The Spirit Catches You and You Fall Down: A Hmong Child, Her American Doctors, and the Collision of Two Cultures is a 1997 book by Anne Fadiman that chronicles the struggles of a Hmong refugee family from Houaysouy, Sainyabuli Province, Laos,[1] the Lees, and their interactions with the health care system in Merced, California. In 2005 Robert Entenmann of St. Olaf College wrote that the book is "certainly the most widely read book on the Hmong experience in America."[2]
On the most basic level, the book tells the story of the family's second youngest and favored daughter, Lia Lee, who was diagnosed with a severe form of epilepsy named Lennox-Gastaut Syndrome, and the cultural conflict that obstructed her treatment.
Through miscommunications about medical dosages and parental refusal to give certain medicines due to mistrust, misunderstandings, and behavioral side effects, and the inability of the doctors to develop more empathy with the traditional Hmong lifestyle or try to learn more about the Hmong culture, Lia's condition worsens. The dichotomy between the Hmong's perceived spiritual factors and the Americans' perceived scientific factors comprises the overall theme of the book.
The book is written in a distinctive style, with every other chapter returning to Lia's story and the chapters in between discussing broader themes of Hmong culture, customs, and history; American involvement in and responsibility for the war in Laos; and the many problems of immigration, especially assimilation and discrimination. While particularly sympathetic to the Hmong, Fadiman presents the situation from the perspectives of both the doctors and the family. An example of medical anthropology, the book has been cited by medical journals and lecturers as an argument for greater cultural competence, and is often assigned to medical, pharmaceutic, and anthropological students in the US. In 1997, it won the National Book Critics Circle Award for General Nonfiction.[3]
Major characters
Lia Lee (Romanized Popular Alphabet: Liab Lis,[4] July 19, 1982 – August 31, 2012.[5]): a Hmong child born in Merced, California, in 1982. Beginning in infancy, Lia experiences severe seizures due to Lennox–Gastaut syndrome, a rare form of epilepsy.
Anne Fadiman: author and narrator of The Spirit Catches You and You Fall Down, writing about her experience with Lia and her family. Throughout the story, she stresses the importance of cultural competence in the doctor-patient relationship (and in the greater medical establishment).
Neil Ernst and Peggy Philp: Lia’s primary care doctors at MCMC. Throughout the story, they clash with Lia's parents, whose adherence to Hmong shamanism conflicts deeply with their own beliefs about Western medicine. Despite the good intentions of Ernst, Philp, and Lia's parents, significant miscommunication and disagreement cause Lia permanent harm.
Foua Yang and Nao Kao Lee: Lia’s parents, who believe fervently in the traditional Hmong approach to medicine.
Jeanine Hilt: a social worker who makes Lia her personal cause and fights on Lia’s behalf. She is presented as one of the few members of the American medical establishment willing to acknowledge Hmong tradition and tailor treatment to Lia's case.[6][7]
Summary
Mercy Medical Center Merced, previously the Merced Community Medical Center; is a new building and not the previous building where Lia Lee was taken
Lia experienced her first seizure at three months of age, but a resident at Merced Community Medical Center misdiagnosed her condition, and the hospital was unable to communicate with her parents since the hospital had no Hmong interpreters. Anne Fadiman wrote that Lia's parents did not give her medication as it was prescribed because they believed that Lia Lee's state showed a sense of spiritual giftedness, and they did not want to take that away. The American doctors did not understand the Hmong traditional remedies that the Lee family used. The doctors treating Lia Lee, Neil and Peggy Ernst, had her removed from her home when she was almost three years of age, and placed into foster care for one year, causing friction with her parents. By age 4½ Lia Lee had been admitted to hospital care 17 times and had made over 100 outpatient visits.[8]
The worst seizure Lia had put her on the verge of death. She went to the emergency room and Dr. Neil Ernst could not do anything. He talked to Lia's parents about transferring her to Fresno, California because Lia would need further treatment that Ernst could not provide. Lia's parents believed their daughter was transferred because of Ernsts' vacation plans.
Lia Lee slipped into a coma after suffering from a tonic-clonic seizure in 1986 when she was four years of age. Lia Lee's doctors believed she would die, but Lia Lee remained alive but with no higher brain functions.[8]
Research
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Fadiman's sources for information about the history of the Hmong include Hmong: History of a People by Keith Quincy. She stated "Were I citing the source of each detail, Quincy's name would attach itself to nearly every sentence in the pages on the Hmong in China."[7] Fadiman's book cited the Quincy theory that the Hmong people originated from Siberia.[9] Entenmann wrote that because of the reliance on Quincy's book, Fadiman's book propagates the idea that Sonom was a Hmong king, a concept that Entenmann says is inaccurate.[2]
Legacy
Marilyn Mochel, a nurse and clinical educator at Sutter Merced Medical Center (now Mercy Medical Center Merced), who heads the hospital's cross-cultural program, said in 1999 that "The book has allowed more dialogue. There's certainly more awareness and dialogue than before. Both sides are teachers and learners."[10]
Lia Lee lived in a persistent vegetative state for 26 years. She died in Sacramento, California, on August 31, 2012, at the age of 30.[5] At that age she weighed 47 pounds (21kg) and was 4feet 7inches (1.40m) tall; many children with severe brain damage have limited growth as they age.[11] Outside of California her death was not widely reported. Fadiman said that pneumonia was the immediate cause of death. Margalit Fox of The New York Times said "[b]ut Lia’s underlying medical issues were more complex still" because she had lived in a persistent vegetative state for such a long period of time. As of 2012 most individuals who go into that state die three to five years afterwards.[5]
In 2019, The Spirit Catches You and You Fall Down was ranked by Slate as one of the 50 greatest nonfiction works of the past 25 years.[12]
Reception
Ralph Jennings of The Modesto Bee said "Hmong, including some among the 2,000 in Modesto, say the book typified conflicts between their culture and American institutions. But some say it didn't capture the complexity of the Hmong culture."[10]
Cheng Lee, a brother of Lia Lee, said that his father and mother liked Fadiman's book.[10]
“Compellingly written, from the heart and from the trenches. I couldn’t wait to finish it, then reread it and ponder it again. It is a powerful case study of a medical tragedy.” - David H. Mark, Journal of the American Medical Association
Anne Fadiman's essay "Hmong Odyssey", adapted from the book, was published in the March–April 1998 Via. The Hmong community leaders in Fresno, California, praised the essay, saying that it was thoughtful and accurate.[13]
↑ Fadiman. "Foua and Nao Kao." The Spirit Catches You and You Fall Down. Farrar, Straus and Giroux. 1997. 103. "[...]I asked her to describe a typical day in Houaysouy, the village in the northwestern province of Sayaboury where the Lee family had lived."
↑ Fadiman, Anne. "Note on Hmong Orthography, Pronunciation, and Quotations." The Spirit Catches You and You Fall Down. Farrar, Straus and Giroux. 1997. 292.
Fox, Renée C., Ph.D. "Cultural Competence and the Culture of Medicine." New England Journal of Medicine. 2005; 353:1316-1319. September 29, 2005. DOI: 10.1056/NEJMp058066
New England Journal of Medicine article 2
Malina, Debra, Ph.D. "Compliance, Caricature, and Culturally Aware Care." New England Journal of Medicine. 2005; 353:1317-1318. September 29, 2005. DOI: 10.1056/NEJMp058064.
Merced is a city in, and the county seat of, Merced County, California, United States, in the San Joaquin Valley. As of the 2020 census, the city had a population of 86,333, up from 78,958 in 2010. Incorporated on April 1, 1889, Merced is a charter city that operates under a council–manager government. It is named after the Merced River, which flows nearby.
Vang Pao was a major general in the Royal Lao Army and later a leader of the Hmong American community in the United States.
In medicine and medical anthropology, a culture-bound syndrome, culture-specific syndrome, or folk illness is a combination of psychiatric and somatic symptoms that are considered to be a recognizable disease only within a specific society or culture. There are no known objective biochemical or structural alterations of body organs or functions, and the disease is not recognized in other cultures. The term culture-bound syndrome was included in the fourth version of the Diagnostic and Statistical Manual of Mental Disorders which also includes a list of the most common culture-bound conditions. Its counterpart in the framework of ICD-10 is the culture-specific disorders defined in Annex 2 of the Diagnostic criteria for research.
Hmong Americans are Americans of Hmong ancestry. Many Hmong Americans immigrated to the United States as refugees in the late 1970s. Over half of the Hmong population from Laos left the country, or attempted to leave, in 1975, at the culmination of the Laotian Civil War.
The Hmong people are an ethnic group currently native to several countries, believed to have come from the Yangtze river basin area in southern China. The Hmong are known in China as the Miao, which encompasses not only Hmong, but also other related groups such as Hmu, Qo Xiong and A-Hmao. There is debate about usage of this term, especially amongst Hmong living in the West, as it is believed by some to be derogatory, although Hmong living in China still call themselves by this name. Throughout recorded history, the Hmong have remained identifiable as Hmong because they have maintained the Hmong language, customs, and ways of life while adopting the ways of the country in which they live. In the 1960s and 1970s, many Hmong were secretly recruited by the American CIA to fight against communism during the Vietnam War. After American armed forces pulled out of Vietnam the Pathet Lao, a communist regime, took over in Laos and ordered the prosecution and re-education of all those who had fought against its cause during the war. While many Hmong are still left in Laos, Thailand, Vietnam, Myanmar, and China, since 1975 many Hmong have fled Laos in fear of persecution. Housed in Thai refugee camps during the 1980s, many have resettled in countries such as the United States, French Guiana, Australia, France, Germany, as well as some who have chosen to stay in Thailand in hope of returning to their own land. In the United States, new generations of Hmong are gradually assimilating into American society while being taught Hmong culture and history by their elders. Many fear that as the older generations pass on, the knowledge of the Hmong among Hmong Americans will die as well.
Anne Fadiman is an American essayist and reporter. Her interests include literary journalism, essays, memoir, and autobiography. She has received the National Book Critics Circle Award, the Los Angeles Times Book Prize for Current Interest, and the Salon Book Award.
Vue Pa Chay's revolt, also called War of the Insane or the Madman's War by French sources, was a Hmong revolt against taxation in the French colonial administration in Indochina lasting from 1918 to 1921. Vue Pa Chay, the leader of the revolt, regularly climbed trees to receive military orders from heaven. The French granted the Hmong a special status in 1920, effectively ending the conflict.
Danielle Ofri is an American essayist, editor, and practicing internist. She is an attending physician at Bellevue Hospital, and a clinical professor of medicine at the New York University School of Medicine. Her writing appears in The New Yorker, The New York Times, and The Lancet.
The Hmong People society originally from Thailand, Laos, Vietnam, and southeast China. As of 2011 the worldwide Hmong population is about four million. The Hmong culture is patrilineal, allowing a husband's family to make all major decisions, even when they solely concern the woman. However, the Hmong women have traditionally carried a large amount of responsibility and some power due to their necessary contribution of food and labor to the family.
The Hmong are a major ethnic group residing in Merced, California. As of 1997, Merced had a high concentration of Hmong residents relative to its population. The Hmong community settled in Merced after Dang Moua, a Hmong community leader, had promoted Merced to the Hmong communities scattered across the United States. As of 2010, there were 4,741 people of Hmong descent living in Merced, comprising 6% of Merced's population.
The Hin Heup massacre was the massacre of 14 Hmong civilians at Hin Heup bridge by Pathet Lao troops.
Mercy Medical Center Merced is a hospital in Merced, California. Dignity Health operates the facility.
Sainyabuli province is a province in northwest Laos. The capital of the province is the town of Saiyabuli. Saiyabuli is the only Lao province that is completely west of the Mekong River.
Kev Dab Kev Qhuas is the common ethnic religion of the Miao people, best translated as the "practice of spirituality". The religion is also called Hmongism by a Hmong American church established in 2012 to organize it among Hmong people in the United States.
The Hmong population in California is the largest in the United States. Most fled to the United States as refugees in the late 1970s due to their cooperation with the Central Intelligence Agency operatives in northern Laos during the Vietnam War, or are a descendant.
Hmong: History of a People is a book by H. Keith Quincy, PhD, published by the Eastern Washington University Press. It was initially published in 1988 with a revised edition published in 1995.
Sonom was a chieftain of the rGyalrong people in China. He was the lord-lama of Greater Jinchuan. He was executed after his January 1776 defeat in the Jinchuan campaigns.
Kao Ly Ilean Her was an American attorney, activist and leader in the Hmong American community in Minnesota. Her was the first Hmong person elected to the University of Minnesota Board of Regents, where she served from 2019 to 2021, and she was executive director of the state government agency Council on Asian Pacific Minnesotans (CAPM) from 1997 to 2012. She was a pioneer for the Hmong community in Minneapolis-St. Paul, becoming the first Hmong woman to be admitted to the Minnesota State Bar Association, founding several nonprofits, and leading the Hmong Elders Center.
Hmongtown Marketplace is an indoor-outdoor marketplace focused on Hmong American products and culture in the Frogtown neighborhood of Saint Paul, Minnesota. Hmongtown was the first Hmong-owned and operated marketplace in the United States and is today noted for its cuisine and produce.
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