In Search of Equity

Introduction

Though the world’s attention is currently focused on the global COVID-19 pandemic, the epidemic of health disparities has existed for centuries in this country. People and organizations that have dedicated their time, talent, and resources to addressing these issues have not fully been able to get a seat at the table of change until recently. Achieving equity in health cannot happen overnight. As with most ideals of systems change, equity takes deliberate awareness and undoing of policies and practices upon which many foundations have been built and from which many in power have benefited. When we discuss systems of unshared power, we dig deeper into the understanding of racism. For everyone to have good health or the opportunity for good health, systems must be set up to purposely achieve this goal. The perpetual narrative of unfair differences that prevent people from having good health has plagued historically marginalized populations for centuries, causing inequities that widen disparities in health and other areas in society.

In North Carolina, fighting for equity has long been a thread in the fabric of public health. In the 1970s, students at the University of North Carolina at Chapel Hill started a Black Student Caucus with the goal of addressing minority health and disparities, well before action on this issue was taken at the federal level. The work of the Black Student Caucus, later renamed the Minority Student Caucus, also helped usher in the creation of the Minority Health Conference, held annually during Black History Month to focus on the issues of minority health and health disparities. Many of those students, as well as student leaders from other schools including our historically black colleges and universities (HBCUs), went on to lead various international organizations focusing on achieving health equity and eliminating health disparities [1].

In the early 1980s, leaders from Black medical schools and other HBCUs presented a report entitled, Blacks and the Health Professions in the 1980s: A National Crisis and a Time for Action, to then-US Secretary of Health and Human Services Margaret Heckler [2]. The information and data presented in this report highlighted the shortage of Blacks in health professions and the growing health disparities in Black and minority populations, prompting Secretary Heckler to establish the task force on Black and Minority Health in 1984 with the goal of examining mortality and adverse health outcomes of Black Americans and other minorities in this country. The findings of the task force were released in the 1985 Report on the Secretary’s Task Force on Black and Minority Health, more widely known as the Heckler Report. The task force recommendations led to the creation of the National Office of Minority Health in 1986 [2].

The original impetus for creating an Office of Minority Health (OMH) within the North Carolina Department of Health and Human Services (NCDHHS) came from a 1987 report of the North Carolina State Center for Health Statistics that highlighted the disproportional morbidity and mortality experienced by minority populations. In response, the state health director established a Minority Health Work Group, charged with making recommendations for the public health system to better meet minority health needs. The final report included six recommendations for addressing minority health issues, including the establishment of an OMH to provide state-level and statewide coordination and collaboration of information, resources, and services on an ongoing basis [3].

In response to this report, the 1992 North Carolina General Assembly (NCGA) established the OMH and the Minority Health Advisory Council (MHAC) via public law H.B. 1340, part 24, sections 165-166. Through this legislation, North Carolina became one of the first states to establish a state OMH tasked with systematically addressing the health status gap between white and minority populations in the state. The primary task of the MHAC is to advise the governor and the secretary of NCDHHS on minority health issues. This 15-member council consists of state legislators, community leaders, and health and human service professionals. The OMH provides staff for the council, and the OMH executive director serves as chief consultant. Together with the MHAC, the OMH advocates for policies and programs that increase racial and ethnic minorities’ access to health and human health services. Its mission and vision are outlined here.

• Mission: To promote and advocate for the elimination of health disparities among all racial and ethnic minorities and other underserved populations in North Carolina.

• Vision: All North Carolinians will enjoy good health regardless of their race and ethnicity, disability or socioeconomic status [3].

In 2001, the OMH changed its name to the North Carolina Office of Minority Health and Health Disparities (NC OMHHD). The focus of the NC OMHHD is to reduce health disparities while promoting health equity strategies. NC OMHHD believes state, local, and community approaches to eliminating health disparities should be a unified effort aimed at increasing the capacity of communities and NCDHHS state and local programs to develop effective strategies and collaborative networks between communitybased organizations and other local public and private agencies.

Since 1992, the office has engaged faith-based organizations, local nonprofits, tribes, and other organizations to reduce health care access barriers and health disparities in communities across the state. To equip these organizations, NC OMHHD provides a range of capacity-building services including training, leadership and skills development, resource development, financial assistance, infrastructure development, consultations, and technical assistance. This approach has helped community-based organizations implement sound business practices, ensure fiscal accountability, write successful grants, influence local and state policies and legislation, and mobilize coalitions to address health disparities.

With the creation of various programs and initiatives, NC OMHHD has expanded its capacity to implement community-based programs and approaches to further reach minority and underserved populations. Recent examples include the Minority Diabetes Program, a statewide collaborative effort between local health departments, local health care providers, and community organizations across the state to prevent individuals from developing type 2 diabetes and related health issues; and the Culturally and Linguistically Appropriate Services (NC CLAS) Program, an initiative that provides free training and technical assistance to equip organizations with resources to address the changing demographics and health care needs of North Carolinians and eliminate the cultural and linguistic barriers that may lead to lower quality of care and increased health disparities [4].

These programs and initiatives helped to build the capacity of faith-based organizations, community-based organizations, American Indian tribal organizations, and local health departments to reduce disparities and improve the health of African American, Hispanic/Latino, and American Indian populations in the state. Past and current programs and initiatives have focused on areas based on the racial and ethnic disparities reports produced by the office in partnership with the State Center for Health Statistics and include infant mortality; HIV/AIDS and other sexually transmitted infections; cancer; homicides; and motor vehicle deaths. In 2018, an updated version of this report focused on health equity and included a new color-coded tracking system to better illustrate the impact of disparities we face in our state. This report received national attention and continues to highlight the systemic changes needed to move the needle to achieve the goal of health equity in our state [5].

At the state level, NC OMHHD leads the NCDHHS in implementing an integrated, comprehensive, and coordinated approach to identifying and reducing disparities in services, access, and health. In the past, plans like From Disparity to Parity in Health: Eliminating Health Disparities Call to Action have guided the work of the NCDHHS and its partners [6]. In addition to building capacity at the community and state levels, NC OMHHD has three other essential functions. The first is to produce research reports that present the data about health disparities in terms that a lay person can understand. These reports are used to educate a wide audience on the realities and specifics of health disparities. Secondly, the office provides culture and interpreter trainings to ensure that culturally appropriate communication, outreach, services, and materials are provided to our state’s diverse population. Lastly, NC OMHHD promotes legislation and policies to improve access to health services for racial/ethnic minorities [4].

In the beginning of the COVID-19 global pandemic, NCDHHS convened the Historically Marginalized Populations (HMP) Work Group, consisting of NCDHHS leadership and external partners, to ensure that members of these communities were not overlooked and were given the proper access to educational resources and supplies, culturally and linguistically appropriate services, and financial opportunities in response to the growing crisis. The vision of the HMP Work Group is to decrease disparities in the rates of COVID-19 infections and improve outcomes for historically marginalized populations for COVID-19 and beyond. The mission of the HMP Work Group is to protect historically marginalized populations from COVID-19 infection, complications when infected, and transmission to others by investing in and directing resources toward prevention and vaccination; testing; case investigation and contact tracing; wraparound services; behavioral health; and to ensure community-based organizations serving HMP have access to state resources to support their communities. HMP Work Group members have been embedded into program-level initiatives to create a feedback loop that ensures two-way conversations, input, feedback, and influence. The HMP Work Group approach is facilitated by NC OMHHD staff and co-led by the NC OMHHD executive director and the NCDHHS deputy secretary for health services.

The efforts toward health equity in North Carolina are also guided by the directives of the Governor’s Executive Order 143, which established the creation of the Andrea Harris Social, Economic, Environmental, and Health Equity Task Force to address the highlighted disparities in communities of color that are disproportionally impacted by COVID-19. The five major focus areas of the Andrea Harris Task Force include access to health care; economic opportunity and business development; educational opportunity; environmental justice and inclusion; and patient engagement [7]. The Governor’s Executive Order 143 specifies that the executive director of the NC OMHHD will serve on this task force to provide subject matter expertise around health equity strategies and approaches. Also highlighted in the Governor’s Executive Order 143 is the charge of NCDHHS to reevaluate and elevate the mission of NC OMHHD and request appropriate funding and resources to meet updated needs [7]. This level of support from the state and from NCDHHS leadership continues to allow the office to identify the most effective ways to provide support to communities across the state.

The importance of achieving equity in North Carolina has been amplified by state leadership, especially since the COVID-19 pandemic and its disproportionate outcomes among the state’s HMP. Even now as NCDHHS responds to the need for equity in the distribution of COVID-19 vaccines, we know that there are many issues that prevent communities with the most need from being able to access vaccines. These issues, many of which have been long identified in the state as contributing to health inequities, include such things as the “digital divide,” which exacerbates unequal access to vaccine providers and available appointments, unequal supply of vaccine providers in rural or low-income communities, and factors including vaccine hesitancy and mistrust among communities of color, especially in the early weeks and months of vaccine distribution. As we continue to provide equitable solutions, access, and resources to savelives, we all must work together as we continue to chip away at the very systemic barriers and policies that prevent us from achieving the goal of everyone having the opportunity to experience good health and well-being. Looking toward the future, NC OMHHD plans to continue its emphasis at the community and state levels by increasing efforts and resources to support capacity building and infrastructure development. NC OMHHD will continue to focus on performance and outcome measures for established programs while also implementing innovative approaches and strategies. The office provides leadership to ensure that issues of health disparities and inequities are recognized and integrated throughout NCDHHS programs and services in collaboration with community partners. The work of equity is ongoing and needed in all communities to ensure that no one is forgotten or left behind. NCMJ