Dr. Wear is professor of behavioral sciences and associate director, Human Values in Medicine/Women in Medicine Program, Northeastern Ohio Universities College of Medicine, Rootstown, Ohio; Dr. Nixon is professor, Division of Ethics and Humanities, Department of Internal Medicine, University of South Florida College of Medicine, Tampa.
The Hmong people have a saying, hais cuaj txub kaum txub, which means, “to speak of all kinds of things.” These few words characterize a highly complex, elaborate worldview shared by the Hmong: Everything in the world is connected, no event occurs in isolation from others, and “you can miss a lot by sticking to the point.”
As we began to write this commentary, we discovered that these beliefs about how the world operates characterize not only Hmong thinking but also any attempt to render Anne Fadiman's remarkable book, The Spirit Catches You and You Fall Down, into an orderly commentary. In fact, throughout the book Fadiman narratively enacts the culture she so skillfully and respectfully chronicles: Because the Hmong themselves cannot be neatly characterized in ways Westerners easily understand, any attempt to describe them in a language not their own cannot be a linear, “rational” exposition. “The long way around,” according to the Hmong, “is often the shortest way from point A to point B.” Fadiman beautifully takes the long way around so that upon finishing the book, readers are profoundly affected by the rich history of the Hmong people, yet perplexed by what American medicine can and should do for non-majority groups, many of them immigrants, who do not share—or care to share—the majority culture's values and beliefs.
Yet, for here, we attempt to “stick to the point.” The book is a story of clashes—the larger one between Hmong culture and American medicine, the more specific one between doctors and a family over the care of a child. Lia Lee was born in 1981 in a U.S. hospital to Foua and Nao Kao Lee, recent Hmong immigrants from Laos. At the age of three months, Lia had her first epileptic seizure, or as the Hmong view this mysterious occurrence, “the spirit catches you and you fall down.” Five years later, after countless seizures, 15 admissions to the county hospital, routine miscommunications and misunderstanding regarding medicines—her anticonvulsant prescriptions changed 23 times in four years, with new directions given each time to a mother who did not read or understand English—Lia has “the big one,” a two-hour seizure secondary to septic shock. Considered brain dead by her doctors, Lia was lovingly viewed by her parents not as dead but as a little girl whose soul had fled her body and become lost.
Throughout the book, Fadiman takes readers on a historical excursion into Hmong culture, which has been marked from the beginning by one “bloody scrimmage” after another, with occasional periods of peace. The Hmong have always responded to “persecution and pressures to assimilate by either fighting or migrating—a pattern that has been repeated so many times, in so many different eras and places, that it begins to seem almost a genetic trait.” Indeed, their desire to be left alone, whether in China or Laos or California, is one of their most problematic features—problematic as determined by the majority culture wherever they are. As Fadiman notes, the Hmong have never had a desire to rule over anyone else but merely want “to be left alone, which … may be the most difficult request any minority can make of a majority culture.”
Alternating with chapters tracing Hmong history are chapters detailing Lia's unfolding medical problems, particularly her doctors' dogged attempt to keep her seizures under control with medications whose regimens her mother only partially understood and accepted, and the Lees' frustrations with American doctors who did not understand what they, her parents, believed was causing their child's seizures and what should be done. In fact, the doctors “had no idea what the Lees were doing to heal Lia because they never thought to ask,” even though most Hmong readily accept “a little medicine and a little neeb”—a middle ground that uses both medicine and healing spirits. Still, Fadiman chronicles these clashes in deeply insightful ways, blaming neither the Lees nor the child's doctors, always mindful of the complex, competing narratives arising from Lia's illness. To speak of Lia's illness and the medical response to it is, truly, to “speak of all kinds of things.”
If nothing else, and even before opening the book, the mysterious title catches your attention, along with the picture of a beautifully-adorned child on the cover. Fadiman's profound sensitivity and her understanding of both Hmong culture and American medicine present questions, not arguments, that medical educators and students should ponder: How do doctors achieve multicultural understandings of patients that give illness context and meaning? How should doctors honor their patients' cultural beliefs and practices that may be in opposition to standard medical practice? Where does the soul fit into the practice of American medicine? And in the quintessentially Cartensian world of medical thought and practice, what might be gained from the Hmong practice of hais cuaj txub kaum txub as we contemplate the mysterious connections between the body and spirit?