by Quang Nguyen
Globally, over 35 million people were living with HIV in 2012 (1). In addition to severe physical and immunological deterioration associated with the progression of the illness, HIV/AIDS also creates a significant neuropsychological burden on those infected and their social networks. This additional suffering contributes to the decreases in medical adherence, increases in risky sexual behaviors, difficulty in status disclosure, acceptance, and coping (2). Consequently, anxiety and pessimism reduces the efficacy of care and treatment. Nevertheless, this emotional damage may create a clinical and social opportunity for music, a “harmonic medicine,” to serve as a counterbalance to the negative emotions caused by HIV-related stigma (3).
Music is all around us. Among speech, writing and performance, music has evolved to become one of the most powerful social, cultural and political practices. The power of this sonic language strongly steams from its ability to create “sensations, imagination, and experience[s]” that persuasively trigger certain emotions and behavioral changes (4). If you have ever shivered just by listening to a song, then you have experienced the emotional power of music. These music-induced sensations are the result of neuronal activations in the orbitofrontal and cingulate cortices of our brain (3). Through complex biochemical interactions, music then encourages a voluntary “musical participation” between those affected and others.
On a more sociological level, music can not only embody one’s political values and experiences but it also can also effectively propagate his or her opinion, ideology, argument and belief. In fact, many social advocates and political enthusiasts around the world have used music as a global resource in the fight against HIV/AIDS pandemic worldwide since early 1980s when the disease was mislabeled the Gay-Related Immune Deficiency (GRID) out of fear and ignorance (5). In this paper, we will take a brief journey into our brain, the center of the nervous system, to investigate how a simple melody of tones that does not contain an “intrinsic reward value” can effectively unite and empower people in their political and emotional responses to the pandemic of HIV/AIDS (6).
Political Consequences of Musical Re-indexing
In his 2011 book, AIDS, Politics, and Music in South Africa, Fraser McNeill reveals the multifactorial power of locally recognized music in propagating safe sex messages among the general public to educate and influence people’s decisions about HIV/AIDS. For example, consider the following pro-protection message:
Khondomu ndi bosso!
Condom is the boss!
I thivhela malwadze!
It prevents sickness!
Khondomu nga i shume.
Khondomu ndi bosso!
Condom is the boss!
Here, the flexible property of music is at work. In fact, these phrases comprise the modified version of one of the famous anti-apartheid songs by Joe Modise, South African Minister of Defense from 1994 to 1999 (7). Taking advantage of the area’s strong musical culture, a group of young women, who called themselves the peer educators with the slogan of ‘Prevention is Better than Cure’ in Venda, a Whembe District of the Thulamela Municipality in Southern Africa, decided to sing these succinct phrases while performing the Venda’s python dance (domba) to convey their message. In an adaptation of a famous Lutheran hymn, the phrase “Jesus is number one!” was also changed into “Condom, condom, condom is number one, no matter what the people say, but condom is number one!” (7) By changing the words of the song, one may change its original meaning by focusing the attention on another target. In this case, by “indexing” AIDS to Boer, a synonymous Dutch term to call conservative supporters of the Nationalist government in 1800s in South Africa, the peer educators had channeled memory and experiences of the people about anti-apartheid struggle in the past to the current struggle against AIDS (7). Another instance demonstrating the powerful usage of “re-indexing” by lyric change is from a song named “I ya vhulaya” or “It kills,” which contributed to the provision of the 2010 recommendation of when to start Antiretroviral Therapy (ART) (7). Currently, for the adults and adolescents, the WHO recommends ART to all people who have the CD4 count of 500 cells/mm3, with a priority for people with the count of less than or equal to 350 cells/mm3 and those with advanced HIV disease (8). Through music, governmental policy about a particular issue is subject to wider public review for changes as a result of the collective effort of people who are musically influenced as the effect of “melody, meter, … timbre” and the lyrics in the music they listen to generates sufficient effective emotional attention (3).
Although cultural, social, and traditional conflicts present some of the most challenging roadblocks in international interventions—especially in developing countries like Nigeria, where laws against same-sex marriage have been particularly harsh—they also provide a unique opportunity for the musical arts. In these contexts, music can participate in infectious disease prevention efforts as a unifying catalyst for “retraditionalization” in the ever-evolving community (7). After all, each human culture has some type of music, and all humans are neurologically and socially capable of “creating and responding to music” (9). This inherent capacity of music to allow people to “sing about what [they] cannot talk about”—accompanied by an explanation of the what causes infection—can be used to drive positive political energy in HIV/AIDS (7).
Neuroarchitecture of Musical Emotion
The work of peer educators in the aforementioned examples is not only social and political action, but it alsobuilds upon a sophisticated “neuroarchitecture” of musical emotion (10). Have you ever had a song that was just stuck in your head? If so, you have experienced “involuntary musical imagery” (INMI), or “earworm” syndrome, in which unwanted familiar and most likely overlearned musical tunes keep repeating in your mind sometimes uncontrollably (11). This common “sticky music” phenomenon, which was postulated to be the result of neural playback circuits, reveals musical transliminality, a hypersensitivity to music due to its powerful cognitive penetrability (11). Providing this music-specific mental penetration—although with a short “life expectancy”—music is a promising untapped resource that, when used correctly, can influence our emotional and mental states through a variety of useful ways (11).
As such, researchers have asked questions such as can music trigger emotional changes that are strong enough to subsequently induce particular actions? What specific changes in the brain that are induced by musical engagement were intentionally or unintentionally recognized and utilized as a tool in HIV/AIDS politics? With the help of current and developing neuro-technology, we are much closer to solving the mystery of musical perception and the brain function.
Musical Rhythm as the Brain’s Temporal Timer
Since music can facilitate communication among people in a community, it can also contribute to the communication of information across the auditory cortex, which is located at the juncture of the Sylvian fissure and adjacent Heschl’s gyrus in human brain (3). At this juncture, centric auditory cortical fields are concentrated, organized by frequency-specific sounds of rhythm and timbre transmitted from the thalamus (3). Musical sounds, with their uniquely structured rhythmic patterns, serve as “sensory timers” that have been shown to improve the recovery of motor functions in neurologically damaged patients with strokes, Parkinson disease, and traumatic brain injury (12). In fact, musical rhythm creates a meaningful sound pattern in time that parallels the “oscillatory ‘rhythmic’ synchronization codes of neural information processing” in the brain (12). In turn, this complex and expansive cortical process induces an additive effect to streamline the transfer of “sensory and cognitive-perceptual information” (6, 12).
Furthermore, it was suggested that music is “written in the time code of rhythm as its sound patterns resembles the oscillatory ‘rhythmic’ processing in the brain (12). This temporal feature of music constitutes the neurobiological foundation of perception and learning (12). When we listen to music, dopamine is released in the nucleus accumbens, affecting the reward pathway that operates in perception, addiction, motivation, and emotion mechanisms (3, 6). Specifically, Salimpoor et al. (2013) revealed that our appreciation of desirable new music is not only due to the auditory cortical processes triggered by one’s listening history but also a result of our temporal expectation of the rewarding value of the music we are listening to, based on the implicit understanding of musical sounds and structure. Temporal control in the oscillatory circuits of the speech center in the brain is essential for coordinating movement, memory, and other executive functions. Existing studies provide strong prima facie evidence music can stimulate the neuronal compensatory network for brain areas whose functions are compromised; thus, music may also contribute to neural plasticity. In fact, listening to music with lyrics has been documented to elicit wider bilateral neural activity than in response to purely verbal materials, and regular self-directed music listening has been shown to increase the compensatory capacity of different brain regions in patients with unilateral MCA stroke (14).
Retrieval of Musical Information and Neuronal Memory
Coupled with the rhythmic pattern, musical “chunking” through melody acts as an effective mnemonic device, which is essential in memory coding (12). For instance, despite Alzheimer’s patients’ inability to learn new songs, perform memory tests like word lists, stories, or figures, they have been shown to be able to retain musical information and skillfully play previously learned songs (14). If patients with neurological disorders can retain music-specific information, then it is unsurprising that music can also be utilized to recreate or trigger profound musical emotions in healthy individuals, especially when that musical information is strongly associated with a particular past event. Neuroscientific studies also support this postulation, linking the differential activation to stimulation in the anterior parabelt regions surrounding the core of auditory cortical fields, thereby connecting auditory stimuli and memory (3). Therefore, music not only allows one to formulate new memories about certain incidents by interpreting and responding to the related musical piece, but also it may help one create a stable neuronal memory that is resistant to certain neurodegenerative forces.
Cognitive Emotion in HIV/AIDS-related Depression
As neurocognition and immunity are progressively compromised in HIV-infected patients, HIV-related depression impedes the efficacy of ART by further worsening their emotional state. Clinically depressed individuals are unable to regulate negative moods as they often have difficulty accepting and reframing negative automatic thoughts (NAT) (15). Inevitably, the accumulation of this emotional distress would impair their “adaptive cognitive coping strategies,” continually increasing their susceptibility to more advanced neurocognitive sequelae like HIV-associated dementia. In addition to other people’ perceptions, compromised behavioral regulation of emotion in HIV-infected individuals can be further complicated by their own internalization of the stigma (15). However, all these behavioral and social challenges, open up the door for “harmonic medicine” to play a role in both socio-behavioral and neuropsychological aspects of HIV/AIDS treatment (3).
Harmonic Medicine in Emotional Neuroscience
It was also shown that modulation of amygdala reactivity plays an important role in recruiting various frontal brain regions, including the dorsolateral prefrontal cortex (DLPFC), orbitofrontal cortex (OFC), and anterior cingulate cortex (ACC). This “amygdala-frontal coupling” has been linked to the ability to self-regulate negative emotion and trigger emotion-related behaviors during distress (16). As a result, music, a highly emotional stimulus can serve as a powerful harmonic medicine for self-regulation of negative emotions, which is an important cognitive coping ability that tends to be only minimally induced in HIV-infected individuals following cognitive and behavioral interventions (15). Furthermore, Särkämö and colleagues (2008) also showed that listening to music everyday could prevent negative mood in patients with middle cerebral artery stroke as they experienced less frequent episodes of depression and confusion.
Just as emotions can be classified as happy or sad, music-specific emotional responses via its complex organization of melody can also be classified by the moods elicited bilaterally by different signal changes in the amygdala and limbic system of the listeners (3, 18). Researchers have also suggested that the increase in hormone concentration in tears, such as that of prolactin, when people experience extreme emotions, e.g. during birth delivery and organism, may be an evolutionary mechanism that facilitates the encoding memory of that extreme emotional experiences (3). This may explain the physical changes in people when they watch orchestra. Therefore, it is not exaggerating to say that music indeed plays an important role in humans’ emotional experience.
Furthermore, foundational elements of music, such as pitch, tone and rhythm, each engage different parts of the brain in a sophisticated bilateral cortical collaboration, creating a combined effect on emotion, memory, and perception (13). In fact, the elaborate interactions among sensory-motor, auditory, and frontal cortical networks have been proposed to elicit musical emotions, thereby influencing behavioral decisions by engaging higher-order cognitive affective regions in the brain for the acquired “inventive salience” of music (6). Therefore, music not only helps lessen the social and cultural burdens on people living with HIV/AIDS by allowing their pain to be musically heard and defragmented, but also it may help to alleviate their psychological challenges by changing or maximizing their brain’s music-dependent plasticity under conditions of external and internal stress (3, 12, 13).
Neuropsychological Integration of Music in HIV/AIDS Prevention, Treatment, Care, and Politics
Music is the building block for the audience’s emotional experience and for the performers themselves to express their message via the musical melody. In the past, the therapeutic value of music has primarily been interpreted within the framework of the indirect consequences of music and one’s cultural and emotional wellbeing (12). However, not until recently has this understanding been more adequately expanded to include the underlying neurology of musical healing power. This wider consideration suggests the potential application of music as therapy and for confronting the politics of HIV/AIDS, a highly stigmatized and emotionally heated disease that has a long history (12).
Musical power to change one’s emotions and behaviors has been utilized in many HIV prevention programs, especially in developing countries where music is often an important cultural value of the people. As HIV/AIDS levies many heavy negative emotional changes that subsequently result in neurocognitive defects, music, along with neuroscience, psychology, and medicine, is an invaluable resource. With proper implementation, it may help improve current disease control, program, and policy planning. As HIV/AIDS incubates fear and emotional distress in those affected, music offers inexpensive healing power that is free of adverse effects and can promote HIV/AIDS prevention. Furthermore, with its powerful capacity to change emotions and alter perceptions and social behavior, music also contains a politics within itself. As McNeill (2011) points out, music is a social solvent for politics, religions, and traditions to homogenize for the better. Lastly, it is also important to recognize that, as gender differences do play a crucial role in emotional reactions to music, certain marginalized populations are more vulnerable to social stigma than others. Thus, musical applications, including political acts and medical or educational implementation, must remain culturally appropriate, gender-relevant, population-specific, and most importantly ethically justified (11).
Reverend Jackson Muteeba, director of the Integrated Development and AIDS Concern (IDAAC) in Iganga, Uganda, asserts that only behavior can serve as the “metaphoric ‘language’” that “AIDS can hear, […] understand, […] for the people to come to terms with the realities of the disease-both cultural and medical” (18). Creative music can evolve to empower stigmatized HIV-infected individuals while educating others, whether infected or not.
Quang Nguyen ‘16 is a sophomore at Duke University majoring in Cellular and Molecular Biology.
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