Remembering a Champion for Public Health Practice

Lloyd Novick, MD, MPH, was a champion for public health practice. Of course, Lloyd was most widely known for founding the Journal of Public Health Management and Practice (JPHMP) and serving as its editor for 30 years. Since its inception, the JPHMP has been a ground-breaking publication unique in its focus on public health practice. The Journal serves as a home for public health practitioners at all levels of government and academia, a place where they can publish their work and learn from their peers. The Journal has stayed true to this vision of supporting public health practitioners laid out by Lloyd in the very first issue: "Our contributors will be not only public health professionals—practitioners in public health agencies, teaching institutions, and other settings—but also public health workers at all levels who are committed to innovation and reform."1 The JPHMP has significantly advanced public health practice and still fills a critical need. However, Dr. Novick was not only a chronicler and thought leader for public health practice but also was a skilled and innovative public health practitioner himself. His profound insights into the field began with his own experience as a public health practitioner for over 30 years, during which time he undoubtedly felt firsthand the need for an outlet for public health practitioners to share their work. His career as a public health practitioner began with a summer epidemiology internship at the California health department in 1962 after his first year of medical school. It continued with leadership positions in New York City (1969-1978: district health officer in Central Harlem and Washington Heights, director of correctional health, and then deputy health commissioner); Vermont (1978-1984: health commissioner and then human services secretary); Arizona (1984-1986: director of the department of health services, including public health); New York State (1986-1995: director of public health); and Onondaga County, New York (1996-2005 health commissioner). It was during his time at New York State that he brought to fruition the idea for a journal for public health practitioners. Lloyd's experiences as an in-the-trenches public health practitioner provided the grounding that enabled him to focus on a broad range of public health practice issues as editor of the JPHMP. Windows on the HIV Epidemic I first started working with Lloyd Novick in 1988 when I joined the New York State Department of Health (NYSDOH) working in communicable disease control. It was clear then that Lloyd was an innovative public health practitioner who was not afraid to push the envelope or think outside the box. In 1986, New York was the epicenter of the human immunodeficiency virus (HIV) epidemic, but surveillance data were based almost solely on reporting of confirmed AIDS cases, which meant that the understanding of the epidemiology of HIV infection was based on transmission patterns years in the past. Soon after his arrival, Lloyd helped to conceive and coordinate the New York State HIV Surveillance Project to get a better handle on up-to-the minute HIV epidemiology. He led a monumental effort to conduct seroprevalence studies in 6 target populations or "windows on the HIV epidemic": newborns, homeless adolescents, prisoners, and clients of family planning, sexually transmitted disease, and drug treatment clinics. These seroprevalence surveys were summarized in a special supplement with 11 research articles published in the American Journal of Public Health in 19912 and provided New York with critical information to direct programmatic efforts during the early responses to the epidemic. One of these seroprevalence windows highlighted the problem of mother-to-child HIV transmission, for which New York led the nation. Lloyd was the first author on seminal papers on the epidemiology mother-to-child transmission through an innovative approach of HIV antibody testing of newborn filter paper blood spots collected universally in New York for screening for unborn errors of metabolism.3,4 This was an idea that he and the New York State public health clinical laboratory director learned about at a visit to the Massachusetts public health laboratory.5 New York geared up the process to test hundreds of newborn specimens a day for HIV. To avoid concerns about identifying the mothers of HIV-positive infants as being HIV infected themselves, essentially HIV testing the mothers without consent, the blood samples were tested anonymously maintaining only the demographic information necessary for the epidemiologic analysis. His work was among the first to demonstrate the extent of HIV infection in childbearing women in any state in the United States. The study found that HIV seroprevalence was much higher than previously appreciated and exceeded 3% of all births in 13 zip codes in New York City. It also showed the tremendous racial and ethnic disparities in the HIV epidemic. Years later, Lloyd would reflect that the results "shocked state health department staff and the public by providing graphic detail about the magnitude of this epidemic."5 These data demanded action to prevent mother-to-child HIV transmission, which became possible following studies showing that a 3-part regimen of zidovudine in the prenatal, intrapartum, and postnatal periods could prevent HIV transmission. Armed with these newborn HIV seroprevalence data, which became linked to the mother's and child's identifying information by state law in 1998, New York has dramatically reduced,6 and now has essentially eliminated, mother-to-child HIV transmission. Even after leaving New York, Lloyd stayed interested in the issue and agreed to publish an issue of the Journal in 2010 with several papers and commentaries on New York's success, for which he wrote the lead editorial.5 His initial work years earlier had made this success possible. Academic Health Department Lloyd Novick was also a force for introducing academic rigor into public health practice. As the editor of JPHMP, he was instrumental in developing the concept of the academic health department.7 His interest in the topic may have come from his very intensive involvement in the development of just such a department during his time at the NYSDOH. At the time of Lloyd's arrival in 1986, the department was at the very beginning of a bold project to develop a school of public health essentially embedded in the state health department. This was done through a memorandum of understanding between the department and University at Albany, part of the State University of New York system. Lloyd was the founding chair of the department of epidemiology and bio-statistics at the school. He oversaw the development of the epidemiology curriculum and the recruitment of faculty, many of whom, as was the case with me, worked at the state health department as our primary job. I accepted a position at the NYSDOH in part because of the opportunity to have a faculty appointment. When I joined the department, the environment was very much that of an academic health department. Practitioners at the beginning of their careers like myself were encouraged and mentored to develop our work products not only beyond what was needed to meet the programmatic needs of the department but also to be academically rigorous enough to be worthy of publication in the peer reviewed literature. Lloyd did not create that environment but certainly fit that mold himself and encouraged those of us working for him in that direction. Many of my colleagues at the health department were faculty at the school. Many students from the school did internships in health department programs. These students became a source of future health department employees. Some were already health department staff seeking continuing education. Lloyd's efforts were integral to the school's early development. The Albany model of a close health department-university collaboration to form a school of public health remains somewhat unique in public health education in the United States. However, the idea of an academic health department has caught on more widely. Lloyd encouraged the publication of papers on the academic health department model and organized a special issue of JPHMP in 2014 on this topic.7 The experience of the University at Albany School of Public Health (now expanded to become the College of Integrated Health Sciences but still accredited by the Council on Education for Public Health), which he was instrumental in founding, was highlighted in the issue.8 Backstories in Epidemiology With his background as both a public health practitioner and educator, Lloyd Novick developed the JPMPH into an educational tool for public health students and practitioners alike. This education mission was carried out through platforms like JPHMP Direct, a companion site for the Journal (https://jphmpdirect.com/) and a volume of case studies in public health, edited jointly with Cynthia Morrow and Lloyd's wife Carole.9 Part of this educational effort was a series telling public health stories to generate interest from students who might be considering careers in public health. The series, entitled Backstories in Epidemiology, consciously followed in the footsteps of Burton Roueche who wrote stories about public health investigations that were published in the New Yorker magazine and were accessible to nonpublic health practitioners. In the introduction to the series, Lloyd wrote, "It is our intention in developing Backstories in Epidemiology to provide an updated (from Roueche) collection.… We are publishing these stories not only because of their interest but also because of their importance to practitioners and students of public health and health professions at all levels. With the explosive growth of public health education at high schools and community colleges, we believe there is a broadening audience for this type of content."10 For the first story in the series, Lloyd selected a typhoid fever outbreak that he remembered from his time at the NYSDOH that he was very involved in. He reached out to ask me to write the story. While I was honored, this was not a standard scientific paper and I was uncertain how to proceed. Lloyd and his wife Carole talked through the concept with me and provided many comments on the early drafts, greatly helping to bring the story to publication.11 The resulting tale was titled "The Mystery in the Pines." (Spoiler alert: it was the orange juice mixed in a garbage can!) This was another example of the many times that I experienced how Lloyd selflessly offered new opportunities, mentored, and urged on even "seasoned" public health professionals to expand their public health practice repertoire. In Memoriam Looking back now on my career as a public health practitioner, I realize I had many points of intersection with Lloyd Novick, only a few of which are mentioned here. Lloyd was always a supportive mentor, even, or perhaps especially, when he was cajoling me to go above and beyond. He had a laconic style and a dry wit that sometimes came out of the blue but which invariably lightened the mood or defused the situation. His innovations in public health practice and the journal he founded will carry on his legacy for future generations of public health practitioners. I will always be grateful for his vision, his mentorship, his humanity, and his friendship.