In 2002, the governor declared health to be one of the pillars of his plan for North Dakota. This declaration helped create groups to address health disparities.

A Disparities Work Group (DWG) was formed within the North Dakota Department of Health (NDDoH). Its mission was to "Provide leadership to raise the awareness of and to eliminate health disparities affecting North Dakota citizens." The vision statement was simply, "Health equity for all North Dakotans." For the definition of health disparities, the group agreed on a comprehensive statement that allows the inclusion of additional groups as they are identified.

"Health disparities in North Dakota are defined as inequalities in health status, utilization, or access due to structural, financial, personal, or cultural barriers. Population categories affected include, but are not limited to, those identified by gender, race or ethnicity, education or income, disability, geographic location, or sexual orientation."

Another effort that grew from the governor's interest in health was Healthy North Dakota (HND), which is a framework for individuals and organizations to support North Dakotans in their efforts to make healthy choices by focusing on wellness and prevention. An HND Health Disparities Committee (HDC) was formed to coordinate efforts addressing health disparities in North Dakota. This Committee was originally co-chaired by Dr. John Baird, Field State Medical Officer, and Dr. Leander "Russ" McDonald, University of North Dakota. Staff member Sherri Paxon, from NDDoH and a member of the DWG, served as the liaison between this committee and the state health department. Committee members represented many organizations, agencies, programs, and disparate groups from across North Dakota. NDDoH DWG members also participated in the HDC. In 2004, the NDDoH DWG was determined not to be a duplicative effort, so the group was officially absorbed into the HDC.

The HDC completed a Logic Model in May 2005, which maps the desired progress of addressing health disparities in North Dakota for seven to 10 years. A key objective in the logic model was to develop an office in the state department of health to concentrate on health equity issues. With this directive from the Committee, in 2006 an infrastructure building grant was obtained from the federal Office of Minority Health (OMH) to explore the feasibility of a state-level office addressing health disparity issues. Along with exploring an office targeting health disparities, the grant required the development of a basic state plan. Utilizing the Logic Model, along with NDDoH programmatic strategic plan sections on health disparities, a basic strategic plan was drafted.

The year 2006 was a year of change and growth for the HDC. At this time, Dr. McDonald stepped back from active participation in the group, due to employment and responsibility changes. Sherri Paxon and Dr. John Baird were named co-facilitators of the infrastructure building grant, were charged with leading efforts to establish an NDDoH health disparities office, and wrote the application for the "State Partnership Grant Program to Improve Minority Health" cooperative agreement from OMH. The HDC stayed true to the value of remaining an inclusive organization by expanding the definition of health disparities to include age and gender identity. The new definition is: "Health disparities in North Dakota are defined as inequalities in health status, utilization, or access due to structural, financial, personal, or cultural barriers. Population categories affected include, but are not limited to, those identified by gender or gender identity, age, race or ethnicity, education or income, disability, geographic location, or sexual orientation."

In 2007, the North Dakota Legislature approved 1.5 FTEs and spending authority for an Office for the Elimination of Health Disparities (OEHD). Dr. Terry Dwelle, NDDoH State Health Officer, authorized the creation of the office, beginning July 2, 2007. Dr. John Baird was designated Section Chief for the newly created Special Populations Section, which houses the OEHD and Children's Special Health Services (CSHS). Sherri Paxon, director of the Division of Chronic Disease, was named interim director for the OEHD. In May 2008, Phyllis Howard steep in as the Director for OEHD.

In August 2007, the NDDoH received a Notice of Award for the "State Partnership Grant Program to Improve Minority Health" cooperative agreement, which began Sept. 1, 2007. The search for a permanent OEHD director and administrative assistant should be completed in the spring of 2008. In December 2007, the HND HDC voted to change the name of the group to the Office for the Elimination of Health Disparities Work Group to better reflect current status and market the newly formed office. The OEHD Work Group remains a part of the Healthy North Dakota initiative.

North Dakota's population includes 5 percent American Indians (AI), who are the largest known disparate population in North Dakota. Initial emphasis on this population was the focus of the HND Disparities Committee (now known as the OEHD Work Group). Early initiatives targeted American Indian health disparities. The North Dakota Indian Affairs Commission and the North Dakota Department of Human Services Tribal Liaison participate in the OEHD Work Group and there are several AI members on the Work Group representing North Dakota tribes.

The Hispanic/Latino population in North Dakota makes up 1.2 percent of the total. During the summer growing and harvesting season, the eastern part of the state receives an influx of migrant workers, mainly of Hispanic/Latino ethnicity. The Asian population in North Dakota is very small, 0.6 percent; Native Hawaiians and other Pacific Islanders make up less than 0.5 percent. In North Dakota, African Americans make up only 0.6 percent of the population. In recent years, North Dakota has received around 500 refugee and 600 immigrant settlers annually. Cass County has one of the highest per capita ratios of resettled refugees in the country with approximately 20 different cultures represented. Language barriers are a significant issue in accessing health care. The largest groups of refugees are primarily Bosnian, Somali, Sudanese, and Kurdish. Another population targeted by the OEHD Work Group is North Dakotans over 65 years of age. An initial partnership has been established with the Aging Services Division with representation on the OEHD Work Group.

Prior to specific funding for minority health in the NDDoH, several active teams and initiatives began that continue to make progress:

• Data Workgroup gathered information for a racial and ethnic disparities burden section for the cooperative agreement application. The intent is to expand this document into an overview of the burden of health disparities in North Dakota.
  
  
• Strategy Workgroup developed an invitational packet to facilitate outreach to North Dakota reservations. This resulted in additional American Indian members participating on the OEHD Work Group and spawned the "Portraits of Health in North Dakota Indian Country Project."
  
  
• Portraits of Health in North Dakota Indian Country Project is a collection of photographs and stories relating health experiences of North Dakota American Indians. This collection is being shown throughout the state and was entered into the Congressional Record for the United States Senate during testimony on American Indian health issues. The display will be shown on two reservations and focus groups will be conducted to further capture the health needs of North Dakota's American Indians.
  
  
• Tribal State Public Health System Assessment was performed on the reservations and prompted one tribe to explore developing a primary preventive care model and comprehensive health board. The Wilson Health Planning Collaborative was recently awarded an $85,000 Rural Health Network Planning Grant to develop a comprehensive and integrated health system plan for an eight-county region in North Dakota that includes the Fort Berthold Reservation. Funding has been secured to build a brand new, state-of-the-art health care facility to serve native and non-native members of an expanded 11-county area.
  
  
• American Indian Community Health Representatives have met with a work group exploring ways to increase reimbursement for the valuable work they do on reservations. Meetings continue with the North Dakota Human Services Department and the Medicaid Division to brainstorm potential reimbursement possibilities.

Though cumulative efforts addressing health disparities are in the early stages in North Dakota, the impact is noteworthy. In a relatively short period of time, a small group of NDDoH staff concerned about health equity issues has grown into a formal, minimally-funded OEHD. The advantage to North Dakota communities and disparate populations lies in the fact there is now a centralized repository to document needs and to coordinate initiatives. Efforts toward increased reimbursement, recording and personalizing health disparities and advancements in comprehensive health care in various American Indian communities all impact native health and are an encouragement for additional initiatives. As NDDoH programs and statewide organizations continue to expand collaborations, there is opportunity for increasing impact on North Dakota communities through increasing health equity and reducing health disparities.

 

Year	Federal	State
FY 2006	$75,000	$0
FY 2007	$125,000	$0

In 2006, funding from the OMH Infrastructure Building Project, assisted in developing a basic state plan for addressing health disparities, for enlarging partnerships and collaborations, and for setting the stage to establish the North Dakota Office for the Elimination of Health Disparities. The award of a three-year cooperative agreement from OMH allows OEHD staffing as well as the opportunity to continue current efforts to reduce health disparities in North Dakota. A number of NDDoH programs devote resources for minority health issues; thus, the Office for the Elimination of Health Disparities and Work Group will capitalize on these pooled and in-kind contributions, while functioning as lead agency and clearinghouse for activities.

Prepared by National Association of State Offices of Minority Health (NASOMH)