Epidemic Episodes:Disease Outbreaks and State Legitimacy in Post-Revolutionary Bolivia1
This article explores three epidemic episodes in 1950s Bolivia: a typhus outbreak in Oruro in September 1954, a typhoid outbreak in Cochabamba in January 1956, and a polio outbreak along the Bolivia-Argentine border in March 1956. Each case discusses state-imposed quarantine and sanitation measures, using newspaper reports and editorials, letters to health officials, and government publications to document institutional responses to these epidemic episodes and people's reactions. Through press coverage, the article analyzes praise and critiques of government responses to these epidemics to assess what measures public health authorities implemented, how effective they were, and how Bolivians felt about their political and medical leadership during these crises. These case studies evidence that Bolivians did not respond uniformly to government containment policies, and responses varied by region and disease. They also demonstrate that quarantines are effective even if not always popular, and that the public's perception of the measures' efficacy and implementation impact their feelings about state legitimacy. Finally, they show that disease outbreaks create opportunities for citizens to critique government officials and push for improvements to public health.
Bolivia, MNR, epidemics, public health
Epidemics upend people's lives, sometimes with little forewarning. They impact every facet of society, causing economic upheaval, curtailing personal mobility, and raising questions about government effectiveness and legitimacy. Epidemics can unite people around a common cause, or they can ignite public panic and breakdown society's social fabric. They tend to expose already existing social, political, and economic tensions, and they may create new ones. Since an epidemic has a "dramatic intensity," it allows for an intimate examination of a society and its rituals, values, norms, and institutions.2
Charles Rosenberg described an epidemic as having an "episodic quality"—an event with an often dramatic beginning and anticlimactic conclusion.3 These episodes are highly visible and tragic, and they demand an immediate official response and public acknowledgement of health risks. During an epidemic, both individual and institutional action (or inaction) come under scrutiny. They generally require some sort of [End Page 477] purposeful, and potentially invasive, government or medical intervention to bring them under control, and they might create opportunities for citizens to make demands on government institutions in the name of health and safety. During a time of widespread uncertainty and fear, do people greet these interventions with thankfulness, with skepticism, or with some other reaction? How do epidemic outbreaks impact citizens' confidence in government and medical institutions?
I will explore these questions through three epidemic episodes in 1950s Bolivia: a typhus outbreak in Oruro in September 1954, a typhoid outbreak in Cochabamba in January 1956, and a polio outbreak along the Bolivia-Argentine border in March 1956. For each case, I discuss state-imposed quarantine and sanitation measures. Using newspaper reports and editorials, letters to health officials, and government publications, I document institutional responses to these epidemic episodes and people's reactions. I use two La Paz-based newspapers: La Nación, the official press of the MNR government that generally trumpeted its initiatives and accomplishments, and El Diario, which tended to be more critical and historically disinclined to comment on the plight of poor, indigenous, or working-class Bolivians.4 Through press coverage, I analyze praise and critiques of government responses to these epidemics to assess what measures public health authorities implemented, how effective they were, and how Bolivians felt about their political and medical leadership during these crises. These case studies evidence that Bolivians did not respond uniformly to government containment policies, and responses varied by region and disease. They also demonstrate that quarantines are effective even if not always popular, and that the public's perception of the measures' efficacy and implementation impact their feelings about state legitimacy. Finally, they show that disease outbreaks create opportunities for citizens to critique government officials and push for improvements to public health.
Disease outbreaks provide a window into state building, government legitimacy, medical authority, and state-society relations because they are moments of crisis and uncertainty. As scholars have noted, disease is a biological entity but also a social construction; diseases have real physiological impacts, but people's experience with them are shaped by cultural beliefs and political attitudes.5 Since social values, culture, political ambitions, and economic concerns frame the way a society understands diseases, they must be examined within a broader historical context. The uncertainty caused by infectious disease outbreaks also provides an opportunity to examine state building, a continuous process that involves manufacturing the consent of the governed.6 It is also a means of acquiring political legitimacy; citizens of a society have to confer legitimacy onto government workers and institutions, and it can be easily revoked during times of crisis. Government interventions into people's private affairs—such as what they eat, how and when they regulate fertility, [End Page 478] and whether or not their children are vaccinated—extend the role of the national government beyond electoral politics and economic regulation. However, these same interventions tend to raise questions about government legitimacy and whether or not it has the right to encroach on personal liberty and dictate private decisions. Given that Bolivia was in the midst of state-building following the 1952 National Revolution, these disease outbreaks allow for an examination of government legitimacy in a post-revolutionary society, and shed light on how governments in tenuous conditions react to crisis situations and how legitimate their actions appear to citizens.
Several scholarly trends are useful for examining state-society relations in this context. The first demonstrates that public health interventions are often an exercise in power rather than altruistic endeavors (although they may be undertaken in the interest of public welfare). This point is especially true when public health initiatives involve organizations external to the society in which they are implemented (such as the Rockefeller Foundation or U.S.-sponsored public health entities),7 or to cement the power and authority of doctors and medical practitioners as a professional group seeking a monopoly on healing practices.8 Another trend highlights people's reactions to disease control measures. While many individuals desire government programs to contain and control infectious diseases, individuals do not always welcome state or medical interventions in their daily lives.9 Specifically, vaccines and treatments that involve drawing blood are often contentious due to their invasive nature.10 A third trend demonstrates the tendency to blame or scapegoat some sector of the population as the cause of disease outbreaks, typically the poor or other marginalized sectors of society that are most at risk for disease due to bad living/working conditions and limited access to health care.11 Each of these trends is evident in the history of public health in post-revolutionary Bolivia.
An already complicated relationship between a state and its citizens during disease outbreaks becomes especially tenuous in situations where the state itself is not fully hegemonic, as was the case in 1950s Bolivia. A social revolution in April 1952 brought the Movimiento Nacionalista Revolucionario (Revolutionary Nationalist Movement, or MNR) to power and precipitated major changes to the country's political climate, social structure, and economy. The MNR vowed to make the country more modern, productive, and equitable. One of the promises that the MNR made to Bolivians was to improve people's quality of life. To this end, after 1952 the MNR dramatically expanded public health services, especially in rural areas. Newly built health centers and mobile units staffed by recently trained nurses and auxiliary medical personnel brought health care to areas of the country where it had been virtually nonexistent. Public health services and medical education benefitted from the support of international organizations like the Pan-American Health Organization and [End Page 479 ] the Servicio Cooperativo Interamericano de Salud Pública (SCISP)—a bilateral organization jointly funded by the U.S. and Bolivian governments. These organizations' influence was similar to the pre-1952 period, when the Rockefeller Foundation worked on yellow fever eradication and endemic disease control, but after 1952 the MNR used these organizations in the service of its own nationalistic, post-revolutionary agenda.12 The 1952 revolution positively impacted Bolivians' overall health; disease control programs reduced or eliminated persistent scourges, and general mortality and infant mortality dropped while life expectancy and living standards increased, although not uniformly.13 By the 1960s, Bolivians in general, and rural Bolivians in particular, had greater access to health care and higher expectations for services provided by the Health Ministry.14
Yet, accessible health care in remote regions was not merely an altruistic offering by the MNR to its constituents; it was also paternalistic. This health infrastructure gave the government a presence in rural regions and an opportunity to secure political loyalty from voters enfranchised for the first time by a 1952 universal suffrage decree. This expansion of public health programs after 1952 helped the MNR consolidate political power and court rural support. It also invited criticism from newly enfranchised citizens and those that helped bring the MNR to power—Bolivians empowered by the 1952 revolution made demands on the state, including pushing the MNR to the left on issues such as agrarian reform and nationalization of the mining industry, as well as advocating for stronger unions, better pay, better working conditions, and access to health care. The MNR was caught between placating its more radical supporters and alienating the more moderate factions that helped put them in power. Therefore, the MNR state was far from hegemonic and its legitimacy was subject to constant negotiation.
Expanding state presence into historically neglected areas of the country was one priority of the MNR government. Another was controlling diseases that strained the national economy and public health resources. To do so, the Health Ministry sought to enlist the help of its citizens to spread awareness about hygienic practices and notify authorities in case of any contagious disease transmission. An announcement in the Health Ministry bulletin in January 1953, republished in the La Paz-based newspaper La Nación—the official press of the MNR government—told Bolivians that "it is necessary to denounce cases of transmissible disease." In general, the MNR used the press masterfully to manufacture public support for its initiatives and to drown out critics.15 This particular publication implored Bolivians to report cases of infectious disease to health authorities by emphasizing the notions of citizenship, social obligation, and the role of the individual in keeping the nation healthy. It noted, "medical science possesses powerful measures to combat diseases and avoid their occurrence and spread, but health authorities can do nothing without the help of the population." As the notice continued, [End Page 480] It is time that citizens know that they have a moral obligation to advise sanitary authorities by phone, letter, or in person about every contagious disease of which they have knowledge. Such notice can save many useful lives. It is not just an obligation; for your own conscience, it is absolutely necessary to provide the contagious person's address so that authorities can vaccinate their family and take the necessary measures for the person to recuperate.
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The announcement explained that, when they received notice of infectious diseases, the Health Ministry sent authorities to ensure that sick people were quarantined so that they could not infect others.16 It showed the importance that health authorities placed on disease control, as well as their willingness to use heavy-handed tactics and infringe on privacy and personal mobility in the interest of public health. It also showed the importance of public cooperation and enlisting citizens in the crusade to eradicate disease. Ensuring public cooperation was essential to legitimize these actions; the people consented to state authority through their cooperation with health mandates, which made them democratic rather than authoritarian. The Health Ministry attempted to manufacture consent and cooperation through these kinds of announcements. These types of mandates, and popular support for and compliance with them, would become especially important in the three epidemic episodes that follow.
Oruro, September 1954
The first epidemic episode focuses on Oruro (and to a lesser extent, La Paz), where an outbreak of exanthematic typhus in September 1954 rattled the city. Oruro is the main city in the Department of Oruro on the western Altiplano, about 12,000 feet above sea level, located halfway between La Paz (the administrative capital) and Sucre (the historic capital). In the 1950s, its population was about 63,000.17 It is a mining town with a cold, windy climate surrounded by flat, arid plains and lakes to the west and the Andes mountains to the east. Exanthematic typhus, which ravaged Oruro in September 1954, is a louse-born disease that runs rampant in overcrowded places with poor sanitation. The disease, which has an incubation period of 10 to 14 days, can be quite severe and even fatal if not treated. Symptoms include fever, chills, muscle aches, and rash. It is treatable with antibiotics, but there is no vaccine. A Health Ministry publication summarizing activities from 1954–1955 identified 609 national cases of exanthematic typhus with a morbidity rate of 23.5 per 100,000 people.18 It named Oruro as a department with "major incidence of infectious disease" in relation to typhus, along with La Paz and Cochabamba.19
In early September 1954, the prefects of La Paz and Oruro simultaneously sounded the alarm about an outbreak of exanthematic typhus in the cities. The La Paz prefect wrote to the Health Minister, Julio Manuel Aramayo, on September 6, 1954, stating that there was a "worsening epidemic of exanthematic typhus" in the city, including 46 serious cases that were being treated in the hospital and six mortalities. He noted that the "population is seriously alarmed, obligating me to require that health authorities observe rigorous prophylaxis measures." These rigorous measures included declaring a quarantine and closing crowded public places, including schools, movie theaters, bars, and restaurants. He commanded temples and barracks to disinfect themselves thoroughly. Despite these measures, he implored Aramayo: "please send urgent help to control the disease."20 [End Page 482]
The situation in Oruro was similar. The prefect's letter, dated September 7, 1954 made an urgent request "to combat a grave epidemic of exanthematic typhus that is abrupt, massive, and virulent." He noted that 47 cases had been identified but that the numbers of ill continued to grow and that the victims were in terrible condition, especially the popular classes due to what he called their "very poor living conditions." He requested that several items to help combat the infection be flown into the city: five fumigators, 200 pounds of DDT, 5,000 capsules of Chloromycetin (an antibiotic), 100 pounds of formol (formalin, a type of formaldehyde—used as a disinfectant) and 100 pounds of creso (also likely a disinfectant). He told Aramayo that all of the city's medical personnel were mobilized and urgently requested the stated items to combat the epidemic and avoid its further spread.21
At this point, the press coverage of the epidemic focused solely on Oruro. Almost two weeks later, on September 19, La Nación reported on a "massive disinfection against typhus" in the city of Oruro. Sanitary workers disinfected public spaces where large numbers of people gathered with DDT, the region's medical authorities convened to learn about the "danger of this epidemic," and the local hospitals suspended visits for two days as a precaution.22 Two days later, on September 21, La Nación elaborated on the disinfection campaign, which enlisted officials from both local and national health institutions who were "working tirelessly on a disinfection campaign of all places where the terrible affliction that has preoccupied the population since the beginning of this month presumably originated." The people working to sanitize the city included a group of 20 female students, called "Enevs," from the Escuela Nacional de Enfermeras y Visitadoras Sociales, that came to the city with "a substantial amount of disinfectant and a commendable mission to put themselves at the service of sanitary authorities." La Nación reported that this disinfection campaign was good for the city in the short term, to stop the further spread of typhus, and in the long term, because it would help prevent future outbreaks. Barracks continued being fumigated and people doused with DDT, while at the same time, according to the newspaper, normal life was starting to resume for citizens living within the city limits, although preventative measures remained in place for locations outside the city. The article specifically noted the reopening of places that sold beverages, suggesting that bars were among the final public spaces reopened by the public health authorities.23 The article seemed to use this tidbit to indicate that health authorities had done and good job of containing the disease and ensuring that normal life could resume as quickly as possible.
As the press focused on the massive sanitation campaign taking place in Oruro, it also highlighted the activities of the Health Minister, Julio Manuel Aramayo. On the same day La Nación singled out the Enevs for praise and recognition, the newspaper noted that Aramayo himself had flown to town with antibiotics to personally assist with the recovery [End Page 483] efforts.24 A follow up article detailed Aramayo's activities while in the city. First, along with other health authorities, he conducted a study on the severity of the epidemic that "presented with alarming character in the population." He visited several homes to collect information about how the outbreak affected different parts of the city, especially the eastern part, where the epidemic began. He also called for the immediate disinfection of houses, streets, and places where people gathered, delivered a large quantity of drugs to fight typhus, and personally attended to serious cases. Finally, he gathered detailed information on people admitted to the hospital and those that died from typhus. On September 23, Aramayo informed the city that the danger of the epidemic had passed.25
The epidemic episode, from September 7, when the Oruro prefect begged Aramayo for rapid assistance, to September 23, when Aramayo declared the outbreak over, lasted 17 days. It required firm government action by local and national institutions that mobilized equipment and individuals. The rapid response, quarantine, and public sanitation measures ensured a relatively quick containment and minimal serious casualties. As a result, La Nación praised sanitary authorities, celebrating the contributions of lowly nursing students as well as Health Minister Aramayo. It is not clear from the sources if locals shared the national press's veneration of the public health measures, but La Nación portrayed local and national responses as efficient and effective, and praised officials for getting orureños back to normal life as quickly as possible.
Cochabamba, January 1956
The next epidemic episode happened in Cochabamba, where a typhoid outbreak shattered Bolivians' confidence in their national health infrastructure. Cochabamba, the principal city in the Department of Cochabamba, is centrally located and nestled in an Andean valley. Its population was roughly 80,000 in the 1950s.26 The climate is semi-arid, and the region lacks the tremendous cold of the Altiplano to the west and the heat and humidity of the lowlands to the east and north. The region does have a history of infectious disease, including yellow fever and malaria.27 Unlike those mosquito-borne illnesses, typhoid is a bacterial infection that is often spread through contaminated food and water. Symptoms include high fever, vomiting, gastrointestinal issues, weakness, and headache. It can be easily treated with antibiotics when caught early, but can be fatal when not treated. A Health Ministry publication summarizing activities from 1954–1955 identified 631 cases in the country during the year with a 24.3 morbidity rate per 100,000 inhabitants.28 It identified Cochabamba as a department with "major incidence of infectious disease" in relation to typhoid, along with La Paz, Oruro, and Potosí.29
The typhoid outbreak lasted from about January 20, 1956, when it was first reported in the press, until January 25, although a few cases were reported in early February. The Health Ministry moved swiftly to contain [End Page 484] the epidemic, dispatching Luis Mealla, a sanitary inspector, to report on the situation. Immediately, Mealla, along with Dr. Miguel Levy, the director of the local health center, and Dr. Rafael Torrico, the head of the central laboratory, asked the municipal government to urgently adopt sanitary measures. These measures included water sanitation, rapid disposal of human waste and trash, food monitoring, especially for milk and vegetables, and prohibition on ice cream sales. The Cochabamba health center worked to educate the populace about typhoid and how to avoid it, and the Office of Rural Endemic Diseases sprayed DDT in places where flies congregated. They organized three vaccination posts in the city and put forth an education campaign for the public about the need to get three doses of the vaccine to obtain immunity, "to which the public responded satisfactorily." Public health nurses helped dispatch the vaccine by staffing posts and administering second and third doses.30 The Health Ministry erected a sanitary barricade that limited the movement of people and goods to and from the city to avoid spreading the disease and required all people entering or leaving the affected area to provide a certificate of typhoid vaccination. The Ministry also encouraged residents to take the "severest hygienic precautions," and health authorities mandated washing and sanitizing fruits and vegetables, boiling drinking water, and preventing food products from leaving the city to limit the spread of typhoid.31 Thanks to these measures, the infection began to decline.
The Health Ministry determined that contaminated water caused the outbreak—torrential rains washed garbage into canals that campesinos used for drinking and washing their clothes.32 The Servicio Cooperativo Interamericano de Salud Pública (SCISP) confirmed this information, and added that consuming raw vegetables, such as lettuce, washed in this contaminated water, and ice cream also facilitated its spread.33 SCISP noted that a lack of chlorination treatment for the region's water facilities contributed to contamination, and thereby drew attention to infrastructural issues as well as natural and human factors.34
Mealla conducted a district inspection on January 24 and provided more details on the situation in a letter that went to municipal and then national authorities. He said that a new outbreak occurred in the last few days, which he called "proof of the [city's] backwardness in terms of urban hygiene, which is a serious and constant danger to the health of the inhabitants." In his capacity as inspector, he noted several observations. First, laboratory analysis of the drinking water and blood samples from patients showed that both endemic and epidemic typhoid were present in the city. Second, contaminated water was the direct cause of the outbreak, which was an even greater concern, he elaborated, "because water is a principle vehicle of transmission that can cause new outbreaks, as well as other diseases that could be more serious." He also noted that, because the city was a site of industry and tourism, it merited greater sanitary attention. He requested funds for water purification so that consumable [End Page 485] water could "meet hygienic standards" and "be appropriate for a civilized and progressive pueblo." As he explained, the presence of the disease was a "dishonor that directly attacks our progress, that causes economic hardship for all types of industry, and deprives residents of central Bolivia of their only summer vacation spot."35 In doing so, he showed the importance of controlling disease for the economy, tourism, and local and national pride. The typhoid outbreak, in his mind, was a blemish on all three.
As Cochabamba and its residents were on lockdown, reports of the extent of the epidemic varied widely in the press, ranging from 15 to over 2,000 cases, with reported cases from all over the city. Mealla and Dr. Jorge Doria Medina, the Director General de Sanidad, who stayed in Cochabamba as a representative of the Health Ministry, conducted a medical survey of the region and identified 193 cases.36 Alarmed at the press coverage, Aramayo personally took control of the campaign, as he had in Oruro a year and a half earlier. He assured the readers of El Diario, a La Paz-based newspaper generally more critical of the MNR government than the celebratory La Nación, that people with malicious intent were spreading false rumors. In reality, he explained, there were very few reported cases of the disease, only 15 patients were hospitalized, and the Health Ministry was controlling the situation with mass vaccinations and disinfection of public places. He reiterated that no one was allowed in or out of Cochabamba without a vaccination certificate.37 By January 25 the epidemic was largely contained, and the official report indicated only 22 people were hospitalized and a handful of patients were treated in their homes. Aramayo asked residents to maintain their "hygienic sense" with continued vaccinations and strict supervision of food and water.38 On January 25, he told the press that mass vaccinations would continue and that there were no new reported cases.39
Though the epidemic itself was short lived, it sparked a debate in the press over the authorities' response and the need for stricter measures on public health and hygiene. First, there was the matter of culpability and response time. SCISP claimed that more than 1,500 cases were identified, and that the epidemic existed for three months before catching the attention of the authorities, placing the blame for the epidemic on the inadequacies of the nation's health infrastructure and ineptitude of its sanitation authorities (however, these claims are not substantiated by the other sources, including the SCISP bulletin published the following month).40 An editorial in El Diario maintained that the authorities took the appropriate measures to control the outbreak, but the conditions that allowed it to happen still existed and expressed the urgent need to address the issue of water purification, echoing Mealla's inspector report.41 The national press echoed SCISP's concerns about infrastructure and water sanitation despite their praise for public health authorities' swift action. There was agreement that something had to be done to prevent a subsequent outbreak. [End Page 486]
Second, the epidemic caused reflection on the efficacy of the nation's health infrastructure beyond Cochabamba. The typhoid outbreak led paceños (La Paz residents) to consider the shortcomings of their own sanitation facilities and El Diario to issue "words of condemnation" for the lack of hygienic conditions in the city's urban spaces. Dr. Hernán Cupio took the opportunity to denounce La Paz's many "grave sanitation problems" to motivate paceños to request preventative measures to avert a similar health crisis. As El Diario noted, this was an opportunity to enact stricter hygienic measures, like making street vendors cover foods exposed to contaminants, such as dust and waste from the streets, and forcing vendors to wash their "dirty" hands after touching money, insects, and other people. These measures should apply not just to individuals, the article noted, but to all public spaces. It recommended conducting sanitary inspections of places where food and drinks were served, like restaurants, bars, and markets, and places where people gathered, such as cinemas, schools, and factories. Furthermore, the press called for organized trash removal throughout the country, a solution to the problem of potable water in rural areas as well as the cities, and massive public vaccinations against typhoid.42 Doria Medina responded to this criticism by acknowledging that water conditions in La Paz were not perfect, and so it was possible for something like typhoid to spread, but he argued that the conditions were good enough that if there was an outbreak, it would not spread widely, especially if people ate well and paid attention to sanitary information.43 In the typhoid epidemic's aftermath, doctors and the press called attention to flaws in national sanitation infrastructure, using the epidemic as opportunity to demand upgrades to these facilities in the interest of public health. Doria Medina, as a Health Ministry representative, deflected this criticism and put the onus for public health on individual behaviors rather than structural deficiencies. Thus, the typhoid epidemic initiated a debate about whether individuals or institutions/infrastructure were more likely to cause or prevent a future episode.
Although the debate that played out in El Diario was limited to the voices of elite groups—doctors, government actors, and journalists—it is reasonable to assume that ideas published in print media were not confined to elite or middle-class discussions, but also entered conversations in non-literate sectors of society. Bolivia was a highly illiterate country in the 1950s, with only 31 percent of the population over 15 years of age considered literate in 1950. However, the MNR helped increase school attendance, and by extension literacy (although the impact was more substantial on men than women), and the literacy rate more than doubled by the 1976 census to 67 percent.44 Spanish-language newspapers did have a limited readership among the popular classes, but newspapers were often posted in public, and people would stand and read them to gathered crowds. As Jerry Knudson explained, "the concepts espoused by La Nación [or any newspaper] found their way into the common vocabulary, spreading by word of mouth among unsophisticated [illiterate] but enthusiastic [End Page 487] supporters of the revolution."45 Therefore, it is likely that illiterate Bolivians were also aware of debates about health infrastructure and disease spread reflected in the national press, even if their own opinions on the matter were not showcased on its front pages.
Health authorities continued to monitor the typhoid situation in other cities. For instance, Dr. Cordoba Core, a sanitary inspector from Oruro, visited La Paz in late January to tell the Health Minister about the status in Oruro—there were currently two cases, so it was not an epidemic, but he was instituting a plan of preventative vaccination to keep it from spreading in the provinces.46 By early February there were no reported cases in Oruro. The city halted importation of fruits and vegetables from Cochabamba and stationed vaccination brigades at the airport and transport offices for large-scale vaccination, especially for any travelers arriving from Cochabamba.47 Strict quarantine measures prevented typhoid from escaping Cochabamba and creating another episode in a different city, showing the efficacy of such measures.
Thus, a relatively short epidemic episode, lasting only five days from when it was reported in the press until Aramayo claimed the situation was under control, led to a fierce public debate among the media, medical professionals, and government representatives about the efficacy of the nation's health and sanitation infrastructure. While quarantine measures, mass vaccinations, and public disinfection kept the situation mostly contained, questions remained about how many cases existed, how well the sanitary authorities did their job, and whether or not another epidemic was inevitable. The press praised the response from sanitary authorities, yet some questioned whether existing sanitary infrastructure would facilitate the spread of another outbreak. This public debate also weighed the importance of individual actions versus infrastructure in preventing and spreading disease. Even though Mealla and others called attention to the water situation in Cochabamba, blame also fell on people, specifically campesinos, that used the contaminated canals to bathe, drink, and wash clothes and vegetables. Thus, the press implicitly stigmatized campesinos for causing the epidemic—they had bad hygiene and sanitation practices that threated the community. In all, the epidemic led to greater regulations on individuals and public spaces (food vendors, restaurants, etc.) but without the infrastructure upgrades called for by Mealla, Cupio, and others.
The Bolivia-Argentine Border, March 1956
The final epidemic episode erupted along the Bolivia-Argentine border, where not long after the Cochabamba episode, a polio outbreak in March 1956 raised questions about health authorities' ability to protect the nation from external threats. This border zone, in the Department of Tarija, includes the town of Bermejo, which is in a valley at the southern edge of the Andes. In the 1950s, Tarija, the principal city, had a population [End Page 488] of 16,000; Bermejo was not even listed in the 1950s census.48 The region is known for high rates of mineral deposits, and the climate can vary widely, ranging from very hot temperatures in the summer to very cold in the winter. The region's remoteness played a role in the spread of disease historically, as it did with polio in March 1956.49 Polio is an infectious disease caused by the poliovirus. Many infected people show no symptoms, while others exhibit flu like symptoms, including sore throat, fever, tiredness, muscle pain, and nausea. In severe cases, the virus attacks the spinal cord and brain, and can result in paralysis and permanent disability or death. Since the 1950s, polio has been slowly eradicated thanks to two vaccines; Jonas Salk developed the first, released in 1955, and then Albert Sabin created an oral vaccine, licensed in 1962, that is the standard used worldwide today. A Health Ministry publication summarizing activities from 1954–1955 identified only one case of acute polio in the country during the year, so it was not endemic to Bolivia nor a major national public health concern.50
A polio outbreak in northern Argentina in March 1956 raised concerns about the spread of disease across international borders. At the onset of the outbreak, Health Ministry officials established a sanitary cordon that lasted from March 6 to March 30, 1956 in order to "impede the entrance into the country of any carrier of the virus and put all those that have penetrated the territory under sanitary control."51 In contrast to the typhus and typhoid epidemics, polio was an external threat to Bolivians: it was carried across the border by outsiders that threatened the nation and its citizens. Therefore, it was necessary to prevent disease carriers from crossing into Bolivian territory, as well as sanitize those that had already penetrated the border. As mandated by the cordon, no one from Argentina could cross the border without presenting a sanitary certificate "indicating that they are in perfect health."52 Foreign workers hired by a Bolivian company had to present clean bills of health and consent to a medical inspection to cross the Bolivian border.53 Eventually, in June, the Bolivian and Argentine governments established a mixed commission designed to regulate immigration by inspecting and sanitizing workers as they crossed the border.54 Unlike in Cochabamba, where "dirty" residents shouldered the blame for spreading typhoid, the polio epidemic was implicitly blamed on Argentines, who had to be supervised, sanitized, and prevented from entering the country. Likewise, the Bolivian government regulated commercial exchange with Argentina because, as the Cochabamba episode showed, the movement of people and goods could spread disease. Some Bolivians, however, voiced sympathy for Argentina. For example, an editorial in El Diario expressed solidarity with Argentina for the "extreme gravity" of the epidemic, especially because the disease disproportionately affected children.55 Therefore, Bolivians had mixed reactions to the infectious threat posed by their southern neighbor—fear and compassion. [End Page 489]
On March 19, two weeks after the implementation of the sanitary cordon, Aramayo, when asked by the press, stated that he knew of no cases of polio in Bolivia. He also indicated that the sanitary cordon had been "intensified" in order to "prevent any carrier of the virus from entering the country," and that to date, "all of those that have penetrated the territory are under sanitary control."56 In doing so, he reassured people that health authorities had done their job and the sanitary cordon was preventing a foreign infection from entering the nation. However, about a week later, on March 27, the mayor of Bermejo, a town that is virtually surrounded by Argentina (it is part of southern Bolivian territory that juts into Argentina), notified authorities that some cases of polio were identified in a "border region," which, he noted, "has justifiably alarmed the population." As a result, according to El Diario, strict sanitary control measures were put in place.57 In addition, the Health Minister noted the strict regulation of all exchanges with Argentina.58
If polio spread beyond the border area, it was not reported in the national press. Despite the late March cases, on April 4 the Health Ministry lifted the sanitary cordon and suspended all precautionary sanitary practices in the Bolivian Embassy and Consulate in Argentina.59 However, the specter of polio continued to haunt the country. For instance, the director of a SCISP health center in Tarija (about 100 miles north of Bermejo), Dr. Antonio Sandoval, felt the need to hold a conference at the city hall, with support from the Rotary Club, "to dispel misconceptions that have caused alarm in Tarija about the polio epidemic that exploded in Argentina." He also insisted on the need to adopt strict hygienic measures. These actions seemed to have "calmed the atmosphere" and helped people understand the exact nature of the disease, especially because rumors were spreading that the disease had arrived in Bermejo, which, according to the SCISP publication, "were inaccurate."60 Additionally, at the same time that the sanitary cordon on the border ended, rumors circulated in La Paz that polio had breached the city. On April 5, the Health Ministry told El Diario that it "denied [the rumors] in the strictest terms," saying there was no evidence of any cases. The Ministry stated that the whispering was "part of a rumor campaign unleashed by the oligarchy" to discredit the MNR government and sow discord among Bolivian citizens.61
Aramayo's claim about the oligarchy's alleged machinations highlights the link between disease and government legitimacy. 1956 was a turning point for the MNR government, when a "period of initial radicalism" lasting from 1952 to 1956—when the MNR implemented universal suffrage, nationalized the tin mining industry, and decreed agrarian reform—gave way to a "revolution in retreat," with the MNR focused on consolidating power.62 Referred to as "reluctant revolutionaries," the MNR faced both internal dissent and a changing political landscape at this critical juncture.63 Additionally, the MNR was captive to popular pressures that dictated the pace and scope of the parties' key reforms. [End Page 490]
The 1956 presidential election was the first opportunity for newly enfranchised Bolivians to vote—the voting population expanded from 200,000 before 1952 to close to a million thanks to the universal suffrage decree— and on June 17, 1956 the MNR won a decisive victory. The election was an important indicator of the popularity of the MNR's policies and the legitimacy of its governance, in the realm of politics, economics, and health matters. Yet it did not alleviate the party's difficulties, and in December 1956 the MNR implemented an IMF and U.S.-backed economic stabilization plan that attempted to stabilize Bolivia's faltering economy and curb rampant inflation. Unfortunately, it also devalued the Bolivian currency, removed price controls and government subsidies, froze wages, and slashed social welfare programs, thereby creating economic hardship and political enmity.64
Given this political and economic context, rumors could signal discontent with the MNR or potentially destabilize the government. When Aramayo used the rumors as an opportunity to denounce the oligarchy, he insinuated that the MNR's political enemies worked to undermine the MNR government by disseminating false information about the spread of disease. Rumors do not have to be true to undercut public trust in government officials or health mandates, especially when related to infectious diseases or invasive medical procedures, like vaccination and sterilization, therefore the rumors' existence and Aramayo's dismissal of them demonstrate the link between public health and government authority.65 The upcoming election provided the perfect opportunity to criticize the MNR government in order to undermine its legitimacy and discredit it with voters, and for the MNR to bolster its support by suggesting that other political factions invented scenarios to weaken its credibility.
Regardless of the rumors' existence or accuracy, and despite Aramayo's vehement denials of active polio cases in the country, on May 25, a health center in Sucre, coincidentally named after the health minister (Health Center Julio M. Aramayo), announced two cases of polio being treated by the center's doctor, Dr. Luis Pereira. In response to this "alarming news," local and national authorities implemented precautions to ensure that it did not become an epidemic.66 Evidently these measures were effective, as the polio coverage disappeared from the daily press.
Once again, a relatively short-lived disease outbreak had far-reaching impacts. It shut down the national border, strained relationships with a neighboring country, and halted all commerce and exchange between Bolivia and Argentina. As a result, Bolivians expressed sympathy with their neighbor as it struggled with its own epidemic, and feared the potential consequences for their own country. Despite Health Ministry proclamations that Bolivians were safe and had nothing to worry about, cases did emerge in Bolivia, even if they were disparate and quickly contained. Finally, the episode demonstrated an element of discontent with the MNR government, as displayed by the emergence of rumors about [End Page 491] disease spread. The polio outbreak became an opportunity to question the efficacy of health authorities and critique the national government. Fear sowed mistrust, and rumors emerged that did not have to be true to be consequential. At the same time, these rumors allowed the government to claim that it was under attack from nefarious forces trying to undercut its authority. In this way, the polio outbreak contributed to political theater centered on state legitimacy.
Comparing Epidemic Episodes
The typhus, typhoid, and polio episodes caused fear in Bolivia about the consequences of the rapid and uncontrollable spread of disease. Epidemics not only afflicted individual Bolivians, but stalled national industry, commerce, and trade. Sanitary measures limited the movement of goods and people in and around infected areas. The Health Ministry's sanitary borders drew definitive lines between the sick and the healthy to prevent the spread of the disease beyond cities or between nations and protect the national economy.
In both the Cochabamba and border episodes, the Health Ministry required documentation to pass through these sanitary borderlands: in the case of Cochabamba, a vaccination certificate, and in the case of Argentina, a sanitary certificate that documented "perfect health" and immunization against polio.67 The government established boundaries between the sick and the healthy both domestically and internationally and required sanitary passports to cross the border from diseased areas to healthy ones. Health authorities curtailed mobility in the name of national wellbeing, and only those that could prove their healthy status were allowed to move freely about the country. Those individuals that could not pay for certificates or vaccinations, which in the case of the Salk vaccine for polio was noted as "very expensive" (and one editorial writer even insinuated that it was not very effective), were tightly contained and monitored.68 These measures were as much about controlling territory and bodies as controlling the spread of disease, demonstrating that mobility was a privilege inextricably linked to the ability to provide a clean bill of health upon request.
While the polio epidemic identifed an external enemy—the unregulated transmission of infectious diseases into Bolivian territory—the typhus and typhoid episodes demonstrated that the enemy was also internal: Bolivia's own citizens could be transmitters of disease. As an editorial in El Diario explained at the beginning of the typhoid outbreak, unknowledgeable campesinos washed their clothes, food, and bodies in polluted canals, therefore, this group's unsanitary practices contributed to the disease's rapid spread. Subsequent articles did not blame campesinos directly for the severity of the outbreak, yet calls for regulation of food vendors and sterilization of public places indicated that Bolivians wanted strict supervision of any place where ordinary and potentially unhygienic [End Page 492] individuals could congregate and infect healthy citizens. Health authorities, however, were not absolved of blame; as the national press and others noted, an inadequate health infrastructure and ill-prepared Health Ministry merited national condemnation. Therefore, the MNR's public health and disease control programs aimed to protect against potential future maladies as well as educate people about hygiene practices, maintain sanitary vigilance through routine inspection of public places, and create an effective national health infrastructure that could supervise public spaces and individuals.
Each episode demonstrated how the national health system functioned in terms of structure and leadership. In each instance, local authorities, when confronted with an outbreak, appealed to national authorities for assistance and supplies to combat the disease. Municipal leaders often did what they could at the local level—enact quarantines, close establishments, sanitize public spaces—but they called in the Health Ministry to expand and legitimize their actions, demonstrating the Health Ministry's authority over national public health matters. In terms of leadership, Health Ministry personnel worked swiftly to contain outbreaks and downplay the threats that they posed. In each case, Aramayo modulated the severity of the situation—he reassured citizens that the number of infected people was low, that people were not dying en masse, and that things were under control to urge calm and avoid panic. Doria Medina did the same thing when confronted about La Paz's water system; he assured residents that the situation was manageable and, if individuals behaved in the proper manner, disaster was easily avoidable. On the one hand, this tendency to deflect and downplay was a method of crowd control, aimed at avoiding public panic that could turn a troubling situation into a catastrophic one. On the other hand, it projected the Health Ministry's authority and promoted public belief in the institution's ability to keep people safe. Both the structure and the leadership of the health system contributed to its legitimacy in the eyes of local authorities, common citizens, and the national press.
For the most part, newspapers, both those that generally supported and critiqued the MNR government, praised the Health Ministry, Aramayo, and national and local workers for their role in containing the epidemics. In the few cases where the press offered criticism, it focused on outdated infrastructure rather than the actions of health authorities or the Ministry, as did doctors and health workers who called attention to sanitary concerns in different parts of the country. As in the Cochabamba episode, the press and public health community united to demand greater attention to issues of water purification, food hygiene, and infrastructural deficiencies, showing the potential of disease outbreaks to unite people in common cause. However, the press also, even if inadvertently, fostered stigma and blame against different groups by labeling campesinos in Cochabamba during the typhoid epidemic and Argentines during the polio [End Page 493] outbreak as vectors of disease. Therefore, these episodes united people around public health concerns at the same time that they divided people by class, race, and nationality.
Overall, these episodes demonstrate several points relevant to the study of disease, state building, and legitimacy. First, they show that quarantines and sanitary cordons, mass disinfections of public space, and controlled movement of people and goods are effective measures for controlling epidemics. Second, they indicate that epidemics tend to exacerbate social divides. In general, the lower classes face greater economic hardship as a result of suspended commercial activity, the expense of vaccines and medications, and restrictions on personal movement. Additionally, people of nonwhite racial and ethnic groups are more likely to be stigmatized as "dirty" or unsanitary, and therefore become scapegoats for outbreaks, even when other factors, like contaminated water, were the real culprits. Finally, disease outbreaks can both bolster and undermine national governments' and health authorities' legitimacy. In these Bolivian episodes, the epidemics generally enhanced the Health Ministry's prestige, thanks mainly to a national press that routinely praised Aramayo, other Ministry employees, and anyone that helped with containment and abatement measures. Yet the episodes also emboldened people to identify problems and demand action, which was both a critique of the Health Ministry and an appeal to its authority; people believed the Health Ministry had the capacity to address these issues, which demonstrates its legitimacy as an institution in the eyes of Bolivian doctors and citizens. However, the prevalence of rumors in the Cochabamba and border episodes had the potential to discredit the Health Ministry and its actions. The rumors' accuracy is irrelevant; if people believed them, they questioned whether the Health Ministry could adequately protect Bolivians from deadly disease outbreaks. The circulation of rumors indicates at least some dissatisfaction with the Health Ministry—and by extension the MNR—and their handling of these epidemics, showing that not all Bolivians found Aramayo credible, nor the Health Ministry legitimate.
Conclusion
As the world currently reels from a global pandemic, it is easy to feel isolated, scared, and uncertain. Yet, as these three epidemic episodes show, people in the past have faced infectious disease outbreaks and societies have emerged from them, although not always unscathed. These episodes from 1950s Bolivia have some lessons for the present moment. First, they demonstrate that protective measures, like quarantines and public sanitation, work, especially when they are implemented swiftly and uncompromisingly. In response to COVID-19, countries that enacted rapid and strict control measures (like New Zealand) began to return to normal life more quickly, while those that waffled in their response continue to suffer repeated outbreaks and struggle to contain the virus. [End Page 494]
Second, they highlight how epidemics can exacerbate social divisions and aggravate political tensions. As evidence mounts that, in the United States, African Americans and Hispanics have suffered the worst casualties from COVID-19, it becomes increasingly clear that race, class, and health disparities impact the virus's effects. Additionally, belief in the actual existence of the virus itself, as well as the efficacy of protective measures, has become a partisan issue. Third, crisis moments can create opportunities to change society for the better. Exacerbated inequality and social tensions make structural problems more obvious and can unite people to demand action, accountability, and an improved ability to confront future crises. This change might not come immediately, but global crisis and prolonged disruption of normal life tend to change perceptions about what is possible or desirable. Finally, as we are witnessing, the global pandemic affects the legitimacy of governments and organizations. Those that trust the Centers for Disease Control and the World Health Organization as credible sources of information follow their mandates for limiting the virus's spread, while people already inclined to distrust government authority and global organizations see the pandemic as a confirmation of their suspicions that these institutions are inept and unnecessary. It is too early to know how the current pandemic will end, but the lessons of the past are, and will continue to be, useful for understanding the present moment. [End Page 495]
Nicole Pacino is an Associate Professor of History at the University of Alabama in Huntsville. Her current book project, entitled Prescription for a Nation: Public Health and the Geography of Political Power in Post-Revolutionary Bolivia, 1952–1964, examines the extension of public health programs to the Bolivian countryside under the National Revolutionary Movement.
Endnotes
1. Parts of this article first appeared in Nicole Pacino, "Constructing a New Bolivian Society: Public Health Reforms and the Consolidation of the Bolivian Revolution," The Latin Americanist 57:4 (2013), 25–56.
2. Charles Rosenberg, "What Is an Epidemic? AIDS in Historical Perspective," Daedalus 118:2 (1989), 2.
3. Ibid., 1.
4. Gonzalo Soruco and Juliet Pinto, "The Mass Media in Bolivia" in Alan B. Albarran, The Handbook of Spanish Language Media (New York: Routledge, 2009), 93. El Diario was founded in partnership with Simón Patiño, one of the tin oligarchs whose holdings the MNR nationalized in 1952, and even though he had already died, nationalization impacted his heirs.
5. Charles E. Rosenberg, "Framing Disease: Illness, Society, and History," in Charles E. Rosenberg and Janet Golden, eds., Framing Disease: Studies in Cultural History (New Brunswick: Rutgers University Press, 1992); Diego Armus, ed., Disease in the History of Modern Latin America: From Malaria to AIDS (Durham: Duke University Press, 2003).
6. Gilbert Joseph and Daniel Nugent, eds., Everyday Forms of State Formation: Revolution and the Negotiation of Rule in Modern Mexico (Durham: Duke University Press, 1994).
7. Ana María Carrillo, "Salud pública y poder en México durante el Cardenismo, 1934–1940," Dynamis: Acta hispanica ad medicinae scientiarumque historiam illustrandam 25 (2005): 145–178; Anne-Emanuelle Birn, Marriage of Convenience: Rockefeller International Health and Revolutionary Mexico (Rochester: University of Rochester Press, 2006); Ann Zulawski, Unequal Cures: Public Health and Political Change in Bolivia, 1900–1950 (Durham: Duke University Press, 2007); Glen Kuecker, "Public Health, Yellow Fever, and the Making of Modern Tampico," Urban History Review/Revue d'histoire urbaine 36:2 (2008): 18–28; Mariola Espinosa, Epidemic Invasions: Yellow Fever and the Limits of Cuban Independence, 1878–1930 (Chicago: University of Chicago Press, 2009); Gabriela Soto Laveaga, "Bringing the Revolution to Medical Schools: Social Service and a Rural Health Emphasis in 1930s Mexico," Mexican Studies/Estudios Mexicanos 29:2 (2013): 397–427; and Carlos S. Dimas, "Harvesting Cholera: Fruit, Disease and Governance in the Cholera Epidemic of Tucumán, Argentina, 1867–68," Journal of Latin American Studies 49:1 (2017): 115–142.
8. Ana María Carrillo, "Profesiones sanitarias y lucha de poderes en el México del siglo XIX," Asclepio 50:2 (1998): 149–168; Claudia Agostoni, "Médicos científicos y médicos ilícitos en la ciudad de México durante el Porfiriato," Estudios de historia moderna y contemporánea de México 19:019 (1999); and Jethro Hernández Berrones, "Revolutionary Medicine: Homeopathy and the Regulation of the Medical Profession in Mexico, 1853–1942," PhD diss., University of California, San Francisco, 2014.
9. For example, see the essays in Armus, Disease in the History of Modern Latin America, as well as Birn, Marriage of Convenience.
10. David Arnold, Colonizing the Body: State Medicine and Epidemic Disease in Nineteenth-century India (Berkeley: University of California Press, 1993), chapter 3; Marcos Cueto, Cold War, Deadly Fevers: Malaria Eradication in Mexico, 1955–1975 (Baltimore: The Johns Hopkins University Press, 2007), 125–128; and Adam Warren, Medicine and Politics in Colonial Peru: Population Growth and the Bourbon Reforms (Pittsburgh: University of Pittsburgh Press, 2010), chapter 3.
11. Paul Farmer, Infections and Inequalities: The Modern Plagues (Berkeley: University of California Press, 2001); Charles Briggs with Clara Mantini-Briggs, Stories in the Time of Cholera: Racial Profiling During a Medical Nightmare (Berkeley: University of California Press, 2003); Marcos Cueto, "Stigma and Blame During an Epidemic: Cholera in Peru, 1991" in Diego Armus, ed., Disease in the History of Modern Latin America: From Malaria to AIDS (Durham: Duke University Press, 2003), 268–289; and Hanni Jalil, "'A Sick, Weak, and Ignorant People': Public Health Education and Prevention in Rural Colombia, 1930–1940," Bulletin of Latin American Research 38:1 (2019): 19–34.
12. Zulawski, Unequal Cures, and Nicole Pacino, "Stimulating a Cooperative Spirit? Public Health and US-Bolivia Relations in the 1950s," Diplomatic History 41:2 (2017): 305–335.
13. Herbert S. Klein, "Social Change in Bolivia since 1952" in Pilar Domingo & Merille Grindle, eds., Proclaiming Revolution: Bolivia in Comparative Perspective (Boston: Harvard University Press, 2003), 232–258.
14. Nicole Pacino, "Bringing the Revolution to the Countryside: Rural Public Health Programmes as State-Building in Post-1952 Bolivia," Bulletin of Latin American Research 38:1 (2019): 50–65.
15. Jerry W. Knudson, The Press and the Bolivian National Revolution (Lexington, KY: Association for Education in Journalism, 1973); and Jerry W. Knudson, Bolivia: Press and Revolution, 1932–1964 (Lanham, MD: University Press of America, 1986); and Gonzalo Soruco and Juliet Pinto, "The Mass Media in Bolivia" in Alan B. Albarran, The Handbook of Spanish Language Media (New York: Routledge, 2009), 95.
16. La Nación, "Es necesario denunciar casos de enfermedades transmisibles," January 27, 1953, 7.
17. República de Bolivia, Ministerio de Hacienda y Estadística, Dirección General de Estadística y Censos, Censo Demográfico, 1950 (La Paz: Editorial "Argote," 1955), cuadro no. 1.
18. Ministerio de Higiene y Salubridad, Informe de Labores, 1954 julio 1955, presentado por el Dr. Julio Manuel Aramayo M., Ministro de Higiene y Salubridad, 21. Archivo y Biblioteca Nacionales de Bolivia (ABNB), Presidencias de la República (PR) 1636.
19. Ibid., 28.
20. Telegram from the prefect of La Paz to Health Minister Aramayo, September 6, 1954. ABNB, PR 833.
21. Telegram from the prefect of Oruro to Health Minister Aramayo, September 7, 1954. ABNB, PR 833.
22. La Nación, "Desinfección masiva contra la exantemática," September 19, 1954, 3.
23. La Nación, "'Enevs' está cumpliendo eficaz campaña contra el tifus," September 21, 1943, 3.
24. La Nación, "El Ministro de Salubridad llevó cooperación." September 21, 1954, 3.
25. La Nación, El Ministro de Higiene coopera personalmente contra el tifus," September 23, 1954, 3.
26. Censo Demográfico, cuadro no. 1.
27. Daniel Gade, Nature and Culture in the Andes (Madison: The University of Wisconsin Press, 1999); and Nicole Pacino, "César Moscoso Carrasco and Malaria Eradication in Bolivia," Oxford Research Encyclopedia of Latin American History (New York, Oxford University Press, 2020).
28. Ministerio de Higiene y Salubridad, Informe de Labores, 1954 julio 1955, 19.
29. Ibid., 28.
30. Servicio Cooperativo Interamericano del Salud Pública, "Fue conjurada la epidemia de tifoidea, paratifoidea, en Cochabamba," Boletín del Servicio Cooperativo Interamericano del Salud Pública en Bolivia VII:81 (February 1956), 5.
31. "El Ministerio de Salubridad está combatiendo un foco de tifoidea que estallo en la ciudad de Cochabamba," El Diario (La Paz), January 20, 1956, 4.
32. "El Ministerio de Salubridad está combatiendo un foco de tifoidea que estallo en la ciudad de Cochabamba," El Diario (La Paz), January 20, 1956, 4.
33. SCISP, "Fue conjurada la epidemia de tifoidea, paratifoidea, en Cochabamba," 5.
34. "El Ministerio de Salubridad está combatiendo un foco de tifoidea que estallo en la ciudad de Cochabamba," El Diario (La Paz), January 20, 1956, 4.
35. Letter from the Inspector Distrital de Salud Pública, Luís Mealla Caso to the Prefecto del Departmento de Cochabamba, Joaquin de Lemoine, regarding a district inspection January 24, 1956. Lemoine forwarded the letter to Ministro de Higiene y Salubridad, Julio Manual Aramayo on January 26, 1956. Aramayo forwarded the letter to President Víctor Paz Estenssoro on February 10, 1956. ABNB, PR 899. The letter originally went to the prefect of the Department of Cochabamba, then to Aramayo at the Health Ministry, and he forwarded it to the President, Víctor Paz Estenssoro on February 10.
36. SCISP, "Fue conjurada la epidemia de tifoidea, paratifoidea, en Cochabamba," 5.
37. "Con la vacunación en masa y otras medidas urgentes se logró detener la fiebre tifoidea en Cochabamba," El Diario (La Paz), January 24, 1956, 4.
38. "Se controló el brote epidémico que se presentó en Cochabamba," El Diario (La Paz), January 25, 1956, 3.
39. "Sigue la vacunación en gran escala contra tifoidea en Cochabamba," El Diario (La Paz), January 25, 1956, 3.
40. "La epidemia de tifoidea," El Diario (La Paz), January 26, 1956.
41. "Prevenciones sanitarias," El Diario (La Paz), January 27, 1956, 3.
42. "Varios y graves son los problemas higienico-sanitarios de la ciudad," El Diario (La Paz), January 27, 1956, 3.
43. "No hay temer de fiebre amarilla en los Yungas ni de tifoidea en La Paz," El Diario (La Paz), January 29, 1956, 5.
44. Klein, "Social Change in Bolivia since 1952," 248.
45. Knudson, The Press and the Bolivian National Revolution, 36.
46. "El inspector de sanidad de Oruro visitó al Ministro," El Diario (La Paz), January 31, 1956, 5.
47. "Ningún caso de tifoidea," El Diario (La Paz), February 5, 1956, 3.
48. Censo Demográfico, cuadro no. 1.
49. Zulawski, Unequal Cures; and Ben Nobbs-Thiessen, "Reshaping the Chaco: Migrant Foodways, Place-making, and the Chaco War," Journal of Latin American Studies 50:3 (2018): 579–611.
50. Ministerio de Higiene y Salubridad, Informe de Labores, 1954 julio 1955, 21.
51. "No hay casos de poliomielitis en el territorio de la Nación, declara el ministro de Higiene," El Diario (La Paz), March 19, 1956, 3.
52. "Se estableció un cordón sanitario en la frontera argentina para evitar la propagación de la poliomielitis," El Diario (La Paz), March 6, 1956, 5.
53. The company was the Compañía Algodonara Boliviana. "Hoy continuarán con los examines médicos a 500 trabajadores," El Diario (La Paz), March 7, 1956, 5.
54. "Una comisión mixta velará por la salud de los braceros que emigran a la Argentina," El Diario (La Paz), June 2, 1956, 5.
55. "La epidemia de poliomielitis," El Diario (La Paz), March 10, 1956, 4.
56. "No hay casos de poliomielitis en el territorio de la Nación, declara el ministro de Higiene," El Diario (La Paz), March 19, 1956, 3.
57. "Algunos casos de poliomielitis se presentaron en la región de Bermejo," El Diario (La Paz), March 27, 1956, 3.
58. "El Ministerio de Higiene tomó disposiciones para regular el intercambio con la Argentina,: El Diario (La Paz), March 27, 1956, 5.
59. "El Ministro de Higiene y Salubridad levantó el cordón sanitario con la Argentina," El Diario (La Paz), April 4, 1956, 5.
60. Servicio Cooperativo Interamericano del Salud Pública, "Conferencia sobre poliomielitis," Boletín del Servicio Cooperativo Interamericano del Salud Pública en Bolivia VII:82 (March 1956), 8.
61. "Desmintióse el rumor de casos de poliomielitis en la ciudad de La Paz," El Diario (La Paz), April 5, 1956, p. 6.
62. Laurence Whitehead, "The Bolivian National Revolution: A Twenty-First Century Perspective" in Proclaiming Revolution: Bolivia in Comparative Perspective, ed. Marilee Grindle and Pilar Domingo (Cambridge: Harvard University Press, 2003), 29, and James Dunkerley, Rebellion in the Veins: Political Struggle in Bolivia, 1952–82 (London: Verso Editions, 1984), 83–119.
63. The party was not an ideologically cohesive unit; the left, moderate, and conservative factions negotiated a power sharing arrangement. Herbert Klein, Bolivia: The Evolution of a Multi-Ethnic Society (New York and Oxford: Oxford University Press, 1992), 241.
64. George Jackson Eder, Inflation and Development in Latin America: A Case History of Inflation and Stabilization in Bolivia, Michigan International Business Studies, no. 8 (Ann Arbor: Program in International Business, Graduate School of Business Administration, University of Michigan, 1968); Jon V. Kofas, "The Politics of Austerity: The IMF and US Foreign Policy in Bolivia, 1956–1964," The Journal of Developing Areas 29:2 (1995): 213–236; and Kevin Young, "Purging the Forces of Darkness: The United States, Monetary Stabilization, and the Containment of the Bolivian Revolution," Diplomatic History 37:3 (2013): 509–537.
65. Luise White, Speaking with Vampires: Rumor and History in Colonial Africa (Berkeley: University of California Press, 2000); James F. Siekmeier, " A Sacrificial Llama? The Expulsion of the Peace Corps from Bolivia in 1971, The Pacific Historical Review 69:1 (2000): 65–87; Erica M. Nelson, "Birth Rights: Bolivia's Politics of Race, Region, and Motherhood, 1964–2005," PhD diss., University of Wisconsin-Madison, 2009; Vanessa Freije, "Speaking of Sterilization: Rumors, the Urban Poor, and the Public Sphere in Greater Mexico City," Hispanic American Historical Review 99:2 (2019): 303–336.
66. "Se presentaron en la capital dos casos de poliomielitis," El Diario (La Paz), May 25, 1956, 3.
67. "Con la vacunación en masa y otras medidas urgentes se logró detener la fiebre tifoidea en Cochabamba," El Diario (La Paz), January 24, 1956, 4; "Se estableció un cordón sanitario en la frontera Argentina para evitar la propagación de la poliomielitis," El Diario (La Paz), March 6, 1956, 5.
68. "No hay casos de poliomielitis en el territorio de la Nación, declara el ministro de Higiene," El Diario (La Paz), March 19, 1956, 3; and "La epidemia de poliomielitis," El Diario (La Paz), March 10, 1956, 4.
