Population Aging and Global Health with June McKoy, MD, MPH, JD, MBA, LLM

• McKoy shares her background which includes growing up in Jamaica and the United Kingdom and achieving degrees in medicine, law and business. She says she did not set out to “collect degrees” but each path has helped her be a stronger advocate for geriatric patients.
• The older population is growing in low and middle income countries and is expected to double by the year 2050. McKoy encourages researchers to start looking at this phenomenon and conducting research about aging to help society prepare for this shift.
• She says alternatives to congregate housing and access to healthcare are two vulnerabilities that older adults face and need to be studied. 
• Topics related to aging that she suggests researchers focus on include, cognitive decline, frailty, cancer as well as aging and HIV/AIDs.
• She also emphasizes that more needs to be done to address the needs of older people during humanitarian and health care response efforts.
• During the COVID-19 pandemic, the burden has been disproportionately on older patients and McKoy hopes that with the end of mask mandates across the U.S. that people will still be considerate of the risks older people face. She encourages all of her patients to continue wearing masks.

Rob Murphy, MD [00:00:06] Welcome to the Explore Global Health podcast. I'm Dr Rob Murphy, executive director of the Harvey Institute for Global Health here at Northwestern University Feinberg School of Medicine. The WHO projects that the world's population of older adults will double by the year 2050, and 80 percent of those older people will be living in low and middle income countries where we do a lot of our work. Preparing for population aging, it needs to start now. Today's guest is here to talk about this phenomenon and what students and trainees need to know to address the needs of older people here in the United States and around the world. Dr. June McKoy, our guest, is a professor of medicine in the Division of Geriatrics, the Division of Medical Education and Preventive Medicine here at Northwestern University Feinberg School of Medicine. She's also a licensed Illinois attorney who's dedicated to protecting human rights and advancing social justice. Welcome to the show, Dr. McKoy.

June McKoy, MD, MPH, JD, MBA, LLM [00:01:04] Thanks for inviting me. Dr. Murphy.

Rob Murphy, MD [00:01:06] You're a member of the Harvey Institute for Global Health here at Northwestern and have a very interesting international background yourself. You're born in Jamaica and have lived on four different continents. Can you share some more details of your background?

June McKoy, MD, MPH, JD, MBA, LLM [00:01:19] I was born in Jamaica and at a young age, migrated to the United Kingdom and resided in Manchester with my family, went back to Jamaica for boarding school or high school, and then again went back to the United Kingdom. My sister, who was interested in coming to the United States to study, came several years before I did and stayed with a relative that we had was living in Chicago. And as siblings tend to do we all started following her and so I came to the United States, did undergraduate for about two and a half years and got my bachelor's degree and again went back to the UK. I later came back here for medical school at Southern Illinois University. I have lived in many countries and hence it's not surprising that I have this deep interest in global health and certainly in human rights. I've studied in Belgium, the Netherlands, in England, in Ireland, in Hong Kong, in Central America. And so I think this exposure, this broad exposure, that evolved over time really has brought me to where I am at this point in my career and really set my interest in this particular area of global health, human rights and definitely human rights as it pertains to older adults.

Rob Murphy, MD [00:02:43] You've got degrees in medicine, law and business. How does your education uniquely prepare you for your work in geriatric medicine in advocating for your patients? How do you pull it all together? Those three things.

June McKoy, MD, MPH, JD, MBA, LLM [00:02:56] Interestingly, I did not start off trying to collect degrees, and I tried to tell that to trainees when they ask, How did you get to where you are? A lot of it is serendipitous. But every single degree that I have acquired have really, really helped me to be the best doctor in general to my patients and a really unique geriatrician, and I think more than anything else, the law has taught me how to advocate for people. The law has teeth. Every medical doctor I have talked tend to be more on the I call the softer side. Really, following the Hippocratic Oath, do no harm and really try to see both sides of an issue. Lawyers do that, too. But the law carries the kind of teeth I think that medicine doesn't carry, and that has allowed me to actually sit at the table with lawyers. My business degree has allowed me to sit at the table with business people, with administrators who are setting policy on the local and often even on the national level. When you think of boards or or councils on which I sit at the NIH and people will tend to listen to someone who speaks the language with which they're familiar. And so the law allow me to have a voice, and it does force people to actually listen to that voice because the voice has the background to support it. And so I think understanding the legalities that really impact or undergird many of the issues social issues facing older adults has helped me to really be a great advocate for them. I have gone to court for patients, I have completed in numerous numbers of guardianship forms to make sure that I keep my patients and other people's patients protected. And I have been able to actually push back on institutions in court, not physical structures, but institutionalized policies that I felt were harmful to my patients and have been successful because of that, because of the law. So, the law has been extremely good for me as a physician practicing with a population who often is not seen. There are what we call the voiceless in many cases, and they're the ones who often are discriminated against. But no one mentions that discrimination that we call age discrimination.

Rob Murphy, MD [00:05:22] I mean, you have an MBA from Kellogg. How does that fit in?

June McKoy, MD, MPH, JD, MBA, LLM [00:05:25] I have been the very fortunate recipient of numerous grant funding from the NIH, and my research has been in cancer and aging in the area of pharma economic studies and looking at cost and cost effectiveness analysis. And having this MBA where I got an opportunity to a lot of classes relate to economics and business, and costs and efficiencies and throughput has really been helpful. It has allowed me to actually provide care and to advocate for a good care, but in a cost effective manner, which is what the government is interested in. It does also allowed me to actually infuse efficiencies in my practice. So, how to get patients efficiently through the system, but make sure that while you're doing that, the outcomes are still quite strong. So I think the MBA it's more than just business per se, it's it gives you a lot of strength. It gives you a background in what we call negotiations. How do you navigate certain decisions and certain options that patients might have? How do you negotiate with an older adult who might begin now to have some cognitive decline? They've got a family member who wants something different for them, maybe their primary provider who wants something different also. How do you help that person to actually negotiate as best as they can from their position and often negotiate so that they're actually getting something that in the end will be their best interest? So, it's sometimes very hard to negotiate certain decisions with older adults who are already often set in their ways. They're not unintelligent, not at all. They're very wise, wiser than you think. But sometimes we know we don't want to be paternalistic, but we know that this is maybe the most safe option for an adult. How do we get that senior adult to kind of see our position? And how do we negotiate a consensus? Those things are actually very widely taught in schools of business and management. So I think I came up with a strong sense of how to negotiate with patients, how to negotiate with providers and how to negotiate with older adults. And negotiation really matters for these older patients.

Rob Murphy, MD [00:07:47] Let's switch gears a little bit and talk about worldwide population aging. I understand the number of older people is growing fastest in Africa, followed by Latin America, the Caribbean and Asia. Many of our listeners are trainees, students, residents, fellows or junior faculty who are currently working in these countries or having experience in these countries, or they're students who hope to be involved in some kind of international work in the coming years. How could they prepare for this shift that's happening to a more older population to an aging population?

June McKoy, MD, MPH, JD, MBA, LLM [00:08:27] That is a critically important question. So many of our students come in with incredible backgrounds as it relates to global health. You know, I want to ask them to infuse aging in their research. And how can you do that? If you're doing global health work and it's related to a research project that has to do with neurologic issues or related to pediatric issues, there are ways to infuse aging in. If you look at globally, a lot of children have become orphaned because of wars that are going on civil wars or just regional conflicts. And many times grandparents are the ones taking care of them. So, finding a way to make sure that you're infusing aging in your research, no matter what the topic is, and then making sure that that research somehow as a policy bent. So, you might be able to work either through an NGO, a non-governmental organization or work directly with people within the ministries of health to bring about some changes for older adults and if the older adult thrives, then those children will thrive. That's just one example. Look at Northwestern. Every single medical student has to do a research project related to the area of scholarly concentration or the AOC. Everybody's mandatory now that every single student does it all the four years. Anything you're doing globally makes sure aging is part of it. We know it's not sexy in many cases because you're dealing with a population that's often invisible. Not because they are invisible, of course, but because that's how governments perceive the elderly. And then for others, maybe just straight out, do your research on aging. Be focused, be intentional. I'm going to do a research project related to aging as it pertains to subsidizing people, as it pertains to pandemics, as it pertains to present humanitarian crises in, let's say, Somalia. How is that affecting the older adult and what can we do? What are some of the policies and not getting involved in your politics, but your policies? And then for those of us who are not the students who are not in those countries, consider partnering with people in those countries to come up with research strategies that can provide answers to the critical questions about the older population in terms of cost, economics, health outcomes, housing, all those kinds of things, infrastructure changes that might benefit those older adults.

Rob Murphy, MD [00:11:03] Let's drill down on that a little bit, because now you know, most of the trainees that are going out there, I would say most of the projects are about maternal child care, neonatal mortality, more focused on the disease of women and disease in the young. But obviously this is going to be changing. What are the common needs and vulnerabilities of older people that should not be overlooked?

June McKoy, MD, MPH, JD, MBA, LLM [00:11:29] Housing. We saw during this pandemic how badly housing really impacted our older adults because many of them were living or are still living in congregant housing. And so when the pandemic came through, it just really swept through their housing situation and led to a lot of deaths among older adults. Look at the infrastructure of housing. There is opportunity in that area to kind of really partner with architects and and city planners to start looking at maybe having housing done differently. Now moving on to access to health. Does that patient was older come to us or do we go to them? Are we seeing a move towards this hospital at home model. It's emerging and we have players like Humana and Kaiser were buying up property because they are looking at this new concept of maybe having a hospital model where it's a smaller numbers of older adults getting care in a special environment that really considers their limitations and their disabilities.

Rob Murphy, MD [00:12:37] Can you give three of the most important common health conditions that's associated with aging, something that they could focus? Their initial ACOS, or a research project on?

June McKoy, MD, MPH, JD, MBA, LLM [00:12:49] Cognitive decline really provides a fertile ground for a lot of research, and it doesn't necessarily mean Alzheimer's disease per se, but there is opportunity for that work to be done too. Cancer and aging. The burden is overwhelming on the older adult because many of them is because of telomere changes over time and just being on Earth long enough to be exposed to all kinds of environmental toxins, so cancer is critically important in the aging population, and I think the third one that I would look at would be frailty. Frailty is, you know, we say, 'Oh, that lady looks frail.' It goes beyond just the way the person looks. It goes to the person's gait speed, the person's energy level. The person always fatigued. It's a person having unintentional weight loss. So looking at frailty in the context of Linda Fried's as all right, it's Linda Freid's criteria above frailty. Everybody's looking at frailty, and it makes sense because with aging comes some changes that places people at risk of frailty. How do we capture, identify those at risk of frailty and then try to institute measures to prevent them from going from pre-frail to frail?

Rob Murphy, MD [00:14:06] I also heard Northwestern is starting a new center on longevity with a focus on HIV. Any comments about aging and HIV?

June McKoy, MD, MPH, JD, MBA, LLM [00:14:15] That has been a focus of my research too. I actually have a paper under review looking at anal cancer in aging patients with HIV, it's an important focus of research right now. We have people literally are, would say, cured. They're certainly living longer and longer. And so they're going to develop all kinds of problems, from cancer to other medical problems. We have some older patients who have survived or are living with HIV slash AIDs, and they're having their own unique cognitive problems based not only on the illness itself, that they had started with what they started, but also some of the treatments that are getting. So there is a lot of work looking at the impact of medication over this very long period of time on patients with HIV.

Rob Murphy, MD [00:15:06] How can humanitarian and health care response efforts be more inclusive of older people? Right now we have Ukrainians. After fleeing the country, it's mostly the people leaving are women, children and the elderly. How can response efforts be more inclusive of older people?

June McKoy, MD, MPH, JD, MBA, LLM [00:15:28] I want to start off by saying it's going to be a challenge, and there are many non-governmental organizations and others and certainly people within the W.H.O. who are looking at this issue. The older population, there's such bias against them. They're seen as get out of my way. You are a burden. You are just taking and not giving back to society. We have to start seeing older people who they are and that they actually contribute to society. We also need to stop treating them in the same way we treat others. This one size fits all doesn't work for older adults. It can be devastating when a state within a country, when the globe just lumps them together and treats them in a humanitarian crisis, the same with the younger people. For instance, if there's a humanitarian crisis, maybe you need to go somewhere to get food. But I have a walker. I cannot barely get there, even out of my house. Much more to get food. I can't stand in the sun for hours waiting on the line in the line to get my food. We need to find a way to seek out the older adult and take the distribution to the. If they're in a tent, we need to start collecting data. Demographics on how many older persons are present in that shelter or that tent and make sure that we're really focusing on their needs. I think that's one thing to do to start seeing the older adult and seeing who they are.

Rob Murphy, MD [00:16:59] COVID 19 has been an incredible challenge for older adults. The vast majority of the COVID deaths are among the elderly. The last couple of waves of infection, the focus, of course, was always on the elderly being at very high risk. It's always listed as one of the big risks. But the unvaccinated younger people were having lots of problems, but now, with the hospitalization rate for the unvaccinated, has dropped proportionally compared to the rate of elderly people who actually are vaccinated, they're taking up more and more of the brunt of this, this disease, because at their many of their ages, the vaccines are just not working and they've got underlying comorbidities as well. Any comments on the response to the COVID 19 and the elderly?

June McKoy, MD, MPH, JD, MBA, LLM [00:17:52] When you have interviews with them or get to talk with an older person on a one on one basis, they feel as if they have been left behind. And I'm jumping off a little bit, but they're dropping off the mask mandate, which everybody was, I guess, was tired off, has been devastating for older adults, because they're scared, they feel that their government has really left them by the wayside, and I've told them then you need to have your own mask mandate, wear your mask all the time when you're with people. And the burden has been disproportionately on older patients for a lot of reasons, but primarily, I think their immune system and the failure of younger populations to understand their risk and to try to mitigate it by being more responsible.

Rob Murphy, MD [00:18:36] And the Swedes in particular have on relatively limited information, have actually put policy in place to give a second booster or fourth shot for the COVID vaccines and in the elderly in Israel. I think it's age 60 and up. And in Sweden, it's age 80 and up. At least it's some kind of attempt. They don't know if that's actually really helping or not. But some groups are actually changing the policy and dealing with the elderly because so many of them are suffering from the morbidity and mortality.

June McKoy, MD, MPH, JD, MBA, LLM [00:19:09] Yes, we were hoping that the federal government would, the CDC certainly would come up with a statement on that and with a fourth shot for older adults. We know the pill has come out, you know a lot more about this than I do. Dr. Murphy. But even where the pill is available that you can take many older adults are stating that they can find it anywhere their doctors are not seem to be very cognizant of when to give them how to do that, and they feel lost and alone, and they're again beginning to isolate themselves a bit.

Rob Murphy, MD [00:19:41] Yeah, it's really a shame because the drug you're referring to is called paxlovid. It's actually a combination drug, two different drugs and antiviral and ritonavir, which is an HIV drug, but at a very low dose, it increases the the drug levels of the the part of it that really works. It's three pills twice a day for five days. I mean, it's not that hard to take, and it has a dramatic effect on severity of disease and death. So, that's just not a hard thing to treat, and I'm really surprised. I was happy to hear from a White House dispatch that they want a test and treat strategy for use of this drug so that it actually gets to where it's supposed to go. But, you know, I haven't seen it happen yet. What final advice do you have for young people just starting out in their career that are interested in global health?

June McKoy, MD, MPH, JD, MBA, LLM [00:20:34] Ask questions and find answers. That's what I want to tell you to do. Keep doing research. We do research every time we ask a question and try to find the answer. We are an institution at Feinberg that's really focused on inquiry driven work. We want our students to always be thinking, our residents to be thinking of questions and finding answers to them. And you can do that through partnerships inside the United States, but also in partnership with countries where they don't have that much resource.

Rob Murphy, MD [00:21:05] Dr. June McKoy, I want to thank you very much for the time you spent answering all of these questions and addressing all these issues.

June McKoy, MD, MPH, JD, MBA, LLM [00:21:14] My pleasure, Dr. Murphy. Thanks for having me.

Rob Murphy, MD [00:21:22] Follow us on Apple Podcasts or wherever you listen to podcasts to hear the latest episodes and join our community that is dedicated to making a lasting positive impact on global health.