20th-century public health (c.1900–present)

OCR Paper 1 brings the People's Health theme up to the present. The 20th century is the period of most dramatic, verifiable improvement in life expectancy — but OCR also expects students to recognise remaining inequalities and new challenges. The key debate: "Has the state solved public health?"

The context: early 20th century

At the start of the century, health inequalities remained stark:

• Boer War (1899–1902): one-third of recruits rejected as unfit. This shocked the government — if citizens were unhealthy, the Empire was at risk.
• Liberal welfare reforms (1906–14): free school meals (1906), school medical inspections (1907), old-age pensions (1908), National Insurance (1911) — the state began accepting responsibility for health.
• Rowntree's survey of York (1901): proved poverty (not laziness) was the cause of ill-health — provided scientific evidence for state action.

World War I and interwar period

• 1918–19 flu pandemic: killed more than WWI (c.50–100 million globally; c.250,000 in UK). Showed limits of medical knowledge even after germ theory.
• Interwar: nutrition improved; infant mortality fell; tuberculosis (TB) rates dropped.
• 1928: Alexander Fleming discovered penicillin (though clinical use required Florey and Chain's development in 1940–41).

The National Health Service (NHS) 1948

The most significant single change in British public health:

• Proposed by the Beveridge Report (1942): identified disease as one of the "Five Giants" to be defeated (alongside want, ignorance, squalor and idleness).
• Aneurin Bevan (Health Secretary) created the NHS — healthcare free at the point of use, funded from taxation.
• Impact: removed financial barrier to seeing a doctor; childhood diseases treated quickly; maternal mortality fell sharply; life expectancy rose from ~68 (1948) to ~81 today.
• Controversies: funding pressures from the start; GPs resisted (eventually agreed with "golden handshake" payment); dental and optical charges introduced within 3 years (1951).

Antibiotics

• Fleming discovered penicillin 1928; Florey and Chain developed it into a usable drug 1940–41.
• First used clinically 1941; mass production by 1943 for Allied forces.
• Transformed treatment of bacterial infections: TB, pneumonia, sepsis — previously deadly — became treatable.
• Problem (21st century): antibiotic resistance — over-prescribing has led to resistant strains (MRSA, etc.).

Mass vaccination

• Smallpox: Edward Jenner's vaccine (1796) was the foundation. Smallpox declared globally eradicated by WHO 1980 — the only human disease to be eradicated.
• 20th-century programmes: BCG vaccine against TB (from 1950s); polio vaccine (Salk 1955, Sabin 1960); MMR (measles, mumps, rubella) from 1988.
• NHS vaccination schedule: routine childhood immunisation eliminated or controlled diseases that had killed millions.
• Anti-vax movements: MMR-autism claim (Wakefield 1998, since retracted and discredited) caused vaccination rates to fall and measles outbreaks to return.

Lifestyle campaigns and remaining inequalities

Despite massive improvements, inequalities persist:

• Health gap: life expectancy in the poorest areas of the UK is up to 10 years less than in the wealthiest.
• Lifestyle diseases: cancer, heart disease, diabetes, obesity — caused by smoking, diet, lack of exercise. The state campaigns (smoking ban 2007; 5-a-day; Change4Life) but cannot force behaviour change.
• Mental health: growing recognition since the 1980s; still underfunded relative to physical health.

Continuity and change: the full thematic picture

The NHS represents a revolution in the state's role — from no public health responsibility (medieval) to universal provision (1948). But:

• Inequalities remain.
• New diseases emerge (HIV/AIDS from 1980s, Covid-19 2020).
• Personal behaviour still a major determinant of health.

Common OCR exam mistakes

1. Saying Fleming developed penicillin — he discovered it (1928). Development into a usable drug was by Florey and Chain (1940–41).
2. Saying the Beveridge Report created the NHS — it proposed it; Bevan created it in 1948.
3. Forgetting the continuity: health inequalities remain despite the NHS; the state cannot guarantee equal outcomes.
4. Saying smallpox was eliminated in the 1800s — Jenner's vaccine was 1796 but global eradication was 1980.