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Sierra Leone: Take It All Off! (Thoughts on Ebola, Maternal Care and Willy Wonka)

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Traditional birthing attendants with Wellbody Alliance learn how to wear their personal protective equipment during a training session at the Wellbody Alliance birthing center in Gbense Chiefdom in Kono District, Sierra Leone The PPE training is part of the new birthing center training protocol due to the presence of the Ebola virus in the region. Image by Michael G. Seamans. Sierra Leone, 2015.

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Traditional birthing attendants recently hired to assist at the Wellbody Alliance birthing center in the rural Gbense Chiefdom in Kono District of eastern Sierra Leone learn how to use personal protective equipment. Image by Michael G. Seamans. Sierra Leone, 2015.

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Dr. Andy Hall with Partners in Health instructs Esther Nguajah, a traditional birthing attendant, on how to shed her personal protective equipment at the Wellbody Alliance birthing center in Gbense Chiefdom in Kono District, Sierra Leone. Image by Michael G. Seamans. Sierra Leone, 2015.

Long before I traveled to Sierra Leone's rural Kono District, I'd heard about the difficulty Ebola responders and health care workers had working in PPE—the personal protective equipment that looks like a flimsy Halloween costume version of an astronaut's spacesuit.

I know removing the suits improperly is one of the causal factors in health worker Ebola deaths, so I was curious to see how burdensome the process really is.

On March 31, I visited the Wellbody Alliance, a small NGO at a health clinic the group opened in Kono about nine years ago. Plans are in full swing to improve the region's maternal care via the soon-to-be opened Wellbody Alliance Delivery Centre. I watched a group of newly hired traditional birth attendants as they learned how to take off PPE, now considered an important part of the childbirthing process.

Most of the health care workers in Sierra Leone who have died of the virus were treating known or suspected Ebola patients, including Dr. Humarr Khan, whose passing made global news. But since his passing, the international media has grown desensitized; now, more than 200 such workers in the country have died of the virus.

“Mothers may have infections, maybe even Ebola, things like HIV. We don't want to spread that material from here, all the way to out there,” Andy Hall, a doctor with the global NGO Partners in Health, said to the workers gathered in a delivery room of the clinic. By American standards, the structure is spare—concrete walls under a tin roof, with generator-provided electricity and freshly painted walls. But compared to most of the local homes, some of which are built with mud and a palm tree thatch, the clinic represents a luxurious expenditure of resources.

“I need one volunteer,” Hall said. “Who's going to go first?”

The workers were attentive, but clearly already suffering from the 90 degree swelter, made infinitely worse by the plastic that went from the tip of their hood-covered heads down to their rubber boots.

“It's hot, yeah?” Hall asked, his British accent pleasant and professional. “This is why when we come in, we always want to drink plenty of water. It's not good coming in and getting sick ourselves because then we can't help anyone. We have to take care of ourselves as well.”

There's no question the suits, with face shield and face mask set into a plastic hood extending down to the ankles, are somewhat dehumanizing, and that's been part of the problem with the spread of Ebola in the region. As PPE-clad workers quickly became associated with what amounted to the well-intentioned but still terrifying kidnapping of Ebola suspects, people learned to flee into the bush, for fear that they would be brought behind the blue tarped walls of the Ebola treatment centers from which too few ever returned.

Clad in their full-bodied white hooded outfits against the white concrete walls, the women looked like they were just about to beam a giant Wonka bar across the room and into a television set, one of many iconic scenes from the psychedelic 1971 movie "Willy Wonka and the Chocolate Factory."

The movie was based on "Charlie and the Chocolate Factory," a 1964 children's book penned by British author Roald Dahl. I loved it as a child; only when I was older did I learn that it was also a racist fantasy, with an incredibly rich white man's factory run by a labor force of imported Africans, who sang and toiled cheerfully for room and board in lieu of wages. Dahl's original vision, of black-skinned jungle pygmies instead of orange-skinned Oompa Loompas, was only changed at the insistence of editors at the publishing company.

But for the women standing in front of me, the Oompa Loompa outfits are not denigrating.

They're ennobling.

In stark contrast to the book's caricatures, the women are not cartoonish lapdogs, but downright heroic, risking their own lives so that more of their country's children may live.

Esther Nguajah volunteered to go first, supported by words of encouragement from the other traditional birth attendants. She stood in a wash basin next to a trash bin facing the sink. An eye-level swath of the wall was covered with a row of signs and pieces of equipment affixed to the wall, to help the women remember the steps.

“The reminder is there for everyone. I need it sometimes as well,” Hall said. “If you're in there for a long period of time, which often we are when we're in delivering children, you get very tired. You lose concentration It happens to everyone . Even the best doctors use it.”

For about 10 minutes, Hall talked her through the exhaustive sequence, full of the kind of nit-picky rules that everyone makes fun of, unless it's a matter of life and death. No one makes fun of these.

Step into the bucket. Open the bin. Wash your hands, at least 60 seconds. Step out of the bucket. Take the apron off, reaching behind carefully to ensure that you touch nothing else as you unsnap it. Apron in the bin. Back in the bucket. Wash hands. Out of the bucket. Grasp the left lapel with the left hand, pull down the suit's front zipper with the right hand, then shimmy and squirm to get the suit down the body. In the bucket. Discard the suit. Wash hands. Exit bucket. Remove the face shield without touching the straps by bending the head forward and tugging on the top of the plate. Face shield in the bin. Enter bucket. Hands. Exit bucket. Pinch the face mask without touching the skin. Close the eyes. Pull off face mask, forward. Bin. Bucket. Hands. Step into a new bucket, this one filled with a chlorine solution. Wiggle the feet out of the big rubber boots, stepping directly into sandals. Gloves off. Hands.

The rigidity of the procedure, the exactness that it demands, sounded almost like computer code written for automatons in some highly roboticized future.

But as the layers peeled off, the suit's unnerving conformity was dispelled, sacrificed to the bin in plastic bits while Esther emerged as if from a cocoon, another piece of her training complete, teeth shining, brow glistening, all sweat and triumph and confidence as she wiggled her toes into her sandals and turned to extend her support to the next woman in the line.