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Health Through Song
Outreach workers in Benin and Guatemala use lyrics to promote health.
by Matthew Davis

Music permeates our daily lives. It graces our weddings and funerals, fills our elevators and waiting rooms, and accents the messages advertisers want us to hear. It can be incidental or inspirational, sensitive or severe, humorous or horrifying. Amid all this remarkable variation, the fundamental intent of the music in our lives never changes: music is communication, intended to carry a message and to influence our responses to that message.

There can be no doubt that music accomplishes these twin goals. For centuries, civilizations have used music to convey needs, wishes, demands, and ideas. But in the past few decades, some have wondered whether the messages in music—specifically, popular music—actually have too much power to influence and possibly even injure people, particularly children. In the 1980s, Congress held hearings with concerned parents that led to warning labels on record albums with explicit lyrics. Following the shooting deaths in a Colorado high school this past spring, government officials openly questioned whether particular forms of music had provoked the tragic actions of the teenage assailants.

As a musician, I have been sensitive to these sharp attacks on music. I didn’t want to agree that some types of music might affect people so adversely. I wanted to believe that a preference for particular types of music was a marker for antisocial behavior—not its cause. Yet I know well the communicative power of music. What has frustrated me is that today’s concerns about the effects of popular music focus exclusively upon the negative impact. I have focused instead on music’s positive potential, particularly the role it can play in improving health through preventive interventions.

From Therapy to Prevention

Since the beginning of recorded time—and likely before, since songs may have been the principal means of preserving personal stories and community histories prior to the written word—humans have used music to help heal the sick and troubled. For the ancient Greeks, a single god, Apollo, had dominion over both music and health. Native American shamans played music as they delivered their incantations and therapies. And for Renaissance physicians, a knowledge of music was indispensable to producing medications with the right mixture of “hot” and “cold” ingredients, and to judging the pulse of any patient.

During the past century, music has played a formal role in Western medicine’s healing efforts. In fact, although it remains controversial, music therapy has gained enough prominence and empirical support—especially in therapy for chronic diseases or for particularly painful illnesses—that its proponents argue that it should be a covered benefit of health insurance.

Comparatively little is known about how music might be used in preventive, rather than therapeutic, health interventions. The few published evaluations of music-based preventive programs have focused on a variety of public health initiatives that have included songs with specific messages.

“Message-songs” have served as elements of successful, multimodal interventions, such as prenatal care promotion efforts in Mexico and water hygiene education programs in Bolivia. To my knowledge, though, no one has tried to measure the precise impact of message-songs in isolation from other health promotion techniques in order to determine how well songs can communicate information and change people’s behavior.

Why should we care about the efficacy of message-songs? First, health care providers and public health officials do not yet have consistently effective ways to encourage healthy behaviors. Meanwhile, advertisers bombard us with message-songs that convince us to eat, drink, and use many products that are harmful to our health. Is it possible to turn the tables and use music just as effectively to promote healthy behaviors?

Second, public health campaigns that rely upon print media fail to communicate with illiterate people and are often written at an above-average reading level. In contrast, songs offer a mode of communication that does not depend upon literacy and can be easily adapted to appeal to audiences with a range of language and cultural backgrounds.

Benin Sings a New Tune

Convinced of the potential for effective message-songs about health, I went in search of individuals and communities who were already using music for this purpose. I was aware that the international health community had experimented with modes of communication that did not rely upon the written word. Therefore, during my second year at HMS, with the support of a Paul Dudley White Scholarship, I traveled to the West African country of Benin, a part of the world renowned for its vivid musical tradition.

In Benin, I met a community nurse and a village singer who, despite living hundreds of miles apart and speaking entirely different languages, had reached the same conclusion: singing about health can inspire people to change their behavior. Yerima, the nurse, told me that he started to sing about health issues out of frustration. He had noticed that the women who came to his village’s two-room health center for prenatal care paid little attention to his lectures on topics such as nutrition and childhood vaccinations. Yet when he composed and performed songs with the same information, he found that his audience became much more interested, and they sang with him in the common call-and-response form of the region.

Given the threat of a cholera epidemic at the time of my visit, I asked whether he could write a new song to communicate fundamental ideas about water hygiene. Yerima disappeared into the back room while the clinic director gave a lecture on cholera, which received scant attention. Five minutes later, Yerima returned and began to shout that cholera causes diarrhea. The crowd responded with sounds of disgust. Yerima then began to sing, repeating a response line for them: kolera baradarorwa (cholera will kill you). Gradually, he began to sing lines of information between the response lines, advising the women to boil their water and urging them to wash their hands and those of their children before eating. In less than ten minutes, a new song had been learned and a new message communicated: simple, fast, effective, memorable.

By listening to a recording I made of Yerima’s performance, a woman in another village learned the cholera song and taught it to other women at her local health center. Yerima and his song had demonstrated the appeal, adaptability, and accessibility of musical health messages.

The village singer I met, Gansin, sang message-songs to highlight the importance of health issues in his community. Gansin, who had followed in his father’s footsteps as the village singer, had been entrusted by his community with the responsibility of preserving the history and life lessons of the village ancestors. But in his 19 years of singing, he had also composed several new songs about such health issues as vaccinations, nutrition, and family relationships. He had even composed a song about oral rehydration therapy—including the recipe!—to sing when diarrheal illnesses were common in the village.

I was struck by Gansin’s obvious commitment, as a musician, to spreading messages about health. In a sense, he was simply fulfilling his obligations as a community resource. But it was also clear from the reactions of the villagers who gathered every time he played that he was an entertainer; the crowd loved his performances whether he sang about watery diarrhea or the beautiful harvest moon. I asked him why, when he could sing about anything at all, he sang about health. “Because without health we cannot sing, we cannot dance, we cannot live,” Gansin replied. “Health is essential.”

The Power of Musical Messages

Inspired by Yerima and Gansin, in 1993 I traveled to Guatemala to conduct a study of message-songs among schoolchildren. While I was there, I also worked in rural village health centers alongside Guatemalan medical students, a role that enabled me to collaborate with local schoolteachers and school directors. Together with the teachers, I developed a curriculum about what they agreed was a major health priority for children—personal hygiene to prevent intestinal parasitic infections.

To determine the children’s knowledge about parasitic infections and their personal hygiene practices, I prepared a written survey in both Spanish and Cakchiquel, the local Mayan language. Working with schools in three separate villages, I administered the survey to nearly 150 third-grade children, who had been able to read and write Spanish as a condition of entry to that grade level. Then I randomized one of the schools to the message-song intervention, while the other two schools received the standard education. In hour-long, weekly sessions for one month, I provided students with brief didactic lessons and led class discussion in Spanish on the learning objectives, followed by a question-and-answer game that emphasized the points already introduced.

I then taught one group a song that conveyed the same information as the question-and-answer game. I wanted the song to be based upon a melody already familiar to the children, to ensure that they were neither confused nor discouraged by an unfamiliar or unattractive melody. The melody that the schoolteachers suggested I use was that of “Frère Jacques.”

Each verse of the song was eight lines long, and the fifth and sixth lines changed with each verse to convey a different learning goal. There were nine verses in all, which I introduced gradually over the course of the month-long intervention. Here is the first verse, in the original Spanish and then an English translation:

No queremos           We don’t want

Las lombrices           The worms

Que debe hacer        What should one do

Para no tener?         To not have them?

Lavese las manos     Wash your hands

Antes de comer.       Before you eat.

Adiós, lombriz.        Bye-bye, worm.

¡Estoy sano!            I’m healthy!

Judging from the eager, laughing responses of all the children involved in the study, they enjoyed the question-and-answer game. But the children in the message-song group seemed especially to enjoy singing the song, and I heard them singing it outside of school. They would even sing verses to me as I walked through the village on my way to the health center.

Measuring Success

The initial appeal of such anecdotal evidence is that it plays to one’s hopes and preconceptions about a particular intervention. After all, one finds what one is seeking. The reality of my more objective survey results was not as clear-cut, however. Through a series of three surveys—given immediately before the intervention, one week after the last instructional session, and one month after the last instructional session—I was able to track each child’s knowledge and self-reported behaviors over the course of the study. I ran into two main problems, however: The children were knowledgeable and well-behaved at the time of the first survey, which did not leave much room to measure improvement. Only if there had been a very large difference between the two groups would I have been able to detect it using the number of children enrolled in my study.

As a result, the findings from my study of Guatemalan schoolchildren were suggestive, but ultimately inconclusive. Overall, students who sang the song seemed more likely to improve their knowledge and behavior as they learned the verses, but were just as likely to forget what they learned as time passed. Although I was disappointed that my field research had lacked the statistical power to find differences between the groups, I remained convinced that there would be a difference to find.

Now at the University of Chicago, I am continuing to try to demonstrate the preventive potential of musical health messages. Part of my work includes collaboration with the Music/Theatre Workshop (MTW), a Chicago-based community organization that performs musical dramas for preteens and adolescents in local schools. The dramas seek to raise awareness about problems such as drug use, teen pregnancy, and violence, and to provide a forum in which young people can discuss their responses to peer and family pressures. We are currently evaluating the impact of an MTW show on inner-city schoolchildren’s rates of substance use.

MTW staff members use songs to reinforce the principal messages of the drama, rather than just using one medium or the other, because they believe that songs emphasize particular points but cannot communicate complex messages as well as drama can. Songs can be sung again and again, anywhere, by individuals or groups. If drama is needed to convey elements of the message, then it may be more difficult for the audience to carry messages away from the performance. Decreased portability may translate into decreased effectiveness.

Medicinal Music of Tomorrow

Many questions remain about the utility of message-songs as a mode of health promotion. To answer such questions will require well-funded research that permits large, controlled field trials with rigorous evaluation components. Funding opportunities for such studies may not be widely available. Yet sometimes the potential for applications drives sponsorship of research in a particular field. I can imagine a variety of ways in which musical messages might influence our health in the future.

One opportunity for musical intervention, for example, might be in the area of non-compliance with outpatient medications, a major reason why people do not enjoy improved health once drugs have been prescribed. Today, microprocessors allow us to set wristwatches with routine alarms to remind patients of appropriate dosing intervals. In the future, a more melodious musical reminder might be installed in a wristwatch or a patient’s daily dosing box. Patients might even select their favorite melodies from an available assortment. If this technology proved effective, pharmaceutical companies would jump at the chance to underwrite such reminders, since non-compliance erodes their customer base.

Television might provide other opportunities for message-song delivery. Today, public service messages promoting healthy behaviors are often relegated to late-night broadcasts, when advertising time is inexpensive, but the audience is small. Recording artists often deliver such public service messages, but only as spoken testimonials, not through their artistic mediums.

In the future, popular musicians might follow the lead of performers such as Gansin in Benin and sing health promotion songs as part of their repertoire. Music videos for these songs might be broadcast during advertising slots in prime-time hours. Television stations could promote the videos in advance, and then use them to draw viewers to watch their programs. Stations, which would reap the benefits of additional viewers, might be persuaded to underwrite the video production. The artists, in turn, would seek the exposure these video broadcasts would offer, as well as the good will engendered by their health promotion efforts.

Will these scenarios of musical health messages come to pass? I think they are not only possible, but likely. As I listened to Yerima and Gansin in Benin, and to the schoolchildren in Guatemala, I saw how effective health promotion through music could be. I dreamed of seeing that sort of public health success in schools and communities around the world. And why not? All it takes is a song.

Matthew Davis ’94 is a Robert Wood Johnson Clinical Scholar at the University of Chicago.

This article appeared in the Summer 1999 issue of the Harvard Medical Alumni Bulletin.