Saturday, August 25, 2012

Review: The Spirit Catches You and You Fall Down

Anne Fadiman, in her book, The Spirit Catches You and You Fall Down, reflected on ways in which cultural dissonance can have tragic consequences for people who are caught in the borderland between two cultures. In this story, the cultural discord between a young girl’s parents and her doctors caused her life to be wasted away because of medical conditions – epilepsy and septic shock – that could have been treatable. While Fadiman’s book is about a specific situation, it can be generalized as a warning about the dangers of cultural conflict for different contexts. So it's a story for all of us.

Fadiman’s book chronicled the story of two cultural realities – Western rationalism and Hmong animism – contentiously crashing into each other to the detriment of a young girl, Lia, who was dependent upon the harmonious collaboration of these two realities for her wellbeing. Both realities failed to help her because of their mutual misunderstanding, suspicion, and prejudice of the other culture. In many ways, it was not a biological pathology that harmed Lia; it was a cultural pathology. As Fadiman wrote: “I have come to believe that her life was not ruined by septic shock or noncompliant parents but by cross-cultural misunderstanding” (262). To illustrate the way in which cultural dissonance contributed to Lia’s medical condition, attention will now focus on three examples of this dissonance from the book: divergent language, cultural prejudice, and conflicting religion.

First, the language of these two cultures was not only different but also difficult to bridge. The hospital didn’t have English-Hmong translators nor did it have bilingual Hmong employees that worked during the night (25). Fadiman describes the dire situation well: “Doctors on the late shift in the emergency room had no way of taking a patient’s medical history, or of asking such questions as Where do you hurt?” (25). There was no way to communicate important information. In Lia’s situation, her parents didn’t speak English and therefore couldn’t communicate any of the details of her seizures – or even the fact that she had seizures. Therefore, the doctors initially misdiagnosed her presenting symptoms as a “bronchial infection” several times (26). The doctors didn’t realize her bronchial issues here caused by seizures. This caused her seizures to go untreated for months. One of her doctors, Neil Ernst, thought in retrospect that her prognosis could have been much better if she had been correctly diagnosed and medicated from the beginning instead of months later (41). But even after Lia got diagnosed correctly, her parents struggled with understanding the diagnosis and providing her with the prescribed medications as directed (28). In fact, Fadiman said: “Over time, her drug regime became so complicated and underwent so many revisions that keeping track of it would have been a monumental task for a family that could read English. For the Lees, it proved to be utterly confounding” (45). They couldn’t read or understand the labels (46). To make matters worse, the doctors didn’t initially provide any assistance to help the Lees understand or administer the drugs (47). So even after Lia received the right diagnosis, her brain was harmed due to the constant change of prescribed drugs and the ongoing issue of her parents’ inability to administer those drugs as prescribed (55). In fact, Dr. Neil Ernst got so frustrated with what he interpreted as the Lees’ noncompliance to the prescriptions that he reported them to Child Protective Services for child abuse (57-59). Unfortunately, this lack of ability to communicate effectively caused Lia to not only receive subpar medical care, but to also be removed from her parents’ home and care for six months for what the state deemed as child abuse.

Second, the Hmong and Western cultures didn’t provide the Lees and their doctors with enough openness to the perspectives of the other culture to provide Lia with the help she needed. Neither group realized that their “view of reality is just one view, not reality itself” (276). They were both prejudiced. From the doctors’ perspective, they thought their rationalistic, medical worldview was the only legitimate way to approach healthcare because of their advanced education and training (76). They incorrectly assumed that their authority would be respected (53), their help would be appreciated (57), and their treatment would be utilized (55). Most of the doctors were baffled by the Hmong taboos against many of the basic practices of modern medicine, including blood tests and surgery (61). But they kept practicing medicine in the way they were trained without effective – or even minimal – attempts at relating the rationalistic Western perspective to the traditional Hmong perspective. Their lack of ability to relate to the Hmong culture was illustrated well by a doctor who said the easiest way to treat a Hmong patient was with a bullet to the head, otherwise known as “high velocity transcortical lead therapy” (63). From the Lee’s perspective, they thought the animist, traditional Hmong worldview was the only legitimate way to approach life. The Hmong people’s history and experience of survival in the face of war, exile, starvation, oppression, etc. has created a resilient culture that is resistant to ways of other cultures (17, 171). They resist assimilation by continuing to speak Hmong, honoring Hmong traditions, practicing Hmong religion, etc. (182-183). If anything, they become “more Hmong” as time goes on (208). Just as the doctors were bewildered by the Lees, the Lees were bewildered by the doctors. For example, the doctors understood Lia’s problem to be epilepsy, while the Lees understood it as soul loss (28). Obviously, if each culture understands the pathology differently, they also seek to treat it differently. While the doctors wanted to prescribe anticonvulsant medications, the Lees wanted to the help of a shaman. Plus, as Hmong people, the Lees had spiritual therapies, medical taboos, social orders, family values, etc. that weren’t understood by their Western doctors. In fact, Fadiman said: “their version of reality fails to match that of their doctors pretty much across the board” (62). Unfortunately, this cultural discord led to severe consequences for Lia. The Lees didn’t understand the importance of giving Lia her medications, causing them to inconsistently provide her with the treatment that could have helped her to live a normal life. The doctors didn’t know how to communicate the importance of Lia’s medications to her parents, causing the Lees to approach the medicine with suspicion instead of embracement. The Lees viewed the doctors as arrogant, coercive authority figures, causing them to resent and frustrate the help from the doctors (61). The doctors viewed the Lees as ignorant, stubborn parents, causing them to remove Lia from the Lees’ house due to noncompliance to the prescriptions (61). The list of examples could go on and on, but the point is already made: cultural conflict contributed to Lia’s condition.

Third, the secular, rationalist doctors and the spiritual, animist Lees had very different religious frameworks. The Lees believed that sickness was caused by a malevolent spirit that steals a person’s soul. The lost soul can only be returned to the body by a ritual performed by a shaman (100). Other practices of traditional Hmong medicine included animal sacrifice, special herbs, skin pinching and name changing (111). The Lees believed in these healing modalities so much that they devoted a large portion of their small income to providing them for Lia (111). In the end, they believed that a combination of “a little” traditional medicine and “a little” Western medicine was best for Lia (100). The doctors disagreed. They thought Lia’s problem was strictly biological and therefore should be treated with a carefully followed medical prescription. Plus the doctors used healing modalities that included blood tests, spinal taps, surgeries, and other treatment strategies that were taboo in the Lees’ religious worldview. Due to the fact that the doctors couldn’t translate their work into the Lees’ religious framework, the Lees never completely embraced the doctors’ medical assistance. Since religion and other “cultural facets give illness context and meaning,” the doctors should have tried harder – especially initially – to work within the Lees’ religious view of reality (265). If they had done that successfully, the Lees might have been more willing to trust the doctors, consent to medical procedures, administer medications consistently, etc. This could have been accomplished by practicing “conjoint treatment”, utilizing Western medical practice along with animist healing modalities (266). Since shaman practices and Hmong healing modalities are safe, there would have been no harm (267). In fact, doctors who have multicultural experience consider conjoint treatment to be beneficial for people like the Hmong who believe in the body-mind-spirit connection (267). If the doctors who worked closely with Lia and her parents had attempted to work within their religious framework and practice conjoint treatment, they might have been able to treat Lia much more successfully. The unbridgeable religio-cultural gulf might have been bridged (259). And Lia might have been given a much better chance at a normal life. In the end, Lia’s mother may have been right when she said: “With Lia it was good to do a little medicine and a little neeb” (100). Lia and her parents needed both modalities of healing. And the doctors needed to realize that “healthcare is a form of barter, rather than a one-sided relationship” (276). While it might be tempting to suggest that Lia’s medical condition was the sole or primary element that compromised her health, it’s clear that her medical problems were dramatically exacerbated by the cultural conflict between Lia’s parents and doctors.

Fadiman's book, The Spirit Catches You and You Fall Down, offers outstanding writing and imperative advice about how to address cultural dissonance. In this story, the life and health of a young girl was tragically compromised. While this narrative is sad, it can also be viewed as a wakeup call for the need for greater cultural competence in all contexts and fields (e.g. schools, businesses, churches, etc.). The hope is that as people become more culturally competent, there will be an influx of mutual respect, shared wisdom, and collaborative achievements. This book should be read far and wide. It might literally save lives.

1 comment:

  1. THANK you for your insight!!! I enjoyed your thoughts and in depth perspective as I wrote a paper for a Spiritual Caring class in Nursing school. I think you're right- cultural awareness DOES save lives!