Commissioner David Axelrod—Consummate Public Servant

In all of our fields, some people are legends. Sometimes happenstance provides us with the opportunity to meet them. More often, we are not so fortunate. For me, the person in the field of public health that I would have welcomed a chance to meet is David Axelrod, MD, the New York State commissioner of health from 1979 to 1991. In the words of the late Governor Mario Cuomo, Axelrod was “the people’s doctor” and “a brilliant, dedicated and marvelously effective public servant.”¹ This month’s AJPH highlights his inspirational leadership style, a refreshing reminder at a time when we are often rallying around our worst rather than best attributes.

Axelrod steered the Department of Health at a time when the winds of change were blowing across the fields of medicine and public health. Through a combination of circumstance and foresight, he was at the epicenter of controversial issues spanning the public health spectrum.

How did he come to have such stature? Perhaps it was from early childhood. Son of an orthodox rabbi, it is likely he was raised to ask questions, seek answers, and root out and eliminate injustices. Or perhaps it was from medical school, where he was taught to understand physiological processes and how the interplay of systems is crucial to health and wellness. Or perhaps it was from being a husband, a father, a mentor, a lifelong student, understanding that our social fabric is weaved together by compassion and caring for those around us.

Magdon-Ismail et al. (p. 85) probe his leadership qualities on the basis of the recollections of his peers. He championed a data-driven approach to scientific integrity and public health. And yet—from conversations with his relatives and others—some condemned him despite his steadfast commitment to public service. He remained true to the bigger calling.

In the words of his son Jonathan, “Dad felt an obligation to others . . . there were people’s lives that he needed to help and what better way than to be their voice” (personal conversation), Axelrod’s métier resulted in exponential improvements in public health in New York State. Janet, his wife of 30 years, said he had an unstoppable curiosity, a passion to learn. In the words of Maimonides—whose teachings he studied—“Your purpose . . . should always be to know . . . the whole that was intended to be known.”² He traveled the real world to explore the unknowns and voyaged into his own imagination to marvel at how to improve it.

THEN AND NOW

As the latest in a line of New York State health commissioners, I have been faced with knotty challenges in our ever-changing public health landscape. I periodically stop at the portraits of my predecessors hanging on my office walls. In shades of blue, Axelrod stands over a lectern with passion in his eyes and, I suspect, words of social justice coming from his mouth. I take notice when those who knew him remark that my actions are in keeping with his teachings, and I quickly reflect when they say I have veered off course.

The parallels between his time as commissioner and today are many, not the least of which is a governor named Cuomo. With New York at the epicenter, Axelrod battled the HIV/AIDS insurgence. Looking at prevalence and trends, he recognized that tackling the epidemic required addressing maternal to child transmission and spread among incarcerated, intravenous drug users and the homeless. Today our department leads the effort End the Epidemic by 2020. And although preexposure prophylaxis and postexposure prophylaxis were not in his toolbox, his foundational principles are still applied.

His was the time of Love Canal, a health crisis that set the precedent for federal government management of environmental disasters. We now wrestle with perfluorinated compounds, harmful algal blooms, and a spreading plume involving 1,4 dioxane. Targeting increased use of antianxiety medication, Axelrod required physicians to send the department copies of all Schedule II prescriptions, better known as the triplicate prescription law. Fast-forward to present day, and the issue is the opioid epidemic.

PROFILE IN LEADERSHIP

Leadership is doing what is correct, not what is convenient. Axelrod personified that principle, taking on thorny topics that others found false justifications to dodge. Although controversial at the time, he established the Bell Commission to look at medical resident work hours. Subsequent regulations redefined postgraduate medical education and addressed medical error. It spawned a national movement. Workforce issues and quality remain paramount amid our departmental activities.

It was Axelrod—with Governor Mario Cuomo’s backing—who convinced the legislature to pass antismoking laws, placing New York as the leader in what ultimately became a global mission championed by the World Health Organization. He cleared the air of inaccurate statements by the tobacco industry. He cleaned the air of harmful toxins. Axelrod’s work led to New York’s Clean Indoor Air Act banning tobacco use in public spaces. Today Governor Andrew Cuomo recently added e-cigarettes.

He championed investments in primary care and advocated health insurance for all, and we share his vision. Our advanced primary care model and New York State of Health are testaments to his perspicacity. Axelrod believed in community engagement, an approach favored today as our state confronts disparities in maternal mortality, legalization of marijuana, and revitalization of Brooklyn.

In his tenure of more than a decade, he saw the cracks in the system and paved a better path for many. Child Health Plus, a program created by Axelrod and Governor Cuomo provided health coverage for Medicaid-ineligible children. It was the model for CHIP (the Children’s Health Insurance Program), recently threatened by federal cuts. Much we take for granted today is a legacy to his vision. He established school-based health centers and regulations for mandatory fencing around pools, and he established the New York State Task Force on Life and the Law.

Even in defeat he had a large impact. Faced with a state legislature that would not update antismoking laws, he enacted a regulation banning smoking from many public places. In 1987, the state’s highest court ruled, in Boreali v. Axelrod, that he had overstepped his authority. The case set a nationwide precedent that courts still follow.

IMPROVED LIVES

Axelrod’s tenacity brought calls for his ouster, even from within his own profession. His brains and badge resulted in more regulations for hospitals and doctors and caused a raucous outcry among the Medical Society of the State of New York. In his own words, “Sometimes proceeding with one’s responsibilities can have personal costs.”³

Although all commissioner decisions are fraught with the challenge of varying viewpoints, our lives are better because of his resolve to confront injustices. His was the face of integrity, scientific reliability, and a sound moral compass. He took the high road even in the rarefied air of unconventional opinions. With his dazzle came a sense that the system is here to serve all people, not just one person or one organization. For those who worked with him, worked for him, or worked against him, his calling in public service was rooted in the belief that courage, kindness, and intelligence must be stirred together in a pot called leadership. So, I ponder—looking out the same window that he did for 12 years—when the days are long, the issues complex, the criticisms harsh—what would David Axelrod do? Oh, to have had the chance to hear his reply.