Spirit Catches You and You Fall Down by Anne Fadiman is a groundbreaking book about cross-cultural communication in health care. The book is about Lia Lee, who was the first in her Hmong family to be born in the United States. Her parents spoke no English. When Lia Lee was three months old, she had her first seizure. Due to misdiagnosis, a string of unfortunate events prevented Lia Lee from receiving the best possible care. Moreover, she was wrested from her family of origin and placed in foster care. The disruption to her life, the misdiagnosis, and the lack of communication between the health care team and her family led to her eventual death after decades in a persistent vegetative state. The Spirit Catches You And You Fall Down has become critical reading material for all health care workers seeking to provide the best quality of care in a multicultural environment.
Lia Lee had epilepsy, a condition known as qaug dab peg in the Hmong culture. Qaug dab peg is regarded "with ambivalence" by the Hmong, according to Fadiman (p. 21). This is not to say that Hmong treat the condition lightly; rather, they treat the condition quite seriously but just not in the same manner as Western medicine. Fadiman makes it clear that the Hmong have a historic and cohesive system of shamanic medicine with its own lexicon, diagnostic, and treatment procedures. The diagnosis of qaug dab peg entails various shamanic rituals and treatments designed to reunite a wandering soul with the suffering body. A diagnosis of qaug dab peg is not viewed as a disease in the same paradigm as Western medicine. Rather, qaug dab peg is viewed primarily as a spiritual condition that is to be accepted and worked with from within a Hmong perspective. Quag dab peg is translated as "the spirit catches you and you fall down," referring to the sinister dab spirit that steals souls.
The Lee family did not want their daughter to undergo invasive surgery, or to take powerful anticonvulsive medications like ampicillin and Dilantin to control seizures and other drugs to counteract symptoms and conditions like pneumonia. However, Lia Lee's seizures became too frequent and severe to ignore, and outside of their Laotian villages they could not find shamanic treatments to help their daughter. They would have preferred that Lia Lee see a traditional Hmong doctor, who would perform the traditional rites that constitute healing and medicine in their culture. Eventually, the parents took Lia Lee back to the hospital.
Once they took this vital step of using the American health care system, they essentially surrendered the right to care for Lia Lee in the manner they believed was best. American law entitles the health care team to make decisions on behalf of Lia Lee in order to save her life. In the case of Lia Lee, unfortunately, the decisions that were made ended up being detrimental even if the doctors and health care team had the child's best interest at heart.
The Lee family made the long journey to the United States with virtually no money. They lived in refugee camps in Thailand before arriving in California. Their eventual destination was Merced, which already had a pre-established Hmong refugee community. Because of the existence of the Hmong refugee community in Merced, it seems criminal that the doctors at Merced Community Medical Center did not try harder to find a translator for the family when they recognized Lia Lee's condition. Had communication been established from the onset, many of Lia Lee's problems might not have manifest.
Communication might have alleviated the parents' fears about the nature of Western medicine. The model of Western medicine is paternalistic, which assumes patient ignorance and often deliberately preserves patient ignorance by cloaking health and illness in jargon. Because Hmong culture is particularly resistant to foreign authority, Fadiman points out the problems with a paternalistic medical model especially when dealing with patients who would prefer to be treated and consulted with deeper respect. The health care team in this case believed they were doing the right thing because they were following procedure, but they did not necessarily act out of respect. The health care team viewed the Hmong beliefs as being primitive and actually as being irrelevant, when those beliefs were highly relevant to treating Lia Lee. The Hmong view paternalistic medicine "not as a gift, but as a form of coercion," (Fadiman 37). No one on the health care team tried to explain why the invasive procedures being used on Lia Lee were possibly saving the child's life.
The Hmong have historically resisted cultural assimilation, to the point where independence is built into the Hmong identity. Anthropologists who have interacted with Hmong have noted, as Fadiman points out, the lengths to which Hmong have gone and will go to ensure the integrity of their culture. When the Hmong arrived in the United States, they did not intend to "become American" but to remain Hmong. As Fadiman puts it, the Hmong do not "melt well" (183). They want to be left alone; they have no ambitions of having power over other people, any more than they want to be subjugated by others. The American medical model is designed to strip power away from patients and families by restricting choice, and creating a frightful environment. Hospitals are also bureaucratic systems, which the Hmong hold in particularly low regard (Fadiman). It is no wonder that the Lee family resisted care. From their perspective, the doctors and other members of the health care team were making Lia Lee's condition worse.
Hmong shamans (txiv neeb) might actually be able to teach American doctors, just as American doctors might be able to teach the shamans. Complementary medicine models allow for dialogue and discourse between different paradigmatic systems. The two systems discussed in the Fadiman book are radically different, but at their core is a desire to help patients. Shamans can teach doctors that viewing the human body as a machine can be counterproductive to healing. Some illnesses can be framed as spiritual conditions that offer the individual an opportunity to explore existential issues. Invasive therapies and methods can lead to mental misery, which can impede healing. Western medicine does not take into account systems like family, culture, spirituality, and community.
Western doctors can dispel superstitious beliefs that are unnecessary, without sacrificing the framework of traditional mythologies and cosmologies. For example, it could have easily been said that the intravenous tubes were not draining Lia Lee of her blood, but were providing her with a magical elixir that could help restore the soul to her body. If the Hmong have a preference for storytelling and myth, then Western medicine can be framed in this way. A simple attempt to explain that Western doctors are doing what they do because it saves lives would help the Hmong understand that txiv neeb are not the only healers. Western doctors might be able to explain that certain interventions are designed to be temporary, or to treat acute problems. When those interventions do not work, then spiritual methods can be used as well. There does not need to be a conflict between traditional and allopathic medicine.
According to Fadiman, the "greatest of all Hmong folktales" is the story of Shee Yee. Shee Yee is the archetypal shaman, a "healer and magician" who was ambushed by nine evil dabs (Fadiman 170). The evil dab brothers ate Shee Yee's flesh and drank Shee Yee's blood. Important symbolic parallels can be made between Lia Lee and Shee Yee, as their flesh was poked and prodded, their blood sucked and sampled. The evel dab brothers waited to ambush Shee Yee, at a crossroads, a strong motif in many traditional tales. The crossroads represents critical moments of choice. In the Shee Yee story, nine different paths correspond with the nine evil brothers. The evil brothers transformed themselves into water buffalo, and so too did the clever Shee Yee. However, Shee Yee quickly changed back to a man and chopped up the evil brothers. The evil brothers continued to fight back, but Shee Yee remains a step ahead. The dab brothers continue to shape shift and transform, with Shee Yee counteracting their moves until finally Shee Yee "went home to his wife," (Fadiman, p. 170). The story represents the ongoing struggle of the Hmong against hostile forces, and the remarkable cleverness and resilience the Hmong have exhibited. Unfortunately, as Fadiman points out, not all Hmong immigrants have fared well with many being victims of violent crimes in America due to their inherently trusting nature. The Hmong social norms are such that violence against others and theft are strongly taboo.
When Lia Lee is placed in foster care, the situation is viewed as stealing the child. Lia Lee does not do well in her first foster care situation, when the Mennonite sisters attempt to address the needs of the child. After a few weeks, Lia Lee is returned, but the foster care battle…