It's also true that events in the larger world have upset the confident expectations for continuously improved health. Smallpox has been banished forever, but the appearance of Legionnaire's Disease, Lyme Disease, and particularly AIDS reminds us that new illnesses have always arisen throughout human history. During this past quarter century, we have come to know even more horrific pathogens, such as Eboli virus, which fortunately have not taken hold in Western societies. But the threat remains.

Skyrocketing medical costs were an issue in the late 1960s, as they are today, although our concern about expenditures in that era now seems quaint. Back then, the United States spent 6 percent of our GDP on health care-about 50 billion dollars annually. I predicted that figure would reach more than 100 billion by 1975. (In fact, it was 132 billion in that year.)

But no one back in 1969 would have foreseen the present astronomical level of expenditure: more than 800 billion dollars a year on health, more than 14 percent of our GDP, with no end in spending growth in sight. The reason was that, back then, nearly everyone imagined that the country would have long since moved to a national health plan, if only to contain costs. Our failure to do so has produced all sorts of unhappy consequences for our nation, ranging from diminished global economic competitiveness to new individual fears in the workplace. Half of all personal bankruptcies in America now result from health costs, and the need to maintain insurance coverage has transformed the work decisions of all Americans, greatly diminishing our once-prized personal mobility.

When I wrote Five Patients, a room at the Massachusetts General Hospital cost $70 a day. Now it costs more than $700. The hospital's annual operating budget was then $35 million a year. Now it is $732 million, far exceeding the rate of inflation for that period.