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The Optimist

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"Slow" fashion brings fast progress to healthcare in Bihar, India

The hottest ticket at India Fashion Week is, oddly, admission to the National Rail Museum in New Delhi. The celebrity designer Samant Chauhan is debuting his latest collection, “Train Memories.” Fashion aficionados mingle with everyday museum-goers, who look befuddled when a parade of models walk out from behind a towering locomotive.

For this show, Chauhan’s designs are inspired by his childhood in the village of Jamalpur, Bihar, a railway hub in the northeastern state of India. As a boy, he rode the rails with his father, who worked for the railroad.

The show is the kind of jaw-dropping spectacle the fashion world has come to expect from Chauhan. He’s been at the vanguard of India’s “slow” fashion movement since graduating, in 2004, from the National Institute of Fashion Technology in New Delhi (the first person from his village to get a higher education). He specializes in the use of tasar silk, a handmade fabric produced by craftspeople in Bihar.

At the time, most people thought of Bihar as one of India’s most impoverished states. Communities along the Ganges River suffered from some of the world’s highest rates of infant mortality and a festering plague of tuberculosis.

Fifteen years later, Chauhan’s designs have taken Bihar to the runways of London, New York, and Paris. And while he was representing Bihar in pop culture, a network of government agencies, NGOs, and multilateral groups, such as The Global Fund, were busy weaving a tapestry of their own, developing an interconnected health system for solving Bihar’s complex health challenges.

20,000 newborn lives saved every year

The clack-clack sounds of handlooms echo in the streets of Puraini, a “cluster” of silk weavers near the city of Bhagalpur, Bihar. This region of India has produced tasar silk fabric since the days of the ancient Silk Road.

To operate a handloom, a weaver simultaneously works a foot pedal, a swing arm, and a pull string that rockets a yarn shuttle back and forth. With the slightest hiccup, the intricate weave will snarl into a bird’s nest of silk. The job is not physically dangerous, although their crowded workshops make weavers vulnerable to outbreaks of infectious diseases, especially tuberculosis. All it takes is for one weaver to come to work with a cough and soon the disease spreads throughout the cluster.

India has over 2 million people with tuberculosis, with untold more going undiagnosed. That represents 27 percent of the world’s tuberculosis burden. The disease strikes close to home for many people, including Chauhan. His uncle, who worked for the railroad, overcame tuberculosis thanks to the high-quality healthcare provided him at the railroad’s private hospital. Silk craftspeople, though, are an impoverished segment of society for whom such benefits would be a dream.

The weavers of Puraini have a guardian angel who visits them wearing her government-issued pink and blue saree. Reshma Khatoon is one of 850,000 accredited social health activists, or ASHAs, hired by the national government to be health advocates in their home villages. ASHAs are themselves like colorful strands of silk shuttling back and forth to strengthen the overall health of their communities. Khatoon was hired in 2005, during the buildup of frontline health workers in the battle against polio. She went door-to-door helping vaccinate the children of Puraini. She was then trained to detect and treat tuberculosis through Project Axshya, a Global Fund-supported initiative.

“Over the years, I’ve treated 20 to 25 cases of tuberculosis,” Khatoon says. Considering that one person with an active case of tuberculosis can infect up to 15 people, it’s fair to say that Khatoon prevented 375 cases. “These days, we don’t see many cases in our village.”

Treating tuberculosis is easier today than ever before. The newly-launched Joint Effort for Elimination of Tuberculosis (supported by the Global Fund) intertwines the public and private health sectors through a centralized data reporting network, coupled with universal access to government-subsidized medication. And a study from 2018, conducted by World Health Partners in the capital city of Patna, saw a 725-percent increase in the number of tuberculosis cases reported to medical professionals.

The trick? Training private pharmacists – who often lack basic medical education – to better diagnose the symptoms of tuberculosis and reward them monetarily for every case they referred for testing and treatment.

These rates are encouraging, but there’s still a large gap to close before health workers are catching all of the cases that go undiagnosed every year. Doing so will be the difference between whether or not India meets its goal of eliminating tuberculosis by 2025.

Over 80% full immunization coverage

A silkworm cocoon looks like an oversized mothball. Several hundred cocoons hang clustered together on ropes tethered to the ceiling of a “grainage,” or small warehouse, in the village of Inarawaran, Bihar. It’s peak monsoon season and the air is humid and warm – ideal conditions for the tasar moth inside each cocoon to emerge.

Under the light of a bare lightbulb, a female moth struggles through an opening in her cocoon. Fully emerged, she measures several inches wingtip to wingtip. Her velvet wings have a green hue, with an iridescent god's eye at the center of each segment.

Munia Muru owns the grainage with her husband, Ramesh Kisku. In the morning, she walks between dangling ropes of cocoons, keeping watch like a nurse in a maternity ward. Spotting the just-emerged female, she plucks the moth from its cocoon and sets her next to a beige-colored moth, a male, encouraging them to...you know. A female tasar moth has only 24 hours to fertilize and lay her eggs before dying. (The male dies shortly after mating.)

Muru and Kisku used to farm tasar cocoons the traditional way – by harvesting them wild in the forests of Katoria. But over the years, the forests shrank as the trees were cut down to make way for agriculture. Equally troubling, they noticed fewer and fewer silkworm caterpillars were surviving to the age when they spin their cocoons. Their yearly cocoon harvest was becoming so meager the family was considering abandoning the trade, though they desperately needed the money to supplement their income as rice farmers. Kisku even asked around about finding work in far-off Patna, though a separation would strain their family.

One day, in 2002, Muru joined a women's self-help group organized through the National Rural Livelihoods Mission. The organization hosts 835,000 such community meetings across Bihar, such that 1 in 5 women now attends a self-health group. Through female empowerment, they learn about everything from infant health, to nutrition, to home economics.

At one session, Muru met an agricultural extension agent with the group Pradan. He knew exactly what was going on with their silkworm crop and suggested Muru and Kisku attend a sericulture (silkworm farming) workshop. They learned that a parasite was attacking the eggs of their tasar moths. Pradan’s experts taught them to swab newly-laid eggs for examination under a microscope – advanced skills for people who didn’t finish primary school. With magnification, the perine parasite stands out like a mushroom head. Kisku destroys the diseased eggs, while Muru gathers the healthy ones for dispersal in the forest to hatch a new generation of healthy silkworms.

As an economic development model, silkworm farming has helped 10,000 families in Bihar rise out of poverty. In the case of Muru and Kisku, their grainage business earns them 50,000 rupees annually (around $770). They’ve paid off their low-interest business loan from Pradan (at two percent interest, versus the 50 percent interest offered by local moneylenders), with plenty left over to improve their standard of living.

ASHA's like Devi are worth their weight in silk

Rita Devi, an ASHA serving the community of Inarawaran, is a welcome sight in her pink and blue saree. She frequents Muru’s self-help group to learn about health problems the women or their family members might be having. In 15 years on the job, Devi has an impressive track record of treating everything from tuberculosis, to leprosy, to malaria. And she’s also been instrumental in organizing immunization campaigns for the village’s children.

Rural villages represent the last mile for vaccination efforts in Bihar. Statewide, immunization rates have increased from 74 to 81 percent over the past five years. Those figures are promising, but they mask an even more impressive rate of progress in Bihar’s five poorest districts where immunization coverage has increased from 63 to 80 percent.

Bihar's immunization coverage increased from 63 to 80 percent

For pregnant women in rural villages, ASHAs are a lifeline for getting prenatal and neonatal care at a regional health facility. When Devi attends a self-help group meeting, her first question is if there are any new pregnancies. Then she a medical shuttle service to transport the pregnant woman, and her, to the nearest hospital. She’s spent many nights at the bedside of mothers-to-be in the hospital.

“I feel very tense when I take a pregnant woman to the hospital,” Devi says. “I don’t feel relaxed again until mother and baby are back home, healthy, in the village.”

From 2011 to 2016, the neonatal mortality rate in Bihar declined by 23 percent, saving the lives of 20,000 babies every year. The stillbirth rate also declined, by 27 percent, a signal of improved intrapartum practices at birth facilities. As with other health statistics in Bihar, these percentages rank poorly on a global scale. But incremental progress in healthcare makes it clear that ASHAs like Devi are worth their weight in silk.

Thanks to a booming textile industry, a growing number of families have the financial means to make smart choices about their health.

“When you create jobs,” Chauhan says, “people spend money on better food, clothing, and taking care of their hygiene. Tasar silk fashion is raising up the quality of life for villagers in Bihar.”

About the Author

Ryan Bell
Ryan Bell is a journalist whose pieces have appeared in publications such as National Geographic and NPR.

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