The Spirit Catches You and You Fall Down is a story about the Hmong people's difficult assimilation into the US culture, demonstrated mainly through Lia Lee's family as they struggle to blend Eastern and Western medical treatments for their daughter's epilepsy. It is also an example of a medical anthropology text, in which both critical medical anthropology and clinically applied medical anthropology are used (see below). After exploring the cultural dissonance and miscommunication between the Hmong and Lia's American doctors, Anne Fadiman states that whether cultural competency, humility or responsiveness are used to describe the closing of this cultural and communication gap, the gap needs to be closed so that patient's lives can be saved (Fadiman 1997: 298). In Lia's case, her epileptic seizures were initially misdiagnosed by a resident who could not communicate with Lia's parents because of language barriers.
Critical Medical Anthropology as seen in The Spirit Catches You and You Fall Down:
In The Spirit Catches You and You Fall Down, critical anthropology is used to describe the U.S. government’s poor handling of Hmong resettlement in America, which ultimately leads many of them to continually rely on welfare programs to meet their living and healthcare needs. It also leads many of them to develop psychological illnesses. In the book, author Anne Fadiman describes president Ronald Raegen’s ambassador-at-large, Eugene Douglas’s reaction, to the mishandled Hmong resettlement. In the book Douglas states, “It was kind of hell they landed into. Really, it couldn’t have been done much worse” (Fadiman 1997: 186). The US resettlement sites, though they had refugee services for the Hmong, were often in very cold, flat areas--topography and climates that the Hmong were very unaccustomed to. Furthermore, many of these sites were in rural areas, and the Hmong were separated from other members of their clan. Fadiman reflects on the effect this had on the Hmong and says, “Group solidarity, the cornerstone of Hmong social organization for more than two thousand years, was completely ignored” (Fadiman 1997: 185). Many Hmong people exhibited “unusually high levels of anxiety, depression and paranoia” (Fadiman 1997:185) because of this disconnection with their clans. Ultimately, many who wanted to be reunited with their clans, ended up moving closer to them on their own. Furthermore, many resettled to California especially because opportunities for farming were apparently better (a skill they were familiar with) and because Refugee Cash Assistance programs for Hmong living in the United States for longer than eighteen months were ending, and California provided the most welfare benefits to two-parent families (Fadiman 1997: 195). Even while in California, the Hmong faced many problems (many of them due to their own cultural barriers) which forced them to remain in the cycle of government funded healthcare aid. Fadiman (1997) describes this problem in detail: “ The conflicting structures of the Hmong culture and the American welfare system make it almost impossible for the average family to become independent. In California, for example, a man with seven children-- a typical Hmong family size-- would have to make $10.60 an hour, working forty hours a week, to equal his welfare stipend and food stamp allowance. But with few marketable skills and little English, he would probably be ineligible for most jobs that paid more than the minimum wage of $5.15 an hour, at which he would have to work an improbably eighty-two hours a week in order to equal his welfare allotment. In addition, until the mid-nineties in most states, if he worked more than one hundred hours a month--as a part-time worker trying to acquire job skills, for example, or a farmer in the start-up phase-- his family would lose their entire welfare grant, al their food stamps, and their health insurance” (Fadiman 1997: 200). One of biggest examples through which the resettlement of the Hmong in the United States and their poor assimilation into the country made them extremely reliant on government-funded access to healthcare is Lia Lee’s case. Throughout The Spirit Catches You and You Fall Down, we are given a detailed account of how Lia’s medical condition, epilepsy, has landed her in the hospital on countless occasions and through the hands of numerous doctors and medical staff. Her parents, like many Hmong families settled in Merced, California, relied solely on welfare programs for her medical treatment. In the afterword of the book, Fadiman (1997) describes how Neil Ernest, one of the Lia’s most involved physicians, calculated that Lia’s case cost the United States government approximately $250,000. This cost did not include the salaries of her doctors, social workers and nurses (Fadiman 1997: 254). |
Clinically Applied Medical Anthropology as seen in The Spirit Catches You and You Fall Down:
Clinically applied medical anthropology was prevalent throughout much of the book. Anne Fadiman exposed the constant cultural clash between the Lia’s Hmong parents and her American doctors which obstructed her treatment on many occasions. Lia’s parents did not speak English and they believed in shamanism, or animal spirits. In fact, epileptics such as Lia were considered to special in the Hmong culture. Fadiman (1997) describes the reason behind this and states, “Hmong epileptics often become shamans. Their seizures are thought to be evidence that they have the power to perceive things other people do not see, as well as facilitating their entry into trances, a prerequisite for their journeys into the realm of the unseen” (Fadiman 1997: 21). Lia’s parents treated her more favorably than their other children because they believed she possessed these special abilities. Only when her seizures continued for extended periods of time did her parents bring her into the hospital. Going to the hospital was considered taboo in the Hmong culture, as was the use of prescription drugs. The Hmong belief of illness and healing was very different than the Western beliefs they came to experience in America. For hundreds of years, the Hmong lived in the mountainous regions of Laos, having very little interaction with even people of the lowland let along Westerners. Even after fleeing Laos and coming to know about Western medicine a little more, they still largely disregarded it. Fadiman (1997) states, “The limited contact the Hmong had with Western medicine in the camp hospitals and clinics had done little to instill confidence, especially when compared to the experiences with shamanistic healing to which they were accustomed to. 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” (Fadiman 1997: 32). For the Hmong, healing involved the presence of a txiv neeb (shamanistic healer), animal sacrifices and herbal remedies. The Hmong language and culture barriers posed many challenges to the medical staff who had to simultaneously stabilize her as well as obtain some sort of medical history from her parents (which they rarely got because of a lack of Hmong-English interpreters in the hospital at that time). Many of the medical staff knew nothing about the Hmong people to begin with, even though the Hmong had fought on the side of Americans against the Vietnamese from 1968-1972. Fadiman (1997) explains the reason for this disconnect and states, “Although they suffered far worse losses per capita than the South Vietnamese, whose agonies were featured daily in the American press, the Hmong were almost completely overlooked, partly because off reporters were barred from Long Tieng...When the Hmong were mentioned, the crucial element of American involvement was usually missing from the account, either because the reporter couldn’t confirm it or because the information was embargoed” (Fadiman 1997: 133). Many of the misunderstandings between Lia’s parents and their initial interactions with her doctors stemmed from the doctors’ lack of exposure they initially had to the Hmong people, and also because many of them were either too busy to research into the Hmong culture, their wasn’t enough written material at the time about them to begin with, or because the language barrier was too much for them to handle. Perhaps one of the biggest reasons for these misunderstandings though was because none of the medical staff ever asked Lia’s parents what they believed to be the root cause of her illness. Even two of her main doctors, Neil and Peggy Ernest, who treated Lia for years, never thought to ask how exactly her parents were healing Lia. It was only until the social worker Jeanine Hilt came into Lia’s life did Lia’s parents come to comply with the medication regimen her doctors had always wanted her to follow. Lia’s parents never followed her medication regimen because they believed the drugs were making her sicker. Jeanine Hilt, using Lia’s most Americanized sister May as a translator, was finally able to communicate and convince Lia’s parents to give her regular doses of Depakene along with their traditional medicine. We of course come to know later in the book that Lia’s grand mal seizure, the one which placed her in a vegetative state for the rest of her life, was caused by undiagnosed septic shock which caused the seizure, not because Lia’s parents weren’t giving her enough Depakene (Lia’s Depakene levels were always at therapeutic levels after Jeanine Hilt entered Lia’s life). Anne Fadiman, after discussing Lia’s case years later with Bruce Thowpaou Bliatout, a Hmong medical administrator, states, “Most important, says Bliatout (and many others as well), practice conjoint treatment--that is, integrate Western allopathic medicine with traditional healing arts, or as Nao Kao Lee put it, use ‘a little medicine and a litlle neeb’” (Fadiman 1997: 266). This very type of conjoint treatment was eventually incorporated into Merced County Medical Center (MCMC), the very hospital Lia’s family was first misunderstood because of their Hmong ways. Fadiman (1997) describes how in 2009, MCMC launched a program called Partners in Healing which legally allowed shamans to be incorporated into a Hmong patient’s medical care (Fadiman 1997: 296). Lia’s case, and more importantly The Spirit Catches You and You Fall Down, which brought attention to the Hmong and American cultural miscommunication, helped the hospital adopt a shaman policy. The New York Times article by Patricia Brown Lee (2009) expands on how this new policy has allowed existing and new Hmong immigrants transition into the American health care system a little better without having to feel forced to abandon their own cultural values. More effective health interventions were achieved once the gap of misunderstanding began to close between the two cultures. |