The Spirit Catches You and You Fall Down: A Hmong Child, Her American Doctors, and the Collision of Two Cultures

Fadiman sets up her main point with the opening statement, “I have come to believe that [Lia’s] life was ruined not by septic shock or noncompliant parents but by cross-cultural misunderstanding” (262). She refers to Lia’s case as a “narrative,” using the terminology of Kleinman who “believes every illness is not a set of pathologies but a personal story” (262). From here, Fadiman narrates several stories about the experiences of Hmong patients in American hospitals. When doctors do not account for their cultural beliefs and practices, the cases end badly. When doctors listen and incorporate their concerns, the outcomes are much better.

Fadiman describes the successful approach of Francesca Farr, a hospital social worker, who makes house calls and uses a cultural broker during her visits with the Hmong. As Fadiman writes, “She worked within the family’s belief system. She did not carry her belief system […] into the negotiations. She never threatened, criticized, or patronized. She said hardly anything about Western medicine” (265). Fadiman contrasts this with the approach of Peggy and Neil who have difficulty accepting and showing “a concern for the psychosocial and cultural facets that give illness context and meaning” (265). Fadiman describes them as “imperfect healers” because they refuse to compromise “whenever a patient crossed the compliance line” (265).

The remainder of the chapter offers solutions for how to improve cross-cultural communication between patients and medical practitioners. Fadiman refers to the work of Bruce Bliatout and his suggestion of practicing “conjoint treatment—that is, integrate Western allopathic medicine with traditional healing arts” (266). This approach, which accounts for psychosocial and cultural factors, establishes trust between patients and their doctors, thus improving outcomes. Fadiman provides several examples of hospitals, including MCMC, using Bliatout’s recommendations and having successful results.

Since 1995, medical schools have begun to incorporate cross-cultural training in their curriculum with varying degrees of success. Students often are taught to disassociate from patients, a type of emotional distancing meant to produce objectivity. This tactic is counter to models that advocate for doctors to bring their humanity to the hospital and recognize patients as complete persons. Fadiman ends the chapter with a description of a dinner between Bill Selvidge and Sukey Waller. They end up arguing over whether it is more important to save a life or a soul. Bill, the doctor, choses the life, and Sukey, the psychologist, choses the soul.

Fadiman returns to the folktale of Shee Yee, the Hmong magician and healer, to explain the origin of illness, which emerges from a large egg filled with evil dabs. Shee Yee fights the dabs and heals people. He travels to a mountain high above earth and never returns but does not forsake people. He sprays holy water from his mouth and drops tools down. Anyone who feels the water or catches the tools are anointed as a txiv neeb—a host for the healing spirit. Only they can fly to the door in the sky and summon Shee Yee’s spirits and ride his horse, pretending to be Shee Yee, thus fooling the evil dabs.

The rest of the chapter describes a healing ceremony that the Lees arrange for Lia. The Lees do not think that Lia will be healed completely since a txiv neeb told them the doctor’s medicines harmed her irreparably. They hope the ceremony will alleviate some of her suffering so that she does not cry at night. Fadiman describes all the steps of the ceremony and narrates the significance of each detail—from the preparation to the ritual itself. She devotes a lot of attention to a key participant in the ceremony, Cha Koua Lee, who is the txiv neeb. At first, Cha Koua Lee appears ordinary to Fadiman but then she describes his transformation into a powerful spiritual mediator as he enters a self-induced trance to try and recover Lia’s soul from the dabs. The Lees still hold out hope that the dabs might take the sacrificial pig’s soul, thus restoring Lia to her former health.

With the support of her family and relatives attending, it is clear Lia is well-loved. Fadiman concludes the chapter—which was the original ending to the book—with a poetic chant from the txiv neeb who repeatedly asks where Lia has gone and calls for her to come home.

In 2012, Fadiman writes the afterword to her book, marking the 15th anniversary of its publication. The afterword provides updates and explains the significance of the book to a wider audience. Lia is still alive although gaunt and stiff. Lia’s siblings primarily care for her since Foua is in fragile health. Nao Kao died in 2003 of heart failure. Fadiman attends the funeral and describes her grief. She also explains the importance of Lia on her life:

How can I say she is not valuable when she means so much to the people around her? How can I say she has nothing to contribute when she altered the course of my family life, my life as a writer, and my whole way of thinking—and may also have some of the people who have read about her? (290).

All of Lia’s doctors have left MCMC and now practice medicine at small rural clinics. Peggy and Neil join Dan Murphy in Oregon, where he advocates for Patient-and-Family-Centered Care. This form of care promotes communication between doctors and patients and gives patients a direct voice in their medical treatment. In 2009, MCMC received national recognition for its program, Partners in Healing, which incorporates shamans in the medical treatment of patients.

Fadiman also discusses recent theories of cross-cultural communication. Citing Kleinman, she explains the pitfalls of a “cultural competency” model that assumes one can know everything about another cultural group and reduce treatment to a series of “do’s and don’ts” (295). Rather, Fadiman speaks of “cultural humility” and “cultural responsiveness,” which “encourages doctors to listen to patients and respond to them both as members of their cultures and as unstereotyped individuals” (295).

Fadiman situates her book within a particular historical moment: “The Spirit Catches You and You Fall Down is a book written in the 1990s about the 1980s” (296). She explains her reasons for not revising parts of the book, including problematic language, as a strategic choice to not disrupt its balance or fall into the trap of “presentism” (300). Fadiman describes the heterogeneity of the Hmong as a cultural group and their internal differentiation, including their growing political clout. Fadiman reiterates that her book was never intended as “the book about the Hmong but as a book about communication and miscommunication across the cultures” (301).

Fadiman concludes with a description of a panel session at U.C. Davis, where she gives a talk with Lia’s parents, May Ying, Neil, and Peggy. Lia’s sister, Mai, who is a student at U.C. Davis, participates and speaks to a crowd of 400 students. Neil explains his reasons for putting Lia in foster care and apologizes for the hurt he caused her family. Afterwards Nao Kao walks up to Neil and says he understands how much Lia’s doctors cared about her and thanks him. Fadiman writes that she believes she witnessed “a common language” (303).