Rethinking global health through ruinous solidarity

In order to truly decolonize the field of global health, it may be necessary for institutions from the Global North to practice "ruinous solidarity," according to a study published May 21, 2025 in the open-access journal PLOS Global Public Health by Daniel Krugman from Brown University, United States, and Alice Bayingana from the University of Sydney, Australia.

Even as scholarship related to decolonizing global health advances, global health institutions from the Global North still largely dominate the field via a "soft money" structure (funded by repeatedly winning grants from donors). This financial dominancy in turn bolsters the ideological power of these Northern institutions in the global health field. Here, Krugman and Bayingana describe ideological and financial structures at a major school of public health in the United States to better understand their makeup and influence.

The authors interviewed 30 faculty members from a school of public health (which remains anonymous to protect their confidentiality). Though most participants supported the overall idea of shifting power to institutions based in the Global South, they expressed contradictory feelings about how that shift would be operationalized. This was primarily present in discussions focused on funding for global health programs and research, as a shift away from funding institutions based in higher-income countries would threaten the researchers' own livelihoods and possibilities for career advancement. The "soft money" systems that fuel most universities' research departments, in which researchers compete for limited grants to fund their own salaries in addition to the research being conducted, reinforces the current entrenched system. Most of the faculty using grants to cover their salary participated in multiple projects adding up to a full salary, with one tenured professor describing themself and other scholars as "…this person who goes out and hunts for grants. If you get them, you survive. And if you don't, you don't." Many faculty described this situation as distracting from the goal of impacting the partner countries they worked with and causing burnout. Others noted how when grant donors changed priorities around countries they were willing to support, this forced them to shutter projects or let down long-term partners due to a lack of funding. However, when discussing hypothetically removing this soft power grant structure and shifting funding directly to the Global South, most participants also expressed anxiety about how this would negatively impact their own livelihoods.

Krugman and Bayingana suggest that for transformation of the global health field to succeed, Northern researchers and institutions must be willing to accept the possibility of losing substantial institutional and personal resources ("ruinous solidarity"), particularly now when science funding in the United States is being cut.

The authors add: "Our qualitative anthropological and linguistic study reveals how inequity in global public health research is reproduced by the 'soft-money' financial structures common across North American schools of public health. Through our interviews with global health faculty at one of these top institutions, we found how having to chase and procure outside grants not only causes them high stress and dismay that their research has less impact than it should, but also blocks changes they want to see. Because American universities need the overhead of soft money grants to stay financially afloat, the incentive to truly redistribute power and opportunity to Global South partners is antithetical to their bottom line. In conversations about decolonizing global health that have grown over the past decade, material systems, not just symbolic power, must be centered. Without real action on the part of elite Northern global health actors to demand their institutions to restructure their financial system--an act that may hurt their jobs and livelihoods--power will stubbornly reproduce through the continued dominance of Northern-grant winning to fund their jobs and their institutions."