Illustration by Carson McNamara
More than 19,000 Richmond residents can go a mile in any direction — sometimes multiple miles — without coming to a pharmacy. Pharmacies are medical and retail oases in most neighborhoods, offering not only medication but also clinical offerings such as vaccines and checkups, groceries, household goods, and more. Those 19,000 Richmonders without that community necessity within reach might not realize it, but their situation has become common enough to have a name: They’re caught in a pharmacy desert.
Lack of retail pharmacy access is a growing problem throughout Virginia and the United States at large as chains including CVS and Walgreens and small community providers alike shut down. Researchers at Virginia Commonwealth University’s School of Pharmacy and the Virginia Board of Pharmacy recently identified 51 pharmacy deserts across the state; in Richmond, the Manchester, Highland Park, Fulton Hill and Dumbarton neighborhoods all lack pharmacies.
Meanwhile, employees of pharmacies are becoming more important to the overall well-being of the Richmonders they serve. Recent legislation in Virginia has expanded the services pharmacists and pharmacy technicians are able to provide to customers, making them a more powerful tool for neighborhood-level care — in theory.
It’s not only businesses that suffer as pharmacies close. A community without a pharmacy often has no health care facility accessible by foot, and studies show that residents not in close proximity to care centers struggle to manage chronic diseases, miss out on preventive care and generally have worse health outcomes than those with care options nearby. In the face of these challenges, local researchers and health care providers are seeking new paths to bring services to these areas of isolation.
Drying Up
Dr. Teresa Salgado, a co-author of VCU’s investigation into these deserts and an associate professor at the School of Pharmacy, likes to think of pharmacies as the “front door to health care.” The role pharmacists play in their communities has grown from filling prescriptions, she says, to include point-of-care services such as preventive care and testing and prescribing medication for common illnesses — all available without having to visit a family doctor.
These options became available in 2020 because nationwide trends for primary care visits plummeted due to the COVID-19 pandemic, highlighting the need for more accessible care options. Shortly after, states including Virginia passed legislation that allowed pharmacists to increase their care offerings, a major shift in the dynamic between pharmacist and patron.
While many pharmacies still need to staff up and train to reach the capacity needed for expansive test-to-treat programs, their vaccine programs have delivered more than 300 million COVID-19 vaccinations and provided 1 out of 3 adults’ flu shots over the past five years. Both successes model a promising path for building test-to-treat services.
Despite pharmacies’ growing ability to offer more services, researchers at the University of Southern California found that nearly 1 in 3 pharmacies across the U.S. have shuttered since 2010. While major chain stores have increasingly eliminated outposts, independent community pharmacies were more than twice as likely to close.
In a study published in February this year, researchers defined a pharmacy desert in Virginia as a census tract with low income (meaning more than 20% of residents in poverty or a median household income less than 80% of a relevant comparator) and low access to a pharmacy (meaning a distance of at least 1 mile from a retail or clinical location). Fulton, Manchester, Dumbarton and Highland Park met those criteria.
“We found that urban areas were most likely to be pharmacy deserts over rural or suburban areas, which stood out to us,” Salgado says. “It just goes to show that it’s those already vulnerable areas, with the already vulnerable populations, that’s where the pharmacies are closing.”
Although it depends on the region, pharmacy closures can be attributed to a variety of factors. Issues such as staffing shortages, chain store overexpansion, access to mail-order prescription services and rising drug costs can spell death for a drugstore.
“Any pharmacy trying to keep their doors open is on a roller coaster ride,” says Tana Kaefer, the director of clinical services and a pharmacist with Richmond’s Bremo Pharmacy. Independently owned and operated, Bremo has been open since 1976; Kaefer has been employed there for 21 years.
Located off Staples Mill Road, Bremo is one of the few community pharmacies in the Richmond region. Bremo has grown by offering sustainable, reliable service methods such as a synchronization model (which bundles multiple prescriptions for convenience) while avoiding the retail-heavy model of most chain stores.
That approach, according to Kaefer, has allowed Bremo to change with the times and adopt specialties, including long-term care for substance use recovery programs and training home care specialists in medication distribution, as they arise. “For us, it’s [about] finding those niches,” she says. “Then, even those are not forever; you have to be constantly evolving.”
While services such as delivery, which Bremo offers throughout Richmond, can aid those living in pharmacy deserts, neighborhoods without in-person pharmacies still miss out on potentially life-saving health care.
Dr. Teresa Salgado of Virginia Commonwealth University, co-author of a recent study on Virginia’s pharmacy deserts (Photo by Jay Paul)
Rewriting the Script
Experts including Salgado and Kaefer admit there isn’t one clear way to heal communities suffering from a lack of local pharmacies. Finding the right solution for each neighborhood involves more hyperlocal knowledge and research than one approach can offer — and even if a pharmacy can open in a desert, survival of the business is no easy feat.
In recent years, pharmacy-assisted programs have brought together specialists from across the medical community to improve both patients’ and pharmacies’ well-being.
The Richmond and Henrico Health Districts, which are the local branches of the Virginia Department of Health, provide public health services to Richmond region residents. Made up of medical professionals and public health experts, they identify pressing health needs across the city and county and design programming to meet those needs, often partnering with accessible clinical facilities like pharmacies.
“Coming out of the pandemic, we had so many kids who didn’t have the vaccinations they needed to start school,” says Becca Bruhl, a children’s health advisor with Richmond and Henrico Health Districts. “So, we came together with some of our partners, specifically schools and area clinics, to figure out a better way to get the kids what they needed. ... We realized that it became more of a common thing for people to go to pharmacies to get vaccines over these last couple of years.”
Bruhl and others at the health districts were looking to leverage the federally funded Vaccines for Children program that provides free immunizations to health care providers, who in turn administer them to eligible children. Two pharmacies were chosen last year to pilot the free vaccines program in Richmond: HOPE Pharmacy in Church Hill and Bremo Pharmacy.
For patients, the program helps connect families to a care center, introduce them to the services pharmacists can provide, and keep children healthy and in school. In return, pharmacies can build a new potential client base and get paid for both their services and time.
“We’ve heard [from patients] that pharmacies have just been incredibly helpful, because they tend to have more accessible hours and are more approachable based on their locations and just generally being trusted; it’s been a nice thing that they can offer,” Bruhl says.
While the pilot programs take off, community drugstores and the broader Richmond medical community have ventured into other methods to address the problems facing pharmacies. For researchers like Salgado, financial stability for pharmacies is one of the largest areas of focus to stop the stream of closures.
“There are times where dispensing a medication is not profitable; it’s quite the opposite — you lose money,” she says. Pharmacy benefit managers, who control reimbursement rates and a pharmacy’s “in-network” status for patients, have provided low rates that threaten the financial stability of pharmacies, according to recent research from the American Economic Liberties Project.
In a move that could incentivize care for the state’s lowest income households and keep pharmacies in business, Virginia passed legislation in 2023 that mandated Medicaid payments for pharmacists’ clinical services. Once a pharmacist is credentialed, those services — including vaccines and test-to-treat procedures — can open a new revenue stream for a business.
While governments and community pharmacies play a role in building new, sustainable paths for viability, researchers including Salgado look to build a coalition of care in hopes of eliminating the current deserts in Richmond and preventing new ones.
“I think the community plays a big role, and that can be clients, but also businesses, nonprofits and other organizations putting time and attention to these deserts,” Salgado says. “Certainly, there needs to be investment if you want things to work out.”
