The Spirit Catches You and You Fall Down: A Hmong Child, Her American Doctors, And the Collision of Two Cultures
I initially chose to read The Spirit Catches You and You Fall Down by Anne Fadiman simply for pleasure, but then I realized that it would be a perfect second entry for this blog. Although the author is American, the book addresses many multi-cultural issues, namely the interactions – and especially miscommunications – between Hmong immigrants in the US and their American doctors. Fadiman’s book is a self-described “fish soup”, a non-fiction account that weaves many different perspectives and timelines together into a cohesive, complex narrative, which allows her to capture more truth than if she’d used a more traditional style of reporting.
I really admire Fadiman’s dedication to her project and impressive lack of ethnocentrism. The book is tied together around the case of Lia Lee, an American-born Hmong girl with severe epilepsy. Fadiman interviews doctors, social workers, anthropologists, and pyschotherapists as well as the Lee nuclear family, their extended family members, clansmen, and many prominent members of the vibrant Hmong community in Merced, California in order to understand her story and put her family’s perspective in context. Through the retelling of fables, anecdotes, case studies, and historical accounts, she also provides exquisite context for understanding Hmong history and culture, as well as the culture of biomedicine in the US (Fadiman 273).
Fadiman doesn’t dwell overly on distinguishing right vs. wrong, nor does she slip into cultural relativism. Instead, the focus of her book is cultural (mis)communication. More specifically, she explains how each side’s misconceptions and biases, as well as their shared language barrier, contribute to a mutual lack of trust and poor doctor-patient relationships (and therefore poor medical care). She also makes great effort to explain many of the parables, traditions, and beliefs of this Hmong community, which really bring the story to life. To my knowledge, hers is the most well-known book in the US today about the Hmong.
Cultural understanding requires cultural brokers, third parties who understand the languages and cultures of the involved parties (in this case the American doctors and Lia’s family) and can ease understanding and communication between them. And to crudely paraphrase what Fadiman states more eloquently, cultural brokers must be treated as equals instead of as mere word-for-word translators. They must even have the power to give commands, in order to get one party to do something which the other party may not know how to ask for. For example, Fadiman cites a case in which a Hmong husband wouldn’t let his pregnant wife take the pills prescribed to her by her doctor (264). Her doctor’s interpreter acted as a cultural broker by correcting the doctor’s breaches of Hmong etiquette (ex. by having her talk to the husband instead of his wife, and by having the doctor wish him good health and happiness before addressing medical issues). This relaxed the patient and her husband and helped her gain their trust, and as a result the pregnant woman took her pills.
The questions about parenting and medicine that Fadiman asks have real, potentially life-saving (or conversely, fatal) consequences. Their answers will change how patients interact with their doctors, what kind of care they receive, and doctors’ attitudes toward their patients when both come from different cultural backgrounds. These are some of the most interesting questions:
– Should parents (or legal guardians) have the right to deny medical care to their children?
According to Fadiman, when a consenting adult declines medical care of some kind, most doctors may grumble but readily accept the autonomy of an individual and the right for an individual to refuse medical care. However, most become incensed when a child, too young to make decisions for herself, is denied access to modern American medical care when it could save her life. You can martyr yourself, but you can’t martyr your child (80).
– Should doctors tailor their treatment methods to fit better with their patients’ cultural backgrounds?
As Fadiman herself asks, “Which would have been more discriminatory, to deprive Lia of the optimal care that another child would have received, or to fail to tailor her treatment in such a way that her family would be most likely to comply with it?” (78).
– How should doctors address their patients’ needs if there are no resources available to understand a patient’s cultural background (e.x. because of a lack of interpreters or cultural brokers)?
This book should be required reading for anyone who wants to learn about Hmong, lives near Hmong communities, or wants to work in medicine or child protection services. Although to be perfectly honest, I think everyone should read this book. I feel obliged to issue a tissue alert for Lia’s story, to say nothing of the wartime recollections of Hmong who fought for the US in Laos. Were it not for the fact that I read most of it in a public setting (i.e. on the Metro) I would surely have cried many times.