuba — the oldest Cuban cultural institution in the province of Oriente, named for the patron saint of the city. The assembly had opened at ten in the morning, as it opened every year, with a quorum. Delegates had been elected from Municipal Colegios across the island: Havana, Camagüey, Cárdenas, Pinar del Río, Holguín, Santa Clara, Sancti Spíritus, Morón, Santiago de Cuba, and a dozen others. The results had been certified. The coalition of democratic medical parties held 124 delegates against 92 for the government’s party. The mathematics of the morning were not close.
The men in military uniform were not delegates. They stood in the corridors of the Club San Carlos with pistols on their hips, and they had been there since the session opened, and everyone in the room understood exactly what their presence meant. The government of Fidel Castro — eleven months old, not yet openly communist, already operating by the methods of a system that does not tolerate autonomous institutions — had sent its military medical commanders to observe the proceedings of the Cuban medical class. To observe, and to be seen observing.
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This book is about what happened before that morning, and what happened after it.
The before is the longer story, and the less-known one. Cuban medicine before 1959 was not a system awaiting salvation. It was one of the most advanced medical establishments in the Western Hemisphere — by any measure that can be verified, by any institution whose data survived the revolution that claimed to improve upon it. Cuba in 1958 had a physician-to-population ratio of one to one thousand: fifth best in the Americas, behind only Argentina, the United States, Uruguay, and Canada. Its capital city contained hospitals that trained physicians from across Latin America and sent its own graduates to postdoctoral programs in Paris, Philadelphia, and Baltimore. Its medical university, founded in 1728, was the sixth in all of Spanish America. Its physicians had demonstrated the mosquito transmission of yellow fever before Walter Reed’s commission arrived to confirm it, described the urinary pathogenicity of Escherichia coli before the organism had a settled name, and built the first histopathological laboratory on the American continent.
They had also built something rarer and more fragile: a self-governing professional institution that had survived two dictatorships, a presidential dissolution decree, a Supreme Court vindication of its right to exist, and thirty-four years of sustained pressure from every government that had ever tried to make Cuban civil society answer to state power. That institution — the Federación Médica de Cuba, later the Colegio Médico Nacional — is the subject of the early chapters of this book, and its destruction is the subject of the later ones.
The after begins in Santiago, in December 1959, in a hotel ballroom where the last free assembly of Cuban physicians ended not with a vote but with a threat, and closes in Miami, in 1992, where Augusto Fernández Conde died at seventy-eight, thirty-one years into an exile he had not chosen, in the city that had become the capital of everything Cuba had lost.
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This is also a family history. The author is the grandson of Carlos Fernández Conde, who was Augusto’s brother and who died in January 1944 — fifteen years before the Santiago assembly, eleven months before the institution Augusto served completed its transformation from the Federación Médica into the Colegio Médico Nacional, at the exact moment the Obligatory Registration decree that Augusto had spent years fighting for was being finalized.
Carlos Fernández Conde was not a physician. He was a journalist — the parliamentary correspondent for the Cuban Senate at the newspaper El Mundo, a Freemason, a man of the Republic who spent his working life in the press gallery of the Capitol building watching the laws of a democratic nation being made. He reported on the passage of the 1940 Constitution. He sat in the gallery when the Senate voted on the Ley de Retiro Médico — the physicians’ retirement law that his brother’s institution had spent eighteen years fighting to obtain, and which Batista signed on January 12, 1943. At the time of his death, Carlos was championing the Ley del Retiro de Periodistas — the journalists’ version of the same law, modeled on the one his brother had just won. To qualify, a journalist needed ten years of service. Carlos had seven. He died without the law. His family received no pension. They received a house, bought by subscription from his colleagues, delivered on the first anniversary of his death.
The physicians got their law. The journalist who covered it from the Senate gallery — whose brother fought for it, whose widow needed it — did not.
That is not a metaphor. It is a fact. And it is the kind of fact this book is built from.
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A note on sources and method. This book rests on three categories of evidence, each treated differently.
The first category is independently verifiable primary sources: official records, peer-reviewed publications, government documents, original institutional histories, and statistics from bodies such as the World Health Organization, the World Bank, and the United States Census. These are cited as established fact.
The second category is published scholarly work — academic monographs, peer-reviewed articles, and documented eyewitness accounts in published form — which is cited with attribution and identified as the finding of the named author rather than as independent consensus.
The third category is family memory and oral testimony. It is not cited in the text as fact. Where it shapes the narrative framing or the emotional register of a passage, the reader is so informed. Family memory is not evidence. It is the reason this book was written.
The governing standard throughout is the same one the physicians of the Federación Médica applied to the institutions they built: if the argument cannot defend itself when challenged, it does not belong here
Fernández’s account of “a specific institution—the organized body of Cuban physicians, from its colonial origins to its destruction in December 1959” covers a subject about which he is well informed through personal experience, professional training, and use of published sources. Therefore, it is no surprise that the author’s passion for his subject is apparent throughout.
Chapters such as “The Man Who Stopped a Plague: Tomás Romay Chacón, 1764–1849” and “A Century of Firsts: Cuban Medical Achievement and the Architecture of a Civilization, 1804–1959,” among others, demonstrate how the history of medicine and human history in general are inseparable. Chacón was a pioneer in understanding the importance of vaccinations against smallpox. Discrepancies between rural health and longevity as compared to the well-being of urban residents are also analyzed. The information Fernández presents here and the conclusions he draws in these and other chapters should interest everyone. They are relevant not only to Cuban history and medical history but to societies everywhere.
One caveat: use of footnotes and more extensive in-text citations of sources might make readers feel more at ease with the origins of Fernández’s account. Notes at the end of each chapter do assure the reader of the factual basis for Fernández’s assertions. However, more citations in paragraphs would create a more accessible vision of the text’s relationship to its sources. lnformal references in paragraphs, as in the discussion of factions within the Federación Médica, are valuable: the names and genealogies of relevant individuals “are documented in Augusto Fernández Conde’s own book — written in 1946.” Such information saves readers the difficulty of trying to correlate between paragraphs and notes at chapters’ ends. More would be welcome.
Nevertheless, the writing is overall quite clear, polished, and well-organized. The book proceeds in logical, easily-followed steps from topic to topic. The subject and analysis should prove to be of interest to anyone interested in Cuban history and the forces that shaped the island’s culture. However, the book is important not only because it collects and records a specific, important series of historical events in one locale. Fernández also provides broader insights into the political, social, and economic factors that affect healthcare in any country and in any historical era. Fernández shows why the practice of medicine cannot exist or function in a vacuum. It is inextricably intertwined with society.