Sir Arthur Conan Doyle arrived in Bloemfontein, South Africa, in April 1900, less than a year into the Second South African Boer War.  At 41, the creator of Sherlock Holmes was too old to join the British Army, but his services as a physician were sorely needed. 

For the next few months, Doyle and the staff of Langman Hospital—a field hospital set up on a cricket pitch on the outskirts of the city—struggled under the number of those sick and dying with typhoid. “For more than two months the hospitals were choked with sick … nearly all enterics [typhoid fever patients] … As many as fifty men died in one day, and more than 1,000 new graves in the cemetery testify to the severity of the epidemic,” wrote Doyle in The Great Boer War.

More than 8,000 British troops succumbed to the disease, a bacterial infection that spreads quickly and can perforate the bowel. Vaccination might have helped to blunt these numbers significantly—the first typhoid vaccine had been developed a few years before the start of the war. But it was still considered experimental and side effects could be severe. The British army opted to make it voluntary, and the vast majority of the troops refused it.

Other nations would not take the same tack. Germany, for instance, had a long tradition of mandatory vaccinations for its troops, and typhoid vaccinations began in 1904 for German armies stationed in German South West Africa (later Namibia). Contemporary studies showed that many lives were most likely saved.

The lessons of both the British and Germans in South Africa were front of mind as the nations prepared for World War I. “More died from the bacilli of this disease than from the bullets of the Boers,” Sir William Osler reminded British Parliament. While the vaccine was still not compulsory for British soldiers, more than 90% chose to be inoculated during the final three years of the Great War.

Less fortunate, however, were the Africans they left behind. While typhoid has been virtually eradicated in high-income countries, populations in the world’s developing countries, largely unvaccinated, have seen the disease persist and mutate. Extensively drug resistant (XDR) typhoid, which is resistant to at least five antibiotic classes, appeared in Pakistan in 2016. By the end of 2020, the CDC had identified nine cases of XDR typhoid spread across six different U.S. states in people with no history of travel to Pakistan. True safety against typhoid, it would seem, calls for a global, coordinated response.