One chilly afternoon last March, from behind the counter of Queens Health Pharmacy, in Elmhurst, Paola Jimenez, 32, looked out at the line of customers standing six feet apart on an empty stretch of Broadway. She grabbed one of the paper bags on the countertop and went outside in a white lab coat and surgical mask, where she was inundated with desperate-sounding requests – one customer was picking up a prescription, another Tylenol. Jimenez extended her arm, waving the bag of medicine she had at a customer in line. People tried to get closer. “Wait, uno por uno!” — one by one — she told them, while trying to adhere to social distancing protocols. She swerved back inside, closed the door and walked back to the counter to fill the next order. 

Everyday between March and June, Jimenez, a pharmacy technician at a tiny outlet between a bicycle shop and dry cleaner’s, battled fear, sadness and exhaustion to provide medicine to the Elmhurst community. Countless times a day, she walked back and forth between the front door, where she reassured worried customers on the sidewalk, and the back of the pharmacy, where she helped with drug preparation.

Queens Health Pharmacy inconspicuously advertises its services in both Spanish and Korean. Elmhurst is one of the most diverse neighborhoods in the city, where just over half of the population is Hispanic and just over a third Asian. The average household income is $65,330, about $30,000 less than the citywide mean income level, according to U.S. Census data. Census statistics indicate that almost 50% of the population work either in the restaurant, accommodation, healthcare, or retail industry and 70% of the population use public transit as their main means of transportation to get to work. When the coronavirus pandemic intensified in mid-March, Mayor Bill de Blasio described Elmhurst Hospital — which is a three minute walk away from Jimenez’s pharmacy — as the “epicenter within the epidenter.” As of Nov. 14, Elmhurst had endured 3947 positive cases and 300 deaths from COVID-19. 

Independent pharmacies became crucial in distributing medication, advice and support to both COVID-19 patients and regular clients during the worst weeks of the crisis. Before the pandemic, independents were struggling to stay afloat as huge chains such as Walgreens and CVS expanded. Now they had become essential, but they were often overlooked.“Everybody only talked about the doctors, the hospitals,” without acknowledging the role of other essential businesses like pharmacies, said Jimenez, who is from Ecuador.

As a pharmacy technician, Jimenez manages the pharmacy’s cluttered main counter, interacts with customers, talks to doctors about prescriptions, and helps the pharmacist prepare prescriptions. “I think that I am a little indispensable because everybody who comes here already knows me,” she said recently. 

On March 1, when New York State confirmed its first coronavirus infection, Queens Health’s owners thought about closing but Jimenez advocated to remain open. She said she was thinking about the dozen of people who would be left without access to their routine prescriptions, or have to scramble to try to transfer the prescription to another pharmacy. So she started wearing a mask, face shield and gloves each day, and made sure to disinfect anything that clients came into contact with when they entered the store. 

At a neighboring pharmacy, just a five-minute walk from Queens Health, senior technician Gabriela Ordonez, 33, was grappling with a COVID-19 outbreak among her staff. Half of them had contracted COVID-19, including herself.

“We  forged on and thank God we are now negative,” she said. They closed off the pharmacy’s retail area, opting to put up a plastic screen between the main counter and the door. The staff passed clients their medications through a zippered opening. In recalling the barrier, Ordonez scrolls through her phone and pulls up a screenshot of a Rolling Stone article published in April, which features a picture of her face through the zipper. The picture was published in multiple media sources, but no publication named her or gave the pharmacy credit, she said in a tone of slight resentment.

By March 20, when New York City recorded 4,007 confirmed cases, Gov. Andrew Cuomo responded by instituting a state-wide lockdown that shut all non-essential businesses. At Queens Health Pharmacy, the lockdown provided clarity. As an essential business, they could stay open, but to control risk, they decided to close off the pharmacy’s small retail space to the public and set up curbside pickup and delivery. 

Business gradually slowed, recalled supervising pharmacist Andrew Chung, 25. “It wasn’t as hectic, it was very quiet, at least out here,” he said, gesturing at the pharmacy’s retail area — two tightly packed aisles overflowing with stacked pharmaceutical products. As the main pharmacist, Chung supervises unlicensed staff, fills out prescriptions and prints out labels. On most days, he works at the pharmacy’s main desk, hidden by shelves of prescription bottles that line the store’s back room. 

For Jimenez, who manages the pharmacy’s customer-facing operations, the pandemic was anything but quiet. It was up to her to meet the demands of the people lining up outside the store. 

Over-the-counter medications to relieve fever, such as Tylenol, were some of the most accessible forms of treatment for COVID-19, especially as the coronavirus saturated hospitals and shut down walk-in clinics, Jimenez said. Many patients would stop at the pharmacy in search of any available medicine that could help mitigate their symptoms. In those cases, Jimenez or Chung would suggest they take Tylenol or Motrin. Other clients would come by the pharmacy to request various kinds of home remedies, including humidifiers and vaporization products, Jimenez said. 

“They went crazy buying Vicks VapoRub, eucalyptus oil,” she said. While she didn’t fully understand why eucalyptus oil was so high in demand, she recalled that she had some older aunts and uncles in Ecuador who used the oils to disinfect their throat and lungs. In April, when Ecuador was battling one of the worst coronavirus outbreaks in South America, street vendors sold eucalyptus branches and products, hailed by “Yachaks,” or shamans, as ways to treat the respiratory symptoms. 

Disinfectants and personal protection equipment (PPE) also sold out quickly. The demand and price charged by their suppliers was so high that it was difficult for the pharmacy to stock enough hand sanitizer, gloves and masks. Before the pandemic, the pharmacy sold a box of 50 surgical masks for $3 or $4, Jimenez said. During the pandemic, that same box could cost anywhere between $25-$35 because suppliers had raised their prices, she affirmed. During peak demand in April, in some cases, the cost of PPE skyrocketed more than 1000%, according to a report by the Society for Healthcare Organization Procurement Professionals.

Certain drug prices increased as well – including some medicines that were being used to treat the symptoms of COVID-19. Between January and June, pharmaceutical companies increased the price for 245 drugs, according to a report by Patients for Affordable Drugs. The report found that the overall increase was on par with drug hikes in 2019 and 2018, yet more than 75% of the price hikes related directly to treatment for COVID-19. 

Prices are largely determined by pharmacy benefit managers, or PBMs, which manage prescription drug plans on behalf of health insurers, and their decisions can create a burden on independent pharmacies like Queens Health. 

Even before the pandemic, it was common for independent pharmacies to fill some prescriptions at a loss, as PBMs regularly reimbursed them for less than the original cost of the medicine, said Thomas D’Angelo, President of the Pharmacists Society of the State of New York. The pandemic exacerbated PBM dominance over the pharmaceutical industry, D’Angelo said. Mail order pharmacies and large chains ran low on supplies, driving patients to community pharmacies; in some ways, this was beneficial, but it also meant there were more patients demanding expensive prescriptions being filled at a loss, he said.

Chung confirmed that, in many cases, they were losing money by providing common medications like Metformin, used to control blood glucose levels. D’Angelo hopes that PBMs will reimburse pharmacies more fairly when coronavirus vaccines are distributed, so that independent pharmacies can maintain standards and staff levels. 

Even as stocks of basic medications and personal protection equipment ran low last spring, more and more patients were coming to the pharmacy. “People would bang on the door, and I had to go and say ‘No, we don’t have any,’ and go back to do the things that were pending inside,” Jimenez recalled. Within minutes, a new patient would be out front, knocking. 

By the time she got back home each day, she was exhausted, scared, frustrated and overcome with sadness at the way the pandemic had changed day-to-day life. “Sometimes I would cry, but out of the frustration of not seeing anyone on the street,” she said.

Since she was a young girl growing up in Ecuador, Jimenez knew she wanted to work in the healthcare industry, where she could help others.

Born in Cuenca, an Ecuadorian colonial city nestled in the southern Andean Azuay province, Jimenez was raised by her grandmother after her parents and siblings emigrated to the U.S. in 1988, when Jimenez was only a year old. Her father was a taxi driver in New York and her mother worked in cleaning services. 

During the 1980s, falls in the price of oil, on which Ecuador’s economy depends, as well as a region-wide economic crisis, spurred mass migration from Ecuador to the U.S., which continued through the 1990s and 2000s. By 2017, over 730,000 Ecuadorians lived in the U.S., making them the 10^th largest Hispanic group in the country, according to the Pew Research Center. U.S. Census data indicates that over a quarter of residents in Elmhurst, Corona, North Corona and Jackson Heights are Ecuadorian, making them the largest nationality subgroup in those four neighborhoods. 

Jimenez moved to the U.S in 2002 at age 15 and four years later, she started working at Queens Health Pharmacy. She remembers wandering into the pharmacy in search of migraine medication; she walked out with a part-time job. In Elmhurst, where just over four out of ten residents speak Spanish, according to U.S. Census data, Jimenez’s bilingual skills made her a valuable employee. 

She had been married to her husband, Andres Jimenez, for a year by then, and had given birth to a daughter, Angelina. In 2006, she enrolled at Bramson ORT College, in Forest Hills, to obtain a pharmacy technician associate’s degree.  

She regrets that she couldn’t follow a more conventional path — graduate high school, go to college, get married or travel, and then have children. “That’s what I dreamed about since I was little,” she said. 

By the end of June, as New York City’s control measures finally began to drive coronavirus infections down, she was exhausted. Non-essential businesses around the city started opening, but the pharmacy’s retail area remained closed. Sandra León, Jimenez’s manager, was helping out during the worst parts of the pandemic, but returned to her day job, leaving Jimenez solely in charge of door duty. 

Filling both prescriptions and over-the-counter orders was incredibly taxing, Jimenez said. She encouraged her bosses to open the retail area to the public on July 6 to lessen her workload — even though she felt that customers in the aisles would make her less safe. Jimenez has been scared of assault at work ever since she was robbed at knifepoint in front of the pharmacy six years ago, and now she had to contend with the added fear of contracting the virus. Keeping the retail area closed provided a respite from fear and reduced the number of shoplifters straggling into the store, but it worked her to the bone.

Jimenez still loves her job. If given the choice, she said she would do nothing else — except maybe be a supervising pharmacist.

The work of pharmacy technicians is ambiguously regulated by New York State law. It has been recognized as essential during the pandemic but the current law is vague about what technicians are allowed to do within a pharmacy. In 2018, the NYS Department of Education enforced existing legislation that said unlicensed staff cannot “measure, weigh, compound or mix ingredients” — tasks that many technicians had been doing for years, especially in hospital pharmacies. The subsequent crackdown led many pharmacy groups to advocate for legislation that clarified technicians’ roles. 

In November 2019, New York State passed a law that clarified what pharmacy technicians may do. The law does not go into effect until April 2021, but Gov. Cuomo issued an executive order on March 23 allowing technicians to undertake expanded responsibilities to streamline pandemic response. The new law officially allows licensed technicians who have obtained certification to prepare, label, dispense and compound (create customized prescriptions) medication under the supervision of a licensed pharmacist.

The changes to Jimenez’s profession caused by the pandemic have continued to accelerate.

On Sept. 9,  the US Department of Health and Human Services (HHS) authorized pharmacists across the country to administer coronavirus vaccines to people three years or older. New York State regulations used to only allow pharmacists to administer flu shots to people 18 years or older. No more than six weeks later, the HHS authorized pharmacy technicians, like Jimenez, to also administer coronavirus vaccinations for the first time, likely exacerbating regulatory tensions between the state and federal guidelines, said Joseph Bova, associate professor of pharmaceutical sciences at Long Island University. According to the new regulation issued on Oct. 20, to be qualified, technicians need to either be registered or licensed with their state pharmacy board. In states that do not legally recognize the profession — like New York — technicians will be required to hold a specific certification from national associations. 

It is unclear how New York pharmacies will respond to the new federal guidance about vaccinations, and the current state of legal ambiguity will likely create additional challenges going forward, said D’Angelo.

“The fact that New York State is so far behind the times, as far as pharmacy practice issues, is going to rear its head here,” he said. 

To administer vaccines, technicians will need to undergo extra training, including specialized vaccination certification and CPR certification — which will take time and resources, D’Angelo added. Technicians would then require increased pharmacist supervision, which D’Angelo said could strain pharmacists who were already stretched thin. 

A few weeks ago at Queens Health, Jimenez saw a man stealing a bottle of shampoo, but was too scared to confront him. Since their reopening in July, Jimenez had already noticed more people blatantly stealing over-the-counter merchandise, which she speculates is because of the economic crisis caused by the pandemic. According to NYPD statistics for the 110^th precinct, which covers Elmhurst and Corona, burglaries increased by about three-quarters between mid-October last year and this year, while robberies also rose by just over eleven percent. “I love working, but the fear is every day,” Jimenez admitted. 

The months of late summer and early fall, before the recent resurgence of the coronavirus around the country and in New York, provided a too-long-forgotten sense of normalcy for Jimenez. Clients could walk inside the pharmacy freely. Her husband went back to work and her daughter is attending classes in person full-time, for now.

On Oct. 3, Jimenez attended her late father-in-law’s two-year memorial service, where she saw all of her extended family in person for the first time since February. While several acquaintances had died from the coronavirus, she thanked God that nobody in her immediate family had succumbed.

The young pharmacy technician is concerned about how the now-intensifying pandemic will interact with the flu season now underway. She worries that people will confuse flu symptoms with those of the coronavirus, increasing demand for  testing and other resources. “They’ll start to get a fever, sniffles, and then they’ll think that it’s the virus, and I mean, this is going to get crazy,” she said.

The mere thought of a second wave, and the loss of her new normal, makes Jimenez pause. She closed her eyes, and brought her hand up to her temple. “Everything just came to my mind,” she said. “Like I said, it’s the stress, but more than stress, it’s the sadness of seeing how everything changes.”