Permission unnecessary: Studying medicine outside the west

While the last century witnessed a march toward gender equality in the United States, the same was not true everywhere in the world. In some countries, traditional patriarchal cultures make it difficult for women to finish high school, let alone study medicine, while in the Scandinavian countries, societal support for women coincides with an even higher proportion of women doctors than exists in the United States. According to data from the Kaiser Family Foundation, as of October 2017, 34 percent of American doctors were women. Yet the relationship between a society’s overall gender equality and the proportion of its doctors who are women is not as straightforward as one might expect. In patriarchal countries like Japan, for example, strong records on women’s rights exist alongside low numbers of women doctors, while in Russia, more than half the doctors are women, but the way that came to be is not a tale of gender equality but rather the opposite.

“These are very complex constructs,” says University of Michigan professor Reshma Jagsi, MD, DPhil, director of the university’s Center for Bioethics and Social Sciences in Medicine. In a 2014 study, Jagsi and colleagues examined the factors that influence women’s participation in medicine in countries with differing proportions of women doctors, according to data from the Organization for Economic Cooperation and Development, as well as different scores on the Gender Inequality Index (GII), a United Nations Development Program measure, in which a higher score indicates greater inequality. “Certainly, when you see a dramatic minority of women in the physician workforce, you might speculate that there are broader issues relating to gender and equity that are causally important,” Jagsi says. “But simply because you see women in the majority or representing half of the workforce does not necessarily mean that the culture is egalitarian.”

Despite the challenges they face, women all over the world are becoming doctors. Some of the best choose to study at Yale.

For instance, first-year medical student Ya Haddy Sallah, MPH, is from Gambia, which suffers from persistent gender inequality. Such harmful practices as female genital mutilation and child marriage persist in the West African nation, and on a list of 156 countries ordered from lowest to highest inequality according to the GII 2015, it ranked 146. Perhaps not surprisingly, Gambia’s patriarchal culture makes it difficult for women to succeed in medicine. Sallah does not remember seeing a single woman doctor while growing up. Her parents valued education and sent her to high school, but many of her peers did not have such opportunities. Gambian girls and boys are treated differently from the beginning, Sallah says. “Girls are expected to do chores in the home, help take care of the younger siblings, while boys have more liberty to play and do other things” and are more likely to be encouraged in school, she says. “I know that in many schools girls dropped out at an early age because their parents thought it was more important to pay for their sons to get an education than it was to pay for their daughters.” In the early 2000s, in an effort to correct the gender disparity in education, the government made secondary school free for girls. But even with free tuition, parents still have to pay for textbooks and uniforms, Sallah notes. And cost is not the only barrier to education. In many families, Sallah says, school is considered less important than meeting traditional social obligations: marriage and childbirth; taking care of the home; working. “The pressure to support the family starts very young for Gambian women,” she says.

This is not to portray Gambian women as victims. Sallah takes care to stress that the resilience of older women from her community helped inspired her career. “I knew that medicine was still a possibility for me because I had seen strong women achieve a lot, despite all the strain that was put on them,” she says.

A template for equality

In other parts of the world, medicine is more gender-neutral or even female-dominated. In Sweden, Finland, and Norway, 40 to 60 percent of doctors are women. This figure likely reflects their societies’ overall emphasis on gender equality—according to the GII, they are among the 10 countries with the lowest gender inequality worldwide, ahead of the United States, which ranks 43 in the hierarchy—as well as such policies as state-sponsored day care that support working mothers.

In Russia, women have consistently been around 70 percent of doctors since the 1950s. This is a statistic with which fifth-year medical student Evgeniya Tyrtova, raised in southern Siberia, is familiar. Having studied in the United States since her senior year of high school, however, Tyrtova finds it hard to gauge how true the statistic is to her own life.

Growing up, Tyrtova never felt as if boys had more opportunities than she did. “Personally, I have never witnessed any kind of gender disparities,” she says. “I believe that the concept of gender equality may stem from the USSR's tradition. In the USSR, equality was cherished in all areas of life, including the workplace.” After the Soviet Union fell in 1991, she says, that view persisted.

After graduating from Fairleigh Dickinson University with a degree in nursing, Tyrtova returned to Russia for several months. She spent five months shadowing a urological oncologist at a hospital. In Russia, as in the United States, surgery is a male-dominated specialty, and of the six or seven physicians in the department, she says, two were women. “But I did not notice that they were treated differently from their male colleagues,” she adds.

According to Jagsi, the rise of women doctors in Russia was more complicated than the simplistic explanation that women were treated equally to men in the USSR. The growth in the proportion of women doctors in Russia followed the deprofessionalization (or proletarianization) of medicine under Soviet rule, when doctors became state employees and medical societies were abolished. Under Soviet rule, the most prestigious and best-paid jobs were in industry. Medicine lost much of its social cachet and became one of the most poorly paid professions. Because of that, Jagsi doubts that the high number of women practicing medicine in former Soviet republics is indicative of a true move toward gender equality. “It may actually speak to a decrease in the power and prestige of the medical profession,” she says. Perhaps, then, the rise of women doctors in Russia is a case of the right outcome proceeding from the wrong reasons.

To further complicate the narrative of female ascendance, increasing the share of women doctors is only the first step toward gender equality in medicine. Even in countries with high proportions of women doctors, such as Norway, Sweden, and Russia, gender disparities remain at leadership levels. There’s also a dearth of women leaders in academic medicine in Kenya and Uganda, where Christine Ngaruiya, MD, MSc, DTMH, assistant professor of emergency medicine at Yale, travels regularly to mentor doctors. It’s important that women have female role models to show them what’s possible professionally, she says. In many universities she’s visited across Africa, young doctors “may not have as many visible mentors to aspire toward because there just aren’t as many women in these positions.” Furthermore, the few women who are in positions of authority are often so busy with clinical work that they have little time for mentorship.

At the same time, Ngaruiya sees evidence that times are changing. For example, she says, the Kenya Medical Association now has its first woman chairperson, Jacqueline Kitulu, MD, MBA. “There are more women that are being afforded the opportunity to pursue higher levels of education, who are more present,” Ngaruiya notes. “And so as a result there’s a movement from them because there’s now, sort of, a quorum.”