Pharmacy

PHARMACY

PHARMACY. There were but few who could claim any prior pharmaceutical training in all the colonies in the seventeenth century. By the end of the eighteenth century, however, and far into the nineteenth, four types of practitioners of pharmacy were identifiable. First was the physician who compounded and dispensed his own medicines and often kept a "Doctor's shop." Second was the apothecary who, like his English model, not only compounded and dispensed drugs, but also diagnosed and prescribed. Third was the druggist, later also to be called a pharmacist. The term "druggist" was originally applied to wholesalers but subsequently described one who compounded medicines in shops in which a major concern was pharmaceuticals and related items. Fourth was the merchant who took on a supply of drugs; many eventually evolved into pharmacists.

The Drugstore

The nineteenth-century American drugstore carried a full line of simples (mainly crude vegetable drugs) and chemicals with which pharmacists compounded and dispensed medicines, with or without a prescription. They were artisans who spread their own plasters and prepared pills, powders, tinctures, ointments, syrups, conserves, medicated waters, and perfumes. Economic necessity forced them to handle such commodities as confections, tobacco, paints, glass, groceries, spices, and liquor. They were thus commonly also merchants, and pharmacists often differed among themselves as to whether theirs was a trade or a profession.

By the mid-nineteenth century this artisanal role of pharmacists had begun to diminish. A pharmaceutical industry was providing medicines that pharmacists had previously made entirely by hand. There was a burgeoning growth of proprietary ("patent") medicines, flamboyantly advertised, with which pharmacists had to deal. Economic competition from department stores, groceries, and chain stores added to the pressure. Late in the century the competition—including that among pharmacists, for the "cut-rate" pharmacy shop had become ubiquitous—led to a number of plans to fix prices, but both these plans and the fair trade statutes of the mid-twentieth century fell afoul of federal antitrust laws.

One peculiarly American development was the drugstore soda fountain, which was an outcome of the pharmacist's knowledge of flavors and carbonated water. The pharmacist Elias Durand operated a soda fountain in his Philadelphia shop as early as 1825. American soft drinks, the colas particularly, had their beginnings in the drugstore. The soda fountain was not to disappear from the drugstore until the mid-twentieth century, when it gave way to more profitable alternative uses for the space.

Science and Technology

The great scientific and technological advances in the medical and biological sciences in the late nineteenth century transformed pharmacy in a number of ways. First, the old materia medica —still showing evidence of ancient lineage—increasingly gave way to new medications based on a better scientific understanding of the etiology of diseases and of the mechanisms of drug action. These medications were the products of synthetic and medicinal chemistry, new powerful tools. Second, in the twentieth century these new medications were largely the discoveries and innovations of the rapidly developing pharmaceutical industry and, moreover, were the products of research and manufacture that the individual pharmacist could not duplicate. This meant that the compounding of medicines by the pharmacist gave way to the dispensing of medications completely prepared by industry. By the 1970s only one percent of prescriptions required some combination or manipulation of ingredients. Third, the sciences gave impetus to the separation of pharmaceutical practice from medical practice.

Pharmacy Law

The training of the pharmacist was accomplished largely through the apprenticeship system and, in the absence of legal restrictions—a concomitant of Jacksonian democracy—it was possible for any persons to set themselves up as pharmacists. The first laws providing for the examination and licensing of pharmacists in an American jurisdiction were passed in Louisiana, where the Franco-Spanish tradition in pharmacy prevailed in regulations of the Territory of Orleans in 1808 and of the state in 1816. The few other such attempts before the Civil War, in three southern states and a few localities, were, in the prevailing democratic milieu, ineffectual.

Rhode Island passed the first modern state law for the examining and licensing of pharmacists in 1870. Pressure for such laws came from the American Pharmaceutical Association, founded in 1852, and from state and territorial pharmaceutical associations (of which there were

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forty-five and two, respectively, by 1900). As a consequence, forty-seven states had such laws by the end of the century. This legislation established state boards of pharmacy, composed originally of pharmacists. The boards, among other powers, examined candidates and imposed educational requirements that became more advanced as the colleges of pharmacy increased the depth and length of the pharmacy curricula. Following standards and accreditation requirements developed by the American Association of Colleges of Pharmacy (founded in 1900) and by the American Council on Pharmaceutical Education (founded in 1932), these curricula increased from two and three-year Graduate in Pharmacy (Ph.G.) and Pharmaceutical Chemist (Ph.C.) programs, to four-and five-year baccalaureate programs, and to six–year Doctor of Pharmacy (Pharm.D.) programs. In 1999 over 45 percent of all the pharmacy graduates in the country received the Pharm.D. degree as their first professional degree.

Under the American constitutional system it was state law that regulated pharmacy and imposed restrictions on the sales of poisons and abortifacients. The federal government first became involved in the regulation of pharmacy with the Pure Food and Drug Act of 1906. That legislation and its principal amendments (1912, 1938, 1952, and 1962) and the Harrison Narcotic Act of 1914 set the stage for what became the very close federal involvement in the control of drugs. "Legend drugs, " requiring a physician's prescription, and a list of "controlled dangerous substances" made the pharmacist subject to federal, as well as state, authority.

Pharmaceutical Education

Pharmaceutical education began in the United States with the founding of the Philadelphia College of Pharmacy (now the University of the Sciences in Philadelphia) in 1821.

The term"college" was intended at first to suggest only a society rather than a school, but the Philadelphia College offered lectures almost from the start. Local societies of pharmacy, also calling themselves colleges, were formed in Boston, New York City, Baltimore, Cincinnati, Chicago, and St. Louis, and all of them sooner or later engaged in pharmaceutical instruction. By 1900 about sixty programs were or had been in operation. The program of instruction in these institutions, especially in the good number that were private and proprietary, was indeed meager, consisting mainly of a series of lectures in the evening in rented rooms.

In 1868 the University of Michigan embarked upon a full program of scientific training in pharmacy, eventually developing a full-time, day program of two years. The University of Wisconsin followed suit in 1883 and nine years later it pioneered in offering a four-year program leading to a bachelor's degree. As noted, the length and the curricular requirements took off from there, reflecting new developments in the pharmaceutical sciences and the changing professional role of the pharmacist, both in and beyond the drugstore. The curriculum changes demanded by the doctorate included more attention to the humanities and emphasized clinical pharmacy and relatively new sciences like pharmacokinetics and pharmacotherapeutics. Externship programs in community, industrial, hospital, and clinical pharmacy became part of the curriculum.

The Changing Role of the Pharmacist

The plethora of new and complex medicines that industry was providing, along with the increasing demands for prescription drugs as the population aged, meant that pharmacists who dealt directly with the patient needed to be more than just artisans who compounded or dispensed drugs. Limited in their freedom of activity by the introduction of Medicaid and Medicare, the new managed care systems, and computerization, pharmacists found that their

choice of drugs and their prices were no longer under their control. The pharmacist assumed a new, consultative role in health-care delivery that demanded knowledge of the drugs and their action in the body and the monitoring of the drug regimen of the patients.

The responsibility of the pharmacist in providing correct and effective medication and in preventing errors was evident in the great expansion of pharmacists into the health field beyond the drugstore. Hospital pharmacy goes back in the United States to before the Revolution; by 1942 hospital pharmacists had become so significant a part of the heath-care community that they formed the American Society of Hospital Pharmacists. As the twentieth century progressed, the practice of clinical pharmacy developed. In clinical pharmacy the pharmacist is responsible in a hospital situation for cooperating with the physician in monitoring the prescribed medications. Clinical and consulting pharmacists also are involved in other institutions, such as nursing homes and assisted living quarters. In recognition of the broader role of clinical and consultative pharmacy, the American Society of Hospital Pharmacists became the American Society of Health System Pharmacists in 1995.

Demographics and Infrastructure

The demography of pharmacy personnel changed quite rapidly in the late twentieth century. Beginning in 1985, more than half of each year's pharmaceutical degree recipients were women. In 1999 women graduates made up 63.5 percent of the total. The ethnicity of personnel was also changing. The percentage of white graduates fell from 86 percent in 1979 to 64 percent in 1999, while the percentage of Asian, Native Hawaiian, and Pacific Islanders rose from under 4 percent to over 18 percent in the same period. African Americans rose from 3.6 percent to 5.6 percent; Hispanics and Latinos declined from 3.8 percent to 3.7 percent.

The last decade of the twentieth century saw a drop in the total number of drugstore outlets from 58,642 in 1990 to 53,105 in 1999. The decline, however, was only among independent pharmacies. They went from 31,879 to 20,649, a decrease of 11,230 units in the decade. Chain stores, supermarket units, and mass merchandiser units all increased in number. One factor in the decline of independent pharmacies was the development of Pharmacy Benefit Management organizations (PBMs) and the accompanying growth of mail-order prescription services.

At the end of the twentieth century the National Community Pharmacists Association (founded as the National Association of Retail Druggists in 1898) still had a membership of 25,000. The American Society of Health-System Pharmacists had an equal number of members. Pharmacy had developed in two directions.

BIBLIOGRAPHY

Cowen, David L., and William H. Helfand. Pharmacy: An Illustrated History. New York: Abrams, 1990.

Higby, Gregory J. In Service to American Pharmacy: The Professional Life of William Procter, Jr. Tuscaloosa: University Alabama Press, 1992.

Nona, Daniel A. "A Brief History of the Present—As Told by Accreditation Standards for Pharmaceutical Education." Journal of the American Pharmaceutical Association 40 no. 5 suppl. 1 (2000).

Ozick, Cynthia. "A Drugstore Eden." In Quarrel & Quandary: Essays by Cynthia Ozick. New York: Knopf, 2000.

Sonnedecker, Glenn. Kremers and Urdang's History of Pharmacy. 4th ed. Philadelphia: Lippincott, 1976.

David L. Cowen

See also Food and Drug Administration ; Hospitals ; Medicine and Surgery ; Pure Food and Drug Movement .