An Ethnography Review:
The Spirit Catches You and You Fall Down
Anne Fadiman
Medical Anthroplogy and Global Health
Alejandro Cerón
November 14, 2012
How are
American doctors supposed to deal with cultures that have opposing beliefs on
causes of illness and course of treatment? Is coercion justified in cases where
the patient’s life is threatened by the rejection of Western medicine? Who is
the judge that can determine which belief is legitimate and which treatment
should be used? These are the kinds of pressing questions that are extremely
relevant to medical professionals today. Therein lies the problem of “underdetermination
of theories”, which is a philosophical phenomenon that states one result can
have many possible hypotheses therefore evidence alone is not sufficient enough
in order to determine which hypothesis is correct. This theory, applied to
global health, renders that different cultural beliefs regarding illness cause
are theories that logically arise from the same group of evidence, the symptoms
of the illness, consequentially, each theory can neither be falsified or proven
because they were created with the same school of logical reasoning.
It is a well-known fact that globalization has
initiated the integration of many diverse cultures into countries far from
their origin. When people immigrate across boundaries, their respective
cultures travel with them. America, for example, is known as the world’s
“melting pot” for its diversity caused by its high immigration rates. However,
an often-overlooked fact is that some cultures do not “melt”; instead they
accept their geographic displacement and attempt to maintain the “pureness” of
their culture by creating isolated communities and avoiding assimilation by all
means.
Of these
communities, Merced, California had a substantial Hmong population gain
precedence during the 1980’s. It is in Merced where the story of Lia Lee, a
Hmong girl with a severe epileptic disorder, takes place, a story that Anne Fadiman
dubs a tragedy caused by the “collision of two cultures.”
In this
essay I will discuss the implications of Anne Fadiman’s book, The Spirit Catches You and You Fall Down,
and also critically analyze her role as an ethnographer. The story is told far
from a neutral perspective, however the issues it uncovers about cultural
competence and the challenges of cross-cultural medicine are crucial to global
health today and in the future. Nonetheless, the novel is acclaimed by medical
professionals nationwide and is used as a text for teaching Medical Ethics
courses in several prestigious medical schools, University of Washington School
of Medicine included. It is an emotional read that led me to question Western
healthcare system altogether, yet I am unsure how I would have dealt with the
situation any differently or if there are any clear solutions that will
meliorate similar situations in the future.
In her
ethnography, Anne Fadiman beautifully captures the culture of the Hmong, an
Asian ethnic group of the mountainous regions of Laos, China, Vietnam, and Thailand.
The Hmong are people well known for their perseverance, rebellious nature, and
independence.
“For as
long as it has been recorded, the history of the Hmong has been a marathon
series of bloody scrimmages, punctuated by occasional periods of peace, though
hardly any of plenty. Over and over again, the Hmong have responded to
persecution and to 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…” (Fadiman 1997:13)
Having allied with the Americans during
the Laotian Civil War (1953-1975), also known as the Secret War because Hmong
guerillas, the Hmong were despised as enemies by Pathet Lao’s communist party upon
war’s end. In order to escape the forceful government and laden resentment in
Laos, thousands of Hmong fled, mostly by walking, to their neighboring country,
Thailand. Because Thailand was merely a temporary refugee camp, eventually the
Hmong relocated again, this time to countries such as France, Canada,
Australia, and most importantly the United States. Although the immigrants were
dispersed into major cities across the nation, by the early to mid 1980’s, they
managed to unite and form several densely populated Hmong-American communities.
An important note is that the Hmong fled Laos because the communist party
threatened their autonomy; therefore, their intentions in America were to come
to a land where they had the freedom to be Hmong. “What the Hmong wanted here
was to be left alone to be Hmong: clustered in all-Hmong enclaves, protected
from government interference, self-sufficient, and agrarian.” (Fadiman 1997:
183)
The
Hmong culture is one that is fundamentally different from Western culture on
virtually every level of comparison. The Hmong communicate strictly orally.
They are mountainous people who survived off “slash and burn” farming
techniques, accustomed to frequent travels due to soil depletion, their most
prosperous crop having been opium. They are spiritual in the sense that they
believe in spirits and how they mustn’t act in a way that anger or provoke
spirits. For example, some Hmong believe they ought not to praise a newborn’s
beauty lest a dab (evil spirit) is
listening and is tempted to steal the child. The contrary is also true that
they should act in a way that is spiritually favorable, such as offering
chicken, cow, or pig sacrifices. Because of such beliefs, the Hmong regularly
practice various rituals and ceremonies. Possibly because of the uniqueness of
the Hmong culture, the Chinese, in as early as the Ming dynasty of the 1300’s,
associated them with the term “Miao”, meaning “barbarian.” It wasn’t long after
the Hmong’s arrival that Americans living within their vicinity also noticed
their peculiar rituals and began spreading rumors and judging them, which in
any case American culture was equivalently mind-boggling for the Hmong.
The
combination of cultural differences, misguided judgments, and language barrier,
made the Hmong especially difficult patients for hospital workers. Because the
Hmong believed every bodily and mental illness were spiritually caused, they
had views opposing that of scientific medicine for virtually every
sickness.
“Not
realizing that when a man named Xiong or Lee or Moua walked into the Family
Practice Center with a stomachache he was actually complaining that the entire
universe was out of balance, the young doctors of Merced frequently failed to
satisfy their Hmong patients. How could they succeed?” (Fadiman 1997:61)
In most cases, the doctors and the Hmong
would share differing negative views about each other. Often times Hmong had
unrealistic expectations from doctors, such as immediate fixes for chronic
illnesses. Or the Hmong would be considered difficult for not obeying doctor’s
orders, which were sometimes due to lack of comprehension or other times
because differing beliefs.
Before
further discussion of Anne Fadiman’s novel, I would like to draw some parallels
from the Hmong people to another group of immigrants, specifically the Russian
émigrés, whom United States saw an influx of refugees in the 1980’s and 1990’s
because of the loosening of Soviet Union emigration laws.
Similar to
the Hmong, elderly Russian Jewish Émigrés are an example of a group of
immigrants who chose to maintain prior cultural practices. Upon arrival, they typically
fail at learning English and the “American” way of living. Because of this, other
American citizens frequently misunderstand them. “The notion of émigrés’
‘failure to assimilate’ failed to take into account the many ways in which
émigrés were nostalgic for Russian institutions and values and critical of
American ones.” (Borovoy and Hine 2008:15) Having a high incidence of diabetes,
these immigrants are often found seeking medical attention. All too often,
health professionals view the elderly Russian Émigrés as noncompliant and lazy because
they don’t obey the strict diet and the intake of prescribed medicine. “In this
context, Russian émigré patients have gained a reputation among physicians,
nurses, and diabetes educators for being poor ‘self-managers.’ (Borovoy and
Hine 2008: 6)” Yet an anthropological study done by Amy Borovoy and Janet Hine reveal
disagreeing evidence.
“In contrast,
Russian émigré patients seemed to be weighing the trade-offs entailed in
diabetic care and arriving at compromises that would allow them to live their
lives while accommodating, within limits, the restrictions of diabetic diets.
Their noncompliance reflects the particularities of their culture and history.”
(Borovoy and Hine 2008:13)
When interviewed, the émigrés indicated,
contrary to popular belief, that they do not indulge gluttonously but do attempt
to measure blood sugar daily and follow the strict medical regimen. Sometimes
they intentionally choose to ignore the doctor’s recommendations but only
because they value partaking in traditional foods, not because they lack self-control.
They also indicated different views on healthcare, risk, and death. One 80-year
old woman stated in an interview, “I’ve been told that [the problem in my foot]
is because of the diabetes, but I believe it is because I’m old. (Borovoy and
Hine 2008: 11)” Because the woman holds different beliefs about the cause of
illness, she is most likely not going to agree and comply by the prescribed
treatment given by American doctors.
The
“tragedy” of Lia Lee follows a similar pattern of events. Lia’s epileptic
disorder first occurs when she is merely a few months old. For several subsequent
years, Foua and Lao Kao, Lia’s parents, both non-English speaking, engage in
close relationship with the health professionals at their local hospital
because of Lia’s frequent hospitalization due to the extreme severity of her
disorder. The inherent problem is that Lia’s parents and the Merced Medical
Center (MCMC) doctors have conflicting beliefs about the sickness.
“Each had
accurately noted the same symptoms, but Dan would have been surprised to hear
that [the seizures] were caused by soul loss, and Lia’s parents would have been
surprised to hear that [the seizures] were caused by an electrochemical storm
inside their daughter’s head…” (Fadiman 1997: 28)
Herein lies the “underdetermination of
theories,” two separate theories derived from the same evidence. Through the
course of Lia’s treatment, there was a constant misunderstanding between the
two parties. Lia’s parents questioned the competency of doctors, the effectiveness
of the prescribed medicine and refused to administer certain drugs they did not
approve of. Lia’s doctors viewed this sort of behavior as noncompliant and
threatening to Lia’s health. At one point, Lia was even taken out of her
parental care and placed in a foster home as a result of doctor’s orders. The
“tragedy” is that the quality of Lia’s care was significantly compromised
because the conflict between two entities that both wanted the best for her.
The Spirit Catches You… is a provocative
read, which is definitely the byproduct of Anne Fadiman’s word choice and opinions.
She takes each reader through the journey of the Lee family’s challenging
endeavor of protecting their beloved daughter from what they believed were the
harms of Western medicine. Her writing stirs up emotions of anger, frustration,
disappointment, and helplessness, all of which guides readers to accept the
heavy weight of cultural competence in global health. It seems like an easy
solution: Increase the cultural competence of healthcare professionals. In
application, however, it is extremely difficult to measure, teach, and
implement into a system. It would be impossible for doctors to be knowledgeable
in every culture, yet if similar cultures are grouped, they would be prone to
stereotyping and overgeneralizations.
Anne
Fadiman states that the “collision of cultures” was inevitable because of the
nature of each particular culture. Because Hmong are historically known to be rebellious
and stubborn, Lia’s parents would have never fully complied with the standard expected
by her doctors. There are serious flaws to such thinking, however, because it
poses a narrow, unchangeable light on Hmong culture. Janelle Taylor, an
anthropologist from the University of Washington, writes in her article, The
Story Catches You and You Fall Down: Tragedy, Ethnography, and “Cultural
Competence”:
“Such a
reductive and determinist vision of ‘culture’ is surprising coming from
Fadiman, because she so clearly also delights in recounting the many creative
and surprising ways the Hmong immigrants have made use of their own cultural
resources, in the new circumstances in which they find themselves.” (Taylor 2003:167)
According to Raymond Williams, as
discussed in Week 5 of lecture, culture is definitely not static. Anne Fadiman
repeatedly emphasizes the Hmong culture’s uncompromising nature that is framed
to be a constantly expressed defining trait of the Hmong. Knowing that culture is
dynamic, she may have chosen to deliberately depict the Hmong in this way
because the story wouldn’t have made sense otherwise. “The book’s narrative is
so compelling precisely because it
employs such a simplistic model of ‘culture’.” (Taylor 2003:160) If not for
Hmong culture, Lia’s parents have no other reason to be so fiercely opposing of
Western medical treatment.
In
situations like the treatment of Lia’s epilepsy or diabetes in Russian émigrés,
clearly, there is a communication gap between the healthcare providers and
patient, one that sprouts from opposing beliefs within each culture,
considering that biomedicine has a culture of its own. What is the best way to
deal with such “clashing cultures”?
Anne Fadiman
refers to Arthur Kleinman’s set of eight questions, which allows for patients
to explain to doctors, their own personal beliefs of illness cause and
treatment. Surely communication of such sort would allow greater understanding
across different cultures, which may possibly alleviate some tension. Borovoy
and Hine accept that “culturally competent medicine” maybe too difficult to
implement, so they propose cultural sensitivity, which needs to be born by the openness
and cooperation within each individual physician.
In
conclusion, the Hmong and Russian émigrés are simply two groups out of the vast
immigrant population within the United States. Further development of
cross-cultural medicine needs to take precedence within global health concerns.
By doing so, medicine will be able to serve its purpose to its full potential
and help the maximum number of people. It is extremely difficult to cooperate when
facing opposing cultural beliefs within healthcare. “Cultural competence” is
flawed in its nature of viewing people as able to become “competent” in
culture. Culture is not something that can be learned as if it was mathematics
or science. It needs to be learned through time and appreciation. An
alternative method is to encourage medical professionals to strive towards
cultural sensitivity and humility, where deeper cultural understanding is
integrated with openness and respect. The “culture of biomedicine” is one that
needs to be accepted and studied as well.
Medical
anthropology needs to further explore other possible methods of bridging the
communication and culture gap within medicine. Kleinman’s set of questions is good
start to a field that needs continual study.
Sources:
Borovoy, Amy and Hine, Janet
2008. Managing
the Unmanageable: Elderly Russian Jewish Émigrés and the Biomedical Culture of
Diabetes Care. Medical Anthropology Quarterly Vol. 22 1-26
Fadiman, Anne
1997. The Spirit Catches You and You Fall Down. New
York: Farrar, straus and Giroux
Taylor, Janelle
2003. The
Story Catches You and You Fall Down: Tragedy, Ethnography, and “Cultural
Competence”. Medical Anthropology Quarterly 17(2): 159-181
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