As a lawyer for the state of New York and the city’s housing authority in the 1980s and 1990s, Alan Aviles championed civil rights and affirmative action. Now the head of the city’s public hospital system, Mr. Aviles directs a health care network that serves 1.3 million New Yorkers, including 400,000 uninsured patients, guided by the same activist principles.

“I really think the issues of health care access are issues at the forefront of this generation’s civil rights concerns,” the president of the New York City Health and Hospitals Corp. said recently.

“Some of my friends who have known me a long time, when I went over to health care, were sort of surprised by that” move, Mr. Aviles said. “From my perspective, it’s not really that strange or long a trip.”

Created in 1970 as a public benefit corporation, HHC is the country’s largest public hospital system, with 7,407 operating beds throughout the five boroughs. HHC oversees 11 acute care hospitals, including Bellevue Hospital Center, Coney Island Hospital, Elmhurst Hospital, Harlem Hospital, Jacobi Medical Center, Kings County Hospital, Lincoln Medical and Mental Health Center, Metropolitan Hospital Center, North Central Bronx Hospital, Queens Hospital, and Woodhull Hospital. It also runs six diagnostic and treatment centers, four skilled nursing facilities, and more than 80 community health clinics.

The $5.4 billion corporation employs 38,000 clinical and administrative staff members, and it operates a Medicaid managed care plan, MetroPlus, with more than 250,000 enrollees. HHC officials said they treat more than 1 million emergency cases annually, a figure they estimate is one-third of all emergency visits citywide.

Mr. Aviles, 56, joined HHC in 1997 as an executive at Elmhurst Hospital in Queens. He was named president of HHC in 2005, and since then, has overseen the corporation’s five-year, $1.3 billion capital plan to renovate HHC facilities. The initiative was launched in 2002 and is underwritten by city bonds.

This past fall, Queens Hospital Center opened its new ambulatory care pavilion, and Jacobi Medical Center began operating a new acute care facility, which features a video telecommunications system in the hospital’s operating rooms. In 2008, three years of construction are scheduled to end with the completion of a new 300,000 square foot facility at Kings County Hospital.

Like many in the Bloomberg administration, Mr. Aviles is focused on technological achievements, including the adoption of electronic health records throughout the HHC system. During a recent tour of Elmhurst Hospital, a 556-bed facility in Queens, Mr. Aviles pointed out a pilot system for an electronic “white board” that monitors patient-staff interactions in the children’s department. He also toured the pharmacy department, which houses an automated prescription-dispensing machine. “I love this stuff, it’s so cool,” he said to a hospital employee.

As a lawyer, Mr. Aviles worked for the state attorney general between 1982 and 1992. In 1983, he was head of the civil rights bureau there when Attorney General Robert Abrams and the Lambda Legal Defense and Education Fund filed a lawsuit against a Manhattan co-op board that was trying to evict an AIDS doctor from its West 12th Street building. The discrimination case, which named the doctor and five patients as plaintiffs, was settled in 1984.

Later in his career, Mr. Aviles served as general counsel for the city’s Housing Authority from 1992 to 1994. He recently sat for an interview with The New York Sun.

Q: Why should the city be in hospital business when we have plenty of good non-profit hospitals?
A: At the end of the day, I think that many of us in the public hospital system would support a move to true universal health care, and at that point, public hospitals would have to compete with everybody else. And to some extent, that’s a trajectory that I certainly feel I put us on. At the same time, it’s our fear that all of the talk of universal health care coverage isn’t truly universal. For example, undocumented immigrants generally are not included among those for whom universal healthcare coverage is sought. And in a city like New York, where 40% of the residents are foreign born, and where there are an estimated 500,000 undocumented immigrants, we are the ultimate safety net for the immigrant communities in New York; we have been since the day public hospitals in New York City started operating.

Is care at public hospitals on par with private hospital care?
In the past, quality has always been judged very subjectively, like who made the “Best Hospitals” list in Newsweek. Beginning about two years ago, the federal government began to actually require the submission of quality data to the Centers for Medicare & Medicaid Services. If you look at that data for New York City, where we have more than 60 hospitals, five of the top 10 performers are HHC facilities. Over the course of the last decade, we have taken a system that certainly has been known for providing access to many patients who otherwise might not have access to healthcare services, to one that provides access that is of a quality that is equal or better than you can get just about anywhere. That is a huge, huge change.

This month, HHC announced it would not distribute baby formula in gift bags to new moms in an effort to promote breastfeeding. What was the impetus for the program, which some have criticized?
The evidence is just so clear that there are significant health benefits for newborns if they’re breastfed. I think there’s been a little bit of misperception that this is simply about removing the formula samples from the gift bags. For us, it has been about education and support. Obviously, for those moms who can’t breastfeed or choose not to, we supply the formula while a baby is here and we certainly wouldn’t let the mom leave the hospital without a bottle of formula to take with her. But we really do think its part of our role to take an activist agenda, to promote healthy living. It’s a mixed message for us to be promoting formula by including it in gift bags since hospitals get free supplies in exchange for doing this marketing for the formula companies.

The medical community in New York is grappling with a malpractice crisis in the form of rising insurance costs, a large number of suits, and high settlements. How has the crisis impacted the city’s public hospitals?
A fundamental difference between us and many other hospitals is that the city is essentially self-funded for malpractice costs, so we don’t actually pay premiums to cover our physicians or to cover the hospital’s liability and potential malpractice cases. Over the last few years, we have done a lot to change the way that we deal with malpractice lawsuits. It used to be handled for us by the city’s Law Department; [as of January] we’ve taken that in house. We’ve brought on board a professional claims manager that helps us in managing all the malpractice claims that come in, and that includes investigating them very quickly so that we know early on whether they’re cases that we should try and settle or whether they’re cases that we should defend to the hilt. So while the rest of industry has been under tremendous pressure because of the rising malpractice premiums, we’ve managed to buck that trend. Also, our hospitals have refined a lot of the patient safety initiatives, and that has manifested itself in fewer notices of claims.

What areas has HHC invested in?
One of the things that we’ve done is to use our electronic records to drive performance improvement, both in terms of consistent evidence-based medicine and in terms of enhancing patient safety. We’re embedding into our electronic medical records a screening tool for depression. By the end of 2008, we expect 80% of the primary care patients to be routinely screened using this tool. Something else that we’ve been able to do is to take the data that is in our electronic medical records and download specific portions of it. …From that data warehouse we run an electronic disease registry. It helps us guide the care for diabetic patients. We are a very mission-driven organization, and part of that is pursuing an activist agenda, not sitting back passively and waiting for sick patients to come to our emergency department. A lot of healthcare is about access to accurate data in a timely way and how you use it.

What philosophy guides you as head of this system?
I came to healthcare without having a life plan to land here. I went to the Bronx High School of Science, and I originally assumed that I would be in the sciences. Then I went to [Columbia College], and I completely switched gears and became an American history major and ultimately wound up going to [Rutgers School of Law]. I was drawn to law school largely as a kid who grew up in the South Bronx, who then went to an Ivy League college and sort of had a keen appreciation for the inequities that are apparent to somebody who comes from the South Bronx and then mingles with kids from the most affluent strata of the country. I was very interested in issues of social justice so that’s what took me into the law and what took me into public advocacy. In healthcare, there are huge disparity issues that cut across race, ethnicity, and income. And HHC, as the largest public hospital system in the country, is sort of the next best thing to universal health care coverage in terms of addressing some of that.

Are you for or against lifting a ban on for-profit hospitals in New York State, and why?
I am not in favor of for-profit hospitals in New York State or anywhere else, as a policy matter. I don’t think that healthcare is a commodity that should be openly traded on the market. I think that healthcare is a public good. There are very pernicious effects when hospitals begin to focus on short-term profits and returns to investors as opposed to maximizing their ability to increase healthcare for patients.

In an effort to overhaul the system, the Berger Commission last year recommended closing five hospitals in New York City. What’s your perspective on that?
I think that the Berger Commission was a good faith effort by some talented folks who confronted what are very, very complicated issues. I think that many of their recommendations were pretty much on the mark. Obviously we were happy that the Berger Commission decided that the public hospital system did not need to be in the crosshairs.

Given the industry’s overall financial challenges, what’s your strategy?
We’ve done a lot to make the system more efficient over the years. This is a system that 12 years ago, probably had 10,000 more employees than it has now. So this is a system that has voluntarily and painfully right-sized itself and made itself much more efficient.
Under Governor Spitzer, Medicaid reimbursement will shift to institutions that serve the most Medicaid patients, which for you is—
Music to my ears. He has said from the beginning that he thought Medicaid dollars should follow Medicaid patients and that hospitals that serve a disproportionate number of Medicaid patients should receive the lion’s share of Medicaid funding. Our rough calculation is that we probably would come out ahead in terms of that shift in making the reimbursement system more rational. Right now hospitals have to be too focused on generating revenue by providing the high-priced services with the largest margins.

What are New Yorkers’ most urgent health care needs?
Certainly some of the chronic diseases disproportionately impact communities of color and low-income communities. The two diseases that continue to take the largest toll in terms of mortality — heart disease and cancer — are two diseases we are very focused on addressing from a prevention and early screening perspective. In areas like breast cancer and prostate cancer, it is not so much that communities of color have a higher incidence of the disease, but it is true that they tend to be diagnosed at a later stage, when it is not as readily treatable.

What’s the significance of HHC’s campaign to improve its facilities within the context of patients’ needs?
It is important because it gives us the opportunity to redesign our space for maximum efficiency; it gives us the opportunity to incorporate state-of-the art information technology; it sends a strong message to our patients that they’re coming into a system that doesn’t offer second-tier quality of care. Finally, it’s important to us from a competitive perspective because at the end of the day, we do believe that it is important for us to become a system of choice for more New Yorkers. It is an unprecedented investment of capital dollars that it is literally transforming the entire system.