The Spirit Catches You and You Fall Down: A Hmong Child, Her American Doctors, and the Collision of Two Cultures

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Press:Farrar, Straus and Giroux Farrar, Straus and Giroux; 1st edition (September 30, 1997)
Publication Date:1997-9-30
Author Name:Anne Fadiman
Edition:1st Edition


Winner of the National Book Critics Circle Award for NonfictionWhen three-month-old Lia Lee Arrived at the county  hospital emergency room in Merced, California, a chain of events was set in motion from which neither she nor her parents nor her doctors would ever recover. 
Lia's parents, Foua and Nao Kao, were part of a large Hmong community in Merced, refugees from the CIA-run "Quiet War" in Laos.
The Hmong, traditionally a close-knit and fiercely people, have been less amenable to assimilation than most immigrants, adhering steadfastly to the rituals and beliefs of their ancestors.
Lia's pediatricians, Neil Ernst and his wife, Peggy Philip, cleaved just as strongly to another tradition: that of Western medicine.
When Lia Lee Entered the American medical system, diagnosed as an epileptic, her story became a tragic case history of cultural miscommunication.Parents and doctors both wanted the best for Lia, but their ideas about the causes of her illness and its treatment could hardly have been more different.
The Hmong see illness aand healing as spiritual matters linked to virtually everything in the universe, while medical community marks a division between body and soul, and concerns itself almost exclusively with the former.
Lia's doctors ascribed her seizures to the misfiring of her cerebral neurons; her parents called her illness, qaug dab peg--the spirit catches you and you fall down--and ascribed it to the wandering of her soul.
The doctors prescribed anticonvulsants; her parents preferred animal sacrifices.

From School Library Journal

YA?A compelling anthropological study. 
The Hmong people in America are mainly refugee families who supported the CIA militaristic efforts in Laos.
They are a clannish group with a firmly established culture that combines issues of health care with a deep spirituality that may be deemed primitive by Western standards.
In Merced, CA, which has a large Hmong community, Lia Lee was born, the 13th child in a family coping with their plunge into a modern and mechanized way of life.
The child suffered an initial seizure at the age of three months.
Her family attributed it to the slamming of the front door by an older sister.
They felt the fright had caused the baby's soul to flee her body and become lost to a malignant spirit.
The report of the family's attempts to cure Lia through shamanistic intervention and the home sacrifices of pigs and chickens is balanced by the intervention of the medical community that insisted upon the removal of the child from deeply loving parents with disastrous results.
This compassionate and understanding account fairly represents the positions of all the parties involved.
The suspense of the child's precarious health, the understanding characterization of the parents and doctors, and especially the insights into Hmong culture make this a very worthwhile read.?Frances Reiher, Fairfax County Public Library, VACopyright 1998 Reed Business Information, Inc.

From Library Journal

Award-winning reporter Fadiman has turned what began as a magazine assignment into a riveting, cross-cultural medicine classic in this anthropological exploration of the Hmong population in Merced County, California. 
Following the case of Lia (a Hmong child with a progressive and unpredictable form of epilepsy), Fadiman maps out the controversies raised by the collision between Western medicine and holistic healing traditions of Hmong immigrants.
Unable to enter the Laotian forest to find herbs for Lia that will "fix her spirit," her family becomes resigned to the Merced County emergency system, which has little understanding of Hmong animist traditions.
Fadiman reveals the rigidity and weaknesses of these two ethnographically separated cultures.
In a shrinking world, this painstakingly researched account of cultural dislocation has a haunting lesson for every healthcare provider.
Highly recommended for all collections.?Rebecca Cress-Ingebo, Fordham Health Sciences Lib., Wright State Univ., Dayton, OhioCopyright 1997 Reed Business Information, Inc.

From The New England Journal of Medicine

In The Spirit Catches You and You Fall Down, Anne Fadiman tells the story of a Hmong family's experience with the American health care system and highlights many of the weaknesses of what some describe as the best health care system in the world. 
Fadiman writes beautifully and weaves the story of the Lees, their doctors, and the social and political history of the Hmong people and their unwilling immigration to the United States into a book that is difficult to put down once started.
The Spirit Catches You will appeal to anyone interested in the culture of medicine and the interface between different cultures.
It will also attract readers interested in the dynamics of power in the doctor-patient relationship and readers who can find inspiration in one family's devotion to a chronically ill child.
Nao Kao and Foua Lee and their children came to the United States because they felt they had no other option.
They could not return to their home in Laos because there they faced persecution, yet they had to leave their refugee camp in Thailand because it had been scheduled to close.
They settled in a Hmong community in California, where their daughter Lia was born.
The treatment of Lia's seizure disorder in the United States, both by her parents and by her health care providers, is the theme of this story.
Fadiman takes the reader through the details of the treatment to paint a full picture of Lia's experience as a chronically ill Hmong child in America.
We learn, for example, that long before the Lees even considered coming to the United States they had heard rumors about American doctors: doctors casually take blood from people, including children (the Hmong believe that the body contains a finite amount of blood that is not replaceable); doctors remove organs from their patients to eat or sell for food; doctors anesthetize patients and in so doing put their patients' souls at large, leading to illness or death; and when Hmong are admitted to the hospital, doctors cut the "spirit-strings" from their wrists, thus disturbing their "life-souls." American doctors, in turn, often consider the Hmong to be ignorant, backward, and too reliant on animal sacrifices and other unacceptable practices.
During Lia's treatment, the assumptions and beliefs that both parties brought to the patient-doctor interaction were never adequately explored.
Doctors often took advantage of their powerful position, and along the way there was a lack of trust and respect between the family and the doctors.
Much of Fadiman's book explores how each party blamed the other for the tragic outcome -- Lia's severe mental and physical disabilities.
In one of the book's final chapters, Fadiman suggests ways in which health care providers can improve their ability to care for patients whose background is different from their own.
The chapter draws heavily on work by Arthur Kleinman and others who began exploring cross-cultural medicine before it became popular.
Readers of Fadiman's book will understand, however, that to provide high-quality, appropriate care for the diverse populations using the U.S.
health care system, health care providers and organizations must adequately assess the need for resources to address a wide range of cross-cultural issues.
Holding a "diversity" or "multicultural" day in a hospital or medical school is a superficial and inadequate approach.
More meaningful is participation by bilingual, bicultural, professionally trained interpreters, the lack of which played a major part in the miscommunication between the Lees and their physicians.
Americans' lack of understanding of the hierarchy in the Hmong community and of how conflicts are resolved was also a major barrier that might have been addressed by a health worker representing the Hmong community.
The Spirit Catches You illustrates how much time, energy, and commitment are necessary to understand another culture's perspective on health and wellness and to translate that understanding into the day-to-day practice of medicine.
Reviewed by JudyAnn Bigby, M.D.
Copyright © 1998 Massachusetts Medical Society.
All rights reserved.
The New England Journal of Medicine is a registered trademark of the MMS.

From Kirkus Reviews

A vivid, deeply felt, and meticulously researched account of the disastrous encounter between two disparate cultures: Western medicine and Eastern spirituality, in this case, of Hmong immigrants from Laos. 
Fadiman, a columnist for Civilization and the new editor of the American Scholar, met the Lees, a Hmong refugee family in Merced, Calif., in 1988, when their daughter Lia was already seven years old and, in the eyes of her American doctors, brain dead.
In the Lees' view, Lia's soul had fled her body and become lost.
At age three months Lia had had her first epileptic seizure--as the Lees put it, ``the spirit catches you and you fall down.'' Lia's treatment was complex--her anticonvulsant prescriptions changed 23 times in four years--and the Lees were sure the medicines were bad for their daughter.
Believing that the family's failure to comply with his instructions constituted child abuse, Lia's doctor had her placed in foster care.
A few months after returning home, Lia was hospitalized with a massive seizure that effectively destroyed her brain.
With death believed to be imminent, the Lees were permitted to take her home.
Two years later, Fadiman found Lia being lovingly cared for by her parents.
Still hoping to reunite her soul with her body, they arranged for a Hmong shaman to perform a healing ceremony featuring the sacrifice of a live pig in their apartment.
Into this heart-wrenching story, Fadiman weaves an account of Hmong history from ancient times to the present, including their work for the CIA in Laos and their resettlement in the US, their culture, spiritual beliefs, ethics, and etiquette.
While Fadiman is keenly aware of the frustrations of doctors striving to provide medical care to those with such a radically different worldview, she urges that physicians at least acknowledge their patients' realities.
A brilliant study in cross-cultural medicine.
-- Copyright ©1997, Kirkus Associates, LP.
All rights reserved.


Fadiman tells her story with a novelist's grace, playing the role of cultural broker, comprehending those who do not comprehend each other and perceiving what might have been done or said to make the outcome different."--Richard Berstein, The New York Times"So good I want to somehow make it required reading...The Spirit Catches You and You Fall Down explores issues of culture, immigration, medicine, and the war in [Laos] with such skill that it's nearly impossible to put down."--Linnea Lannon, The Detroit Free Press "This is a captivating riveting book--a must-read not only for medical professionals, anthropologists, and journalists, but for anyone interested in how to negotiate cultural difference in a shrinking world.
Fadiman's ability to empathize with the resolutely independent Hmong as well as with the remarkable doctors, caseworkers, and officials of Merced County makes her narrative both richly textured and deeply illuminating.
Sometimes the stakes here are multicultural harmony and understanding; sometimes they're literally life and death--whether in wartime Laos or in American emergency rooms.
But whatever the stakes and wherever the setting, Fadiman's reporting is meticulous, and prose is a delight.
From start to finish, a truly impressive achievement."--Michael Berube, author of Life As We Know It

About the Author

Anne Fadiman's compassionate account of this cultural impasse is literary journalism at its finest. 
The Spirit Catches You and You Fall Down moves from hospital corridors to healing cereomies, and from the hill country of Laos to the living rooms of Merced, uncovering in its path the complex sources and implications of two dramatically clashing worldviews.

Excerpt. © Reprinted by permission. All rights reserved.

THE SPIRIT CATCHES YOU AND YOU FALL DOWN (Chapter 1)Birth If Lia Lee had been born in the highlands of northwest Laos, where her parents and twelve of her brothers and sisters were born, her mother would have squatted on the floor of the house that her father had built from ax-hewn planks thatched with bamboo and grass. 
The floor was dirt, but it was clean.
Her mother, Foua, sprinkled it regularly with water to keep the dust down and swept it every morning and evening with a broom she had made of grass and bark.
She used a bamboo dustpan, which she had also made herself, to collect the feces of the children who were too young to defecate outside, and emptied its contents in the forest.
Even if Foua had been a less fastidious housekeeper, her newborn babies wouldn’t have gotten dirty, since she never let them actually touch the floor.
She remains proud to this day that she delivered each of them into her own hands, reaching between her legs to ease out the head and then letting the rest of the body slip out onto her bent forearms.
No birth attendant was present, though if her throat became dry during labor, her husband, Nao Kao, was permitted to bring her a cup of hot water, as long as he averted his eyes from her body.
Because Foua believed that moaning or screaming would thwart the birth, she labored in silence, with the exception of an occasional prayer to her ancestors.
She was so quiet that although most of her babies were born at night, her older children slept undisturbed on a communal bamboo pallet a few feet away, and woke only when they heard the cry of their new brother or sister.
After each birth, Nao Kao cut the umbilical cord with heated scissors and tied it with string.
Then Foua washed the baby with water she had carried from the stream, usually in the early phases of labor, in a wooden and bamboo pack-barrel strapped to her back.Foua conceived, carried, and bore all her children with ease, but had there been any problems, she would have had recourse to a variety of remedies that were commonly used by the Hmong, the hilltribe to which her family belonged.
If a Hmong couple failed to produce children, they could call in a txiv neeb, a shaman who was believed to have the ability to enter a trance, summon a posse of helpful familiars, ride a winged horse over the twelve mountains between the earth and the sky, cross an ocean inhabited by dragons, and (starting with bribes of food and money and, if necessary, working up to a necromantic sword) negotiate for his patients’ health with the spirits who lived in the realm of the unseen.
A txiv neeb might be able to cure infertility by asking the couple to sacrifice a dog, a cat, a chicken, or a sheep.
After the animal’s throat was cut, the txiv neeb would string a rope bridge from the doorpost to the marriage bed, over which the soul of the couple’s future baby, which had been detained by a malevolent spirit called a dab, could now freely travel to earth.
One could also take certain precautions to avoid becoming infertile in the first place.
For example, no Hmong woman of childbearing age would ever think of setting foot inside a cave, because a particularly unpleasant kind of dab sometimes lived there who liked to eat flesh and drink blood and could make his victim sterile by having sexual intercourse with her.Once a Hmong woman became pregnant, she could ensure the health of her child by paying close attention to her food cravings.
If she craved ginger and failed to eat it, her child would be born with an extra finger or toe.
If she craved chicken flesh and did not eat it, her child would have a blemish near its ear.
If she craved eggs and did not eat them, her child would have a lumpy head.
When a Hmong woman felt the first pangs of labor, she would hurry home from the rice or opium fields, where she had continued to work throughout her pregnancy.
It was important to reach her own house, or at least the house of one of her husband’s cousins, because if she gave birth anywhere else a dab might injure her.
A long or arduous labor could be eased by drinking the water in which a key had been boiled, in order to unlock the birth canal; by having her family array bowls of sacred water around the room and chant prayers over them; or, if the difficulty stemmed from having treated an elder member of the family with insufficient respect, by washing the offended relative’s fingertips and apologizing like crazy until the relative finally said, “I forgive you.”Soon after the birth, while the mother and baby were still lying together next to the fire pit, the father dug a hole at least two feet deep in the dirt floor and buried the placenta.
If it was a girl, her placenta was buried under her parents’ bed; if it was a boy, his placenta was buried in a place of greater honor, near the base of the house’s central wooden pillar, in which a male spirit, a domestic guardian who held up the roof of the house and watched over its residents, made his home.
The placenta was always buried with the smooth side, the side that had faced the fetus inside the womb, turned upward, since if it was upside down, the baby might vomit after nursing.
If the baby’s face erupted in spots, that meant the placenta was being attacked by ants underground, and boiling water was poured into the burial hole as an insecticide.
In the Hmong language, the word for placenta means “jacket.” It is considered one’s first and finest garment.
When a Hmong dies, his or her soul must travel back from place to place, retracing the path of its life geography, until it reaches the burial place of its placental jacket, and puts it on.
Only after the soul is properly dressed in the clothing in which it was born can it continue its dangerous journey, past murderous dabs and giant poisonous caterpillars, around man-eating rocks and impassable oceans, to the place beyond the sky where it is reunited with its ancestors and from which it will someday be sent to be reborn as the soul of a new baby.
If the soul cannot find its jacket, it is condemned to an eternity of wandering, naked and alone.Because the Lees are among the 150,000 Hmong who have fled Laos since their country fell to communist forces in 1975, they do not know if their house is still standing, or if the five male and seven female placentas that Nao Kao buried under the dirt floor are still there.
They believe that half of the placentas have already been put to their final use, since four of their sons and two of their daughters died of various causes before the Lees came to the United States.
The Lees believe that someday the souls of most of the rest of their family will have a long way to travel, since they will have to retrace their steps from Merced, California, where the family has spent fifteen of its seventeen years in this country; to Portland, Oregon, where they lived before Merced; to Honolulu, Hawaii, where their airplane from Thailand first landed; to two Thai refugee camps; and finally back to their home village in Laos.The Lees’ thirteenth child, Mai, was born in a refugee camp in Thailand.
Her placenta was buried under their hut.
Their fourteenth child, Lia, was born in the Merced Community Medical Center, a modern public hospital that serves an agricultural county in California’s Central Valley, where many Hmong refugees have resettled.
Lia’s placenta was incinerated.
Some Hmong women have asked the doctors at MCMC, as the hospital is commonly called, if they could take their babies’ placentas home.
Several of the doctors have acquiesced, packing the placentas in plastic bags or take-out containers from the hospital cafeteria; most have refused, in some cases because they have assumed that the women planned to eat the placentas, and have found that idea disgusting, and in some cases because they have feared the possible spread of hepatitis B, which is carried by at least fifteen percent of the Hmong refugees in the United States.
Foua never thought to ask, since she speaks no English, and when she delivered Lia, no one present spoke Hmong.
In any case, the Lees’ apartment had a wooden floor covered with wall-to-wall carpeting, so burying the placenta would have been a difficult proposition.When Lia was born, at 7:09 p.m.
on July 19, 1982, Foua was lying on her back on a steel table, her body covered with sterile drapes, her genital area painted with a brown Betadine solution, with a high-wattage lamp trained on her perineum.
There were no family members in the room.
Gary Thueson, a family practice resident who did the delivery, noted in the chart that in order to speed the labor, he had artificially ruptured Foua’s amniotic sac by poking it with a foot-long plastic “amni-hook” that no anesthesia was used; that no episiotomy, an incision to enlarge the vaginal opening, was necessary; and that after the birth, Foua received a standard intravenous dose of Pitocin to constrict her uterus.
Thueson also noted that Lia was a “healthy infant” whose weight, 8 pounds 7 ounces, and condition were “appropriate for gestational age” (an estimate he based on observation alone, since Foua had received no prenatal care, was not certain how long she had been pregnant, and could not have told Dr.
Thueson even if she had known).
Foua thinks that Lia was her largest baby, although she isn’t sure, since none of her thirteen elder children were weighed at birth.
Lia’s Apgar scores, an assessment of a newborn infant’s heart rate, respiration, muscle tone, color, and reflexes, were good: one minute after her birth she scored 7 on a scale of 10, and four minutes later she scored 9.
When she was six minutes old, her color was described as “pink” and her activity as “crying.” Lia was shown briefly to her mother.
Then she was placed in a steel and Plexiglas warmer, where a nurse fastened a plastic identification band around her wrist and recorded her footprints by inking the soles of her feet with a stamp pad and pressing them against a Newborn I...


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Comment List (Total:14)

  •     Great! On time and a fantastic read
  •     sometimes wish that I could choose something other than I "liked" it. The book is well written and fairly presents both sides of an impossible situation. It brought back memories of the Vietnam War which I, in a selfish way, do not want to recall. It also left me feeling hopeless that we continue to get involved in regime change around the world and sacrifice not only our own soldiers but negatively affect the lives of those we purport to help. "Those who do not learn from history are bound to repeat it." We don't seem to be capable of learning. The Hmong did not resettle here because they sought a better life and opportunity, they did so to survive. I had never thought of the difference until I read this sad story. It is difficult to be asked to choose between western medicine, which looks for a "cure" at all costs, and the Hmong belief that all illness is based in your spirit. I cannot deny that the book is informative and worthy of reading by anyone, especially those who are too young to understand the Vietnam war and the role we asked these people to take on and our neglect of them after the fact. I do not have to say that I enjoyed it.
  •     Fast shipping. Item as described. Thanks!
  •     Great product.
  •     Great book for gaining perspective about diversity.
  •     good
  •     This book is a must read and has left an impression on me that will last for the rest of my life! It truly changed me
  •     Amazing book! It's a must read for anyone in the healthcare industry. Actually, it's a book that everyone should read.
  •     People who are not familiar with Hmong Americans may read this book and assume that all/most Hmong Americans are like the Lee family and other Hmong families presented in the book. The events that took place with the Lee family occured when Hmong first arrived here in the late 70s/early 80s. These days, the majority of Hmong Americans are a lot more Americanized compared to the early 1980s. Although the assimilation has been slow compared to other first generation Americans, things have changed a lot since then. For example, many Hmong no longer practice the traditional Hmong religion and have converted to Christianity. The Lee family was a lot more traditional than most Hmong American families in the early 80s. I just wanted to clear this up.Having said that, I enjoyed this book because it does the impossible. Fadiman is able to make the reader better understand the traditional Hmong culture, a culture that seems irrational and is opposite of western culture. It doesn't mean that you will agree with the Hmong culture but you will better understand it, including why the family did/did not do certain things to help their daughter who had epilepsy. I also believe that this book is important for those who work with the public because it promotes sensitivity towards other cultures. The doctors and the family had the very best intentions for the daughter who had epilepsy but the cultural barriers were just too much.
  •     Very good interesting book
  •     Enlightening. Helps me to understand the difficulty both the Hmoung and the American medical environments had when working with each other.
  •     I read this book for a class. It is a very interesting look at cross-cultural understanding in a medical case, and I have been recommending it to my friends in the medical field.
  •     The Spirit Catches You and You Fall is a novel based on the clash of two cultures---the Hmong culture and the American culture. A little Hmong girl is diagnosed with epilepsy which her parents believe is caused by spirits. Because of this belief, they try to cure her illness not with western medication but their own Hmong ways. There is a huge misunderstanding between the parents and the doctors that Anne Fadiman explores. Anne Fadiman provides readers with a vivid, detailed history of the Hmong in Laos to their involvement in the Vietnam War to their struggles in America that explains this clash. On the other hand, she also explains why Americans see and felt the way they did about the Hmong culture particularly the doctors. One shortcoming is that the author implies that Hmong Americans and their experiences are completely homogenous, but the beauty of this book is that she is able to view both sides without judgment. As a Hmong American, it's hard to imagine an American who can achieve this, but the author achieves this so beautifully. It's hard to look at something from a totally different perspective especially because westerners are very rigid about their beliefs and have a sense of superiority in regards to other cultures thus I was shocked that Fadiman was able to communicate and understand the Hmong in such a way. She did a great job of digging beyond the surface and really understanding the Hmong people, their beliefs, and where they are coming from. As a Hmong American, I think she did a great job! She talked of things that I couldn't imagine an American even knowing about until I read this book. It's great to know that an American can look at the Hmong culture without judgment and even come to admire it and see some good in it even though it's very different from her own beliefs. I recommend this book to anyone especially those that are interested in learning more about the Hmong.
  •     This book was written in 1997 and I first read it in nursing school. Although it’s been almost twenty years, “The Spirit Catches You and You Fall Down” is just as relevant now as it was when it was written. In fact, I somehow mentioned the book to my mother in law and when I found out she hadn’t read it, I bought her a copy for Christmas. I then felt compelled to re-read the book myself, and discovered that I’ve lent out my copy. It’s been long enough that I’m guessing that I’m not getting my copy back- especially since I don’t recall who has my copy! I came to Amazon today to purchase another copy for myself. The book is just that good.Anne Fadiman’s book is really engaging and just draws the reader in. Although “The Spirit Catches You and You Fall Down” touches on so sensitive subjects, Anne Fadiman manages to illustrate the cultural differences so starkly that I ended up feeling sympathetic to both the western medical community that was trying to treat Lia Lee as well as Lia’s family and her community. It’s written far more like a dialogue between author and reader than a narrative.I work as a nurse I often think of this book when I watch a new mom stuff cotton in her ears, put a towel over her head before going outside, reject the hospital food in favor of broth and chicken brought in by family, or politely remind me over and over “No ice in the water please!”. I honestly think this book should be required reading for doctors, nurses, social workers, foster parents, etc.

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