In June, an unusual email arrived in the inbox of an NPR global health correspondent.
The headline was: "Merck Foundation together with First Lady of Burundi release 'Plus Qu'une Mere' an empowering French Song as courtesy to all infertile women in Burundi and Africa."
The email had a link to a video of a performance with an all-female choir. Wearing traditional African clothing printed with the Merck Foundation's logo, they sing a song with lyrics that encourage people not to blame women for infertility.
They're performing before an audience of maybe a hundred people, most of them in similar Merck garb.
The video raises a number of questions: Can a song be helpful to women who are infertile? What is the role of the First Lady of Burundi in this project? And ... why is nearly everyone in the choir and audience wearing the Merck logo? To learn more, NPR spoke to the Merck Foundation and to specialists who deal with infertility and the impact of musical health messages.
A Musical Message
Since 2016, the Foundation has been staging music videos, performances and songs (as well as fashion shows and media trainings) to send the message to African countries that a woman should not be blamed if she is unable to bear children.
The campaign messaging also notes that for those women and men who do seek fertility treatments, Merck has options.
(As for the garb of the choir singers, one global health researcher interviewed by NPR was not concerned. In parts of sub-Saharan Africa, explains Jocelyn E. Finlay, a senior research scientist at Harvard T.H. Chan School of Public Health, it's common for community leaders to celebrate special events by printing large swaths of traditional African fabric with the logo of a sponsoring group for guests to turn into clothing.)
Merck's efforts are important because infertility is an under-researched issue around the world, says Finlay, who studies reproductive health in low-income countries.
"The overall message is not a bad one," she says of Merck's campaign. "Not much [in terms of funds and research] is going on for maternal health right now — priorities are shifting elsewhere. Merck is one of the few organizations that prioritize women's health in developing countries" through research, partnerships with local health care institutions and public education.
And Merck is doing more than hosting fashion shows and making music videos.
The Foundation also sponsors an Embryology & Fertility Training Program, a three-month course in clinical and practical matters in more than 30 countries across Africa and Asia. Since 2015, the program has trained 109 fertility specialists.
Rasha Kelej, CEO of Merck Foundation, said she could not share the budget of the program because the figure is "hard to extract." It is part of Merck's larger effort to provide training to health-care workers in the developing world on such medical concerns as cancer, diabetes and rehabilitation, she says. And that broader effort includes support and financial contributions from its partners, including the Manipal Academy of Higher Education in India and the International Institute for Training and Research in Reproductive Health in the form of free tuition and other donations.
The infertility program is especially critical in sub-Saharan Africa. While the region has some of the highest birth rates in the world, it also has one of the highest rates of infertility globally, according to the World Health Organization. Around the world, more than 180 million couples face infertility. In the poorest countries, the 12-month infertility prevalence rate — failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sex — ranges from 6.9 to 9.3%, according to WHO.
As in many parts of the world, women in sub-Saharan Africa who can't have children often feel a sense of shame. "There is an expectation that women can bear children. And when they don't get pregnant, then it's assumed it's the woman's fault," says Finlay.
Most cases of infertility in this region are caused by infections, for example STDs or pelvic infections, according to a 2011 study in Facts, Views and Vision in OB-GYN. Some of these causes are treatable, but the techniques are often too expensive for the majority of the population. And there are few fertility specialists and treatments on the continent, says Finlay.
Infertility Care For All
Merck Foundation, says Kelej, is ramping up fertility services to people from all income levels. In addition to its training program, it has teamed up with the International Federation of Fertility Societies to provide fertility services to public hospitals across Africa. The idea is to provide low-income patients who are trying to conceive with basic treatments — for example, removing fibroids or treating infections.
In this partnership, Merck connects African fertility specialists to technical experts who travel to the local clinic. They demonstrate how to use the medical equipment or provide assistance in setting up an in-vitro fertilization center. So far, Merck and IFFS have helped set up fertility clinics in public hospitals in Uganda and Guinea.
"We want women and couples to have access to everything: information and health. We want to change their mindset around infertility and let them know they have a choice," says Kelej.
Songs To 'Empower' Women
The "More Than A Mother" campaign has so far launched 14 local songs with singers from Gambia, Ghana, Kenya, Rwanda and Sierra Leone. Merck says the songs were created to "empower" women with the message that there is more to life than being a mother. Men shouldn't blame women if they aren't able to have children. One lyric goes, "Life is bigger than having children, my friend."
And the songs point out that infertility can also be an issue for men. In a song called "Life Is Bigger," Rwandan artist Tom Close, sings: "Yes, she might be the one with the problem. But you might as well be the one with the problem."
Close is one of the many artists that the Foundation enlisted to create songs and music videos to reflect local culture and language. The musicians also include the local all-female choir from Burundi, a singer named Sunita from Gambia and a Kenyan rapper (with more than a million Instagram followers) known as Octopizzo.
And of course, there is the song written and performed by the First Lady of Burundi, H.E. Madam Denise Nkurunziza. Kelej says that Nkurunziza is a singer in her own right and put out versions of her "More Than A Mother" song in French, English and Kirundi, a Bantu language spoken in her country.
Some of the videos can be found on the Foundation's YouTube channel. The goal is for the songs to get local TV and radio airplay.
If done well, musical messaging can be a good strategy, says Carlos Chirinos Espin, a professor of music and global health and the director of New York University's Music and Social Change Lab. "There is a body of literature that shows entertainment education has a strong ability to change behaviors in health."
According to the 2019 SAGE International Encyclopedia of Music and Culture, music has helped change attitudes and inform the public about diseases from HIV/AIDS to malaria. Espin himself helped develop a campaign during the Ebola crisis called Africa Stop Ebola, to raise awareness about the pandemic.
But some global health advocates and ethnomusicologists interviewed for this story say that the "More Than A Mother" music videos fall flat. In one video from August 2018, for example, Merck Foundation teamed up with Octopizzo and Rozzi, a singer from Sierra Leone.
Titled "Octopizzo ft. Rozzi, Remix of Merck More Than A Mother Song," it shows an African man kicking his wife out of a house because she can't have children. A few scenes later, the woman — wearing an African print garment and visibly disheveled — goes to meet with a woman sitting behind a big desk and computer at an office building. That woman is Kelej, CEO of the Merck Foundation.
Kelej, an Egyptian national with blonde hair and Western clothing, lifts the woman's downcast face with her hands. Seconds later, the African woman is walking down the hall of a building wearing Western clothing. In the next scenes, her fortune changes. She starts her own business, meets the man of her dreams, gets remarried and — with the support of her husband, begins infertility treatments.
The video is "problematic," says Austin C. Okigbo, an associate professor of global health and ethnomusicology at the University of Colorado, Boulder. It makes it seem as if the biomedical intervention solves all problems, but it "does not solve the culturally rooted problem of blaming women for infertility."
"A medical solution [only works] when the cultural biases have been addressed," he adds. "It can be an option for those who wish to go that route. It means that Merck is out to sell their product and not there to address the problem of infertility stigma."
Kelej disagrees with the criticism. "I don't believe there is a dual message," she says. "We want women and couples to have access to everything: information and health. We want to change their mindset around infertility and let them know they have a choice."
The Octopizzo and Rozzi video raises other concerns. Some social justice advocates are uneasy with the imagery in the video featuring Kelej. The African woman's life is only transformed after meeting Kelej and working with the Merck Foundation.
The power dynamic between Kelej — who works for a Western multinational pharmaceutical company — and the African woman evokes the white savior complex, says Nora Rahimian, the co-founder of #CultureFix, a global network of artists who use the arts to create social change. It feels "neocolonial. There are power dynamics at play."
Whether or not the music was effective in helping to change public opinion on infertility is a matter of time and research, says Okigbo. "The only way you can know is to deploy a qualitative analysis before and after the campaign to see if the level of awareness has changed, maybe after one or two years."
One thing is certain, say the five researchers interviewed for this story: The Merck Foundation represents a business — and it has the company's bottom line in mind.
"They are not going to be able to create a demand for their product unless they educate their consumers that they should demand a product," says Usha Sundaram, a senior lecturer in consumer and digital marketing at the Norwich Business School at the University of East Anglia. "It's textbook marketing."