Culture plays a major role in The Spirit Catches You and You Fall Down. Every other chapter shares some aspect of Hmong history or culture: food, clothing, language, family structure, birthing rituals, and so on. The Hmong traditionally lived high in the mountains of Laos, where they practiced agriculture and subsisted primarily on rice, vegetables, herbs, and occasionally pork or chicken. They believe that most disease has a spiritual cause and can be alleviated through traditional forms of healing such as rubbing the skin with coins, creating a vacuum by igniting cotton soaked in alcohol under a tiny cup, or drawing disease out with an egg. A tvix neeb, or shaman, could conduct more powerful healing; such a figure is thought to be able to get rid of evil spirits called dabs and retrieve lost souls.
Certain aspects of Hmong culture, such as taboos against medical procedures, beliefs about the origins of diseases, and power structures within the family and the clan often conflict with the culture of western medicine, resulting in misunderstandings between doctors and patients. Other aspects, such as utilizing animal sacrifice in shamanic ceremonies, have lead to conflicts between the Hmong and their American neighbors; for instance, some Americans believe the Hmong are kidnapping and killing neighborhood dogs. Lia Lee's tragedy is presented as the result of this cultural collision and highlights the need for a new model of cultural understanding and cooperation.
Fadiman advocates for doctors to consider their patients' stories about their disease and to try to use a model of cooperation rather than coercion. For example, Foua explained to Fadiman that she felt it was important to use both western medicine and neeb, or shamanic ritual. The Hmong believe that sometimes people get sick due to something that happens to their soul, or because they encounter an evil spirit called a dab. Such illnesses require spiritual healing, which can be rendered less effective by medication. Foua felt that the doctors wouldn't let them give just a little medication because they didn't understand about the soul. Had they done so, they might have been able to engage in cultural compromise, inviting a tvix neeb to work alongside the doctors who might have been able to convince the family that the amount of medication prescribed was beneficial. Lia's former hospital has since successfully adopted similar practices.
Another theme is the lack of power afforded to Hmong refugees. Whereas in Laos they had been free to follow their culture and to live independently, in the United States their freedom was curtailed. Welfare made them dependent upon others for sustenance, with few jobs available that did not require English proficiency and other skills they didn't have. They feared the American penal system, which punished crimes far differently than they had done in Laos. Most importantly for the Lees, they were no longer considered the ultimate decision makers for their children. A Minnesota physician summarized this view: "Once the police are called and court orders are obtained… the differences are no longer about beliefs. The differences are about power. Doctors have the power to call the police and to access state power which Hmong parents do not have" (84).
Related to power is knowledge, and in particular, the matter of whose knowledge is privileged. Spirit reveals that Western doctors' knowledge is considered superior to Hmong beliefs. Even Fadiman, whose sympathies lie with the Lees, expresses this view: "Dwight Conquergood's philosophy of health care as a form of barter, rather than a one-sided relationship, ignores the fact that, for better or for worse, Western medicine is one-sided. Doctors endure medical school and residency in order to acquire knowledge that their patients do not have" (276). However, Lia's neurologist admitted that it might have been a medical error which caused Lia to lose her brain function, and that the large dosages of medication in her system may have made her more susceptible to the septic shock that caused the brain damage. Furthermore, the fact that the Lees kept Lia alive for 26 more years suggests that their love and care was more powerful than the doctors' medicine. The story therefore begs the question of whether it is in the patient's best interest to privilege Western knowledge.
Lia's story reveals the strength of the family within Hmong culture. While most American families would have committed a daughter with brain damage to an institution, the Lees cared for Lia for 26 years, bathing her, dressing her impeccably, and even celebrating her birthday each year. Their care is likely what kept her alive for so long, when the doctors believed she would die within days.
Hmong families tend to be large, with an average of 9.5 children per family among refugees in the United States during the mid-eighties. Children are cherished and ancestors revered; one of the hardest parts about fleeing Laos leaving older family members alone to die. They place great importance on the clan; for instance, one reason that Foua and Nao Kao accepted Fadiman and her interpreter, May Ying, is that May Ying's husband belonged to the Lee's clan. Fadiman notes that family obligations sometimes put enormous demands on people, such as Jonas Vangay, a community leader who lived with his wife, his three children, his two brothers and their wives, and his brothers' ten children. Vangay explains that for a Hmong, unlike an American, "it is never everyone for himself" (247).
Clearly, Foua and Nao Kao loved their daughter Lia very much, and it may be their love (and subsequent care for her) that prolonged Lia's life. Others who showed love also met with success. Jeanine Hilt, the social worker assigned to Lia when she was placed in foster care, grew to love the family, and in return, they loved her too. She alone among Lia's caregivers thought to ask Foua and Nao Kao about their beliefs about Lia's epilepsy and to learn about their customs. Because of the love she showed them, Foua accepted her help and learned to administer Lia's medication, which led to regaining custody. Another social worker was able to persuade a patient with tuberculosis to take her medication by working within the family's belief system; like Jeanine, she loved her clients. In Fadiman's opinion, Lia's doctors, Neil Ernst and Peggy Philp, liked the Hmong, but they didn't love them. It may have been this lack of love that hindered them from considering their patients' points of view and adjusting their methods accordingly.
Hope Amidst Loss
The majority of Hmong living in Laos lost both friends and relatives and their homes as a result of the Hmong involvement in the Vietnam War. They gave up nearly all their possessions; by immigrating to a country in which many had to rely on welfare, a large number of them gave up their independence. However, one thing the new arrivals held onto was hope. When resettlement agencies located them far from their clansmen, they relocated themselves to reestablish a sense of community. When faced with the challenge of taking a written driver's test, they used a "crib sheet" to pass and thereby earn the license they needed to stay close to relatives. Likewise, despite their loss, Lia's family never gave up hope that their daughter's soul would return.
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