The Cambridge dictionary defines trust as “to believe that someone is good and honest and will not harm you, or that something is safe and reliable”.1 Developing trust in relationships, institutions, and other areas of life can take years, and it can crumble in a matter of moments if violated. Nowhere is trust, safety, and reliability more important than in the relationship between health care provider and patient. Physicians, pharmacists, and nurses have always been viewed as central and trustworthy members of communities2; doctors used to make house calls on horses and the local apothecaries would provide the medication the doctors prescribed.3 Fast-forward to today, with advanced models of health care and merged practice systems, and this trust-filled health care relationship is still key to providing an environment that encourages positive patient outcomes and improved quality of life.4
Trustworthy leadership is a character trait that is key to the practice of pharmacy and sought out in potential pharmacists. No greater example of this can be found than in the Oath of the Pharmacist, which states: “I promise to devote myself to a lifetime of service to others”; “I will consider the welfare of humanity and relief of suffering my primary concerns”; and, “I take these vows voluntarily with the full realization of the responsibility with which I am entrusted by the public”.5 Pharmacists have always been on the front lines of providing care, coordinating medication delivery during natural disasters and historic moments like the influenza pandemic of 1918 and the H1N1 avian influenza pandemic.6–8 The Oath states: “I will apply my knowledge, experience, and skills to the best of my ability to assure optimal outcomes for all patients,” but it does not say what the conditions must be.5
Pharmacists are stakeholders of public trust and continue to rank highly in public perception.9 According to Gallup’s annual survey, pharmacists have ranked in the top five of the most trusted professions for the last 18 years.10 This trust has been built through the accessibility, capabilities, problem-solving skills, and bridge-building ability pharmacists employ daily in their service to their community and through every patient encounter. Pharmacists train extensively to gain the knowledge and skills necessary to provide the best health care possible and deliver expert medication advice to each patient they serve.11
According to the National Association of Chain Drug Stores, nearly 90% of Americans live within five miles of a community pharmacy, and patients visit their pharmacy an average of 35 times per year, as compared to an average of four visits per year to their medical provider.11 Not only do patients trust their pharmacists with medication questions, they also rely on them for sound advice about the need for vaccines. Pharmacists have been recognized as part of the “immunization neighborhood” for many years now.12 Due to ease of access, community pharmacists are well-positioned to increase vaccination rates in their communities and prove the necessity of pharmacists’ medication skills in every avenue of health care, whether they get reimbursed for it or not.11,13
When the world came to a screeching halt in March 2020 due to the COVID-19 pandemic, pharmacists had to recall their oath and kick their problem-solving skills into high gear. While other businesses closed and the public retreated, pharmacists kept their hospitals, clinics, and businesses operational to keep knowledge about health and medication flowing. Pharmacists were identified as essential workers providing expert medication coordination and services.6 Patients still needed medicine, consults, vaccines, and care. Pharmacists figured out how to do it, all while putting their staff, families, and operations into the COVID-19 tsunami of uncertainty and remained calm, truthful, and reliable. Pharmacists brought out plexiglass to keep their staff as safe as possible; they made hand sanitizer; they ordered and kept stock of valuable masks, gloves, and other patient protective equipment. They problem-solved and created mobile clinics to administer vaccines and provide important health consults, and found new methods to incorporate telepharmacy, ambulatory pharmacy, and other services to keep medication compliance and other needs consistent.9 Pharmacists provided clear communication regarding COVID-19 and continued to administer appropriate childhood and adult influenza vaccines.9,11,12,14 In many instances, community pharmacists became the “one-stop shop” for all things COVID-19; at a time of so much misinformation out in the world; the public trusted the pharmacist to tell them the truth.6
Due to the collaboration, coordination, and communication of community pharmacies, health was protected, and disease was prevented.6,9,12
Even as pharmacists managed the COVID-19 crisis, the federal government enacted an emergency declaration that overrode every current state and governing authority with respect to pharmacists’ (and other health providers’) ability to administer vaccines. Under the Public Readiness and Emergency Preparedness (PREP) Act, pharmacists can order and administer all appropriate childhood and adult vaccines, including COVID-19 vaccines for persons aged three years and older.14–16 For the first time, federal authority was granted to pharmacy technicians with advanced training to complete the vaccination process by administering COVID-19 and influenza vaccines to appropriate persons.15,16 While pharmacy technicians have always been tasked with ensuring that administrative duties are completed and often serve as the experts in pharmacy operations, it was not until COVID-19 that they helped fill vaccine administration gaps.17 The UNC Eshelman School of Pharmacy took early measures to create its own version of immunization training for technicians in North Carolina. Since March 2021, the Eshelman team has trained 117 pharmacy technicians spanning the vast areas of pharmacy practice in the state (Personal communication, Austin Companion, UNC Office of Lifelong Learning; January 23, 2023).
Once PREP was enacted, regardless of the practice setting, pharmacists devoted countless hours and resources to ensuring all patients received vaccine education and addressing any concerns or uncertainties.6,9 If a site was accessible, clean, and had space, pharmacists worked hard to create equal access to COVID-19 vaccines, especially for those in underserved communities and members of racial and ethnic minority groups.6,9 Patients with limiting disabilities and limited mobility received help from creative collaborations established by pharmacists. No patient or place was too far away; North Carolina pharmacists volunteered and led mass vaccine clinics at nontraditional sites including places of worship, large auditoriums, community shelters, school partnerships, offices, and business parking lots (Personal communication, Cody Clifton, North Carolina CPESN; January 23, 2023).
Between federal partnerships with pharmacy chains and the Community Pharmacy Enhanced Services Network (CPESN), which both include independent owners across the country, participating pharmacists fully vaccinated 51,554,294 people from February 11, 2021, through September 4, 2021.6 About 74% of those vaccination records contained information about race and ethnicity. Of those who documented their race and ethnicity, 43% were from racial and ethnic groups other than non-Hispanic White.6 A US Government Accountability Office analysis suggests that pharmacists fully vaccinated a disproportionately greater share of non-Hispanic Asian and Hispanic or Latino persons.6 Unpublished data from CPESN for North Carolina pharmacies show a similar correlation in vaccinating underserved and minority neighborhoods. In total, 218 North Carolina CPESN pharmacies gave a total 463,850 COVID vaccines between February and September 2021.18
The Path Forward
COVID-19 forced a paradigm shift in health care. Pharmacists were unquestionably shoved to the forefront of leadership to problem-solve medication issues that erupted because of the pandemic. Expansion of vaccine authority led to expansion of other services, such as test-and-treat and ordering COVID-19-specific therapies like monoclonal antibodies and Paxlovid. Authority was given and pharmacists figured out how to get the job done to maintain consistency in the public trust for their profession.
National leaders and organizations have provided a united voice of concern and declaration that the expanded services provided through the PREP Act need to remain in place. An April 2021 letter to United States Department of Health and Human Services Secretary Xavier Becerra requested to make permanent the regulatory flexibilities that have allowed pharmacists to support our nation’s public health response to the pandemic.19 Permanence of the expanded authority will secure pharmacists’ ability to order all approved vaccines, authorize test-and-treat, remove operational barriers, and sustain the ability of pharmacists to be paid for these services.19–21 Other leaders are speaking out about the need for pharmacists to be paid for all their clinical services, not just those performed during the pandemic.19
Payment for services related to post-COVID-19 conditions and other clinical services is already being questioned, since the state of emergency will be rescinded in May 2023. The PREP Act is likely to expire in October 2024, and former state governing authority over pharmacists and technicians will likely return to pre-COVID-19 rules and statutes. Is this really the direction in which we need to head? Should state boards of pharmacy and pharmacy associations not make plans now, working with state legislatures to ensure this well-manned, well-trained health care force is allowed to maintain its ability to navigate all areas of medication expertise? Pharmacists need the ability to work at the top of their license. Pharmacy technicians should not retreat to administration and dispensing skills only. How many vaccines would not have been administered, had technicians not been trained to do so? The North Carolina Association of Pharmacists is already working to draft legislation that will keep expanded authority for pharmacists a reality for those practicing in the state.22
Pharmacists also need to be recognized as health care providers at both the national and state level.19,20 This new proclamation would allow pharmacists to be paid for services that they either have been giving away for free or never provided in the first place because they would not be eligible for reimbursement. If the nation wants its community pharmacists to continue to serve as central sites of medication expertise for cities, towns, rural communities, and underserved populations, then states and federal authorities need to act now to ensure proper authority and payment are a permanent part of pharmacy practice moving forward.
We cannot afford to lose our pharmacy soldiers. In a nation that is already suffering from post-COVID-19 burnout and health care provider shortages, especially in rural communities, we need “all hands on deck” to ensure these essential pharmacy providers are around and equipped when the next pandemic threatens.
The author would like to acknowledge the mentorship and support provided by Macary Weck Marciniak, PharmD, BCACP, BCPS, FAPhA, of UNC Eshelman School of Pharmacy, throughout the manuscript process.
Disclosure of interests
O.G. acknowledges that she is an employee of the UNC Eshelman School of Pharmacy at the University of North Carolina at Chapel Hill. She reports no potential conflicts of interests.