In the spring, WashU student Priscilla Cruz received an email from the ethics board of a children’s hospital in Honduras in response to research plans she had submitted for review. The email contained the board’s approval. But what caught her eye was the Spanish honorific in front of her name. The email was addressed to Doctora Priscilla Cruz, or Dr. Priscilla Cruz in English.
“I didn’t correct them, but in my head, I thought, ‘Oh, wow. Not quite. Not quite yet’,” said Cruz, an MD/MPH student at WashU School of Public Health and WashU Medicine. Cruz was conducting the study under the supervision of Caline Mattar, MD, an associate professor of medicine at WashU Medicine and a secondary faculty member at the School of Public Health.
The board’s confusion was understandable. Even though she did not yet have her degree, Cruz was the undisputed leader of the project, which was aimed at finding ways to reduce the rate of catheter-associated bloodstream infections at the hospital. She led the writing of the grant proposal to obtain funding, coordinated team meetings, developed a best-practices checklist and a focus-group interview guide and, overall, kept everything running. The project was one of two that Cruz conducted under Mattar’s guidance as part of her training to earn a master’s degree in public health.
“The MPH program has been an incredibly valuable experience,” said Cruz, who started working toward her master’s degree in public health at WashU’s Brown School. The MPH program has since become part of WashU School of Public Health. “There are a lot of skill sets that a public health program trains you in that we don’t get so much in medical school. It’s thinking, ‘How do we optimize people’s lives so people can achieve their best sense of health?’ rather than, ‘What do we need to do to fix the things that are wrong?’ I would love to see more medical students get a chance to develop that perspective and think critically about medicine in the context of public health.”
Melding medicine with public health
Cruz started working with Mattar on infectious-diseases projects as a first-year student, and quickly proved herself a capable researcher. So, when Hospital Maria, a children’s hospital in Honduras, reached out to Mattar to ask for help lowering its rates of central line-associated bloodstream infections, Mattar tapped Cruz to lead the project.
Central-line catheters are plastic tubes that are placed in or near the heart. They deliver medicine and fluids directly into the bloodstream, dialyze the blood and monitor blood flow and pressure. At pediatric hospitals, they usually are placed in children undergoing heart surgery or dialysis as an alternative to repeated needle sticks, which can be challenging to do with children and potentially damaging to their tiny veins. But along with these advantages comes a major risk: If not carefully maintained, central lines can serve as a superhighway straight into the bloodstream for bacteria, leading to life-threatening conditions such as sepsis and heart infections. About a quarter of people who develop a bloodstream infection from an infected central-line catheter do not survive.
“We have a bundle of practices that have been proven, when taken together, to be sufficient to prevent catheter infections,” Mattar said. “These practices include how you clean the skin, how you clean the catheter, how you dress the site. The problem is that a lot of the tools we use to get these things done are not available in Honduras. We are trying to figure out how to adapt these interventions, which were developed and validated in high-income countries, for a resource-limited setting so we can accomplish the same thing using fewer resources and locally available tools.”
In the U.S., central line-associated bloodstream infection rates are public record. Rates are reported as the number of infections per 1,000 catheter-days, with one catheter-day defined as one person using a catheter for one day. Hospitals aim for zero. St. Louis Children’s Hospital, for example, has a rate of just under one infection per 1,000 catheter-days, which is considered good. Hospital Maria’s rate hovered around 15, despite focused efforts of the hospital’s medical and nursing staff.
Mattar obtained a Global Incubator Seed Grant to help the hospital’s staff figure out why their infection rate remained so high. The research team has developed a checklist for providers to use when inserting and maintaining catheters; they hope the checklist will ensure sterility and start bringing the rate down. Now they are conducting focus groups with providers to get a better sense of what the people in the hospital see as the barriers to reducing infection rates.
“We’re trying to understand both individual and systemic limitations they may have,” Cruz said. “We will use that information to design and implement interventions that hopefully will reduce those numbers.”
At the same time, Cruz was working on another project with Mattar, this one focused on understanding why physicians from low- and middle-income countries migrate to high-income countries, beyond the obvious draw of higher pay.
“Health-care providers, like all people, have the right to live where they choose, but in the context of health systems, physician migration at large scale causes health-care shortages and puts incredible strain on health systems that are already under duress,” Cruz said. “The discussion is not about how to keep people in one place. It’s about how to increase the benefits and minimize the harms of physician migration to health systems in low- and middle-income countries while respecting individual autonomy.”
Their study, a survey of 13 countries representing all six World Health Organization (WHO) regions — Africa, the Americas, Southeast Asia, Europe, the Eastern Mediterranean and the Western Pacific — showed that poor working conditions and lack of opportunities for advanced training were also major drivers of physician migration. The final report will be published in the coming weeks by the World Medical Association as the “Global Physician Migration Report” — but Mattar presented the top-line conclusions at the World Health Assembly meeting in Geneva in May. As the decision-making body of the WHO, the World Health Assembly will vote on a resolution on health-workforce migration next year.
“Priscilla’s contributions have been invaluable to a document that is going to be very important for high-level political decision-making,” Mattar said. “Often these sorts of decisions are made with very little data. Here we have collected the data, and hopefully that will help steer the conversation around the real issues that need to be addressed.”
Looking ahead
These days, much of Cruz’s time is devoted to applying to internal medicine residency programs as a precursor for subspecialty training in infectious diseases. Although she continues to conduct focus groups for the bloodstream-infection project and hopes to write up the results before she graduates, she has wrapped up her year as a public health student and is focused on figuring out the next step in her career.
Cruz is the American-born daughter of a Nicaraguan physician who moved to the U.S. before she was born and continued to provide care for a largely Spanish-speaking patient population in the U.S. This immigrant background has shaped how she thinks about medicine and health, and underpins her commitment to public health.
“[Public health is] thinking, ‘How do we optimize people’s lives so people can achieve their best sense of health?’ rather than, ‘What do we need to do to fix the things that are wrong?’ “
MD/MPH student Priscilla Cruz
“I had a very hybrid childhood,” Cruz said. “I was the only member of my family born here. My household was very culturally Nicaraguan, and we always spoke Spanish at home. That upbringing really does drive a lot of the reason why my professional and personal interests delve so much into immigrant and refugee health, and language accessibility in health and medicine, because that was something that was very close and personal to me growing up. I think a lot about questions like, ‘What does it mean to provide the best possible care in a community that has financial or language or legal constraints? What can we do to improve the health of these populations at large, despite those constraints?’
“I pursued this public health degree because I knew I wanted the knowledge and the skill set it would give me,” she continued. “At the end of the day, treating one person is also going to have broader effects in the community and, simultaneously, if you want to have a broader effect on the community, you can’t just take each patient in a vacuum. I think maybe that isn’t talked about enough with medical students. It’s hard to think bigger when so much is already on your plate and everything is already so stressful, but I think it’s so valuable to pull back just a little bit and try to see the bigger picture.”
For Mattar, after four years of working together, knowing Cruz will graduate soon is bittersweet.
“I have had many talented students over the years, but I don’t think I have had anyone as phenomenal as Priscilla,” Mattar said, “My hope is that ultimately she stays for her specialty training and joins the faculty at WashU. She will excel wherever she goes, but she is so phenomenal I hope to keep her here.”
Writer
Tamara Schneider, MPH, PhD, is the senior science writer and assistant director of communications for WashU School of Public Health. She holds a bachelor’s degree in molecular biophysics & biochemistry and in sociology from Yale University, a master’s in public health from the University of California, Berkeley, and a PhD in biomedical science from the University of California, San Diego.