The year is 2029. Alarmed by the evidence that most of the break-throughs in biomedical science are coming from Asia and Europe, the newly inaugurated President of the United States asks the National Academy of Sciences (NAS) to help the nation understand how we lost our preeminent leadership position.

The concern was not merely academic, not just the fact that Americans were now only occasionally seen in the ranks of awardees of Nobel Prizes and constituted fewer and fewer of the authors of articles in the very top scientific journals. Instead, the public’s concern was mostly economic: several new blockbuster pharmaceuticals were coming onto the market each year, highly successful treatments for several kinds of cancer, diabetes, Parkinson’s disease, and schizophrenia. Most were invented, patented, tested, and manufactured in Asia and Europe; none in the United States. Essentially all of the economic stimuli created by these drugs—including all of the jobs—had been unintentionally “outsourced.” Worse yet, a country that had developed powerful antiviral compounds to treat the last two pandemic bird flu viruses was on rocky political terms with the United States and had refused shipments of the drugs; a vigorous black market had developed, but there was no legal supply.

It was not difficult for the NAS Committee in 2029 to trace the root causes of the U.S. fall from preeminence in biomedical science. American college students had always paid close attention to what their peers had to say: The stories of a decade-long post-baccalaureate training period characterized by long hours and low pay were discouraging enough, but when coupled with the slim chance of advancing to an independent re-