Seven late-middle-aged Zulu women filed into the windowless break room. They worked as custodians in the public South African hospital where I was spending my summer. My colleague, a native Zulu speaker, explained that we were conducting an infection control audit throughout the hospital and offered to read through the survey with anyone who needed help.
Meanwhile, I sat in a corner of the room, collecting consent forms and observing the women. One woman furrowed her brow and hunched over the questionnaire as she painstakingly circled her answers. Another started working on the survey, frequently asking her friend for clarification. After a while, she got so discouraged that she heaved a big sigh, flung the survey down, and walked out of the room. A third woman flew through the survey and finished in record time. I looked through her answers and saw that she had marked “angazi” for every question—Zulu for “I don’t know.”
I thought back to why we were conducting the study in the first place. Tuberculosis, especially the multidrug-resistant (MDR-TB) variety, was a huge concern in our province of KwaZulu-Natal, where there had been 3,040 cases of MDR-TB and 285 cases of extensively drug-resistant TB in 2007. In the dim hospital corridors, coughing patients crowded the benches. Beyond the halls, each ward housed dozens of beds, mixing TB patients with others, most of whom had HIV/AIDS. The “isolation room” for suspected cases of MDR-TB was depressingly inadequate, with capacity for only three patients in the 1,000-bed hospital and no negative-pressure capabilities. The elevators had been nicknamed the “MDR Express” since their lack of ventilation aided the spread MDR-TB, so the staff of the nonprofit where I worked always took the stairs to our fifth-floor office within the hospital. It was not the safest place to work.
We had designed this audit to better understand the strengths and weaknesses of the hospital’s infection control practices. One chronic problem was that the nurse in charge of infection control was notoriously neglectful of her duties. We hoped the survey results would demonstrate to her the dire need for greater infection control in the hospital and give her evidence-based targets for improvement.
As I watched the women struggling with the questionnaire, doubts were seeded in my mind. Although the audit tool had been translated into Zulu and tested for reading ease, I felt terrible about causing unnecessary frustration. These were women in their 50s who worked long hours at manual labor in a decrepit public hospital for low wages, who had been through the injustices of apartheid and the agonies of poverty, and who were likely to be exhausted at home taking care of grandchildren who had been orphaned by AIDS. The thought that I might be placing an additional burden on their lives by asking them to participate in an aggravating task was troubling.
The next day, as we surveyed the radiology department staff, those seeds of doubt took shape. As one of the technicians handed me her survey, she asked with a healthy amount of skepticism, “Is anything really going to change because of this?”
That was the crux of the matter. If the report we generated from the audit was used to improve the conditions of the hospital, the health of everyone, from the cleaning staff to the patients, would improve. The whole enterprise, including the exasperation of the beleaguered Zulu custodian, would be worthwhile.
Currently, my colleagues at the nonprofit are trying to whet the infection control nurse’s appetite for reform with suggestions gathered from the survey, but there have been no concrete results thus far. The hospital halls are still dingy, the staff are still confused about proper use of N95 masks, and extractor fans are still nowhere to be found. So with regard to whether the audit was valuable, I’m left feeling like the Zulu custodian who circled “angazi” for every question: “I don’t know.”
What I do know is that even non-interventional research is rarely benign. Without follow-up and implementation, it can detract from participants’ well-being and benefit no one. The hundreds of research studies that take place every year through our university have the potential to achieve enormous good, but only if the findings are applied. We owe it to the participants to create value—not just academic papers—from our research.
Kristin Huang is a second-year medical student at HMS.
The opinions expressed in this column are not necessarily those of Harvard Medical School, its affiliated institutions, or Harvard University.
