In The Spirit Catches You and You Fall Down, Anne Fadiman narrates the story of Lia, a Hmong girl suffering from epilepsy who was surrounded by challenges due to conflicting viewpoints of her parents and her health care providers. For the Hmong people, epileptic seizures are viewed as a positive trait; those people who suffered from seizures are attributed to be a “twix neeb”, or “a person with a healing spirit” (Fadiman, 1997, pg. 21). Lia’s parents—Foau and Nao Kao (the Lees)—considered her condition as both a blessing and an honour.
However, in some way, they also considered it as an illness because they made use of medical aid offered by doctors to relieve its clinical manifestations. A lot of the Hmong’s conflicting ideas against western medicine, stem from their belief of keeping the body and spirit intact for the afterlife. They thought that some western procedures caused harm to patients instead of making them better. Consequently, the doctors at Merced Community Medical Center did not have the cultural understanding of such belief system of the Hmong (Fadiman, 1997).
Although both sides want positive health outcomes for Lia, the Lees lack of understanding of Western culture, and the health care providers’ ethnocentric biases of Hmong culture hindered progress which eventually lead to Lia’s death. The story of Lia has a profound influence in the medical field, because it highlights the importance of culturally competent care. Her story, and the Lees encounter with health care professionals serves as a lesson to aspiring doctors and nurses around the world.
Developing sensitivity to other cultures is vital in health care because it enables a person to appreciate diversity. It is only then that health care providers can provide patient-centred care that transcends cultural barriers and differences. Doctor-patient/family relationship is central in the delivery of high quality treatment and care of individuals. In The Spirit Catches You and You Fall Down, the contrasting description of Lia’s illness by the Lees and the doctors serves as the main misunderstanding between them.
This shows the lack of communication between both ends; and therefore, the lack of any doctor-patient/family relationship being established. Fadiman (1997) illustrates the problem when she explained that “Dan had no way of knowing that Foua and Nao Kao had already diagnosed their daughter’s problem… [as] the spirit catches you and you fall down, [while] Foua and Nao Kao had no way of knowing that Dan had diagnosed it as epilepsy… ” (pg. 28).
Different diagnoses, or understanding of the health condition resulted into a conflicting approach to treatment. Lia’s doctors diagnosed the illness as epilepsy—a neurological disorder which had no cure; however, its symptoms of seizures can be controlled using medications (Fadiman, 1997, pg. 29). Consequently, Lia’s parents needed to commit and follow a strict regimen for the drug therapy to make positive changes in Lia’s condition. However, due to a different understanding of the illness, the Lees had some reservations about medications.
According to Foa, it was good to take some medicine in conjunction with their shamanic rituals, but not too much, because it interferes with their effect (Fadiman, 1997, pg. 101). The Lees noncompliance to the doctor’s orders could have been prevented or redirected if the doctors took effort on understanding the significance of the soul to the Hmong people. Educating the family about the importance of medications, as well as supporting their efforts to seek spiritual help establishes the physician-family relationship.
The miscommunication between the doctors and the Lees, or the lack thereof, is the primary reason Lia did not receive the treatment she deserved. Western medicine is considered as a culture because it is a knowledge that is being exhibited and collectively practiced by a group of health care professionals such as doctors, nurses, pharmacists and many others. Therefore, in order for patients to have trust on western medicine, health care providers need to respect the cultures of others.
Lia’s doctors lacked effort in learning about the Hmong culture and their practices; most of what they know about the Hmong were speculations and stereotypes which were spread through gossips. Thus, the world view of the Hmong was not respected because they were perceived as ignorant and primitive (Fadiman, 1997). For example, if the doctors only knew why Hmong women prefer to bring their child’s placenta home, they would not have to fear in the idea of women eating placentas; because after all, it was buried and preserved as a garment for the soul in the afterlife (Fadiman, 1997 pg. -6).
Moreover, if these practices were asked and studied by the doctors, they would have a better understanding of the Hmong worldview. The Hmong had a more holistic view of the world; for the Hmong, everything is linked together like medicine and religion. This is contrary to the western worldview of Lia’s doctors, who were rationalists (Fadiman, 1997, pg. 29). The opposing worldviews made it even harder for negotiations to happen, because there was a notion that western medicine was more powerful than the Hmong culture.
This was evidenced by Lia becoming a government property, when at that time, “the differences [were] no longer about beliefs… [but rather] about power” (Fadiman, 1997, pg. 84). Consequently, Lia’s parents felt powerless because their traditional healing practices were not valued since taking away Lia validated the superiority of the medications, and in general, the culture of western medicine. Furthermore, understanding the history of the Hmong and their language of distress, would have enabled the doctors to be more empathic to emotions displayed by Lia’s parents.
The story of how the Hmong were driven from their homes in both China and Laos and fought in the Vietnam War, while only to be abandoned by the Americans was a significant one (Fadiman, pg. 119-139). Consequently, connections can be made between the Lees and the Hmong’s noncompliance, and their lack of trust with western medicine if there was effort to study their history. Fadiman suggests that non-compliance is an innate characteristic of the Hmong, and that forcing them to comply with a treatment that is contrary to their beliefs is nearly impossible, and therefore frustrating (1997, pg. 1).
With the Lees we see a different form of suffering. This is highlighted when Dan expressed his feelings of overwhelming pressure to stop the seizures, and shock at Lia’s parents passive attitude towards the seizures (Fadiman, 1997, pg. 53). One can argue that the Lees are apathetic to Lia’s condition due to noncompliance, but this is their language of distress. By means of valuing family, traditions and spirituality, the Lees are able to overcome the challenges in whatever time and setting they are in.
It is also for that reason the Hmong culture thrived in America, given that they are at risk of assimilation to the dominant culture. Durey et. al (2016) presents a theoretical framework (in context to colonization and improving health disparities among the indigenous group of Australia) that could have been applied by the health care providers at Merced hospital. Per Durey et. al (2016) being culturally competent means having the knowledge in the impact of colonization to critically analyze the idea of power innate in the notion of “whiteness” (pg. 2).
Accordingly, the Doctors at Merced hospital needed to learn how to critically reflect on their own attitudes and biases toward the Hmong; because their failure to do so, caused false interpretations of the Lees’ behaviour. Furthermore, the journal talks about 5 capabilities of a health care provider which include relational capabilities (Durey et al. , 2016, pg. 4). Per Durey et. al (2016) “relational capabilities include interpersonal communication skills that are inclusive, collaborative, foster intercultural partnerships and reach shared understandings” (pg. 4).
Unfortunately, the doctors at Merced did not have the ‘relational capabilities’ needed to provide the best care for Lia. Although they tried to reach out to Lia’s parents, there was no effort to collaborate, or compromise with what they wanted, which was to seek spiritual help at the same time. According to Dr. Ernst, the situation felt as if there was this sheet of ‘Saran Wrap’ that obstructed their effort to reach out to Lia’s parents; consequently, they could not really take full control in treating Lia (Fadiman, 1997, pg. 48). Based on his statement, the collision which lead to Lia’s death was between Hmong culture and Western Medicine.
To put it simply, Western medicine saves lives whereas the shamanic rituals can save the soul of Lia. The doctors had this notion that they were superior to the Hmong culture, because they possess the medical knowledge to save lives. However, this was not essentially true in the case of Lia, and in the eyes of her parents because they stood firm in their traditional healing practices, and strongly believed that they had kept Lia alive for many years. In fact, they believed that all these years the medications (and other medical procedures) have caused so much harm to Lia.
Ultimately, medical science is a collective practice and knowledge that is evidenced base and well researched, thus one could argue that it cannot be culturally compromised. However, it can also be argued that cultural competence in medicine can enhance the quality and the effectiveness of care and treatment. Per Purnell (2002), “culture has powerful influence on one’s interpretation of and responses to health care” (pg. 193). Therefore, it is important to recognize these interpretations of culture, and consider them when assessing and planning for interventions.
Understanding the worldview of other cultures cultivates sensitivity, which in turn enables health care providers to appreciate diversity. A doctor-patient/family relationship should be established at all times; this enables the health care provider to provide patient education and teaching as needed. It also enables the patient and family to freely express any concerns or wishes. If a patient wish to seeks spiritual help, let him or her seek spiritual help; the healthcare provider can not to heal the soul, but he or she can advocate for the soul.