The Spirit Catches You and You Fall Down follows the medical story of a girl named Lia Lee in the 1980’s. She is the youngest child of a refugee Hmong family from Laos who immigrated to California. Anne Fadiman delves into the lack of cross-cultural communication generating conflict between Western Medicine and Hmong culture. Therefore, this article will elucidate the impact of cultural competency on prognosis.  

When Lia was three months old, her older sister, Yer, slammed a door, which was followed by Lia’s first seizure. Her parents, Foua and Nao Kao, diagnosed her with quag dab peg, which means “the spirit catches you and you fall down”. They believed the loud noise frightened her soul and it was now lost. In Hmong-English dictionaries quag dab peg is often translated as epilepsy. It is an illness of distinction, where the Hmong see it as a sign that one has the potential to be divine. However, through their pride, Foua and Nao Kao were gravely concerned for Lia’s health.  

Lia’s epilepsy was diagnosed late, as the first two times she was brought to the local emergency room at Merced Community Medical Center, the seizure stopped before they arrived. With no interpreters and the Lees being unable to speak English, they could not explain why they had brought their daughter in. When she was finally diagnosed with epilepsy a few months later, her treatment was managed by two pediatricians, Neil Ernst and Peggy Philips. They provided the Lees with a complex medical regimen, though the Lees were not compliant. This was due to, both, a lack of understanding and a distrust in Western medicine. They had noticed side effects, making their daughter act sluggish and believed the medicine was making her sicker. After months of noncompliance and many subsequent seizures, a frustrated Dr. Ernst called Child Protective Services due to neglect, citing that Lia may end up with irreversible brain damage and possible death. Lia was taken into foster care for six months. 

Conflicts in the medical office between doctors and patients are normally restricted to differences in beliefs, however once the court is involved, this is intensified to differences in power. The Hmong immigrated as refugees to a country that promised freedom. So, there is a lot of irony when this country takes it away on the basis of differences in beliefs. 

Dwight Conquergood, an ethnographer known for his work with the Hmong, explains that the term “compliance” must be removed as it implies authority. He states that healthcare is a form of bargaining between patient and physician, yet Western medicine tends to be one-sided. Lia Lee’s tragedy was the result of lack of negotiation and cultural collision. Instead of trying to convince our patients that as physicians, we know what is best, we must look at it as mediation, requiring compromise on both sides. With this, it is the duty of the physician to decide what is critical and what can be compromised. This method of negotiation was practiced by their social worker, Jeanine Hilt, and Lia was okay for a while, being cared for under a combined practice of the Hmong beliefs and Western Medicine. 

This did not last long, however, when one day, Lia fell off a swing and began to seize. Stabilized at the hospital, Lia developed an infection and was put on a breathing tube for two weeks. After she was stabilized, her medical regiment was adjusted, which was soon followed by a seizure that lasted two hours. She was transferred to the Valley Children’s Hospital in Fresno, where she was diagnosed with septic shock and brain death. Believing this was due to the abundance of medication, her parents took her home, treating her solely with natural Hmong healing remedies. Although paralyzed, Lia Lee survived for 26 years. 

Anne Fadiman’s investigation of Lia Lee’s tragic medical journey revealed that her neurologist acknowledged that the septic shock and subsequent brain death may have been due to Lia’s rigorous anti-epileptic regiment, causing immunosuppression. If Lia’s doctors had allowed Foua and Nao Kao to properly express their concerns, through interpretation and cultural competence, Lia’s medical complications may have been avoidable. The Spirit Catches You and You Fall Down illuminates the importance of acknowledging the belief systems of patients. During Fadiman’s interviews, Foua mentioned that although doctors can fix sicknesses involving the body, the Hmong believe some people are sick in their soul. She remembered that when Lia had a little bit of medicine and a little bit of neeb, she did not get sick as much. She explained that the doctors would not allow this because they did not understand the soul. 

Arthur Kleinman, a psychiatrist and medical anthropologist, explains that a combined treatment, such as the one Foua suggested, promotes trust between doctors and patients, improving the outcome, since psychosocial factors can significantly affect illness. Furthermore, the culture of biomedicine must be acknowledged, as Western medicine has its own interests, emotions and biases. If this isn’t recognized, are we fully equipped to handle the culture of someone else? Arthur Kleiman suggests that the medical practice must be taught and understood as a process of cultural compromise, subsequently increasing cultural competency.

References

Fadmian A. (1997). The spirit catches you and you fall down: A Hmong child, her American doctors, and the collision of two cultures. Farrar, Straus, and Giroux.