Notes on the book by Anne Fadiman “The Spirit Catches You and You Fall Down”

The book “The Spirit Catches You and You Fall Down” raises many issues, including the cultural barriers, their impact on health care, immigration, racism, laws and rules, and many more. While the book is really about the collision of two systems – the system of medical care in United States and the world system of the Hmong population, it is also about the deeper reasons for the problems that rose in this story. A lot of the Hmong character, brave and noncompliant, is demonstrated through the history of the Hmong people, their involvement in the “American” war (where it was seen as an advantage), their belief that the U.S. is a “free country”, and the many ways in which the U.S. had betrayed them. This, together with their experience with Western doctors in the refugee camp destroyed the last bits of faith they had in this medical system. 

The book describes the story of a Hmong girl Lia who is diagnosed with epilepsy and the battle between her parents and the American doctors for the ways to treat her. While it may be easy to take sides here, we realise that we take these sides based on our own biased perception of what would be right. If we stand with the Western medical system, where the body is put before the soul, we are most likely to see the Hmong family as wrongdoing and agree with the steps the doctors have taken to treat Lia. If, on the contrary, we believe that the Hmong approach is the right one, that there is a spiritual side to illness that has to be considered and respected just as the physical side of it, then we start seeing doctors as “evil” and incompetent. 

What really happened was that both doctors and parents cared tremendously about Lia and wished with all their hearts to help her. The problem was in that their understanding of what would be best for her was so much different that the conflict naturally grew out of it. It was heartwarming, though, to know that in the end Lia’s father had shown that he had realised that the doctors meant well and had done all in their power to try to help his daughter (p. 303).

Dr. Dave Schneider  said that it was not the language barrier that was the most important problem, but rather the cultural barrier (p. 69). I think, this basically explains the idea behind the story. The cultural barrier here means that each party had their own cultural background, including the understanding of illness and its roots. The Hmong believe that the most common source of illness is soul loss, and that the life-souls of newborn babies are particularly susceptible to becoming separated from their bodies and even being stolen by an evil spirit called a ‘dab’. This is why traditionally  from the Hmong point of view Lia had to be cured from the perspective of the spirit.

 Given that the Western medical approach does not take into consideration these kinds of of ideas, the doctors prescribed classical medical treatment for the seizures. Lia’s mother Foua did what she though to be fair and decided that her daughter will benefit from a little bit of both – western medicine and spiritual healing (p. 100). From her perspective, she had made a step towards compromise. The doctors, on the other hand, rejected such approach and insisted on their way to be the only right way. 

Here another important issue rises – who has the power to make the decision about the child’s health? In Hmong culture it is the parents who hold the ultimate power. In the U.S. it is the doctor, to the extent that if the parents refuse to give medications prescribed by the doctor to their child, the doctors have the right and obligation to call the social services and have the child moved to a foster care where she would be given the medication prescribed. Dr. Neil Ernst believed that by reporting the Lees and having Lia moved to a foster family he was providing the highest standard of care for his little patient, while seeing her parents’ noncompliance as a form of child abuse. 

Yet, from the book we know that everybody who had seen the Lees would confirm that they had been the most loving and caring parents that one can possibly imagine. It seems as if doctors have been blinded by their one-sided views and fighting the war against their own goal, as years later they come to subtly agree that they may have made a mistake in Lia’s treatment which may have caused the final big seizure  that resulted in the end of all brain activity. Any consideration of what might have happened if any of the parties had behaved differently is anyhow a speculation, just as imagining whether Fadiman’s boyfriend would have proposed had she not worn that traditional bride’s dress (p. 102); or whether her head ache would have passed without using traditional Hmong healing. 

The issue remains, though, in that while the Hmong did consider Western approach at least to some extent, the doctors had no consideration for the Hmong culture whatsoever. I think that the most sharp example of it is that nobody (except for Jeanine Hilt) even asked the family of how they saw the cause of Lia’s illness and how they thought it had to be cured. 

Even though many felt compassionate for the Hmong, there has not been much result in their attempts to help them, as they kept trying to explain things to the Hmong from the Western perspective, like Martin Kilgore, who tried to teach the Lees something useful from his perspective, like taking a pulse. One of the not many who succeeded at actually helping the Hmong with their cultural needs was Dr. Roger Fife, who provided the Hmong families with the placentas after the babies’ birth; though because of helping them he was losing respect of his colleagues. Western doctors so eagerly embrace new drugs, technologies, and procedures; yet they may rely too much on the “culture of biomedicine” which can blind them to the merits of cross-cultural medicine (p. 273).

The importance of including the patient’s understanding of the illness in the picture can not be overemphasised.  A psychiatrist and medical anthropologist Arthur Kleinman, who developed eight questions to articulate a patient’s “explanatory model” of their illness, gave a retroactive advice to Lia’s doctors to get rid of the term “compliance,” to work with the family rather than trying to coerce them, and to recognize that the culture of biomedicine has its own biases (p. 261). His idea is that combining western medicine with traditional healing arts not only promotes trust between patients and doctors, but also improves the outcome due to the psychosomatic nature of much disease.