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EP79 Songs About Ebola and the Power of Radio in Global Health Communication with Dr. Carlos Chirinos
Alexandra Arriaga: Hello everyone and welcome back to I AM GPH. My name is Alexandra Arriaga, and in this episode we are going to be talking to Dr. Carlos Chirinos, who is a Clinical Music and Global Health Associate Professor at NYU. His research is at the intersection of public health communication and music, looking at how media narratives driven by music artists and music-based interventions contribute to engaging communities in disease prevention and control in the context of existent or potential health emergencies. He has been a key consultant for radio and music projects in Africa with funding from the World Bank, USAID, IDRC and the Wellcome Trust. In 2015, Dr. Chirinos received an award from the White House Office of Science and Technology Policy, the Centers for Disease Control and Prevention, CDC, and the U.S. Department of Defense and USAID, to develop Africa Stop Ebola, a global music campaign to raise awareness about Ebola in West Africa. Carlos is a composer, producer and performer, and holds Masters in Ethnomusicology and a PhD from the University of London. If you'd like to learn more about his work and the way music, communications, and public health intersect, please stay tuned. I am so happy to have here with me today, Dr. Carlos Chirinos, my fellow Venezuelan. How are you doing today?
Carlos Chirinos: I'm fine, thank you. How are you?
Alexandra Arriaga: I'm doing great. So to start us off, can you tell us about your journey and how you found your way to be working at the intersection of music and public health?
Carlos Chirinos: I started as every young student going to university, and I was also a musician, but my bachelor's degree was in social anthropology back in Venezuela. As you know, Venezuela has a large indigenous population inhabiting the forested areas, the Amazon forest, in Southern Venezuela. At the end of my career, of my BA, I became an assistant for an established researcher, Dr. Stanford Zent, who specializes in Piaroa and Hoti indigenous communities. And my first job out of school was to help him with research to try to understand the impact of illegal mining on indigenous people's health. So I wasn't really trained in health, but as an anthropologist and part of a research team, we were really exploring what were the not necessarily the health, specific health impact, but the environmental health impact of illegal mining. This was an area of gold mining, illegal gold mining, which has all the implications affecting indigenous people. But I was also a musician. I'm a clarinet player, a saxophone player, and my passion was music. So inevitably every time I went to an indigenous community, I will end up talking about music. And I found that music was a perfect, soft way to establish conversations, establish relationships with people in a way that allowed me to learn about other social and cultural aspects of their lives. So as part of that, I moved to the UK where I worked in the music industry and I also went back to college to do a Master's in Ethnomusicology. And part of that was, again, that interest of understanding how music shapes this cultural and society in general. And part of my journey, I ended up at a college of the University of London called the School of Oriental and African Studies, SOAS. Is the only specialized college in the world focusing on the regions of Africa, Asia and the Middle East. So as part of that, I founded a radio station called SOAS Radio. And it was initially a station just to broadcast music, but quickly I got involved with a number of research projects from researchers working in this institution that were working in Africa in particular. And I was passionate about traveling to Africa, and my first project in Africa using radio, and this is where things started to kind of get into shape to describe my current work, I became a consultant, a radio communication consultant, for a project looking to work with indigenous peoples in Congo, to help them deal, navigate a logging concession. And the idea was to bring, engage, the communities in decisions regarding the way in which the forest was managed. So this was my experience with radio working with indigenous peoples in Africa. And immediately as part of that, I became very interested in the role that radio plays among indigenous peoples and among communities living in rural areas, what is called the Last Mile. Those communities are really living in close contact with wildlife. So obviously this brings immediately a health issue, which is the potential for a spillover of zoonotic diseases. As part of that, I continued to work in different projects, some of them were on HIV/AIDS prevention, some of them were more on governance and disseminating the idea of governance, but through my experience working with radio stations across Africa, I came to learn really the importance the radio stations or the role that radio stations were playing in raising awareness, public awareness, about health threats. And that was kind of my first initial contact with the public health realm. I then completed my PhD in development studies and I conducted my PhD as an action research agenda looking at the role of music and radio during the Ebola epidemic of 2014-15, in Guinea. And part of that is what kind of nurtures my experience now.
Alexandra Arriaga: That's such an amazing story and I'm super curious, what do you think was one of the biggest impacts of radio on Ebola? Why do you think that was so important?
Carlos Chirinos: Well, as part of my research, I investigated the public perception of the communication intervention during the Ebola epidemic as well as the perception of the health workers working for Médecins Sans Frontières, MSF, in Guinea. This was a long process whereby I conducted surveys, I conducted interviews with health workers and health worker managers, to try to understand the challenges that they were facing in the field. And a consistent feedback I received was that because in these last mile scenarios where rural communities live, there's an assumption in the global public health community, and I'm not generalizing, but there is an assumption that people in those countries or in those regions understand scientific language, understand official languages, and this is very far from the truth. So one of the reasons why the health workers consistently reported the effectiveness of radio was because radio stations are located usually in the perimeter where people live. Therefore, radio stations instead of relying communication from the centers of power to the communities, they translate that, they translate it into local languages, they translate it into local meanings. So that was very important for the health workers, for example, in West Africa during the Ebola epidemic to give warnings to the communities that health workers will visit eventually. And this kind of brings us to the idea of how a health intervention is experienced by people living in rural areas. There is an objective experience of disease and there is also subjective experience of disease. And we often assume that there is only the objective experience. You know, the symptoms, there is fever, there are certain physical symptoms, but this objective experience, we are not necessarily 100% sure what that is and how people, depending on their location, depending on their cultural background, will experience a disease outbreak, particularly when the disease outbreak is followed by a response and this response is in emergency mode and consists of people from the country as well as international health workers. So obviously, at this point you really need to think about the way in which biomedical interventions are developed or are implemented among communities that have never had experience or have very negative previous experiences with health interventions. So the idea of health workers, usually perhaps white health workers, for example, in the case of Africa, arriving with protective suits. In the views of people who have had negative previous experience with health interventions, the legacy of colonialism, which is very fresh, I mean most of these countries only gained their independence 60 years ago, so there is still the memory of a negative experience with the former colonizer. So for some of these communities, the presence, the simple presence of a white person that they have never seen creates concern that are very logical when you put yourself in their shoes.
Alexandra Arriaga: Absolutely.
Carlos Chirinos: And this obviously influences the way in which they will respond to the epidemic or to the... they will respond to the response to the epidemic, and this is where things get complex. What I did in my research was I tried to understand why do people resist medical interventions, and social resistance to medical intervention is a common thread in all the emergency, health emergencies, that we have so far. There is always a certain level of misinformation, there is a degree of mistrust in the health sector, there is mistrust in political leaders, there's mistrust in the alliances between political leaders and health authorities, and this adds to that level of fear and panic that usually prompts people to reject medical interventions in general.
Alexandra Arriaga: Yeah, I can see how that acceptability varies depending on who the intervention is coming from. And like you said, you guys were in close proximity to these places, so it makes sense that the people living there would be more trusting and maybe more accepting off whatever information you guys had to share with them.
Carlos Chirinos: Exactly. But as part of that, when you think about the way health communication is developed, most of the initial communication responses are in the form of prescriptive messaging. And it's messaging that is designed to target at the biomedical threat, right? Which is the pathogen. But the response from people to messaging is mixed, and what I found is that people going through a crisis, a moral crisis in which there is doubts about the nature of the response or the origin of a disease will tend to respond better to narrative forms of communication, in the form of a storytelling as opposed to a prescriptive message that just says, "Wash your hands." So the narrative approach and communication brings up the value of culturally centered communication, which is the idea that the local notions of health and disease need to be taken into account when developing messaging-
Alexandra Arriaga: Of course.
Carlos Chirinos: -appropriate for the communities that are mostly affected. So as part of my research, I worked with a number of West African artists. Again, bringing my previous experience with music, and this is kind of the way things happen, during an emergency. I wasn't thinking, "I'm going to write a song and I'm going to disseminate a song," but I received one night a call from a colleague that was very concerned about the impact that the Ebola epidemic was having on African artists, West African artists coming to Europe. They were being turned down, they were being canceled, their gigs were being canceled, and I'm talking about very well established West African artists, Tinken Jaffa Coli, Amadou & Mariam, Oumou Sangaré, and a number of others. So as part of that conversation back in 2014, I raised the issue of like, well if they are concerned, what if we perhaps develop, create a song that kind of translates the protocol to respond to Ebola into a narrative form and that will be in the form of a song and that this song will then be disseminated by a community radio station, by WhatsApp, YouTube, to reach those communities that are really disengaged. And to do this song, we really use a number of theoretical models, and one is the celebrity capital model. The celebrity capital model is based on social capital. And it's the idea that celebrities, music artists in particular, have developed a relationship with their fans for a number of years, way before an emergency strikes. So in that respect, a musical artist is perhaps in a better position with their communities, with their fans, to communicate concerns, communicate emergency information, than the position in which a health minister is. In most of these low income countries, the idea that people have about a health minister is that it is a political position, is not necessarily knowledge, it doesn't reflect knowledge, it doesn't reflect expertise, it reflects you are connected, you have a political connection and that's why you are in that position. So seeing or hearing someone speak on radio or TV about an epidemic and about a disease that can potentially kill you using jargon, using biomedical jargon that people living in rural areas where illiteracy is in some cases 95%, so people don't know how to read or write, really creates that sense of doubt and mistrust. So using the celebrity capital model, we tried to work with artists and train the artists to help them explain these issues to their communities. So we created a song that features 12 artists, is sang in seven different languages most of them is spoken in the region affected of Guinea, Liberia, and Sierra Leone. And maybe I play a little bit of the song for you?
Alexandra Arriaga: Yes, absolutely. We would love to hear it. This is genius, by the way. I love the fact that you guys not only are taking the social context into account, but you're also backing up these interventions through research. That's amazing.
Carlos Chirinos: Yeah, obviously that was the driving force behind this to try to really understand what works best in an emergency situation among rural communities in West Africa.
Alexandra Arriaga: That's amazing. That sounds so cool. So I think I heard a little bit of French. Can you tell us about the meaning of the song?
Carlos Chirinos: Sure. So the song starts with a French phrase, and as I said, it features 12 different artists. Some of them sing in Susu and in Kisii and Bambara, these are languages that are primarily spoken in the Mano River region of Guinea, Liberia, and Sierra Leone. That was the hotspot of the Ebola outbreak in 2014. Essentially, the first case appeared in a village right there in that point. So it was the language used was very important. But then when we started thinking about the song, and I'm a core writer of the song, so I worked with each of these artists to develop their phrases and their narrative, I tried to translate the official World Health Organization protocol to respond to Ebola into a song. Obviously I failed because it was really complex, complex biomedical jargon translated into a song that doesn't make sense. However, something that I quickly learned by speaking with these artists who had families in these affected regions was that the major problem was not the biomedical understanding of the problem, but the emotional connection with the problem. Ebola is a disease of close contact. It happens usually among families, so where the mother gets infected, the children are infected, the husband is infected, is very close contact disease. So it affects firstly the caregivers of the patient. So obviously how do you tell a mother that is seeing their son or daughter going through a disease not to hug or not to care for their child? You have to put the child in a room and not touch them. How do you explain that? That's hard, right?
Alexandra Arriaga: It's hard. Yeah.
Carlos Chirinos: So one of the issues that I encountered is that, again and this kind of challenging the notions of health communication, is that decisions, health decisions, are not rational decisions. Health decisions involve emotions, beliefs, religious beliefs, it involves perceptions, it involves the previous experiences of people with health facilitators and health actors. So in order to change a behavior related to these aspects, the communication cannot just be messaging. And what we found is that more important than the message was the process of creating the message. So just to give you an example, the song, it starts with a phrase that says, "Africa is very sad to see their children dying," and immediately says, "Don't touch the dying, don't touch the deceased." This is the first phrase of the song. "Everybody is in danger, young and old, please do it for your families." That is the first verse of the song. Now to unpack this, is saying a lot of things that connect with health communication and one is, the idea that "Everybody is at risk." Often when a new disease appears in a region where there is no previous experience with a disease, people will associate this new disease with an existing killer disease, and in this case for example, was HIV/AIDS. What people in this region really knew as a killer disease was HIV/AIDS. And one of the factors in HIV/AIDS prevention is that it usually affects a very specific group of people. It can be through mother to child, but it affects people that are sexually active, for example. Now that wasn't a kind of an issue with Ebola because Ebola did not respect these boundaries. Ebola really affected children, the elder, all around. And then the appealing to do it for your families is part of the health belief model. If you don't think this can affect you, that's okay, but do it for your family. Do it for your mother, do it for your children. So part of the narrative was already introducing certain health communication principles to encourage people to really think about the disease and the threat of the disease. But really the song develops into a narrative that appeals to trust. So trust in the health workers and then hope, which was if any of the listeners remember back at the beginning of the Ebola epidemic, there was very little hope. It was like very dramatic. And what we have learned is that this communication doesn't necessarily help because once people lose hope, they are able to take greater risks, and that's what we heard for example from some of our informants about people running out into the bushes, into the forest. Is like, "Well, if there's no solution for me, I'm going to run into the forest or I'm going to run into the city because I have no hope." So part of what the song was trying to do was helping build that hope, that sense of hope, and also bring together the health workers and the artists using the celebrity capital model to try to increase the community's trust in the health workers and their response in general.
Alexandra Arriaga: So this was definitely a more holistic view of an issue. You are taking into account the emotional component, you're taking into account the trust issues that may be there, that's a lot. That's a lot to unpack, but that's incredibly important job. I'm so glad that you were involved in it. So continuing with the conversation, in some places around the world, well-intentioned health workers may not be welcomed into the community. Kind of like what we were talking about, right? How there's this lack of trust. Some are even turned away or worse, injured or killed. Why does this happen and what are some common barriers that health workers face?
Carlos Chirinos: Common barriers are usually part of what we just talked about, the subjective experience of people with disease. And the subjective experience is framed in cultural perceptions of illness. And part of the reason why in the case of the West African epidemic, we still have an epidemic ongoing in the Congo. The Congo is a different social scenario where there is a civil war going on. In the case of West Africa, in Guinea in particular, the experience of indigenous communities, particularly those that live in rural areas, they are really in close contact with wildlife. Again, the potential for zoonotic disease transmission from animals to humans is usually there. Their experience with dominant groups in the region was always in negative terms. Guinea in particular had a history of rejection from the dominant Muslim dominant groups that dominate the political life of the country, they have historically pushed indigenous communities out into forested areas. They receive less opportunities for work, they receive less opportunities for power. So the immediate response of people living in these areas is they associate the health worker with those political powers. Because essentially if you're arriving in a rural area with a brand new SUV, black SUV-
Alexandra Arriaga: You're clearly not from there.
Carlos Chirinos: You're clearly not from there, you're coming from the center of power, that means you are associated with them. So this is what actually has been defined in the literature as the political etiology, that the origin of a disease is attributed by people to the political dynamic of the country, not to the pathogen. And this has been found in Egypt, this has been found in Zimbabwe in examples with cholera, for example, with kidney disease, in which categorically, all those people interviewed or surveyed those who have been affected put the blame on a political infrastructure, not on the pathogen. They don't really see the pathogen as the problem, they see the lack of political commitment to help our community ended up in a lack of appropriate water provision or appropriate sanitation or appropriate provision of medicine, medical services. So in the end, this is what frames the arrival of a health worker to an affected community. You and a health worker might be arriving there with the best intentions, but the previous experience of these communities with people that look like them has been negative. So that is one of the first problems that health workers face and is attached to that mistrust, that lack of trust that communities do not have with their governments. And that extends obviously to the global governance system of the health sector. So people seeing a logo of World Health Organization in the middle of the forest in a remote area, rural area, immediately connects them to that experience with former colonial powers. They understand WHO, World Health Organization, this is in Switzerland, this is Europe, this is our former colonizers. So these connected to rural and urban myths, usually sparks ideas about what are the real intentions of these health workers? Are they here to take our body parts and sell them in Europe? Are they here to take our blood? And this clashes immediately with local notions of body parts and body fluids. So that misunderstanding or that lack of connection between a rural community and the health workers is not totally illogical. It appears to be logical to us when we think about it from our point of view, well, we're sending health workers to help you, but if you put yourself in their shoes, they're not seeing that. This is seen in responses to health emergencies that the communication coming from institutions is uncoordinated, and this lack of coordination in the communication response creates more fear, more stress, because when they are seeing that even people that are in charge are not consistent in their communication, that raises doubts. Add to these of course the problem of communication through social media and what people are sharing, I think that what is important here is the radios in rural areas. Broadcast radio stations have that potential to reach to communities in advance of visits from health workers, and this was reported systematically across the Ebola epidemic of West Africa. Wherever there were any research or there were any surveys conducted about the perception of the response, most of the health workers admitted that in cases in which radio was not used in advance, and radio being the main communication tool, there were also megaphones, using markets, there was also TV spots, leaflets, posters, but radio had that potential to be more effective because radio usually was translated by a local host that had a relationship again with their audiences using a local language, not using an official language, and the listener gives a sense of trust. So whenever in cases in the interviews I conducted in one area, those health workers going to the field were proceeded by messaging through radio, broadcast radio, in local languages, they were well received in those communities, because they knew they were coming. And it's basic. Imagine if we are told the Martians are coming from Mars next week, we will be prepared as opposed to Martians arriving suddenly in our town. And this is exactly the same feeling that most of these people were going through. Never seen a white person, never seen a black SUV, the protective gear, and suddenly they are parachuting in a region where they have never seen. Of course, they are going to create fear. So one of the advantages of broadcast radio is that potential to really reach those communities. Also to train them to identify, and this is one of the projects I'm working on now.
Alexandra Arriaga: That was going to be my next question for you actually.
Carlos Chirinos: One of the projects I'm working on now, which I've been working for a long time already for a number of years, is building a community radio station for pastoralists, Maasai communities, The Ngorongoro Conservation Area in Northern Tanzania. This is a community that has been living in this area for centuries and they are pastoralists. That means their livelihood is around the maintenance of cattle and livestock. Now these communities as well as living in an area where they have livestock and they have cattle, they're also living together with wildlife. The Ngorongoro Conservation Area is one of the hotspots of wildlife in Africa. So these communities are at the highest risks of contact with pathogens coming from animals to humans. So one of the ideas that we started working sometime ago was to help these communities or improve these communities capacity to identify and report diseases to authorities, what is known as disease surveillance.
Alexandra Arriaga: So you're not really trying to change the way they live or the way they interact with the wildlife, you're just trying to teach them how to react appropriately when there's the presence of disease?
Carlos Chirinos: Exactly. And part of that, since their livelihoods are really, go around animals, both cattle, livestock and wildlife, they are really at the forefront of these potential spillover of disease from animals to humans. So the idea of the radio station again, and it's funny that we're talking about this, this week we are finally setting up the transmitter in the Ngorongoro Conservation Area. And I didn't mention this, but the Ngorongoro Conservation Area is also a very popular park, is the second most popular tourist destination in Africa.
Alexandra Arriaga: Oh wow! So it makes extra sense.
Carlos Chirinos: Yes. And it's inhabited by over 120,000 Maasai community, so Maasai people. So it's very important that the radio station is going to play a role that will hopefully help the communities be in close communication with the health authorities but also facilitate communication among themselves. And the idea is that we will create programs that will use music as well as information to help the pastoralists better understand their risks, better understand symptoms and ways to share that information with others to raise an early alarm. So the radio station in this case, for example, plays that role of raising early alarm about potential infectious diseases that have the potential to infect other animals and potentially humans as well.
Alexandra Arriaga: I think it's super interesting that you're talking to us about the relationship between music and health communications and just doing this incredible work. And you know on the podcast we've actually had a lot of guests that do work at the intersection of public health and another domain. And one example is recently we talked to someone who was in technology and entrepreneurship, mixing it with public health. Now you're a great example of doing successful, meaningful work, like I said, between music, communication, and public health. Can you talk about what that kind of work looks like as a career and what roles are there, what skill sets are important, and finally, what advice would you have for students who are listening to you and are thinking, "Wow! I really want to do that"?
Carlos Chirinos: Well, I think, again, part of what I learned from my research and my work is that the role of health communicators and health communication in general is changing from a media heavy approach of messaging to the area's community engagement and social mobilization. And this is kind of a part of the health communication agenda, but not necessarily communication the way we understood it or we used to work around. Community engagement really addresses problems of communication at the interpersonal level as opposed to a one way communication using a leaflet or a poster. And that partly is also the advantage of broadcast radio. Broadcast radio has that potential for users to communicate back with the radio station via phone calls. And hearing your voice on the radio helps a long way with that. So part of what I think students willing to go into this area of work you should gain training is in communication theory, also understanding the reasons why people resist health intervention. So the social, cultural, political barriers to access health because in the end a communication intervention is really addressing those. So it really needs to start with an understanding of those factors. And then really believing or trusting your gut about the right model of communication. In my case has been music broadcast radio mainly because music brings together the narrative approach, brings together the culturally centered approach, which is the idea that I'm not going to do the message as an expert, I'm going to enable the communities to develop the messaging and the messaging will have better impact. And also really paying close attention, particularly those professionals willing to work in the low income countries in the developing world, is the power that media outlets like broadcast radio has. Obviously, this is not to say that mobile phone communication doesn't have a power, it has a very strong power penetration, but it relies on textual communication, it relies on one-to-one communication, it has the potential to spread misinformation as well. Also this happens with radio. Since it's inserted in the communities they serve, they have the potential to bring this community engagement aspect a lot closer. So perhaps gaining training in communications skills, developing narratives, working with established, in my case with established artists that kind of have that social capital that I don't have, has also helped me kind of gain the trust of communities and allowed me really to work with the communities to help them develop their own agendas.
Alexandra Arriaga: Nice. And then finally, where do you find the creative inspiration to drive your narratives?
Carlos Chirinos: I think the creative inspiration that I get is from passion and love for music. Understanding or assessing how music plays a bigger role in people's lives. Apart from entertainment, music shapes people's identities, music shapes people's behaviors ultimately. So I tend to find inspiration in music, all types of music, and in particularly music coming out from Africa and from low income communities. I try not to just see the celebrities, but try to look at the local celebrities and what information they might have, what important knowledge they might be sharing with the world, and that's how my research started actually. I started by listening to songs that talked about disease and then I have made a list of hundreds of songs that talk about disease. I found at least 40-something songs about Ebola alone, produced during the West African epidemic, one of them is mine before the other artists had spontaneously created those songs. That was part of the inspiration that I found to get into this area of work.
Alexandra Arriaga: Well, thank you so much for sharing your fascinating journey with us and we hope to keep in touch and see what you do next.