The Role of the Pharmacist in Public Health

The American Public Health Association,

I. Statement of the Problem The pharmacist's role is expanding beyond the traditional product-oriented functions of dispensing and distributing medicines and health supplies. The pharmacist's services of today include more patient-oriented, administrative and public health functions. There are many functions of public health that can benefit from pharmacists' unique expertise that may include pharmacotherapy, access to care, and prevention services.1-5 Apart from dispensing medicine, pharmacists have proven to be an accessible resource for health and medication information. The pharmacist's centralized placement in the community and clinical expertise are invaluable. The reexamination and integration of public health practice into pharmacological training and pharmaceutical care is essential. The encouragement of cross-training will also maximize resources and aid in addressing the work force needs within the fields of pharmacy and public health. II. Purpose The American Public Health Association has historically supported the pharmacist's role in public health.59 This policy aims to provide leadership and guidance in identifying and promoting the pharmacist's current and future role in public health and to describe the framework for maximizing this function. Through transdisciplinary approaches, it is envisioned that the pharmacist's contribution to the public health work force, health education, disease prevention and health promotion, public health advocacy, and health quality will aid in achieving optimal public health outcomes.

A. Role Recognition Pharmacists are not formally classified as a profession within the public health work force, unlike public health nutritionists, nurses and physicians. The public health role of the pharmacist is yet to be clearly defined, broadly recognized and sufficiently promoted by public health agencies, pharmacy educators or other health care professionals.6 Pharmacists offer an accessibility that is rare among health care professionals. The pharmacist has health knowledge on which to build and is often uniquely sited in the community to provide public health services, in some cases 24 hours per day. No appointment is needed at most community pharmacies. Pharmacists work in a variety of public settings, including hospitals, drug, grocery and retail stores, and nursing homes. This convenience creates a large window of opportunity in which to provide public health services, therefore filling a void related to access to care and prevention. Further, pharmacists in the community are in an ideal position to act as information resources on lifestyle changes that can influence healthy outcomes.7,8 Pharmacists are involved in health screenings (e.g.,. diabetes, cholesterol, osteoporosis),9-11 immunizations,12 pain control,13 participatory and clinical research, and counseling/ health education.14 They also provide information on self-management (e.g. hypertension, asthma, HIV), smoking cessation,15,16 alcohol, tobacco and other drug use prevention, family planning,17 medication indications and conditions (dyslipidemia).7,15

B. Public Health Education of Pharmacists Due to the prominence of drugs in modern medicine, most health professionals are trained to be familiar with pharmacological concepts. Public health nurses, physicians, physician assistants, nurse practitioners, dentists, nutritionists and other health workers need varying degrees of knowledge related to drug therapy. Pharmacists of today are actively teaching physician assistants, nurses, and physicians various techniques of prescribing medications and issues related to the drug use process.14,18 Information about drugs is taught through mechanisms such as in-service training, newsletters, seminars, courses in nursing and medical schools, and continuing education. These illustrate ways pharmacists can add to the refinement of knowledge within the public health system.19,20 Schools of public health have the opportunity to expose their students to the contribution pharmacists make to public health and the training of public health workers. There is a growing need for dually trained professionals in pharmacy and public health. A small number of colleges of pharmacy offer dual degree programs with PharmD/MPH options,21,22 but overall, pharmacy students are only exposed to public health concepts on a fleeting basis. Few courses are devoted solely to public health in pharmacy, and virtually no textbooks exist to emphasize the role of pharmacy in public health. Consequently, there exists a need for pharmacy schools to incorporate public health and pharmacoepidemiology courses into their curriculum and train pharmacists as public health professionals.23,24 In 2004, the American Association of Colleges of Pharmacy (AACP) recognized the important role pharmacists can play in public health by including population-based care in its Center for Excellence in Pharmacy Education (CAPE) Educational Outcomes.25 The outcomes emphasized the pharmacist's role in "health improvement, wellness, and disease prevention." It also highlighted the need for pharmacist involvement in ensuring access to quality care and advancing public health policy.

C. Levels of Pharmacist Public Health Activity Medicine continues to evolve from a disease-oriented practice to one that is more patient-centered and focused on prevention. The profession of pharmacy has undergone a similar metamorphosis: from a concentration on medication dispensing to a focus on safe and effective medication use to achieve optimal patient outcomes. As patients move through the continuum of care, pharmacists have ample opportunity to provide population-based care. In fact, studies have shown that pharmacists with more comprehensive responsibilities have lowered total costs and improved quality of care outcomes achieved by health care systems, particularly related to chronic conditions.26-32 To fully utilize the pharmacist's expertise, these broad functions may be carried out by individuals, systems, and facilities in diverse sectors, encompassing both macro and micro level activities. At the micro level, public health activities may be one of many tasks among a pharmacist's set of responsibilities. For example, a community pharmacist who speaks to community groups about drug abuse and provides hypertension screening in his or her pharmacy is providing public health services at the micro level, while a pharmacist who is the drug program administrator of a state Medicaid program is providing services at the macro level. Performing public health activities on the micro level still preserves their identity as a pharmacist. Conversely, when a pharmacist works on the macro level in the capacity of health planning, evaluation and administration, his/her identity as a pharmacist is oftentimes threatened. Many pharmacists have asserted themselves and established a pronounced functional capacity in public health. However, overall, pharmacists are an underutilized source of factual and anecdotal health data that could assist health planners as they seek to meet community needs.18 It is essential to transform the participation in public health activities as more than additional tasks, but as a vehicle through which all activities are filtered. The ability to motivate public health action is particularly challenging within the confines of the traditional fee-for-product system. In many instances, pharmacists are not compensated for health promotion or disease prevention and management activities. Therefore, they are more inclined to curb these activities, and maximize the duties of dispensing medications for which they can get paid. Pharmacists who perform duties on the micro level many times are not compensated for this work, while financial incentives may exist for duties performed on the macro level. For instance, the incorporation of preventive methods may have positive fiscal implications on an institutional level. Consequently, the pharmacist in senior management may strongly advocate and embrace public health strategies. The macro level of public health has been frequently overlooked in the field of pharmacy when exposing students and early professionals to public health. This is particularly due to the low proportion of pharmacists who hold such positions. This dearth of pharmacists involved in public health activities on a macro level also means there are relatively few pharmacists available to act as role models that make institutional changes. Pharmacists that have specific health system management responsibilities oftentimes have core responsibilities that can be linked with public health efforts. For example, a pharmacist helping to design an institution's medication safety procedures is supporting Healthy People 2010 by reducing the number of hospital admissions due to drug therapy management problems.33-35 Drug safety is extremely important in protecting lives and decreasing health care costs. Macro level pharmacists with further training (to include health administration and health economics) may be better prepared to address the public's needs and plan system-level changes that provide incentives to pharmacists performing public health activities. 

D. Public Health and Pharmacists' Services 1. Essential Health Services and the Pharmacist's Role Public health is "what we, as a society do collectively to assure the condition for people to be healthy."36 Through the execution of essential health services, public health has evolved through a variety of stages to arrive at sustaining community health and quality of life. Through shared responsibility, the pharmacist is equipped to strengthen the existing public health system. The pharmacist has many functions that align with those of the essential health services that are critical to public health.60 Pharmacists are in a unique setting central to the community that enables them to monitor health status, develop and mobilize community partners and empower community members through education, screening, and dissemination of information. The expertise of the pharmacist is not isolated to the education of the immediate community, but can also be utilized to inform laws and regulations. As mentioned above, pharmacists are involved in educating doctors, nurses and other health care professionals on various techniques of prescribing medications and issues related to the drug use process,14,18 thereby fulfilling the eighth essential health services function assuring a competent public health and personal health care work force. Further, the ample availability of pharmacists to the public can aid in meeting the health care needs of the uninsured and underinsured while alleviating the burden of the existing public health work force 2. Pharmacists and the Core Public Health Functions The Institutes of Medicine (IOM) in the Future of Public Health in the 21st Century established three major functions of public health: 1) Assessment, 2) Policy Development, and 3) Assurance.36 The topics of research, legislation/advocacy and medical errors tie in nicely with the role of pharmacists in public health. Assessment A. The Pharmacist and Public Health Assessment through Research The pharmacist can play a unique role in the evaluation process to assure that medications are effectively being utilized. It is envisioned that a population analysis of medications patterns can add to the body of public health knowledge generating better treatment regimens, identifying medication errors and adverse drug events,37,38 and improving the quality of patient care.39 Research involving pharmacists can create trend analyses and report longitudinal changes in patterns of medication use that may ordinarily be missed. Such findings will ultimately benefit the community and population-at-large. This illustrates the need and opportunity for public health and pharmacy professions to work in collaboration to conduct valuable research. Pharmacists have a role in developing "population-specific, evidence-based disease management programs and protocols based upon analysis of epidemiologic and pharmaco-economic data, medication use criteria, medication use review and risk reduction strategies as well.40 Pharmacists, health practitioners, public health agencies, and regulatory and other stakeholders should collaborate to generate answers. Academia and health agencies can also initiate relationships with local pharmacy organizations to provide epidemiological data on prescribing patterns, patterns of illness, and various socioeconomic factors related to prevalent disease states. A community pharmacist can be strategic in assisting health surveys, and in advising people about and referring them to public health services.

B. The Pharmacist and Public Health Preparedness
A confluence of events has refocused attention on the role pharmacists can play in public health planning and emergency preparedness. The importance of medication distribution and patient care during disasters is vital.41 For example, many local boards of health require that a pharmacist be a member of the group in response to potential public health dangers. Pharmacists often offer alternatives to care and solutions to staff shortages in emergencies. 

Shortages are not limited to staff but also valuable resources. The emergence of smallpox and influenza scares has called attention to the problem that dwindling supply of critical medications pose.42 For instance, the development of a plan for influenza vaccine redistribution is a potentially useful exercise that pharmacists hopefully will never need to execute but would be a very critical contributor. Plans such as these can be readily adapted to various natural disasters, bioterrorism acts, or similar emergency situations.43,44 Pharmacists should be prepared to quickly assess and respond to critical situations and have been a welcomed addition to the collaborative emergency team. The critical role of the pharmacists to protect the nation from public health dangers is noted by one pharmacist's leadership role as a part of the Commissioned Corps Readiness Force (CCRF) team after Sept. 11 at Ground Zero to provide medical, mental and public health services to responders.45 Additionally several pharmacists' service as members of response teams at five anthrax events in the United States should also be noted. Pharmacists have become increasingly involved in emergency response, managing the Strategic National Stockpile (SNS), responding to natural disasters,46,47 and working to rebuild health care infrastructure in Afghanistan and the drug regulatory system in Iraq. 

Policy Development: The Pharmacist in Public Health Legislation, Regulation and Advocacy
The promulgation of public health legislation and subsequent regulation is not a field generally associated with the pharmacist's role. However, there are a myriad of public health concerns which legislators and regulatory agencies address that relate to pharmacists and the products they dispense. Legislators and those who develop and approve policy oftentimes need testimony, data and feedback on pending and implemented laws and regulations. Pharmacists are in a prominent position to provide background data, legislative content and exposition to local, state and federal governments. As medication-use experts and experienced health system administrators, pharmacists can and should contribute to public health legislation and regulation.

Many local, state and federal agencies have begun to recognize the need for pharmacists' input. At the federal level, pharmacists are employed in such entities as the Agency for Healthcare Research and Quality (ARHQ), the Centers for Medicare & Medicaid Services (CMS), the Food and Drug Administration (FDA), Department of Veterans Affairs (VA), U.S. Public Health Service and the Bureau of Health Professions of the Health Resources and Services Administration (HRSA). Although they hold positions within these key agencies, there still exists a shortage of pharmacists working within these areas. The need to increase pharmacists' involvement in regulatory agencies along with other public health stakeholders is essential. Pharmacists can take a more proactive role in impacting legislation and regulation through advocacy in state and local boards of health, their state boards of pharmacy and national associations.

Pharmacists at the state and local levels administer the drug component of the Medicaid and Medicare programs, as well as regulate the practice of pharmacy. This is particularly relevant in lieu of changes in the Medicare program to include prescription drugs under Part D.48 Although pharmacists are generally recognized and compensated for dispensing medication under this plan, public health activities and preventive services performed by pharmacists are not reimbursed. Therefore, recognition of pharmacists as Medicare providers is key. Pharmacists can play a vital role in the success of Medicare Part D by decreasing health care costs through appropriate medication use and prevention of medication errors.49 Lifestyles changes are critical to evoke prevention. The pharmacist's role in promoting lifestyle changes is not recognized, and therefore coverage is lacking for prevention activities, which poses an area of grave concern for pharmacy and public health professionals alike. It is important that local, state and federal agencies recognize the role of the pharmacist in contributing to the public's health, and should identify mechanisms to include pharmacists' involvement.

Assurance: Improved Access to Quality Care, Prevention of Medical Errors and the Pharmacist
Health care system managers, administrators, and evaluators are intimately involved in assuring appropriate allocation of services to meet patient needs and demands. Prominent considerations of the role of pharmacists in health care management include: the distribution of drugs and supplies, delivering drug related information and consultation to meet needs of patients and health team members. Consequently, there should be more effort to fully utilize the wealth of drug knowledge the pharmacist brings. As aforementioned, the unique assets that pharmacists bring have already been recognized within many public health jurisdictions. 

Pharmacists can prevent medical errors by both: 1) increasing patient health literacy50,51 and 2) serving as a systematic check and balance.49,52,53 The Institutes of Medicine's book entitled "To Err is Human" reported "Because of the immense variety and complexity of medications now available, it is impossible for nurses or doctors to keep up with all of the information required for safe medication use. The pharmacist has become the essential resource& and thus access to his or her expertise must be possible at all times.49 Inclusion of pharmacist services in the clinical services subsystem permits full interaction and use of his or her expertise. In this manner, pharmacists may contribute to the system's management function by providing essential information (e.g., the number and cost of prescriptions dispensed), and meeting the needs of the system by providing health care education and services. To aid in this expanded role, the pharmacist should be trained to contribute to a variety of public health services and functions, particularly those involving abusable substances and medicines, and those requiring the cooperation of community pharmacists and public health workers. 

Another key area of assurance is access to health services and resources. Pharmaceuticals are among the most frequently used therapeutic modalities. There exists a need to provide counseling to patients to assist in increasing compliance with therapeutic regimens based on empirical, up-to-date information to assure that medicines are taken properly. In an era where chronic (i.e. hypertension and diabetes) and infectious diseases (HIV and tuberculosis)55 require lengthy medication treatment regimens, pharmacists are vital. These needs, coupled with the need for primary care practitioners in underserved areas, point to the greater use of the pharmacist.

A pharmacist currently contributes to patient care through hospitals, home care, long-term care, community pharmacy or other components of organized health care systems. Many inpatient and ambulatory care programs have added a clinical pharmacy segment to the traditional distribution function, and an increasing number of pharmacy practitioners are engaged in clinical practice. Furthermore, much like the role of the nurse practitioner and physician assistant, the role of the pharmacist has expanded to allow for the provisional prescribing of medications in collaboration with a physician within some jurisdictions. This function would be critical in areas where there may be a shortage of physicians or other qualified health care professionals.

E. Pharmacists and Prevention
Through health screenings and health education, pharmacists play a key role in prevention as well as access to care. In light of work force shortages among health professionals, pharmacists may act as first responders, providing clinical advice to include over-the-counter (OTC) relief that may aid in decreasing unnecessary emergency room visits for common conditions. Protocols are often developed and vetted by Pharmacy and Therapeutics (P&T) Advisory Committees. Pharmacists are often involved in the clinical management of chronic diseases, and minor disease diagnosis and treatment. Further, pharmacists provide an excellent source of human capital to the community by conducting primary prevention through health education. Primary prevention is the essence of public health. Consequently, greater emphasis regarding the role of pharmacists in the public health infrastructure needs to be recognized. 

Pharmacists also provide rehabilitation support to individuals and communities by giving advice on the use and selection of surgical appliances and equipment. The literature is abundant with examples of the pharmacist functioning in hypertensive and colorectal screening, sexually transmitted disease control and contraception programs, providing health education, and advising patients of OTC drug choice and use. In rural areas, pharmacists have supported environmental programs such as water pollution control, chemotherapeutic agents, sanitation, and waste disposal.56

Pharmacists in rural areas are another key area of concern and fill a void in both the pharmacy and public health arena. Given rural health often reflects an area of greater geographic need, the connection between rural and health disparities cannot be ignored.57 In many rural areas that have fewer available resources, the local pharmacist offers a much needed source of clinical expertise. This is also true in impoverished urban areas. Pharmacists are particularly valuable assets in these disenfranchised sub-sectors of the community, because the pharmacist acts as an easily accessible resource for health information and screening. Through consultation with local pharmacists, many community members may avoid costly emergency room visits for those common acute ailments or conditions that temporary OTC drugs could provide relief, particularly among those lacking insurance. Therefore, pharmacists can play a role in addressing and eliminating health disparities.35,58 Pharmacists, like all health providers, should be engaged in activities which may lead to eliminating health disparities, through cultural competence training, collecting data on medication use in special populations and promoting diversity in the work force. 

III. Desired Action
In order to facilitate further development in this area, APHA:
1. Supports greater inclusion of public health concepts in the curricula of schools of pharmacy, as well as the development of more joint PharmD/MPH programs; 
2. Reiterates the need for increased awareness of the role of pharmacists in public health through the dissemination of information among schools of public health, professional societies, policy-makers and other health care employers; 
3. Encourages the transdisciplinary collaborations of health planning agencies, schools of public health, schools of pharmacy, public health agencies, policy-makers and pharmacy and public health professionals to develop legislation and advocate for plans that address health care needs spanning from local to worldwide.
4. Supports the influx of more pharmacists trained in public health, in response to the pharmacist and public health worker shortages; 
5. Urges Congress to charge CMS to recognize pharmacists as health care providers within its programs (e.g., under Medicare) to function in public health capacities and to be eligible for proper reimbursement in such capacities. As is the case with all licensed providers, this should be restricted to services provided within the terms of the state pharmacy licensure regulations; and
6. Encourages the participation of pharmacists and other public health professionals in transdisciplinary research. 
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