THE CAROLINA JOURNAL OF PHARMACY THE CAROLINA JOURNAL OF PHARMACY 5

THE CAROLINA JOURNAL OF PHARMACY THE CAROLINA JOURNAL OF PHARMACY

PHARMACY IN THE PUBLIC HEALTH ARENA

By Steven R Moore, M.P.H., F.R.S.H.

Food and Drug Administration

Rockville, MD 20857

and

Assistant Professor

Howard University School of Pharmacy

Washington, D.C. 20059

Note: The views in this paper are solely those of the author

The nature of public health pharmacy in the United States is, at best, an ill-defined entity. It is essentially the practice of pharmacy within the area of public health. The Milbank Memorial Fund Commission defined public health as, "The effort organized by society to protect, promote, and restore the people’s health. The programs, services and institutions involved emphasize the prevention of disease and the health needs of the population as a whole." Certainly this definition could include just about anything remotely involved with pharmacy, and some individuals assume this to be the case.

Several individuals and groups have sought to provide a clearer definition of public health pharmacy by describing activities that pharmacists undertake in their practice. Spencer included the following activities: 1) having knowledge of disease patterns prevalent in neighborhoods, 2) reporting of accidental poisonings, 3) referral of patients to physicians, 4) monitoring of communicable disease patterns, 5) assistance to international travelers on medications, 6) supporting chronic disease prevention, 7) participating in community health education programs, 8) participating in health planning activities, 9) becoming acquainted with local public health department and personnel, 10) participating in family planning activities, 11) becoming acquainted with local organizations helping people lose weight, 12) becoming alert to environmental conditions prevailing in the community, 13) detecting potential suicides and seeking appropriate aid, 14) advising local agencies about drug and alcohol abuse, and, 15) participating in public health research.²

Bush and Johnson divided public health activities by pharmacists into two levels, the micro and macro. On the micro level, primary prevention activities such as patient education, patient counseling, screening and referral were mentioned. On the macro level, activities included identifying community health problems, setting health priorities, formulating policy, management and administration, community education, interaction with community service programs and, research and evaluation activities.

Milne and Johnson provided specific activities for the pharmacist within the public health agency. The first group of activities involved "provider" roles such as community policy and planning of drug services. The second group of activities involved "consumer" outreach such as poison control, rational drug selection assistance, and reducing access barriers. The third group of activities involved "environmental" efforts such as interrupting self destructive drug use, and controlling drugs and chemicals in the environment. The fourth group of activities involved "health care delivery" activities such as intra-agency drug system efficiency, coordination with private sector drug systems, and interagency cooperation on drug delivery systems.

In 1980, the American Public Health Association adopted a position paper, "The Role of the Pharmacist in Public Health."⁶The paper described the public health arena and pharmacist activities. Included in these activities were 1) participation in health planning activities, 2) involvement in personal health services delivery, 3) counseling, educating and screening patients, 4) participation in the legislative and regulatory processes, and 5) encouragement of formal educational training in public health.

Given the diversity of the views on the activities that relate to public health pharmacy, there are two interesting components that appear. First is the location. The activities must be located within the public arena. This arena may be the community pharmacy, the Public Health ambulatory clinic, the health department, a public facility (such as a hospital), the government hearing room or the public agency office. Under optimal conditions, this location is free from physical, financial, or legislative barriers that would hinder access and its activities are well known and understood by its recipient population.

The second component to public health pharmacy is the nature of the activities. One set of criteria suggested four benchmarks for appraising the nature of the activities. First, the activity should be perceived as suitable to the individual, yet conducive to the entire health system. Second, the activity should be involved in linkages of the local and referable health system. Third, the activity should provide adequate and appropriate services in the most economical fashion to the health system. Fourth, the activity involves active participation by the individual in the public health area.

Using the interlinkages of the activity and location components, it is easy to see that some pharmacists in community pharmacies may be involved in far more public health activities than are comparable pharmacists employed in public facilities who are doing little but perfunctory dispensing activities.

The state of public health pharmacy in the United States is somewhat unclear. In the private sector, activities such as patient counseling, patient education and screening are often viewed as peripheral activities that are provided only when resources allow. The activities do not produce revenue and are to cut back when in competition with other revenue producing activities. Even when undertaken, the activities are, often ill planned and without support linkages to other facilities that may be needed. Hopefully this is changing and future standards of pharmacy practice will dictate more involvement in this area.

Unfortunately, many of the pharmacists in the public sector have little more effectiveness. Though hired and maintained as public employees, they often have no training, little sensitivity and little motivation to get involved in public health activities. They remain private health practitioners in public health clothing One of the reasons that this has occurred are the archaic standards by which pharmacists are classified under the federal personnel system. The qualification standards and position classification Standards of the office of Personnel Management for pharmacists were last upgraded in February-March of 1968. They recognize traditional pharmacy functions of hospital pharmacists. Growth in the series is generated from staff pharmacists, to pharmacist-in-charge, to chief pharmacist. Elements that reward or even recognize training experience or competency in public health are absent. Even the clinical functions of these levels are defined as "the selection, compounding, dispensing and preservation of drugs, medicines, and other therapeutic agents."¹

Thus, pharmacists now are involved in many different areas of the Federal Government, but seldom remain classified as a the guidelines that are Federal Government, and used as models by other government activities, it is little wonder that state and local governments pigeonhole pharmacists in the same way.

The current situation in public health pharmacy in the United States is the result of several interacting factors. First, the schools of pharmacy have little real expertise or faculty depth in public health. Little course work is devoted to public health and even when it is offered, faculty expertise in public health is rudimentary. One researcher found little consensus in schools of pharmacy on the nature of public health or the ability to implement such studies even if there was such a concensus.^8,9 With competition for existing resources that ii facing pharmacy schools, there is little prospect for any real change in this area in the near future.

Second, the public health pharmacist has maintained a low profile and exerts little influence in the field of public health. Public health pharmacy practice virtually absent in organized public health circles and established pharmacy organizations do little to foster their presence within their ranks. Role models in public health pharmacy are, few and there is little done to link student exposure to these role models. There is no recognized specialty and little real appreciation, of public health pharmacy within pharmacy circles.

Third, there is little real expertise or demand for public health pharmacy within schools of public health. Faculty expertise on matters related to pharmacy is extremely limited and identifiable pharmacy faculty members are also difficult to find. There has been little real recruitment of pharmacists to schools of public health and enrollment for pharmacists remains minimal.

Fourth, there is little other than personal motivation to encourage individual pharmacists to obtain expertise in public health. Government managers do little to recruit or reward pharmacists for public health training or experience, especially when compared to other pharmacists working in the Government. There is no appreciable salary difference for public health pharmacists; indeed many may be working for far less than private sector pharmacists. Pharmacists who have reached positions of importance in public health do little to upgrade the status of public health pharmacy.

Fifth, resources in the public sector are tightly controlled under established budgets. The predominant feeling is that maximum use of resources must be undertaken with minimum expenditures. Traditionally, this has meant filling positions with the individual that meets minimal standards. Unfortunately, this has created the image that pharmacist capabilities are limited in public health and the "count and pour" mentality tires the cycle of keeping minimally qualified individuals as the pharmacists in the public system.

If the concept of public health pharmacy is to exist, certain steps are necessary. First, the pharmacy educators must the importance of public health and begin to involve pharmacy educators in the field. To implement this, adjunct faculty appointments for public health pharmacists should be arranged. These adjunct faculty members can serve as role models, preceptors and part time faculty for the students. Additionally, continuing education programs for practicing pharmacists can be undertaken to sensitize and challenge them toward greater public health involvement. Faculty directed research can also be directed to pharmacy as a provider of public health needs instead of pharmacy as a business.

Second, the basis for classification and qualification of Government pharmacists caring in the public sector have current expertise and commensurate duties. With the prospects for a much tighter job market in the public sector, care can be taken to insure that the individuals with the greatest public health exposure or experience are hired. Pharmacists with no particular skills or interest in public health should not be hired to work in public health purely as an expedient measure for managers. Rather, careful scrutiny should be taken to encourage greater training and experience for pharmacists who wish to work in the public sector. Third, the enrichment of clinical skills that will enable pharmacists to enlarge their role in clinical activities should be preserved. The triage function that pharmacists can, and in many instances should perform, can only be successfully undertaken with proper training. Both on the preparatory and continuing education levels, these skills should be encouraged and stimulated. And finally, the multifaceted mixture of health professionals involved in public health should adapt the knowledge and skills of pharmacy into the provision of public health. Although very parochial in much of their training, adaptive pharmacists have much to offer in the area. Through new linkages and alliances, this addition of yet another specialized service component can significantly aid in the public's health.

REFERENCES

1. Higher Education for Public Health. Milbank, Memorial Fund, New York, NY, 1976.

2. F. J. Spencer. "The Pharmacist and Public Health," Remington’s Pharmaceutical Sciences, 16th Edition, Mack Publishing Company, 1980: p. 1676.1667.

3. P. J. Bush and K. W. Johnson, "Where is the Public Health Pharmacist," Am J Pharm Educ 43: 249252 (1979).

4. T. J. Milne and R. E. Johnson, ‘"The Role of the Pharmacist in Public Health Agencies," Pharmacy Services Committee, American Public Health Association, November, 1979.

5. "The Role of the Pharmacist in Public Health," Am J Pub Health 71: 213.216 (1981).

6. S. R. Moore, "The Myth of The Public Health Pharmacist in the USA," Journal of the Royal Society of Health 101: 155.158, 162 (1981).

7. Position Classification Standards, "Series 660." United States Office of Personnel Management, February, 1966.

8. M. R. Gibson, Am J Pharm Educ 36: 189. 561(1972).

9. M. R. Gibson, Am J. Pharm Educ 37: 1 (1973).