A legendary figure of global health journalism, Laurie Garrett challenged a university audience this week with her insightful, incisive, and energizing lecture on the future of global health. The winner of the three prestigious “P” prizes—Pulitzer, Polk, and Peabody—was invited to Duke as a guest speaker to help launch the university’s Global Health Week. Those who have read her most recent online commentary, “Money or Die: A Watershed Moment for Global Public Health,” published earlier this month in Foreign Affairs, may have an idea of what her talk was about.

Garrett spoke about potential threats to global health which affect the sustainability of projects and the ambitious goals of reducing the burden of disease in the world. A major threat has been decreasing funding due to the global economic crisis, coupled with a shift in donor composition. Donor support for global health increased by 10% from 2002 to 2008 but dropped 4% in 2010, according to Garrett. All sources—from private donations, nongovernmental organizations (NGOs), and faith-based organizations to European contributions—have been affected.

The Bill & Melinda Gates Foundation is now responsible for 68% of total private funding for global health in the world while the United States government contributes 52% of all global health funding. The World Health Organization, in contrast, was the second biggest donor in the world in 1990 and the leader in the global efforts, had the same global health budget in 2010 as two decades ago, and in the current fiscal year faces a budget shortfall of one billion dollars. By comparison, the US government increased its funding from one to seven billion dollars during the same 20 years.

But it is not only the “end of the age of generosity” which threatens global health’s future, according to Garrett. The decreased funding and shift in donor composition must be seen in connection with increased dependency, lack of alignment, and lack of harmonization of aid. These black evils of the best intentions make much of the aid fragile, inefficient, and unsustainable. When 60,000 NGOs are dedicated to HIV eradication in Africa, and there are still 34 million HIV-infected people in the world, can we call this a success story? And, as Garrett asked, what happens with current health projects if the Gates Foundation decides to redirect the money to a different sphere?

I had the opportunity to ask Garrett if she sees any window of opportunity in this somewhat somber picture. She pointed to the important role of activists, calling for public pressure in order to increase the diversity of actors contributing to global health, which can enhance competition and decrease the hazards and risks resulting from donor dependency. She suggested that private donors increase their commitment, highlighting those donors who take advantage of natural resources from developing countries, while people seem to be hit forever by the resource curse, struggling with disease and poverty. Many private companies waving the flag of generosity and claiming to contribute to disease elimination actually invest much less than they could, and most of this money comes from their public relations budgets, Garret added.

There is one more crisis affecting the field of global health: an identity crisis. What exactly is global health? Who decides this? Is it the poor countries? Is it the academics? Is it the foundations? These are questions Laurie Garrett asked and that we all should ask ourselves. Let’s take this invitation and be aware of this “very sobering moment” for the field, as she said. Donating is easy. It’s much more difficult to make it effective and to change the way of doing it.