A Scandalously Short Introduction to the History of Pharmacy

Chapter 8 - The Twentieth Century

In the 19th century, pharmacy began a transformation from an art to a science. Natural products that were long a staple in the pharmaceutical armament were being analysed for their chemical makeup. Scientists began exploring the structure of drugs, linking structure to the activity of compounds, and they began to synthesise compounds with similar structures. Industry was in its infancy but the mass production of drug products had started. there was no longer the need for Pharmacists to know the habitat, the part of the plant used and the time of gathering of their raw aterials. New standards and new knowledge meant new opportunities for precision in prescribing compounding and dosing; opportunities that pharmacy and medicine had never known before.

As noted in an earlier chapter, it was in the 20th century that we saw a virtual explosion in drug development. This is perhaps most evident in the proliferation of antibiotics. In 1928, Alexander Fleming observed the inhibitory effects of a mould contaminate in a plate culture of staphylococcus bacteria. The mould culture was Penicillium notatum, hence the name penicillin. Ten years later, a group at Oxford refined a technique to extract sufficient quantities of the drug for testing. By the onset of World War II, penicillin was being mass-produced. In 1999, the number and types of available antibiotics have grown exponentially. Besides penicillin, we have extended spectrum penicillins, cephalosporins, sulfas, arninoglycosides, tetracyclines, erythromycins, quinolones, vancomycin, and clindamycin, to name a few.

With the rapid growth in the number and classes of medicines, it would be difficult to pick key drugs that have changed healthcare dramatically. However, it is possible to list the top drug categories that have had a great impact on worldwide society.

Vaccines

In the last half of the 20th century, vaccines have prevented millions of deaths from diseases such as smallpox and measles.

Antibiotics

At the beginning of this millennium, infection was one of the major causes for premature death. In the last decades of the millennium, we speak in terms of the causative organism in an infection and whether it is sensitive to an array of anti-infectives.

Contraceptives

This class has had major effects on the social dynamics of our society and medicine.

Antineoplastics

Cancer is no longer an automatically terminal disease. Some types of cancer are now curable.

Analgesic/Anaesthetics

Use of anaesthetics has contributed greatly to the development of surgical medicine. Analgesics have not only relieved the pain of injury, arthritis, and headache, but they have also improved the quality of life for many sufferers.

Cardiovascular agents

Along with lifestyle modifications, these agents have improved the quality of life, decreased the chances of the development of other cardiovascular problems, and decreased the occurrence of early death and disability for many patients.

Mental health drugs

Before the discovery and development of these drugs, individuals suffering form depression, bipolar disease, schizophrenia, obsessive compulsive disorder, and other mental health illnesses that were refractory to conventional medical therapy had no other recourse.

The Future

The face of pharmacy may have changed over the past 1000 years, but its traditional role remains the same. Although the preparation and preservation of drug products have moved from the pharmacy to the pharmaceutical industry, the pharmacist continues to fulfil the prescriber's intentions by not only dispensing a medication but also by providing a quality product, providing adviceand information, and monitoring drug therapy.

Looking to the Future  from two viewpoints ; 70 years apart !

1. Circa 1933  (Mr. K.Williams, Australasian Pharmaceutical Notes & News, Jan 10th 1933)

"The future of pharmacy as a whole depends upon the cultivation and development of the professional side of the business of a chemist and druggist, the principal bases and components of which are the owning and managerial personnel, and theoretical and practical knowledge of materia medica, distribution by sale to the public of drugs, medicines, and appliances, in accordance with `the law; application of special knowledge of the pharmacist to the making of medicinal preparations for human and animal ailments; utilisation of these forms of medicament, and the employment of drugs and compounds in dispensing; manufacture and sale of pharmaceutical preparations for general domestic and toilet use; sale of poisons subject to legal requirements and procedure; the preparation of antidotes, etc.

"For the preceding and similar purposes, it is a pre-requisite that such a business shall be owned or personally conducted and supervised by a qualified person as provided for by law. It is desirable and even necessary that its qualified principal or manager should have had instruction in and possess a fair general knowledge of pharmacology with special reference to the bio-chemical and biological products to which a vogue will be given by the new British Pharmacopoeia.

"Post-graduate courses in food and drug analysis and bacteriology for the pharmacist would be in-valuable as professional aids in business.

"The future fortunes of pharmacy, if they are to be useful and prosperous, are dependent mainly on action through official organizations in order to ensure co-operation and unity in professional and business policy and practice, especially as to a minimum tariff in dispensing. As to the sale of poisons it is essential to the public interest, and as a fundamental right of the pharmacist that, as far as practicable, these should be handled exclusively by pharmacists who can do much to prevent the indiscriminate sale of potent drugs. In virtue of his qualification, and their experience of him, the public have" confidence in the pharmacist, but this confidence must not 'be abused.

2 - Circa 2004  ( Mr.Jay Hooper, President of the Pharmaceutical Society of Australia) 
With increasing pressure to rein-in Australia's health costs and a looming crisis in trained health professionals, future pharmacists would play a vastly different role than they do at present. The pharmacists of the future would not be sitting behind a counter dispensing medicines - this be undertaken by trained technicians and dispensary assistants - they would be out there interacting one-on-one with patients.

Governments had been working to make optimal use of workforce skills and ensure best health outcomes, and they had recognised that a complementary realignment of existing workforce roles, or the creation of new roles, may be necessary. Any workforce redesign will address health needs, the provision of sustainable quality care and the required competencies to meet service needs.

That means the Pharmaceutical Societies being intimately involved in the curriculum of pharmacy schools and also being intimately involved in the continuing professional education of pharmacists and doing so in such a way as to ensure that it is focused on professional standards and ethics and not subject to undue influences. In order for pharmacists to have an appropriate role in the health-care continuum they need have to look at new models for the practice of pharmacy. and in so doing they also have to ensure that the practice of pharmacy is both attractive and rewarding to ensure the best and brightest consider it as a worthwhile career and enroll in pharmacy degrees.

While health care must be safe and in line with community expectations, it must also be grounded in economic and financial reality. Optimal use of pharmacists is the key to this economic reality and sustainability of health care in Australia. The profession should seriously consider pharmacists being given a role in the provision of prescribing, vaccination and screening services, but one of the major issues for pharmacists is going to be the ability to adapt to new practice models.

Throughout the last half century the Pharmaceutical Benefits Scheme (PBS) has become a major source of remuneration for pharmacists' professional services. Under this system pharmacists are paid for supply of a PBS benefit - which is defined as a product. In the early days of the PBS when there were less than 100 medications on the list, a significant part of the pharmacist's time was devoted to the compounding of these products. The paternalistic medical model prevailed where intervention and counselling was a minor activity. In this model it was quite reasonable to base remuneration on supplying a pharmaceutical product.

However, the pendulum has swung full circle and now very little time is spent in compounding. There are over 1500 different medications on the PBS now and health consumers are demanding a patient-focused shared or empowered model of delivery. The medications are far more complex and it is essential that pharmacists add value in extensive counselling services and contribute to significant interventions.The remuneration for supply and dispensing functions no longer reflects the nature of the activity. The real challenge for pharmacists is to be seen as the solution to Australia's undoubted health-care workforce problem. Pharmacists have to be willing to demonstrate a visible, credible, consistent and competent option, as well as being an attractive financial alternative.

Perhaps the goal of pharmacy in the future is to have a prescriber write the following prescription:

Joe Smith (Medical history attached)
Dispense: antihypertensive medication
Wouldn't that be something to look forward to?