The Spirit Catches You and You Fall Down

To understand the struggles that the Hmong people face living in America it is important to understand where they come from and what they have gone through. The majority of the Hmong people originate from the mountainous country of Laos. The mountains created isolation from the neighboring cultures and cultivated a clan identity. They were part of a society where everyone worked together and lived off the land. They also practiced oral tradition since they could not read or write any language.

Unfortunately, in the 1960’s Laos became the battlefield for the Vietnam War. The land was destroyed and the Hmong were forced to move or fight. Many evacuated while many were trained and armed by the U. S. as a secret guerrilla army. During this time of war, the Hmong lost all self-sufficiency, and became dependent on the U. S. for food as well as survival. An exodus of Hmong from Laos to Thailand was the death of many. The Hmong were hunted and forced to leave everything behind. The clan identity was left behind as well for it was everyman for himself. Those that were lucky enough to make it to Thailand were faced with assimilation.

The Hmong saw assimilation as an insult and a threat to their culture. In order to resist oppression, the Hmong took the United State’s promise of land and government support, and moved to America. Still resisting assimilation in the U. S. , the Hmong were faced with culture shock. One of the biggest differences between Hmong culture and American culture is the practice of medicine. Anne Fadiman in “The Spirit Catches You and You Fall Down” tells this clash as the story of Lia Lee and her American doctors. Lia Lee is a Hmong child that was born in the U. S. n July 19, 1982, after her parents, Foua and Nao Kao Lee, moved to America. She was delivered at a hospital in Merced, California they way Americans think is normal-on a metal table, scissors to snip the placenta, washing the baby with soap, and putting the baby in a heated box. Normal childbirth for the Hmong would be the mother pulling the baby out herself in silence on the dirt floor of their hut and then burying the placenta under the house. The Hmong believe that when you die your soul will come back to get your placenta. When Lia was three months old, her sister, Yer, slammed the front door in her face.

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Moments later Lia’s eyes rolled up, her arms flailed over her head, and she fainted. Lia’s parents believe that the noise of the door had been so frightening that her soul fled her body and became lost. The resulting symptoms are recognized as Quag Dab Peg, “The spirit catches you and you fall down”. Having Quag Dab Peg gives the person the power to perceive things others cannot see, and is a prerequisite for the journey into the realm of the unseen. Quag Dab Peg is considered an honor and blessing in Hmong culture. It allows the person the opportunity of becoming a txiv neeb, or spirit healer.

It also confers an enormous amount of social status in the community because the txiv neeb is seen as a person of high moral character since the spirit chose them. In Hmong culture, saving face is of high importance. Foua and Nao Kao Lee brought Lia to Merced Community Medical Center (MCMC) after she had 20 of what Americans call seizures. At times, the Lees believed that Lia’s epilepsy wasn’t as much of a medical problem as a gift. The Hmong believed in shamanistic animism, which asserts that malevolent spirits are constantly seeking human souls, especially those of vulnerable or unloved children.

Their hope was that if the spirits decided to keep hold of Lia, that long-term she would become a tvix neeb, and if she did not become a tvix neeb, then their hope was that the sickness would be short-term. The American doctors in MCMC view the Hmong as problematic patients and were not empathetic with the traditional Hmong lifestyles. Because there are no interpreters, communication is always an issue, they bring lots of family members with them as well as animals, and they make loud noises. When Foua and Nao Kao arrived at MCMC Lia had stopped seizing and was coughing.

The doctors were forced to as they put it “practice veterinary medicine” since they couldn’t talk with the Lees, and treated Lia for her cough. They diagnosed Lia with early bronchiopneumonia because she exhibited those symptoms. The doctors had no way of knowing that the bronchial congestion was caused by aspiration of saliva or vomit during her seizure without trying to communicate with the Lees. The doctors put a pen and paper in front of the Lees and had them scribble on it. The doctors assumed the Lees would be able to buy and administer the medications that the paper described in detail.

In reality the Lees had no idea what they just signed and walked out. This same situation happened a few more times until one time the Lees brought Lia in when she was still seizing and Dr. Dan Murphy was on shift. Dr. Murphy had some knowledge of the Hmong and could certainly diagnose her with epilepsy. In Hmong-English dictionaries Quad Dab Peg translates to epilepsy. Lees parents and the American doctors both knew what disease she had but to different cultures it meant different things. As stated above, in Hmong culture it was a privilege and was caused by Lia losing her soul.

In American culture, we believe epilepsy is caused by a sporadic malfunction of the brain due to a head injury, tumor, infection, etc. We view it as a disease and that it needs to be taken care of by giving the person anticonvulsant drugs since there is no cure. This is just what Dr. Murphy did. Lia was discharged with specific instructions on what medications to take, how much of each, and what time of day they were to be taken. Considering Hmong don’t have the same time keeping system as Americans, can’t read, don’t know how to measure medicine, and don’t believe in all this medication, Lia did not receive any medication.

The Lees believed a txiv neeb could help Lia, so they had one come over and sacrificed a cow for her. It did not help and the American doctors continued to see Lia not getting better when her parents kept bringing her to MCMC. The American doctors thought that because Lia had no levels of medication in her blood her parents were guilty of child abuse. If they would have seen how much the Lees loved and cared for Lia at home they would have known this was not the case. Instead, they got the government involved and took Lia from the Lees and sent her to a foster home.

The Lees welcomed Lia home after a year apart and lots of work with a social worker, Jeanine, whom was very interested in the Hmong and helped with administering the seizure medications. Hmong have many customs and folkways that are contradicted by those of the American mainstream and medical communities; for example, upon Lia’s arrival home her parents sacrificed a cow to propitiate ancestors and cure her illness. They performed traditional Hmong medial practices like coin rubbing, pinching Lia, gave her an herb necklace, and tried changing Lia’s name so that the spirit would leave her body and not be able to find her.

On Nov. 25, 1986 not long after being home, Lia had another seizure episode. After ten minutes had passed, Foua and Nao Kao got in touch with their nephew who could speak enough English to get an ambulance. By calling for an ambulance Lia was given more attention upon arrival in the emergency room, but it delayed her treatment. Lia continued to seize for two hours and was barely breathing. A twenty-minute bout of status elipticus is considered life threatening. Lia was transferred to Fresno Intensive Care Unit for Pediatrics.

Foua and Nao Kao thought that Lia was being transferred because the doctor at MCMC was going on vacation, but in fact it was because Fresno had a pediatric unit. At Fresno Lia was diagnosed with septic shock, the result of a bacterial invasion of the circulatory system that triggers the failure of one organ after another starting with the lungs and then moving to the brain. She also developed a condition in which her blood cannot clot. Lia’s EEG was flat. She had no brain activity left. The doctors decided to discontinue the anticonvulsants because she was dead to them.

The doctors explained that her seizure medicines lowered her immune system responses, which allowed a bacterium to take over and stop brain activity. Foua and Nao Kao were somewhat right; the doctors were giving too much medicine and not enough neeb. It is most likely though that if the Lees were still in Laos, Lia would have died before she was out of her infancy, from a prolonged bout of untreated status epilepticus. Foua and Nao Kao finally got permission to bring their daughter home as they had been insisting the whole time. Lia went home on Dec. , 1986 as a quadriplegic, spastic, incontinent, incapable of purposeful movement, and in a persistent vegetative state. To Lia’s parents she went home as their little princess that they loved with all their heart. At home, Lia’s parents adored her and never left her side. They fed her teas from powdered roots and herbs, made several pig sacrifices, and bathed and dressed her multiple times a day. Because of the quality care Lia was receiving, she was stable and her medical check-ups decreased. Lia did not die but did not recover.

Examination of this unfortunate story of a clash of two cultures has led to the discovery of what can be done to facilitate cooperation between cultures. Dr. Arthur Kleinman from Harvard Medical School designed a series of eight questions to elicit a patient’s explanatory model and enable the understanding of other cultures. The questions include: “What do you call the problem? Why do you think it started when it did? What kind of treatment do you think the patient should receive? What do you fear most about the sickness?

If the doctors at MCMC had taken the time to find a translator and sit down with the Lees to ask these questions, Lia might not be in a vegetative state. Other suggestions that could have aided in cooperation between the doctors and patients are female doctors for female patients, involvement of the patient’s families in all decisions, the use of interpreters who are both bilingual and bicultural, and the practice of conjoint treatment. The doctor using Western allopathic medicine can cure the disease but the indigenous healer heals the illness. This strategy promotes trust between the cultures.

One person’s worldviews should not dominate another’s because they feel it is right. We need to realize our view of reality is only a view, not reality itself. In the U. S. , the medical community rarely has ways to communicate with people of cultures so radically different from mainstream American culture; even a good translator will find it difficult interpreting concepts between the two different cultures' world-concepts. Doctors need to be able to transcend culture and practice cultural responsiveness where they listen to patients and respond to them both as members of their cultures and as un-stereotyped individuals.

A whole doctor-whole-patient approach is imperative: Ask not what disease the person has but rather what person the disease has. I am glad to hear that we have been moving in this direction as an American culture since 1995. Medicine in the U. S has been teaching students to separate emotions from the patient; dissociation is part of the job. In the last decade, efforts have been made to correct this way of thinking, and realize you are treating another human being not a universifiable body. Classes incorporating culture studies are being required as part of medical school and undergraduate school curriculum as well.

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