“Without a measureless and perpetual uncertainty, the drama of human life would be destroyed.”
– Winston Churchill

It wasn’t long ago, back in the pandemic, when pharmacies were heroes. And, boy, were they:  315 million Covid vaccinations given during the main Federal effort (FRPP), nearly half of all the U.S. Covid vaxxing… all while keeping up their usual pharmacy duties.  Definitely heroic.

And yet, back from the battle, what’s happened to those heroes? Rite-Aid filed for bankruptcy. Walgreen’s announced mass store closures. And John Beckner of the National Community Pharmacists Association (NCPA) told us last year that among independent pharmacies there’s an average of one closure per day. Some way to treat a hero.

Photo by Nathan Dumlao

Meanwhile, other heroes of the pandemic aren’t having it much better: I’m thinking here of the folks of public health. And they, too, are, facing a fresh set of uncertainties.

So, here’s our question: Could pharmacies and public health come together again in a way that makes both stronger? We asked Jason Briscoe that question and he not only gave us an emphatic YES, but added, “Why wait for the next pandemic?”

Jason is a pharmacist who headed operations for a regional drug chain before joining STChealth as Vice President, working to bring technology efficiencies to healthcare. We visited with him to ask about the future of pharmacies and of public health. He began with an interested distinction:

“Let’s begin with defining ‘public health.’ There’s Public Health, with a capital P and capital H that would be the system of government agencies and organizations, while lowercase public health is the objective of community health and well-being that includes the private sector. Those in Public Health agencies and organizations measure outcomes and sometimes they also deploy their own tactics in delivering health care at the local level, but that’s also what the private sector does.  Healthcare is personal and local, taking place between a trusted healthcare provider and an individual person or a patient, so leveraging the trusted relationships of those health care providers in concert with Public Health is the opportunity.”

Jason Briscoe

An opportunity to do what, specifically?

“During Covid, when the lights were bright and the stakes were high, pharmacies executed.  So, do we need to wait for the next pandemic?  Right now, there are problems to solve for patients, whether it’s chronic disease – obesity, diabetes, smoking cessation, you name it — there are problems to solve and patients who need help in getting them solved. That’s where the light bulb continues to stay lit.”

That makes sense, but let’s dig deeper into that first dot you’re connecting, the one about pharmacies needing more opportunities. We started by talking about all the pharmacy closures, so perhaps Public Health should be nervous about partnering with a struggling industry.  What’s your take on what’s gone wrong?

There’s the matter of payment reform, and there are plenty of people talking about that. But what else is needed is striking the right balance of the proportion of total revenue that comes from clinical services in relation to dispensing prescriptions. I’m not advocating for community pharmacy to be decoupled from the dispensing function — that’s something that’s really important because in many ways it’s what creates the opportunity for patients all across this country to have direct, face to face, frequent access to highly trained, highly skilled, trusted health care providers in community pharmacists. Oftentimes the dispensing function in a pharmacy is unheralded because a mail order pharmacy or an Amazon pharmacy can put pills in a bottle and ship them to your house – potentially even in a drone. But I don’t want to see the dispensing function ripped out of the community pharmacy because there is value in your pharmacist who you deal with knowing the full view of you as a patient and much, much more than a name and a prescription number.

“At the same time, community pharmacies cannot only hang their hat on putting pills in a bottle; they must continue to find ways to diversify revenue streams, not only for profitable growth but for maintaining relevancy. Why do I not want to get my prescriptions delivered to my front door by a drone? It’s because the relationships that I create with my pharmacist and that team, and the fact that I could go there for an immunization or a point of care test or diabetes education or whatever else it may be.  Again – healthcare is local; healthcare is personal.

“In sum, it’s that that shift of diversifying relevancy and diversifying revenue streams. And that’s where I see the big opportunity to partner with Public Health.”

But you have a problem: pharmacies are cutting costs by cutting back on the hours they are open and by cutting staff. How are they going to be doing education if there’s a line of people waiting for their prescriptions?

“OK, here’s where the technology comes in. You’re a pharmacist and I know you only have so many hours in the day and my goal is to do 20 clinical activities a day or, for sake of an example, let’s just say it’s 20 immunizations a day.  Where do you start? It’s not by having a conversation with every patient that comes in, only to have some say, ‘you gave me my shingles shot last week, you knucklehead.’ No, you use the information that’s in their system, plus what’s in the in the registry, to create programs that would say, ‘all right today I’m going to talk to 20 patients about a the importance of being protected against shingles and I can have confidence that I’m not going to have my staff take wasted steps because this forecast put at my fingertips at the right time for the right patients to have those conversations.’ This creates clinical efficiency to focus in on the conversations I should be having.

“Now, will those 20 conversations lead to 20 immunizations? Maybe or maybe not. But, you then you have the ability to say if Store One is executing 10 out of 20 times in the 20 conversations, and Store Two it’s 2 out of 20, you just identified an opportunity for improvement with Store 2. Nobody has the time to take wasted steps and nobody really has the time to do a research project prior to every encounter. But we can automate that, allowing you to see who you should talk to about clinical service XYZ and who needs to have a conversation about what vaccine. Thus, you’re creating time as you create public health opportunities.”

Okay, that’s the pharmacy piece. Now how would you sum up your thinking on pharmacies and Public Health working together?

“One, if pharmacies are in need of more opportunities; and, two, they proven the ability to deliver on the things Public Health cares about, then let’s connect those dots. And let’s do it in non-pandemic times to start covering more ground and doing right by patients. Whether it’s immunizations or clinical services, that’s the intersection — community pharmacy can be an extension of, and a driver for Public Health (and public health) all day, every day. Let’s just connect the dots.”

Photo by Anton Darius

---

STATS OF THE MONTH

Public Health Stress Testing:

How resilient are your communities?

By Bill Davenhall, Geospatial Advocate

“Community resilience” is a popular phrase these days. The American Psychological Association says this about resilience:

“Resilience is like a muscle that can be strengthened over time. It involves a combination of internal qualities, such as optimism, self-awareness, and problem-solving skills, as well as external supports, such as strong relationships and access to resources.^”

They add that “community resilience” is, “The capacity of individuals and households to absorb, endure, and recover from the health, social, and economic impacts of a disaster such as a hurricane or pandemic.”

These ideas are quantified by the U.S. Census Bureau as Community Resilience Estimates, which track how socially vulnerable every neighborhood in the United States is to the impacts of a disaster. The Community Resilience Estimates use American Community Survey microdata and Population Estimates Program data to measure the capacity of individuals and households to absorb the external stresses of the impacts of a disaster. The Census Bureau conducts these experimental surveys to study the impact of “natural disasters” on the resident population of every neighborhood across America. (You can read more about the Resilience experimental surveys here. )

The U.S. Census Bureau fielded a large experimental survey of households to learn more about such things.  Here are a few things we learned:

• People living in about 458 counties would likely struggle with in encountering an unexpected /wide-area disaster event in their community.
• States with the most people that would likely be considered seriously “vulnerable” include CA, TX, NY, FL, IL, AZ, NV, WA,MI, and PA.

Go here to learn of the estimated size of the populations in any county’s “social resilience.” At this site you will find data that can be searched by any neighborhood in the U.S. (Census data on each State, County, and Census Tract).

Why is this important to know? you ask:

Most unexpected events cause major disruptions to the flow of community activities and preparedness efforts that various agencies, volunteers, and public health entities would face in the wake of the “mad scramble” that usually takes place in providing immediate  assistance and support for a geographic population. A fast-spreading infectious disease in these “high” social vulnerability “risk geographies” can seriously diminish the ability of any community institution to respond. Knowing one of your geographies is more vulnerable will likely contribute to the ultimate capacity to bounce back or leverage the resilience that may already exist.

Below is a table of the counties with over a half million persons that would likely be seriously vulnerable in such a wide area disaster. Check on some areas you may be familiar with — you might be surprised.

Maya Angelou, an American poet laurate, is credited in saying, “Do the best you can until you know better. Then when you know better, do better.” Not a bad way to view and use this interesting experimental data from the Census Bureau’s American Community Survey to know where you might need to strengthen a community’s social resilience.

When thinking of global health emergencies, including pandemics and terrorism, and after all the preparedness measures, here’s our big question:

Are we safer now?

That’s the sort of rhetorical ask that is meant to lead into the same sad answer: “NO! Everything is getting worse.” But not so fast: The answer we expected is not what we got when we spoke with Brad Goble, a Canadian consultant working around the world, including with NATO and with the Global Health Security Initiative community. He surprised us by responding to our question about the state of the world’s security by saying this:

“I’ve been extremely optimistic. We have made enormous progress in the last 50 years, and particularly the last few years. We have made the world safer.”

Naturally, we wanted to hear more. “The global effort really started after 9/11,” he began. “Then, in 2007, we had the Global Health Security Agenda. But it was in 2020, when we had the first pandemic of our era, that we discovered just how underprepared we had been and that’s when lots of lessons were learned.”

Brad suggested that one of the most significant responses to the pandemic was the creation of by the EU of HERA, the Health Emergency Preparedness and Response Authority. Of that organization, he told us, “The European countries really did respond, demonstrating that they are taking health security seriously.” An article from the journal Health Policy put “seriously” in perspective: “The European Union (EU) Health Emergency Preparedness and Response Authority (HERA) is a new Directorate-General within the European Commission. With a budget of at least €1 billion per annum, about the same as the World Health Organization (WHO) holds in its core budget, HERA is set to become a major global health player.” The goals of HERA included what’s called “horizon scanning”, the monitoring of potential health threats, but also the support for increased drug and vaccine manufacturing capacity, and the stockpiling of medical countermeasures.

Indeed, Brad points out, “There is a shift in the international scene. For many years, the U.S. held the keys to advances in health security; but now global units are recognizing that they need to become more engaged. The world is paying more attention.”

One current example of international cooperation is mpox (the virus originally known as monkeypox, thanks to its discovery among medical research monkeys in Denmark in 1958). “When the WHO brought monkeypox onto the international stage,” Brad explained, “the international community pushed significant support into Africa. This was a positive development, but it also served to keep possible pandemics at bay. Organizations around the world now understand the incentive to get engaged.”

Brad did interject one note of concern, and that involved the WHO’s Global Pandemic Treaty. The WHO includes 194 member states and the treaty is designed to increase collaboration around pandemics. Collaboration seems like the sort of goal everyone can get behind, but two years on, the full agreement has yet to be signed, with the chief obstacle being legally binding rules on vaccine-sharing. He said, “Given the change in the political climate, there is uncertainty about the role of the United States in international agreements and specifically the Pandemic Treaty.”

This relates to Brad’s assessment that more nations and organizations have been stepping up support: “Concerns about the U.S. involvement has been a net positive because of that increased support elsewhere.” He went on to add, “Being Canadian and having worked with the United States, it has been fascinating and a privilege to be involved in work with those from the U.S. I am gob smacked by the capabilities and leadership among the people of the U.S. international health safety system. The two most important traits for change are collaboration and trust, and those are the very things we have counted on from our American colleagues. Their collaboration and trust have driven enormous progress. Without the U.S., should they really pull back from international efforts, we could have a speed-wobble and even go backwards, but hand to heart, I think we will continue to work together to make the world safer.”

Speaking of world safety, we know that Brad’s work has included dealing with the effects of the Russia-Ukraine War. More positive news: “Given the new administration in the U.S., the EU is now working on post-conflict needs. NATO is now working to cauterize against future conflict.”

And, finally, we asked Brad to reflect on where he sees his international work headed: “I come from a military background and now also work in public health. Think about the amount of money spent on each of those. And when it comes to global security, there are synergies. That the conversation we’re having now, how to bring both defense and public health together in ways that stop wasting money.”

(START SIDEBAR)

We got to interview Brad last year, and you can read more about his counter-terrorism work in “Something Wicked This Way Comes” at

Something Wicked This Way Comes And Where You Fit Into The Defense

Here is the brief bio from that article.

BRAD GOBLE and

The day the world got smaller

Goble is Canadian, a graduate of the Canadian version of West Point, the Royal Military College, and served fifteen years in the military. He described how he came to be involved in the fight against the CBRN threats (Chemical, Biological, Radiological, Nuclear):

“I backed in. The General I had worked for was retiring and I was ready for a new career. So I’d gone back and gotten an MBA from Queens University, and I became one of the people working to create the Canadian version of the CDC. This was right before 9/11. After that happened, the world got smaller, and we became more focused on new and emerging threats. Not long after 9/11, Tommy Thompson, then Secretary of HHS, came to Canada to meet with our Minister of Health, and out of those meetings came the Global Health Security Initiative – bringing together the ministers of health from the G-7 countries, Mexico, the WHO and the European Commission.  I was one of the people assigned to figure out how the international community prioritized investments against threats.”

(Photo: Brad Goble outside the United Nations HQ in Geneva)

“After 9/11, we were paying more attention to what the bad actors were doing,” Goble explained, “working to assess the new threats and to coordinate the work of defense departments and health organizations.” Included in that work was the development of plans to deal with terrorist attacks, which Brad summed up this way: “We couldn’t assume rational behavior – we have to assume crazy.”

---

STATS OF THE MONTH

Does the Geography of Population Change Really Matter?

By Bill Davenhall, Geospatial Advocate

Sometimes just the way organizations group and present data makes you stop and think — like TED talks analytics perhaps?

Here is a typical example of a recent update of population data collected and published by a commercial demographic research company (Scan\US, LLC).  It contains 2024 estimates from the US Census Bureau and estimated population counts by 12 age groups they selected from among a host of various combinations.  It probably reflects what most demographic researchers would want to see.  Healthcare of course, has interest in many of these groupings, largely influenced by decades of use by groups like the DHHS and the CDC.

While it may look a bit daunting to many, it’s a straightforward table of population counts by age groups. Does anything “pop” out to you? – Do your eyes quickly search for the  significant increases and decreases represented in this chart and does this quick look suggest some ideas or concerns about what your observing? Are there other discoveries looming here? Does it encourage you to become curious about what some of these estimated changes (maybe trends)  portend for the various “geographic patches” of the population you care most about?

So here is what jumped out at me:

•  Serious growth among populations living in Non-Family Households. Do you understand the impacts of this?
• Conversely, there are far fewer people living in what has been more traditional Family Households. Interesting ideas here?
• Five (5)  million more people in 2029 will be over 75 years of age. Surprised this is a growth market?
• 346,553 fewer children under 5 years of age showing up by 2029? Any alarm bells ringing yet?
• 1 million fewer children 5-14 years of age by 2029? Create angst in your organizational plans?
• 8.3 million new people expected by 2029?  Will you lose any sleep over this trend?
• 55–64 year-olds in 2029 will be rare. Who knew?

Planning for and delivering your messaging and solutions to the various groups in all the geographies you care about, is no easy task. It requires a lot of analytics and understanding of the populations that you will serve. Geographical analysis of your data could be the best antidote for the pain of unexpected surprise.

As always, I appreciate a 2^nd opinion,

                                Population Changes by Age Group, 2024-2029