There is growing recognition today of the importance of cultural differences in many spheres of life, including health care. Anne Fadiman wrote a nonfiction book entitled The Spirit Catches You and You Fall Down, which is the story of a young Hmong girl named Lia Lee who had epilepsy. The family lived in a refugee camp in California, and Lia’s parents treated her with traditional Hmong remedies. This was regarded by American doctors as neglect, and Lia was taken away from her family. To address the issues of cultural dimensions and cultural conflict in the book, it is necessary to summarize the story, discuss the themes of collectivism and uncertainty avoidance, examine the two conflicting parties’ biases and stereotypes, and explore the concepts of assimilation, multiculturalism, and reconciliation in the context of Lia’s story.
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The book has two categories of chapters in it: some of them narrate the story of Lia Lee and her family, while other chapters discuss the history and culture of the Hmong people in general. The first chapter is dedicated to Lia’s birth; out of 14 children of Foua Yang and her husband at the time, Nao Kao Lee, 12 had been born in Laos and delivered according to Hmong traditions (Fadiman 3). From the beginning, the reader becomes familiar with the complex Hmong culture, which features many elaborate beliefs and rituals. Specifically, many traditions are related to the way a child should be delivered and treated during the first days of his or her life. An important role in these beliefs and rituals is played by the txiv neeb (Fadiman 4), a shaman.
In addition, the author reflects on the history of the Hmong people and the way they were repeatedly oppressed in many countries in which they lived. Going back to Lia, Fadiman tells the story of Lia’s first seizure, which her parents called “qaug dab peg,” which means ‘the [soul-stealing] spirit catches you and you fall down’” (Fadiman 20). They tried many traditional remedies to treat their daughter’s condition the way they understood it. Later, the young girl was admitted to a hospital, but her epilepsy was not diagnosed at the time, primarily because the doctors could not communicate with Lia’s parents (they did not speak English, and the hospital did not have an interpreter).
When the condition was finally diagnosed and medicines were prescribed, Lia’s parents were reluctant to give all of the medicines to their daughter, and they preferred to apply “a little medicine and a little neeb [the healing spirit]” (Fadiman 106). The latter refers to their traditional healing practices. Thinking that Lia had received poor treatment, her doctors took her away from her family and placed her in foster care (the girl was not yet three years old). Lia was getting worse, and more frequent major seizures eventually left her brain-dead at the age of four (Fadiman 150). Although the doctors thought that Lia would die shortly and discharged her from the hospital, Lia’s parents managed to take care of her and support her for many years; this, according to Fox, was an example of redefining care. Lia Lee died in 2012 when she was 30 years old.
Individualism and Collectivism
One of the cultural dimensions discussed by theorists is the dimension of individualism versus collectivism, and it is extensively explored in Fadiman’s book. According to the author’s discussion of Hmong culture, the Hmong community in Merced, California, had remarkably strong internal bonds. For example, Hmong people residing in the refugee camp preferred to buy their traditional medicines in a market just outside the camp instead of going to the camp hospital (Fadiman 36). It is evident that living in a community that provided support and helped them follow traditional values and attitudes was extremely important in Hmong culture, and this importance was dramatically underestimated by the doctors who treated Lia Lee.
The members of the Hmong community were highly critical of the decision to take Lia away and place her in foster care (Fadiman 84). Their indignation was related not only to the fact that Lia had been taken away from her parents but also to the fact that she had been taken away from a community that wanted to take care of her according to its own traditions of collectivism. As a result, people in the camp became suspicious of the medical community and saw it as a coercive authority. The reason the community valued collectivism so highly was the great amount of oppression to which the Hmong people had been subjected during their history. Fadiman repeatedly refers to this factor throughout the book. Not having their own country, they always lived among other people who were often hostile to them; to preserve their culture, the Hmong people had to develop strong community bonds and traditions of collectivism.
However, the role of individualism in the Hmong culture should not be overlooked. It is noteworthy that Hmong women deliver their children themselves without any attendants (Fadiman 3), and a Hmong person Fadiman interviewed stressed that parents are primarily responsible for their children, not the community (84). Brooks stresses that American society is quite individualistic and competitive; at the same time, there is a growing acknowledgment of the importance of close-knit communities and integrating collectivist values. Many societies have in fact identified a need to return to communitarianism today (Weaver 59). Apparently, the American culture that the Lee family faced was still too individualistic for them, and their collectivist values were not properly respected.
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Another cultural dimension that should be discussed in the context of this book is uncertainty avoidance. According to Croucher, high uncertainty avoidance in a society means that it has many rules and regulations aimed at decreasing the level of unpredictability; therefore cultures with low uncertainty avoidance have fewer rules and codes of conduct (88). It is evident that the Hmong culture has a high level of uncertainty avoidance. From the beginning of the book, Fadiman describes many complicated rituals and beliefs to which the Hmong people adhere in order to avoid negative scenarios and uncertainty.
These avoidance behaviors can be observed in the first chapter. Many of the things that happen to her at the hospital where she is delivering her fourteenth child surprise Foua Yang; for example, she refuses to drink iced water because the Hmong people believe that “cold foods during the postpartum period make the blood congeal in the womb instead of cleansing it by flowing freely, and that a woman who does not observe the taboo against them will develop itchy skin or diarrhea in her old age” (Fadiman 8). This is a very specific guideline with a detailed list of outcomes, and there is a remarkable number of such guidelines encountered by the reader throughout the book. American culture has a lower level of uncertainty avoidance, and this was another reason for cultural conflict. Lia Lee’s doctors failed to recognize the importance of complying with the avoidance-related cultural guidelines respected by the family. This compliance was expressed by adhering to traditional remedies and applying the “healing spirit” to the process of treating Lia.
Culture Conflict: Stereotyping, Bias, and Discrimination
Stereotyping, bias, and discrimination play a significant role in the development of the cultural conflict that affected the Lee family. Stereotyping is closely related to prejudice, and the origin of prejudice is separation. Many people emphasize differences and stress the distinction between “us” and “them.” It has been widely recognized that the mechanism behind this thinking is a simplification: in a complicated world, it is easier to think that all the representatives of a certain culture or people with a certain skin color share common characteristics, often negative ones.
While some people appreciate differences and diversity, other people fear otherness and treat different people with suspicion. These two worldviews are demonstrated in the attitudes the health care providers in Merced, California, demonstrated toward Hmong food (Hmong women often refused to eat hospital food and had traditional meals delivered to them by their families). According to Fadiman, one obstetrician said that this food “always smelled great,” while another one described it as “some horrible stinking concoction that smelled like the chicken had been dead for a week” (9). This is a striking example of the difference between appreciating otherness and rejecting it.
However, it should be noted that bias was shown by both sides in the conflict. For example, after Hmong women had babies at the hospital, most doctors refused to give them the placenta, which the women wanted to bury in their home according to the traditional beliefs. The doctors were afraid that “the women planned to eat the placentas, and have found that idea disgusting” (Fadiman 6); they were also concerned about the spread of diseases through the consumption of the placenta. In turn, the Hmong population of a refugee camp in Thailand shared a number of biased and destructive beliefs about the Americans, as they thought that, when Hmong patients died, American doctors ate their brains (Fadiman 32). Based on these myths, Lia’s parents and her doctors did not trust each other, although both parties genuinely wanted to help the little girl and did their best to do so.
Assimilation and Multiculturalism
It can be argued that a certain degree of assimilation and a multicultural approach could have prevented the negative consequences that Lia’s disease had for her and for those around her. If the Lee family had been more assimilated into American society, they would have been more willing to comply with medical prescriptions, and Lia would not have been taken away from them. However, if the doctors had employed a multicultural approach and had demonstrated cultural competence in the delivery of care, they would not have separated the child from her family, while the separation arguably had a dramatically harmful effect on her health. It is noteworthy that Lia’s parents were open to compromise, as they adopted the attitude of “a little medicine and a little neeb” (Fadiman 106). The doctors, however, turned out to be less flexible, as they firmly believed in the superiority of Western medicine over the traditional remedies, in whose effectiveness the Hmong people strongly believed.
However, assimilation and multiculturalism require establishing trust, and the two parties of the conflict apparently did not trust each other. While some Hmong people preferred a doctor to a shaman despite the fact that they considered doctors’ approaches to care inferior to their own (Fadiman 77), many were reluctant to follow prescriptions. Lia’s parents ultimately became certain that their daughter’s vegetative state was the result of improper treatment provided by American doctors. This shows that stereotypes and biases described above are difficult to overcome. Kolbert stresses that people tend to experience pleasure when their beliefs are reaffirmed and to experience discomfort when their beliefs are challenged. Moreover, even when it is revealed that certain information provided to a person is false, the person may be reluctant to stop believing that information. The lack of cultural consideration in the conflict over Lia Lee was largely the result of the two parties’ reluctance to overcome their bias and stereotypical thinking (see Culture Conflict: Stereotyping, Bias, and Discrimination) and to admit that their negative images of one another were based on false premises.
Reconciliation of two positions (e.g., cultural worldviews) is associated with reaching a compromise and achieving mutual understanding. However, as has been established, what is needed to reconcile conflicting worldviews is a willingness to be open and overcome stereotypes. The Lee family’s beliefs concerning the way an ill child should be treated were specific and complicated, and what the doctors who treated Lia could not understand was how important it was for the family to adhere to these beliefs. As was discussed, the Hmong people have had a difficult history of oppression and living among people who practiced discrimination against them. Under these circumstances, the Hmong people developed many guidelines to regulate their everyday lives (see Uncertainty Avoidance); this was their instrument for preserving their culture and preventing assimilation. This is why they refused to eat food that was not prepared according to their detailed and particular rituals; it is how they protected the boundaries of their community and survived as a people.
However, the American doctors involved in the conflict were not willing to consider the importance of Hmong traditions and thought that Lia’s parents neglected her and obstructed proper medical treatment. If the doctors had been more respectful, they could have convinced the Lee family to meet them halfway; i.e., to practice rituals that the doctors did not regard as harmful and to give appropriate medicines to Lia at the same time. In turn, the girl’s parents could have admitted that the doctors only wanted to help Lia and could have allowed the doctors to deliver the necessary treatment while applying their traditional remedies as well. However, a reconciliation was not reached because the two parties did not allow one another to do what each party believed had to be done to help Lia.
Fadiman succeeded in telling the story of Lia Lee in a way that the reader can see both sides of the cultural conflict. Lia’s parents and her doctors wanted to help the young girl, and they all were acting according to what they thought was the best way to help, but they lacked understanding of one another’s approaches. The two parties also had stereotypes about each other and were reluctant to overcome them. As a result of the lack of multiculturalism and cultural competences in care and the lack of appreciation and respect toward each other’s beliefs, Lia’s doctors and parents failed to achieve reconciliation, which could have prevented Lia’s dramatically negative health outcomes and her family’s suffering.
Brooks, David. “Communities of Character.” The New York Times. 2015, Web.
Croucher, Stephen M., editor. Global Perspectives on Intercultural Communication. Routledge, 2017.
Fadiman, Anne. The Spirit Catches You and You Fall Down: A Hmong Child, Her American Doctors, and the Collision of Two Cultures. Farrar, Straus and Giroux, 1998.
Fox, Margalit. “Lia Lee Dies; Life Went on Around Her, Redefining Care.” The New York Times. 2012, Web.
Kolbert, Elizabeth. “Why Facts Don’t Change our Minds.” The New Yorker. 2017, Web.
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Weaver, Gary Rodger. Intercultural Relations: Communication, Identity and Conflict. 3rd ed., Pearson, 2014.