Anne Fadiman's 1997 novel The Spirit Catches You and You Fall Down: A Hmong Child, Her American Doctors, and the Collision of Two Cultures tells the story of a struggling Hmong family and their attempts to treat the epilepsy of their daughter Lia Lee. A tremendous culture conflict is presented within this work, as the American doctors cannot communicate with the family effectively, due to the language and culture barriers. One of the central conflicts between the American doctors and the Hmong is that the Hmong see epilepsy as something belonging to the divine, while the doctors only see it as a disease. This creates immense conflict between the two sides, as one side just wants Lia Lee to be okay, and the other wants to cure her of the epilepsy. The issue at the core of the book is communication and cultural barriers that hinder the treatment of this young girl. The Hmong have very traditionalist views and somewhat damaging ideas (based in myth) of what American medicine is supposed to do. The Americans, on the other hand, also do not do what they can to help the parents help their child, growing frustrated at the lack of easy communication.
In 1982, Lia Lee, in her first year of life, is taken to the hospital after having a seizure; this was a nerve wracking experience for the Lee family, as they had heard all kinds of horror stories about American doctors in a Thai refugee camp. From these stories and experiences, they thought that American doctors ate livers and kidneys of the Hmong, and that Hmong are sold as food in cans after being cut up when they die in America. These are obviously very hazardous, counterproductive viewpoints to be given, but that is the perspective from which they come, which makes it harder for the Americans to do their job. The Americans, however, are not completely at fault, as they have their own issues that they needed to address, and needed to have more cultural sensitivity in dealing with the Lees.
In various chapters, Fadiman alternates between subject to subject, instead of following a strict narrative. The American doctors are unable and unwilling to learn more about Hmong culture, leaving them helpless to help Lia Lee. This is used as a simple example to examine more about the immigrations, assimilation and discrimination problems inherent in American-Hmong culture conflict. When the Lees go to MCMC and work with the doctors there, there is tremendous conflict in terms of what her treatment should be. The doctors prescribe Tegretol and Phenobarbital, but the Lees start to become more than more overwhelmed with another daughter, Foua, having a fifteenth child. The huge number of Hmong in the family starts to see Lia be deprived of treatment, as they simply do not have time.
The overall conflict between the two camps (the Lees and Drs. Ernst and Philip) is that the doctors feel the need to obey the Hippocratic Oath; they feel that seeing that Lia is not receiving the treatment she requires is child endangerment. However, the way the Hmong want her treatment to be tailored simply would not be satisfactory in the eyes of these doctors. Many of the attempts to give Lia a specific dosage went misunderstood and not followed by the Lees, and this left them uncertain as to how to give Lia the help she needed to receive. In fact, the Supreme Court decision in 1943 to make children who are in medical danger removed from their families came into play here, and Ernst reported Lia to the authorities. Lia was placed in a foster home for two weeks, essentially as a warning to Lia's parents that she could be taken away if a life-saving treatment was withheld from her. However, her problems became even worse away from her parents.
One of the biggest problems is the cultural barrier that exists between the Hmong and the doctors. The different cultures presented are in direct conflict, as Hmong culture focuses on the strict dichotomy between life and death, while American medicine has codified and quantified every aspect of wellness, to the point of confusion for the Lees. Hmong patients see symptoms as a link to a spiritual and universal imbalance, and not something that they should cure with medicines or personal treatment. At the same time, they acquiesce to the doctors' requests, but for potentially damaging reasons. The language and culture barriers that existed prevented the Lees from truly understanding the medications and instructions their doctors gave them to give Lia. They could not express their frustration or confusion, because of the language barrier and the cultural idea that passive obedience, regardless of understanding, was best to protect the doctor's dignity, while also pretending that they know what they are talking about. To ask for further explanation would be to dishonor oneself in front of others, and so pride likely played a factor in the Lees' respective mistakes.
According to Fadiman, Lia belonged with the Lees and not with the doctors; the fault was on the doctors for not understanding Hmong culture. However, there were many different things that the parents could have done to make sure their daughter had a much more preferable outcome to her treatment of her epilepsy. First of all, a dramatic shift in priorities needed to be taken; they were not in Laos anymore, even though they wanted to maintain that culture. As a result, they needed to make some adjustments to American life; first of all, they needed to find a way to reconcile their distrust of doctors and their immense spirituality. Given that they saw the epilepsy as a potentially good thing (likening the condition to great authors and poets who had epilepsy), that attitude needed to change, and they had to focus their efforts on getting better.
One of the most dramatic things the family could have done was refrain from having children. According to traditional Hmong culture, having a large family is very common; however, the introduction of more and more family members by Loua and others places their resources and time commitment in danger. Because of all the different children they were breastfeeding, they did not have time to administer Lia's medication, which put her life in danger. If they took steps to administer birth control, or take some sort of family planning, the number of mouths to feed would be fewer, and they could focus more on Lia's care. However, the ideal of having a large family was too important to give up, and they did not recognize or consider the consequences of these actions, or how they would affect Lia.
While there were plenty of things that the Lees could have done to change Lia's outcome, there were steps that Drs. Ernst and Philip could have made to make their approaches more palatable to the Hmong. Learning to speak the language, even fundamentally, could have been a great help. The language barrier was a significant obstacle in their attempts to care for Lia, and even learning rudimentary Picking up conversational Hmong would have gone a long way towards meeting them halfway and communicating with greater specificity the needs of their daughter. They could have explained that the epilepsy is a severe problem, and what exactly all of the medications they administered did for her.
Meeting the Lees halfway on cultural matters as well would have helped their efforts immensely. Learning to find ways to make the treatment regimens more palatable or understandable from a Hmong context might have made them more relatable. From the beginning, the doctors and the Lees had a very confrontational relationship; they always seemed to argue about how best to treat Lia. Both parties could have benefited from reaching a middle ground, a consensus on Lia's epilepsy; if that had happened before treatment had begun, there would not be as many conflicts.
The hospital and personnel could have presented Lia with better quality of care in many ways. By providing her with inpatient care, and allowing her to stay at the hospital, it would have been possible to keep her somewhat isolated from family influence, and would have provided dedicated staff to administering her treatment. However, it would be far from economically viable, and it would have been incredibly inconvenient and heartbreaking for the Lees as well. To that end, there was no simple solution to the problem, as both sets of individuals on opposing sides of Lia's treatment simply could not see eye to eye.
Despite all of these efforts to help save Lia, each side forcing their ideology and perspectives on the other, Lia had a very large seizure on November 25, 1986. This seizure lasted two hours, and she was sent to Fresno at the Valley Children's Hospital to receive care. After that point, the doctors gave her one medication that had a very easy dosing schedule. Despite the slim projections of the doctors, Lia lived for several years after the big seizure. Perhaps there is something to be said for that; this type of dosing change acted as a compromise between the American doctors' array of medicines and the Hmong's reticence to employ any type of nonspiritual treatment. By keeping the dose simple, there was no need to worry about misunderstanding, and the Hmong did not have to shame themselves by asking, keeping their pride.
The conflicts presented here are a textbook example of cultural relativism - the Lees come from a very strict, supernatural and holistic epistemology for medicine, while the American doctors at the Merced Community Center attempt to use modern medicine, each side believing that their way is better. The language barrier is tremendous, as neither side behaves at their best; instead of getting translators or attempting to meet each other at a middle ground, the Lees become frustrated at the constant string of increasingly convoluted medicines and dosing schedules, while the American doctors get frustrated at the Lees' inability to simply accept that their way is better. By not recognizing the merits of either side, Lia's treatment suffered much more than it needed to.
In conclusion, the book The Spirit Catches You and You Fall Down offers an interesting insight into the communication and language barriers that exist between wildly different cultures, even when the stakes are as high as medical treatment. The American doctors looked down upon the Hmong's adherence to spirituality and their unwillingness to communicate, while the Hmong did not understand exactly what the American doctors were trying to say, feeling their pride hurt at the implication they could not take care of their child. Given hindsight and proper planning, both the Hmong family and the doctors at MCMC would have been better able to communicate Lia's predicament, and have fewer speedbumps in her treatment. As it stands now, however, the story stands as a testament to how stubborn East-West culture conflict can often get in the way of life-and-death decisions. Both sides were committed to proving each other right; Lia's health suffered as a result. While the doctors wanted to provide medical scientific treatments, the Hmong traditionalism needed to be dealt with, and it was not to a satisfactory degree. Through small changes in perspective and education about each others' point of view and culture, both parties could have come together to give Lia the help she needed.
References
Fadiman, A. (1997). The spirit catches you and you fall down. New York: Farrar, Straus and Giroux.
