In a lecture hall of one of Pakistan's most prestigious medical schools, a handful of male students sits in the far top corner, clearly outnumbered by the rows and rows of female students listening intently to the doctor lecturing about insulin.
In a country better known for honor killings of women and low literacy rates for girls, Pakistan's medical schools are a reflection of how women's roles are evolving. Women now make up the vast majority of students studying medicine, a gradual change that's come about after a quota favoring male admittance into medical school was lifted in 1991.
The trend is a step forward for women in Pakistan, a largely conservative Muslim country. But there remain obstacles. Many women graduates don't go on to work as doctors, largely because of pressure from family and society to get married and stop working — so much so that there are now concerns over the impact on the country's health care system.
At Dow Medical College in the southern port city of Karachi, the female students said they are adamant they will work.
Standing in the school's courtyard as fellow students — almost all of them women — gathered between classes, Ayesha Sultan described why she wants to become a doctor.
"I wanted to serve humanity, and I believe that I was born for this," said Sultan, who is in her first year. "The women here are really striving hard to get a position, especially in this country where women's discrimination is to the zenith, so I think that's why you find a lot of women here."
For years, a government-imposed quota mandated that 80 percent of the seats at medical schools went to men and 20 percent to women. Then the Supreme Court ruled that the quota was unconstitutional and that admission should be based solely on merit.
Now about 80 to 85 percent of Pakistan's medical students are women, said Dr. Mirza Ali Azhar, the secretary general of the Pakistan Medical Association. Statistics gathered by The Associated Press show that at medical schools in some deeply conservative areas of the country such as Baluchistan in the southwest and Khyber Pakhtunkhwa province in the northwest, men still outnumber women. But in Punjab and Sindh provinces, which turn out the vast bulk of medical students, the women dominate. At Dow, it is currently about 70 percent women to 30 percent men.
In comparison, about 47 percent of medical students in the U.S. are women, according to the Association of American Medical Colleges.
There are a number of different reasons why men don't make the cut, say students, faculty and medical officials. Medical school takes too long and is too difficult. Boys have more freedom to leave the house than girls, so they have more distractions. Boys want a career path in business or IT that will make them more money and faster, in part because they need to earn money to raise families.
"In our society, girls are working harder. They are just more concentrated on their studies," said Azhar. Boys also see how hard doctors have to work even after they get their degree. "They do not like to work hard as a matter of fact."
Ammara Khan is fully prepared for the years that it will take to fulfill her dream of becoming a neurosurgeon. She decided she wanted to pursue neurosurgery after watching an operation while volunteering at the Aga Khan University Hospital in Karachi.
"It's like an adrenaline rush, and I knew I wanted to be that and nothing else," she said.
Still, medical officials and students acknowledge many women don't go on to practice medicine.
At Dow, for example, just about all the male graduates work as doctors, but only an estimated half the women do, says Dr. Umar Farooq, the school's pro-vice chancellor. Nationwide figures on how many women graduates forgo actual practice don't exist, but despite years of increased women's enrollment, the gender breakdown of doctors remains lopsided. Of the 132,988 doctors registered with the Pakistan Medical and Dental Council, 58,789 are women. The number of female specialists is even smaller: 7,524 out of 28,686.
The pressure on women to get married, have kids and stay home to raise them is powerful.
The prestige of a medical degree gives a woman a boost in marriage prospects, so many parents push their daughters to enroll, many students and faculty said. Prospective in-laws like the idea of having a doctor in the family and want their sons to have an educated wife to ensure the grandchildren are educated as well.
But that doesn't mean they want the woman to actually use her degree and take away from child-raising time.
"They want a doctor label but they don't want it to go anywhere. They don't think you're a real person who might want to specialize or work on it," said Beenish Ehsan, a student at Dow.
Her own family supports her completing the initial five years of medical college. But when she started talking about further studies for a specialization, they worried it would take away from her future family life.
"They're like, 'No, but you'll take care of the house, won't you?'" Ehsan said.
"You have to convince them," she said, adding that too many women don't push back against their families. "Sometimes girls give up too soon, I feel."
There are also cultural impediments. Women who do work often don't want to do so in rural areas far from their families or don't want night shifts, given the country's deteriorating law and order. Some male patients only want to be treated by men because they don't want women touching them or because they perceive the men to be smarter and more qualified.
During the 2010 floods that devastated Pakistan, Dow wanted to send medical students to Sindh province to treat victims but were hindered by the school's overwhelmingly female enrollment, admissions director Rana Qamar Masood said. The boys could go on their own for long stretches. The girls were also lobbying heavily to go, but the school decided to send them in teams on buses with chaperones out of concern for their safety. They would return home each evening, thus limiting how far they could travel.
"We are responsible for these girls. How can we send them out to these hard-hit areas?" she said. "These are the ground realities in our society."
Amid concerns over the number of the doctors in the future, proposals are being touted to rebalance the student body. Masood said she would support some sort of gender bias in admissions to bring in more male students. The PMA has floated the idea of building a number of medical schools just for boys. Already there are five medical schools for women.
Among the students, some said a new quota was necessary. Others said it would be unfair.
"That would be injustice. Girls are studying harder," said one male student, Aleem Uddin Khan, who said it took him two tries to get into Dow. "If we want the seats, we should study hard."
The debate here echoes the "mommy wars" in the U.S., where women have been trying to figure out the balance between work and home life for years.
Midhat Lakhani, a Dow student, has only to look to her mother, who's a doctor, to know it's possible to pursue a career and have a family. Her mom took her postgraduate exams 15 days after giving birth to Midhat's sister.
"You have to be supermom, obviously," she said.
Associated Press writer Adil Jawad in Karachi, Riaz Khan in Peshawar, Abdul Sattar in Quetta and Zarar Khan in Islamabad contributed to this report.
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