Healing hands in conflict zones
UF Health physicians put themselves at risk to provide critical medical relief around the globe
Taking the Hippocratic Oath is widely known among physicians as a rite of passage into medicine. One of the oldest binding documents in history, the oath written by the Greek physician Hippocrates compels doctors to treat their patients to the best of their ability, to protect patients’ privacy, and to set an example for future generations of physicians.
Many doctors expand the parameters of this sacred promise beyond their clinical practices by going out into the world to heal, often putting themselves at risk in the process.
For decades, University of Florida physicians have ventured into war-torn regions, conflict zones and developing countries around the world to bring lifesaving care to the most vulnerable patients. They work with their medical brethren on the ground under arduous conditions, bringing needed expertise and equipment to remote areas where disease and adverse health conditions often have the upper hand.
Here are some of their stories.
Rebuilding lives and health care systems
UF Health internist treats Venezuelan refugees, despite threat of guerillas and COVID-19
By: Crystal Long
On the border of Venezuela sits the small city of Cúcuta, Colombia, one of the most heavily trafficked border crossing points for fleeing Venezuela refugees. The city struggles under the weight of a massive exodus of over 4.6 million people escaping a protracted political and economic crisis in Caracas.
For those trying to rebuild their lives, leaving the turmoil behind is often only the beginning – most arrive to Cúcuta suffering from malnutrition, without money, and with nowhere to live apart from makeshift squatter shacks in sprawling, malaria-ridden refugee encampments.
Complicating matters, control of the area is contested between the Colombian military and the Ejército de Liberación Nacional, or ELN, a militant guerilla group known for carrying out attacks on infrastructure and government targets to exert control of the border.
The situation is difficult and desperation often leads to volatility in the refugee camps, but it is here that Riley Jones, M.D., DTM&H, a global health postdoctoral associate in the University of Florida College of Medicine’s department of medicine, is in his element.
Jones arrived in Cúcuta in mid-February 2020 to work in the camps, where he would apply his training in internal medicine and tropical diseases to the humanitarian crisis and provide treatment to Venezuelan refugees.
At first glance, Colombia appears to be a dangerous place, volatile and violent. Jones recognizes the conflict and instability, but added, “Like most places, one of the keys to working safely in Cucuta is learning how information spreads. It’s usually there, you just have to learn how to listen for it. For the most part, people are reasonable, especially when it comes to medical services.”
Surprisingly, movement and safety information that Jones and his local colleagues came to trust came from the local hair salons. According to the gossiping customers, a tell-tale sign of trouble is a lack of taxi traffic. If the taxis are running, you are probably safe to go out. If not, you should stay inside.
Within a week of his arrival, Jones received a recorded message, delivered on WhatsApp. It was a warning from the ELN that they would enforce a border lockdown for the next 72 hours – anyone attempting to cross, except for medical personnel or for medical reasons, would be killed.
Jones is part of a niche group of internists who focus on the long-term assistance that is needed to rebuild the health care infrastructure of areas such as Cucuta that are recovering from conflict or civil war. His research as part of a fellowship in global health has led to several trips outside of the U.S.
Global health has traditionally been a profession of solitude, but Jones, and others, are working to change this by integrating their families. His travel companions include his wife, Rachel, and 3-year-old daughter Coraline. Jones acknowledged that traveling with his family isn’t always easy, but he said they’ve learned to adapt.
“Early on, we had to come to an understanding on what is negotiable and what is nonnegotiable for us as a family,’’ he said. “Every day, we designate family and play time with our daughter as nonnegotiable.”
As a family, they have figured out what amenities are wants and what are needs: Reasonable access to food, shelter, clean water and safety for his family are necessities.
The key, he said, is being able to adjust to a new culture, learn how to prepare and have realistic expectations. For example, Jones would buy bags of reliably clean water from the same man every day on the same corner of the road.
“My idea of what is negotiable has changed since I first began traveling,’’ he said. “You can’t expect to always have access to running water, cell phone service or electricity.”
You also learn to expect the unexpected. Jones recalled how quickly things changed when COVID-19 first came to the area. Knowing the order would soon come to evacuate, he did his best to prepare his local counterparts for the coming COVID-19 surge.
One major effort was putting together a public health education campaign to teach handwashing, social distancing and principles of practical case identification and isolation to the residents of El Talento, the largest of the refugee camps. Less than a week after learning that COVID-19 was in South America and three days into the educational campaign, he and his family were given 24 hours to evacuate.
Upon returning to the U.S., he was immediately back at work at UF managing patients admitted with COVID-19, developing and disseminating treatment protocols, and working with UF epidemiologists on research and community contact tracing.
As the pandemic grew, he was asked to present webinars for UF’s international partners and nongovernmental organizations such as MedGlobal and the United Nations High Commissioner for Refugees on adapting COVID treatment protocols to low-resource settings and refugee camps.
His experiences, Jones said, have prepared him for an outbreak like the novel coronavirus pandemic.
“Not to lessen the seriousness of the pandemic, because this virus deserves respect, but reusing PPE and working with limited resources is not unusual in global health,’’ he said. “My experiences in South America and West Africa, for example, where I’ve had to reuse the same mask, gown and goggles for multiple days, has prepared me for this like no other practice could have.”
When he was in Colombia, Jones partnered with MedGlobal to work in a small clinic in Cúcuta. He noted the importance of working with the local doctors and respecting the way they have to practice medicine in their country. Each provider arrives with their own specialty and background, but you have to be prepared for anything.
“To be successful, you have to be flexible, but it also requires a sense of self-awareness and knowing your limitations,” Jones said. “You cannot take a cowboy approach to medicine, no matter where you are in the world.”
Recognizing that some physicians may be hesitant to travel to conflict areas to provide medical care, Jones views it as vital to his career satisfaction and family life.
“When we set out to clarify, as a family, our shared sense of vision for our one life, we kept coming back to our work in global health,’’ he said. “UF sees the value in what we’re doing in these refugee and conflict zones, so we’ve made it work well for us and for UF.”
As more stories appear in the news about physician and health care worker burnout, he said, “Practicing in recovering countries reignites me. There is a return of purpose when you consider what you’re doing here. The problems are incomprehensibly large and so many are in need of urgent help, but you do what you can for one person at a time. Drop by drop, rivers are made.”
Mending hearts in the Middle East
UF Health pediatric cardiologist travels to Gaza and the West Bank to save children
By: Alisha Katz
Wearing surgical scrubs and a stethoscope around his neck, Frederick “Jay” Fricker, M.D., a long-time pediatric cardiologist at the UF Health Congenital Heart Center, adds another layer to his work uniform on special occasions. When he is saving lives in a conflict zone halfway across the globe, Fricker pulls a khaki vest over his scrubs.
On the right breast pocket are stitched the letters PCRF: Palestinian Children’s Relief Fund.
For 25 years, Fricker has medically cared for populations living in dangerous areas overseas. After moving to Gainesville in 1995, Fricker, a professor of pediatrics at the UF College of Medicine, became involved with his church and heard about an opportunity to provide primary care services in Africa. He was hooked. Since then, Fricker has traveled to South America’s Amazon region, as well as Uganda.
In 2010, former UF Health pediatric heart surgeon Adil Husain, M.D., who worked with Fricker at the time, mentioned a medical humanitarian trip offered through PCRF. The United States nongovernmental organization has supplied free medical care and humanitarian relief to children in the Middle East, specifically in Gaza and the West Bank, for over 25 years. The pediatric cardiology program was one of the earliest programs established by PCRF.
After learning more about PCRF and connecting with president and CEO Steve Sosebee, Fricker decided this was for him. Since 2010, he has traveled to the region with PCRF every year, with the exception of 2014 when the situation there was deemed to be too dangerous.
Recently, Fricker recalled his first trip to the Middle East with a team of eight to 10 clinicians.
After touching down at Israel’s Ben Gurion Airport, Fricker and team were escorted by Israeli security to the border. Through the Erez Crossing gate from Israel into the Gaza Strip, a team of Palestinians guided them to their destination.
“PCRF had a big team on the ground, so I never felt the least bit afraid,” Fricker said. “But I would say the time I felt most vulnerable was when I went to Gaza City and was separated from the team. Steve needed me to screen patients in refugee camps with our portable echocardiogram machine. The Palestinians picked me up from the hotel where I stayed in Gaza City for two nights. In Gaza City, there was always a lot of gunfire. That’s the only time I felt a little alone.”
On each trip, Fricker and team screen a handful of babies and children — some of whom are missing limbs — and operate for five days. On his last mission, Fricker and team screened 25 to 30 children, and operated on 10.
During these trips, the team looks for patients with congenital heart conditions that can be repaired with anticipated usual postsurgical recovery. These heart conditions include atrial septal defect, ventricular septal defect, tetralogy of Fallot, coarctation of the aorta and atrioventricular septal defect.
Many infants with complex conditions cannot have surgery because any patient who is treated has to be discharged from the intensive care unit before the team leaves. Otherwise, these patients would not receive essential postoperative care. A limited number of patients are sent to Israel for surgery outside of the efforts of PCRF’s pediatric cardiology team.
Another challenge is inadequate equipment to properly screen patients.
“On this last trip, the echo machine was broken,” Fricker said. “They had to turn it on and leave it on. Otherwise, if they turned it off, they couldn’t turn it back on again and they’d have to get an engineer. So, we left it on for the whole week in the operating room in order to perform transesophageal echocardiograms after the repairs.
“In general,’’ he said, “infrastructure and spare parts are a problem because of funding. The Palestinian nurses and hospital staff are amazing and accomplish much with their limited resources.”
The team also brings with them surgical instruments, as well as toys, clothes and soccer balls for the children.
While serving these patients and their families, many of whom only spoke Arabic, Fricker said he sees a commonality between families in the Middle East and in the United States.
“Just like parents everywhere, they love their kids,” Fricker said. “They cry when they are sick. They’re not any different.”
Building bridges to better care
UF Health pediatric surgeon creates strong ties with local medical community in Rwanda
By: Lauren Gajda
Even after 10 years and more trips than she can count, when UF Health pediatric surgeon Robin Petroze, M.D., M.P.H., moves about in Rwanda, she’s still called “Mzungu.’’
Translated as “foreigner’’ or “outsider,’’ the word reminds Petroze of the importance of building strong collaborations with the small medical community serving this country of 12 million in East Africa. As with any type of mission trip or international academic venture, she said, the important thing is to avoid a savior complex and to develop sustainable local relationships.
“Given the history within Rwanda, you have to remember that you are a guest and have the option of leaving,” said Petroze. “It’s also really important to understand your role and the historical/political context in which you are working. Going in unprepared is one of the most dangerous things you can do.”
Petroze’s passion for Rwanda began when she was a general surgery resident at the University of Virginia and spent two years as a research fellow in the country studying the burden of surgical disease and contributing to surgical education.
Now an assistant professor in the UF College of Medicine’s department of surgery, she travels to Rwanda to deliver care in their 520-bed hospital as well as mentor, train and teach medical students and residents.
There is only one pediatric surgeon in the country, so for nearly two years, Petroze has provided some clinical respite for him and filled in as a faculty member at the University of Rwanda on the pediatric surgical service. Together, they are developing outcomes research and quality improvement projects for neonatal surgical conditions.
Before her first trip to Rwanda in 2009, Petroze researched the nation’s history. Much of what she learned dealt with the 1994 genocide against the Tutsi ethnic minority, where close to 1 million people were killed during a 100-day period.
Since then, Rwanda has developed a reputation as one of the safest places in the world, according to websites offering advice for travelers. The ongoing COVID-19 pandemic, however, has led to a travel advisory from the U.S. Department of State about traveling to the country.
Petroze said she has been able to do her work in Rwanda without fear for her safety. “I feel more comfortable there walking on the streets than I do here in the United States,” she said.
The genocide wiped out the health infrastructure in the country. In the early 2000s, Rwanda had the worst health indicators in the world with the highest maternity mortality and the worst child survival rates. Since then, the country has made dramatic strides in health care development with a substantive focus on health equity.
“Seeing both the need, as well as a government and a population that is really engaged in making changes, are part of why I chose Rwanda,” said Petroze.
Much of Petroze’s international work is done in academic collaboration with surgical training programs around the world. She is involved in the College of Surgeons of East, Central and Southern Africa, or COSECSA, which is the regional college for higher certifications of surgeons in regards to education, research and publications and is similar to the American College of Surgeons in the U.S. COSECSA has worked to standardize training certifications in different regions in order to improve access to surgical care in multiple nations.
While Rwanda is considered relatively safe for travelers, regional conflicts, particularly in the neighboring Democratic Republic of Congo, and significant health concerns such as Ebola are present. Over her time in Rwanda, Petroze has noticed times when there have been larger refugee populations from conflicts in bordering nations.
“I’ve had to trust the local government and my direct colleagues to tell us what is happening in the country,” said Petroze. “Trusting others has allowed myself to be more vulnerable, which can be both scary and liberating.”
Petroze’s passion for global health and providing care in distant countries is rewarding, she said, but it can also be emotionally challenging.
“There are times when you do the right thing, but the patients don’t survive because you don’t have the same resources you have here in the U.S.,” she said. “Some conditions we treat as pediatric surgeons have a 95% survival rate here and a 5% survival rate there.
“Sometimes, going back and forth can be frustrating and heart-wrenching,’’ Petroze said, “because you know there are kids in parts of the world who have access to great health care and kids in other parts who don’t.”
Unusual spring break trips give UF Health student volunteers new perspectives on health care
By: Crystal Long
Serge Geffrard was 8 years old and living in Haiti the first time he saw a doctor. The visit left an imprint on him far beyond the treatment for a bad cough.
As a teen, Geffrard emigrated from the impoverished country with his family to South Florida. His path eventually led to Gainesville, where he graduated from the University of Florida College of Medicine in 1998.
But Geffrard’s heart never really left his home country. His need to give back to the underserved people of Haiti led him in 1996, as a second-year medical student, to organize the first Project Haiti trip. He and 10 of his classmates spent the week of spring break in Haiti, offering needed medical services and launching what has become the longest-running international health outreach project at UF.
Geffrard, now a pediatric cardiologist in Stockbridge, Georgia, in 2004 co-founded Project Haiti Heart, a nonprofit organization that provides medical, humanitarian and spiritual help to the people of Haiti.
The inaugural 1996 trip was led by Eloise Harman, M.D., now professor emeritus in the UF College of Medicine’s department of medicine, and Parker Small Jr., M.D., professor emeritus in the UF College of Medicine’s department of medicine and department of pediatrics, in a collaboration with the University of Miami and Project Medishare.
In Project Haiti’s annual spring break trip, the team of volunteers from a variety of specialties strikes a balance between service and education. The team can treat over 1,000 patients at mobile clinic sites and has expanded to include residents and physicians from family medicine, pharmacy, dentistry, obstetrics and gynecology and surgery. Pharmacy students and a pharmacist are essential in dispensing medication and more importantly, recommending substitutes when medications are not available.
At times, when a dentist and dental residents can accompany the team, dental extractions are a large part of the treatments provided. Conditions aren’t always favorable, and they often have to work outside, sterilizing instruments using a pressure cooker and propane gas.
A volatile political climate, along with natural disasters make Haiti a challenging environment for the team. Following a devastating earthquake in 2010, Harman and Geffrard traveled back to Haiti, against the guidance of institutions in the United States.
Harman described scenes most people can barely imagine.
“The collapsed buildings, tent cities and the smell of decomposition from people trapped beneath the rubble was unbelievable,” she said. It is as an image that will never be erased from her memory.
Project Haiti organizers traveled to Jimani, a border town in the Dominican Republic, where they treated Haitians injured by the earthquake. Their trips resumed to Haiti in 2012.
While the major focus of Project Haiti has been to bring medical assistance to underserved populations, the endeavor also provided an invaluable educational experience for the UF students.
“This work allows students to find an appreciation for global health and what it’s like to provide medical care in developing countries,’’ Harman explained. “They have a real appreciation for what is available to us in the U.S.”
One of the biggest challenges Harman and her students experience is the language barrier. Explaining a diagnosis or treatment plan, even with translators, can be frustrating. The pharmacists experience their own difficulties because many of the people have the same or similar names. Things as simple as a childproof container have proven problematic because they are unable to explain how to open the containers.
Another challenge is the ability to keep records and reach back to patients they have treated. The team has witnessed some of the most heartbreaking conditions – biopsies that revealed advanced-stage cancer, adults blinded by cataracts, malnourished babies.
Even in the reality of these hardships, Harman said the people of Haiti have always been grateful and would even come back years later to see the doctors and pay thanks.
Harman is sensitive to the unique challenge and conditions the health care professionals in Haiti face, and she is cautious not to offend them.
“You have to recognize that they do things differently because they have to,’’ she said. “They are required to be resourceful.”
As Harman reflected on her experiences in Haiti, one thing that stands out are the orphanages. Many of the children there had parents, but they just can’t afford to care for them.
“The kids were anxious for affection and would flock to play Frisbee with the medical students,’’ she said.
One day, Harman recalled, as she boarded a bus leaving a settlement around a sugar plantation, a woman stopped her. At first, Harman couldn’t understand what the woman was asking. Then the woman pointed at Harman’s shoes. Harman thought, why not? She was at the end the trip. When she boarded the bus, her students took notice of her missing shoes and many of them followed her lead and donated their shoes as well. Now, it has become a tradition to donate their shoes at the end of each trip.
Even the simplest of gestures can leave a lasting imprint.