“Don’t read The House of God,” one of my professors told me in my first year of medical school.

He was talking about Samuel Shem’s 1978 novel about medical residency, an infamous book whose legacy still looms large in academic medicine. Shem — the pen name of psychiatrist Stephen Bergman — wrote it about his training at Harvard’s Beth Israel Hospital (which ultimately became Beth Israel Deaconess Medical Center) in Boston.

My professor told me not to read it, I imagine, because it’s a deeply cynical book and perhaps he hoped to preserve my idealism. Even though it has been more than 40 years since its publication, doctors today still debate whether it deserves its place in the canon of medical literature.

The novel follows Dr. Roy Basch, a fictional version of Shem, and his fellow residents during the first year of their medical training. They learn to deflect responsibility for challenging patients, put lies in their patients’ medical records and conduct romantic affairs with the nursing staff.

Basch’s friends even coin a term that is still in wide use in real hospitals today: Elderly patients with a long list of chronic conditions are still sometimes called “gomers,” which stands for “Get Out of My Emergency Room.”

Like any banned book, The House of God piqued my curiosity, and I finally read it this past year. I’m a family physician and a little over a year out of training, and I read it at the perfect time.

I got all the inside jokes about residency — and many were laugh-out-loud funny — but I am now far enough removed that the cynicism felt like satire rather than reality.

The House of God also felt dated. Basch and his cohort — who were, notably, all men, although not all white — didn’t have electronic medical records or hospital mergers to contend with. They wrote their notes about patients in paper charts. And it was almost quaint how much time the doctors spent chatting with patients in their hospital rooms.

It couldn’t be more different from my experience as a resident in the 21st century, which was deeply influenced by technology. There’s research to suggest that my cohort of medical residents spent about a third of our working hours looking at a computer — 112 of about 320 working hours a month.

In The House of God, set several decades before I set foot in a hospital, where were the smartphones? Where was the talk of RVUs — relative value units, a tool used by Medicare to pay for different medical services — or the push to squeeze more patients into each day?

That’s where Shem’s new book comes in. Man’s 4th Best Hospital is the fictional sequel to The House of God, and Basch and the gang are back together to fight against corporate medicine. This time the novel is set in a present-day academic medical center, and almost every doctor-patient interaction has been corrupted by greed and distracting technology.

Basch’s team has added a few more female physicians to its ranks, and together they battle a behemoth of an electronic medical record system. The hospital administrators in Shem’s latest book pressure the doctors to spend less time with every patient.

If The House of God is the great medical novel of the generation of physicians who came before me, perhaps Man’s 4th Best Hospital is the book for my cohort. It still has Shem’s zany brand of humor, but it also takes a hard look at forces that threaten the integrity of modern health care.

I spoke with Shem about Man’s 4th Best Hospital (which hit bookstores this week) and about his hopes for the future of medicine.

This interview has been edited for clarity and length.

The protagonist in Man’s 4th Best Hospital, Dr. Roy Basch, doesn’t have a smartphone. I hear you don’t either. Why not?

If I had a smartphone, I would not be able to write any other novels. I have a bit of an addictive personality. I’d just be in it all the time. … I’ve got a flip phone. You can text me, but it has to be in the form of a question. I have this alphabetical keyboard. You either get an “OK” or an “N-O.”

A big theme in the novel is that technology has the potential to undermine the doctor-patient relationship. What made you want to focus on this?

I got a call out of the blue five years ago from NYU medical school. They said, “Do you want to be a professor at NYU med?” And I said, “What? Why?” And they said, “We want you to teach.” When I first got there, because I had been out of medicine [and hadn’t practiced since 1994], I figured, “Oh, I’ll look into what’s going on.” And I spent a night at Bellevue.

On the one hand, it’s absolutely amazing what medicine can do now. I remember I had a patient in The House of God [in the 1970s] with multiple myeloma. And that was a death sentence. We came in; we did the biopsy. He was dead. He was going to be dead. And that was that. Now it’s curable.

At Bellevue, I saw the magnificence of modern medicine. But like someone from Mars coming in and looking at this fresh, I immediately grasped the issues of money and effects of screens — computers’ and smartphones’.

And it just blew me away. It blew me away: the grandeur of medicine now and the horrific things that are happening to people who are really, sincerely, with love, trying to practice it. They are crunched, by being at the mercy of the financially focused system and technology.

In Man’s 4th Best Hospital, there’s a fair amount of nostalgia for the “good old days” of medicine in the 1960s and 1970s, before electronic medical records. What was better in that era?

If you ask doctors of my generation, “Why did you go into medicine?” they say, “I love the work. I really want to do good for people. I’m respected in the community, and I’ll make enough money.” Now: … “I want to have a good lifestyle.” Because you can’t make a ton of money in medicine anymore. You don’t have the respect of your community anymore. They may not even know much about you in a community because of all these [hospital] consolidations.

Do you think anything in medicine has gotten better?

The danger of isolation and the danger of being in a hierarchical system — students now are protected a lot more from that. When I was in training, interns were just so incredibly exhausted that they started doing really stupid things to themselves and patients. The atmosphere of training, by and large in most specialties, is much better.

You wrote an essay in 2002 titled “Fiction as Resistance,” about the power of novels to help make political and cultural change. What kind of resistance today can help fix American health care?

When somebody falls down, up onstage at a theater, do you ever hear the call go out, “Is there an insurance executive in the house?” No. If there are no doctors practicing medicine, there’s no health care. Doctors have to do something they have almost never done: They have to stick together. We have to stick together for what we want, in terms of the kind of health care we want to deliver, and to free ourselves from this computer mess that is driving everybody crazy, literally crazy.

Doctors don’t have a great track record of political activism, and only about half of physicians voted in recent general elections. What do you think might inspire more doctors to speak out?

Look at the difference between nurses and doctors. Nurses have great unions, powerful unions. They almost always win.

Doctors have never, ever formed anything like what the nurses have in terms of groups or unions. And that’s a big problem. So doctors somehow have to find a way — and under pressure, we might — to stick together. Doctors have to make an alliance with nurses, and other health care workers, and patients. That’s a solid group of people representing themselves in terms of what we think is good health care.

The profession we love has been taken over, with us sitting there in front of screens all day, doing data entry in a computer factory.

Health care is a big issue for the upcoming election. What kind of changes are you hoping we’ll see?

There will be some kind of national health care system within five years. … You know, America thinks it has to invent things all over again all the time. Look at Australia. Look at France. Look at Canada. They have national systems, and they also have private insurance. Don’t get rid of insurance.

The two biggest subjects for the election are health care and health care. … The bad news is, it’s really hard to get done. The good news is, I think it’s inevitable. The good news is, it’s so bad it can’t go on.

One of the major criticisms of The House of God is that it’s sexist. It seems like your hero, Dr. Basch, has gotten a little more enlightened by the time of Man’s 4th Best Hospital. Does this reflect a change you’ve also experienced personally?

I was roundly criticized for the way women were seen in The House of God.

I remember the first rotation I had as a medical student at Harvard med was at Beth Israel, doing surgery. It got to be late at night, and I was trailing the surgeon around, and he went into the on-call room. There was a bunk bed there, and he started getting ready to go to bed. And I said, “Well, I’ll take the top bunk.” And he said, “You can’t sleep here.” So I left, and in walked a nurse. I was shocked.

Things have changed, and I am very, very glad. I don’t know if it seems conscious — I was very pleased to have total gender equity in the Fat Man Clinic [where the characters in Man’s 4th Best Hospital work] by the end of the book.

What made you feel like it was time to update The House of God?

I write to point out injustice as I see it, to resist injustice, and the danger of isolation, and the healing power of good connection. … We can help our patients to get better — but nobody has time to make the human connection to go along with getting them better.

Mara Gordon is a family physician in Camden, N.J., and a contributor to NPR. You can follow her on Twitter: @MaraGordonMD.

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You’d think that as a poor country grows wealthier, more of its children would get vaccinated for preventable diseases such as polio, measles and pneumonia.

But a review published in Nature this month offers a different perspective.

“The countries that are really poor get a lot of support for the vaccinations. The countries that are really rich can afford to pay for the vaccines anyway,” says Beate Kampmann, director of the Vaccine Centre at the London School of Hygiene & Tropical Medicine and author of the review.

But, she says, “the middle-income countries are in a tricky situation because they don’t qualify for support, yet they don’t necessarily have the financial resources and stability to purchase the vaccines.”

Adrien de Chaisemartin, director of strategy and performance at Gavi, the Vaccine Alliance, agrees: “More and more vulnerable populations live in middle-income countries.” Gavi, an international nonprofit that helps buy and distribute vaccines, projects that 70% of the world’s under-immunized children will live in middle-income countries by 2030.

Brazil, India, Indonesia and Nigeria were among the 10 countries with the most children who lacked basic vaccinations in 2018 — for example, shots to prevent diphtheria, tetanus and pertussis by age 1. Each of those countries meets the World Bank’s definition of a middle-income country: an average annual income (known as the gross national income, or GNI, per capita) between $1,026 and $12,375. In Nigeria alone, 3 million kids are undervaccinated. That’s 15% of the world’s total of children who lack key vaccinations.

By contrast, vaccination rates can be high in poor countries, according to global health researchers, who say that Gavi has boosted the numbers. Rwanda, for instance, despite having a GNI of $780 per person, now has a near-universal coverage rate for childhood vaccines, on par with some of the wealthiest countries.

But in general, once a country reaches a GNI per capita threshold over $1,580 for three years, support from Gavi tapers off. And despite their improved fortunes, countries don’t always choose to fund childhood vaccines.

Angola is among the middle-income countries with the lowest vaccination rates. Diamonds and oil have helped propel the country out of low-income status, and its president is a billionaire. Yet an estimated 30% to 40% of children there did not receive basic vaccines in 2018.

The lag in vaccination rates is caused by any number of reasons. “There’s a whole list of middle-income countries, and they’re not all the same,” says Kampmann.

For example, Sam Agbo, former chief of child survival and development for UNICEF Angola, says Angola’s leadership does not fully fund immunization programs. Agbo blames a political system that he says is mired in corruption, financial mismanagement and lots of debt. So it’s hard to increase the health care budget. “Primary health care is not sexy,” he says. “People are interested in building hospitals and specialized centers rather than investing in preventive care.”

Gavi’s de Chaisemartin groups Angola with other resource-rich but corruption-plagued countries like the Democratic Republic of Congo, Nigeria, Papua New Guinea and East Timor. “These are countries where the GNI is relatively high because of their oil resources, for the most part, but that doesn’t translate into a stronger health system,” says de Chaisemartin.

Then there’s the matter of cost. Countries that buy vaccines on the open market might pay over $100 a shot.

Public attitudes also play a role. In Brazil, which is on the high end of the middle-income spectrum, an immunization program that once outperformed World Health Organization recommendations has been declining for three years. Jorge Kalil Filho, an immunology professor at the University of Sao Paulo, says public inattention and anti-vaccine campaigns, popular on social media, are undermining progress.

De Chaisemartin says the global health community needs to adjust to an unprecedented global economic shift. “Fifteen years ago, the world was divided between poor countries, where most poor people were living, and high-income countries,” says de Chaisemartin. “Now you have a lot of middle-income countries with very poor and vulnerable populations.”

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Dr. Kimberly Sue is the medical director of the Harm Reduction Coalition, a national advocacy group that works to change U.S. policies and attitudes about the treatment of drug users. She’s also a Harvard-trained anthropologist and a physician at the Rikers Island jail system in New York.

Sue thinks it’s a huge mistake to put people with drug use disorder behind bars.

“Incarceration is not an effective social policy,” she says. “It’s not an evidence-based policy. It’s not effective in deterring crime. But we continue to rely on it for reasons that have to do with morality.”

While a quarter or more of the U.S. prison population has an addiction to opioids, only 5% of those individuals receive medication for their chronic condition, Sue notes, despite the growing agreement among doctors that this approach to treatment saves lives.

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In addition to her Rikers Island work with incarcerated women, Dr. Kimberly Sue is medical director of the Harm Reduction Coalition, an advocacy group that works to change U.S. policies and attitudes toward syringe exchanges and other evidence-based approaches to treating drug addiction.

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Statistics suggest that women might benefit most from improvements in treatment, she says. The rate of death from prescription opioid overdose has gone up nearly 500% among women since 1999, compared with 200% among men. And in recent decades, women’s rate of incarceration has grown at twice the rate of men’s.

We spoke with Sue about her new book, Getting Wrecked: Women, Incarceration, and the American Opioid Crisis, which is based on firsthand accounts from female inmates she has treated.

This interview has been edited for clarity and length.

What are some of the arguments that jail is not the best public health solution to opioid use?

Incarceration in many cases harms people. We know that, for example, having been in solitary confinement increases your risk of death after release — like in the case of Kalief Browder, a young Bronx man who killed himself after three years at Rikers.

And the rate of opioid overdose in the first two weeks after people leave prison and jail is between 30 and 120 times higher than the general population.

In most of the county-level jails in this country, people are forced to withdraw off lifesaving, stabilizing medications [like methadone] against their will. Methadone is a treatment for opioid use disorder that you cannot access in jails in many places in this country.

There are documented cases of suicide around the country — including in my book — of people who are going through withdrawal in jails and either committing suicide or dying as a combination of medical neglect and loss of body fluids related to dehydration.

Can you describe that example from your book?

One of the women I took care of and interviewed at MCI-Framingham, a women’s state prison in Massachusetts, was in the health services unit — where they send people when they’re first coming in — and she heard someone withdrawing from methadone. That person was screaming — she was, you know, in agony. And then [my patient] stopped hearing her screaming. [My patient and other prisoners] tried to get the guards’ attention. And they found out that she had hung herself.

People going through withdrawal in jail health facilities — it’s not the same as being an inpatient in my hospital, with nurses monitoring you and someone with medical training taking care of you. These are cinder block cells where people are going through diarrhea, vomiting, sweats, muscle aches. And many jails around the country are getting lawsuits that are being settled for situations like this.

People in the commercial jail and prison system believe that what they do is the best way, but it’s not the equivalent of the standard of care that we offer in the community.

How do jails and prisons explain not having methadone available, if that endangers lives?

And liquid methadone costs pennies. It’s not a matter of cost — it’s a matter of political will.

The way I like to describe it is, if your brother had a heart attack and then became incarcerated, we would continue all six of the lifesaving medications he was prescribed, no matter what the cost — even hundreds of thousands of dollars a year. But if he had an opioid overdose and became incarcerated, they’d just stop the medication he was prescribed for opioid use disorder — they just wouldn’t give it to him.

In no other chronic health condition do we discriminate like this. There’s such a stigma that’s encoded into our policies.

You write about that in your book: “The crisis we face is not opioids. The crisis we face is a war on people who use drugs, and on our reliance on incarceration as a catch-all policy solution.”

Yes. And it’s not just opioids. As a doctor who takes care of people who use drugs, I don’t have a problem with people who use drugs. But there are so many people in this country who really hate them and don’t care if they die. Or don’t care if they are able to have lives of dignity and respect.

Is that because of stigma getting in the way? The idea that if you do drugs, you deserve whatever happens to you?

Yeah. The idea that substance use is a disease of the will is very heavily entrenched in American ideology. We have a hatred of people who are dependent on anything — including the government — for support. The idea of people being on welfare, the idea of people not working. We have these very strong puritanical roots and the idea that we make our bed, we lie in it, and you pull yourself up by your own bootstraps. It pits people against each other in a way.

People who use drugs — they have a physical dependence on a substance. It doesn’t necessarily mean that they’re bad people, but our society tells them that they’re bad people.

Notice that I don’t call substance use disorder a disease. It’s really much more complex than that. I don’t want it to be all medicalized, because so much of the answer is not in medicine. If you think about getting addicted to heroin or pills in West Virginia, a lot of it might have to do with poverty. As a doctor, so much of what I’d like to be able to do for you is to give you a job, you know? To give you an education and more opportunities. I’d like to give you a prescription for housing.

How does all this more specifically impact women?

For as long as we’ve been a country, women have been criminalized — not only for substance use, but for disorderly housekeeping, for leaving marriages, for abortion, for lewd behavior. Women have been criminalized basically for being seen as deviating from a certain upper-middle-class white morality.

Because women have the potential to be pregnant or are often mothers, there’s this added moralizing directed at women who use drugs. There have been laws, for example, that send women to jail for twice as long as they would sentence men for drinking in public, because of the idea that women had farther to fall.

Some of the women in my book were low-level drug dealers. And they didn’t have anything to give prosecutors, so they would get thrown under the bus by the men who were much higher up who had more information. So they would take the rap.

The rate of incarceration of women is still relatively small compared to that of men, but it’s gone up 840% over the past 40 years.

Other countries don’t do this. Portugal is held up as one of those models.

What is different in Portugal?

Portugal has decriminalized drug use. So if someone has problematic substance use, they don’t go to prison or jail for that.

So, is there no stigma associated with drug use there?

I just listened to a podcast episode by this guy who went around Portugal and asked people, “How does your society feel about people who use drugs?” And the people he interviewed were like, “They’re just people struggling. It’s not their problem — it’s a social problem.”

Basically, substance use is treated like a social condition, and all of the services that an individual would need get wrapped around it. They have mobile vans to bring methadone to where you’re living. Their system shows that it doesn’t have to be the way we do it in the U.S.

After Portugal decriminalized drug use, overdose deaths decreased by 80% and HIV rates went from 52% to 6%. It’s not a perfect model, but it’s so much better.

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