Dr. Danny Avula speaks at an event in 2018 during which he was named director of both the Richmond and Henrico County health departments. (Katie O'Connor/Virginia Mercury)

Dr. Danny Avula, director of the Richmond City Health District, spent about a year as the acting director of the Henrico County Health Department while the state tried to fill the position.

But finding someone new was easier said than done.

The state classifies the position of health director as a critically hard job to fill, said Chris Gordon, chief of staff to the Virginia Department of Health’s deputy commissioner for community health services.

Right now, five of the state’s 35 health districts are relying on acting directors. The director position for the Cumberland Plateau Health District, which serves Buchanan, Dickenson, Russell and Tazewell counties, has been vacant for about two years.

The position comes with a slew of incentives — a signing bonus, hefty annual leave, student loan repayment and moving reimbursements. But those incentives are stacked against hiring challenges, foremost among them that Virginia is one of few states to require local health directors have medical degrees.

“People who are coming out of school, they’ve got debts, we can’t always match what some of these other organizations can do,” said Bob Hicks, VDH’s deputy commissioner for community health services.

VDH is testing out new strategies to deal with the difficulty of filling the positions, in particular combining leadership between some health districts.

Avula was named permanent director of both Richmond and Henrico health districts, a decision that makes sense, multiple officials from both localities said at an event on Thursday announcing the change.

Public health problems don’t adhere to county or city lines, and what’s afflicting one community is very likely affecting another nearby.

“Part of the way the role of the public health department has changed is that we have distinct functions that we have and will continue to provide,” Avula said, “but more and more as we understand that health is this complex combination of housing and income and concentrations of poverty and family stability, all of those things, health departments need to be convening broader sets of stakeholders.

“We need to be driving these more complicated strategies. So it takes a different kind of leadership effort on the part of the health department.”

And it also allows health districts to continue to meet the state’s requirement that they be headed by physicians, even though that makes hiring more difficult.

“When health districts are led by physicians, you keep public health and the science at the forefront of decision-making when it comes to the health of the community,” Gordon said.

While some other states require that local directors have medical degrees in some cases — such as if the state health commissioner isn’t a physician or if the municipality has more than 500,000 residents — most accept other advanced degrees, like a master’s in public health.

According to the National Association of County and City Health Officials, only 12 percent of all top executives at local health departments have medical degrees, though that number shoots up to 40 percent when the population is larger than 500,000 people.

Hicks described the option to consolidate leadership as a pilot, and that the state will watch the model and see if it works. But simply putting one person in charge of two districts, essentially doubling their workload, and expecting the same outcome isn’t realistic, Gordon said.

So the state is testing shaking up the leadership model more by allowing directors to create a chief operating officer role, who would essentially help the director “execute” his or her vision, Gordon said. Several of the directors who oversee more than one district are considering adding that position.

Avula said he’s considering adding a chief operating officer more focused on internal operations while Avula can concentrate on making connections with community partners and working with health systems, among other tasks.

Richmond and Henrico won’t be the first health districts in Virginia overseen by the same director. Roanoke and Alleghany County both share health directors, as do the Central Virginia, West Piedmont, Pittsylvania/Danville and Southside districts.

“Historically some of these changes were made when there were budget reductions during the recession and things like that,” Hicks said. “We’re not doing that here, we’re just looking at it entirely different. We’re not taking any resources away, in fact we’re probably opening up sources for additional resources, whether it’s grants, general fund dollars.”

But even where they share leadership, each health district operates separately to an extent because each receives their own local and state funding, as well as numerous grants.

“The intent is really to keep the majority of the operations of the departments separate because county and city funds will go to fund the services that are serving their communities,” Avula said. “That said, there are a number of places where we can work together really well.”

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Katie O'Connor
Katie, a Manassas native, has covered health care, commercial real estate, law, agriculture and tourism for the Richmond Times-Dispatch, Richmond BizSense and the Northern Virginia Daily. Last year, she was named an Association of Health Care Journalists Regional Health Journalism Fellow, a program to aid journalists in making national health stories local and using data in their reporting. She is a graduate of the College of William and Mary, where she was executive editor of The Flat Hat, the college paper, and editor-in-chief of The Gallery, the college’s literary magazine.