Behind the Front Lines

Jennifer Avegno landed the job she was made for
Ja1

It was early in the day on March 9 when Jennifer Avegno, while working in her office on the eighth floor of City Hall, got a call from an emergency physician at New Orleans’ Veterans Affairs Hospital. A patient the doctor had admitted to the hospital had just tested positive for COVID-19, the virus that was then raging in China and some European countries and was gaining a foothold in the United States.

Avegno did not panic when she heard the news. “We knew the virus was coming, it was already in 30-some other states, and we thought we were ready for that first case,” the city’s 47-year-old health director said.

But what the VA doctor told her next gave Avegno chills. The patient in question had not shown any of the symptoms that local doctors were expecting to see in a coronavirus infection and had not traveled in recent months. The next day Avegno learned that two more people had tested positive for COVID-19. The patients were not related to one another and had never met, and again, neither had traveled.

“I realized that these were not the cases we had expected,” Avegno said. “The virus was here, and it had already spread in the community.”

“Community spread” is a term used to describe an illness that cannot be traced to a single source of transmission or to a specific individual known to have the disease. By the time a member of the community shows symptoms and seeks medical care, it may be impossible to guess how he or she became infected or how many others in the community already have the virus, a situation that frustrates efforts to control the further spread of the disease.

Avegno had collaborated for weeks with other local and state health officials, and public health experts around the country to plan the city’s response to the pandemic, which appeared to have erupted in China before making its way to Europe and then the U.S.  She felt that she and her cohorts had laid solid plans for the inevitable arrival of the novel coronavirus in New Orleans.

But they had assumed the virus would come to the city via incoming travelers. In a hypothetical scenario, a visitor would arrive at the airport from, say, China or Italy, take a cab to a downtown hotel, check in, then go out to dinner, a bar or maybe a music club. If the traveler later fell ill and tested positive for COVID-19, health officials would try to develop a list of everyone the patient had come into contact with, try to reach them and ask them to quarantine for 14 days.

“We are very familiar with contact tracing in dealing with things like measles or tuberculosis, and that’s what we were planning for,” Avegno said.

But now she could see that the city was facing a challenge even trickier than contact tracing. The coronavirus likely had been in the city for weeks and probably had already spread to hundreds, maybe thousands, of local people. Like her peers in such cities as New York, Detroit and Seattle, which also were experiencing community spread, Avegno saw that New Orleans was behind the curve in defending itself against the virus.

What followed this realization was a frenzy of phone calls and consultations with public health experts near and far – state health department and homeland security officials, and medical specialists throughout Louisiana; researchers at the Centers for Disease Control; infectious disease experts at Johns Hopkins University; and doctors at major medical centers around the country. It was clear that New Orleans physicians and hospitals needed to prepare themselves for an onslaught of infectious disease that might seem to be coming from everywhere.

DEFENDING PUBLIC HEALTH

Medical professionals who take on leadership roles in public health don’t generally expect that they will land smack in the center of a major health crisis, or that a massive outbreak of disease will actually occur on their watch. So it was with Jennifer Avegno when she signed on to head the New Orleans Health Department in 2018. Her focus then was on how she might advance progress against many of the local population’s chronic health problems, such as diabetes and high blood pressure.

But Avegno’s professional life took a big turn several months ago as New Orleans and the world learned of a new threat to the public well-being. The crisis that developed around the novel coronavirus demanded everything that Avegno could muster from her experience as an emergency room physician and educator. People who know her say the slender, brown-haired dynamo who often appears in hospital scrubs, even around City Hall, is well-suited to her role.

The New Orleans native who attended St. Mary’s Dominican High School, earned an undergraduate degree from the University of Notre Dame and a master’s from Tulane University before starting medical school at Louisiana State University, where she focused on emergency medicine. Soon after graduation she joined the faculties of both LSU and Tulane and eventually came to direct undergraduate emergency medicine education for both schools, all while practicing her specialty in local hospital emergency rooms.

Early on, Avegno, who is known among colleagues as a patient-focused clinician, took an interest in how the illnesses and injuries she regularly saw in the emergency department related to chronic health, social and economic problems in the surrounding community. She took particular note of matters affecting people’s access to care and disparities in health among different segments of the population. She saw the impact of violence, sexual assault and homelessness on the community’s overall well-being, and wanted to bring more public attention to these “social determinants” of health.

In 2017 Avegno established and became director of a community health relations division within LSU’s emergency medicine section and began working with local organizations and government to develop programs and partnerships aimed at improving health outcomes throughout the local population.

Her work may seem to have led naturally to her current role as city health director, but Avegno says when threw her name in as a candidate for the job she did not have high hopes. “I did not expect to get a call back, much less an interview,” she said. But Mayor Latoya Cantrell asked her to sign on.

Avegno says the was “thrilled” to take a leadership role in public health, which she sees as closely related to emergency care. “In emergency medicine we have extensive experience in disaster response, which is a large part of public health, and we also see what happens when chronic diseases turn into acute issues because they have gone unaddressed. We see the impact of violence, trauma and racism quite starkly in the emergency department.”

“I realized that these were not the cases we had expected. The virus was here, and it had already spread in the community.”

‘LIKE A TSUNAMI’

Emergency physicians were also on the front lines when the coronavirus arrived in New Orleans. “When COVID came, it came not to a clinic or inside a hospital, it came to the emergency department,” she said.

Avegno, who still works at least one shift per week in the emergency department at University Medical Center, believes that her ongoing experience with people in distress helps her relate not only to patients’ problems but also to those who care for them.

“When COVID started, the fear was palpable among patients and health care workers,” she said. “That was really important for me to see because it helped inform our decision making. We took this very seriously, very early, because we realized that if we didn’t, we were going to be overwhelmed quickly.”

Though doctors had tried to prepare for the virus, its actual arrival delivered a jolt. James Aiken, a longtime emergency physician and faculty member at LSU School of Medicine, says doctors who initially had thought coronavirus patients would present with fever, cough and shortness of breath had to shift gears and recognize that the virus could produce a broader range of symptoms and impacts. They began seeing, for instance, an unusual number of patients coming in with heart attacks and they only later learned that 10 percent of patients acutely infected with the coronavirus have secondary cardiac damage.

Aiken, who co-chairs LSU’s disaster medicine and emergency services division, says the effect of pre-existing conditions, such as hypertension or obesity, on the disease also was not initially clear. So as doctors analyzed data and struggled to manage the virus, “we were seeing people who just deteriorated rapidly right in front of us,” he said.

The ongoing challenge to understand the many faces of COVID-19 is “probably the most powerful learning curve” he has faced in his career, Aiken said, adding: “The disease came in like a tsunami.”

PUBLIC RESPONSIBILITY

As that viral storm descended on New Orleans, Avegno widened her containment strategy from tracking transmission of the virus to include the broad public safety measures being recommended by national and international authorities. In press conferences with the mayor, Avegno advised citizens to avoid crowds, stay home as much as possible and wash their hands often.

She said that New Orleans’ extensive experience with past disasters such as hurricanes and floods had helped cement relations between her office and all the agencies that typically respond in emergency situations. “Even though our initial plans didn’t go as expected, because we have really good relationships with these agencies, we pivoted quickly. I think places that didn’t have those pre-existing relationships were a little slower to get their response started.”

Through weeks of confused national messaging over measures such as self-isolating and the need to wear protective face coverings, Avegno helped the mayor keep pressure on citizens to take responsibility for their own safety, and gradually, the numbers of new COVID-19 cases in the city began to plateau. An emergency physician colleague who has experience in Avegno’s position says that her communication skills came in handy.

“She cuts through the nonsense, she’s real, and when you hear her speak, you don’t get the sense that she’s trying to BS you,” said Joseph Kanter, who preceded Avegno as city health director and now is assistant state health director.

Kanter said Avegno’s ability to quickly size up the virus threat and communicate it accurately to her colleagues at City Hall has been crucial during the pandemic. “She’s data-driven and able to see the forest for the trees in a way that very few other people I’ve worked with can do,” he said.

Just as important, he adds, she knows how to stretch resources to meet needs. “Emergency physicians are experts at making the best of limited resources, and that’s essentially what public health professionals do,” Kanter said. “They work in an underfunded environment and they improvise to meet public needs in challenging situations.”


COMPLICATING CORONA

It’s difficult to imagine a better way to complicate New Orleans’ struggle against the coronavirus than, say, allowing thousands of people to congregate in city streets. And that happened repeatedly throughout the month of June.

Part of a nationwide protest against racism and killings of African Americans by law enforcement officers, the local marches and rallies against racial hatred correlated with similar events in cities around the country.

At a time when public health officials had shut down schools and businesses and ordered citizens to stay at home in order to avoid spreading COVID-19, protestors donned protective face coverings and poured into streets.

But New Orleans City Health Director Jennifer Avegno, who had advised Mayor Latoya Cantrell to issue a stay-at-home order for local residents in March, had a somewhat surprising reaction to the protestors.

“From a pure infectious disease standpoint, we know that large uncontrolled open gatherings can be super-spreader events, and we do not want the virus to spread,” she says. But she adds that after several months during which large numbers of citizens regularly wore protective masks when they were near other people, it has become clear that masks do help decrease the risk of spreading the virus. “I have been encouraged to see that at our protests almost all people are wearing masks,” Avegno said.

After the pandemic began, public health officials urged people to use caution in “essential” activities, such as buying groceries, and avoid “non-essential” activities, such as having dinner parties, and Avegno said it occurs to her that protests against racism, which she considers a public health threat, are important.

“I think that individuals’ ability to peacefully exercise their constitutional rights to free speech are far more essential than my backyard barbeque,” she said.

She acknowledges that the protests create a “tricky” health situation, and she encourages protestors not only to continue wearing masks but also to get tested for the coronavirus at mobile testing sites around the city.

“We recognize that these are historic times and all of these issues really need to be discussed,” she said. “It’s time to talk about racism as a public health issue in a meaningful way.”


COMMUNITY BLOWBACK

Colleagues say that Avegno has a knack for making difficult decisions look easy, probably because of her emergency experience. But in the ER she rarely faced the kind of backlash that erupted early in the city’s struggle with the coronavirus. While the city had proceeded with its normal Mardi Gras celebration on Feb. 25, two weeks later, after New Orleans reported its first case of COVID-19, Cantrell made an unpopular move.

On March 10, after consulting with Avegno, the mayor cancelled Orleans Parish parades scheduled for the upcoming St. Patrick’s Day weekend. For some people, calling off the popular event was a step too far. Criticism echoed through the tourism industry and from members of the general populace. Even Louisiana’s Lt. Gov. Billy Nungesser weighed in saying he was “disappointed” in the mayor’s decision and that he would not cancel his own plans to ride in a St. Patrick’s Day parade in neighboring Jefferson Parish. A week later, New Orleans reported almost 200 virus infections and by the end of the month the city had reached a COVID-19 death rate higher than any other U.S. city.

Avegno concedes that the parade cancellation hit a nerve with many people. “I even had friends who said, ‘I can’t believe you did that,’ but it didn’t take long for folks to realize that it was the right thing to do,” she said. Early projections of COVID-19 cases suggested 1,300 people could die if the city took no restrictive actions. “At that point I think we had 400 deaths, and though 400 is a lot, it could have been much worse,” Avegno said. “I know our actions helped save lives.”

In the following week, the mayor issued a stay-at-home order for all residents. “We had already cancelled schools – we were ahead of the rest of the state and most other states in that,” Avegno said. “In public health you have to make early decisions before you know a lot about what you’re dealing with, and that may be politically unpopular but you have to wait for history to judge.”

LESSONS IN DIVERSITY

As the pandemic wore on and new case data became available, one thing that became clear was that the coronavirus was having a disproportionately serious impact on African Americans, as is true of some of the chronic diseases that are high on Avegno’s list of local public health dangers. Her concern over such vulnerabilities runs deep.

Growing up in her family’s home in River Ridge, Avegno was the oldest in a family of eight children and the only child actually born to her parents, Royann and Ashton Avegno. After the couple learned of a genetic anomaly that would prevent them from having more children, they decided to adopt, and their first adoption was, as Royann Avegno puts it, “traditional” – a baby of the same race as the adoptive parents.

The couple had their hearts set on a houseful of kids and when it became difficult to find more available “traditional” babies, they embraced the idea of having a diverse family with wide-ranging needs. They adopted an eight-month-old Korean boy who had serious health issues, and later a Chinese child who had cerebral palsy.

Ultimately, the Avegnos’ seven adoptions included an African American toddler, two bi-racial children and two terminally ill babies. Both of the latter lived much longer than their doctors had predicted, and Royann Avegno says “the realization that we could make such a difference in their lives meant everything.”

Jennifer Avegno says her upbringing among children with serious illnesses and social challenges profoundly influenced her. “I learned that others’ needs often trump your own,” she said. “If a sibling had a health crisis and had to go to the ICU at Children’s Hospital, my parents had to be with them most of the time.” She also saw that acceptance of her multi-racial family in the broader community was sometimes lacking.

“I learned at a young age that there are greater things than what’s happening in your own little world, and boy was that a wonderful lesson,” she said. “It was a good thing to grow up and really see that world as it was. Now, as a parent, I know how hard it was.”

Avegno and her husband of four years, Kurt Weigle, who is president of the Downtown Development District, have a blended family that includes three daughters and a son, ranging in age from 11 to 17. Avegno says the kids have managed their pandemic lifestyle well.

“I was worried that their friends would say, ‘Your mother’s the one that won’t let us have birthday parties and sleepovers,’ but they have been great,” she said. “The kids have been really mature about handing all the restrictions and they want to make sure they are setting a good example, which for teenagers is kind of remarkable.”

“I learned that others’ needs often trump your own…there are greater things than what’s happening in your own little world, and boy was that a wonderful lesson.”

SCHOOLS AND BUSINESSES

Thoughts of her kids made it difficult for Avegno to recommend closing local schools in the early stage of the pandemic, and she realizes that the prolonged closure has been a setback in their education. “I’m concerned about what it’s done to my own kids’ development, but I’m really concerned for kids who didn’t have access to digital resources and online learning through the summer and who need access to special services such as speech therapy that they only get in the school setting.”

Avegno believes that the public health risk of keeping schools closed likely is higher than the risk of returning kids to classrooms, and she wants schools to be able to reopen in the fall. As with the schools, she worries about local businesses that have been damaged by the city’s prolonged shutdown.

“I have had discussions with lots of businesses, and for the most part they get it – they don’t want to put their customers or their employees at risk, and I don’t blame them. But I understand that the shutdown has also been devastating to them.”

Some of the hardest-hit companies are in the tourism industry and many are headquartered downtown, within the business district that Avegno’s husband oversees.

Weigle says that he and Avegno have had many discussions about the economic effects of the city’s stay-at-home order and other public health restrictions. “Jen was always concerned about what impact this was going to have on the economy of the city,” he said. “She knew some businesses were going to have a hard time with it and that bothered her, but her priority had to be protecting the health and safety of the citizens of New Orleans.”

‘HORRIFIC’ AND AWESOME

While public health professionals are consumed with understanding and battling the coronavirus, many also find themselves somewhat in awe of the new infectious disease.

Susan Hassig, an epidemiologist and longtime medical educator, began her public health career in the 1980s, during the HIV/AIDS pandemic, and ultimately became known for her extensive research into HIV transmission and prevention. Now an associate professor of epidemiology at Tulane University, she has watched the coronavirus saga unfold with an intense awareness of the challenges it presents.

“I honestly thought that the next big pandemic I would have in my career would be a pandemic influenza,” Hassig said. “The fact that this is not influenza is in some ways intellectually intriguing and fascinating, but also horrifying at the same time.”

She points out that in teaching her students about infectious diseases, she’s generally telling them about events that have occurred in the past. “But this is in real time and it’s very different,” she says. “It has made the past four months feel like four years.”

Like many of her colleagues, Hassig has watched the city’s health director from afar and often tried to imagine herself in that role. She says the experience has sparked her respect for Avegno’s work.

“The thing that Dr. Avegno does so well is, she finds a way to communicate what can be very complicated information and complex medical issues in understandable ways and with great calm and confidence,” Hassig said. “And remember, as health director for New Orleans she’s not just dealing with coronavirus but with everything else that’s still going on.”

Hassig noted, for instance, that the mosquito-borne West Nile Virus may be returning to Louisiana, and problems such as sexually transmitted diseases remain a challenge in many areas. In addition, a host of chronic diseases and conditions that have plagued New Orleans for decades still impinge on the health of many local citizens.

Avegno says she has not lost sight of any of it and intends to keep marshalling resources toward mitigating the social and economic factors that affect public health.

“I want the city health department to continue to galvanize the community behind improving local health outcomes,” she said. “I think we are making headway on some bold ideas and those are not going to stop because of COVID. If anything, the virus has given us an opportunity to focus on the systemic health inequities that we have been talking about for years.”

Avegno now is hoping that New Orleans can avoid a second wave of the coronavirus and return to a more normal way of life. But she says citizens should understand that the need for caution is ongoing.

“For the foreseeable future we’re going to be wearing masks, doing physical distancing and trying to limit our contact with each other,” she said. “I know that is really hard for New Orleans, but we have done it so well, and I think all of that will continue until we get a vaccine.”


WHAT IS PUBLIC HEALTH?

“Today, everybody knows what public health is for the first time,” Edward Trapido joked as he reflects on how COVID-19 has deepened the interest of almost everybody in the fight against infectious disease.

An epidemiologist and associate dean of LSU’s school of public health, Trapido noted that while the basic mission of practitioners – to protect the public’s health – has not changed over time, the scope of what that job entails has evolved.

While infectious disease was long the main focus of public health professionals, he said that in recent decades there has been increased emphasis on “health issues that go across a lifetime” – chronic diseases such as cancer, heart disease and diabetes, which in much of the world have become major killers.

Another shift in the field is a relatively new focus on dealing with “social determinants” that make some populations especially vulnerable to poor health. These factors include housing conditions, poverty and scarce access to health care, disease-prevention and nutritional services. “If we don’t address these things, then we are never going to change health outcomes experienced by the population,” Trapido said.

More recently, the coronavirus seems to have brought the public health field full circle, with infectious disease once again becoming the top priority. “When COVID came along, it changed everything, at least for a period of time,” Trapido said.

The virus forced a reallocation of public health resources to focus specifically on issues at hand. “There’s suddenly a return to the importance of infectious disease and an awareness that the population has a role in preventing Covid as well as the other diseases,” he said.

Ja2


 

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