The 1802 Saint-Domingue Yellow Fever Epidemic and the Louisiana Purchase

Abstract

Epidemics have been pivotal in the history of the world as exemplified by a yellow fever epidemic in the Caribbean that clearly altered New World geopolitics. By the end of the 18th century, yellow fever-then an "emerging disease"-was widespread throughout the Caribbean and particularly lethal in Saint-Domingue (present day Haiti). From 1793 to 1798, case fatality rates among British troops in the West Indies (including Saint-Domingue) were as high as 70%. A worse fate befell newly arrived French armed forces in 1802, ostensibly sent by Napoleon to suppress a rebellion and to reestablish slavery. Historians have disagreed on why Napoleon initially dispatched nearly 30 000 soldiers and sailors to the island. Evidence suggests the troops were actually an expeditionary force with intensions to invade North America through New Orleans and to establish a major holding in the Mississippi valley. However, lacking knowledge of basic prevention and control measures, mortality from the disease left only a small and shattered fraction of his troops alive, thwarting his secret ambition to colonize and hold French-held lands, which later became better known as the Louisiana Purchase. If an event of the magnitude of France's experience were to occur in the 21st century, it might also have profound unanticipated consequences.

Full text

The 1802 Saint-Domingue Yellow Fever Epidemic
and the Louisiana Purchase
John S. Marr, MD; John T. Cathey, MS
rrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrr
Epidemics have been pivotal in the history of the world as
exemplified by a yellow fever epidemic in the Caribbean
that clearly altered New World geopolitics. By the end of
the 18th century, yellow fever—then an “emerging
disease”—was widespread throughout the Caribbean and
particularly lethal in Saint-Domingue (present day Haiti). From
1793 to 1798, case fatality rates among British troops in the
West Indies (including Saint-Domingue) were as high as 70%. A
worse fate befell newly arrived French armed forces in 1802,
ostensibly sent by Napoleon to suppress a rebellion and to
reestablish slavery. Historians have disagreed on why Napoleon
initially dispatched nearly 30 000 soldiers and sailors to the
island. Evidence suggests the troops were actually an
expeditionary force with intensions to invade North America
through New Orleans and to establish a major holding in the
Mississippi valley. However, lacking knowledge of basic
prevention and control measures, mortality from the disease left
only a small and shattered fraction of his troops alive, thwarting
his secret ambition to colonize and hold French-held lands,
which later became better known as the Louisiana Purchase. If
an event of the magnitude of France’s experience were to occur
in the 21st century, it might also have profound unanticipated
consequences.
KEY WORDS: Aedes, dengue hemorrhagic fever, epidemics,
Haiti, history, 19th century, yellow fever.
●Yellow Fever in the New World
Historians have speculated that New World yellow
fever epidemics began in the Caribbean basin in 1647-
1648. Carter,1a major yellow fever historian, con-
cluded that its origin was West Africa and got im-
ported (along with malaria) as a result of the massive
J Public Health Management Practice
, 2013, 19(1), 77–82
Copyright C2013 Wolters Kluwer Health |Lippincott Williams & Wilkins
slave trade. Epidemics raged on the coastal Americas
and Caribbean islands for more than 300 years, influ-
encing the political landscape of 5 colonizing Euro-
pean countries. However, the largest recorded yellow
fever epidemic with the highest case fatality rate oc-
curred in 1802 in Saint-Domingue (Table 1).2At that
time, Saint-Domingue—the western third of the island
of Espa˜
nola (Spanish)/Hispaniola (English)—had been
retaken from England in 1798. The English had occu-
pied the colony since 1793 to suppress slave rebellion
and to control buccaneers who had preyed on Euro-
pean ships for more than a century (the Figure). In
a 6-year period, Great Britain had experienced more
than 100 000 killed or made ill from the disease in their
West Indian possessions.3From 1793 to 1798, case fa-
tality rates among British troops in the West Indies (in-
cluding Saint-Domingue) were as high as 70%. This
devastating experience was a primary reason for their
withdrawal, along with their defeat by Haitian revolu-
tionaries, led by General Francois Dominique Toussaint
L’Ouverture, who successfully abolished slavery on the
island.
●The French Reinvasion of Saint-Domingue
and the Epidemic of 1802
Although the French had earlier assisted the Haitians
in fighting the British and Spanish and in freeing slaves,
Napoleon later resisted Toussaint’s attempt to take
full control of the island. With secret intentions of
Author Affiliations: Department of Community and Public Health, Virginia
Commonwealth University School of Medicine, Richmond, Virginia (Dr Marr); and
King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia (Dr
Cathey).
The authors thank Alfred Crosby, Duane Gubler, Myron G. Schultz, Cabell
Smith, and Jack Woodall, for their important comments and suggestions, and the
reviewers, who improved the article with important suggestions.
No conflicts of interests are declared. There were no sources of support.
Correspondence: John S. Marr, MD, 6315 Pig Mountain Road, Free Union,
VA 22940 (Jsmarr4@earthlink.net).
DOI: 10.1097/PHH.0b013e318252eea8
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
77

78 ❘Journal of Public Health Management and Practice
TABLE 1 ●Major New World Yellow Fever Epidemics
qqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqq
Date
Estimated
Duration, mo Place
Estimated
Mortality
1672-1673 24 Cuba 2000
1793 5 Philadelphia, Pennsylvania 5000
1798 4 New York, New York 2100
1802-1803 14 Saint Domingue 29 000-55 000
1853 4 New Orleans, Louisiana 7800
1853 3 Norfolk, Virginia 3000
1873 2 Philadelphia, Pennsylvania 5000
1873 6 Memphis, Tennessee 2000
1878 6 New Orleans, Louisiana 4046
1878 6 Mississippi Valley 13 000
From Kohn2
reoccupying the island and reinstituting slavery, in the
late fall of 1801, Napoleon sent an initial force under
his brother-in-law, General Victor Emmanuel Charles
LeClerc, which led to war.4Napoleon’s strategic plans
were to eventually include a force of 60 000 soldiers and
sailors to subdue and co-opt the Haitian military, which
numbered less than a militia of 55 000 soldiers and
100 000 irregulars.5The largest fleet France had ever
mounted consisted of a total of 86 frigates and ships
of the line carrying 31 131 troops and artilleries from
its revolutionary armies, including a 5200-man Polish
legion. However, the recent observations by the med-
ical historian, McNeill,6note “considerable confusion
surrounds the numbers of French military personnel
sent to St. Domingue with totals in the literature rang-
ing from 60,000 to 82,000.” Ships landed in 3 different
ports in the spring of 1802. Twenty thousand soldiers
and sailors followed in later months. (In comparison,
40 000 soldiers, 10 000 sailors, 14 frigates, 13 ships of the
line, and 400 transport ships were used in Napoleon’s
failed 1799 Egyptian campaign.)7After arrival of his
troops, LeClerc was faced with fighting a guerrilla war
against Toussaint for several months along the coast
and immediate inland enclaves but eventually suc-
ceeded in restoring trade. Toussaint, faced with increas-
ing defections from his own followers, eventually was
tricked by LeClerc into a meeting where he was ar-
rested and exiled to Europe to die in a French jail. But
the struggle against the French was taken up by his
successor, Jean-Jacques Dessalines. The conflict contin-
ued, resulting in a Haitian declaration of independence
in 1804.
Within a year of LeClerc’s arrival in Haiti, he was
faced with a more serious problem than the rebellious
FIGURE ●Portion of Map Created by French Explorer Louis Hennepina
qqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqq
aShowing the Louisiana territory and portions of the Caribbean, including the island of Saint-Domingue located immediately east of “I de Cuba” (map originally entitled
Carte de
la Nouvelle France et de la Louisiane Nouvellement decouverte
, ca. 1683). Reproduced with permission from the Louisiana State Museum, New Orleans, Louisiana.
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

Yellow Fever and the Louisiana Purchase ❘79
Haitians. His troops were succumbing in droves to
the most grievous epidemic of yellow fever in history.
Forts with garrisoned troops and offshore ships pro-
vided suitable environments for mosquito breeding.
Estimates of the death toll vary along with estimates of
the number of troops sent to Saint-Domingue. McNeill
reports that 50 000 to 55 000 (80%-85%) French soldiers
died, predominately because of yellow fever with only
a few related to combat (along with more than 20 000
deaths among civilians). By any standards, the number
of deaths and case fatality rate are difficult to compre-
hend unless one takes into account a convergence of
environmental and ecological factors ideal for an epi-
demiological disaster. McNeill documented how tem-
perature, rainfall, and ecological changes all favored
Aedes propagation, and mosquito density and longevity
in the Caribbean, all conducive to the spread of yellow
fever in the Caribbean between 1620 and 1914.6
The epidemic began in the spring of 1802. In April
and May of that year, LeClerc wrote to Denis Descr`
es,
the French Minister of Marine:8
A man cannot work hard here without risking his life
and it is quite impossible for me to remain here for
more than six months . . . my health is so wretched that I
would consider myself lucky if I could last for that time!
The mortality continues and makes fearful ravages. . . . .
You will see that the army which you calculated at
twenty-six thousand men is reduced at this moment to
twelve thousand . . . . At this moment I have thirty-six
hundred men in the hospital. In the last fortnight I have
lost thirty to fifty men a day in the colony, and there is
no day when two hundred to two hundred and fifty
men do not enter the hospital, while no more than fifty
come out.
●Factors Contributing to Mortality
There have been previous attempts to explain the high
case fatality rate among the French troops and civil-
ians compared with other New World yellow fever epi-
demics (Table 1). This extraordinary Saint-Domingue
figure also exceeds estimated rates for other lethal
arthropod-borne diseases (Table 2). The ranges in mor-
tality rates for these diseases are based on a spectrum
of historical and contemporary epidemics; the wide
ranges suggest that numerous adverse conditions are
responsible for these estimates. For example, an inor-
dinately high-case fatality rate for Oroya fever (90%)
is attributed to salmonellosis coinfection, whereas the
usual, commonly accepted rate for systemic bartonel-
losis is 40%.9In Saint-Domingue the confluence of
the many confined, immunologically naive hosts, a
large reservoir of infected individuals, favorable cli-
matic conditions, and the macro- and microenviron-
ments conducive to vector multiplication may have
TABLE 2 ●Arthropod-Borne Disease by Vector and Case
Fatality Rate
qqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqq
Disease Vector Case Fatality Rate, %
Yellow fever Mosquito 20-50
Dengue hemorrhagic fever Mosquito 40-50
Crimean-Congo hemorrhagic fever Tick 2-50
Epidemic typhus Louse 10-40
Rocky Mountain spotted fever Tick 20-80
Systemic bartonellosis (Oroya fever) Sand fly 10-90
Bubonic plague Flea 50-60
Malaria Mosquito 1-20
From Heymann.9
been synchronized in such a way as to create the condi-
tions for the epidemic. In addition, an element absent
in other yellow fever outbreaks of the era was ongo-
ing warfare and the presence of an opponent with an
understanding of how the fevers differentially affected
the Europeans, particularly those newly arrived. In ad-
dition to being a guerrilla tactician, Toussaint had med-
ical knowledge and an awareness of when and where
the fevers would strike his European enemies.6He ap-
parently knew that by maneuvering the whites into
the ports and lowlands during the rainy season, they
would die in droves. In a letter to Dessalines, he wrote:
“Do not forget that while waiting for the rainy season,
which will rid us of our enemies, we have only destruc-
tion and fire as our weapons.”6This observation sug-
gests that Toussaint knew more about the environmen-
tal conditions conducive to yellow fever transmission.
●Yellow Fever Endemicity and Epidemicity
The Haitian historian, David Patrick Geggus,7notes
that, in the 1780s, an established French town on Saint-
Domingue experienced an overall annual mortality rate
of only 2.86% in its soldiers and 1.85% in sailors. He
suggested that the indigenous population and occupy-
ing troops had been largely free of endemic disease (pri-
marily malaria and yellow fever) due to an acquired im-
munity or infrequent contact with infected vectors, or
both. In the mid 1700s, epidemics on Saint-Domingue
were less frequent; tended to occur during summer
months; and, in some years, the population was en-
tirely free of disease. He posed 3 determinants for the
subsequent disastrous epidemic during the British oc-
cupation. These factors may also be applicable to the
French, along with additional considerations.
1. Increased concentrations of confined, recently ar-
rived, nonimmunes.
2. Increased importation of vectors from nearby islands
and Africa.
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80 ❘Journal of Public Health Management and Practice
3. Climatic conditions conducive to multiplication of
vectors.
As demonstrated by the earlier English occupation,
newly arrived European troops—not “seasoned” to the
Americas—were perhaps more susceptible to infection,
as a consequence of a miserable and unhealthy ocean
passage.6They had no time to acclimatize before en-
gaging in fighting in an unfavorable tropical climate.
Garrisoned facilities and nearby ships offered suitable
confined environments for Aedes breeding in fresh wa-
ter containers. There had to have been close proxim-
ity between susceptible troops, mosquitoes, and men
suffering from yellow fever, which ensured continuing
transmission and escalation of disease. Like the British
forces, the French were tightly confined. The ongoing
hostilities prevented escape from the disease to Aedes-
free mountain elevations or nearby countryside, which
was a common reaction when yellow fever erupted
in American cities that may have decreased estimated
overall case fatality rates. In skirmishes along the coast,
infected mosquitoes would have also abounded. The
importation of additional Aedes vectors from other
French colonies in the Caribbean or directly from Africa
on slave ships is certainly possible.
Geggus suggested an additional contributing factor
to the high mortality rate—French medical practices. By
1800, Great Britain had begun to discard antiphlogistic
practices, but, in the Caribbean, Britishers had prob-
ably used its therapeutic medicine, as did the French
who continued to favor this philosophy. One practice
in particular—venesection—was advocated by French
physicians for most illnesses, even wounds. A most in-
fluential medical figure at the time was Francois Joseph
Victor Broussais—“the most sanguinary physician in
history”—who continued to promote frequent blood
letting for most conditions well into the 19th century.10
From as little as 30 mL to as much as 3 to 6 pt of blood
might be rapidly taken from the patient to improve
his outcome. This antiphlogistic practice was common-
place in the French West Indies at the time. Bloodletting
among sick and injured soldiers, sailors, and civilians
suffering from any condition—including yellow fever
(a hemorrhagic fever) or malaria (an acute hemolytic
disease)—may have also added to the unusually high
mortality rates observed among French troops. In ad-
dition to bloodletting, French medicine advocated a
gastric purgative (calomel), blistering, and a daily bot-
tle of Madeira (or rum) for each soldier to “comble de la
d´
eraison” induced by fever.11
In addition, dengue fever and dengue hemorrhagic
fever—well known to the French as maladie de Siam,
brought from other Caribbean colonies and Africa—
have not been fully considered. According to Gubler,12
both dengue and dengue hemorrhagic fever may have
been present in the New World as early as 1635 and both
were certainly present at the turn of the 18th century.
The French colonies in Southeast Asia had experienced
a disease compatible with dengue hemorrhagic fever
for decades, and its hemorrhagic signs and symptoms
resemble yellow fever enough that the 2 diseases may
have been indistinguishable at the time.
In the late fall, 1803 the remaining French troops
on Saint-Domingue began a withdrawal after suf-
fering the death of most of their forces, including
LeClerc and 5 other generals.13 In November 1803
Jean-Jacques Dessalines, Toussaint L’Ouverture’s suc-
cessor, defeated the last French forces at the Battle of
Verti`
eres. Two months later on January 1, 1804, he de-
clared independence, naming the new republic Haiti
(Ayiti, Taino for “land of high mountains”).
●Consequences and Counterfactuals
The epidemic resulted in an alteration of Napoleon’s
plan for his Caribbean possessions, and a bolder de-
sign on other New World territories. Although the im-
portance of yellow fever throughout the Americas has
been well documented by Carter, McNeill, and others,
Ackerknecht14 was one of the first medical historians to
propose that it had profound effects in the shaping the
early history of the United States.
Perhaps the most important epidemic in history was
that of Santo Domingo in 1802. It killed 29,000 of 33,000
soldiers and sailors sent by Napoleon to Santo Domingo
with the aim of reconquering that island and thereafter
the Mississippi valley. Napoleon might have succeeded
in his plans despite the heroic resistance of the Negroes
in Haiti, if the yellow fever had not*[sic] been nipped in
the bud. Had Napoleon succeeded there would have
followed a trichotomy of the North American continent
into French, Spanish and English regions.
Ackerknecht’s suggestion of an ulterior plan is not
mentioned by many historians who focus on the dis-
ease alone, or the rebellion itself; some argue that
reinstitution of slavery was his sole intent. Thus,
Corbett11 offered 2 possible motives for this disastrous
French misadventure—a “linear plot theory” (a North
American invasion) and the “Saint-Domingue-Center
view”; the latter proposed that Napoleon wished only
to reestablish a lucrative colony—“the Pearl of the
Antilles”—as a cash cow (vache `
alait)andtore-
institute an Exclusif on sugar exportation. However,
there is substantial evidence that he had greater am-
bitions. In a 1934 study of 18th-century French diplo-
macy in Louisiana, Lyon,15 cited a June 4, 1802, let-
ter from Napoleon to Decr`
es that revealed his true
*No doubt, he intended to say “nipped in the bud.”
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Yellow Fever and the Louisiana Purchase ❘81
intentions toward New World territories. His appar-
ent objective at the time was not only to suppress the
ongoing slave revolt on the island of Saint-Domingue,
but also to prepare for an invasion of the Mississippi
valley through New Orleans. With Saint-Domingue un-
der control, Napoleon readied another force in ports
along the coast of Holland:
My intention, Citizen Minister, is that we take
possession of Louisiana with the shortest possible
delay, that this expedition be organized in the greatest
secrecy, and that it have the appearance of being
directed on St. Domingo. The troops that I intend for it
being on the Scheldt, I should like them to depart from
Antwerp or Flushing.
France had already begun to prepare the southern
Mississippi region against possible aggression by
Americans infiltrating the upper valley, knowing that
the United States did not possess a significant armed
force—only a small coast guard fleet (no warships)
and a recently reconstituted army of fewer than 20 000
soldiers. The United States was already involved in
the quasi-war with France because its merchant ships
transporting sugar to Great Britain were being inter-
cepted. A 1799 letter from Thomas Jefferson to James
Madison substantiates a fear that Southern slaves
(estimated to be more than half a million) would rebel,
assisted by “Caribbean Black sailors” and a French
armed force.16 In addition, Napoleon anticipated that
these combined forces would be joined by 20 000 sym-
pathetic, disaffected Native Americans.17 These Indians
living on the east side of the Mississippi—Chickasaws,
Choctaws, Alibamons, Creeks, and others—were re-
ported as “devoted” to the French and were to receive
gifts that included “4,000 trading muskets, painted
yellow with some black flowers and a ferocious beast
on the butt end; 1000 (superior) muskets for the chiefs;
150 carbines; 20 000 pounds of powder; 25 000 gun
flints; 10 000 ramrods; 10 000 briquets; 5000 pickaxes;
1000 sabres; 5000 tomahawks; 3000 trading razors,
10 000 woolen strips; 1000 muslin shirts for the chiefs;
500 coats of Carcassonne blue cloth; with red collars
and cuffs; 500 black handkerchiefs, etc., etc.”.15
Earlier, in 1799, Toussaint had refused to comply with
the French Directory’s plan to invade Jamaica and then
Louisiana. The plan was put into abeyance for 2 years
until Napoleon took power as First Consul in 1801. By
that time, he had declared himself governor general for
life and the leader of the Republic of Saint-Domingue.
Napoleon, ignoring these declarations, dictated a letter
to Toussaint suggesting he was readying the plan:4
I am instructing the Minister of Marine to forward to
you your commission of Captain General of the French
part of St. Domingo. The government could hardly offer
you greater proof of its confidence in you. Use your
influence to the utmost for the maintenance of peace
and the encouragement of agriculture. Train and
organize the National Guard and the troops of the line. I
hope the time is not far distant when an army from St.
Domingo will be able to contribute to the extension of
French possessions and glory in your part of the world.
I salute you affectionately,
Bonaparte
Remarking on the above the American historian and
journalist, Henry Adams, stated:18
Bonaparte explained the subject in confidential papers,
which would not have been secret unless they had
expressed his true objects. St. Domingo, like all the West
Indies, suffered a serious disadvantage, being
dependent for its supplies chiefly on the United
States—a dangerous neighbor both by its political
example and its commercial or maritime rivalry with
the mother country. The First Consul hoped to correct
the evil by substituting Louisiana for the United States
as the source of supplies for St. Domingo. In case of
war, either with the United States or England,
St. Domingo and the other French colonies in the West
Indies could be safely left to themselves, if Louisiana
and perhaps also Florida could be made a certain base
of supplies—for the islands had only famine to fear.
Napoleon eventually changed his plans and ordered a
separate fleet, assembled in Holland, to be sent directly
to Louisiana, possibly to avoid further ravages of dis-
ease on Saint-Domingue. For a time, he successfully
deceived both American and British observers:
Troops are now going out from some of the northern
parts of France for Sto Domingo, with orders to march
directly into the mountains and attack the Blacks before
the Fever can make much ravage among them. (troops
don’t want to go) there was a threat to shoot every 10th
man. Their fears of the climate of Sto Dom are natural,
for out of the late army of 35,000 men, 32,000 died of the
fever. But soldiers here are made to do anything. The
country is under a strong military government, which is
perhaps the most powerful upon earth. The affairs of
this government are transacted in great mystery,
compared to that of the US. 19
That force never left Holland due to a delay in ob-
taining official royal delivery of the lands from Spain
(cash-strapped, Spain had no colonial intentions for
the area). The order did not arrive until October, af-
ter which the English Channel ports became icebound.
Great Britain and the United States had become suspi-
cious of the concentration of ships and the British block-
aded the ports. By the following spring, the total expen-
ditures for the expeditions had reached 2 000 000 francs
(US $5.5 million in 2012). Napoleon, with grander plans
in mind, lost interest in his North America intentions
and sold off the territories to the United States in April
1803—the Louisiana Purchase.
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82 ❘Journal of Public Health Management and Practice
●Conclusions
One hundred years before the epidemiology of yel-
low fever was elucidated by Walter Reed and others,
lack of knowledge of basic preventive and control mea-
sures in the early 19th century led to one of the largest
epidemics of yellow fever in history. Indeed, effective
measures were absent (improper isolation and quar-
antine measures) or counterproductive (venesection);
all facilitated transmission of disease and subsequent
deaths. Volumes have been written on the historical im-
pact of yellow fever epidemics in North America. (The
famous 1793 Philadelphia epidemic was attributed to
ships carrying fleeing citizens and mosquitoes from
Saint-Domingue.) Scores of other books and articles
have been written on the Haitian revolution, focusing
on Toussaint L’Ouverture and the heroism of his fel-
low countrymen, but few authors fully acknowledge
the significant contribution of yellow fever to subse-
quent events. Had Napoleon succeeded, it is certain
he would have reinstituted slavery; enacted a sugar
Exclusif; fortified the island; and strengthened his other
Caribbean and North American possessions, includ-
ing the Louisiana territories. As Ackerknecht14 noted,
the epidemic had a pivotal effect on the history of
the United States. The once profitable New World
colony would have become a jewel in Napoleon’s
crown—a crown he was to place on his own head in
1804. The Louisiana territories would also have be-
come a major part of the tripartite European hold in
North America. The Haitian epidemic was an unantic-
ipated catastrophe that changed Old and New World
history.
If a Black Swan event of the magnitude of France’s
experience were to occur in the 21st century, it might
also have unexpected economic and geopolitical con-
sequences. The history of yellow fever has ranged be-
tween complete ignorance of prevention and control
measures to present day knowledge that may not an-
ticipate future scenarios. A continuing mystery is why
the disease has never appeared in Asia and the Indian
subcontinent where its mosquito vector is abundant. In-
nate immunity, stringent immunization requirements,
isolation and quarantine measures, and infrequent in-
troduction of the virus do not seem to explain the con-
tinuing absence of the disease in these areas. With ab-
solute increases in air travel, international tourism, and
favorable climatic conditions, the disease may conceiv-
ably be successfully inoculated into the only continent
that has been inexplicably free of yellow fever. These
factors might also play elsewhere, reestablishing it (and
dengue fever) in suitable European, North American,
and Caribbean locales.20 The last chapter on the history
of yellow fever may not have been written.
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