Chapter 3: The Spirit Catches You and You Fall Down
When Lia Lee was about three months old, her older sister Yer slammed the front door. In response, Lia's eyes rolled up, her arms jerked over her head, and she fainted. Her parents assumed the noise of the door had caused her soul to flee. They recognized the symptoms as qaug dab peg, "the spirit catches you and you fall down," with the spirit considered to be a soul-snatching dab.
Qaug dab peg can also be translated as epilepsy. While the Hmong acknowledge epilepsy as a serious and potentially dangerous disease, they also believe it confers on the sufferer a certain mark of distinction. The Hmong often see seizures as evidence that an epileptic can see things that others cannot, and that they can more easily enter trances to journey to the spirit world. A tvix neeb may conclude from the symptoms of shivering and pain that a person has been chosen to be a host for a neeb, or healing spirit, and he or she undergoes the arduous training to become a tvix neeb him- or herself.
Because of this belief, the Lees were both concerned and proud of Lia. Fao and Nao Kao hoped Lia could be healed, but they also considered her special. The doctors did not know this; several had inferred that "spirits" were somehow involved in the Lees' understanding of the disease, but only their social worker, Jeanine Hilt, had asked the Lees what they actually believed.
Whether because she was sick, considered "special" because of her epilepsy, or some other reason, Lia was her parents' favorite child. Unfortunately, they also blamed her sister Yer for slamming the door, and treated her differently as well. Lia had at least twenty more seizures in the next few months; twice her parents were worried enough to bring her to the emergency room at Merced Community Medical Center (MCMC). Although they were skeptical of Western medical techniques, three of their children had been saved by hospitals in Thailand, while one who had not gone to the hospital had died. Although they maintained their beliefs about illness (for instance, in Thailand they moved to a new house because they thought a dead person buried under their old house might have wished to harm them), they realized that Western doctors could also be of help.
Unlike many county hospitals, the MCMC is clean, modern, and well equipped. It is a teaching hospital, staffed in part by faculty and residents of the Family Practice Residency, affiliated with the University of California at Davis. At the same time, it has suffered from financial problems for twenty years. One reason is that the hospital accepts all patients regardless of their ability to pay; only around 20% of patients have private insurance, and reimbursements from public programs have been lowered or restricted in recent times. The population has also been changing in expensive ways: there are now 12,000 Hmong among Merced's 61,000 residents, and, while many chose not to use its services, there are still a large number of Hmong patients requiring higher than average levels of time and attention. There is no money in the budget for interpreters, so the hospital has hired bilingual Hmong lab assistants, nurse's aides, and transporters who translate when they are not performing their other duties. Often there are no Hmong-speaking employees at night, so doctors have had to communicate sensitive information through embarrassed children or teenagers. Sometimes doctors have no way of taking a patient's medical history, asking about symptoms, or obtaining essential information such as when the patient last ate, which can lead to dangerous side effects in the case of emergency surgery.
On the first two occasions when Foua and Nao Kao brought Lia to the emergency room, there were no interpreters present. The Lees could not explain what had happened, since Lia's seizure had already stopped. The only obvious symptoms were a cough and congestion in her chest. An X ray led to the diagnosis of early bronchopneumonia or tracheobronchitis and a prescription for antibiotics. Nao was given instructions written in English to administer the medicine and come back in ten days for a follow-up appointment, but since he could not speak or read English, he did not follow them.
Four months later, the Lees returned to the emergency room a third time. This time, they brought with them a cousin who spoke some English. The resident on duty was Dan Murphy, considered the doctor most interested in and knowledgeable about the Hmong. Lia was still having seizures when they arrived, and Dan correctly diagnosed her with epilepsy. He understood that epilepsy is a "sporadic malfunction of the brain" (28), often with cause unknown, in which "damaged cells in the cerebral cortex transmit neural impulses simultaneously and chaotically" (29). A focal seizure involves only a small part of the brain, while a generalized seizure involves electrical disturbance in a wide area. During the latter, the patient loses consciousness, either for a short time (petit mal or "absence" seizures), or for a longer period (grand mal). Lia was having a grand mal seizure. Epilepsy cannot be cured, but it can normally be controlled through the use of anticonvulsant drugs.
Despite Dan's respect for the Hmong worldview, his own view was rationalist. Unlike the Hmong - and others who throughout history have noted the spiritual passion accompanying a seizure - he believed no disease was any more divine than any other, and that it was merely ignorance that made some people think differently. He admitted Lia as an inpatient and ordered a number of tests, including a spinal tap, a CT scan, an EEG, a chest X ray, and blood work. The tests did not reveal the cause of Lia's epilepsy, although she was diagnosed with aspiration pneumonia, a side effect of the seizure. Her parents took turns staying with her at the hospital. When she was discharged, the parents were told to give her ampicillin twice a day to treat the pneumonia, and Dilantin elixir, an anticonvulsant, twice daily to suppress further grand mal seizures.
Chapter 4: Do Doctors Eat Brains?
The Hmong traditionally mistrust Western medicine, and for good reason. Their own tvix neeb spent many hours with a sick person, traveled to the patient's home, never needed to ask overly personal questions or ask a patient to undress, could diagnose a patient immediately, and knew that to treat the body, you also have to treat the soul. Western doctors, on the other hand, spent only a short time with a sick person, required the patient to come to the hospital, asked rude and intimate questions about his or her life, required patients to take off their clothes, often took blood samples, required many days for a diagnosis, and never even mentioned the soul. Many doctors' procedures actually seemed to do more harm than good. Most Hmong believe that the body has only a finite amount of blood, so repeatedly taking the blood is seen as harmful or even fatal. They believe that people's souls are wandering when they are unconscious, so anesthesia can lead to illness or death. Surgery is taboo in Hmong culture, as cutting the body leads to perpetual imbalance and possible disfigurement in the next life. Autopsies, too, are forbidden, as Hmong believe souls cannot be reborn if organs are removed after death. Only antibiotics were well received, possibly because the shots reminded the Hmong of traditional dermal treatments such as acupuncture, pinching, scraping with implements, or burning. A pill or a shot that could cure an infection practically overnight was most welcome.
Foua Yang and Nao Kao Lee were therefore in the minority when they brought their three sick children to the hospital in their refugee camp in Thailand. Most Hmong considered the hospital to house spirits of people who had died and were eager to claim more souls. They were far more likely to use their indigenous healing arts of shamanism, dermal treatments, and/or herbalism.
One reason the Hmong may have avoided the hospitals at refugee camps is that many medical staff were also Christian missionaries who mistrusted indigenous forms of medicine and showed a lack of respect for traditional beliefs. Dwight Conquergood, an ethnographer working at Ban Vanai, one of the refugee camps, noted that doctors and nurses routinely cut off spirit-strings from people's wrists or neck-wrings, which held infants' life-souls, because they considered them unsanitary. Rather than working with the shamans, they tried to undermine their authority. Conquergood, on the other hand, incorporated Hmong traditions into his public health campaigns and met with far more success. To encourage refugees to vaccinate their dogs against rabies, for instance, he made a Rabies Parade with three characters from Hmong folktales and had one of them explain the etiology of the disease through a bullhorn. The next day, the previously empty vaccination stations were teeming with clients. Conquergood believed the Western doctors and nurses at the camp were less successful because they considered themselves to hold all the knowledge, rather than viewing their relationship as one of mutual learning.
Chapter 3 introduces the major dichotomy between Lia's parents and doctors with regard to her illness. MCMC resident Dan Murphy diagnosed her problem as epilepsy, a neurological disorder marked by "an electrochemical storm… that had been stirred up by the misfiring of aberrant brain cells" (28). Her parents, on the other hand, had diagnosed it as the "illness where the spirit catches you and you fall down" (28). They believed that Lia's soul had fled her body when her sister slammed a door, and that the soul had become lost or stolen by a spirit called a dab. Many epileptics are perceived as having become the host of a healing spirit, or neeb, and are therefore marked as future shamans. Thus, while Lia's doctors wished only to cure or at least manage Lia's epilepsy, her parents were conflicted between their desire for her safety and the belief that her epilepsy promised her a life of honor among her community. This dichotomy foreshadows the problems that will later occur between the two parties. Each has a very different "explanatory model," grounded in a different culture, which will lead them to behave in ways that often conflict.
Chapter 4 places the present conflict in context by examining more generally the uneasy relationship between the Hmong and the western medical system. It explains the reasoning behind many of the Hmong taboos, such as surgery and blood-taking, which MCMC doctors had noticed but failed to understand. It can be argued that Fadiman, herself a westerner, displays an implicit bias by assuming her audience is non-Hmong; her intent seems to be to inform western readers about the Hmong while presupposing prior understanding about the US medical system.
This chapter also presents the example of ethnographer Dwight Conquergood, who respected Hmong culture and felt that knowledge should be transferred in two directions, with both western doctors and Hmong healers learning from one another. By using theater and characters from Hmong folktales (as opposed to lecturing from a position of power), Conquergood was able to present public health information in a form that the Hmong understand and accept.
This example suggests that the Hmong may be more compromising and willing to change than Fadiman asserts, as long as they can comprehend the benefits of such change. Similarly, the Lees learned from their experience with western doctors in Thailand that they do have the power to save lives, as the three children they had brought to the hospital in their refugee camp had survived and the one they had kept home had not. For this reason they brought Lia to MCMC whenever she had a seizure, despite a mistrust of doctors among many of their people. One can argue, then, that the Hmong are not always unwilling to compromise, as long as they understand the reasons for doing so.
Some reviewers have argued that Fadiman stereotypes the Hmong and/or simplifies their beliefs. It is clear that she has conducted thorough research, yet one may ask whether her sources reflected the culture as a whole and whether what she was told had been simplified or modified for a western audience. As an example, one Hmong reviewer does not remember epilepsy as bringing honor to a person; she remembers only the stigma attached to the disease. The fact that it is associated with spirit possession, she explained, made it even more frightening. Fadiman's attribution of specific cultural traits also ignores the individual differences between peopleAt the same time, she does her best to elicit many different points of view and to substantiate her claims with data.