The Spirit Catches You and You Fall Down: A Hmong Child, Her American Doctors, and the Collision of Two Cultures

“Although the Hmong believe that illness can be caused by a variety of sources […] by far the most common cause of illness is soul loss. Although the Hmong do not agree on just how many souls people have (estimates range from one to thirty-two; the Lees believe there is only one), there is a general consensus that whatever the number, it is the life-soul, whose presence is necessary for health and happiness, that tends to get lost. A life soul can be separated from its body through anger, grief, fear, curiosity, or wanderlust. The life-souls of newborn babies are especially prone to disappearance, since they are so small, so vulnerable, and so precariously poised between the realm of the unseen, from which they have just traveled, and the realm of the living.”

This quotation emphasizes the importance of the life-soul in Hmong culture. It provides context to the Lees’s understanding of Lia’s illness, which they attribute to soul-loss. The passage illustrates Fadiman’s close attention to Hmong conceptions of health and illness and her descriptive, ethnographic prose.

“The professor of French who told me this story said, ‘Fish Soup. That’s the essence of the Hmong.’ The Hmong have a phrase, hais cuaj txub kaum txub, which means ‘to speak of all kinds of things.’ It is often used at the beginning of an oral narrative as a way of reminding the listeners that the world is full of things that may not seem to be connected but actually are; that no event occurs in isolation; that you can miss a lot by sticking to the point; and that the storyteller is likely to be rather long-winded”

This quotation conveys the tone of Fadiman’s research, particularly her interactions with Hmong respondents who talk at length about their history and cultural beliefs and practices. Like fish soup, her respondents like “to speak of all kinds of things,” which Fadiman skillfully captures and reconveys in her extended narratives of Hmong life in China, Laos, and the United States. The story of how fish soup is made is a metaphor for the Hmong way of doing things in general.

“The history of the Hmong yields several lessons that anyone who deals with them might do well to remember. Among the most obvious of these are that the Hmong do not like to take orders; that they do not like to lose; that they would rather flee, fight, or die than surrender; that they are not intimidated by being outnumbered; that they are rarely persuaded that the customs of other cultures, even those more powerful than their own, are superior; and that they are capable of getting very angry. Whether you find these traits infuriating or admirable depends largely on whether or not you are trying to make a Hmong do something he or she would prefer not to do. Those who have tried to defeat, deceive, govern, regulate, constrain, assimilate, intimidate, or patronize the Hmong have, as a rule, disliked them intensely.”

This exposition summarizes some of the core traits of the Hmong, which is their great dislike for coercion and their preference to fight or flee from situations of oppression. Here, Fadiman addresses the history of the Hmong in China and Indochina, which she then, in later parts of the book, connects to Hmong survival strategies in the United States. The passage prefigures some of the conflicts and frustrations that Lia’s doctors face when trying to force the Lees to administer Lia’s medications correctly.

“When Lia was about three months old, her older sister Yer slammed the front door of the Lees’ apartment. A few moments later, Lia’s eyes rolled up, her arms jerked over her head, and she fainted. The Lees had little doubt what had happened. Despite the careful installation of Lia’s soul during the hu plig ceremony, the noise of the door had been so profoundly frightening that her soul had fled her body and become lost. The recognized the resulting symptoms as qaug dab peg, which means ‘the spirit catches you and you fall down.’ The spirit referred to in this phrase is a soul-stealing dab; peg means to catch or hit; and qaug means to fall over with one’s roots still in the ground, as grain might be beaten down by wind or rain.”

This narrative provides an explanation of Lia’s illness from the Lees’s perspective. They attribute her seizures to soul-loss, which occurs when Lia’s older sister slams the front door and the loud noise scares Lia’s soul away. The passage also reveals Fadiman’s close attention to Hmong terminology and the multilayered association with Hmong cultural values, including their agrarian past.

“A txiv neeb might spend as much as eight hours in a sick person’s home; doctors forced their patients, no matter how weak they were, to come to the hospital, and then might spend only twenty minutes at their bedsides. Txiv neebs were polite and never needed to ask questions; doctors asked many rude and intimate questions about patients’ lives, right down to their sexual and excretory habits. Txiv neebs could render an immediate diagnosis; doctors often demanded samples of blood (or even urine or feces, which they liked to keep in little bottles), took X rays, and waited for days for the results to come back from the laboratory—and then, after all that, sometimes they were unable to identify the cause of the problem. Txiv neebs never undressed their patients; doctors asked patients to take off all their clothes, and sometimes dared to put their fingers inside women’s vaginas. Txiv neebs knew that to treat the body without treating the soul was an act of patent folly; doctors never even mentioned the soul.”

This passage describes key differences between txiv neebs (shamans) and American doctors. It is an example of how Fadiman incorporates cultural relativism into her writing, as she presents the viewpoint of the Hmong and what they consider to be good healers. This passage makes it easier to understand why the Hmong distrust American doctors.

“The absence of good interpreters was only part of the communication problem. Neil felt that Nao Kao put up a ‘stone wall’ and was sometimes deliberately deceitful. Peggy felt that Foua was ‘either very stupid or a loonybird’ because her answers, even on those occasions when they were accurately translated, often didn’t make sense. Neither doctor could tell how much of their inability to get through was caused by what they perceived as defects of intelligence or moral character, and how much was caused by cultural barriers. Neil recalled later, ‘It felt as if there was this layer of Saran Wrap or something between us, and they were on one side of it and we are on the other side of it. And we were reaching and reaching and we could kind of get into their area, but we couldn’t touch them. So we couldn’t really accomplish what we were trying to do, which was to take care of Lia’”

This passage illustrates the complications of cross-cultural communication between doctors and Hmong patients at MCMC. Neil and Peggy are frustrated by the Lees’s unwillingness to administer Lia’s medicines correctly and do not understand why they have so much trouble communicating with them, even when interpreters are available. The passage reveals Neil and Peggy’s inability to connect with the Lees while also showing their concern for Lia’s welfare, as they know good communication with her parents is necessary for effective treatment.

1.        “Lia’s problems are very behavioral. Cries constantly. Real disruptive, real anger. Will cry non-stop 2-5 a.m.—kicking. Won’t give in. Family is on edge.

Tantruming. Withholds food. Looks at Dee, takes off her panties and pees.

Pooping on floor now.

Bit herself on lip.

Lia crying 4 days straight. Smearing feces.

Intense crying again. Stripped herself, peed on the floor, went on a wave of destruction. Had to sedate her.”

This passage describes the home visit of a social worker who is checking in on Lia while she is under the care of Tom and Dee Korda, her foster parents. Lia is extremely disruptive and acting out because she misses her family. It shows the immense trauma of separating her from her parents. The passage also is an example of Fadiman using primary sources, in this case a government record, to support her interview findings.

“With May Ying at my side, I was not an official, not a threat, not a critic, not a person who was trying to persuade the Lees to do anything they did not wish to do, not even someone to be taken very seriously. My insignificance was my saving grace.”

Fadiman employs May Ying as a cultural broker to help mediate her meetings with the Lees. The Lees warmly accept Fadiman into their home, and she attributes their hospitality to her and May Ying’s low social status. As young women, they are not a threat to the Lees. With May Ying’s help, Fadiman learns a lot about the Lees, their history, and cultural values, and is given direct access to Lia’s medical records.

“Neil said, ‘I felt like there was this giant snowball that was coming down the mountain and we were trying to hold it up there and it just kept pushing us. I remember talking to the parents and telling them that Lia’s seizures were getting worse and more frequent and that someday she might have one we couldn’t stop. It was so haunting. I started to have nightmares that it was going to happen, and I would be the one on call, and I couldn’t stop it and she was going to die right before my eyes. It was inevitable. It was just a matter of when.’”

This passage foreshadows Lia’s final neurological crisis, in which she has a massive epileptic seizure that leaves her brain dead. It also provides a counterbalance to some of the personal trauma that the Lees experience. Lia’s doctors also feel immense strain and anxiety trying to treat Lia and worry about not being able to help her when she is in medical distress.

“The most drastic change bred by the war was the loss of the single asset the Hmong prized most highly: their self-sufficiency. With their fields left rotting, their livestock abandoned, and their mountains emptied of game, more than 100,000 Hmong were kept alive by U.S.-sponsored food drops—weather and enemy fire permitting, fifty tons of rice a day, delivered by parachute from Air America cargo planes.”

Fadiman alternates her chapters about Lia with historical narratives about Hmong wartime experiences in Laos. The Hmong supported the US military in secret operations against the North Vietnamese. This quotation describes the destruction to their livelihood and increasing dependence on US aid. Fadiman connects these events to the predicament of Hmong refugees in the United States who, no longer able to work as farmers, rely on government welfare to support themselves and their families.

“Dr. Kopacz, for example, who worked on Lia for more than twelve hours straight, failed to notice her sex. ‘His metabolic acidosis was decreased after initial bolus of bicarbonate,’ he wrote. ‘His peripheral perfusion improved and pulse oximetry started reading a value that correlated with saturation on the arterial blood samples.’ Here was American medicine at its worst and its best: the patient was reduced from a girl to an analyzable collection of symptoms, and the physician, thereby able to husband his energies, succeeded in keeping her alive”

This quotation summarizes the best and most detrimental aspects of American medicine. Dr. Kopacz saves Lia’s life by relying on his expert knowledge and using highly sophisticated technologies, but he also fails to see her as a person and misidentifies her as a boy. This tension between treating a person’s symptoms and recognizing them as a whole person sits at the heart of the cultural conflict between Lia’s parents and her doctors.

“‘The doctors put a hole in her back before we got to the hospital,’ he said. ‘I don’t know why they did it. I wasn’t there yet and they didn’t give me any paper to sign. They just sucked her backbone like that and it makes me disappointed and sad because that is how Lia was lost.’ In other words, Nao Kao attributed Lia’s deteriorating condition to the spinal tap, a procedure many Hmong believe to be potentially crippling both in this life and in future lives. Foua’s explanation was, ‘They just took her to the hospital and they didn’t fix her. She got very sick and I think it is because they gave her too much medicine.’”

When Lia goes into status epilepticus, her doctors aggressively treat her condition. This quotation expresses the despair of Nao Kao and Foua, who believe that these medical interventions caused greater harm to Lia, leading to the ultimate loss of her soul. The quotation raises ethical question of how to acquire true, informed consent in moments of medical emergency.

“They wanted Hmong culture to disappear. But the Hmong cannot be assimilated. The Chinese cannot assimilate the Hmong. The Pathet Lao cannot assimilate the Hmong. After two thousand years we can still say we are Hmong.”

This quotation is from a Hmong leader, Blia Yao Moua, who describes the violence enacted against the Hmong by the North Vietnamese in postwar Laos. He links these brutalizing tactics to a long history of persecution and notes that, despite coercive tactics of ethnocide and assimilation, the Hmong identity remains intact. Fadiman connects this historical narrative to the Hmong’s continuing reluctance to assimilate to American cultural life.

“The night the Lees told me about their postwar experiences, I remember saying, because I did not know what to say, ‘That must have been terrible.’ And Foua gave me a brief, opaque look, and said, ‘Yes, it was very sad. But when we were running from Laos at least we hoped that our lives would be better. It was not as sad as after Lia went to Fresno and got sick.’”

This quotation highlights two traumas: (1) the Lees’s postwar experiences and (2) Lia’s final seizure, which leaves her brain dead. Despite the immense uncertainty of fleeing for their lives in Laos, Foua finds it more bearable than Lia’s brain death because they at least had hope for a better life. There is very little chance of Lia recovering from her neurological crisis, and the quotation underscores her family’s pain and sense of hopelessness.

“‘She was in a vegetative state. But that was one angry vegetable.’

Calling Lia a vegetable was, it seemed to me, just one more form of avoidance. In describing what had happened to her, he and Peggy both used the kinds of terms favored by doctors in MASH, gallows-humor slang wielded in times of extreme stress on the theory that if you laugh at something it can’t break your heart. ‘Lia got gorked.’ ‘She crumped.’ ‘She fried her brain.’ ‘She vegged out.’ ‘She crapped out.’ ‘She went to hell.’ ‘No one’s at home, the lights are out.’”

Fadiman pays close attention to language in her research, and this passage shows the seeming callousness of Lia’s doctors when describing her condition in non-clinical terms. Still, rather than judge Lia’s doctors for their insensitivity, Fadiman notes that their language reflects a strategy of avoidance to not feel connected to their patient; otherwise, it would be too emotionally devastating. In later chapters, Fadiman addresses the disassociation of doctors from patients as part of standard medical training to help them become more objective and dispassionate in their work.

“Seventeen years later, Foua and Nao Kao use American appliances but they still speak only Hmong, celebrate only Hmong holidays, practice only the Hmong religion, cook only Hmong dishes, sing only Hmong songs, play only Hmong musical instruments, tell only Hmong stories, and know far more about current political events in Laos and Thailand than about those in the United States. When I first met them, during their eighth year in this country, only one American adult, Jeanine Hilt, had ever been invited to their home as a guest. It would be hard to imagine anything further from the vaunted American ideal of assimilation, in which immigrants are expected to submerge their cultural differences in order to embrace a shared national identity. E pluribus unum: from many, one.”

This passage describes the continuity of Hmong culture and traditions in the United States and the Lees’s lack of assimilation to American cultural values. The retention of a distinct, ethnic identity has both positive and negative consequences for Hmong immigrants. On the one hand, they are a highly unified group, supporting one another in times of need. On the other hand, they experience a high incidence of xenophobia and alienation from American society, which further contributes to their socioeconomic marginalization.

“Suddenly, Lia was, as Bill Selvidge once told me dryly, ‘just the sort of patient nurses like.’ She had metamorphosed from a hyperactive child with a frightening disorder and inaccessible veins into an inert, uncomplaining body who would probably never need another IV. Simultaneously, in the eyes of the family practice staff, her parents were miraculously transformed from child abusers to model caregivers.”

This quotation reveals the arbitrariness and coercive power of the term “compliance.” Prior to Lia’s neurological crisis, the medical staff at MCMC regard her as a difficult, uncooperative patient. When she no longer has any autonomy, their opinion dramatically changes, and they find it easy to treat her. Meanwhile Foua and Nao Kao continue to care for Lia with the same devotion and affection as before. Their actions have not changed—just the medical staff’s perception of them.

“Lia was still a beautiful child. She was nothing like the patients in vegetative states whom I had seen in hospitals, pasty-skinned carcasses with slack mouths, hair like straw, bodies that smelled of urine even after they were bathed. Lia’s black hair was still shiny, her skin was soft and fine, her lips were still pink and shaped like a Cupid’s bow. She smelled delicious. It therefore never seemed strange to me that her family treated her as one would an especially winsome baby: a diapered, bottle-fed, fussing baby who just happened to be three feet tall.”

Lia, to the astonishment of her doctors, defies all expectations and lives long after her brain death. This passage shows how this is possible, as her parents continue to care for her, treating her not like an outcast or invalid but as a person, much like a baby, needing continuous attention and affection. The description of Lia’s physical condition also is characteristic of Fadiman’s ethnographic writing style.

“What had come over to them today? It seemed as if my open, animated garrulous friends, faced with someone they viewed as an authority figure—even though he would probably have quit his job before he ever treated them coercively—had entered a vegetative state themselves. They hadn’t said twenty words since Martin arrived. They hadn’t laughed, smiled, or looked him in the eye. And then I thought: these must be the people Neil and Peggy have been dealing with all these years. No wonder everyone but Jeanine thinks they are impenetrable and stupid. Of, course, Martin had undergone an equally unseemly metamorphosis himself, from savant to bumbler. It was as if, by a process of reverse alchemy, each party in this doomed relationship had managed to covert the other’s gold into dross.”

This passage details the unsuccessful visit of a public health nurse to the Lees’s home. In this case, the nurse is knowledgeable of Hmong political history and has a genuine interest in Hmong culture. However, his status as an authority figure, who dispenses advice on how to care for Lia, makes it difficult for the Lees to trust and accept him and, for the first time, Fadiman sees how the doctors at MCMC formed their negative impression of the Lees. Neither side is able to communicate effectively with the other, and Fadiman poetically describes the process as converting “gold into dross,” which also is the title of the chapter.

“‘Lia’s parents think that the problem was caused by too much medicine.’

‘Well,’ said Dr. Hutchinson, ‘that may not be too far from the truth.’

I stared at him.

‘Go back to Merced,’ he said, ‘and tell all those people at MCMC that the family didn’t do this to the kid. We did.’

Driving back to Merced, I was in a state of shock myself. I had known about Lia’s sepsis, but I had always assumed that her seizure disorder had been the root of the problem. The Lees were right after all, I thought. Lia’s medicine did make her sick!”

This conversation is between Fadiman and Terry Hutchinson, the neurologist who treats Lia at Valley Children’s Hospital in Fresno. Dr. Hutchinson informs Fadiman that the anticonvulsant medicine, Depakene, might have weakened Lia’s immune system, making her more susceptible to bacteria in her blood that led to septic shock and eventually her coma. The seizure disorder, according to Dr. Hutchinson, was not the cause of Lia’s final neurological crisis. Lia’s parents are correct that Lia’s medicine made her sick—a major finding that validates their understanding of Lia’s illness and shows some of the failings of the biomedical establishment.

“Of course, the Lees’ perspective might have been unfathomable to the doctors as the doctors’ perspective was to the Lees. Hmong culture, as Blia Yao Moua observed to me, is not Cartesian. Nothing could be more Cartesian than Western medicine. Trying to understand Lia and her family by reading her medical chart (something I spent hundreds of hours doing) was like deconstructing a love sonnet by reducing it to a series of syllogisms. Yet to the residents and pediatricians who had cared for her since she was three months old, there was no guide to Lia’s world except her chart. As each of them struggled to make sense of a set of problems that were not expressible in the language they knew, the chart simply grew longer and longer, until it contained more than 400,000 words. Every one of those words reflected its author’s intelligence, training, and good intentions, but not a single one dealt with the Lees’ perception of their daughter’s illness.”

This passage explains why the Lees and Lia’s doctors have such difficulty communicating with each other. Blia Yao Moua points out fundamental differences in worldviews. Western medicine is highly rationalist and reduces Lia to a series of symptoms, as described in her medical chart. Lia’s doctors fail to ask the Lees what they think is the reason for Lia’s illness and, in doing so, fail to reach common ground for how to help her most effectively. This quotation also shows Fadiman’s literary writing style, as she eloquently expresses the difficulty of reducing sonnets to a series of syllogisms, similar to how Lia’s doctors reduce her to a set of pathologies, failing to recognize her as a whole person.

“Once, several years ago, when I romanticized the Hmong more (though admired them less) than I do now, I had a conversation with a Minnesota epidemiologist at a health care conference. Knowing she had worked with the Hmong, I started to lament the insensitivity of Western medicine. The epidemiologist looked at me sharply. ‘Western medicine saves lives,’ she said. Oh. Right. I had to keep reminding myself of that. It was all that cold, linear, Cartesian, non-Hmong-like thinking which saved my father from colon cancer, saved my husband and me from infertility, and, if she had swallowed her anticonvulsants from the start, might have saved Lia from brain damage.”

This quotation offers a corrective to Fadiman’s points about how the biomedical establishment fails its patients. A conversation with an epidemiologist helps Fadiman remember that Western medicine saves lives and has been instrumental in improving the quality of her life and that of her family. She also recognizes that if Lia’s parents had used anticonvulsant medications from the start, there is the possibility that Lia’s brain damage might not have occurred.

1.        “Where are you?

Where have you gone?

Are you visiting your brother?

Are you visiting your sister?

Are you visiting your cousin?

Are you looking at a flower?

Are you in Laos?

Are you in Thailand?

Are you in the sky?

Have you gone to the sun?

Have you gone to the moon?

Come home to your house

Come home to your mother

Come home to your father

Come home to your sisters

Come home to your brother

I am calling you!

I am calling you!

Come home through this door

Come home to your family

Come home

Come home

Come home

Come home

Come home

Come home

Come home.”

This passage records the chant of a txiv neeb who is performing a healing ceremony for Lia to lessen her suffering. The chant asks for Lia’s soul to return home so that she may be restored to her former self. It reveals the cultural beliefs of the Hmong and their understanding of illness and healing through the concept of soul-loss. The chant is the original ending to the book and conveys a tone of wistfulness as her parents hold out some hope that Lia’s soul will come back.