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Pharmacists and Machines
by Sir Hugh N. Linstead
T
o some Americans, Europe nlay seem a museum. So far as pharmacy is concerned, however, I want you to 'believe that it is a laboratory for research and development. There was once a time when the English Channel insulated Britain from Europe. It may be that to some extent the Atlantic insulates the United States. Modern communications, however, operate as much in the world of ideas as in the world of transportation and one finds that ideas germinate at the same time in many different countries. All industrialized nations are 8.t about the same stage of development. Gagarin may be in orbit before Glenn but if Glenn should be first on the moon, Gagarin will not be far behind. When I first came to America nearly 30 years ago, I remember offering a great deal of what was doubtless good advice to my American colleagues. I am wiser today. Nevertheless, if I tell you about the crisis through which pharmacy is passing in Europe, I would like to think that onr experience may be of some service to you when the fall-out reaches America. The crisis is not a chance one. It is the result of industrial and political forces which have been steadily developing over the last hundred years and which have accelerated their speed as the result of two world wars. The first is industrialization. The second is an awakening social conscience which we call social security but for which some Americans have other and less gentle names. The impact of these two forces on community pharmacy is heavy. The compounding of medicaments is ceas-
pharmacists and ing to be a function of the pharmacists and has been rightly and inevitably transferred to the manufacturers. At the same time public authorities have been forced to take an increasing concern in the manner in which medicine, pharmacy and the other healing professions do their work if only because very large sums of public money are being spent in health service schemes. There are clear signs in Canada of the movement of affairs towards an extension of the social services. You in America have felt the full impact of industrialization but so far only the first stirrings of social security. There is a completely reversed situation in Poland, where the social services are highly developed but not so the industrialization of drug manufacture. Pharmacy is completely nationalized. The pharmacies themselves are of the very highest quality. Pharmacists themselves, all salaried public servants, are doing nothing but professional work. The great bulk of the prescriptions must be individually compounded and the speciality has yet to make a serious impact. Nevertheless even here the state manufacturers are beginning to develop their specialities and as the country's wealth expands foreign specialities will increasingly find their way into Polish pharmacies. American pharmacy, already subjected to the benefits and the evils of industrialization, must in future years increasingly come to terms with social security. Poland, with a complete system of public social services, will in its turn feel increasingly the effects of the speciality taking the place of the individually ~compounded medicine.
Sir Hugh N. Linstead, secretary of the Pharmaceutical Society of Great Britain, was greeted at the Las Vegas airport by William S. Apple, executive director of APhA, who welcomed him to the l09th annual meeting of the Association.
Of all the European pharmaceutical organizations, the German seems to have stood up most strongly against the two current trends. We all know how highly industrialized German pharmacy is. The German pharmaceutical industry in the quality of its research and in the skill and determination of its production and merchandising is unsurpassed, in quality if not in quantity, even by the American pharmaceutical industry. In Germany too, the social services are probably more highly developed than in any other country. Social service costs in Germany represent a much higher proportion of the expenditure of a German manufacturer than in any other country. However, even in the face of the full effects of both these forces, the German pharmacy has remained a highly ethical establishment and seems to have successfully resisted the worst effects of both.
picture in Germany The largest single factor in maintaining the high professional standard of German pharmacy has been the old legal provision which limited the distribution of pharmacies on a geographical and population basis. After the war we were able to maintain this tradition in the French and British zones of occupation. In the American zone, however, other counsels prevailed and for the period of the occupation the free opening of pharmacies was permitted. When the Germans resumed responsibility for the government of the French, American and British zones tht> old conditions were re-imposed in the American zone. A few years ago, however, the legality of the restriction was challenged and the high court of constitutionallaw in West Germany decided in June 1958 that the opening of new pharmacies should be free from control. The court declared itself to be influenced by the following considerations. Limitation, at least as it is applied in Germany, had resulted in dividing the pharmaceutical profession into two types of pharmacist-the owner and the employee, the latter condemned to remain an employee by the conditions restricting the opening of new pharmacies. The court maintained that a pharmacist should have the right to decide his future for himself without hindrance by public authority. It did not believe that an increase in the number of pharmacies would endanger an orderly distribution of drugs and medicines. The court recognized that one of the results of its
machines decision might be the opening of numbers of under-staffed pharmacies with the consequent danger of a general lowering of standards. It concluded, however, that this would not necessarily occur and the example of Switzerland encouraged the view that an excessive growth of new pharmacies was unlikely. German pharmacy has naturally been disturbed by this decision and is seeking to find ways by which the profession itself can voluntarily control the expanThe sion of new establishments. Netherlands has found that it is possible to secure this without legal sanctions, but Dutch pharmacy is a much more compact community than is German pharmacy. It seems probable that this high court decision has removed the strongest defense protecting German pharmacy from the fun effects of commercialism and that it may well lead to notable changes in the practice of pharmacy in that country unless some other influence can be brought into play. That this might happen is not just wishful thinking.
trends in France France has a highly developed pharmaceutical industry and an elaborate system of social insurance. Like most other countries on the continent of Europe, and unlike Great Britain, the system is not operated directly by the state. Instead, there is an elaborate network of so-called mutualities. These are a type of insurance company usually organized according to industries. These mutualities administer social security benefits to their members on behalf of the state. They are large and powerful organizations. Among other benefits they reimburse their members for the cost of medicines prescribed for them under the social security scheme. The immense power and resources of the mutualities are now being felt by French community pharmacy which is under perpetual pressure to grant rebates on medicines supplied to members of these societies. So far French pharmacists have been able to hold out against this pressure with fair success but an ominous development has been the opening of their own pharmacies by these mutualities. This process, if it were carried very far, could change the character of French pharmacy. At present French pharmacies are mainly owner-operated. A growth of mutuality pharmacies would mean that the controlling pharmacist would increasingly be a manager.
For his "unselfish devotion and contributions to the highest standards of pharmaceutical service," Sir Hugh N. Linstead, member of the British Parliament and president of the International Pharmaceutical Federation, received a certificate of honorary membership in APhA from then President J. Warren Lansdowne.
One of the points much in dispute between pharmacists and the authorities in European countries is whether payment for a prescription is to be made by the patient or by the mutuality. A process whereby the patient pays the pharmacist and collects the money subsequently by refund from the mutuality acts as a mild deterrent against too free use of the service. Under this system the pharmacist is paid at once whereas under the alternative scheme, whereby the patient does not pay and the pharmacist sends the prescription charge to the mutuality for payment, he may have to wait some time for his money. While the position of French pharmacy in the face of the mutualities is an uncertain one, there has been a much more direct attack upon it as the result of the industrialization of the manufacture of medicines. Some years ago, after the reform of the French constitution by General de Gaulle and the setting up of the Fifth Republic, the French government set on foot a broad
inquiry into restrictive practices which could be held to operate against the efficient functioning of the French economy. The result of the inquiry became known as the Plan Rueff after its author. That part of the plan which surveyed pharmacy proposed two modifications in the traditional structure and organization of pharmacy. The first, concerned with the control of the pharmaceutical industry, has already been put into operation. The second, relating to community pharmacy, has fortunately not yet been implemented. In industry under the old law, a company manufacturing pharmaceuticals, if its capital was under $100,000, was required to have the majority of its shareholders pharmacists. Above $100,000, shares could be held by non-pharmacists. Furthermore the president, managing director and the secretary of any manufacturing pharmaceutical company were required to be pharmacists and also a majority of the board of directors. Following the Plan Rueff this has been Vol. NS2 No.6, June 1962
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swept away and replaced by a provision which works like this. If the capital is less than $100,000, the old rules apply. If the capital lies between $100,000 and $400,000, the majority of the shareholders need not be pharmacists although the majority of the directors must be and also the president, the managing director and the secretary. If the capital is over $400,000, only two of the directors need be pharmacists. Neither the chairman nor the president need be a pharmacist but there must be a pharmacist specifically nominated as administrateur mandate. As you see, by a stroke of the pen the pharmaceutical industry has been freed from effective pharmaceutical control. The propositions of the Plan Rueff relating to community pharmacy turn upon certain conclusions of which the following are the most pertinenti-A new definition of the pharmacist's monopoly insofar as it relates to supply to the public-the restrictions upon the items covered by the monopoly should be relaxed so as to exdude(a) certain medicaments in regular use which are non-toxic, of which the list will be fixed and periodically reviewed by a public authority and (b) the majority of surgical appliances (dressings, etc.), with certain exceptions also to be determined by means of an official list. 2-An amendment of the provisions at present regulating the limitation of pharmacies-the committee has not been able to embark upon a sufficiently profound inquiry to be able to express a firm opinion about the limitation of the number of drug stores. Nevertheless it has been impressed by the lack of convincing argument in favor of a control which makes such inroads into common law rights. It has also been struck with the inconveniences which result from the present practice. As I have said, legislative effect has not so far been given to these proposals affecting community pharmacy but they have naturally given rise to the greatest apprehension among French pharmacists. The Ordre National des Pharmaciens de France has circulated to all its members a substantial criticism of the plan . It is bound in scarlet and splashed across the cover in white is the warning La Pharmacie en Danger.
forces in Great Britain Great Britain has not escaped from the influence of both forces-industrialization and a state health service. Industrialization of pharmacy has followed very much the same line as in America. But for the existence of the National Health Service its impact would no doubt have been equally great; even taking account of this limitation upon its expansion, it has had a 346
very profound effect upon the professional functions of the pharmacist. Our experience is similar to yours and American firms are playing an increasing part in Great Britain. The Association of the British Pharmaceutical Industry now has a number of American members. So far the lion has lain down peacefully with the eagle and there has been no Boston tea party in reverse. What may be more interesting is the impact of the National Health Service. The service has to some extent stood between community pharmacy and the worst effects of industrialization. It has of course in other ways profoundly affected the practice of pharmacy. For both these reasons I ought to give you a very brief picture of how it works. Indeed there is a further reason why I should do so- many American accounts of what the service is and how it works have been very grossly distorted. It has many defects and it contains some dangers. Nevertheless it works well, it is popular with the people, it is now accepted by most of the professions who have to work in it and I am sure that even its greatest critics would be hard put to it to propose an alternative which would confer equal benefits on so many people. To clear away one or two fundamental misconceptions I will make one or two categorical statements about the principles upon which the service is based. First, apart from those working in hospitals, many of whom do private work as well as health service work, neither doctors nor pharmacists are salaried employees of the state. They are paid for the work they do and doctors are free to do as much or as little health service work as they wish and to supplement it with as much private work as comes their way. Second, the service is not centralized in the Ministry of Health except in the most formal sensc. Most of the dayto-day control of the hospitals, of the general practitioner service and of the pharmaceutical service, to take only some examples, is exercised by committees representing the public and the professions concerned. Virtually all professional questions are decided by members of the professions themselves. Third, a medical practitioner is free to prescribe any medicine for a patient which he in his own judgment considers that patient needs. The only control over prescribing exerciscd by the Minister of Health is the sending of a regional medical officer to discuss his prescribing with any doctor who habitually prescribes excessively expensive drugs and very occasionally, requiring the doctor to justify before a committee of other practitioners continued excessive prescribing. Perhaps the dominating question in
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the development of the National Health Service should be how to resolve the inevitable conflict between professional freedom and essential state oversight where large sums of public money are involved. In fact that question has been subordinated to the simpler question of how to find enough money to pay for it all. The report upon which the British social security plan was built at the conclusion of the last war estimated that the National Health Service would cost 178 million pounds sterling to the exchequer each year. In fact next year it is likely to cost 900 million pounds sterling, of which about 700 million pounds sterling will fall on the exchequer. This great divergence between estimate and reality is largely due to underestimating both demand (which may be artificial to some extent) and need. In practice it has meant that from its inception the service has promised more than it has been able to afford within the limits of the national budget. Consequently, ever since 1948 the main energies of its administrators have had to be directed to securing all possible economies instead of to a process of steady development. To some extent that is represented by the contributions which now have to be made for some of the benefits such as spectacles, dentures and medicines. It is my estimation that this pruning process is now largely over. A promising sign that the service has turned the corner is a very substantial building program for hospitals which has just been announced.
increasing cost The pharmaceutical service has attracted particular attention because of a steady rise in its cost. The number of prescriptions has remained fairly steady- about 210 million annually for 50 million people. But the cost o(each item has steadily risen owing to the increasing use of new and more expensive drugs. I shall not be surprised if the average soon reaches 8/4d or $2 bearing in mind differences in the value of money. This 8/4d is about three times the cost in 1948 when the service started and it has only been kept down by the most strenuous efforts with what we call the British National Formulary which gives recipes for non-speciality medicines and advice about equivalent preparations for expensive specialties. Prescribers' Notes are circulated to general practitioners advising them on rational prescribing and in rare but regular cases practitioners are interviewed as I have indicated. The cumulative effect of all this activity is to make prescribers cost-conscious and to wean them away from undue dependence on specialities and on the detail man from the manufacturer. As a re(continued on page 374)
Sir Hugh N. Linstead (continued from page 346) suIt, about 60 percent of the medicines prescribed under the National H ealth Service are for specialities and the remainder a re not. On the European continent 90 percent or more of prescribed medicines a re for specialities and I suspect that in the United States a nd Canada the percenta ge is even higher. In addition to this control over the invasion of specialities, the Minister of Health has also a review committee headed by e minent physicians who classify a ll new specialities into classes according t o their valu e as therapeutic agen t s and the possibility of their being replaced by pharmacopeial or non official drugs. This classification serves as a therapeutic guide to prescribers. These then are the ways in which the National Health Service has controlled the effects of the industrialization of medicines u pon the practice of pharmacy. It does at least insure tha t 40 percent of the med icines dispensed by the pharmacist call for some other pharmaceutical process than handing out a prepacked medicine. There is, of course, a large element of state control in the pharmaceutical service although it a ffords very substantial freedom t o the pharmacist. To what exte nt has this process changed the character of the practice of community pharmacy? As in most pharmaceutical questions the answer has to be divided into two-the professional aspects and the economic aspect. On balance the National Hea lth Service has brought a very large increase in the amount of the professional work done by pharmacists. It has reduced the variety of compounding beca use of the greater t endency to standardization in prescribing. It has enabled pharmacists to be more dependent upon professional work and therefore less anxious to seek nonprofessional commerce. On the debit side it has in theory limited the profession al fr eedom of the pharmacist to th e extent that he is dealing with two clientsthe patient a nd the minister-instead of one. It has put the pharmacist in the position where the minister's rules and the ethical code of his profession may come into conflict. But most of this is in the fi eld of theory and by good sense on both sides conflicts of this sort have been avoided. It is only where economics have come into the picture tha t there has been a rea l conflict and of that I give two examples. Successive ministers of health have imposed cha rges payable by the patient to the pharmacist when the prescription is collected. These were originally 15 cents per prescription form (irrespective of the number of items), then 15 cents per item and more recently 30 cents per item-30 cents being equivalent to 50 cents in American spending terms. These charges, pa rticula rl y the increases, have given rise t o much criticism by the public who has to pay them a nd to a certain amount of real hardship in spite of the special provisions for indigents. Th e pharmacist has had to bear the brunt of th ese disagreeable reactions and this has led to friction and to strained 374
relations between pharmacy and the minister of health . A more recent cause of friction has been occasioned by the minister's a ttempt t o slow down the rate of increase of the cost of each prescription item. The pha rmacist is paid for each item by a complicated calculation which includes a percentage added to the cost of the actual medicament supplied. Until recently this oncost was 25 percent. The minister's case was tha t 25 percent could be justified when the cost of the individual drug was low but as the cost mounted, the 25 percent represented a la rger amount of money for what was essentially the same service. He therefore made a reassessment of the oncost on a sliding scale which has meant that the total oncost payable will be cut out by some four a nd a half million dolla rs a year. An attempt was made to reach an agreement by negotiation but it broke d own and the new a mount was imposed by the minister unila terally. This is an impressive reminder of the power and influence which the minister can wield when he considers it necessary to do so.
common market These glimpses show how confusing the pattern of pharmacy in Europe is t oday. Fifty years ago it was a patchwork but it was a t least comprehensible. Each country had its own na tional system which made sense within its own frontiers. One of the exciting questions for us in Europe just now is whether the European Economic Community, otherwise known as the European common market, will succeed in devising an orderly pattern of pharmacy within the frontiers of the new Europe. The six member countries of the community-France, West Germany, Italy, Belgium, the Netherlands a nd Luxembourg-are setting t o work with great energy to build a unified system not only commercially but professionally also. The basis is the Treaty of R ome. This provides among other things tha t within a limited period of time there shall be free interchange of professional qualifications between the six countries a nd the freedom to practice one's profession anywhere within them . There are reservations about the practice of medicine a nd the practice of pharmacy a nd there a re working parties trying t o throw up the salient points tha t have to be decided before the general principles of the treaty can be applied to those two professions. What the champions of the United Europe want to create is one code of practice for the whole community. Before this can be done agreement must be reached on a t least three thorny pointshow an equivalence of qualificatio n is to be measured what conditions must be attached to the right of a foreigner to practice in anoth er country of the six whether there should be a unified system controlling the distribution of pharm acies geographically a nd in accordance with population needs.
It is too early yet to say whether a code agreeable to everybody can be worked out. The six governments a re, however, pressing forward the political union of the community a nd there may well be some steam rolling of pharmaceutical objec-
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tions if there is difficulty in securing agreement within the pharmaceutical field . Britain has not yet j oined the community although her a pplica tion to do so is under consideration. If she does, it will not be easy t o integrate her essentially free trade system of pharmacy into the much more rigid continental system. Looking at the community as a whole, however, it does offer to pharmacy in Europe a unique opportunity of making a new start. This is what I had in mind when I stated earlier that it was not entirely wishful thinking to hope tha t new barriers could be raised t o protect community pharmacy against industrialization a nd undue state control. Within the European community there could be a new outlook on the service pharmacists a re required to provide and the conditions necessary for them to provide it appropriately. Furthermore, it could become increasingly difficult for individual governments to upset the established practice of pharmacy by unilateral action. There is therefore real hope here tha t some of the lessons of the past can be applied in this new venture from the very beginning. There seems t o be considerable relevance between our problems and yours and the two main influences that I have been tracing are both potent in America. You may not be as conscious of the increased concern of the state in your affairs as we are. In America is there good medical attention readily available to everyone in your community who is in need of it, irrespective of what a sick person can afford to pay? If the answer to this question is an unqualified yes, then a general public health service may not expand ra pidly. But if, in all honesty, you have to admit that the answer is not unqualified, then it is inevita ble that the state will increasingly step in, in America as it has done in Europe, to provide for the deficiencies. Be that as it may, however, no one can be unaware of the revolution that industrialization has created in the conditions in which pharmacy is practiced in the United States. Those who can look back to the conditions of 30 years ago will know whether it is true to say of the United States, as it is certainly true to say of Europe, tha t community pharmacy has gone into solution. The question for us is how is it going to crystallize out; more specifically, what can we do to shape its future to our estima te of the public need. By we, I mean those bodies of individuals who a re in a position to make decisions that can influence the course of events. Whether we approach the question from the point of view of providing the service needed by the public or of maintaining the influence of our profession, there is one clear prima ry necessity-to maintain the value of the pharmaceutical qualification. Far from the industrializa tion of pharmacy making it less necessary for the pharmacist t o be well informed over the whole field of the sciences that touch pharmacy, the reverse is the case. The pharmacist needs to know thoroughly the articles he is handling. He needs to know their composition, their manufacture, their standardization and, above all , their uses. The physician cannot have at his fingertips a knowledge of all the medicaments
that today are at his disposal a nd that are born and die with such frequency a nd speed. He must rely on the pha rmacist and the pharmacist must be equipped t o answer the physician's questions with assurance based on knowledge. Of all the ma ny claims of the pha rmaceutica l curriculum, pharmacology stands out as being the subject in which the future pharmacist must be a master. It must be developed in our curricula both widely and deeply and this may r equire of course an orientation of our pure science teaching in the direction of more biology and physiology. In my country it is not a field enthusiastically cultivated by doctor s and it is one of those sciences into which the pharmacist can readily move. The masterly address, " The Scientific Status of Pha rmacology," given before the American Association for the Advancement of Science by Professor Cha uncey D. Leake of Ohio State Un iversity a nd printed in the February American Journal of Hospital Pharmacy, concerns itself with this same idea. I emphasize pharmacology in particular, but what I want to emphasize in general is that under the conditions of t oday and tomorrow a high standa rd of educationa l a ttainment is the only t hing that can keep pharmaceutical influence a live in industry or in distribution. In a world becom ing more and more mecha nica l the educational qualities of the individua l become of in creasing significance.
the political game The salva tion of pha rmacy is not t o be found through politica l manifest a tions. Playing the political game pays off only if you have politica l power. The great trade unions have politica l power a nd can use it. Speaking generally, the professions have not. Professional men are not naturally politically minded. They can usually see both sides of a n argument whereas your politicians only see one. They lack the influence of numbers. They will never use the strike weapon . They work by themselves or in small groups. This is not to say that the politica l r oad is not for them to foll ow. But if they have a politica l case to make, it must stand or fall on its merits a nd on the persuasiveness of a rgument. It cannot be expected to prevail merely by force of numbers or by political influence. I have been a politician for more tha n 20 years a nd I can end orse what the founder of our pharmaceutical society, J acob Bell, himself a m ember of P a rlia ment, wrote more tha n a hundred years agoIt may be as well to recapitulate the moral which may be drawn from our past history, namely, that political con· troversies and mercenary disputes are injurious to the interest and character of all parties-that the most effectual method which any class of men can adopt for securing their political rights and advancing their professional standing, consists not in dispute and warm argument, but in a steady and persever· ing attention to intellectual improvement and the establishment of such regulations as are calculated to insure collective privileges by increaSing the amount of individual merit. Intellectual improvement-tha t 376
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say education; the establishment of regulations-that is to say a code of professional ethics supported by a professional disciplinary tribuna l; individual meritthe personal qualities of the individua l pharmacist--these were the necessities picked out by Bell during a formative period in the history of British pharmacy. They seem to me to be as valid t oday as guide posts as they then were a nd t o contain in them what is essentia l for meeting the needs of the public as much as for preserving the cohesion a nd the qua lity of our profession. Devotion to the id eals represented by these three principles is not enough, however. They have to be projected to the public a nd to governments. This is the a rt of public relations, an art of which a ll professions, pharmacy among them, a re poor practitioners. Neverth eless, professional men a re slow to accept the idea that sales technics a re an appropriate ac tivity within the professiona l field. They a re right insofar as they are thinking of the norma l t echnics of commercial advertising. They a re wrong insofar as they ignore the central place which the propagation of ideas occupies in the world t oday. Ca mpaigning for the a ttention and education of the public has become a n activity of such diverse bodies as governments, political parties, organized r eligious bodies, societies in favor of this or against that a nd many others. Professional bodies ignore it a t their peril. The subject of public r ela tions in pharmacy is t o be discussed at a congress of French and British pharmacists to be held in France in May 1963 and one paper stat esAll the professions have certain valuable assets. Their members carry responsibilities to the community over and above the standards of conduct laid down by the law for all citizens. These responsibilities are the product of the traditions of the profeSSIon established by the practice of the best practitioners. They may be enforced in part by professional tribunals but they should be maintained mainly by the conscience of the indIvidual professional ma n. It is an asset to any community to have among its citizens groups of men a nimated in their activities by ideals which transcend the orthodox "fair day's work for a fa ir day's pay." But does the public understand this and appreciate how the community can be impoverished by a gradual erosion of the responsibilities that the proud title of "profession" carries with it? What are the particular assets that the pharmaceutical profession can offer to the community? Essentially they are responsibility and knowled ge. Responsibility involves advising the physicia n and the public. It requires the pharmacist sometimes to say no when it may be to his superficial advantage to say yes. It calls for metiCUlous care in the conduct of his business and the performance of pharmaceutical operations. Knowledge involves not only mastery of the science of pharmacy but also an understanding of men and women and of the human problems that are part of a profeSSional relationship with them. Does the public understand the scope and importance of these services? Does the government? Do pharmacists have the professional freedom that is essential to the proper performance of these services? Is the pharmacist ade-
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quately rewarded financially for them? If in any country the general answer to these questions is no, then the public relations of pharmacy in that country are inadequate. In a n y process of public rela tions it must be remembered that in the long term "the truth will out." Public r elations cannot ma ke a poor pharmaceu tical service appear to be a good one. If the image of a good professional picture is to be projected the picture itself needs t o be good. To this extent therefore the most importa nt public relations officer in pharmacy is the pharmacist himself. He cannot divest himself of this responsibility by delegation to a professional bod y or to a public rela tions organization. He must himself be proud of his profession a nd mindful of its traditions a nd standards. No campaign t o ex t ol his quality can succeed if the contrary is manifest in his pharmacy or in t he service that he offers. In sp ite of the special example of some of the newly born countries, it is broadly true to say that the 19th century was a cen · tury of nationa lism while the 20th century is a century of internationa lism . We in Europe are moving fairly rapidly t owards the integra tion of that continent just as you in the Americas a re groping t oward s closer unity between the United States a nd Central and South America. Similar tendencies a re showing themselves in embryo in Africa a nd a mong the Ara b States. W ithin t hese la rge in ternationa l movements there are moves to secure closer co-operation a nd under standin g between professional groups. You have your Pan-American Congress of Pharmacy; we ha ve in Europe a committee representing the pharmaceutical organizations of the six countries of the European econ omic community. I ha ve recently had the privilege of attending the Eighth P an-Ara bic Congress in Cairo. The oldest organ ization in this field is, of course, the International Pharmaceutical Federation. We include in our membership pharmacentical societies fr om a ll over the world a nd the AMERICAN PHARMACEUTICAL ASSOCIATION has vigorously participated in our work to our great benefit a nd encouragement. At this present moment, one of the imp ortant problems for the federation, in consultation with representatives fr om other continents, is to look at t he world situa tion of pharmacy a fresh and to see whether there are steps t o be takenconstitutional or practical- Which can bring a bout co-ordination between what our federa tion is doing a nd what other interna tiona l groups a re seeking to achieve. I do not think anyone of us can be satisfi ed tha t we have yet found the answer to the co-ordination of professional pharmacy internationally a nd this is why I want to encourage my colleagues in the fed eration to study the question more profoundly. Our problems are essentially the same in every country; our ideals a re the same; a ll of us a re bound to profit from a n increasing intercha nge of experience and ideas which modern communications made possible. Pharmacy has become international. The pha rmacist must become internationa l likewise. •
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o some Americans, Europe nlay seem a museum. So far as pharmacy is concerned, however, I want you to 'believe that it is a laboratory for research and development. There was once a time when the English Channel insulated Britain from Europe. It may be that to some extent the Atlantic insulates the United States. Modern communications, however, operate as much in the world of ideas as in the world of transportation and one finds that ideas germinate at the same time in many different countries. All industrialized nations are 8.t about the same stage of development. Gagarin may be in orbit before Glenn but if Glenn should be first on the moon, Gagarin will not be far behind. When I first came to America nearly 30 years ago, I remember offering a great deal of what was doubtless good advice to my American colleagues. I am wiser today. Nevertheless, if I tell you about the crisis through which pharmacy is passing in Europe, I would like to think that onr experience may be of some service to you when the fall-out reaches America. The crisis is not a chance one. It is the result of industrial and political forces which have been steadily developing over the last hundred years and which have accelerated their speed as the result of two world wars. The first is industrialization. The second is an awakening social conscience which we call social security but for which some Americans have other and less gentle names. The impact of these two forces on community pharmacy is heavy. The compounding of medicaments is ceas-
pharmacists and ing to be a function of the pharmacists and has been rightly and inevitably transferred to the manufacturers. At the same time public authorities have been forced to take an increasing concern in the manner in which medicine, pharmacy and the other healing professions do their work if only because very large sums of public money are being spent in health service schemes. There are clear signs in Canada of the movement of affairs towards an extension of the social services. You in America have felt the full impact of industrialization but so far only the first stirrings of social security. There is a completely reversed situation in Poland, where the social services are highly developed but not so the industrialization of drug manufacture. Pharmacy is completely nationalized. The pharmacies themselves are of the very highest quality. Pharmacists themselves, all salaried public servants, are doing nothing but professional work. The great bulk of the prescriptions must be individually compounded and the speciality has yet to make a serious impact. Nevertheless even here the state manufacturers are beginning to develop their specialities and as the country's wealth expands foreign specialities will increasingly find their way into Polish pharmacies. American pharmacy, already subjected to the benefits and the evils of industrialization, must in future years increasingly come to terms with social security. Poland, with a complete system of public social services, will in its turn feel increasingly the effects of the speciality taking the place of the individually ~compounded medicine.
Sir Hugh N. Linstead, secretary of the Pharmaceutical Society of Great Britain, was greeted at the Las Vegas airport by William S. Apple, executive director of APhA, who welcomed him to the l09th annual meeting of the Association.
Of all the European pharmaceutical organizations, the German seems to have stood up most strongly against the two current trends. We all know how highly industrialized German pharmacy is. The German pharmaceutical industry in the quality of its research and in the skill and determination of its production and merchandising is unsurpassed, in quality if not in quantity, even by the American pharmaceutical industry. In Germany too, the social services are probably more highly developed than in any other country. Social service costs in Germany represent a much higher proportion of the expenditure of a German manufacturer than in any other country. However, even in the face of the full effects of both these forces, the German pharmacy has remained a highly ethical establishment and seems to have successfully resisted the worst effects of both.
picture in Germany The largest single factor in maintaining the high professional standard of German pharmacy has been the old legal provision which limited the distribution of pharmacies on a geographical and population basis. After the war we were able to maintain this tradition in the French and British zones of occupation. In the American zone, however, other counsels prevailed and for the period of the occupation the free opening of pharmacies was permitted. When the Germans resumed responsibility for the government of the French, American and British zones tht> old conditions were re-imposed in the American zone. A few years ago, however, the legality of the restriction was challenged and the high court of constitutionallaw in West Germany decided in June 1958 that the opening of new pharmacies should be free from control. The court declared itself to be influenced by the following considerations. Limitation, at least as it is applied in Germany, had resulted in dividing the pharmaceutical profession into two types of pharmacist-the owner and the employee, the latter condemned to remain an employee by the conditions restricting the opening of new pharmacies. The court maintained that a pharmacist should have the right to decide his future for himself without hindrance by public authority. It did not believe that an increase in the number of pharmacies would endanger an orderly distribution of drugs and medicines. The court recognized that one of the results of its
machines decision might be the opening of numbers of under-staffed pharmacies with the consequent danger of a general lowering of standards. It concluded, however, that this would not necessarily occur and the example of Switzerland encouraged the view that an excessive growth of new pharmacies was unlikely. German pharmacy has naturally been disturbed by this decision and is seeking to find ways by which the profession itself can voluntarily control the expanThe sion of new establishments. Netherlands has found that it is possible to secure this without legal sanctions, but Dutch pharmacy is a much more compact community than is German pharmacy. It seems probable that this high court decision has removed the strongest defense protecting German pharmacy from the fun effects of commercialism and that it may well lead to notable changes in the practice of pharmacy in that country unless some other influence can be brought into play. That this might happen is not just wishful thinking.
trends in France France has a highly developed pharmaceutical industry and an elaborate system of social insurance. Like most other countries on the continent of Europe, and unlike Great Britain, the system is not operated directly by the state. Instead, there is an elaborate network of so-called mutualities. These are a type of insurance company usually organized according to industries. These mutualities administer social security benefits to their members on behalf of the state. They are large and powerful organizations. Among other benefits they reimburse their members for the cost of medicines prescribed for them under the social security scheme. The immense power and resources of the mutualities are now being felt by French community pharmacy which is under perpetual pressure to grant rebates on medicines supplied to members of these societies. So far French pharmacists have been able to hold out against this pressure with fair success but an ominous development has been the opening of their own pharmacies by these mutualities. This process, if it were carried very far, could change the character of French pharmacy. At present French pharmacies are mainly owner-operated. A growth of mutuality pharmacies would mean that the controlling pharmacist would increasingly be a manager.
For his "unselfish devotion and contributions to the highest standards of pharmaceutical service," Sir Hugh N. Linstead, member of the British Parliament and president of the International Pharmaceutical Federation, received a certificate of honorary membership in APhA from then President J. Warren Lansdowne.
One of the points much in dispute between pharmacists and the authorities in European countries is whether payment for a prescription is to be made by the patient or by the mutuality. A process whereby the patient pays the pharmacist and collects the money subsequently by refund from the mutuality acts as a mild deterrent against too free use of the service. Under this system the pharmacist is paid at once whereas under the alternative scheme, whereby the patient does not pay and the pharmacist sends the prescription charge to the mutuality for payment, he may have to wait some time for his money. While the position of French pharmacy in the face of the mutualities is an uncertain one, there has been a much more direct attack upon it as the result of the industrialization of the manufacture of medicines. Some years ago, after the reform of the French constitution by General de Gaulle and the setting up of the Fifth Republic, the French government set on foot a broad
inquiry into restrictive practices which could be held to operate against the efficient functioning of the French economy. The result of the inquiry became known as the Plan Rueff after its author. That part of the plan which surveyed pharmacy proposed two modifications in the traditional structure and organization of pharmacy. The first, concerned with the control of the pharmaceutical industry, has already been put into operation. The second, relating to community pharmacy, has fortunately not yet been implemented. In industry under the old law, a company manufacturing pharmaceuticals, if its capital was under $100,000, was required to have the majority of its shareholders pharmacists. Above $100,000, shares could be held by non-pharmacists. Furthermore the president, managing director and the secretary of any manufacturing pharmaceutical company were required to be pharmacists and also a majority of the board of directors. Following the Plan Rueff this has been Vol. NS2 No.6, June 1962
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swept away and replaced by a provision which works like this. If the capital is less than $100,000, the old rules apply. If the capital lies between $100,000 and $400,000, the majority of the shareholders need not be pharmacists although the majority of the directors must be and also the president, the managing director and the secretary. If the capital is over $400,000, only two of the directors need be pharmacists. Neither the chairman nor the president need be a pharmacist but there must be a pharmacist specifically nominated as administrateur mandate. As you see, by a stroke of the pen the pharmaceutical industry has been freed from effective pharmaceutical control. The propositions of the Plan Rueff relating to community pharmacy turn upon certain conclusions of which the following are the most pertinenti-A new definition of the pharmacist's monopoly insofar as it relates to supply to the public-the restrictions upon the items covered by the monopoly should be relaxed so as to exdude(a) certain medicaments in regular use which are non-toxic, of which the list will be fixed and periodically reviewed by a public authority and (b) the majority of surgical appliances (dressings, etc.), with certain exceptions also to be determined by means of an official list. 2-An amendment of the provisions at present regulating the limitation of pharmacies-the committee has not been able to embark upon a sufficiently profound inquiry to be able to express a firm opinion about the limitation of the number of drug stores. Nevertheless it has been impressed by the lack of convincing argument in favor of a control which makes such inroads into common law rights. It has also been struck with the inconveniences which result from the present practice. As I have said, legislative effect has not so far been given to these proposals affecting community pharmacy but they have naturally given rise to the greatest apprehension among French pharmacists. The Ordre National des Pharmaciens de France has circulated to all its members a substantial criticism of the plan . It is bound in scarlet and splashed across the cover in white is the warning La Pharmacie en Danger.
forces in Great Britain Great Britain has not escaped from the influence of both forces-industrialization and a state health service. Industrialization of pharmacy has followed very much the same line as in America. But for the existence of the National Health Service its impact would no doubt have been equally great; even taking account of this limitation upon its expansion, it has had a 346
very profound effect upon the professional functions of the pharmacist. Our experience is similar to yours and American firms are playing an increasing part in Great Britain. The Association of the British Pharmaceutical Industry now has a number of American members. So far the lion has lain down peacefully with the eagle and there has been no Boston tea party in reverse. What may be more interesting is the impact of the National Health Service. The service has to some extent stood between community pharmacy and the worst effects of industrialization. It has of course in other ways profoundly affected the practice of pharmacy. For both these reasons I ought to give you a very brief picture of how it works. Indeed there is a further reason why I should do so- many American accounts of what the service is and how it works have been very grossly distorted. It has many defects and it contains some dangers. Nevertheless it works well, it is popular with the people, it is now accepted by most of the professions who have to work in it and I am sure that even its greatest critics would be hard put to it to propose an alternative which would confer equal benefits on so many people. To clear away one or two fundamental misconceptions I will make one or two categorical statements about the principles upon which the service is based. First, apart from those working in hospitals, many of whom do private work as well as health service work, neither doctors nor pharmacists are salaried employees of the state. They are paid for the work they do and doctors are free to do as much or as little health service work as they wish and to supplement it with as much private work as comes their way. Second, the service is not centralized in the Ministry of Health except in the most formal sensc. Most of the dayto-day control of the hospitals, of the general practitioner service and of the pharmaceutical service, to take only some examples, is exercised by committees representing the public and the professions concerned. Virtually all professional questions are decided by members of the professions themselves. Third, a medical practitioner is free to prescribe any medicine for a patient which he in his own judgment considers that patient needs. The only control over prescribing exerciscd by the Minister of Health is the sending of a regional medical officer to discuss his prescribing with any doctor who habitually prescribes excessively expensive drugs and very occasionally, requiring the doctor to justify before a committee of other practitioners continued excessive prescribing. Perhaps the dominating question in
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the development of the National Health Service should be how to resolve the inevitable conflict between professional freedom and essential state oversight where large sums of public money are involved. In fact that question has been subordinated to the simpler question of how to find enough money to pay for it all. The report upon which the British social security plan was built at the conclusion of the last war estimated that the National Health Service would cost 178 million pounds sterling to the exchequer each year. In fact next year it is likely to cost 900 million pounds sterling, of which about 700 million pounds sterling will fall on the exchequer. This great divergence between estimate and reality is largely due to underestimating both demand (which may be artificial to some extent) and need. In practice it has meant that from its inception the service has promised more than it has been able to afford within the limits of the national budget. Consequently, ever since 1948 the main energies of its administrators have had to be directed to securing all possible economies instead of to a process of steady development. To some extent that is represented by the contributions which now have to be made for some of the benefits such as spectacles, dentures and medicines. It is my estimation that this pruning process is now largely over. A promising sign that the service has turned the corner is a very substantial building program for hospitals which has just been announced.
increasing cost The pharmaceutical service has attracted particular attention because of a steady rise in its cost. The number of prescriptions has remained fairly steady- about 210 million annually for 50 million people. But the cost o(each item has steadily risen owing to the increasing use of new and more expensive drugs. I shall not be surprised if the average soon reaches 8/4d or $2 bearing in mind differences in the value of money. This 8/4d is about three times the cost in 1948 when the service started and it has only been kept down by the most strenuous efforts with what we call the British National Formulary which gives recipes for non-speciality medicines and advice about equivalent preparations for expensive specialties. Prescribers' Notes are circulated to general practitioners advising them on rational prescribing and in rare but regular cases practitioners are interviewed as I have indicated. The cumulative effect of all this activity is to make prescribers cost-conscious and to wean them away from undue dependence on specialities and on the detail man from the manufacturer. As a re(continued on page 374)
Sir Hugh N. Linstead (continued from page 346) suIt, about 60 percent of the medicines prescribed under the National H ealth Service are for specialities and the remainder a re not. On the European continent 90 percent or more of prescribed medicines a re for specialities and I suspect that in the United States a nd Canada the percenta ge is even higher. In addition to this control over the invasion of specialities, the Minister of Health has also a review committee headed by e minent physicians who classify a ll new specialities into classes according t o their valu e as therapeutic agen t s and the possibility of their being replaced by pharmacopeial or non official drugs. This classification serves as a therapeutic guide to prescribers. These then are the ways in which the National Health Service has controlled the effects of the industrialization of medicines u pon the practice of pharmacy. It does at least insure tha t 40 percent of the med icines dispensed by the pharmacist call for some other pharmaceutical process than handing out a prepacked medicine. There is, of course, a large element of state control in the pharmaceutical service although it a ffords very substantial freedom t o the pharmacist. To what exte nt has this process changed the character of the practice of community pharmacy? As in most pharmaceutical questions the answer has to be divided into two-the professional aspects and the economic aspect. On balance the National Hea lth Service has brought a very large increase in the amount of the professional work done by pharmacists. It has reduced the variety of compounding beca use of the greater t endency to standardization in prescribing. It has enabled pharmacists to be more dependent upon professional work and therefore less anxious to seek nonprofessional commerce. On the debit side it has in theory limited the profession al fr eedom of the pharmacist to th e extent that he is dealing with two clientsthe patient a nd the minister-instead of one. It has put the pharmacist in the position where the minister's rules and the ethical code of his profession may come into conflict. But most of this is in the fi eld of theory and by good sense on both sides conflicts of this sort have been avoided. It is only where economics have come into the picture tha t there has been a rea l conflict and of that I give two examples. Successive ministers of health have imposed cha rges payable by the patient to the pharmacist when the prescription is collected. These were originally 15 cents per prescription form (irrespective of the number of items), then 15 cents per item and more recently 30 cents per item-30 cents being equivalent to 50 cents in American spending terms. These charges, pa rticula rl y the increases, have given rise t o much criticism by the public who has to pay them a nd to a certain amount of real hardship in spite of the special provisions for indigents. Th e pharmacist has had to bear the brunt of th ese disagreeable reactions and this has led to friction and to strained 374
relations between pharmacy and the minister of health . A more recent cause of friction has been occasioned by the minister's a ttempt t o slow down the rate of increase of the cost of each prescription item. The pha rmacist is paid for each item by a complicated calculation which includes a percentage added to the cost of the actual medicament supplied. Until recently this oncost was 25 percent. The minister's case was tha t 25 percent could be justified when the cost of the individual drug was low but as the cost mounted, the 25 percent represented a la rger amount of money for what was essentially the same service. He therefore made a reassessment of the oncost on a sliding scale which has meant that the total oncost payable will be cut out by some four a nd a half million dolla rs a year. An attempt was made to reach an agreement by negotiation but it broke d own and the new a mount was imposed by the minister unila terally. This is an impressive reminder of the power and influence which the minister can wield when he considers it necessary to do so.
common market These glimpses show how confusing the pattern of pharmacy in Europe is t oday. Fifty years ago it was a patchwork but it was a t least comprehensible. Each country had its own na tional system which made sense within its own frontiers. One of the exciting questions for us in Europe just now is whether the European Economic Community, otherwise known as the European common market, will succeed in devising an orderly pattern of pharmacy within the frontiers of the new Europe. The six member countries of the community-France, West Germany, Italy, Belgium, the Netherlands a nd Luxembourg-are setting t o work with great energy to build a unified system not only commercially but professionally also. The basis is the Treaty of R ome. This provides among other things tha t within a limited period of time there shall be free interchange of professional qualifications between the six countries a nd the freedom to practice one's profession anywhere within them . There are reservations about the practice of medicine a nd the practice of pharmacy a nd there a re working parties trying t o throw up the salient points tha t have to be decided before the general principles of the treaty can be applied to those two professions. What the champions of the United Europe want to create is one code of practice for the whole community. Before this can be done agreement must be reached on a t least three thorny pointshow an equivalence of qualificatio n is to be measured what conditions must be attached to the right of a foreigner to practice in anoth er country of the six whether there should be a unified system controlling the distribution of pharm acies geographically a nd in accordance with population needs.
It is too early yet to say whether a code agreeable to everybody can be worked out. The six governments a re, however, pressing forward the political union of the community a nd there may well be some steam rolling of pharmaceutical objec-
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tions if there is difficulty in securing agreement within the pharmaceutical field . Britain has not yet j oined the community although her a pplica tion to do so is under consideration. If she does, it will not be easy t o integrate her essentially free trade system of pharmacy into the much more rigid continental system. Looking at the community as a whole, however, it does offer to pharmacy in Europe a unique opportunity of making a new start. This is what I had in mind when I stated earlier that it was not entirely wishful thinking to hope tha t new barriers could be raised t o protect community pharmacy against industrialization a nd undue state control. Within the European community there could be a new outlook on the service pharmacists a re required to provide and the conditions necessary for them to provide it appropriately. Furthermore, it could become increasingly difficult for individual governments to upset the established practice of pharmacy by unilateral action. There is therefore real hope here tha t some of the lessons of the past can be applied in this new venture from the very beginning. There seems t o be considerable relevance between our problems and yours and the two main influences that I have been tracing are both potent in America. You may not be as conscious of the increased concern of the state in your affairs as we are. In America is there good medical attention readily available to everyone in your community who is in need of it, irrespective of what a sick person can afford to pay? If the answer to this question is an unqualified yes, then a general public health service may not expand ra pidly. But if, in all honesty, you have to admit that the answer is not unqualified, then it is inevita ble that the state will increasingly step in, in America as it has done in Europe, to provide for the deficiencies. Be that as it may, however, no one can be unaware of the revolution that industrialization has created in the conditions in which pharmacy is practiced in the United States. Those who can look back to the conditions of 30 years ago will know whether it is true to say of the United States, as it is certainly true to say of Europe, tha t community pharmacy has gone into solution. The question for us is how is it going to crystallize out; more specifically, what can we do to shape its future to our estima te of the public need. By we, I mean those bodies of individuals who a re in a position to make decisions that can influence the course of events. Whether we approach the question from the point of view of providing the service needed by the public or of maintaining the influence of our profession, there is one clear prima ry necessity-to maintain the value of the pharmaceutical qualification. Far from the industrializa tion of pharmacy making it less necessary for the pharmacist t o be well informed over the whole field of the sciences that touch pharmacy, the reverse is the case. The pharmacist needs to know thoroughly the articles he is handling. He needs to know their composition, their manufacture, their standardization and, above all , their uses. The physician cannot have at his fingertips a knowledge of all the medicaments
that today are at his disposal a nd that are born and die with such frequency a nd speed. He must rely on the pha rmacist and the pharmacist must be equipped t o answer the physician's questions with assurance based on knowledge. Of all the ma ny claims of the pha rmaceutica l curriculum, pharmacology stands out as being the subject in which the future pharmacist must be a master. It must be developed in our curricula both widely and deeply and this may r equire of course an orientation of our pure science teaching in the direction of more biology and physiology. In my country it is not a field enthusiastically cultivated by doctor s and it is one of those sciences into which the pharmacist can readily move. The masterly address, " The Scientific Status of Pha rmacology," given before the American Association for the Advancement of Science by Professor Cha uncey D. Leake of Ohio State Un iversity a nd printed in the February American Journal of Hospital Pharmacy, concerns itself with this same idea. I emphasize pharmacology in particular, but what I want to emphasize in general is that under the conditions of t oday and tomorrow a high standa rd of educationa l a ttainment is the only t hing that can keep pharmaceutical influence a live in industry or in distribution. In a world becom ing more and more mecha nica l the educational qualities of the individua l become of in creasing significance.
the political game The salva tion of pha rmacy is not t o be found through politica l manifest a tions. Playing the political game pays off only if you have politica l power. The great trade unions have politica l power a nd can use it. Speaking generally, the professions have not. Professional men are not naturally politically minded. They can usually see both sides of a n argument whereas your politicians only see one. They lack the influence of numbers. They will never use the strike weapon . They work by themselves or in small groups. This is not to say that the politica l r oad is not for them to foll ow. But if they have a politica l case to make, it must stand or fall on its merits a nd on the persuasiveness of a rgument. It cannot be expected to prevail merely by force of numbers or by political influence. I have been a politician for more tha n 20 years a nd I can end orse what the founder of our pharmaceutical society, J acob Bell, himself a m ember of P a rlia ment, wrote more tha n a hundred years agoIt may be as well to recapitulate the moral which may be drawn from our past history, namely, that political con· troversies and mercenary disputes are injurious to the interest and character of all parties-that the most effectual method which any class of men can adopt for securing their political rights and advancing their professional standing, consists not in dispute and warm argument, but in a steady and persever· ing attention to intellectual improvement and the establishment of such regulations as are calculated to insure collective privileges by increaSing the amount of individual merit. Intellectual improvement-tha t 376
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say education; the establishment of regulations-that is to say a code of professional ethics supported by a professional disciplinary tribuna l; individual meritthe personal qualities of the individua l pharmacist--these were the necessities picked out by Bell during a formative period in the history of British pharmacy. They seem to me to be as valid t oday as guide posts as they then were a nd t o contain in them what is essentia l for meeting the needs of the public as much as for preserving the cohesion a nd the qua lity of our profession. Devotion to the id eals represented by these three principles is not enough, however. They have to be projected to the public a nd to governments. This is the a rt of public relations, an art of which a ll professions, pharmacy among them, a re poor practitioners. Neverth eless, professional men a re slow to accept the idea that sales technics a re an appropriate ac tivity within the professiona l field. They a re right insofar as they are thinking of the norma l t echnics of commercial advertising. They a re wrong insofar as they ignore the central place which the propagation of ideas occupies in the world t oday. Ca mpaigning for the a ttention and education of the public has become a n activity of such diverse bodies as governments, political parties, organized r eligious bodies, societies in favor of this or against that a nd many others. Professional bodies ignore it a t their peril. The subject of public r ela tions in pharmacy is t o be discussed at a congress of French and British pharmacists to be held in France in May 1963 and one paper stat esAll the professions have certain valuable assets. Their members carry responsibilities to the community over and above the standards of conduct laid down by the law for all citizens. These responsibilities are the product of the traditions of the profeSSIon established by the practice of the best practitioners. They may be enforced in part by professional tribunals but they should be maintained mainly by the conscience of the indIvidual professional ma n. It is an asset to any community to have among its citizens groups of men a nimated in their activities by ideals which transcend the orthodox "fair day's work for a fa ir day's pay." But does the public understand this and appreciate how the community can be impoverished by a gradual erosion of the responsibilities that the proud title of "profession" carries with it? What are the particular assets that the pharmaceutical profession can offer to the community? Essentially they are responsibility and knowled ge. Responsibility involves advising the physicia n and the public. It requires the pharmacist sometimes to say no when it may be to his superficial advantage to say yes. It calls for metiCUlous care in the conduct of his business and the performance of pharmaceutical operations. Knowledge involves not only mastery of the science of pharmacy but also an understanding of men and women and of the human problems that are part of a profeSSional relationship with them. Does the public understand the scope and importance of these services? Does the government? Do pharmacists have the professional freedom that is essential to the proper performance of these services? Is the pharmacist ade-
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quately rewarded financially for them? If in any country the general answer to these questions is no, then the public relations of pharmacy in that country are inadequate. In a n y process of public rela tions it must be remembered that in the long term "the truth will out." Public r elations cannot ma ke a poor pharmaceu tical service appear to be a good one. If the image of a good professional picture is to be projected the picture itself needs t o be good. To this extent therefore the most importa nt public relations officer in pharmacy is the pharmacist himself. He cannot divest himself of this responsibility by delegation to a professional bod y or to a public rela tions organization. He must himself be proud of his profession a nd mindful of its traditions a nd standards. No campaign t o ex t ol his quality can succeed if the contrary is manifest in his pharmacy or in t he service that he offers. In sp ite of the special example of some of the newly born countries, it is broadly true to say that the 19th century was a cen · tury of nationa lism while the 20th century is a century of internationa lism . We in Europe are moving fairly rapidly t owards the integra tion of that continent just as you in the Americas a re groping t oward s closer unity between the United States a nd Central and South America. Similar tendencies a re showing themselves in embryo in Africa a nd a mong the Ara b States. W ithin t hese la rge in ternationa l movements there are moves to secure closer co-operation a nd under standin g between professional groups. You have your Pan-American Congress of Pharmacy; we ha ve in Europe a committee representing the pharmaceutical organizations of the six countries of the European econ omic community. I ha ve recently had the privilege of attending the Eighth P an-Ara bic Congress in Cairo. The oldest organ ization in this field is, of course, the International Pharmaceutical Federation. We include in our membership pharmacentical societies fr om a ll over the world a nd the AMERICAN PHARMACEUTICAL ASSOCIATION has vigorously participated in our work to our great benefit a nd encouragement. At this present moment, one of the imp ortant problems for the federation, in consultation with representatives fr om other continents, is to look at t he world situa tion of pharmacy a fresh and to see whether there are steps t o be takenconstitutional or practical- Which can bring a bout co-ordination between what our federa tion is doing a nd what other interna tiona l groups a re seeking to achieve. I do not think anyone of us can be satisfi ed tha t we have yet found the answer to the co-ordination of professional pharmacy internationally a nd this is why I want to encourage my colleagues in the fed eration to study the question more profoundly. Our problems are essentially the same in every country; our ideals a re the same; a ll of us a re bound to profit from a n increasing intercha nge of experience and ideas which modern communications made possible. Pharmacy has become international. The pha rmacist must become internationa l likewise. •