South Africans know a lot about waiting: long queues and reception rooms are part of our daily lives. Whether it’s at the clinic, hospital, Home Affairs, or the traffic department – we wait. But what if all this waiting could be bad for our health?

This is the question that a team of researchers from the Africa Health Research Institute (AHRI) and six other institutions across South Africa and the UK are trying to find the answer to. Umoya omuhle, which means a ‘breath of fresh air’ in isiZulu, is a three-year collaborative project that aims to bring new ideas to improve infection prevention and control for drug-resistant tuberculosis (TB) in primary health clinics in South Africa.

At just past seven in the morning, a clinic in a northern suburb of Durban is already in full swing, with patients filling up the waiting rooms fast. The AHRI Umoya omuhle team has begun its work for the day. A few team members move around the facility, handing out red lanyards with unique barcodes to everyone in the waiting areas, including staff members. More AHRI staff wait at the main entrance and other key areas of the clinic with barcode scanners. Every person that enters the facility is scanned. The same is done if they go into another area of the clinic.

(Above: left to right: The Umoya omuhle team –  Sithembiso Luthuli, Emmerencia Gumede, Yutu Dlamini, Thandekile Nene, Gugu Myeni, Nonhlanhla Madlopha, Duduzile Mkhwanazi, Sanj Karat, Nompilo Ndlela, Sphiwe Mthethwa)

We know from previous experience in South Africa and elsewhere that TB is transmitted within health facilities. The researchers aim to estimate, within the facilities, where the highest risk areas are for TB transmission. For example, is the highest risk in waiting areas or in consulting rooms?

“All the data are collected anonymously; neither patients nor staff give us any personal identifying details. This makes things go a bit faster and means we are not interrupting services by trying to gather too much information. For instance, for staff we just collect job descriptions, and for patients and visitors we ask for age group, sex, and why they have come to the clinic,” explains London School of Hygiene & Tropical Medicine (LSHTM) research fellow Sanj Karat, who is coordinating this part of the study.

In the corner of some of the rooms is a monitor that measures the carbon dioxide levels in the air. This allows the researchers to get rough estimations of ventilation in key spaces while the clinics are in normal use. The team will return later, when the facility isn’t busy, and do more experiments, including discharging fire extinguishers into a room and measuring how quickly the carbon dioxide escapes. The measurements can then be used to estimate how well the space is ventilated.

(Above: Dr Sanj Karat releases carbon dioxide to measure ventilation in a clinic waiting area in KwaZulu-Natal as part of the Umoya omuhle collaborative project) 

The Umoya omuhle study focuses on 12 clinics in South Africa: six in KwaZulu-Natal and six in the Western Cape. The multi-disciplinary study brings together clinicians, anthropologists, epidemiologists, mathematical modellers, and health economists, all with the ultimate goal of trying to design interventions to reduce the transmission of TB in primary healthcare facilities.

“We are trying to make estimates around lots of things that could affect TB transmission. This includes the number of people with TB among those attending the clinics – and in the surrounding communities; how people mix with each other outside of clinics and where they spend their time; how people use the space in health facilities; and how well those spaces are ventilated. The social science team, meanwhile, is trying to understand the behaviours and motivations of staff and patients, and the influence of policies. Because if you want to implement a change, it’s really important to consider the context and the wider, systemic aspects to understand how to actually make any change effective and sustainable,” says Sanj.

“We all know that sometimes there are long queues at clinics. One important question we are asking is: if we cut the amount of time that people spend waiting, could that reduce the risk of TB transmission? If our research shows that the answer is yes, then the next step will be to design ways to reduce how long people spend waiting in clinics.”

TB is an global problem, and the researchers are acutely aware of the need to make any proposed interventions as widely applicable as possible. The next step would then be to test them formally, to see if they work.

Story by Phumla Ngcobo