More than two-weeks after protests erupted in Baltimore surrounding the death of Freddie Gray, many pharmacies in inner-city Baltimore remained closed or were operating under limited hours, disrupting access to essential medications for many residents; three of them are still closed today. People, predominantly poor minorities, relying on these local, mostly retail, pharmacies to fill their prescription medications, suddenly found that their medicines were out of reach. Such impacts were especially of concern for the elderly and those with chronic conditions — residents already at risk for poor health outcomes.
The situation was so bad that the Baltimore City Health Department stepped in to respond, telling residents to call the "311" service line for help obtaining prescription medications and offering transportation to, or delivery from, non-local pharmacies that were open for business.
While this leadership on the part of local public health officials is commendable, as with other elements of the Baltimore protests, these short-term efforts to support community residents do not overcome a much more serious, pervasive and insidious public health problem: Chronically ill black and Hispanic residents are nearly half as likely to take lifesaving medications than whites with similar illnesses, largely because they don't have access to them.
Over the past decade federal policy efforts attempting to address this problem have focused on ensuring prescription medications are affordable. These efforts — from the implementation of Medicare Part-D in 2006 to the more recent implementation of Medicaid expansion under the Affordable Care Act — risk missing the mark. Affordable medications may not be accessible. In other words, one may afford the medication, but cannot afford to get it, and, as the late Surgeon General C. Everett Koop reminded us, "medicines do not work in those who don't take them."
The Baltimore experience provides a glimpse into why access to medications depends upon so much more than prescription drug coverage alone. A study I published with colleagues last year in Health Affairs revealed that, as a matter of fact, minority residents are more likely to live in "pharmacy deserts." There are substantially fewer pharmacies in predominantly black and Hispanic neighborhoods than in white neighborhoods.
This gap in pharmacy access, which we found had widened over the last 10 years, may worsen amid the expected rise in pharmacy closures planned by retailers such as Walgreens. Unfortunately, but not unpredictably, the vast majority of these closures are likely to occur in minority neighborhoods, since they are less profitable likely due to greater rates of care for the publicly insured. Retail pharmacies are, after all, part of the private sector, often leveraging a public good for financial gain.
And yet it doesn't have to be this way. One natural place for pharmacies is within federally qualified community health centers (FQHCs) that are projected to expand over the next several years. In fact, in an effort to improve access to primary health care, the Affordable Care Act allocates millions of dollars to fund the development of hundreds of new community health centers in medically underserved areas. The vast majority of these areas are not only minority neighborhoods but also pharmacy deserts. Federal funding should also support the development of pharmacies within existing FQHCs and the incorporation of pharmacies into newly established centers. This will offer communities stable, unmitigated, access to their medications.
Ensuring access to pharmacies is a public health imperative. One of the most enduring images of the Baltimore protests will be the burning of a chain pharmacy. Beyond the opprobrium against "looters" and "outside infiltrators," what is imperative is to understand the message and the demand for access to public health goods and to pharmacies accountable to local community needs. If we continue to ignore the role of pharmacies, more and more people, living in minority neighborhoods already vulnerable to impoverishment and ill health, will continue to encounter barriers in accessing medications, and our public health goal of reducing health disparities — including life expectancy which in Baltimore differs by more than 20 years depending on your neighborhood — will continue to remain out of reach.
Dima M. Qato is an assistant professor in the Department of Pharmacy Systems, Outcomes and Policy at the University of Illinois at Chicago. Her email is dimaqato@uic.edu.