HISTORY117 - Pharmacy

This blog arose from a visit to the University of Arizona’s Coit Museum of Pharmacy and Health Sciences that Pat and I made in August.  We were intrigued with the exhibits displaying the history of pharmacy - a very well put together presentation.  I wanted to learn more about the subject; this blog is the result.

 

After a short introduction, I’ll discuss the history of pharmacy from ancient times through the present, and then finish with a look at the future of pharmacy.

As usual, I will list my principal resources at the end.

 

Introduction

Pharmacy is the science of preparation, dispensing, and optimal use of medications to protect or improve patient health.  Its scope includes the cultivation of plants that are used as drugs, the synthesis of chemical compounds of medicinal value, and the analysis of medicinal agents.  Pharmacists are responsible for the preparation of the dosage forms of drugs, such as tablets, capsules, and sterile solutions for injection, and for counseling patients on their proper use. 

The evolution of pharmacy, ranging from the ancient times to the modern era is a crucial reflection of the advancements in science, technology, and healthcare systems.

 

Ancient Civilizations

Prehistoric people used medicinal plants such as herbs, and learned pharmaceutical techniques through instinct, by watching injured animals’ behavior, using cool water, leaves, dirt, or mud as a soothing agent or to stop bleeding.  Knowledge of materials with healing properties would have passed down through different groups.  In ancient times, pharmacy was primarily associated with religion and mysticism. 

Mesopotamia and Egypt: Documentation on clay tablets suggests that early forms of pharmacy emerged in Mesopotamia around 2600 BC, with remedies based on herbs, vines, roots, and barks.  Ancient Egyptian knowledge of pharmacology was recorded in various papyri, including two from the 16^th century BC: the Ebers Papyrus, documenting more than 800 remedies, and the Edwin Smith Papyrus.  Each group of people would have a designated person who was the equivalent of a priest, pharmacist, and physician all in one.

Ancient Greece and Rome: The Greeks believed that illness was divine punishment, and that healing or medicine was a gift from the gods.  Their pharmacists were considered healers who had access to divine knowledge.  Later in ancient Greece, thinkers like Diocles of Carystus (4^th century BC) studied medicinal plants, while Pedanius Dioscorides (1^st century AD), known as the “father of pharmacology” compiled a comprehensive work on medicinal substances, De Materia Medica, which became influential throughout the Middle Ages and beyond.  The Romans organized medical and pharmaceutical knowledge, and converted theories into rules.  Greeks and Romans prepared their own prescriptions.

The father of pharmacology, ancient Grecian Pedanius Dioscorides.

 

Arab Influence: The Arabs played a pivotal role in the development of pharmacies, introducing innovative techniques of distillation, plant extraction, and substance mixing in the 2^nd century AD. The first established privately owned pharmacies appeared in Baghdad in the 8^th century AD.  Hospital pharmacies followed in the 12^th century AD.

Middle Ages and Renaissance

After the fifth century fall of the Western Roman Empire, medicinal knowledge in Europe suffered due to the loss of Greek medicinal texts.  In the early 11^th century, Salerno scholar Constantinos Africanus translated many Arabic books into Latin.  In addition, Arabic medicine also became more widely known due to Muslim Spain.

During the Middle Ages, pharmacy began to shift towards a more scientific approach.  Alchemists experimented with various substances in search of the elixir of life and other mystical cures.  Alchemists were also instrumental in developing new medicines, such as the use of mercury as a treatment for syphilis.

Pharmacy-like shops began appearing in Europe during the 12^th century.

A crucial development occurred in 1240 when European Holy Roman Emperor Frederic II decreed the separation of the physician's and pharmacist’s professions.  The trend towards pharmacy specialization continued in Bruges, Belgium where a law was passed that forbade physicians to prepare medications for patients.  Pharmacists began to focus on the preparation and compounding of medicines, which led to the development of new drugs to treat various ailments. 

Holy Roman Emperor Frederic II decreed the separation of the physician's and pharmacist’s professions in 1240.

 

The Renaissance witnessed a more scientific and professional approach to pharmacy. The advent of the printing press in the 15^thcentury facilitated the spread of medical knowledge, and pharmacists began organizing into professional organizations.  The Royal College of Apothecaries of Valencia, founded in 1441, is considered the oldest in the world. 

Note: “Apothecaries” is an older term, equivalent to the more modern word “pharmacists.”  I use “pharmacists” throughout this article. 

The training of pharmacists during the late Middle Ages primarily occurred through a system of apprenticeships regulated by the professional guilds.

 

Birth of American Pharmacy

Notwithstanding 13^th century European decrees and laws trying to separate the medical and pharmacy professions, in the 18^th and 19^th centuries, American pharmacy evolved from a combination of traditional pharmacists, physician-run drug shops, and general stores selling medicines.  

Early American pharmacists were both drug sellers and providers of medical advice, particularly in areas with limited access to physicians. They often manufactured their own medicines, utilizing a combination of imported and domestically produced ingredients.  Many physicians also ran their own pharmacies, dispensing medications alongside their medical practice.  General stores, particularly in rural areas, often carried a variety of medicines, including patent medicines (medicines that were sold without a prescription and often without regulation).

Christopher Marshall, an Irish immigrant, opened one of the first pharmacies in Colonial America in Philadelphia in 1729, serving as a community pharmacy and a training ground for aspiring pharmacists.

In Colonial America, training to be a pharmacist was primarily through a seven-year apprenticeship to an experienced practitioner, not formal schools.  Apprentices learned through a combination of hands-on experience and study of texts, eventually becoming competent enough to be examined by a guild or company of pharmacists.  (A formal pharmacy education system and state licensing began to emerge later, with the first college of pharmacy established in 1821.  See below.)

The first hospital pharmacy in the United States was established at Pennsylvania Hospital in Philadelphia in 1752.  Jonathan Roberts was the first pharmacist at the hospital, which was also the first public hospital in the country. 

 

Painting of Jonathan Roberts n the pharmacy at the first public hospital in Colonial America.

The 18^th and 19^th centuries saw a rise in patent medicines with secret formulas and exaggerated claims of cures. 

In these early days, many physicians were concerned about the quality of both medicine and pharmacists in the country. They founded the United States Pharmacopeia (USP) in 1820 to develop and publish uniform sets of guidelines and standards of practice.  The USP still performs this function today.

In addition to more standardization, there was a desire for more formalization and training within the practice, as well.  The Philadelphia College of Pharmacy was subsequently founded in 1821, becoming America’s first pharmacy school.  The development of formal pharmacy training programs occurred throughout the 19^th century. 

American pharmacy continued to evolve and adapt to new challenges and opportunities.  The introduction of new technologies, such as the microscope, enabled pharmacists to better understand the composition of drugs and the different mechanisms of disease.

The United States formed the American Pharmaceutical Association in 1852, with its main purpose to advance pharmacists' roles in patient care, assist in furthering career development, spread information about tools and resources, and raise awareness about the roles of pharmacists and their contribution to patient care.

Education for pharmacists became more science-based after the Morrill Land-Grant Act of 1862 that spurred the creation of state universities, including the University of Michigan, which offered the first science-based pharmacy program in 1868. 

By the late 1880s, German dye manufacturers had perfected the purification of individual organic compounds from tar and other mineral sources and had also established rudimentary methods in organic chemical synthesis.

In the late 19^th century, firms other than the pharmacies themselves began centralized manufacturing of medicinal preparations.

 

Modern Era and Evolving Roles

The evolution of required education for pharmacists continued with the establishment of the Bachelor of Science degree in the early 20^th century, a requirement that was later superseded by the mandatory Doctor of Pharmacy degree by 2004. 

The “Soda Fountain” Era: 1920-1949. The early 20^th century saw the rise of industrialization across America, bringing unprecedented changes to every industry, including pharmacy. Compounding medications - long a specialized role the pharmacist alone performed - was not as necessary as it once was because drugs were being mass-produced and shipped to pharmacies.  This created an identity crisis of sorts for the profession: They weren’t making medicines; they were simply dispensing them. Furthermore, ethical standards at the time barred pharmacists from talking to patients about their medications, considering it a violation of their privacy.

Prevented from doing as much hands-on healthcare work as in the past, pharmacists turned to more front-end sales to be profitable.  Candy, household items, fountain-poured soda pops and - especially during Prohibition years - medicinal alcohol all became profit drivers for pharmacies.  It got to the point where less than 1% of pharmacists in the country got more than 50% of their sales from prescription drugs.

In the 1940s, because of restrictions on talking to patients about their medications, pharmacies often included soda fountains to maintain profits.

 

However, by the midpoint of the 20^th century, things would start to change again.

The “Customer Turned Patient” Era: 1950-1979. This period in pharmacy history was defined by a deep divide within the profession around the mix of nonclinical vs. clinical activities of pharmacists.  The Durham-Humphrey Bill in 1951 significantly changed the pharmacist's role by requiring a physician's prescription for many medications, limiting pharmacists to dispensing and recommending over-the-counter drugs.  Pharmacists began to step away from the soda counter and back behind the pharmacist window.  However, they were still mostly dispensing medication, not clinical advice.

This began to change in the 1960s when visionary pharmacist Eugene White, in his own pharmacy, instituted a transformational shift in how pharmacies could be run with an enhanced focus on patient care.  Some of his innovations would come to define what many people of the postwar generation would think of when they thought of pharmacy, including detailed record systems to keep track of a family’s prescriptions, a support staff to help with administration and patient care, and more availability to counsel patients on medications, drug interactions, and other clinical concerns.

This last point was a major difference in the ethical standards of how pharmacists had been able to care for patients.  For decades, pharmacists were instructed to avoid counseling patients directly, but now that behavior was being viewed as an important part of the role.

The “Pharmaceutical Care” Era: 1980-2009. The Clinical Pharmacy Movement starting in the 1980s began to expand the role of pharmacists, enabling them to provide patient counseling and manage chronic conditions.

By the 1990s, the pharmacist’s role had expanded to permit patient counseling. 

In the 1990s, pharmacists also began to increase their role as community immunizers by administering vaccinations.  Allowing pharmacists to immunize patients on-site at pharmacies was a critical reason for the increase in the immunized population going into the new century.  Pharmacies became critical vaccine distribution sites for national and more-localized disease outbreaks. This was most recently observed during the COVID-19 pandemic.

The “Pharmacy Evolution” Era: 2010 to Present. The Affordable Care Act (ACA) of 2010 expanded health insurance coverage, which increased access to prescription drugs for millions of Americans.  The closure of the Medicare Part D "doughnut hole" improved affordability for seniors.  The ACA also increased pharmaceutical companies' financial responsibilities through provisions like the Coverage Gap Discount Program and the Branded Prescription Drug Fee.

The period from 2010 to the present witnessed a dynamic evolution in the pharmacy industry, marked by significant closures, shifts in ownership, expansion of pharmacist roles, technological advancements, and lately, the specter of “Big Pharma.” 

Nearly one in three U.S. retail pharmacies closed between 2010 and 2021, disproportionately impacting independent pharmacies and communities with a high percentage of Medicaid and Medicare patients.  This trend has been attributed to factors like corporate consolidation, reduced profitability of front-end drugstore sales, and the ability of mass retailers to use generic drugs as loss leaders.  Chain, supermarket, and mass retailer pharmacies now represent almost two-thirds of all U.S. pharmacy locations.

Mail-order pharmacies have gained significant market share due to the increasing preference for online shopping and convenience.  

The role of pharmacists continued to expand.  Pharmacists are increasingly integrated into both inpatient and outpatient settings, managing chronic conditions like diabetes and hypertension, prescribing medications (subject to state limits), providing pre-discharge education, and even working in emergency departments.

Automation technologies, including automated dispensing cabinets and robotics, have streamlined medication use and allowed pharmacists to focus on patient care.  Other technological advancements include digital biomarkers, digital therapeutics, clinical informatics, and flexible manufacturing for personalized medicine

Today, pharmacists are increasingly involved in Medication Therapy Management, a pharmacist-provided service that helps patients optimize their medication use for better health outcomes by conducting comprehensive medication reviews, creating personalized medication action plans, and providing patient education.

Clouding the “Pharmacy Evolution” Era was the development of “Big Pharma,” referring to the few large, influential, and profitable pharmaceutical companies (like Pfizer, Johnson & Johnson, AbbVie, and Merck & Co.) that develop and manufacture prescription and over-the-counter drugs and other medical products.  The term is often used to describe the industry's controversial practices, such as alleged prioritization of profit over public health, high drug pricing, and political lobbying.  These pharmaceutical companies are often criticized for pricing medications excessively, making treatments unaffordable for many patients, and hindering access to essential drugs. 

 

Future Trends

The future of pharmacy is evolving towards a more patient-centric, technology-driven, and clinically focused model.  This shift will require pharmacists to adapt to new technologies, expand their clinical knowledge, and embrace a more proactive approach to patient care. 

Pharmacists are expected to become more involved in direct patient care, including prescribing and monitoring medications, and providing personalized health advice. 

Automation, artificial intelligence, and digital tools will streamline operations, and enhance medication management, patient care, and efficiency through tasks like drug interaction analysis, workflow automation, and predicting medication demand.  By analyzing a patient's genetic profile, pharmacists will move beyond the traditional "one-size-fits-all" approach to medication by proactively identifying the most effective drugs and dosages, predicting side effects, and improving patient outcomes. 

Reimbursement models will shift towards value-based care, incentivizing pharmacists to provide more comprehensive and proactive services. 

Telepharmacy and virtual consultations will become more prevalent, expanding access to care and improving medication adherence. 

Pharmacies are expected to evolve into wellness centers, offering services like health screenings, preventive care, and community outreach programs. 

Pharmacists will work more closely with other healthcare professionals to improve patient outcomes. 

Pharmacies will face increased competition from online pharmacies, mail-order services, and other healthcare providers. 

“Big Pharma” will face increasing pricing pressures from legislation and increased competition.

 

 

 

"Always laugh when you can. It is cheap medicine." -  Lord Byron

 

 

 

Sources

My principal sources include: “History of pharmacy,” Wikipedia.com; “The history of pharmacy,” express-script.com; “The Evolution of Pharmacy: Mysticism to Modern Medicine,” customcompounding.com; “The History of Pharmacy Practice,” researchgate.net; plus, numerous other online sources, including answers to queries using Google in AI Mode.