The Spirit Catches You and You Fall Down: Cultural Misunderstanding

Hmong People come from a mountainous area just south of China. Due to political unrest and in search of farmland they migrated southwards. The Spirit Catches You and You Fall Down: A Hmong Child, Her American Doctors, and the Collision of Two Cultures is a 1997 book by Anne Fadiman that tells the struggles of a Hmong refugee family from Laos, the Lees, and their interactions with the health care system in Merced, California. The stories’ focus is on the family's second youngest and favored daughter, Lia Lee, who after various visits to the cramped and burdened county hospital was diagnosed by doctors with a critical form of epilepsy at the age of three. Her parents, on the other hand, considered her illness as qaug dab peg (“the spirit catches you and you fall down”). This deceivingly simple distinction is the reason for the cultural misunderstandings that torment Lia’s care and is the focus of what The Spirit Catches You and You Fall Down tries to explore. Anne Fadiman argued that Lia’s fate was not caused by septic shock or noncompliant parents or medicine, but by cultural misunderstanding. Lee’s attempt to understand, and to be understood, makes clear the challenges of the differences in medical views, language barriers, and the ignorance of cultural understanding.

Traditionally the Hmong do not practice western medicine nor had they encountered it until they arrived at the Thai refugee camps, and became more exposed to its practice in the United States. The Hmong practice spiritual healing and shamanistic rituals, also known as neeb. These rituals enlist various tools such as sacred animals to please dabs (bad spirits), and musical tools like gongs and finger bells, blessed water, chants, and herbs, as well as other traditional healing methods to find a person’s lost soul. Western medicine does not practice these activities, and this is where the healing systems of the western doctors and Hmong came to clash. The Hmong who live in Merced do not completely embrace western medicine because to them it is very intrusive and can cause them to lose their souls. Anne Fadiman notes that such practices as anesthesia and repeated blood samples can cause the soul to wander. Such practices can also cause various illnesses, death, and the possibility that the person will be physically incomplete, once they are reincarnated because the body is essentially being tampered with. This is why the Lees and other Hmong clans find it so troublesome to go to the hospital and refuse to comply with the doctors’ methods. In return, doctors at the MCMC became frustrated and exhausted when dealing with the Hmong while trying to save their lives. Neither side - the Hmong or the medical doctors - are able to break through cultural barriers and understand the opposite side even though they both have good intentions.

While doctors saw Lia’s disease as simply a birth trauma, the Lees believed the condition was spiritual in nature. Specifically, in this case of epilepsy, they believed an evil spirit had caught Lia’s soul, causing her to “fall down.” The doctors at MCMC faintly understood the concept of the spirits, which were a part of epilepsy among the Hmong, but the Doctors saw the disease as untreatable. The language barrier and cultural differences between the Lees and the doctors of MCMC prevented the Lees from obtaining an accurate patient diagnosis and treatment.

Communicating across cultures carries a great number of challenges. Language can have many different meanings in a particular language that may not exist in another. In Lia’s case, this language barrier of communication made it difficult for doctors to ask basic questions including: where do you hurt, have you had a fever, and how long have you been hurting? The hospital did not have English-Hmong translators or bilingual Hmong employees that worked during the night shift. Fadiman, describing the critical situation, states: “Doctors on the late shift in the emergency room had no way of taking a patient’s medical history, or of asking such questions as where do you hurt?”. As a result of this language barrier, Lia’s parents had no way of communicating important information, including any of the details of her seizures – or even the fact that she had seizures. This is the reason doctors originally misdiagnosed her, presenting symptoms as a “bronchial infection” instead of her actual diagnosis of epilepsy.

A study conducted by Rebeca R. Henry also shows how language barriers affected how the Hmong viewed western medicine. When asked about the vaccinations their children received, Hmong parents stated they either did not remember or did not receive explanations about the immunizations prior to the administration of the vaccine in clinics. When questioned what illnesses immunizations prevented, parents either did not know or gave answers that indicated incorrect expectations about the effects of immunizations. For example, they described immunizations as providing protection from 'all sicknesses.” Some parents believed that 'shots using a needle' were a type of treatment against all diseases. Because of miscommunication between those giving immunizations and Hmong parents, the majority of Hmong parents did not draw a connection between specific types of immunizations and the specific illnesses they are designed for.

The Hmong have difficulty accepting the reasoning behind the disease, although they seek care from western medicine. They have been exposed to “new” chronic illnesses that are out of a shaman’s scope of practice. Their traditional theories and methods cannot explain or cure illnesses. As a result, patients were more inclusive of western medical practices if the circumstances were out of the shamans’ realm or if the shaman recommended treatment to help assist the problem. Fadiman also mentions that by taking Hmong religious beliefs into account, some doctors were able to help their patients. Fadiman discusses how grants in California were used for, “Integrating mental health delivery services utilizing Hmong healers and western mental health providers”. The grants were deemed a huge success as shamans were enrolled in hospitals to help Hmong patients.

With immigration on the rise, it has become even more important to be aware of and better understand one’s own culture and other cultures around the world. The doctors at MCMC showed that Americans need to be more sensitive to different cultures, even more so as it relates to cross-cultural medical treatment. Lia’s struggle has become a symbol for disabled children and immigrants frightened by Western medicine. Even though she never spoke a word after age 4, Lia taught a lot of doctors and nurses to care for people from other cultures with more sensitivity. The challenges that the Lees faced taught us how important it is to understand and respect everyone’s culture.

Fadiman does a good job presenting each side equally and fairly while expressing empathy and awareness to both sides. Fadiman uses this novel to challenge our beliefs of what it means to be a good parent and a good doctor, and what happens when those beliefs conflict. Lia's condition and the demands created by the collision of values had no simple solution, and Fadiman does a good job of not placing the blame on either side. The novel describes the importance of recognizing and affirming cultural differences in healthcare encounters, as well as a strategy for navigating encounters where these cultural differences can impact care and outcomes.

References

1. Capps, L. L. (1994). Change and Continuity in the Medical Culture of the Hmong in Kansas City. Medical Anthropology Quarterly, 8(2), 161-177. doi:10.1525/maq.1994.8.2.02a00020
2. Fadiman, A. (2012). A Hmong child, her American doctors, and the collision of two cultures: A Hmong child, her American doctors, and the collision of two cultures. New York: Farrar, Straus and Giroux.
3. Henry, R. R. (1999). Measles, Hmong, and Metaphor: Culture Change and Illness Management under Conditions of Immigration. Medical Anthropology Quarterly, 13(1), 32-50. doi:10.1525/maq.1999.13.1.32