From Ebola to Coronavirus — A Simple Practice of Sticker-Photo Portraits for Health Care Workers

Jianjay Moore-Potter (left) in Monrovia, Liberia, in 2015, and Anna Chico (right) at Stanford in April 2020. Mary Beth Heffernan’s PPE Portrait Project started in Liberia during the Ebola crisis, and has since been revived at Stanford.  (Courtesy of Marc Campos and Cati Brown-Johnson)

The scene has become a familiar one at COVID-19 testing centers: health care workers clad in head-to-toe personal protective equipment with eyes peeking out behind an N95 mask and goggles. Expressions and smiles are hidden behind a protective layer.

The image becomes even more stark when thinking of those alone, in isolation. “The stories of people dying alone with no one in their room except an occasional masked health care worker struck the psyche of the country,” said L.A.-based artist Mary Beth Heffernan. “That has been the turning point in the U.S. for realizing that there's a need to make a human connection.”

Heffernan is trying to create that human connection by printing photographs of health care workers faces on stickers. They are placed on the chest of their protective suit so patients can see what they look like. She teamed up with Stanford research scientist Cati Brown-Johnson in April to pilot the program at a Stanford drive-through coronavirus test site.

Mary Beth Heffernan applies a PPE portrait to the apron of Zoe Dewalt, a nurse at an Ebola treatment unit in Paynesville, Liberia, in 2015. (Courtesy of Marc Campos, Occidental College)

It’s a simple way to personalize the experience, but one that works. Heffernan knows because she piloted the concept in Liberia in 2015 during the Ebola crisis.

Lessons From Liberia

In 2014, while on sabbatical from teaching at Occidental College in L.A., Heffernan saw a powerful image — three health care workers in head-to-toe protective gear looking like some kind of “evil platypus.” As she recalls, “there was something both futuristic and primitive about the get up, as if it were a kind of low rent costume from a Star Wars movie — I just found it incredibly disturbing and frightening to think about what it would be like to be a patient.”

Her gut reaction was to create an imagined picture of the health care worker on the outside of the protective suit.

She began reading detailed accounts about Ebola, and specifically, accounts of patients and doctors. Reading accounts of those who survived, and had gone through isolation, “they felt completely dehumanized,” she said.

She set aside her other projects and plunged in to explore options for rural Liberia, “how to take portraits of health care workers and print them out on adhesive labels without electricity?”

After extensive research, she emailed Dr. J. Soka Moses in Liberia. He responded enthusiastically, and a month later Dr. Moses Massaquoi — then chair of Ebola Case Management for Liberia — issued her an invitation to Liberia (NPR featured the original project in 2015).

In February 2015, she was on a plane to Liberia partnering directly with the government, “not a white woman-sort-of-freelancer-do-gooder, but invited by case management of Liberia,” she said. As she unloaded her six large boxes of printers, vinyl labels and water-resistant ink and supplies, a fellow passenger asked if she was moving to Liberia. She stayed for three weeks, left her supplies and returned to the U.S.

According to Jennifer Giovanni, head of infection control at a treatment center in a rural part of Liberia, the project did start working. Giovanni said the photos have made a huge difference — not only for the patients.

The Portrait Project Pilots at Stanford

Fast forward to today and Heffernan is now partnered with Stanford to bring the PPE portrait project to life again in an effort to share how much warmth a simple photo sticker can bring.

As the novel coronavirus escalated, Stanford research scientist Cati Brown-Johnson remembered seeing Heffernan’s prior work and thought, “This needs to be happening right this second.”

“It's very simple, very straightforward,” Brown-Johnson said.

The pilot project has since expanded to provide portrait stickers for Stanford Hospital’s health care workers in primary and palliative care and at least 10 other U.S. locations, including UMass and USC-Keck, are in various stages of implementation. Heffernan also said people in Italy and Canada have contacted her to find out how they might do something similar.

Dr. Winnie Teuteberg, at Stanford, works in the field of hospice and palliative medicine. (Winnie Teuteberg)

Brown-Johnson’s research is in humanism and the connection between doctor and patient. “I get really interested in things that help patients heal themselves,” she said.

Brown-Johnson said a patient's mindset can become more positive when a provider is warm and competent. Research is beginning to reflect this.

Although protective equipment signals competence, she said, there's also "zero warmth in PPE."

Heffernan’s portraits remind patients of a provider's humanity. In addition, Brown-Johnson said health care providers told her they felt more comfortable approaching cars when they had a portrait on.

“That helps them feel more comfortable,” Brown-Johnson said.

Brown-Johnson admits that more broadly, the portraits are an extra task that needs to be done for a health care system that is already strapped. But she’s willing to get past that.

“I think it's really important to have a champion on site, somebody that's really excited about this, that can kind of stay on top of it — that can continue printing and printing stickers,” she said.

From a scientific standpoint, Brown-Johnson said it’s also a great example of multiple simultaneous discovery. Folks at other hospitals were posting laminated portraits as part of the “share your smile movement,” encouraging health professionals to wear a laminated portrait. The original concept Heffernan developed is a sticker, in part, so it can be easily thrown out with the used suit. The laminated portraits need to be disinfected each time — yet they only need to be printed once.

Future Implementation

Heffernan and Brown-Johnson want to share how simple it is to do.

“I really want to see this used as widely as possible and where it's not possible for some reason, I really want to encourage providers to look for ways to connect with their patients,” Brown-Johnson said.

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In the future, Heffernan would like to see PPE portraits in all health care situations where providers are masked — such as when doctors are interacting with immunocompromised patients or pediatric oncology, where PPE is often necessary to interact with patients.

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For Heffernan, the portrait project stems from her artistic work, which is largely influenced by feminist art and the use of objects to change relationships.

But Heffernan is less concerned with terminology and more concerned with the idea that “the art is not the portrait itself, but is what it acts as a catalyst for, which is a change in relations between the health care worker and the patient. So for me, the patient and the health care worker — in a sense, are creating the art.”

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