In a recent interview with Networking Magazine, New York State Health Commissioner Dr. Antonia Coello Novello looked back at the health challenges she encountered when she came to the state in June of 1999, and recalls that the nature of the situations almost made her think she was "back in a Third World country." From 1993-1996, she had served as United Nations Children's Fund (UNICEF) Special Representative for Health and Nutrition, providing leadership on global efforts to eliminate iodine and Vitamin A deficiency disorders, immunizing children and preventing smoking and substance abuse in youth. But on assuming her post in New York State, her initiation included an E. coli bacteria epidemic involving 1,100 cases, two Boy Scouts on Long Island who contracted malaria, and a "panicky" situation over the West Nile virus. Now, As Commissioner, she is responsible for a $32 billion budget, the largest of any New York State agency and over one-third the total of the entire NYS budget.

Dr. Novello is no stranger to challenge. Overcoming a chronic health condition that plagued her childhood and young adult years, she graduated from the University of Puerto Rico, her native land, with a B.S. degree in 1965 and an M.D. degree in 1970. Her long and distinguished career is characterized by leadership in many national and world programs serving the most vulnerable, from infants to the elderly. In 1990, President George Bush, Sr. appointed Dr. Novello the 14th Surgeon General of the United States, the first woman and first Hispanic to serve in that position. She humbly believes she was "in the right place at the right time" when she was chosen for the post. While she was co-chairing an NIH women's task force for health, and advocating to have women participants in traditionally male-dominated health studies, she says, "I guess I caught someone's eye."

Having worked in private practice and public service, and among international health professionals, Dr. Novello is well qualified to comment on our nation's healthcare system. She believes that all citizens should have access to the healthcare they need, but adds, "that doesn't necessarily mean that the only solution is a government-run healthcare system." Instead she says, "Government's role should be to provide incentives for the private sector healthcare marketplace to operate more efficiently in order to maximize employment-based coverage and other private sector coverage, like tax credits. It also has a role to subsidize healthcare for those persons who are excluded from private sector coverage by virtue of where they work, how much they earn, or their medical conditions."

Dr. Novello doesn't see the healthcare system in crisis. But in a system so vast, she says, in order to assess its status, "one has to look at the big picture." She identifies "new challenges" to the system and says, "We have to be prepared to meet them." New medicines and new technology are top on her list, and Dr. Novello emphasizes that "people need to be trained" to enter the profession.

The provisions for care in the outpatient setting "has changed the face of medicine," remarks Dr. Novello, and she calls the growing outpatient centers "good for patients," giving both "patients and doctors a choice." Whereas outpatient clinics licensed under the Public Health Law are subject to the same oversight as hospitals, the Commissioner confirms that physician office practices are considered the private practice of medicine and are not subject to Public Health Law licensure. The only jurisdiction is with respect to the individual physician's license. This issue has been troublesome for many Long Island and New York State hospitals.

As Surgeon General, Dr. Novello says, she had "the bully pulpit of the world," and she advised the public on health matters from diet and nutrition to environmental health hazards and AIDS. But in New York it's quite different. Here, she says she has been provided the funding to "take action, solve health issues, and extend a broader sensitivity."

A compassionate and impassioned health professional, Dr. Novello recalls, too, New York's September 11 tragedy. She spent six weeks in the City and traveled to every hospital to make sure that staff members "did their best at the moment," and she instructed that no person seeking treatment should be asked "who pays, what insurance do you have, who will take care of the bill," adding, "the state will take care of paying your bills." In addition to Medicaid, the state has the ability to provide funds to cover charity care. During the 4 months following 9/11, New York State assisted more than 340,000 people with emergency medical coverage.

"We have been the state to lead the others," remarks Dr. Novello. "I think I'm a better human being as a result of coming to New York."

"We have 87 million minorities in New York State, 3 million of those people were not born here," Dr. Novello says, "and the people in New York speak 167 different languages." She suspects that the estimate of 44 million Americans without health insurance is short the real figure, and believes that number may be as high as 58 million. Most are new immigrants. They may be poor, she adds, but they work hard, and often their employers don't offer health insurance.

"But, it's not about the numbers," states Dr. Novello. "It's about the barriers." Many people aren't educated to what the state has to offer them, she adds, "And education is power."

Looking at this melting pot that is New York, Dr. Novello notes that all of the printed material in New York's managed care programs are translated into at least five languages Ð English, Spanish, Haitian/Creole, Chinese and Russian. In New York City, translations also extend to Yiddish and Arabic. She adds that New York has an African American population that are still carrying the Tuskegee legacy that makes them doubt they are receiving the same treatment and modalities as others. Onto this backdrop, she splashes the need for "sensitivity to and knowledge of culture," and notes that this tone must be brushed through the healthcare system.

Dr. Novello sees "barriers of institutions," too Ð the rich going to doctors and specialists and the poor being attended by residents; the rich going to hospitals and medical centers and the poor going to clinics. However, the New York State Hospital Code, she says, "states that no person shall be denied admission to the hospital because of race, creed, national origin, sex, disability, sexual orientation or source of payment."
One of her "pet peeves" is that "physicians' competence must include sensitivity to culture." She worries that when people enter medical schools in their mid-twenties, they already have biases. "Physicians need to acknowledge those biases, or forever they will make bad decisions" with regard to patients, and she calls for training doctors in communication skills.
In his nomination of Dr. Novello as Health Commissioner, Governor George Pataki touted her commitment to children as invaluable in the state's continuing quest to build the nation's leading children's health program, Child Health Plus.
"The provisions for children's healthcare are better in New York State than in any other part of the world," comments the Commissioner. While our child health status is "good," she adds, "it isn't as good as some states, because of our high poverty and immigrant populations. Under Child Health Plus, designed to help the working poor, health coverage is extended to children from birth to age 19. She points out that New York has an aggressive accelerated enrollment program to bring in children, and caseworkers are available who speak their language. School based clinics see 200,000 children a year, taking care of them so parents need not leave their workplace and risk losing their jobs. "Our programs are a port of entry for healthcare, from dental to mental," she adds.

Under her leadership, the state has taken steps to protect the Family Health Plus and Child Health Plus programs for those people for which they were intended. Dr. Novello acknowledges that the Governor's recent proposed changes to Family Health Plus are worrisome to residents. But she adds, "Perception vs. reality can damage a good policy." She notes that people perceive that the state is going to cut vision and dental coverage, but she says, the proposal only eliminates payment for glasses and participants will still receive eye examinations and surgeries. People will be able to go to clinics for dental care, if they have Medicaid coverage. The changes, she contends, are to bring the program in line with Healthy New York.

The Health Commissioner's goals include a continuation of programs for the poor. "We're the Department of Health, not the Department of the Budget, but you have to balance both," claims Dr. Novello. "We want to help solve disparities in healthcare for those that feel they don't even have a choice, and we want people to recognize that there's a heart here." Additionally, she is proud that New York continues its commitment to assist women in the diagnosis and treatment of cervical cancer.

Making sure the system of healthcare delivery is as free of error as possible is another of the Commissioner's goals. She is proud to have developed a system "to recognize hospitals, nursing and assisted living homes, or community health centers that are able to assess major errors in their operations, and implement changes and save lives."

Projects the Commissioner is working on include the establishment of a committee of physicians, pharmacies and pharmacists to oversee a preferred drug program where they will select the "best" medications at "better" prices for doctors to prescribe to patients. Two of her objectives result from legislation: the creation of a database of Emergency Room visits and the compilation of a Physicians' Index. Her department is currently gathering a wide array of ER data, from the medical problem presented to the patient's encounter and the outcome. She believes the information will allow the state to identify potential broader health issues, help hospitals with surveillance of incidents, and assess where hospitals are in need of funding. The Physicians' Index, available on the health department's website, lists data on 72,000 physicians, including training, certifications, expertise, practice locations, and insurance acceptance, as well as disciplinary, malpractice and conviction information.

Dr. Novello is proud of the department's accomplishments, in particular, its statistics in the area of smoking cessation. During her first year in office, the department recorded a 24% decline in smoking per capita, as compared to the national average of 9%. In addition, from 2000 to 2002, New York has seen a 22% decline in smoking among high school students and 33% among middle school students.
Dr. Novello served her pediatric internship and residency at the University of Michigan, and completed her subspecialty training in pediatric nephrology. In 1978, after working in private practice, she joined the U.S. Public Health Service and spent 12 years at the National Institutes of Health, specifically working on pediatric HIV/AIDS and women's health issues.

Administrator, researcher, lecturer and author, Dr. Novello is first and foremost a physician whose motto is "good science and good sense."