The size of the Zoroastrian population is in sharp decline, reports Jeetha D’Silva, so the federal government has decided to fund advocacy and in vitro fertilisation in the hope of bucking the trend

By Jeetha D’Silva | BMJ

A select team of doctors from throughout India will soon be working on an initiative that is as much of demographic importance as it is of medical interest. This government led programme, Jiyo Parsi, intends to use medical technology to boost the population of the fast shrinking Parsi community—the Zoroastrians of India—a distinct ethno-religious minority community that has made considerable contributions to India’s economic and social development.
Parsis—a population in decline

India’s population of Parsis has declined from 114 890 in 1941 to 69 001 in 20011—a paradox in a country that is grappling with a burgeoning population of more than 1.2 billion. A government document on the community has stated that only one Parsi family out of nine has a child below the age of 10.2

A 2011 study found that the main factor behind the sharp fall in Parsi numbers is the abysmally low fertility of the community, as expressed by a total fertility rate of only 0.89 children per woman in 2001, well below 2.1 children, the rate that is required for a stable population.3 The study, which was conducted by Zubin Shroff, then a doctoral candidate, and Marcia Castro, professor, both at the Harvard School of Public Health, also found that fertility in the community has been declining for more than a century: the total fertility rate among the Parsis in Mumbai was 4.41 children in 1881, declining to 0.94 in 1999. Deaths have exceeded births in every year since 1955, and the decade 1961-70 was the first period when the total fertility rate was found to have fallen below the level necessary to maintain the population.4 Studies have attributed the drop in fertility rates to social reasons. Many Parsi adults do not get married, and for those who do, their average age is 27 years for women and 32 years for men. Therefore the average child bearing age is also higher than that of the general population.5

“While the prevalence of infertility is not much higher in the Parsi community, it is the social factors that cause couples to delay starting a family due to which the chances that they will need medical intervention to deal with fertility related issues are higher,” Anahita Pandole, head of the Jiyo Parsi medical initiative in Mumbai, told the BMJ.

At the launch of the project in September, the minister for minority affairs, K Rahman Khan, said, “This is a small step to pay our debt to the Parsi community for their contribution to the country. We cannot afford to lose this community.”6 “The Parsi community is an important and integral part of India’s diverse population,” Lalit K Panwar, secretary at the Ministry for Minority Affairs, said. “If we do not check the decline in the community’s population, it will become extinct in a few decades,” he added.

A few other communities are also declining in number, including Jews, who have mostly migrated to Israel, and some of the indigenous tribes of the Andaman Islands. But Panwar said that this is the first instance of government intervention in such a “sensitive and personal” matter.
Funding for the initiative

Despite many Indians lacking access to even basic healthcare, the scheme hasn’t attracted much opposition because it is being funded by the Ministry of Minority Affairs, which has its own corpus intended for the welfare of minority groups and does not take away from projects run by the Ministry of Health. In addition, the investment, Rs 20m (£200 000; £234 345; $323 000) a year, is negligible from a government funding perspective.

To implement this project, the government will collaborate with doctors through a not for profit organisation and fund fertility treatments of Parsi couples, among other measures, including advocacy to encourage the youth of the community to marry at an earlier age rather than the existing norm of marrying in their late 20s and 30s.

Shroff, author of the demographic study and a Parsi, explained, “It is laudable that the government of India has taken this issue into cognisance . . . Advocacy for early marriage and fertility treatment may play a role in increasing fertility and hence stemming the population decline.”
How the scheme works—advocacy and medical assistance

The project started in October and is being implemented by the New Delhi based Parzor Foundation, a not for profit organisation that works to preserve the Parsi Zoroastrian heritage. According to the plan prepared by the Ministry of Minority Affairs, the scheme will have two components—advocacy and medical assistance. The advocacy will involve counselling families, encouraging early marriage among the community’s youth, and advocating parenthood at the right time.

The medical component will involve treating fertility related issues as soon as they are detected. In the case of couples who need further treatment, the programme will also provide assisted reproductive technologies, which include in vitro fertilisation and intra cytoplasmic sperm injection.

To deal with infertility, financial assistance would be provided for investigation and detection of infertility, counselling, and treatment to married couples after their problem is medically detected.2 The government will provide 50-100% of the treatment costs depending on income of the family, subject to a maximum cost of Rs 500 000. Financial assistance will cover the cost of medicines and post-medical expenditure.

In addition, the programme extends the benefit of financial aid even to the community’s unmarried young members to treat the usual clinical problems that might result in infertility. The government has offered funding of Rs 15 000 rupees to young (from adolescence to age 30) men and Rs 25 000 to young women who need medical assistance. The government has allocated Rs 100m for the project that will be disbursed over the period of the 12th five year plan (from 2012 to 2017).

The Parzor Foundation has set up two teams. Anahita Pandole, who heads the medical assistance component, told the BMJ that this initiative will build on the community’s previous efforts to stem the decline in its numbers. Pandole had earlier started a centre in Mumbai at the behest of community leaders who were concerned about the decline. “We started working with couples within the community about eight years ago,” she said, speaking of an initiative of the Bombay Parsi Punchayet, a community organisation. “Over the years we had a good response and we were able to help many families,” she said. Now, Pandole will be in charge of the programme’s first centre at Jaslok hospital, a leading referral hospital in the city.

In Delhi, the foundation will set up its first centre at the All India Institute of Medical Sciences, a leading government hospital. “As the project progresses we may open another centre in the suburbs since there are young Parsi couples in the newer Parsi colonies in those regions,” Shernaz Cama, director of the UNESCO Parzor Project, Parzor Foundation, said.

Other hospitals, especially in cities such as Ahmedabad and Pune, are being examined for empanelling. Cama added that any doctor or hospital who would like to be involved should approach the local Parsi community’s association and discuss the facilities available and the success rates. These will then be verified by the medical panel constituted by Parzor before a decision is taken. “We need results and will work with any hospital which has a proven track record in the treatment of infertility,” explained Cama.

Throughout the country, the doctors and hospitals that will be involved will be paid for treatment by the government as a direct cash transfer, and the cost of drugs will be reimbursed to the patients. Cama said that the project will benefit many Parsi couples. “A sizeable proportion of the young Parsis are actually supporting a large number of dependants: ageing parents and extended family members who may not have married. Many of these couples have modest incomes, and the burden of the ageing population is so much that they cannot afford infertility treatment,” she said. Cama added that although some people might question why an affluent community needs government support, the fact is that wealthy Parsis are few and mostly restricted to the city of Mumbai.
Too little too late?

While the project gets into the implementation stage, there is a legitimate concern: will it make a difference? Might it be a case of too little being done too late? In his study, Shroff said that the growth rates make it clear that a massive change in fertility would be required to keep the Parsi population in 2051 at its 2001 strength. “A doubling of fertility would lead to a 2051 population that is still 30-40% smaller than that observed in 2001. Only a fertility level three times larger than that recorded for 2001 would produce a positive population growth, or an increase in the Parsi population.” Shroff told BMJ that he is cautious in his optimism. “Given the extremely low TFR [total fertility rate] and the age structure of the population it would probably be too much to expect any sustained increase in the Parsi population in the near future. Slowing the decline however, is an important first step,” he said.