Since the early days of American medicine, pharmacies have played a vital role in ensuring the health of local communities. As trusted local advisors, pharmacists have served as a major point of access to essential medicines, testing, emergency care and medical advice for those in their communities. With the introduction of the COVID-19 vaccines and the provision of Paxlovid, this role has expanded to pandemic prevention and preparedness. As efforts to deliver COVID-19 vaccines gained momentum, pharmacies became the primary entry point across the country, eventually culminating in the administration of more than 258 million doses of COVID-19 vaccines by US pharmacies.
Despite their importance, we continue to see significant disparities in pharmacy access in this country. As physicians, we do our best to work with patients to ensure they have access to their medications and often ask questions like “which pharmacy is closest to you” or “which pharmacy do you prefer”. Despite our best efforts, studies show that only 72 percent of new drugs are picked up by patients. While there are many barriers to drug access — such as costs, navigating insurance, and healthcare literacy — our recent work focused on the logistics of physically going to a pharmacy.
Pharmacy deserts, a term originally borrowed from the FDA’s “food deserts,” are areas where access to pharmacies is limited by geography, resulting in challenges in accessing essential drugs and medical care pharmacies. These types of areas are unfortunately rampant in the United States. As many as one in three neighborhoods in our largest cities are located in a pharmacy desert, and they disproportionately impact racial/ethnic minorities.
While these important previous studies focused on the physical distance from a patient’s home to the nearest pharmacy, in a recent paper we used open source tools to estimate actual travel time. For example, when we think about which supermarket is the most convenient or accessible, we generally think about the time it takes to get there rather than the distance. This preference is even more evident in urban environments where distance and time can be very poorly correlated (ie short distances can be long due to the high density of road networks, traffic patterns and public transport routes).
In our study of more than 4,500 neighborhoods in the four largest U.S. cities, we found that when factoring in travel time — by car and public transportation — half a million people lived in the pharmacy desert. In all four cities, these deserts were much more common in predominantly black and Latino neighborhoods. In cities with robust public transportation (NYC, Chicago), public transportation pharmacy deserts are less common than auto pharmacy deserts. Our findings highlighted the need to think carefully about the meaning of equity and access when evaluating access to medical care. Though important, thinking about distance from point A to B only gives part of the story.
More broadly, the idea of an access “desert” – used by various government agencies – is in need of revision.
While absolute distance to a location can be a useful way to start a conversation about access, we believe that these definitions are incomplete if they do not include real world measurements such as travel time as a criterion.
Armed with our findings, we have begun to work carefully with patients to ensure that when we prescribe, our patients can easily get their medications. Some of these barriers can be overcome with home delivery, while others require careful planning with patients to ensure their chosen pharmacy is one they can access. In addition, since pharmacy closures are more common in black and Latino neighborhoods, and because independent pharmacies play an excessive role in these neighborhoods, some have suggested encouraging pharmacies to open locations in desert neighborhoods by increasing Medicare and Medicaid reimbursement and into federal programs that increase payments to primary care providers. Ultimately, we suspect that a combination of these strategies would ensure sustainable and equitable access to pharmacies for all our patients.
dr. Peter Kahn is a fellow in the Pulmonary, Critical Care, and Sleep Medicine Section at Yale School of Medicine. He graduated with honors from the Albert Einstein College of Medicine and his MPH from the Johns Hopkins Bloomberg School of Public Health in the Department of Health Policy and Management. The research of Dr. Kahn has focused on health policy with a particular interest in the impact of climate change and utilities on health policy. Follow him on Twitter @PeterKahnMD
dr. Xiaohan Ying works in the internal medicine department at New York Presbyterian Hospital/Weill Cornell. He graduated from Wharton with a focus in Healthcare Management and Policy and received his MD from Weill Cornell Medicine. dr. Ying previously worked as a health consultant and his research focuses on health inequalities and health policies.
dr. Stan Mathis is the medical director of an ACT team and an assistant professor in the Yale Department of Psychiatry. A background in architecture and urban planning forms the basis for his clinical and research/educational work. By caring for patients at home or in the community, he sees first-hand the impact of the extrahospital environment on their lives and well-being. He also co-developed a curriculum that combines data-driven and experiential learning to help psychiatrists develop a deeper understanding of New Haven and the forces, historical and current, that affect its population.