A Narrative Nonfiction Classic on Cultural Clashes in Medicine

Book review: The Spirit Catches You and You Fall Down, by Anne Fadiman (Amazon / Book Depository)

Published twenty years ago this year, this book consistently tops lists of the best (narrative) nonfiction. I was late reading it, but so glad I finally got around to it. This’ll be my last review this year – next week I’ll post my year end best-of lists – and I really wanted to cover it now since it was definitely one of the best things I read this year.

It’s one of those books that manages to be so captivating in its subject matter, well-researched, and smoothly written that even despite not initially having heaps of interest in its subject, I loved reading it.

The story is a kind of dual narrative: first, of the Lee family, refugees living in Merced, California; and of the doctors at Mercy Medical Center Merced who treat the Lees’ baby daughter Lia for epilepsy over the course of several years. And from both sides, the massive culture clash that ensues.

The heart of this conflict is that the Lees’ background includes a shaman-animistic belief structure, which influences their ideas about health, medicine, and treatment. It doesn’t gel with the doctors’ complicated instructions about medicines and administration, medical tests, disagreements about underlying causes, and this isn’t even touching on the language barrier that makes communication and “compliance” with prescribed treatment more complicated by leaps and bounds.

Everyone in Merced’s Lee and Yang clans knew what had happened to Lia (those bad doctors!), just as everyone on the pediatric floor at MCMC knew what had happened to Lia (those bad parents!). Lia’s case had confirmed the Hmong community’s worst prejudices about the medical profession and the medical community’s worst prejudices about the Hmong.

The Lees are Hmong, a mountain-living people from Asia, primarily from China, Vietnam, and Laos. Many Hmong fought with the United States in the Laotian Civil War between the Communist Pathet Lao and the US-backed Royal Lao Government. The Hmong were promised safety and refuge in America if they supported the CIA during what was really a proxy war between the US and the Soviet Union. They were able to immigrate, but as Fadiman details, cultural assimilation to their new country didn’t come easily. Younger generations have fared much better, as is often the case with immigrant families, but there’s something especially stubborn, or incompatible, or both, about the new Hmong in America.

Some newcomers wore pajamas as street clothes; poured water on electric stoves to extinguish them; lit charcoal fires in their living rooms; stored blankets in their refrigerators; washed rice in their toilets; washed their clothes in swimming pools; washed their hair with Lestoil; cooked with motor oil and furniture polish; drank Clorox; ate cat food; planted crops in public parks; shot and ate skunks, porcupines, woodpeckers, robins, egrets, sparrows, and a bald eagle; and hunted pigeons with crossbows in the streets of Philadelphia.

If the United States seemed incomprehensible to the Hmong, the Hmong seemed equally incomprehensible to the United States. Journalists seized excitedly on a label that is still trotted out at regular intervals: “the most primitive refugee group in America.”

The book manages to be something of a cultural study of the Hmong as a people as well as their experience in America, where they fiercely clung to their cultural heritage, having been promised this was possible in the land of the free.

It’s also a study of immigration and the uphill battle that refugees face in being able to work, learn the language, and assimilate to the point of feeling comfortable and being accepted in their new country. Fadiman extensively details why this is so difficult and even undesirable for the Hmong.

The title is an approximate English translation of the Hmong word for epilepsy, and like many Hmong terms it’s an illustrative one describing a situation more than it’s a word, and this is yet another problem creating a chasm in understanding between American and Hmong culture: a language barrier that’s difficult to bridge even with translators and interpreters. A cultural understanding of both sides, almost the ability to anticipate how cultural beliefs will influence perception and decision-making in both parties, is necessary for an interpreter just as much as knowing both vocabularies.

Hmong, like Lia’s parents, believe that shamanistic spirits, “dab”, are responsible for illness, among other things. Fadiman shows how others were ultimately successful in communicating cross-culturally with Hmong, which unfortunately wasn’t the case in Lia’s treatment, despite her hardworking doctors’ efforts to help her. I loved this story of Dwight Conquergood, an ethnographer working in a refugee camp, who cottoned on to how pleas for action to Hmong can’t rely solely on western scientific or medical explanations, but have to appeal to and/or be filtered through their belief structure:

Conquergood’s first challenge came after an outbreak of rabies among the camp dogs prompted a mass dog-vaccination campaign by the medical staff, during which the Ban Vinai inhabitants failed to bring in a single dog to be inoculated. Conquergood was asked to come up with a new campaign. He decided on a Rabies Parade, a procession led by three important characters from Hmong folktales—a tiger, a chicken, and a dab—dressed in homemade costumes. The cast, like its audience, was one hundred percent Hmong. As the parade snaked through the camp, the tiger danced and played the qeej, the dab sang and banged a drum, and the chicken (chosen for this crucial role because of its traditional powers of augury) explained the etiology of rabies through a bullhorn.

A deserving nonfiction classic. Fadiman weaves together so much information on different topics in a fascinatingly readable narrative. It’s well-written and eye-opening, with an incredibly important underlying issue, about understanding the important role of cultural differences in medical treatment. My rating: 4.5/5

The Spirit Catches You and You Fall Down:
A Hmong Child, Her American Doctors, and the Collision of Two Cultures
by Anne Fadiman
published 1997 by Farrar, Straus and Giroux

(Amazon / Book Depository)