Over the past year, I’ve worked as a Project Assistant to Dr. Lucas Richert, the George Urdang Chair in the History of Pharmacy at University of Wisconsin-Madison, for his upcoming book project tentatively titled Drug Store, Inc. The project tracks the role of American consumerism, corporatism, and cultures of health in the development of pharmacies in the United States throughout the twentieth century. My tasks included rifling through archival materials in the Kremers Reference Files at the American Institute for the History of Pharmacy, flagging important materials, writing brief summaries of them, and utilizing those materials for various deliverables, including co-authored articles and presentations. My aim in this post is to reflect on my time in the archives to consider what archival materials on drug history from the twentieth century might suggest about the problems that we face regarding drugs and pharmacy in the twenty-first century.
Let’s begin by contextualizing the role of pharmacies during the early twentieth century in the U.S. Take a look at the cartoon shown here titled “The Age of Drugs” from a 1900 edition of the satirical magazine Puck. On the left side of the cartoon, a saloon keeper stands with arms crossed, a frown on his face, a cigar between his fingers in one hand, and the index finger of his other hand wagging towards the right side of the cartoon, where customers scramble towards the counter of a pharmacist who holds a bottle that says “bracer” and stands next to other bottles with labels that say “opium,” “cocaine,” and “stimulant.” In the foreground, a small child next to the counter walks away with a bottle that says “soothing syrup” on it. The tagline offers the perspective of the saloon keeper, who says, “The drunkard I make is going out of fashion. I can’t keep up with this fellow,” referring to the pharmacist. The cartoon highlights the vexed position that the pharmacist occupied in U.S. society at the turn of the twentieth century because, at that time, drug regulation remained quite slim, which meant that the pharmacist not only acted as a medical professional who sold medicinal remedies but also offered various psychoactive drugs that put them in competition with saloons and bars, who sold alcohol and nicotine, two psychoactive staples of U.S. culture. Pharmacies often operated at a local level, sold a variety of psychoactive and medicinal products, and bore little resemblance to the chain pharmacies of today.
As the twentieth century progressed, those local pharmacists became more sophisticated with the design of their stores in order to maximize traffic and profit. Dr. Richert and I co-authored an article on this topic titled “‘Conscientious Guardian’ v. ‘Commercialized Jungle’: Pharmacies and Pharmacy Design in the Postwar U.S.” that is forthcoming in the Journal for the History of Medicine and Allied Sciences. The metaphor in the title refers to a debate between twentieth century pharmacists about whether they acted as healers (conscientious guardians) who solely sold medicines or retailers (commercialized jungle) who sold a variety of other products. What became clear through the archival materials—like the 1956 Johnson & Johnson manual shown here—was that, whether or not pharmacists desired to be healers, they needed to learn business skills like design, merchandising, and marketing in order to survive in the commercialized jungle, eventually selling anything from beach balls to booze alongside more typical medicines.
The complicated position that pharmacists occupied in the twentieth century—as both healers and retailers—became the starting point of a presentation titled “‘The Pharmacy Image’: Advertising, Marketing, and the Business Education of U.S. Pharmacists 1900-1975” that I gave at the 2023 British Society for the History of Pharmacy conference. A central premise of my presentation was that pharmacists learned to curate a brand by reading trade magazines that offered business advice on topics that the pharmacy curriculum did not cover. The aim was to draw customers into the pharmacy and cultivate trust with patients and consumers. Through this presentation, I began to grasp how, at least in modern pharmacies, much of the advertising is completed by marketing teams that are hired by major pharmaceutical companies such as Walgreens or CVS. Prior to the consolidation of many community pharmacies into chain pharmacies, however, local pharmacists needed to learn the business skills necessary to survive in the increasingly competitive commercialized jungle, which led to a continual struggle to balance the drive for profit with their roles as guardians of health.
A key material that demonstrated how pharmacists were thinking about advertising was a collection of posters by Frank Pinchak, a practicing pharmacist in the mid-twentieth century who created “ethical” window displays to replace “commercial” ones so as to bolster the credibility of pharmacists. Below you’ll find one example of these displays, though you can peruse the whole Pinchak collection on the American Institute for the History of Pharmacy website. I highlight this specific example about opium because of how it demonstrates the push towards establishing credibility for pharmacists. On the bottom of the middle poster, it states that opium “in the right hand [is] one of the greatest contributions to medicine,” but “in the wrong hand [is] the beginning of the end!” Although Pinchak tried to establish the credibility of pharmacists by moving from commercial displays to ethical displays, he did so by making clear that pharmacists are the sole legitimate purveyors of drugs. Unlike the earlier Puck cartoon that implied pharmacists handed out opium bottles to create new “drunkards,” Pinchak sought to convey that pharmacists had the so-called “right” hands to offer these drugs.
The image of pharmacies and pharmacists have changed a lot since those early years of commercial development, however. In the U.S. today, the pharmaceutical industry is under increasing scrutiny regarding their role in the ongoing opioid crisis that has turned into an overdose crisis. Part of the image of pharmacists comes from the trust that is placed on them to be legitimate purveyors of medicines, even those that have a psychoactive component, such as opioids. What became clear from my work in the archives is that pharmacies in the U.S. have always had a tumultuous relationship with psychoactives throughout the twentieth century, especially as it pertains to their roles as trustworthy healers. In particular, three psychoactives—alcohol, nicotine, and caffeine—have been widely available in pharmacies throughout U.S. history.
The Morton Pharmacy Story exemplified the fraught relationship that pharmacists in the twentieth century had with psychoactives, particularly nicotine. In this pamphlet from 2007, an article titled “Drugs of Choice” detailed the decision that Peter Morton made in 1991: to completely forego the sale of tobacco products due to it conflicting with his beliefs about protecting patient health. Despite losing about $75,000 annually, Morton stated his rationale bluntly: “It’s difficult to promote wellness and sell cigarettes at the same time. From a credibility standpoint, it has an impact. Why jeopardize your credibility by selling cigarettes?” Not only did such sales damage patient health, according to Morton, but it ruined the credibility of pharmacists. I should note that Morton was in the minority here. Tobacco products have been—and continue to be—widely available in U.S. pharmacies, whether with a prescription in the early twentieth century, or behind the counter in the twenty-first.
My questions about the relationship between psychoactives and pharmacy brought me into contact with a number of materials about the regulation of such drugs. Dr. Richert and I co-presented on this topic at the 2023 American Association for the History of Medicine conference and for the American Institute for the History of Pharmacy 2023 Kreminar series with a talk titled “‘What is the Soft Drug Problem?’: Gatekeeping, Pharmacist Authority, and the Pharmaceutical Industry, 1925-1975.” What we found is that the delineation between “hard drugs” and “soft drugs,” at least in a U.S. context, came down to whether such drugs were scheduled and regulated as “illicit” or not. A drug was “soft” if it was prescribed by a physician and dispensed by a pharmacist, but a drug was “hard” if it was not.
It is never so simple or clear, though. Consider the political cartoon below from March 1925 in The Bulletin of Pharmacy. F. Lyons, the cartoonist, depicted pharmacists and people who use drugs as chained by their necks to a wall with a sign on it that says “violently insane only.” The tagline at the bottom says: “One went batty from dope, the other from trying to live up to Harrison law regulations. A joke or a tragedy?” The implication is that the Harrison Act and the subsequent court cases following it damaged both parties involved. An outcome of the Harrison Act was that pharmacists could no longer prescribe drugs to help people who suffer with addiction in order to help them maintain their current condition or eventually taper of their drug of choice. For instance, someone who struggled with addiction to opioids could no longer be prescribed opioids by a pharmacist, effectively forcing them into an illicit market. In turn, pharmacists became bogged down by continual paperwork to prove their credibility.
This cartoon became a touchstone for me when it came to the role of drug regulation as it relates to psychoactives and pharmacy in the U.S. Today, when the credibility of the pharmaceutical industry has come under scrutiny for their advertising and prescribing practices, I think back to this cartoon from almost 100 years ago. Of course, both pharmacists and people who use drugs are depicted as the recipients of negative outcomes, but the major implication is that the catalyst of such problems is drug regulation itself. The current overdose crisis was created, in part, because of a predatory pharmaceutical industry and overprescription, but that is not the whole story. A major factor contributing to the overdose crisis remains the prohibitionist policies that seek to incarcerate, rather than help, people who use drugs. People who use drugs continue to overdose at alarming rates because the illicit drug supply has become tainted with fentanyl, a potent opioid. To be clear, the problem is not simply fentanyl itself: the problem is that people who use drugs cannot accurately detect and dose what is in their supply because drug policies in the U.S. rarely allow drug testing and checking services, because naloxone access remains incredibly limited, and because the stigma around people who use drugs remains intractable. For fear of “enabling” people who use drugs, the U.S. continues prohibitionist policies unabated, despite its role in exacerbating the overdose crisis.
Is it a joke or a tragedy that, after 100 years, the U.S. still struggles with similar drug problems? I don’t wish to make light of the current problems that we face, specifically the overdose crisis, so in my view, it’s a tragedy. What seems like a cruel joke, though, is that, after over a century of drug regulation, the U.S. continues to utilize the same prohibitionist policies and stigmatization tactics. It’s time to turn to harm reduction as the new paradigm for approaching drug policy and addressing drug problems. My work over the past year in the archives showed me that, despite new medicines hitting pharmacies and new drugs hitting the streets, the drug regulation of the U.S. is anything but new. It still exacerbates drug problems. What is new are harm reduction solutions that we can use in order to address issues related to drugs like the overdose crisis.
All images courtesy of the Kremers Reference Files at the American Institute for the History of Pharmacy.