The Spirit Catches You and You Fall Down- Anne Fadiman (1997)

Click here to buy this book

Anne Fadiman’s 1997 book The Spirit Catches You and You Fall Down is a remarkable analysis of cross-cultural conflicts in medicine in the case of Hmong patients treated in Merced, California. The book follows the story of Lia Lee, the child of Hmong refugees living in Merced in the 1980s, who developed epilepsy at a young age. The rift that existed between the priorities of her American doctors and those of her parents tragically compromised Lia’s long term health. Moreover, this work provides an informed insight into Hmong culture, religion, society and history and argues compellingly in favour of a better understanding of different cultural approaches to health and medicine within the American medical system.

The Hmong are a mountain-dwelling people that originate from China but expanded south to highland territories of Laos, Vietnam and Thailand in a mass migration to escape Chinese persecution in the eighteenth century. The Hmong traditionally occupy land only at very high elevations and subsist on slash-and-burn agriculture. They maintain a unique language, culture and religion based on strict familial and clan structures and a belief in shamanist animism. How large numbers of this minority group ended up living in a small city in California is dissected by Fadiman; in the 1970s Hmong tribesmen in Laos were recruited by the CIA to help fight the communist Pathet Lao that challenged the US-backed royal government at the height of the Vietnam War. When Laos fell to communist forces in 1975, many Hmong fled west over the Thai border in fear of reprisals. The majority of these refugees eventually settled in the United States after being promised that they would be supported in the case of a communist victory.

Fadiman’s case study is the Hmong community in Merced. When the book was published, the city’s Hmong population totalled twelve thousand (of a total population of sixty one thousand), most of whom lived in a concentrated area of the city. First-generation refugees struggled with unemployment and dependency on welfare as a result of their lack of appropriate skills and poor English. Fadiman explains the fear that much of the Hmong community had of American hospitals, beginning with myths such as that ‘American doctors eat brains’ penetrating the Thai refugee camps where thousands of Hmong awaited re-settlement. Furthermore, the Hmong hold strong taboos against invasive medical procedures, believing that the body and soul are intrinsically linked. Without being able to effectively communicate this information to their doctors in Merced, the Hmong population were merely seen by medical professionals as extremely difficult and noncompliant patients.

When Fadiman asked the Lee family what it was that they believed had caused their daughter’s epilepsy, they told her that Lia’s condition was quag dab peg, a Hmong name that translates as ‘the spirit catches you and you fall down’. Lia’s first seizure occurred after her older sister slammed a door in the house; according to the Lees, Lia’s young soul had been frightened out of her body and stolen by an evil spirit called a dab. Nobody at the Merced County Medical Centre, to where Lia was carried in her parents’ arms throughout her childhood, asked the Lees for their explanation of Lia’s condition. Despite the significant Hmong population of the city, no interpreters were employed at the clinic; to the doctors who treated Lia, her parents were a source of frustration due to their refusal to administer Lia’s anticonvulsant medicines because of their lack of understanding of Western medical ideas.

The study was borne from an assignment Fadiman was given for The New Yorker (which was never published). Fadiman decided to expand her project into what would become her debut book, one for which, over the course of eight years, she claims to have read everything relevant that was available on Hmong culture and history at that time, along with conducting interviews with those on both sides of the Merced conflict in order to come to understand the roots, nature and potential solution to the issue.

This is an incredibly well-researched book that shows appreciation of both sides of the conflict that troubled Merced’s medical community in the late eighties. Fadiman acts as a sensitive and respectful broker between the two sides and highlights the damage that can be done when two cultures collide in a field as critical as medicine. The reception of her book has been profound. It was awarded the National Book Critics Circle Award in 1997 and is now used as recommended reading for medical students studying cultural cohesion in many institutions in the United States. In a 2012 interview with Rain Taxi, Fadiman talks about how things have changed since the period in which she was researching the book:

“I was actually just in Merced a couple of days ago and I saw the new hospital. And their interpreters are terrific, they have amazing training programmes, they let shamans in to do healing ceremonies right in the emergency room… Medical students now take classes in cultural competency, there’s a legal mandate for medical interpreting, everywhere. So things have really improved, but that doesn’t mean that there isn’t still room for improvement, there’s still incredible cross-cultural gulfs in medical care”.

Although the setting of this book is within the American medical system, I gained from it a lot of information about Hmong culture and history that may be useful for the purpose of my project. In 2005, there were 460,000 Hmong in Laos and the number surpasses one million in Vietnam. They remain a disengaged element of these two countries’ societies and are often discriminated against. It has been insightful for me to learn more about the fascinating culture of this secretive group. Moreover, I found this book incredibly compelling. Fadiman delves down to the roots of the cultural conflict that gripped the case of Lia Lee and I believe that even a hardened cynic couldn’t fail to be won around by her engaging explanation. The book draws upon concerning issues for the medical system in America but its influence seems to have been wholly positive in affecting change in a very important area.