Physician Advocate for the People

On the recent day when President Biden signed a resolution formally ending the coronavirus national emergency, Valenciano marked 648 days (July 1, 2021, to April 10, 2023 ) as the DeKalb County Board of Health director. She has stepped up during an exodus: a national study found between 2017 and 2021 that 46% of state and local public health employees left their jobs. The front line of public health is likely less prepared for the next pandemic than it was for COVID-19. 

“We applaud Dr. Valenciano and her work to lead the DeKalb County Health Department, especially during these challenging public health times,” said Adriane Casalotti, chief of government and public affairs for the National Association of County and City Health Officials, which attracted more than 3,100 of them to its annual Preparedness Summit in Atlanta in late April.

“Local health officials come from many different academic backgrounds; however, they all possess a wide range of skills and experience to effectively serve their communities,” Casalotti added. “In this way, preventive medicine practitioners, who receive training in a variety of disciplines, are well suited to working in health departments.” 

Valenciano’s sudden impact energizes her Emory mentors and peers, who battle blank stares even in the medical community when they mention preventive medicine. This field is practically secret even in a city known as the nation’s public health capital, home to the CDC, Carter Center, Task Force for Global Health, CARE, and others. Did you know that James W. Curran, who led the CDC’s national AIDS response and the Emory Rollins School of Public Health, trained in preventive medicine at Harvard Medical School?

While Emory University has trained MD/MPH students for public health leadership roles for more than 40 years (First graduate Edwin Trevathan (82M, 82PH), most medical students don’t discover their specialty until their rotations or later. One rotation at Emory is preventive medicine.

“It doesn’t have a very big footprint,” said Sarah Dupont 18M 18MPH 21MR 22F, a prev med-trained Emory primary care physician and associate program director of Emory's Public Health and General Preventive Medicine Residency & Fellowship Program. “A lot of times in public health, research and recommendations seem really distant from everyday primary care practice, but you need that clinical perspective in order to craft recommendations. And as a clinician, you need to understand the recommendations in order to implement them. Preventive medicine is a whole specialty in which those two translate for each other.”

Prev med faces enormous competition from better-known specialties, said Richard A. Goodman 01L , 11F, a leading physician in public health since 1978 and advisor to the Emory program. He points out that Emory is home to one of the largest medical training programs in the country, with more than 1,300 residents and fellows in more than 100 training programs and 200 first-year positions.  

“It would seem to be a paradox or maybe even an irony that you have a medical residency and fellowship training program in preventive medicine, situated at Emory University with the Rollins School of Public Health and literally adjacent to the CDC,” Goodman said. “And yet so little is understood about the specialty and about the program itself.”

“People should care because our program and 41 like it across the country are training doctors to prevent a lot of people from getting sick at one time instead of helping one patient at a time get well,” he added. “For the same dollar you spend on an individual patient getting well, you can potentially protect a community.”  

Emory’s Public Health and General Preventive Medicine Residency & Fellowship Program attracts doctors like Valenciano and Dupont who typically have treated patients one-on-one (like through a primary care residency) and encountered systemic barriers to them getting healthy. Instead of burning out, they seek to make a bigger difference to more patients by preventing illness, not just treating it. 

 “I worked in an underserved clinic in a food desert, and my patients’ problems were often beyond what I could manage in a 15-minute appointment,” recalled 2019 resident Elizabeth Rabold 19MPH 19MR. “Financial insecurity, and lack of mental health services, social workers, dietitians, and healthy food options were challenges that prevented them from meeting their health goals. I was looking for a way to explore how I could have a larger impact, and at Emory, I could gain training in preventive medicine, population health and earn a master's in public health all at the same time. The program also had ties with the infectious disease clinic at the Atlanta VA, which stood out to me because I was interested in HIV.”  Rabold now serves as CDC medical officer for the Maternal and Child Health Branch of the Division of Global HIV and Tuberculosis.   

Since 1994, Emory has trained 59 public health and preventive care doctors. Their residency spans 1 to 2 years, and for each of those years, requires at least two months serving in a governmental public health setting. Two fellows who graduated in May 2023 will enter positions in public health agencies: Siri Chirumamilla 23MPH 23MR in a management/ technical position at the Los Angeles County Department of Public Health, and Alex Molinari 23MR as a CDC EIS officer.

As insiders, prev med residents see how barriers to health are addressed through surveillance, outbreak detection, disease prevention, and control, and emergency preparedness/response. This exposure is critical for inspiring doctors like Valenciano to enter this type of public service, and say no to 9-to-5 specialty practices that usually pay more.  

“If you can't get talented people learning about how county boards of public health run, then why would they respond to an opportunity that on the surface seems to be a poorly advertised, poorly funded government job?” said Family and Preventive Medicine Chair Theodore M. “Ted” Johnson II.

Valenciano grew up in Miami, raised by a single mom. “We didn't have health insurance, so my experience with the health care system was actually going to the Florida Department of Public Health for my immunizations and most of my well childcare,” she recalled. “I actually didn't get health insurance until I went to college.”

During summers with her extended family in Colombia, Valenciano saw people suffering because they could not access health care and had no one to fight for them. Though no one in her immediate family had attended college, Valenciano decided to become a doctor.  

At Brown University, she learned the name for the gaps she had observed about health and social class, wealth, geography, race and other factors: social determinants of health. “My mind was blown,” she said. “And I loved it.”

With an undergraduate degree in community health, she followed the need—to New Orleans after Hurricane Katrina and a master of public health degree at Tulane University. "Sandra is a born public servant who has been committed to applying her considerable talent, expertise and exceptional leadership skills to improving the public's health since the early days of her career,” said Google Chief Health Officer Karen Bollinger DeSalvo, her Tulane mentor.

Medical school still beckoned to Valenciano because her voice “as a physician and advocating for the community is very powerful, especially thinking about myself as a Hispanic woman advocating for underserved communities,” Valenciano said.

At her Boston University School of Medicine rotations and a Yale University internal medicine residency, Spanish-speaking patients eagerly sought her out.

“I love that one on one, but I just felt this angst,’’ Valenciano said. “I felt like I was practicing Bandaid medicine with a vulnerable population. If you don't have access to healthy foods, a safe place to exercise, and if you can't communicate with a pharmacist and get medications that are the correct dose, then I'm putting a Bandaid on you. I really despise when patients are called noncompliant, because they are actually trying to do all the things. Just look at all these things that block their progress.”

Where could her medical and public health skills best fit? In 2017, Valenciano moved to Atlanta to become a “disease detective” with the CDC Epidemic Intelligence Service (EIS), racking up miles traveling to places like Mozambique, where she worked on pneumococcal vaccination efforts, and South Dakota, for a Legionnaire’s disease outbreak.

But social inequities still gnawed at her. She had global, federal, and clinical experience, but not local. Communication was one of her greatest skills, but she hadn’t connected with the people who most needed her voice. 

After seeking advice from CDC physicians who had trained in prev med, Valenciano enrolled at Emory because the program would customize the training to her career goals. Her timing was perfect.

The fellowship placements are scheduled a year in advance, so there was no inkling that her assignments in early 2020, first at the Georgia Department of Public Health and then DeKalb County Board of Health, would seat her at coronavirus briefings before Georgia even got its first case.

In one early project, Valenciano took charge of creating standard operating procedures for testing sites. In time, she helped respond to vaccine hesitancy, misinformation, racial disparities in access to health care and distrust in institutions.

For example, she worked with IT people to collect COVID-19 data from undocumented people who were afraid of deportation.

“She didn't seem intimidated at all by the scale of it, or the list of tasks that needed to be handled,” said her colleague and Emory Public Health and General Preventive Medicine Residency & Fellowship program director Sara Turbow 12M 12MPH 15MR 20F, who worked on plans to reopen DeKalb regional health centers during COVID-19. “She's able to quickly assess a situation, laser in on the challenges and say, ‘Let's start thinking about them now.’ Someone else might have realized later that we’re missing data from the whole population of undocumented folks, but Sandra has already anticipated the problem.”

Valenciano is someone who loves to tackle big problems while keeping her eye on details. She even keeps her inbox email at zero. The front line of an evolving pandemic completely immersed her.

“It was amazing. I literally like just became a part of the health department,” she said.  “I thought it was so cool that they're dealing with this outbreak, but they're also dealing with measles and all these other things happening. There was so much we didn't know about COVID-19 and things were changing so rapidly, but what I was witnessing was how dedicated everybody was. I was working 80 or 100 hours a week like I had in my residency, because this is such a dedicated group of people and I felt that I was a part of the team.” 

As her Emory training ended, Valenciano stayed at the Board of Health. In summer 2020, Valenciano was hired as medical director. The next year, when her boss Sandra Ford got promoted to special assistant to the president for public health and science, Valenciano got promoted to a job she had imagined was two to five years away.

Her Emory and CDC connections helped her quickly get up to speed on finance, media interviews, and other facets of leadership that were less familiar to her. On Dec. 31, 2020, Valenciano rolled up her sleeve to get one of the county’s first COVID-19 vaccinations as cameras clicked. The photo op was to help educate and motivate people to do the same.

Valenciano had found her people and calling in the ever-changing DeKalb ecosystem. The pandemic may be ebbing but the daily issues in public health do not.

“The people who had the greatest burden of COVID-19 were our communities of color or underserved communities, our low-income population,” she said. “The data shows that where we had the greatest number of cases and the lowest vaccination rates, those areas before the pandemic had the greatest rates of obesity, diabetes, asthma, infant mortality and chronic diseases. Those underlying risk factors didn't change and so we need to continue addressing those issues.”

Valenciano keeps a role at the Emory School of Medicine, as adjunct professor in the Department of Family and Preventive Medicine. Prev med residents come through her doors like she once did.

In 2021, Dupont spent her two-month prev med fellowship assignment working under Valenciano. When the county received mobile vaccination units, Dupont worked on procedures and strategy for getting the most people vaccinated. Valenciano showed her the difference that a trained physician can make to an entire county.

“Sandra is willing and able to make difficult decisions, because there are no easy decisions when it comes to applied public health in the county,” said Dupont, who today practices primary care and works with the Georgia Gear grant to improve geriatric medicine in Georgia. “You don't get the luxury of purity of method. You just have to make the best of it, and Sandra is decisive when someone needs to call the shots and take the responsibility. I think medicine prepares you for that because as a doctor, it's your final call on the team.”

Creating healthier communities, according to Valenciano, involves what we all do collectively to assure the conditions in which people can be healthy. Her department is partnering with neighborhoods, PTAs, civic groups, faith organizations and others to improve health. Her staff is tracking health trends so that resources can be focused on the most pressing concerns. They are raising public awareness of local health issues, stopping the spread of disease through education and early detection, and providing services to help people stay well.

At the May 2023 board meeting, Valenciano presented a $47.3 million FY2024 budget. She inherited a $1.5 million operating deficit, now trimmed to $270,000. The state gave $2,000 raises to help retain staff after COVID-19. 

Pandemic data shows the persistence of the county’s socioeconomic disparities. From the more affluent northern part of the county to the south, COVID-19 vaccination rates decreased  and deaths increased. Chronic diseases follow the same pattern: sickness and death increase with poverty.

“Look at the disproportionate rate of morbidity and mortality by African American and Latinx members of our community,” said board chair Sonia Alvarez-Robinson. “We seem to not be moving the needle an inch … what if anything are we engaged in at the county level or the state level to try to resolve at some point these inequities?”

“Great question,” Valenciano replied, explaining that her team is strategically employing its mobile units from the pandemic response to bring needed resources to residents in the most affected zip codes. A mobile farmer’s market with the DeKalb Extension Service has already shown success. Showing up consistently over time is critical to building relationships and trust.

“We're hoping to address our healthcare disparities through changing our model, trying to be more community focused,” Valenciano said. “But our challenges are our workforce and resources.” In the trenches of local public health, prev med doctors like Valenciano pass up job offers that pay more. This work is a calling.

“The money isn't worth it if I'm not doing what I'm supposed to be doing,” Valenciano said in an interview. “I could have taken a job that would compensate me at a higher level, but would I really be doing what I want to be doing with the community? The people that I want to serve? Probably not.”