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

Nonfiction | Book | Adult | Published in 1997

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Summary

Chapter Summaries & Analyses

Preface-Chapter 3

Chapters 4-7

Chapters 8-11

Chapters 12-16

Chapter 17-Afterword

Key Figures

Themes

Index of Terms

Important Quotes

Essay Topics

Tools

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Discussion Questions

Themes

Cross-Cultural Communication and Miscommunication

The theme of cross-cultural miscommunication features predominately in Fadiman’s book. Early on, she describes the experience of listening to the interview recordings of Lia’s family and her doctors. Fadiman wishes she could splice the recordings together so she can hear their voices “on a single tape, speaking a common language” (ix). The desire to hear a common language is central to her study of cross-cultural conflict at MCMC—a conflict that ends tragically for Lia and her family. For, as Fadiman summarizes at the end of the book, “I have come to believe that [Lia’s] life was ruined not by septic shock or noncompliant parents but by cross-cultural misunderstanding” (262).

Fadiman relies on extended, ethnographic narratives to set up two very different worldviews about the etiology of Lia’s illness. The first details the cultural beliefs and traditional healing practices of Lia’s family and wider Hmong society. The second explains the cultural paradigm of Western biomedicine, which relies on Cartesian, rationalist reasoning. The divergent perspectives of the Lee family and Lia’s doctors repeatedly collide, as neither side understands the other—an issue that is more than a problem of insufficient translation. For instance, Lia’s family attribute her seizures to soul loss, which they call quag dab peg or “the spirit catches you and you fall down” (21). Her doctors meanwhile view the seizures as part of a neurological disorder “caused by an electrochemical storm inside [Lia’s] head that had been stirred up by the misfiring of aberrant brain cells” (28). Lia’s family and doctors recognize the same symptoms (the seizures), yet their treatment plans are radically different. The Lees use shamans, animal sacrifices, and herbal remedies to restore Lia’s soul whereas her doctors rely on anticonvulsant medications and surgical interventions to control her seizures.

More than just a difference in perspective, however, these different worldviews are connected to different institutions of power that ultimately privilege the biomedical establishment. For instance, Lia’s doctors instruct a regimen of medication that is highly complex and undergoes numerous revisions. The Lees, confused, and concerned about the side-effects, do not administer the medicines as prescribed. Lia’s doctors are unsure if their “non-compliance” is intentional, “defects of intelligence or moral character,” or a result of “cultural barriers” (47). Either way, they find it unacceptable, and Neil reports the Lees to Child Protective Services who, with the support of the court, remove Lia from her parent’s custody and place her in foster care. Highly aware of these power asymmetries, Fadiman writes:

For better or for worse, Western medicine is one-sided. Doctors endure medical school and residency in order to acquire knowledge that their patients do not have. Unless the culture of medicine changes, it would be asking a lot of them to consider, much less adopt, the notion that, as Francesca Farr put it ‘our view of reality is only a view, not reality itself’ (276).

Nonetheless, while Fadiman’s book is largely about cross-cultural miscommunication, she also presents numerous possibilities to improve channels of communication so that doctors and patients can enact effective treatment plans. Fadiman cites the work of Arthur Kleinman and his eight questions, which are “designed to elicit a patient’s ‘explanatory model’” (260). Jettisoning ideas of compliance, using a model of mediation, and recognizing biomedicine as a cultural system also are steps towards achieving productive cross-cultural communication. The insights of Bruce Thowpaou Bliatout and his recommendation to practice “conjoint treatment—that is integrate Western allopathic medicine with traditional healing arts” (266), offers another model of care that establishes trust between patients and doctors and produces positive outcomes. In the afterword to the book, Fadiman follows up on many of these ideas by documenting recent, innovative approaches to cross-cultural communication in health care settings. She cites programs like Partners in Healing, which incorporates shamans in treatment plans, and hospital services that pay greater attention to patients’ religious, spiritual, psychological, and dietary needs.

For Lia’s family and her doctors, though, genuine cross-cultural communication eludes them for most of the book. This changes in 2003, when after the original publication of her book, Fadiman invites Lia’s family and doctors to a conference at U.C. Davis to discuss their experiences. Afterwards Nao Kao approaches Neil and, for the first time, acknowledges how much Lia’s doctors cared about her and thanks him. Fadiman concludes the book with the following, “In that moment, before we all headed to dinner, I heard what I had imagined when I wrote the preface to this book fifteen years ago: a common language” (303). This moment of shared empathy is very different from the original ending to the book, where Fadiman writes about the txiv neeb imploring for Lia’s soul to return home, to no answer.

Cultural Relativism as a Methodological Approach

Closely connected to Fadiman’s preoccupation with cross-cultural communication is her emphasis on cultural relativism. Cultural relativism is a methodological approach that does not judge another culture by one’s own standards but rather views them on their own terms. Fadiman uses this approach to better understand the Lees and their conceptions of health, illness, and healing, which she contextualizes within a larger framework of Hmong cultural beliefs and practices.

As part of her strategy to learn more about the Lees, Fadiman adopts many culturally-sensitive research tactics. She follows the advice of Sukey Waller and employs a cultural broker to help her figure out how to ask questions and act appropriately. As Waller explains, “‘I don’t call my staff interpreters,’ she told me. ‘I call them cultural brokers. They teach me. When I don’t know what to do, I ask them.’” (95). Fadiman reiterates the importance of cultural brokers at the end of the book when she details the success of Francesca Farr, a social worker who visits the homes of her Hmong clients: “She took along a capable and assertive interpreter whom she treated as a cultural broker (by definition her equal, and in this case her superior), not a translator (her inferior)” (264-65). Fadiman attributes Farr’s success to her ability to listen to her clients and her use of cultural relativism: “She worked within the family’s belief system. She did not carry her belief system—which included a feminist distaste for being forced to deal with the husband instead of the wife—into the negotiations. She never threatened, criticized, or patronized” (265).

Hiring a cultural broker proves beneficial to Fadiman’s research; the Lees warmly accept her and May Ying into their home, viewing them not as authority figures but as honorary family members. As a result, Fadiman gains access into a world that Lia’s doctors do not see, and she forms a very different opinion of the Lees: “Within thirty seconds, I could see I was dealing with a family that bore little resemblance to the one the doctors had described. The Lees struck me as smart, humorous, talkative, and energetic” (97). Fadiman spends a lot of time with the Lees in their home, observing, listening, and asking questions about Lia and their lives. She gains their trust and writes that the Lees have their own agenda too, “which, as Nao Kao, once put it, was ‘to tell you about Hmong culture so you can understand our way and explain it to the doctors’” (100). During these visits, the Lees explain why they prefer not to give Lia too much medicine, for it interferes with the neeb’s (or healing spirit’s) effect on the soul.

When Fadiman explains the Lees preference to use “a little medicine and a little neeb” to treat Lia, which they view as “eminently reasonable and their doctors as incapable of compromise,” Neil and Peggy “[shake] their heads in puzzlement and consternation” (110). Neil and Peggy’s response reveals their inability to grasp “the psychosocial and cultural facets that give illness context and meaning,” which is why Fadiman describes them as “imperfect healers,” at least during their early years of treating Lia (265).

Of note, all of Lia’s doctors fail to ask the Lees what they think caused Lia’s illness and what could cure it; the only person who expresses interest is their social worker, Jeanine Hilt, who Fadiman describes as having deep empathy for the Lees. Empathy is the cornerstone to cross-cultural communication, as seen at the end of the book when Nao Kao and Neil finally reach a common understanding. Cultural relativism, with its emphasis on suspending judgement, offers the possibility of working towards this goal. It is the antidote to ethnocentrism, the belief that one’s own culture is superior to another culture—a perspective that makes it difficult to tolerate other belief systems and practices. In its most extreme form, ethnocentrism manifests as bigotry and racism. Fadiman’s book offers a cautionary tale of what can happen when doctors, while not intentionally ethnocentric, find it difficult to compromise their medical knowledge and work ethic to accommodate different belief systems. Her book also shows the power of cultural relativism and its potential to illuminate multifaceted approaches to healing.

Hmong Cultural Values: Autonomy and Self-Sufficiency

Fadiman structures the book so that the chapters alternate between telling Lia’s medical story with historical narratives that provide greater depth to Hmong cultural values, like self-sufficiency and autonomy. Fadiman links the migration of the Hmong from China, Laos, Thailand, and eventually the United States as part of their determination to remain independent and free from persecution. The Hmong, unlike many of the societies that try to subjugate them, express no interest in ruling over others or assimilating to dominant norms; they just want to be left alone to practice their own way of life, which Fadiman describes as perhaps “the most difficult request any minority can make of a majority culture” (14).

While the Hmong prefer to exist as a self-sufficient, insular society, and manage to do this for extended periods of time in the mountains of China and Laos, geopolitical forces eventually encroach on their way of life. The Hmong support the American military during the Vietnam War, directly participating in combat in Laos and suffer huge casualties. The fallout from the war is extreme, as most Hmong are displaced from their villages and no longer can survive as subsistence farmers, a severe blow to their self-sufficiency. As Fadiman writes:

The most dramatic 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 the mountains emptied of game, more than 100,000 Hmong were kept alive by U.S.-sponsored food drops (137).

Their dependency on foreign aid continues in the refugee camps in Thailand, which Fadiman describes as a “dress rehearsal” for their experiences in the United States:

Ban Vinai was, in effect, a large-scale charitable institution that continued the job, effectively begun by wartime rice drops, of eroding Hmong self-sufficiency. Depending on how you looked at it, life there was either a catastrophic deracination or a useful dress rehearsal for life in the American inner cities to which many of its inhabitants would ultimately relocate (165-66).

When the Hmong reach the United States, they experience hostility from Americans for their reliance on government welfare; however, the Hmong view these payments not only as vital but also as justified given their sacrifices to the American war effort in Laos. Even so, the erosion to their sense of self-worth runs deep, as expressed by Foua, who reflects: “What I miss in Laos is that free spirit, doing what you want to do. You own your own fields, your own rice, your own plants, your own fruit trees. I miss that feeling of freeness. I miss having something that really belongs to me” (105). In the book’s afterword, Fadiman believes that it “was impossible for Foua, Nao Kao, and many other Hmong refugees their age to reassemble lives as emotionally rich as the ones they’d led in their villages in Laos” (297), in part because of their lack of autonomy and self-sufficiency in the United States. She describes them as a “sacrificed generation” yet also recognizes their important contributions to their children’s lives (297). Their children, in turn, have reasserted Hmong values of autonomy and self-sufficiency through educational pursuits and jobs while retaining a sense of communality and connection to their ethnic identity and cultural traditions.