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Dr Catherine McGowan from the London School of Hygiene & Tropical Medicine recently spent eight weeks volunteering at the Ebola Treatment Centre in Kerry Town, Sierra Leone. Reflecting on her experiences, she wrote the following article, which was 

The "selflessness of aid workers and medical volunteers" was praised both by the Queen in her and by TIME magazine, who named '' their person of the year 2014.  This emphasis on international staff, particularly doctors and nurses, gives a misleading impression about who is doing what in West Africa, and overlooks the huge contribution that national staff are making in their fight against Ebola. Even when national staff are recognised, the focus again tends to be on the doctors and nurses, with some attention devoted to the burial teams.

But for every one doctor and three nurses working at an Ebola treatment unit there are approximately 26 water, sanitation and hygiene (WASH) staff. Most of the WASH staff are recruited locally. Some of the senior WASH staff are former teachers who lost their jobs when the schools closed. The remainder were hired with little or no previous related work experience; only a fraction of the approximately 300 WASH staff had worn personal protective equipment before. 

Nearly all of the WASH staff come from communities directly affected by the outbreak, and most knew people who died of Ebola. The WASH staff arguably have more knowledge about the realities of Ebola than anyone, and yet they come out in great numbers to obtain employment at the treatment units. They work in a challenging environment, they see difficult things, and they are paid far less than one might expect. And, when the international staff return home following a deployment, the WASH staff carry on.

Officially, WASH staff are responsible for cleaning/disinfecting wards, cleaning spills (e.g. blood, vomit, excrement), emptying buckets of vomit/excrement, handling dead bodies, disinfecting ambulances, and waste management including the operation and maintenance of the incinerators. Needless to say, WASH staff wear full personal protective equipment. As mentioned by almost every returning health worker, personal protective equipment is hot and uncomfortable; however, wearing personal protective equipment in a tropical climate while operating an incinerator is another matter entirely.

Unofficially, the WASH staff are a point of contact with the patients. Many of the clinical and nursing staff do not speak Krio (the lingua franca in Sierra Leone) so patients often opt to communicate with the WASH staff, who are easily identified even in personal protective equipment as they wear large green gloves rather than the smaller white ones worn by medical staff.  It is not unusual to hear the WASH staff on the radios relaying patient concerns and complaints to the nursing station.

The WASH staff are at considerable risk in an Ebola treatment centre. They are exposed to Ebola at least as much, if not more, than the clinicians and nursing staff. Many of them do not tell their families or friends that they are working at the units out of fear that they will be stigmatised.  Many struggle to find a place to live, to find an accommodating landlord who will allow them to rent a room. Many will lose their jobs when Ebola has been brought under control. The stigma and the secrecy may last some time longer. It takes bravery to leave one's community to travel overseas to work in an Ebola treatment unit. But it takes extraordinary bravery to work in an Ebola treatment unit without leaving one's community.

When an international staff member contracts Ebola the media attention is instantaneous, the patient's condition updated daily. I doubt very much that we will hear when a member of the WASH staff gets Ebola. The next time you read an interview with an international doctor or nurse newly returned from their deployment and recounting desperately sad, and now too familiar, stories about the struggle and the suffering please give some thought to the many WASH staff who remain.