PUBLIC HEALTH

PHARMACY(WITH
PHARMACOEPIDEMI
OLOGY)
Leslie M. Daileg, RPh, M.D., MPH
 PUBLIC HEALTH PHARMACY (WITH
PHARMACOEPIDEMIOLOGY)

• Introduction to Public Health

• Public Health Definition and Key Terms
• History of Public Health
• A Public Health Approach
• Core Functions and Essential Services of Public Health
• Stakeholder Roles in Public Health
• Determining and Influencing the Public’s Health
 LEARNING OBJECTIVES;

After this course, you will be able to:

• Describe the purpose of public health

• Define key terms used in public health
• Identify prominent events in the history of public health
• Recognize the core public health functions and services
• Describe the role of different stakeholders in the field of public health
• List some determinants of health
• Recognize how individual determinants of health affect population health
 Public Health Definition and Key Terms

• Public Health
Charles-Edward Armory Winslow is a leading figure in the development of the modern study
of public health. His definition of public health, developed almost a century ago, is as follows:

• “Public health is the science and art of preventing disease, prolonging life and promoting health through the
organized efforts and informed choices of society, organizations, public and private communities, and individuals.”

• Note the influences at the broader, societal, and community levels as well as the individual levels
 The Mission of Public Health

• “Fulfilling society’s interest in assuring conditions in which people can be healthy.”

—Institute of Medicine

• “Public health aims to provide maximum benefit for the largest number of people.”
—World Health Organization

• Public health focuses on groups of people, rather than just an individual. At the core of public
health lies the principle of social justice, providing people the right to be healthy and to live in
conditions that will support their health.
 Terms and Definition
• Clinical care
prevention, treatment, and management of illness and the preservation of mental and physical well-being through the
services offered by medical and allied health professions; also known as health care.
• Determinant
factor that contributes to the generation of a trait.
• Epidemic or outbreak
occurrence in a community or region of cases of an illness, specific health-related behavior, or other health-related event
clearly in excess of normal expectancy. Both terms are used interchangeably; however, epidemic usually refers to a larger
geographic distribution of illness or health-related events.
• Health outcome
result of a medical condition that directly affects the length or quality of a person’s life.
 The History of Public Health

Few historical highlights through four lenses,

✓ Sanitation and environmental health,

✓ Pandemics,
✓ Disaster response and preparedness, and
✓ Prevention and policy.
 1. SANITATION AND
ENVIRONMENTAL HEALTH-
✓ encompasses the control of disease and promotion of health through sanitation to
ensure a healthy environment.

➢ 500 BCE- Greeks and Romans practice community sanitation measures

➢ 1840s- The Public Health Act of 1848 was established in the United Kingdom
➢ 1870- The Environmental Protection Agency was founded. The Nixon
Administration established the Environmental Protection Agency, which protects
human health by safeguarding air, water, and land.
 2. PANDEMICS
✓are epidemics or outbreaks of disease that spread far and wide, affecting the
populations of multiple continents.

➢INFLUENZA- 500 million infected worldwide in 1918

the Spanish flu infected 500 million people across the world, including remote Pacific
islands and the Arctic, killing 20 to 50 million persons. More recently, the influenza
pandemic in 2009 infected persons in 214 countries, causing almost 19,000 confirmed
deaths
➢ POLIO- Vaccine introduced in 1955; eradication initiative launched in 1988.
Historically, polio was a common and highly feared disease that caused severe illness, including
paralysis, and death among thousands of people each year. Thousands of people lined up to
receive the polio vaccine after it was introduced in 1955. An initiative to eradicate polio was
launched in 1988 because of outbreaks in more than 125 countries.
➢ HIV- 34 million living with HIV worldwide; 20% decline in new infections since
2001
Public health has responded to this pandemic by developing new ways to diagnose and treat
those who are infected. New infections of HIV are down 20% over the past 10 years, which is a
sign that public health interventions are successful.
 3. PREPAREDNESS FOR DISASTER
RESPONSE

• Biologic Warfare- Plague used as a weapon of war during the Siege of Kaffa. The use of
biological warfare to infect people and animals goes back centuries.
• September 2001- Public health surveillance conducted after the 9/11 attacks.
• In the immediate wake of the terrorist attacks on September 11, 2001, public health workers
were on the ground at the World Trade Center and the Pentagon, conducting surveillance to
identify outbreaks of diseases or other possible health conditions resulting from the attacks.
• Public health workers closely monitored the health of first responders, city residents, and
environmental conditions to detect health threats during the cleanup after the attack.
• Hurricane Katrina-public health workers and other disaster-relief agencies
tirelessly provided emergency services. Teams were dispatched to conduct
surveillance for illness and injury among people who evacuated to shelters
and other places of refuge after the storm.
4. PREVENTION THROUGH POLICY-
• Public health works to protect and improve health, not just by responding to disease
outbreaks or preparing for natural or human-made disasters, but also by
implementing policies that support these efforts on a societal level.
• Book of Leviticus- The world’s first written health code
• As far back as 1500 BCE, Leviticus, the third book of the Hebrew Bible, is believed
to be the first written health code in the world. The book deals with personal and
community responsibilities and includes guidance regarding bodily cleanliness,
sexual health behaviors, protection against contagious diseases, and isolation of
lepers.
• Tobacco Laws- Laws banning smoking in the workplace and other public
places have been developed to encourage smokers to quit while protecting
nonsmokers from the effects of second-hand smoke. Implementation of sin
tax.
• Obesity- Food labeling and promotion of physical activity
Efforts to highlight fat, sugar, and salt content in foods through labeling
regulations have been developed along with the promotion of physical activity
in schools, workplaces, and neighborhoods.
A PUBLIC HEALTH APPROACH
1. What is the problem?
In public health, we identify the problem by using surveillance systems to monitor health events and
behaviors occurring among a population.
2. “What is the cause of the problem?”
Are there factors that might make certain populations more susceptible to disease, such as something in
the environment or certain behaviors that people are practicing?
3. “What intervention works to address the problem?”
what has worked in the past in addressing this same problem and if a proposed intervention makes sense
with our affected population.
4. How can we implement the intervention? Given the resources we have and what we know about the affected
population, will this work?”
 Public Health Core Sciences

• To implement the public health approach, practitioners use and apply

scientific methods. These methods come from a series of core sciences that
provide the foundation.
• These five core sciences can help us protect and promote the public’s health
by giving public health practitioners the answers they need.
• Public health is better able to respond to the situation by using contributions
from each of these sciences.
• One science alone cannot answer the questions and provide a solution; it is
the application of these core sciences together.
❑ Public Health Surveillance- use to monitor a public health situation.
❑ Epidemiology -determine where diseases originate, how or why they move through populations,
and how we can prevent them.
❑ Public Health Laboratories support public health by performing tests to confirm disease
diagnoses. Laboratories also support public health by conducting research and training.
❑ Public Health Informatics -deals with the methods for collecting, compiling, and presenting
health information. It enables us to use electronic data effectively when addressing a public health
situation.
❑ Prevention Effectiveness is closely linked to public health policy. Prevention effectiveness
studies provide important economic information for decision makers to help them choose the
best option available.
 Assignment
• Example of case: Cholera — A Public Health Approach
• During the early 1800s in London, cholera, a fatal intestinal disease, was rampant, causing
death to tens of thousands of people within hours of the first symptoms. At the time —
which was before bacteria and viruses were recognized as the cause for many diseases —
popular opinion held that cholera was caused by bad air coming from rotting organic matter.
• John Snow, a British physician during that time, had a different opinion of cholera. He
believed that the illness was spreading by way of a contaminated water supply because
sewage was routinely dumped into the Thames River and cesspools near town wells. Because
of his work tracing the source of the cholera outbreak, he is often considered the father of
modern epidemiology. His research changed the way we look at disease.
• Public health approach to Snow’s research of the cholera outbreak
1. What is the problem?
2. Risk Factor Identification — What Is the Cause?
3. Intervention Evaluation — What Works?
4. Implementation — How Do You Do It?
Three Core Functions of Public Health

• In 1988, the Institute of Medicine defined three core functions of public

health agencies that must be carried out at all levels of government for the
overall public health system to work effectively.
• The three core functions are assessment, policy development, and assurance.
a. Assessment is knowing what needs to be done;
b. Policy development is being part of the solution to get it done; and
c. Assurance is making sure it gets done.
• Ten essential public health services are grouped under the three core
functions.
• These services are not a prescription for what public health agencies should
be doing. Instead, they are intended to serve as a descriptive tool to capture
the field of public health and to communicate what public health provides.
 Example: TOBACCO USE
PREVENTION

• . Assessment
• Monitor health status: Monitor smoking use among segments of the population, such
as youth.
• Diagnose and investigate health problems: Investigate risk factors associated with
tobacco use.
• 2. Policy Development
• Inform, educate, and empower people about health concerns: Place public service
announcements on television regarding the dangers of smoking.
• Mobilize community partnerships: Work with advocacy groups to develop
antismoking interventions that will work in a specific community.
• Develop policies and plans: Passage of Proposition 99 (the cigarette tax to fund
antismoking campaigns); smoke-free workplaces, apartment complexes, and other
shared spaces.
• Assurance
• Enforce laws and regulations: Enforcement of policies and laws, such as placement of cigarette vending
machines.
• Link people to needed personal health services: Address potential barriers related to culture and the
language of materials, or staff serving special population groups. In California, ads in the tobacco control
media campaign were broadcast in Spanish and Mandarin as well as English.
• Assure a competent public health and personal health care workforce: Ensure a knowledgeable
workforce is in place to develop and implement the antismoking campaign.
• Evaluate effectiveness: Ongoing evaluation of the campaign to ensure it works as desired; determining how
it might be improved.
• Research for new innovative solutions to health programs: Take insights gained from the field on what
works and confirm them through collaborative study with health researchers.
 Core Functions at Government Levels
Assessment Policy Development Assurance

FEDERAL National tobacco public health Smoking ban Federal grants

surveillance on commercial flights for antismoking
research

STATE Monitor state Increase Funding

tobacco use tobacco tax for campaign through
Proposition 99

LOCAL Report on local County laws Resources to help

tobacco use prohibiting smokers quit
smoking in bars in multiple languages
 Stakeholder Roles in Public Health

• The field of public health is broad and interdisciplinary. Beyond government,

it requires stakeholders with skills in intervention programs, policies,
research, evaluation, and education.
Other sectors and that have a stake in public health;
• Transportation
• Housing,
• Schools,
• City planning, or law enforcement.
• Nongovernmental organizations (often referred to as “NGOs”) play a key
role in public health, especially at the community level. NGOs serve many
different purposes from advocacy or education to emergency relief and
economic development. General types of NGOs include
• Health care plays a vital role in protecting and promoting the public’s health
along with public health organizations. The two have differences that are
worth highlighting here. Public health focuses on populations, while clinical
care focuses on the individual patient.

• Health care and public health are complementary. When they work
collaboratively, all people benefit.
Public Health Health Care

Population focus Individual patient focus

Public health ethic Personal service ethic

Prevention or public Diagnosis and treatment emphasis

health emphasis

Joint laboratory Joint laboratory

and field involvement and patient involvement

Clinical sciences peripheral to professional training Clinical sciences essential to professional training

Public sector basis Private sector basis

 Interpretation of the Health Problem and
Need for Treatment
Genesis of Social Pharmacy
1.1 Concepts of Health and Illness
Definitions and Meaning of Health and Illness
• Social Epidemiology
1.2 Models and Frameworks for Health and Illness Behaviors
Individual and Interpersonal Models of Health and Illness Behavior
• Health Promotion: Program Planning & Evaluation
 Social pharmacy as a field of study: The needs
and challenges in global pharmacy education

Significant changes in the practice of pharmacy

• Pharmacy curricula
- changing economic, political, and social environment
 Pharmacist's role had expanded

• More direct interaction with the public

❖provision of health
❖advice on the safe and rational use of medications
• Extensive transitions in pharmacy curricula at the global level
• Incorporation of social and behavioral sciences topics
 Social Pharmacy

• Initially-social distribution of drug use and ‘ ‘pharmacoepidemiology’’

• Recognized-mapping drug use in the population
❖perspective on pharmacy that complements the behavioral and physical
science
❖ social implication associated with the therapeutic and nontherapeutic uses of
pharmaceutical preparations
❖individual and group behavior and the social systems
 The Alma-Ata Declaration of 1978

• Major milestone of the twentieth century in the field of public health, and it
identified primary health care as the key to the attainment of the goal of
Health for All.
• The Conference strongly reaffirms that health, which is a state of complete physical,
mental, and social well-being, and not merely the absence of disease or infirmity, is a
fundamental human right and that the attainment of the highest possible level of
health is a most important world-wide social goal whose realization requires the
action of many other social and economic sectors in addition to the health sector.
• The existing gross inequality in the health status of the people, particularly
between developed and developing countries as well as within countries, is
politically, socially, and economically unacceptable and is, therefore, of common
concern to all countries.
• The people have a right and duty to participate individually and collectively in the
planning and implementation of their health care.
• Primary health care is essential health care based on practical, scientifically sound, and
socially acceptable methods and technology made universally accessible to individuals
and families in the community through their full participation and at a cost that the
community and country can afford to maintain at every stage of their development in the
spirit of self-reliance and self-determination. It forms an integral part both of the country's
health system, of which it is the central function and main focus, and of the overall social
and economic development of the community. It is the first level of contact of individuals,
the family, and community with the national health system bringing health care as close as
possible to where people live and work, and constitutes the first elements of a continuing
health care process.
• An acceptable level of health for all the people of the world by the year
2000 can be attained through a fuller and better use of the world's resources,
a considerable part of which is now spent on armaments and military
conflicts. A genuine policy of independence, peace, détente, and
disarmament could and should release additional resources that could well be
devoted to peaceful aims and in particular to the acceleration of social and
economic development of which primary health care, as an essential part,
should be allotted its proper share.
 Definitions and Meaning of Health &
Illness

• Definitions of health
Constitution of the World Health Organization, April 7, 1948
• Health is a state of complete physical, mental and social wellbeing.
• An individual, if he is to be considered healthy, should not suffer from any
disease (....“and not merely the absence of disease or infirmity or sickness”)
• Three types of definition of health
• Absence of any disease or impairment.
• A state that allows the individual to adequately cope with all demands of
daily life
• (implying also the absence of disease and impairment).
• A state of balance, an equilibrium that an individual has established within
himself and between himself and his social and physical environment.
 1st & 2nd types of definition of health

• Health is the absence of any disease or impairment.

• Health Is a state that allows the individual to adequately cope with all demands of daily life
(implying also the absence of disease and impairment).

• Consequences...
➢ Individuals who have abnormalities counted as symptoms of a disease but do not feel ill.
➢ body tissues of others do not demonstrate changes but who feel ill and do not function
well.
➢People who hear voices and might be candidates for psychiatric examination and treatment
 3rd Type of definition of health
•Health is a state of balance, an equilibrium that an individual has established
within himself and between himself and his social and physical environment.
• Those with a disease or impairment will be considered as being healthy
• Diseases do not replace individuals’ health
• Doctor must explore how individuals who have a disease feel about it
- to view the disease in the context of the person to make a judgment about his
level of health
 Disease as a Conceptual Tool

• A type of internal state which impairs health (i.e., reduces one or more functional ability below typical
efficiency). – Boorse
• Seven themes in line with the notion of disease
➢ Pain, suffering and discomfort
➢ Treatment by physicians
➢ Statistical normality
➢ Disability
➢ Adaptation
➢ Homeostasis
➢ Value
▪ Definition of disease
• A state in which human capacity fluctuates and represents a deviation from
biomedical standard or normal human condition.
✓Medical intervention
✓Diagnosed through medical analysis
✓Not always the presence of a pathological agent
 Government Programs
• The Philippine Health Agenda for 2016 to 2022
• Health has been a priority in the Philippine development agenda since the
adoption of the Millennium Declaration. Among the eight Millennium
Development Goals (MDGs), there are three health-specific goals—for child health
(MDG4), maternal health (MDG5), and combating HIV/AIDS, malaria, and other
diseases (MDG6). In addition, the goal for reducing poverty (MDG1) includes
nutrition targets, which directly impact health; and three other goals address social
dimensions critical for improving health—education (MDG2), gender equality
(MDG3), and environmental sustainability (MDG7).
•
• The principal health-specific SDG is SDG No. 3: Ensure Healthy Lives and
Promote Well-Being for All at All Ages. Within SDG 3 are nine major targets
namely:
• 1. Reduce the global Maternal Mortality Rate (MMR) to less than 70 per
100,000 live births .
• 2. End preventable deaths of newborns and under-five children.
• 3. End the epidemics of AIDS, tuberculosis, malaria, and neglected tropical
diseases and combat hepatitis, water-borne diseases, and other communicable
diseases
• 4. Reduce by 1/3 pre-mature mortality from NCDs through prevention &
treatment, & promote mental health & wellbeing
• 5. Strengthen prevention & treatment of substance abuse, including narcotic
abuse & harmful use of alcohol.
• 6. Halve global deaths & injuries from traffic accidents
• 7. Ensure universal access to Sexual & Reproductive Health (SRH) care
services, including family planning, information & education, & integration
of Reproductive Health into national strategies & programs.
• 8. Achieve universal health coverage (UHC), including financial risk
protection, access to quality essential health care services, & access to safe,
effective, quality, & affordable essential medicines & vaccines for all.
• 9. Substantially reduce the number of deaths & illnesses from hazardous
chemicals & air, water, and soil pollution & contamination.
• Health Agenda for 2016 to 2022
• Within the framework of the MDGs and the SDGs, the Philippine Health
Agenda can be summed as follows:
• Unfinished Agenda:
• High rates of avertable child, maternal and infectious disease illness
and deaths – the unachieved Health-Related Millennium Development
Goals
• a. As of 2015, the MMR was at 204 mothers dying per 100,000 live births – a
far cry from the MDG-MMR target of 52 per 100,000 by 2015 and even
more than the MMR of 192/100,000 live births recorded at baseline in 1990.
• b. As of 2015, the Infant Mortality Rate (IMR) was 20 infants dying per
1,000 live births – just shy of the MDG-IMR target of 19. We could have
done better but neonatal mortality rate, a component of IMR did not go
down, the reason being that maternal mortality has not been reduced.
• c. As of 2015, as many as 25 new cases of HIV/AIDS were being reported
to be diagnosed on a daily basis. In 2000, less than one new case of
HIV/AIDS was being diagnosed every day.
• d. The prevalence of smear-positive Tuberculosis has increased from
246/100,000 population in 1990 to 273/100,000 population in 2008. The
target for 2015 is 0.0.
• Other Infectious Diseases
• Communicable diseases remain a serious concern in the Philippines. While the
country’s disease burden shifts away from communicable to non-communicable
diseases (NCDs), it is important to improve upon the gains made in controlling
infectious diseases such as measles and not to ignore the threat of emerging
communicable diseases such as Ebola, MERS-COV, bird flu and Zika infection.
• Resurging vector borne diseases, including dengue and leptospirosis, and most
recently, Zika virus infection, are also substantial public health problems.
• Antimicrobial resistance (AMR) is a growing challenge, largely due to
inappropriate and irrational use of anti- infective drugs in humans and animals.
• Under-nutrition
• An important contributor to both NCDs and communicable diseases is
under-nutrition and early stunting, which occur when children are deprived
of the proper nutrients from the time of conception through the first two
years of life (the “first 1,000 days”).
• Injuries
• NCDs, including cancer, cardiovascular diseases, chronic respiratory
diseases, diabetes, and accidental injuries are now the most frequent causes
of death in the Philippines.
• When it comes to injuries, rapid motorization and expansion of road
infrastructure has led to an increase in traffic fatalities. Traffic-related deaths
and injuries most often affect the poor as they are the ones who utilize the
most dangerous type of motorized vehicles - motorcycles.
• Pervasive Agenda - Health Inequity
• Health inequities are differences in health status or in the distribution of
health resources between different population groups, arising from the social
conditions in which people are born, grow, live, work and age.
• Maternal health is an indicator that thoroughly demonstrates the wide gaps in
health care and outcomes between rich and poor in the country.
• The Aquino Health Agenda
• In the words of President Benigno S. Aquino III, his social contract with
the people will bring his administration “from treating health as just another
area for political patronage to recognizing the advancement and protection
of public health, which includes responsible parenthood, as key measures of
good governance.” After six years, the Aquino administration has a mixed
bag of results to show for its efforts
• National Health Insurance
• Health Facilities Enhancement
• There is no disputing the fact that most of our government health facilities,
are in a state of disrepair, inadequately equipped, scantily supplied and poorly
manned.
• Health Human Resources
• Interventions don’t deliver themselves. Thus an adequate number of health
care workers (HCW) at every level of health care, from primary to tertiary,
must be available through a service delivery network of both public and
private sources to provide the appropriate service to those who need them.
• Priority should thus be given to augmenting and strengthening health
human resources, specifically the health workers who are at the
frontline of our health care delivery networks.
• Legislation
• Credit must be given to President Aquino and his congressional allies as well as
civil society for the passage of four landmark laws that have the potential of
improving the state of health care in the Philippines. These are:
• 1) The Reproductive Health and Responsible Parenthood Law (RA 10354) of
2012,
• 2) The Sin Tax Reform Law (RA 10351) of 2012,
• 3) The National Health Insurance Act of 2013
• 4) The Graphic Health Warnings Law of 2014
• Some Social Determinants of Health
• Social determinants of health refer to the conditions in which people are
born, grow, live, work and age that affect their health.
• THE HEALTH CARE TEAM
• This is group of persons who share a common objectives determined by community needs and toward the achievement of which each
member of the team contributes in accordance with her/his competence and skills, and respecting the functions of the other.” Definition
•
• THE PHYSICIAN: a physician is a person who is legally authorized to practice medicine. In hospital setting, the physician is responsible
for the medical diagnosis and for determining the therapy required by a person who is ill or injured.
• THE NURSE: number of personnel may be involved in h A ealth team. The team leader ‘head nurse’ is responsible for delegation of
duties to members of her team and care given to the patients.
• DIETITICIAN: Dietitian design special diets and they supervise the preparation of meals according to doctor's prescription.
• PHYSIOTHERAPIST: The physiotherapist provide assistance to patient who has problem related to musculoskeletal system. Functions:
1. Assessing mobility and strength 2. Providing therapeutic measures 3. Teaching patients new skills and measures.
• SOCIAL WORKER : Social worker provide assistance to the family and patient. He provide assistance in the problems such as finances,
counselling or marital problems, adoption of children etc.
• OCCUPATIONAL THERAPIST: The occupational therapist assists patient with some impairment of function to gain skills as they
relate to activities of daily living and help with a skill that is therapeutic.
• LABORATORY SCIENTIST: examines and study specimens such as urine, faeces, blood and discharge from wound.
• RADIOLOGIC TECHNOLOGIST: assists with wide variety of X-Ray procedures.
• PHARMACISTS: Pharmacists dispense drugs and medications prescribed by physicians, physician assistants, nurse practitioners, and
dentists.
• The Role of the Pharmacist in Public Health
• 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. Role Recognition Pharmacists are not formally classified as a profession
within the public health work force, unlike public health nutritionists, nurses
and physicians
• Pharmacists offer an accessibility that is rare among health care professionals.
• 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
• 2. 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.
• 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.
• 3. 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.
 Pharmacists and Prevention

• Through health screenings and health education,

• -providing clinical advice to include over-the-counter (OTC) relief that may aid in
decreasing unnecessary emergency room visits for common conditions.
• Pharmacists also provide rehabilitation support to individuals and communities by
giving advice on the use and selection of surgical appliances and equipment.
• 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. Therefore, pharmacists can play a role in addressing and eliminating
health disparities