The annual Gates Letter has been a must-read for global health experts for years, and as a global health professional with 25 years in the field, it’s one I look forward to. But this year, I think it missed the mark.

In years past, it has offered a reflection on efforts in global health, domestic efforts for public education, climate change, and other key areas. In each letter, the Gates usually offer a unique perspective, optimism and vision for a better world, while sharing ideas for transformative action. The contents of the Gates Letters have tracked closely with their titles, from ‘Why We Swing for the Fences’ to ‘We Didn’t See This Coming’.

2020 was an unprecedented year for public health. Commensurate with this, it was imperative that this year’s Gates Letter met the need for a bold global health vision. But it failed to provide the much-needed leadership we’ve seen in the past.

This year’s letter is titled ‘The Year Global Health Went Local’. In it, Bill and Melinda Gates explain how the term “global health” has historically been used by rich countries to refer to people’s health in poor countries, but the COVID-19 virus has turned this idea upside down. By moving fast and furiously across geographies, the virus has effectively collapsed the artificial distinctions and borders between the rich and poor countries.

These are all sound thoughts. However, the letter stops short of diving into the topics that first come to mind when we read ‘local’ and ‘global health’ in the title. And in comparison with years past, it is missing the call for bold action steps from communities.

3 Things I Wished the Letter Had Said

First, I wish it had said that the systemic breakdowns that we highlight in global health and other countries are similar to the ones we face locally. 2020 brought all nations, rich and poor, to the same public health level playing field. We saw first-hand how global health went local in the face of addressing COVID-19. In wealthy countries like the United States, we experienced the same risks and challenges as we have witnessed in poor nations in recent years as they’ve fought diseases such as malaria or Ebola.

These challenges include the disconnect between federal and state government actions, shortages of health care workers, the rationing of medical equipment, insufficient data systems, difficulty in reaching marginalized populations, lack of trust and access to care, vaccine hesitancy, mismatched public health messaging, discrepancies in medical information systems, the interface of science and politics playing out amidst a public health emergency, and all in the background of the highest number of COVID-19 deaths recorded in any country.

Global health went local, and despite it, the Gates didn’t offer a clear vision of action or path forward for overcoming these massive challenges.

Second, I wished the Gates Letter had discussed the challenges in equity with the COVID-19 vaccine roll-out and potential solutions to this global issue. For the past 20 years, the Gates have been champions of vaccines and immunisations, helping to introduce new and underutilised vaccines globally, leading R&D efforts, financing global health causes among other leadership efforts.

The COVID-19 vaccine rollout is riddled with inequities. The rich countries have bought 60 per cent of the world’s vaccine supply and aim to vaccinate 70 per cent of their adult populations in next few months, while poor countries will receive vaccines to cover a mere 20 per cent of their population over the course of the year. Inequities will be created at a massive scale in access, timing, type, and coverage. This in itself will create a new order of global health insecurity and instability, both globally and locally, for years to come. The Gates letter is silent on this topic.

Third, I wished the Gates Letter had acknowledged how the implementation of global health programs lies at the local level with each individual, community, district, and county, and if we work collectively we can make progress. This would amplify government emphasis of local partners in development. This doesn’t mean that international partners such as Palladium are not essential in global health. On the contrary, it is their partnerships with local partners that will help achieve the goals.

Finally, more than anything, I wish the Gates Letter had claimed its rightful place as a leader in the international health architecture, with their big, bold ideas, their unifying vision, and their motivating, inspiring, and actionable steps to save lives and build a better tomorrow.

2020 was a year unlike any other in the last century. It led to awareness in nearly every human on the planet of the importance of global health. But if we’re to harness that awareness and continue to build a better future, the Gates, as major players in the global health space, must seize the opportunity and maintain their visionary leadership in the realm of public health.

Rochika G. Chaudhry, MA, MPH is Director of Palladium's Health System Innovations. For more information, contact info@thepalladiumgroup.com.