Advocacy as an Origin of Pediatrics

Dr Jacobi’s Vision

The phrase structural drivers of health (SDoH) is new, and strategies for integrating SDoH screening into clinical practice are still being investigated.¹ However, the idea that social, historical, and cultural forces and structures are as relevant to one’s health as one’s (or one’s parents’) individual choices and genes is not new. Indeed, structural determinants formed the basis of Dr Abraham Jacobi’s approach to practicing medicine and promoting the development of the field of pediatrics. Jacobi believed a physician’s role did not begin and end in an examination room. Seeing children living and toiling in substandard and unsafe conditions, Jacobi came to realize that a few clinical encounters were insufficient to address the material health needs of many of the nation’s youth. In his 1912 farewell address as president of the American Medical Association (AMA), he exhorted his fellow members to get involved in policy making and public affairs: “[O]ur main position in life should be to wake up our neighbors, particularly the general practitioners, that vast number of men all over the country, and see to it that they participate in public affairs. Nobody’s influence is universal, but every man can influence more or less state officials.”²

This was not a one-off statement, as Jacobi devoted much of his career to public health and to improving the living and working conditions of those living in poverty. In 1904, he wrote: “It is not enough to work at the individual bedside in the hospital. In the near or dim future, the pediatrician is to sit in and control school boards, health departments, and legislatures. He is the legitimate advisor to the judge and the jury, and a seat for the physician in the councils of the republic is what people have a right to demand.”³ Those who would criticize his activism as promoting “socialism” were told: “Where mothers and babies are concerned, the term charity should be supplemented with responsibility. It is useless to call that socialism or communism.”⁴ For Jacobi, the assumption of civic activism roles was as much a part of medical professionalism as diagnosing and treating disease. He wrote or co-wrote hundreds of scientific papers that were compiled after his death into 8 volumes totaling more than 4000 pages.⁵ Beginning in the second half of the 19th century, Jacobi’s work served as a focus of pediatric thought and teaching, with his methods and ideas still cited today.^6,7

Origins of Pediatrics

Born in Prussia (now Germany) in 1831, Jacobi fled to America from his home country in 1853, after being imprisoned for his participation in the revolutions of 1848.⁵ Once established in America, he quickly became a leader in developing the field of pediatrics. He was the first to create a free pediatric clinic in the United States,⁸ the first professor of pediatrics (at New York Medical College), the founder and chair of the AMA’s Section on Pediatrics, the founder and president of the American Pediatric Society, and the founder of New York City’s first pediatric department in a general hospital.⁹ He also established a method of bedside teaching in which medical school faculty conduct teaching rounds in hospitals with actual patients.^9,10

For Jacobi, the assumption of civic activism roles was as much a part of medical professionalism as diagnosing and treating disease. 

In his many academic and professional posts—including serving as president of the AMA in 1912 at the age of 82⁸—Jacobi advanced a vision of a healthier, more just American childhood by reaching out to fellow physician legislators and the public. A colleague wrote of him: 

It is not alone as a medical man that Dr. Jacobi is worthy of honor. He has also sought to promote the welfare of his fellow-men, as a man and a citizen. He has taught the propriety of physicians taking an interest in public affairs, and has exemplified his teaching by taking an active part in many matters of civic and political importance, serving on public committees, addressing legislative bodies, and urging questions of public policy.⁸ 

The breadth of issues Jacobi took to be determinative of a child’s health was wide, ranging from pollution¹¹ to labor conditions¹⁰ and extending to the care of women who were mothers, whom he described as deserving recognition and “reward” for their service “to mankind in the shape of a healthy child.”¹² Jacobi promoted women’s needs for sanitary living conditions to care well for children in utero, after birth, and throughout their growth and development.¹²

Criticism of Industry, Government, and Physicians

Jacobi believed that modern industry posed important harms to American citizens and he frequently criticized corporate and government policies and practices that would, for example,  allow “a boy of 12 [to work] in a coal mine at 4 cents an hour” or withhold that “4 cents . . . from him and his starving family on account of a debt incurred by his father who was killed in the same coal mine.”⁴ When leaders in the canning industry argued that they simply had to work their child labor force until midnight, lest the food spoil, he sardonically remarked: “The freshness of the strawberry must be preserved even if the children perish.”⁴

To Jacobi, government not only failed to protect children and their parents, but insufficiently protected air quality and food safety. Jacobi stated: “If you build houses unfit to breathe in, you steal air which is common property.”¹² And he worked to provide pasteurized milk to babies who could not breastfeed; the availability of milk was a structural determinant in early childhood development because industrialization’s effect on family structures lead to a decline in breastfeeding during the mid-to-late 1800s.¹³ As Jacobi noted in 1912, “starving women make no milk.”¹²

Jacobi did not, however, lay all blame for children’s and women’s ill health at the feet of government and industry. He felt his fellow physicians could do more to promote public health. About physicians, Jacobi said: “Indeed there is no class of citizens that takes less interest in municipal, and political, other than sanitary, affairs, than doctors. It is true their vocation takes all their time and is exhausting; but the examples of European parliaments in which good medical men are representing the people, should not be lost on us.”¹⁴ In Jacobi’s inaugural address as president of the American Pediatric Society, he encouraged physicians to take active roles in improving hygiene and sanitation to promote disease prevention.⁸ Jacobi’slegacy of emphasizing structural determinants’ importance to children’s and everyone’s health is still a model of public health professionalism today.