Experts Discuss Expanding the Role of the Pharmacist in Public Health

Christina Madison, PharmD, FCCP, AAHIVP: Hello, everyone, and welcome to another episode of Public Health Matters, part of the Pharmacy Times Pharmacy Focus podcast series. I'm so excited to have another incredible guest with me here today, Dr. Sandra Leal. She has so many accolades and honors to her credit, I want to let her say what is most important to her. But her current role with CVS Health is what the topic of today is. And as another fellow public health champion, I am just thrilled to be able to interview her today. And with that, Dr. Leal, can you introduce yourself to our audience, for those of us listening at home, or for those of us watching on YouTube?

Sandra Leal, PharmD, MPH, FAPhA, CDCES: Sure. So, it's great to be here, Christina, thank you so much for having me. And I love talking about the role of pharmacists in public health. It's been my passion, I think very similar to your passion, to see how pharmacists could advance the profession in this area. So, I'm currently the vice president for pharmacy practice innovation and advocacy at CVS Health, and it's been really great to work in this area, really looking at the opportunities of the expanded role of the pharmacist and what we can do to really fill in the gaps in public health and primary care. So, I'm also the immediate past president of the American Pharmacists Association (APhA), so it's been a busy 3 years. I just finished my term in March of this past year, and between the serving as president and being on the board, it was a 6-year commitment with APhA that I was really, really happy to participate in, especially during the time of the pandemic. I think I probably got, you know, placed in this role for whatever reason during this time, and it was one of the most incredible experiences and opportunities that I've had. Just some other things that I'm currently involved with: I sit on the board of the National Center for Farm Worker Health; that's been a passion of mine for many, many years. My father was a farm worker, and so I always figured that if we could do really good work for people that are most challenged, the farm workers that have, you know, language barriers, that have challenges accessing care, that have access issues, we could really do a lot for anybody else. Because, you know, working with medically underserved populations and populations that struggle has always been a part of my career, and really trying to advance how pharmacists can play a key role in being able to do that.

Christina Madison, PharmD, FCCP, AAHIVP: Yeah, I just I've had the joy and pleasure of kind of following your career along for the past probably 2-and-a-half, 3 years. So, right around the time that I believe you were announced as the incoming president, and then when you transitioned to this new role from your previous position and still, you know, very, very much an advocate for the work at the border and migrant health, which I very much appreciate. And it's also near and dear to my heart. So as far as like, you know, this whirlwind, that's been your leadership journey. Can you tell me a little bit about how that came to be? Because I think, you know, a lot of times people don't know how the sausage is made. And, you know, I just finished reading this book, it's called Two Weeks’ Notice by Amy Porterfield, and she talks about how a lot of times we judge ourselves [compared] to people, you know, based on what their outward appearance is, what they're doing, but we don't really talk about the back end, right? So, don't ever judge your back on somebody else's front end. So, I would love to hear a little bit about, you know, sort of how you came to be in all of your leadership roles and really what the importance of being a woman of color is for representation within health care and the profession of pharmacy.

Sandra Leal, PharmD, MPH, FAPhA, CDCES: Yeah, no, absolutely. I think, you know, one of the reasons I ended up becoming a pharmacist was because of some of the barriers my own parents experienced in trying to access care. I grew up on the border in Arizona, and I still live in Tucson and my mom still lives in Rio Rico. And so, whenever we needed access to care, [when] we had questions about anything, we would go to the pharmacist in Mexico, the pharmacies in Mexico to receive our care, mostly because we couldn't find providers in our community that spoke the language that was very predominant in my community, which was Spanish. So that really was one of the reasons why I became a pharmacist. I wanted to be a provider that could speak the language, have the culture of the community that I work with. And, you know, in my family, we had a lot of family members that had type 2 diabetes, so that was always a real important area for me to focus on and deliver care around that area.

So, to answer your question about my journey, you know, when I started in pharmacy school, my goal was to essentially to come back to my community and provide care. And so, I ended up working at a federally qualified health center for 14 years and really developed and designed a diabetes program. Essentially, it was really embedded in the community to be able to provide diabetes care for people that would otherwise have challenges to either see an endocrinologist or afford a copay. I mean, just significant challenges that were very common in my community. And so over time, I did that for about 14 years and developed a very enhanced collaborative practice model where the pharmacists were embedded in the care team. And so, the opportunity arose to go over to the University of Arizona, and they had a start-up at the time—Symphony Rx. it was doing medication therapy management, right when Part D passed and MTM was authorized. So, I was working alongside them. At that time, well, what happened with that I was like, “Well, I can do this work that I'm doing in [federally qualified health centers], or we can try to take this model and try to scale these types of efforts nationally, and then use tools to reach people that were having trouble, you know, being reached.”

So, we essentially—not we, but myself—I ended up moving over as vice president for innovation there and like looking at the models that were implemented in the FQHC but trying to scale those nationally through telehealth models and trying to reach rural communities, communities that had language barriers, where they had access to care issues. That was my reason for moving over to that organization. And then with time, you know, all of this work around the role of the pharmacist, what I kept seeing as a barrier is the recognition for our services to be able to do this more as usual care as opposed to like a best practice or, you know, if you get lucky and you get to see a pharmacist in this kind of way, then you get this additional service. I wanted it to become the standard of care of how pharmacists are part of the team, how they help manage people who have issues with chronic conditions, acute conditions, or whatever as it relates to their medical issues, or medicine issues specifically, and then be able to roll out and work on ways to be able to like leverage that resource.

So, when the opportunity arose to come to CVS Health, I came in through the Medical Affairs side at Aetna. And it was really to look at the role of a pharmacist in medical affairs and see how we could look at that expanded scope opportunity. And look at it from that payer lens, versus what I was trying to do historically was like knock on the doors of payers and whoever would listen to say, “Hey, can you recognize pharmacists for their expanded scope opportunities?” What if, actually, we're doing it from the other side, from the Aetna side?

Christina Madison, PharmD, FCCP, AAHIVP: You’re on the inside.

Sandra Leal, PharmD, MPH, FAPhA, CDCES: Yeah, it was exactly that goal. And so, in my role now, I've sort of moved a little bit over to the pharmacy side and we're looking at that same thing. We're looking at expanded scope or looking at the massive impact pharmacists had during the pandemic and seeing how we can retain those flexibilities, the recognition from the federal government. And then also [with] payers on all of these clinical opportunities, we have to fill in the gap to make sure we're providing a safety net for people to be advocates for patients. You know, we identified so many barriers to care during the pandemic—social determinants, things that we know pharmacists can address because of the relationships of trust, the frequency of time that people come into that pharmacy, or the pharmacist can have that relationship to be able to do that. You know, it's sort of funny, because that happened during the same time I was pregnant. I'm like, I am in the epicenter of all of this stuff happening in my family, and if you would have asked me when I was in pharmacy school or before if I ever imagined myself as president of APhA and working for this big organization that like, you know, leads and hiring pharmacists, I would have probably said, “No, I don't think so. I'll probably be seeing patients.” So, I sort of changed my trajectory, but it was all because I saw the need to really impact more of that population health policy legislation and trying to make a big impact for patients and the profession.

Christina Madison, PharmD, FCCP, AAHIVP: Wow, what an incredible journey. And even though I think I've heard pieces of it before, it's still so inspiring, as someone else who really wants to see more representation in the C-suite. Right? Let's, you know, let's just be honest, I feel like there's a ceiling, right? There's this glass ceiling within pharmacy, but then there's also a color barrier as well. So I feel like even as a woman, like even if we do get beyond that point, it's even more difficult to see people who look like you, you know, and it's hard because I think oftentimes when I speak to younger pharmacists or student pharmacists, they're like, “How did you do it? How did you get there?” And it's like, it's this whole thought process around if there's no seats, are you at the table? You need to build your own table. And I feel like that's really been very much part of your trajectory. You know, like, oh, you don't have somebody that's doing that, that can help you. Like, you know, “Oh, you guys don't prioritize migrant workers and farm workers? I'm going to be on their organizational board.” I just think it's so awesome

Sandra Leal, PharmD, MPH, FAPhA, CDCES: And it's been so interesting, both from a pharmacy perspective and then just to your point, you know, I was the 11th woman pharmacist president of the American Pharmacists Association, of 166 presidents. I remember the first time I walked into the boardroom of APhA and I saw the wall of presidents, I'm like, “Oh, my gosh, we will need a lot more diversity.” And then we need women just in general. I mean, it was so lopsided, so that even that experience of walking in there and like one day, my portrait will be on the wall. So, I'm super excited that, you know, I can check the box on that.

But even to the point of pharmacist representation, a couple of the groups that I joined, initially, my first board was the Association of Clinicians for the Underserved, and they had never had a pharmacist sit on the board. And then the National Center for Farmworker Health, they never had a pharmacist sit on the board for that. So, it was just sort of breaking through barriers to make sure pharmacy was represented at those tables. And then to your point, I've been in a lot of, now, like working in these companies and boardrooms and investors calls and things like that, and there isn't a lot of diversity. I think it's improving; it's starting to gain more traction. But, you know, it is sometimes interesting to see that there is not that diversity yet. And we still have to push for that. We still have to have our voices heard. And we want to make sure we're representing the communities that we serve at the end of the day. I think that's our intention. We just have to be more active and able to do that effectively.

Christina Madison, PharmD, FCCP, AAHIVP: Yeah, so I recently spoke at the HIV Biomedical Conference, and I met someone there that is from CVS. And I thought it was really interesting. My whole presentation was actually on implementation of pharmacist-led PrEP services, PrEP and PEP care for HIV. And I thought it was so interesting, because when they introduced themselves, they told me that they were the National HIV, Sexual Health, and Health Equity liaison. And I was like, I didn't even know that this was a position! So, I just think it's so cool that you guys are doing all of these things. And I just kind of wanted to know if you could talk a little bit about—obviously, I don't want to know all the secret sauce, if you can't tell me—but, you know, tell me a little bit about some of these, like, more unique initiatives that you guys are working on, specifically in the public health space.

Sandra Leal, PharmD, MPH, FAPhA, CDCES: Yeah. And it's so funny, because I think I met the same person you met this week. I mean, this is a big organization. And I actually remember reading that title, like, oh, wow, that's great. We have this person doing this work, you know, like just talking about opportunities and talking about it from the lens of the pharmacist and what we can do with HIV PrEP and the scope of opportunities. And so those are things that we look at, right? Especially in my role, what we want to do is really maintain and increase the access to pharmacy services. So, what are our areas of opportunity out there, where we're seeing a lot of traction, what we can really jump into. And so, when I look at some of the opportunities we have, all of the things that happened during the pandemic, and trying to retain those flexibilities and advocate with policy and legislation to continue to maintain that post-pandemic. So, you've got things like immunization testing, vaccinations, even treatment, like we were one of the first and one of the few pharmacies that implemented Paxlovid prescribing when the federal government authorized that, and we implemented Epic in the pharmacy to be able to make sure that we had things like access to the lab data, the diagnosis. That's huge. And to me, it's very foundational to all of these other services that we want to provide because we become part of the care team through that technology, right? That's huge. That's a big part of how we're trying to advance the care that we're doing.

The other thing that we're doing is really looking at what else we can target. So, women's health [is a] big, big topic. The area of opportunity we're seeing—expanded scope for hormonal contraceptive prescribing being authorized state by state, we already had 10 states. Here in CVS Health, we're already prescribing hormonal contraceptives. And what we're trying to do is as we're seeing expanded scope opportunities, what other states can we advance of this work that we've already been investing in? Just because we know it's such an incredible need, we want to make sure women have the support they need, that they have advocacy and that they have the information that they need. So that's another area of opportunity we're leaning into and we're looking at. What else? You know, the other scopes I mentioned earlier, HIV PrEP, smoking cessation.

Just looking at the landscape of how quickly things are changing with pharmacy. We're looking at it from a federal level, but we're also seeing incredible movement on the state level and trying to see where we can fit into, make sure we're filling the gaps for patients. We're also partnering, I mentioned Epic, but also our digital solutions. You know, I think the number one thing I get asked is like, how can pharmacists do this, if they're so busy? Well, leveraging new tools, new technologies, we're able to make sure that we're giving that transparency to people about where their medications are [so] they're not calling the pharmacy all the time. And that that gives the pharmacist more time to do that.

But at the end of the day, I think one of the things that's going to be the significant factor in pharmacists being able to do this more is actually getting recognition and sustainability so that we can do this work more, right? It's really hard to do this work if we're not getting that support, to create sustainable models and then allocate resources to be able to do that work. And so that's really where we're advocating on all of these efforts to be able to be more effective in doing that. So, I know that that comes up quite a bit. So, I just definitely wanted to address that. But other than what, what else is out there. I mean, every day I look at what other pandemics or crises are coming out—mental health, we've got a big issue with that; obesity; prediabetes. I mean, you name it, there's so much opportunity and simply not enough providers of any kind. And we've seen, you know, workforce issues with nursing, with pharmacy, with all these groups. How do we engage? How do we give people the opportunity, the tools to do their job and be supported in their efforts to try to combat some of these really critical areas that we have to step into?

Christina Madison, PharmD, FCCP, AAHIVP: Yeah, I mean, I couldn't agree with you more. You know, just listening to you and hearing you talk, a couple of things came to my mind. I was like, “Oh, what about, you know, substance use disorder and like using the pharmacist to help with things like buprenorphine and naltrexone, you know, long-acting naltrexone injections, not to mention now Narcan, and being able to assist in getting Narcan out to people who need it?” And then, you know, hot off the presses, I just heard today that the FDA, the first board meeting concluded and had a unanimous decision to send the OTC progestin-only contraceptive pill to the next step for that to be potentially approved for OTC use. So, I think, you know, there's a lot of things that we can do within that reproductive health and gender-based health space. I mean, even just thinking about sexual health, when we think about PrEP and PEP, like, we’ve got to talk about sex, right, when we talk about that. So why are we not doing STI testing and screening, in addition to talking about that? I mean, obviously, that's part of the assessment. But us as the pharmacist, we should be able to do that. You know, we can send people home with home collection tests. And that's my thought process. Like anything that has a known diagnosis, right, we have a test, it's either positive or negative. And as medication experts, the pharmacists should be able to do it.

And I feel like I saw that so much at the health department when I first started working there. You know, at the very beginning of my career, I started working there in 2007 and they’d never had a pharmacist before. And it was just crazy to me that so much of public health—granted, I love my nursing colleagues—but all of the clinical services were run by nursing. And I'm like, how did we miss this boat? Like, how did that happen? How did pharmacists get left on the shore? So, I don't know, I don't know how we do it. But I'm so glad that you guys are, you know, putting your foot in the water and really making some serious waves.

Sandra Leal, PharmD, MPH, FAPhA, CDCES: Yeah, no, I mean, I think that that's definitely a commitment from CVS that, you know, the organization's enterprise is really looking at those opportunities and what can we do to help reach the patients for whatever their needs are and be able to do that effectively. So, it is a constant conversation. We're constantly scanning the environment to see what makes sense for us to step into. But to your point, gosh, there is no dearth of opportunities. We're talking every day and I'm glad. Thanks for the update on the OTC birth control. I was waiting on that OTC Narcan, you know, looking at that what else is coming down the pike that we have to address here pretty quickly.

Christina Madison, PharmD, FCCP, AAHIVP: Absolutely. So, I know you spoke a little bit about your time at APhA and, you know, this giant 6-year commitment that was your presidency. And now you’re past president, which obviously has a bunch of duties as well. I'm curious, like, of that time, what do you feel was the one most important, or biggest accomplishment that you were able to achieve during your tenure?

Sandra Leal, PharmD, MPH, FAPhA, CDCES: So, I think about a couple of things that really stand out in my mind. During the pandemic, you know, one of the things that we did was really keep our pharmacists informed about the latest information related to what was happening, related to new guidelines, you know, tools that people needed. So that was huge. And we've completely revamped how we were doing [that]. Even serving as president during that time, my first half of the presidency was completely virtual, my second half started to normalize more. But we ended up doing like these town halls where we would host every other week, at least during my time, and just bring subject matter experts just keep people up to date and engaged and connected for the most important information for that time. So, I think that was probably one of the biggest things that we did during that time.

The other big thing that we did, and that was part of my tenure, was really investing in the work of the diversity, equity, and inclusion task force. So, it started as a task force and one of the things that I did right before I left is made it a permanent committee. So, it wasn't going to be just the task force for a couple years, you're done. It's actually now part of the way that APhA does business. And it looks at the strategy around how we're more inclusive, how we actually look at policy, how we do strategic planning, and that's to have more representation and really invest in those efforts. So, I'm very proud of that work. As I was finishing my term, we had basically a report out of the last 2 to 3 years of work that we did during that that initial task force, but now what happened recently is we're actually looking for appointments. I know that that was Valerie Prince's—the current president's—task to identify people that would then serve on the permanent committee moving forward. And so, I'm really happy that that's permanent, it's not going to go away. And we're going to continue to make that part of how APhA does business. It's something that you can say, that you love something that's going to last, and I think that's going to be a very good investment for the profession.

Christina Madison, PharmD, FCCP, AAHIVP: I agree, I feel that you've definitely made your mark, and I'm excited to see all of the things that your legacy creates in the future. Because again, as someone else who is, you know, an advocate of public health and the expansion of pharmacists and public health, it makes me very happy to see someone else that is such an advocate and really understands at the, like, basic level, you know, why? Pharmacists probably don't think that they're working in public health, but literally, every pharmacist is doing public health. Like, you walk into the pharmacy, you give a vaccination, you're practicing public health. Absolutely, we have to remind pharmacists of that.

Sandra Leal, PharmD, MPH, FAPhA, CDCES: It's reminded me of a story that I read. I always used to work with a medical assistant that I used to work on, like, if you give somebody a vaccine, it's going to last for whatever that duration of coverage with a vaccine; it's an amazing intervention. You're like, literally either saving people's lives or saving them from a bad event. And it’s such a rewarding thing. I think sometimes we forget, because we're doing the work, but it's so critical just to pause and reflect on what a just incredible opportunity we have to be advocates and to really impact public health. So, that's one of the other things I love to do [is] just talk about the role of pharmacists, the advocacy, how we impact public health. I mean, I just hope people remember, in commencement season, everybody with all these speeches is reminding me why we became a pharmacist and it's just good to be reminded of the massive impact we have every day. And then during the pandemic, I mean, my goodness, if you needed an example or to show, you know, proof that pharmacists make a difference. We made a difference.

Christina Madison, PharmD, FCCP, AAHIVP: Yeah, I don't think I could have said that any better. It's so interesting, you know, because I graduated in 2004. But in my class, we had sort of this elective that we could take, which was the APhA pharmacy-based immunization program. Which, thinking back, I think it's so hilarious, because it was like an option that we could take, but we could take it like right after graduation. And I was like, that seems like it'd be useful, right? And then fast forward to not only being, you know, an advocate immunizer but then being a trainer. So, I've been a trainer for APhA since 2008, and so it's funny because I think about all the pharmacists that I've trained, you know, just in my city, and then thinking about, like, how many times we would do these giant vaccination trainings. It's pretty incredible to think about not just all the people that you train, but then all those people that went off and how many vaccinations that they administered. And just looking at the profession as a whole. You know, I think I heard a recent statistic that 80% of all vaccinations are administered either by a pharmacy or pharmacist, which is astounding.

Sandra Leal, PharmD, MPH, FAPhA, CDCES: It is huge. And you look at the opportunities with like testing and being a point of access for people, all of the different care that's out there that we have to address. You really need pharmacists to be part of that team to help manage that. And I know that there's all this discussion about why the pharmacist. I'm like, why not? Right? Like, we've proven it, we do it, people come to see us way more than others. Sometimes we should leverage that access point. It is, I call it, like the entry into health care. And you know, we do that work, we navigate people through whatever issues they're having, we advocate for them. It's mind-blowing to me that we haven't done it yet, like recognize the pharmacists in this role more, just because we need that help.

Christina Madison, PharmD, FCCP, AAHIVP: And I think oftentimes, you know, people forget not only that this is a service, but that is literally one of the most successful public health initiatives in medical history, right? The vaccination, the fact that we've eliminated things like smallpox and almost polio from the globe, but also that it can be profitable. Like, I think that's the one piece that keeps getting missed. And, you know, even just thinking about like the beginning of the vaccine rollout for COVID, when HRSA was offering such an amazing reimbursement rate, like, it's unheard of that you would get $40.44 per vaccination, like that is just incredibly profitable. And if you have somebody who's specifically doing vaccine management, you could have easily made quite a bit of money during that time. Granted, obviously, there are other vaccinations that you can do that with. I just think about, you know, partnering with LGBTQIA+ centers, you know, and vaccinations around sexual health. One of the things that I did with my clinic when I first started with them is implementing vaccination services that they had never done. They're like, “Oh, we do flu every year.” I'm like, that's not what this is. Like, that's not what I'm talking about. You know, like, you can't just say you do flu. You have 80%, actually, almost 90% of our patient population identifies in the LGBTQIA+ space, and they had never even thought about giving like Hep A, Hep B, HPV vaccine, and then all of my HIV-positive patients needed like meningococcal, pneumococcal, all the things. We are missing the boat. Like, I feel like every primary care office, but in particular, offices that service special populations, like people who are immunosuppressed, rheumatology offices, oncology offices, OBGYNs—why are the OBGYNs not administering HPV? Like, it drives you batty, right? So, like, these are all the things that I would love to at least put that out in the universe and hope that people feel like that is something that they could potentially pursue. You know, with all the burnout in our profession, I'm like, “Hey, guys, public health, we're over here. Water's warm, we're super happy with our jobs,” right? Like, come on over.

Sandra Leal, PharmD, MPH, FAPhA, CDCES: No, absolutely. And it just takes collaboration to be able to do that, right? Like just being able to partner together and do that, because we know everybody has struggles, but how do we amplify the work we can do together? So, I think that's one of the things [is] that we shouldn't be thinking of it as competition, but really collaboration. And who wins at the end of the day? It's the patient that wins. It's a person that needs that care that wins. And I mean, from my perspective, why I went to be a health care provider or pharmacist was to be able to be an access point and help people when they need the help the most.

Christina Madison, PharmD, FCCP, AAHIVP: Yeah. So, you know, with all of that being said, not that I think that you have a crystal ball. However, I do know that you do have your finger on the pulse of the things. So, I'm curious, you know, with everything that's happening right now and with the end of the Public Health Declaration emergency happening tomorrow, where do you see pharmacists and public health in the future? Where do you see us? What do you think's going to happen, if you had a crystal ball?

Sandra Leal, PharmD, MPH, FAPhA, CDCES: Yeah, I mean, I think we're going to continue to make gains, right? I mean, I wish it was more like, you know, sign of a pen and boom, we've got HR7070 approved or our foot in the door for Medicare Part B to get us started, because I think that really sets the ball rolling on like the implementation. So, one thing is to get recognition. The other one is to actually implement it and get the pharmacists part of that process. And, you know, I could speak all day about what it takes. It's the credentialing, it's all of that stuff. That's more of the nuts and bolts on it, but that would be awesome to do federally. What we're still going to see is that incremental state-by-state win, and every day I'm hearing [about it]. I mean, right now the legislative sessions are active and you're seeing states passed, you know, collaborative practice, school pay. New York, New Jersey, hormonal contraceptives, tech immunization. So, we're going to move in that direction. I feel like the train has left the station; it's just a matter of how quick and then how we scale that to be able to do this work even more. So, I don't think we're ever going to put it back. It's just a matter of continuing to push and advocate and, you know, we're all learning from each other and those states that have been successful.

This is one thing I love about APhA and NASPA, the state association group, they talk to each other. And they're like, hey, well, what was successful in this state that we can implement in this state? And what did you show? Who do you talk to? What did you do? So, I feel like that momentum is there. And again, I don't think that's going to turn back. I just think we need to all reinvest and just remind each other why we went into pharmacy. Like, really recognize that, you know, pharmacies are access points, they're places where people go and the frequency of that is so critical. And that access point is something that we need to invest in and continue to make sure that we continue to offer services that people might not get otherwise. That is just a key thing that we just have to keep investing in and doing. And so, we'll keep working on it.

But I'm excited. I'm excited about the future where things are going, like I said, I feel like there's tons of work ahead of us. And, you know, like you, I think we're excited about public health and what pharmacy does. There's not a single day I wake up and I don't want to do what I do. And I hope that those that are feeling frustrated realize, hey, there's all of this positive momentum, energy, come talk to us, what can we do to engage you to, like, move forward in this direction. I'd love to pass the baton right to these individuals to keep moving the profession forward and push forward. So, a lot of work to be done, but exciting work.

Christina Madison, PharmD, FCCP, AAHIVP: Absolutely. So, I always love to ask my guests this question because I feel like, you know, these little pearls of wisdom are so, so useful. If you could give any advice to your younger selves, what would it be and why?

Sandra Leal, PharmD, MPH, FAPhA, CDCES: You know, I probably would say don't be so hard on yourself and just relax, it's going to be okay. Because I feel like, a lot of the time that I was trying to do this work, I was so hard on myself, just trying to go through pharmacy school, start these practices, and I've been very persistent. So, I would tell myself [to] continue to be persistent. Continue to have that passion that you do for what you do, because it's going to be okay. And, you know, I think we all go through that with the work that we do. It's hard, hard work. If it was easy, everybody would be doing it. But if you really like what you do, it's just going to be okay, and you don't have to worry about what the future is going to turn out to be. Again, I would have never fathomed in 100 years that I would have ever had the opportunity to be at APhA and to be in this particular role., so I'm super excited about where my future is heading. And I always keep thinking, how have I peaked? Is this downhill from here? But every day, I get surprised when you're doing pretty good. The opportunity, I'm like, I guess not, not yet. There's something else for me, and we'll keep going.

Christina Madison, PharmD, FCCP, AAHIVP: That's so cool. I love that so much. So, this has been such an incredible conversation. You're so lovely. You're so gracious and so humble. You know, you are a rock star, right, like, within our profession. It's so interesting, because when I talk to people about going to meetings and networking and talking to folks, and they're like, who did you talk to? Who did you meet? It's like, you have to remember, you know, you're incredible in your own right. And I just like to remind people, you have done so many milestones, just incredible, groundbreaking things. Don't forget to give yourself credit for all of the things that you've done and also the people that you've mentored and helped throughout the process and people that you've probably impacted that you don't even realize that the trajectory of their careers changed because of what you're doing, and the example that you're setting. So, I just wanted to say thank you.

Sandra Leal, PharmD, MPH, FAPhA, CDCES: I will say the same to you, and thank you for everything you've done. I know you've been incredibly active in just contributing so much to the profession. You mentioned something earlier that I love, you know, how do you train that next group and then amplify yourself? I always said you need to replicate yourself to really continue to help people more. And so, thank you for everything you've done.

Christina Madison, PharmD, FCCP, AAHIVP: I receive that, and I affirm that. Thank you. Well, we have come to the end of this episode and there's so many just fantastic points that were discussed. I hope that our audience comes away more well informed and that we have lit a fire under people to go and think about more things related to public health, the profession of pharmacy, and how we move things forward in order to create healthier and happier communities. So, with that being said, I'm sure that people probably want to find out more about you or more about CVS Health, or just in general, you know, follow along your journey. And I know you're very active on social media. Would you like to tell people where they can find you, where they can reach out to you?

Sandra Leal, PharmD, MPH, FAPhA, CDCES: Yeah, absolutely. I feel like LinkedIn is probably my best platform, I try to post a lot of things about what we're doing actively here at CVS Health so you can keep track of some of our efforts. And then on LinkedIn, I also post a lot about just the profession, you know, profession activities, how we are advancing the role of the pharmacist, public health, vaccinations, so everything that I can to really promote what we're doing. So that would be the best place. I'm also on Twitter. I don't post nearly as much on Twitter, but LinkedIn is definitely the place to go.

Christina Madison, PharmD, FCCP, AAHIVP: Yes, that's where I'm at and that's where I found out most of the things that I find out about you is on LinkedIn as well. Awesome. Well, I could probably talk to you for hours, but I want to be mindful and respectful of your time. So, you know, I am just so grateful that we had the opportunity to have this conversation and just wanted to remind the audience to continue to follow us for more episodes of Public Health Matters, as well as taking a look at Pharmacy Times’ other podcasts offerings. This is only one component of the Pharmacy Focus podcast series, so you've got lots of different content out there. Please like and subscribe and comment and let us know what we can do better or if there's more guests that you would like to see in the future that are incredible, just like Dr. Leal. And with that I will leave you with this: as your host, Dr. Christina Madison, also known as the Public Health Pharmacist, remember public health matters.