Calling the shots

When the COVID-19 crisis began in early 2020, Dr. Danny Avula was the joint director of the Henrico County and Richmond health departments, a big job placing him in charge of public health for more than 560,000 residents. However, in early January, the scope of Avula’s responsibilities widened considerably after Virginia Gov. Ralph Northam tapped him to become the state’s vaccine coordinator — a position Avula says brought “a level of intensity that I’ve never experienced.”

Avula has dealt calmly with the pressure and achieved solid results. Initially, Virginia was one of the poorest-performing states for vaccine administration, at one point ranking worst in the nation. But, by early February, the commonwealth rose into the top 10 states for the percentage of available vaccine doses administered.   

The state launched an online vaccine registration system and phone hotline in February. Like other states, Virginia prioritized vaccinations of people at higher risk for serious illness or death from coronavirus, including health care workers, nursing home residents and older adults. But by late May, any Virginian who wants a vaccination should be able to receive one, Avula forecasts.

Speaking with Virginia Business in early March after a month and a half as state vaccine coordinator, the pressure was still on, but the doctor could see a light at the end of the tunnel.

A University of Virginia and Virginia Commonwealth University School of Medicine alumnus, Avula has served as Richmond and Henrico health director since 2009. He and his wife, Mary Kay, a kindergarten teacher for Richmond Public Schools, have five children and live in the city. Avula says he will be happy to return to his regular job after laboring in the media spotlight — noting that working with his colleagues and in the communities he serves “is a huge part of what drives my work-life satisfaction.” 

Virginia Business: When did you first think COVID was going to really affect people’s lives in Virginia?

Dr. Danny Avula: The turning point was watching the speed of spread in Italy and Iran [in February 2020]. We started to see the headlines out of Italy, the severe numbers of hospitalization, just the rapid spread. I think that was the moment where this felt like a different kind of emerging global threat. We’ve lived through a bunch in the last decade: Zika and Ebola in 2014 and H1N1 in 2009, and even mutations or variants of COVID. We’ve seen these things emerge, but because of the different characteristics, the viruses have largely been either quickly identified or quickly contained — whereas this one was totally different. It felt like, “OK, this is going to be a real threat for the United States.”

VB: Have you had any personal encounters with COVID? Has anyone close to you had it?

Avula: Yes. For sure. My uncle died of COVID in India, and then one of my best friends’ fathers who I grew up around the dinner table with, he passed away early on. I think back in April, we all joined for my first Zoom funeral. Then my dad actually had COVID, although he recovered pretty well without much significant impact at all.

VB: You have several children at home. How have they adjusted to remote schooling?

Avula: I would say the kids have actually been great for the most part. My 20-year-old, it’s been a harder hit just because they had to limit social connection. We’ve got five [kids], who are 9, 11, 12, 14 and 20. We, from the beginning of this, had two families that were our quarantine bubble, and they live right in our neighborhood. They’re our best friends. The men in those families were my roommates in college.

If you asked any of my kids, they’re like, “Yes, virtual school is great,” because they don’t have to do as much work, it feels easier, it’s less time, and then they just have the afternoon to go hang out with their best friends.

I would say they’re clearly not getting a great education. I don’t think the virtual format translates well for younger kids, and then I’ll say my wife has had the hardest time. She’s a kindergarten teacher in the city, and so trying to engage kindergartners through the virtual platform has just been extraordinarily difficult.

VB: You were named state vaccine coordinator more than three weeks after the first Virginian was vaccinated for COVID. What do you think would have happened if the governor had decided to create that position a couple of months ahead of the vaccinations?

Avula: It’s impossible to know. I just think that at every step of this response, there had to be a combination of looking back and asking, “What are we learning from what we’ve done?”

[It’s] about being in the present and constantly having to generate new responses. At each turn, there [was] a new, unexpected unknown, and then trying to be able to pull yourself out of that and look forward and say, “OK, what do we need to be anticipating and planning for down the road?” I will say more than half the time, we had no idea. Nobody could have predicted the degree to which our understanding of COVID would change — the degree to which we went from thinking this was highly spread through contact to the fact that contact’s really not that big a deal. It’s really about respiratory spread.

You remember the early messaging in March and April [2020]: “Don’t really worry about masks. Let’s keep the masks for health care personnel.” Then by the end of April, we were saying, “OK, actually, masks are going to be the most important thing we can do to stem the spread of this disease.” I think it’s really hard to know what we could have anticipated differently. Right now, I would say the work around [COVID] variants falls into that category.

VB: How did the state government determine that retail pharmacies were best positioned to focus on vaccinating people ages 65 and older?

Avula: Really, the data. When the Federal Retail Pharmacy [Program] came in, the entire state was in [Phase] 1b. [Editor’s note: Phase 1b includes frontline essential workers, people over 65, people under 65 with certain health conditions and correctional facility inmates.] [We had] gotten through the very high-risk 1a [group] — long-term care facilities, nursing homes, assisted living facilities and health care workers. No matter how you slice the data, age really is the risk factor that most skews towards hospitalization and death.

It became the intersection of what does the data say, and how do you practically operationalize this? When you think about people ages 16 to 64 with underlying conditions, that’s a big group of people with a wide range of risk. You have 30-year-olds with asthma and a 64-year-old with lymphoma that are in the same bucket.

Meanwhile, people who are 65 to 74 have a 90 times greater chance of dying if they were to contract COVID, and people who are 75 to 84 have a 220 times greater chance of dying.

VB: When do you think your job will shift from vaccinating as many people as fast as possible to convincing reluctant Virginians that it’s safe to get vaccinated?

Avula: I think that’ll start in May. Based on our anticipated supply, what we’ve mapped out over the next few weeks, I think we’ll be able to get through all of the [Phase] 1b population that wants to get vaccinated, by the second or third week of April. As we get into May, we’re going to open up to [Phase] 1c, and then to the general population. [Editor’s note: Phase 1c comprises essential workers in sectors such as construction, energy, finance and legal services.]

I see, towards the end of May, the supply and demand are going to flip, where we have gotten to 65% or so of the population, and we’re going to have to really work hard to get that last 10% [to reach herd immunity]. Even this far into our vaccination effort, there’s still a significant amount of vaccine hesitancy, particularly among younger Americans, and then among Black and Hispanic Americans.

VB: Do you think that businesses can legally enforce employees to get vaccinated?

Avula: Because these vaccines are under an emergency use authorization, there’s no way for there to be a governmental mandate that requires vaccination. What I don’t know are the legal pathways for private entities to require it. My guess is that if the government can’t require it, then probably private entities won’t be able to require it either. I don’t see that happening anytime soon.

VB: You’ve talked about herd immunity. When we reach that point, will we still need to take precautions?

Avula: I think it depends on what happens with these variants. The variants are real concerns. We’re increasingly seeing the U.K. variant pop up around the country and here in Virginia. What we’ve seen in other countries — the United Kingdom, Denmark, Israel [and] multiple countries across the world — is that really, within the course of two months, the new variant has become the dominant strain. Our CDC modelers, at least a couple of weeks ago, were saying likely by the end of March, the U.K. variant will be the dominant strain here in the United States. [Editor’s note: As of March 15, Virginia had identified 49 U.K. variant cases.]

I think what we’re doing right now is the right thing. It’s maintaining our commitment to mask wearing, [social] distancing and staying home when you’re sick, but also [getting] people vaccinated as quickly as possible. The hope is that the combination of adherence to mitigation and rapid vaccination will temper the degree to which the U.K. variant becomes a new issue and a new spike of disease in our community.

VB: Do you think that people are
sufficiently aware that we still need to
be careful and wear masks even after
getting vaccinated?

Avula: Yes. Certainly, in our communications from the Virginia Department of Health, that’s been really consistent. As I followed the national headlines and watch some of the international voices on this, that is really consistent. Like I said, I think that guidance could actually change over the next couple of months, just as we gather more data. I do think that’s pretty clearly and consistently the guidance. Now, how that actually is lived out, I imagine there are a lot of people who, once they get their vaccine feel like, “OK, this is my newfound life.”

VB: What takeaway lessons have you learned from this pandemic that could help for the next public health crisis?

Avula: I started my career in 2009 when H1N1 hit, and while local governments were very supportive, this was largely public health-led. Federal funding allowed us to expand our teams and set up vaccination all over the place. The scope of the response was able to be managed within the agency of public health. I think with COVID, it’s a completely different story.

It happened on a scale like nothing anybody has ever experienced. I think the localities that moved to this whole-of-government mentality — that this is not something that the health department by itself can solve or address, but really requires the full weight and planning and integration of all of our sectors — I think that’s the learning I would apply. We would move to that mindset much quicker than we did. I think the same is true in state government.

The move from [Phase] 1a to 1b, which was largely initiated by the federal government, happened in a context where we were thinking and being told we would get a ton more vaccine [doses] to be able to support that increased demand, and it didn’t happen. We went from a very manageable Phase 1a to a very difficult to manage Phase 1b, where you had 50% of Virginians who were eligible yet still only getting … about 100,000 or 105,000 new doses a week.

It would have been clearer for the people of Virginia … to have more narrowly defined who was eligible at that point, based on incoming supply. Instead, a lot of people were frustrated. I think that’s what drove so much anxiety and fear and concern. I think if we had the ability to do that over again, it would be really keeping our demand in more manageable buckets.

VB: How is the state vaccination registry working out?

Avula: I think for the most part, it definitely has worked. More than half a million people have registered since that went live. I also think having a centralized call center has made a huge difference, because when we went from [Phase] 1a to 1b and totally opened up the eligibility, that led to a scenario where local health departments just couldn’t manage the [call] volume.

VB: Have you gotten the vaccine?

Avula: I have not yet. I am still in group 1b. I’m in that tier, what do we call it? Continuity of government.

VB: When do you think you will?

Avula: I think by the end of March. When I look at how quickly we’re moving through the tiers, and especially when I look at how much vaccine is coming in, by the end of March we should get to that continuity of government tier.

VB: Has your wife gotten vaccinated, as a teacher?

Avula: She has been offered it. We talked about it, [but] we can do social distancing in our lives. We can do most of our work from home. I’m doing a lot more in the office these days, but she’s home all the time. From that standpoint, she just said, “Why don’t I wait so that we can make sure our 65-and-ups get their vaccine?”

VB: Do you think that this whole
experience is going to interest more people in public health careers?

Avula: That’s an interesting question. I think it will. … On a really practical level, it actually [already] has brought a lot more people into public health. All this federal funding, when I was at the local health department, we went from an organization of about 250 to an organization of over 400. There’s many, many people who now know what the health department does who didn’t before. Yes, I think it will lead a lot of people to the field, which is good, because the reality is that COVID has also led to a lot of burnout, right? We’ve lost a lot of folks; we had a lot of people move to other careers. We’ve had a lot of people who just need a break because the public health infrastructure has been under incredible strain.

VB: After the vaccinations are over,
will you resume your position as health
director for Richmond and Henrico?

Avula: Absolutely. I can’t wait to get back. Part of it is just that this [state job] is just … a level of intensity that I’ve never experienced. But those are my people, our local health department — we have an incredible team. So much of the joy and satisfaction of the work for me is in the team, but it’s also the integration into our local communities. Really feeling that deep connection to the work on the ground is a huge part of what drives my work-life satisfaction. ν