January 2006 | Back to Table of Contents

Face to Face

Minimalist

By Kim Kiser

Sometimes on foot, sometimes on bike, Kenneth McMillan, M.D., delivers the most basic of primary care to patients on the streets of Minneapolis.

You got 50 cents?” A scruffy-looking man calls to us as we approach a small circle of people who sit on the ground behind a strip mall on Minnehaha Avenue in south Minneapolis. Several are carefully printing their pleas for cash—“Help the homeless, God bless you”—on salvaged pieces of cardboard. Kenneth McMillan, M.D., explains to the man that we don’t have money, and that we’re just “kolas,” the Lakota word for friends. He then pulls the remains of his lunch from his coat pocket and offers the man an apple and orange.

The man, whose face is marked by the knife wounds of wind, cold, and sun, takes the apple. Others look up, recognizing the slight, white-haired man wearing jeans and a dark blue jacket and carrying a blue medical pack as “doc” from the Kola Health Outreach Program for Homeless Native Americans. When McMillan asks how they’re doing, “clinic” opens and he begins to practice field medicine in the most literal sense.

McMillan crouches on the patchy ground next to a pile of blankets and a folded tarp and looks at a young man’s hand. The former boxer is having trouble making a fist. McMillan touches the knuckles and explains how the cold can affect arthritis—a problem not uncommon among these men and women, who each night turn this piece of land just feet from the railroad tracks into their camp.

The 58-year-old physician moves on to his next patient, a woman whose leg is immobilized in a brace. And after learning that the man who had asked him for money is scheduled for knee surgery in a couple of weeks, McMillan stresses the importance of being sober beforehand and encourages him to stop by his clinic.

That clinic is a single room in the basement of Anishinabe Wakiagun, a residence for 40 otherwise homeless Native Americans who are addicted to alcohol and not necessarily trying to quit. It’s the place where, for the past six years, McMillan has provided this most basic of primary care to a population of patients you won’t find in a typical doctor’s office. He explains that many of the 10 to 15 people he sees there on Monday, Wednesday, and Friday mornings are just out of treatment, have fallen off the wagon, or have been drinking through the night. Some have just come into town from the reservations, most have no medical insurance, and virtually none of them would get medical care if it weren’t for McMillan and a handful of volunteer nurses.

As director of medical services for the Kola program, which also provides some social services and mental health care, McMillan does everything from patching up wounds, to ordering prescription refills, to treating sore feet, to screening for hypertension and diabetes, to dealing with the consequences of chronic alcoholism and living on the street. “A lot of what I see is a mixture of chronic and acute situations because of their chemical dependency,” McMillan says. “Some are in psychological crisis, some come in with acute psychosis and are off their meds. We have schizophrenics who are too drunk to access the proper place to renew their meds.” McMillan goes on, listing a litany of problems he deals with, including domestic violence and the need for housing and insurance—problems that medical training doesn’t always prepare one for.

McMillan struggles to describe his clinic, explaining that it is “sort of like urgent care but not full emergency care” and “not a full-fledged primary care clinic” either. Although he maintains a small stockpile of medications and has basic equipment and diagnostic tools, McMillan makes a lot of referrals. He sometimes personally takes patients to Hennepin County Medical Center for crisis psychiatric care or to area clinics for blood work or an X-ray, or calls specialists and asks them to see a patient. “We do the initial triage,” he explains.

And that means doing a lot of listening. When Sam (not his real name), a middle-aged man with a neat, black ponytail who is just out of detox explains that he’s having trouble sleeping, McMillan directs him to the chair across from his desk, then listens patiently as he learns that Sam’s mother died of cirrhosis of the liver, that his father was killed in an accident involving alcohol, and that he lost three uncles last year. “I want to walk the right path,” he tells McMillan.

As he types notes into a computerized record and checks for Sam’s General Assistance number, McMillan offers words of encouragement. When Sam explains that he’s living in a rehab center, attending AA meetings, and taking part in a sweat lodge that night, McMillan tells him he’s doing the right thing in trying to address the spiritual aspects of his life as well as the physical ones.

The doctor then hands Sam two prescriptions and examines his blackened toe—a consequence of walking nearly everywhere he goes—and remarks about how exercise is built into the lifestyle of the homeless. “I think we can help get you on the right path,” McMillan tells his patient.

A Chance Meeting
That path to health and good living is paved with the slippery stones of poverty, substance abuse, disease, and violence that can throw the most earnest effort off balance without warning. Compounding the challenge of staying on course is the stiff wind of distrust that Native Americans have for the government and other institutions that goes back hundreds of years. McMillan sees that lack of trust play out when patients refuse to go to the emergency room or other clinics in the area, including those catering specifically to Native Americans. “They don’t want to spend hours waiting, and they don’t want to be tied down. So we try to treat them in a culturally sensitive way here. We don’t want anyone to go out of here without feeling like we’ve done something for them.”

In the early 1990s, little was being done to address the medical problems of homeless Native Americans in the Twin Cities—especially those who had been in and out of detox. In 1991, a group from the Native American community, including Gordon Thayer, now executive director of the American Indian Community Development Corporation, which operates the Kola program, did a snapshot survey of homeless native people and found 285 on Franklin Avenue or in Peavey Park in one morning. By the time the corporation opened Wakiagun in 1996, 55 people had died on the streets of Minneapolis during the previous five years because of causes related to alcoholism.

About the same time, Hennepin County was looking for ways to curb the cost of treating members of this population who would show up in the Hennepin County Medical Center (HCMC) emergency room with problems that had gone untreated for too long. A 2003 report from the U.S. Commission on Civil Rights found that alcohol and substance abuse, the consequences of domestic and other violence, diabetes, cancer, mental illness, heart disease, poor dental health, and infectious disease are the most common afflictions among Native Americans, homeless or not.

Meanwhile, McMillan had encountered a detour in his own path. The son of missionary parents who was born in Congo and a surgeon by training, he had been working in a 100-bed rural hospital that served more than a quarter million people in the African nation. When civil war broke out in the fall of 1996, McMillan and his family were evacuated to Minnesota, where his wife Ginny, who worked as a nurse and whom he met in Africa, was from, leaving everything they had behind.

“I came here and thought What do we want to do?” Since his training at Wayne State University Medical School in Detroit in the 1970s, surgery in the United States had gone high tech. It had also become more specialized. McMillan tried for two years to return to Congo, taking courses to upgrade his skills and doing locum tenens emergency room and urgent care work for hospitals in Sandstone and Deer River, Minnesota. Then a new rebellion broke out in Congo.

McMillan knew that his dream of returning was out of the question—at least for the time being. Within weeks of making the decision to stay in Minnesota, he met Thayer through Crystal Evangelical Free Church. The church provides support to a ministry that Thayer runs for the Native American community.

Thayer explained that the American Indian Development Corporation had received a grant from Hennepin County for a program that would put two case managers and a nurse on the street to treat and triage homeless Native Americans for medical and other problems. “He said, ‘We don’t know where we’re going to get a nurse, what do you think?’ I said, ‘Sure, I could do nursing as well as anything else,’” McMillan recalls.

Having spent nearly all of his life in Africa, McMillan didn’t know anything about the Native American cultures in the United States. “I sided up to Gordon and said ‘I don’t know how to do this. Should I grow my hair long, should I get a ponytail, should I wear beads?’ He said, ‘No, just be yourself. It’s your actions and your attitude that will help you adapt to the native community.’”

During those early days, McMillan set out on his bicycle and began looking for camps of homeless Native Americans along the Mississippi River and near the railroad tracks in south Minneapolis. Within two weeks, he had a list of about 100 people who either came to the clinic or who depended on him to come and treat them in the field. “It was all word of mouth,” he recalls. “Once we saw the first few, word got around. And pretty soon I was their doc and Kola was their program.”

For McMillan, who is on the payroll 32 hours a week, making Kola the patients’ program has meant taking calls on his cell phone during the evenings and on weekends from individuals who may need a prescription refill, advice on whether to go to the ER, or help if then end up in prison. (He even took a call on a recent trip to Kenya from a Minneapolis patient. “You have to look at our population. They have a hard enough time getting to a phone,” he explains.) Gaining trust has also meant leaving the clinic to treat a patient in the dual clenches of schizophrenia and alcoholism who was too violent to be let inside the building. Or telling a volunteer he was being too preachy. Or not calling the police when a patient had a gun. “I felt trusted by even some of the worst ones, which is amazing,” he says. “They’ve grown to accept me as a white person, and I’ve grown to respect and appreciate them.”

He credits having experienced being a minority (having lived for so many years in a black community in Africa) and living through the Simba rebellion in 1964, a political crisis during which his missionary father was killed and he was held captive and wounded, as helping him see things from the perspective of his patients. “I have tremendous respect for their level of trauma—not just present trauma, but historical trauma, being pushed off their land and in many cases abused or mistreated or killed. I can really appreciate now why they have depression, family violence, and addictions.”

Tenuous Existence
Since it began in 1999, the Kola program, like so many of the patients it serves, has gone through its own struggle to survive. Within two years of starting the medical outreach, McMillan had Kola credentialed with most health plans. “We were able to do some billing and started to get income to pay my malpractice and put some medicines on the shelf,” he says. However, when the county dropped funding in 2003 during a round of budget cuts, McMillan worked for more than six months without pay.

This past year, the program has relied on a grant from the Healthier Minnesota Community Clinic fund, which provides support to safety-net providers. The grant was not renewed for 2006. McMillan hopes to be able to find other funding and perhaps do more billing of insurers—particularly for the time and services he provides to patients who receive health coverage through state
programs.

McMillan says that although it can be shown that the presence of Anishinabe Wakiagun, where a number of his patients live, has reduced emergency-room visits at HCMC by 20 percent and detox admissions by 85 percent, the patient population he sees isn’t one that lends itself to the yardsticks used to measure health outcomes in most clinics. He says, for example, getting his patients to go for testing or follow-up care or to a dentist means catching them in their sober moments—a feat that’s not always easy. “If they’re drinking, those clinics don’t want to see them,” he explains, then reflects on the definition of success for his patients. “Is it staying sober for a year? Two years? Medicine is becoming more focused on outcomes, but what is considered a good outcome in this case?”

McMillan does have some evidence showing that his medical outreach is making a difference: the fact that he has provided care for more than 650 people in the past six years who otherwise may have gone without and that this year the number of consultations he does has gone up from eight to 12 per day to 10 to 15 as word of his service continues to spread. A student from the University of Minnesota School of Public Health is analyzing data that will provide more details on the diseases McMillan is treating, the number and type of health screenings he’s performing, the number of referrals he’s making and to which clinics, and the extent to which his patients have health insurance.

In addition to collecting data, McMillan has been educating himself in order to better understand and serve his patients. A Bush Foundation Medical Fellowship, which helped pay his bills when the county cut Kola’s funding in 2003, allowed McMillan to do rotations in addiction medicine with Hennepin Faculty Associates physicians and at the Minneapolis Veterans Affairs Medical Center, take public health courses at the University of Minnesota, and travel to Native American clinics around the country to learn about their models for delivering care. “He’s developed insight into the native population and alcohol use and treatment,” says James Struve, M.D., a family and geriatric physician at the nearby Bloomington Lake Clinic, who has assisted McMillan on occasion. “The triad of chronic substance abuse, poor nutrition, and mental illness is a tough combination,” he says, adding that homelessness creates myriad problems of its own for McMillan’s patients. “They need a little bit of a door opened,” he says, “and I think Ken presents just a start of a possibility. The fact that he is interested in them is a huge start.”

That interest has produced some individual successes. When describing the changes he’s seen since the Kola outreach program began, Thayer tells of the individuals whom McMillan has touched: the man who eventually became sober, worked as a custodian at Wakiagun, and kept his own apartment before he was beaten to death two years ago; another who was honored last year for his sobriety; and a third who is now sober, living on his own, and working a part-time job. “We have a saying here that you can’t rebuild a community without rebuilding the lives of people in that community. Dr. Ken has been very effective in helping us do that.”

Although McMillan hopes one day to go back to Congo, for now he plans to continue delivering the most basic of care to homeless Native Americans—a work that goes beyond healing physical wounds. “I would love to be part of a bigger reconciliation and rebuilding,” he explains. “But for now it’s personal. I’ve learned that I’m part of a one-on-one reconciliation of whites to Indians.” And with that in mind, he’ll continue to walk the paths along the river and the railroad tracks being “doc” and kola to the people he meets along the way. MM

Kim Kiser is associate editor of Minnesota Medicine.