Where Is the Public Health Pharmacist?

Patricia J. Bush and Keith W. Johnson

Department of Community and Family Medicine, Georgetown University School of Medicine, Washington DC 20007 and Drug Information Division, United Stares Pharmacopeial Convention Inc., Rockville MD 20852

Recently, a member of the governing board of the American Public Health Association (APHA) spoke to a graduate seminar in pharmacy administration about the activities of the APHA. "How many pharmacists are members?" queried one of the students. About 120 (0.4 percent) of a total membership of 30,000 was the response. Following the seminar, the questioner wondered aloud why so few pharmacists belonged. "Well," said another student, "There aren’t any public health pharmacists are there?"

Of course the student was right; there is no group of persons known as public health pharmacists as there are public health physicians and public health nurses, who with PhDs form the bulk of membership in the APHA. Nevertheless, there may be pharmacists engaged in public health activities who, for one reason or another, have not joined the APHA, or who perhaps do not recognize they are doing public health. Moreover, it may be reasonable to shrug one’s shoulders and say. "So what? Who needs public health pharmacists anyway?"

It will be argued here that some, but not nearly enough, pharmacists are now engaged in public health activities. Furthermore, both the public and the profession of pharmacy benefit from public health pharmacists, but pharmacy education has failed to recognize the potential for pharmacists in public health as well as to acquaint pharmacy students and practitioners with role models in public health.

As defined in 1976 by a Milbank Memorial Fund Commission on Higher Education for Public Health, "Public Health is 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."(l)

Thus, the scope of public health is wide. Those who provide a preventive health service on the basis of a demonstrated need in a population group are "doing" public health, as are individuals involved in health-care planning and policy, and those who evaluate programs. However, the common threads are organized and collective. Public health problems are not health problems considered as they occur in a series of individuals presenting themselves to a health-care provider, but are considered in the context of a community as a whole. Public health professionals answer questions like: "How frequently does this illness occur, and to whom? How important is it relative to other health problems? What can the community do to prevent it?"

One way to look at public health functions is by stratification. At the micro level, the service is relatively direct as compared to the macro or planning level. For example, the director of a venereal disease clinic is functioning at the micro level, whereas the individual who perceived the need in the population compared to other needs, determined that there should be such a clinic, and allocated resources for it, is functioning at the macro level. Viewed in terms of these levels, the public health role for particular categories of health professionals can be seen from two perspectives: (i) at the micro level. From the perspective of a health professional whose primary role is not in public health, but who is performing some public health function, And (ii) at the macro level, from the perspective of a health professional whose primary role is in public health.

Traditionally, medical education has been disease-oriented, turning only in recent years to patient-orientation. The parallel situation in pharmacy has been an historic drug orientation with recent emphasis on patient and interprofessional relationships. Usually, health professionals study basic sciences and then learn by "practicing" those skills believed necessary to perform their future roles under the guidance of role models. For pharmacy students, this traditionally has meant learning about the drug, its source, formulation, and activity, as well as how to translate a doctor’s order into a therapeutic product. When pharmacy students "practiced," there was not necessarily any interaction between the pharmacy student and patients or customers, or between the pharmacy student and other health professionals. Role models were often restricted to nonpracticing faculty members until the student’s apprenticeship. As pharmacy education became more patient-oriented, students began to "practice" in clinical settings, and while they were still under the wing of a school of pharmacy, their role models began to include community and hospital pharmacists. In this respect, pharmaceutical education began to resemble that of medicine, nursing, and dentistry, i.e. health professional students interacting with patients under the guidance of practitioners. However, medicine and nursing educators long ago recognized that the health education model, whether disease- or patient-oriented, failed in terms of teaching public health, because of its inherent inability to take a population perspective. Their solution, of course, resulted in the special schools and departments which now teach public health and train public health professionals.

The establishment of the first school of public health at The John Hopkins University over 60 years ago was a turning point in public health education. The school introduced specialization and emphasized research and training in the science of hygiene and public health as well as its application( 1).

Today, there are 20 schools of public health, and almost every medical school has a department of community medicine that incorporates the teaching of public health concepts. These schools and departments neither produce nor employ one predominant type of health professional, as contrasted with schools of medicine, law, dentistry, nursing, and pharmacy. Instead, professional functions are performed by persons from a variety of backgrounds who adapt their knowledge and skills to the field, and those such as biostatisticians, epidemiologists, environmental specialists, nutritionists and health educators, whose primary training is focused on public health problems. Moreover, education must address not only the professional but the executive functions that comprise public health. Executive functions (meaning managing, policy making, and planning) are performed by those with broad education and experience in public health, who have acquired expertise in developing policy, setting priorities, allocating resources, and organizing administrative structure.

In addition, providing role models outside of the schools of public health and departments of community medicine has always been problematic. Solutions vary from simple role description to externships. For example, at the Georgetown University School of Medicine, the Department of Community and Family Medicine provide summer externships in the Indian Health Service, rotations through community-based clinics (mental health, venereal disease, alcohol and drug abuse, and family planning), an elective in the Montgomery County Maryland Public Health Department, and biostatistics and epidemiology research experience in federal agencies, in addition to lectures from professionals working in the public health field. These persons, more than others, are involved in the formulation of health- care policy, health-care planning, and program implementation, direction, and evaluation, especially at the national level. These persons then, more than others, affect the practice arrangements of other health professionals, as well as the equity, quality of, and access to health services by the population. They work at the macro level.

To date, it is primarily the macro level sort of public health professional that has been ignored by pharmacy education in its half-hearted attempt to expose students to public health. Moreover, the practicing pharmacist who is involved in public health activities is so rare that (despite lip service given in classes and professional journals about the pharmacist’s involvement in counseling, family planning, drug abuse, venereal disease, etc.) relatively few pharmacists are available as role models.

It must be remembered that role models have a strong influence on the style and choice of professional practice. To social analysts like Parsons and Merton, a role is a set of expectations held toward the occupant of a particular position in a social system(2,3). For purposes here, the concept of the role-set, which recognizes that individuals may occupy a number of roles, is the most pertinent, especially since roles may be ordered with some more dominant than others (4). For example, instead of considering public health activities as part of a community pharmacist’s role (i.e., as fulfilling his or her and other’s expectations regarding pharmacist’s activities), public health activities may be considered as a role among a community pharmacist’s set of roles. And this contributes in part to the problem that an individual might fail to perform any public health functions, and still be recognized as a pharmacist. It is easy to justify one’s existence with the inclusion of that one role in a set of roles. This situation could not exist for those whose occupation is public health, but who also happen to be pharmacists.

PHARMACY PUBLIC HEALTH EDUCATION

As reviewed by Gibson (5), following its mention in the fourth edition of The Pharmaceutical Syllabus in 1932, public health received "rather scant attention by pharmaceutical education, if we are to assess the attention of the articles appearing in the American Journal of Pharmaceutical Education." A seminar was held in 1965 to discuss the public health curricula in colleges of pharmacy (6), following the APhA’s publication of a study of the feasibility of using pharmacies as distributors of health literature(7). Until 1972, no study had assessed whether pharmaceutical education prepared pharmacists to do what so many said they should do. In that year, Gibson undertook a survey of public health instruction in colleges of pharmacy and tested graduating seniors in 67 participating colleges (5). The implications derived from that survey were that pharmacy education suffered from: (i) the lack of a definition of public health in pharmacy (or pharmacy in public health), (ii) the lack of perceived relevance to pharmacy students, (iii) the lack of a textbook focusing on the role of pharmacy in public health, (iv) the lack of pharmacy faculty educated in and with appropriate experience to teach public health, and (v) the lack of sites where students could become involved with public health projects, and work, with public health personnel.

There is little reason to believe that Gibson’s articles revolutionized public health education in pharmacy. There are few courses devoted solely to public health pharmacy despite the fact that the American Council on Pharmaceutical Education accreditation guidelines provide a fertile base on which to build courses in pharmacy public health. ACPE’s accreditation standards include:

"Professional Studies and Training. Include a variety of professional courses and experiences which may be represented in the following manner:

Although "bits and pieces" of the elements required for training in pharmacy public health are present in most curricula, they are not recognized or presented as such. Just as the role of public health pharmacy gets lost in a set of roles, training in public health pharmacy gets lost in the traditional elements of the pharmacy curriculum.

There still is no textbook emphasizing the role of pharmacy in public health, and nonpharmacy public health instructors are not familiar enough with pharmacy to provide relevant courses or Practiced experiences. Unfortunately the 1978 Report of the Committee for Establishing Standards for Undergraduate Education in Pharmacy Administration of the American Association of Colleges of Pharmacy did not include a subcommittee report on public health, although, "bits and pieces" are present throughout the Subcommitee Report on the Social and Behavioral Sciences(9).

PHARMACISTS DOING PUBLIC HEALTH

As previously outlined, there are two levels of public health activities and, although pharmacists are involved at both levels, little or no attention has been devoted to preparing pharmacists to work at the macro level.

There is no doubt that pharmacists can and should perform micro public health activities, despite the lack of direct financial incentives. In most instances these activities are on an individual pharmacist-to- patient basis. At this level, pharmacists hand out literature and counsel patients about such public health matters as smoking, alcohol and drug abuse, poisoning, venereal disease, hypertension, cancer danger signals, nutrition, and mental health. Some pharmacists are involved in organized community public health programs which include educating the public about and screening for hypertension, diabetes, and cancer (l0). Others speak to school children about drug abuse (11). Although many have written about new roles for pharmacists such as monitoring drug compliance, drug surveillance, drug utilization review, advising the consumer about OTC agents, triage, and serving as physician surrogates and members of health teams (l2-15), these also tend to be roles performed at the micro level, and in some instances an activities which one might have supposed were not new roles, but activities the public had a right to expect of its pharmacists. More recently, Kilwein has written about "The Pharmacist and Public Health," commenting that more pharmacy graduates should pursue further education in schools of public health, and that pharmacists are important community resource parsons on drug-related matters (16). Burton and Smith have noted that pharmacists can provide a community service by explaining the benefits their customers are entitled to under federal, state, and local legislation (17). Not only can pharmacists explain the benefits, but they could tell people where they can apply for benefits and social services. Thus, pharmacists are not lacking for public health activities to perform, or people to tell them what they should be doing.

Despite the lack of role models or a pharmacy education specifically preparing them to do so, a number of pharmacists hold positions at the macro level of public health. Some, but not all, have obtained further degrees in public health, most especially the MPH. The individuals are found at such federal agencies as the Food and Drug Administration, the National Center for Health Services Research, the Health Care Financing Administration, Social Security Administration, Veterans Administration, US Public Health Service, Office of Technology Assessment, Bureau of Health Manpower, and the Federal Trade Commission. Other pharmacists are employed at the state level, most especially in Medicaid programs. Still others, have positions in the private sector, some doing research and evaluation, and others working as administrators, particularly in third-party payment programs. What these persons have in common is that their perspective is that of the population as a whole group (or collection of groups) rather than that of the individual patient. As pharmacists working at the macro level ; they perform the following: (i) identify health-related community problems; (ii) set health priorities; (iii) formulate policy and make decisions; (iv) perform management and administrative functions; (v) educate the community to recognize, and cooperate in serving, its health needs; (vi) advise, consult, and support community service programs, and (vii) perform research and/or evaluate activities in public health.

NEED FOR PUBLIC HEALTH PHARMACISTS

The lack of attention to the need for pharmacists at the macro level of the health-care system has affected the micro level as well. It is the macro level public health pharmacist who can address the problem of incentives for pharmacists to perform micro level public health activities. Macro level public health pharmacists who are knowledge-able about the training and abilities of pharmacists (and who under-stand the health-care system, interprofessional relationships and health economics) can suggest system level changes that can provide direct and indirect incentives (money and its substitutes) to pharmacists to perform public health activities.

Before such incentives are developed it is necessary to demonstrate that there is a need for pharmacists to perform these activities. Public health pharmacists are also likely to be the best persons to carry out such demonstrations and their evaluations. Therefore, in addition to the public health activities that are performed by any specialist at the macro level, there is a special need for the public health pharmacist to: (i) justify the need for pharmacists to have a public health role; (ii) define the public health role for pharmacists; (iii) teach and serve as role models in public health, (iv) evaluate the performance of the pharmacist’s public health role; (v) design and help implement system level changes that provide public health role incentives to pharmacists, and (vi) disseminate information about new functions, program evaluations, and the results of health services research,

What can pharmacy educators do to remedy the situation? First, they should recognize that there are two levels where pharmacists need to participate in public health, and that having, pharmacists at the macro level may be critical to having them perform public health activities at the micro level. Second, develop competency-based curricula in public health. Third, support publication of a text that addresses the pharmacist’s role in public health and the organization of health care. Fourth, modernize public health courses, e.g., students need to learn about Medicaid, HMOs formulas, etc., far more than they need to learn about yellow fever epidemics and arthropod-borne diseases. Fifth, provide exposure of students to adequate role models, i.e., real-world pharmacists working at both levels in, public health. Sixth, explore innovative programs to obtain these goals, and share experiences; e.g., the Philadelphia College of Pharmacy and Science has offered a course in which "role models" are brought to the campus to discuss the opportunities in their fields, and recently the Virginia Commonwealth University School of Pharmacy has arranged an externship for a student at a PSRO. Seventh, strongly encourage an increase in the number of pharmacists who obtain the Masters Degree in Public Health so they can: (i) act as role models at the macro level and (ii) develop logical roles for public health pharmacists at both the micro and macro levels.

Today, more than ever, there is a recognition that health resources are scarce, that planning is essential, and that traditional "sickness" services are limited in what they can do. A health-care system must be a partnership between the public and the health professional to increase the likelihood that people will stay well and that, when ill, they will take appropriate action in an appropriate system. The community pharmacist, if only because of his or her location, has a public health role in such a system. However, pharmacy will lose out if it continues to take a parochial view. Pharmacy needs persons who can take a population focus and maximize the chance that both the people and pharmacy will benefit. We look to education to provide the leadership for the future.

Am. J. Pharm. Educ., 43,249-2S2( 1979); received 216179, accepted 615179.

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