Pakistan's medical schools are filled with women but only about half them go on to practise, or further study, after qualifying.
Is there a doctor in the house? In Pakistan, quite possibly
KARACHI // In a lecture hall of one of Pakistan's most prestigious medical schools, a handful of male students sit 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 honour 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 has come about since a quota favouring male admittance into medical school was lifted in 1991.
The trend is a step forward for women in Pakistan, but obstacles remain. Many women graduates do not 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 healthcare system.
At Dow Medical College in Karachi, the female students were adamant that they would work.
Standing in the school's courtyard as fellow students - almost all of them women - gathered between classes, Ayesha Sultan described why she wanted to become a doctor.
"I wanted to serve humanity, and I believe that I was born for this," said Ms 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 required that 80 per cent of the places at medical schools went to men and 20 per cent 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 per cent of Pakistan's medical students are women, said Dr Mirza Ali Azhar, the secretary general of the Pakistan Medical Association.
At medical schools in some deeply conservative areas of the country such as Baluchistan in the south-west and Khyber Pakhtunkhwa province in the north-west, men still outnumber women. But in Punjab and Sindh provinces, which turn out the vast bulk of medical graduates, the women dominate. At Dow, the student body is about 70 per cent women.
In comparison, about 47 per cent of medical students in the United States are women, according to the Association of American Medical Colleges.
Medical officials and students in Pakistan acknowledge that many women do not go on to practise medicine.
At Dow, for example, virtually all the male graduates go on to work as doctors, while it is estimated that only about half of the women do, said Dr Umar Farooq, the school's pro-vice chancellor. Nationwide figures on how many women graduates forgo actual practice do not exist, but despite years of increased women's enrolment, 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 children 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 enrol, many students and faculty members 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 does not 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 specialise 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 specialisation, they worried that it would take away from her future family life.
"They're like: 'No, but you'll take care of the house, won't you?'" Ms Ehsan said.
"You have to convince them," she said, adding that too many women were not prepared to push back against their families. "Sometimes girls give up too soon, I feel."
There are also cultural impediments. Women who do work often do not want to do so in rural areas far from their families or do not want night shifts, given the country's deteriorating law and order. Some male patients want to be treated only 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 enrolment, said admissions director Rana Qamar Masood. The boys could go on their own for long stretches. The girls also lobbied 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?" Ms Masood said. "These are the ground realities in our society."
Amid concerns over the number of doctors in the future, proposals are being touted to rebalance the student body. Ms 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 men-only medical schools. 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 attempts to get into Dow. "If we want the seats, we should study hard."
The debate here echoes the one in many western countries, 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 is a doctor, to know it is possible to pursue a career and have a family. Her mother took her postgraduate exams 15 days after giving birth to Midhat's sister.
"You have to be supermum, obviously," she said.