Butler Beaudoin

Dr. Emerson

IDMD 102

13 February 2024

Where to Point the Finger?

Qaug dab peg: The Spirit Catches You and You Fall Down. That was the diagnosis Lia’s Hmong community had given her when she started having violent seizures. The American doctors knew the ailment by another name: epilepsy. In Anne Fadiman’s compelling novel, The Spirit Catches You and You Fall Down, the struggle of providing medical treatment across cultural boundaries is vividly depicted. The first four chapters recount the beginning of Lia Lee’s journey and illustrate how cultural assumptions can lead to unfavorable healthcare outcomes. In my presentation, I recounted the events of each chapter and analyzed the significance of their titles.

Chapter one is thoughtfully titled “Birth.” Not only does Fadiman describe the birth of Lia, the beginning of the story, but she also discusses the traditional practices of the Hmong people concerning the birth of a child and how they differ from those of Americans. Chapter two, “Fish Soup,” recounts the history and reflects on the culture of the Hmong people, providing some context for the narrative. Chapter three fittingly shares its name with the novel, “The Spirit Catches You and You Fall Down,” and recounts the onset of Lia’s epilepsy, or qaug dab peg. The language barrier initially prevented Lia’s parents from explaining what happened, and the doctors subsequently misdiagnosed her. “Do Doctors Eat Brains” is a strange title for chapter 4 and a seemingly stranger question to ask regarding western medicine. Still, it seems this is the general perception many Hmong possess regarding physicians in the United States.

These are my discussion questions:

1. In chapter one, most doctors refused to give the placentas to the mothers, fearing they would eat them and spread disease. How should doctors react when acknowledging their patients’ cultural traditions could be hazardous to their health?
2. Although we have many translators today, do language barriers still play a role in improper treatments? “The Spirit Catches You and You Fall Down” translation of Qaug dab peg might not necessarily imply epilepsy to an unknowing person (for instance a person familiar with the Hmong language but not the disease).
3. During Lia’s initial hospital visit she was misdiagnosed. Is there a way we can avoid this in the future even with language barriers?
4. The Hmong people’s questions for the woman returning from the United States suggest a bad perception of American healthcare. How can we reverse poor perceptions concerning western medicine?
5. Dwight Conquergood’s efforts to integrate inoculation into the local culture proved effective in Ban Vinai. How can we apply methods like this to our healthcare system?

The questions sparked a discussion of where to begin when addressing the poor healthcare with which Lia was provided. Should the blame be placed on individual physicians or was it a systemic, intersectional failure on the part of the US healthcare system? On the one hand, doctors should have probably asked more questions and communicated more effectively, but the lack of translators and education on Hmong culture was probably more detrimental. We also discussed the methods Dwight Conquergood used in chapter four to spread awareness for canine inoculation in Ban Vinai. Some felt it was manipulative and coercive, while others regarded it as merely informative and engaging. I tend to agree with the latter because the Hmong were not forced in any way to inoculate their dogs. Overall, it was a productive discussion, but I would like to delve deeper into the subject of who should be blamed for Lia’s poor healthcare.

Response:

Throughout these first four chapters, I feel that a type of “war between cultures” is unfolding. Lia’s parents Foua and Nao Kao have strong Hmong roots and frequently opposed the American doctors’ medical treatments in favor of their own traditional medical practices. There are obvious systemic failures present in this situation such as the lack of translators and access to other nearby medical facilities for low-income families like the Lees. Problems like these may not play as large a role today as they did in the eighties, but cultural differences can certainly still have an impact on how patients are treated. Although it may be easy for someone reading Fadiman’s book to immediately point a finger at Lia’s doctors for her continual decline, it is difficult for me to hastily assign blame in this fashion. I believe it is crucial to view the issue from not only the Lee’s perspective, but also that of the doctors.

Later in the book, Fadiman recounts the harrowing events of the Lees’ escape from Laos and eventual arrival in the United States. With no money or resources, the Lees were reduced to living in a small apartment in Merced, California with virtually no furniture, essentially surviving off welfare checks. When I initially read that neither Foua nor Nao Kao worked to provide for their nine children, I was greatly troubled. Fadiman later explains, however, that the Lee’s were farmers back in Laos and the skills in which they were proficient were virtually useless in the US. Additionally, as I continued to ponder this, I realized that the language barrier would make them poor candidates for most career fields until they learned English, which Fadiman mentions they were attempting to do.

The Lee’s held their Hmong traditions and culture in very high regard, but they were also open to American medical practices. Although epilepsy is regarded as an honor in Hmong culture, Foua and Nao Kao were still concerned for their daughter’s health and took her to the hospital. Their idea of a proper treatment plan consisted of American medicine alongside Hmong Neeb, but the doctors were reluctant to implement this plan. Although some doctors probably were biased against the Hmong people and their medical practices, I feel that the primary reason for this reluctance was poor communication. The language barrier was the primary issue in this case, but I feel that poor communication still plagues the physician-patient relationship even today. How do we address this issue in the modern context though? Although I feel both parties should bear some responsibility for communicating effectively, I think the onus should lie with the doctor to ensure both parties fully understand one other. For example, a wide variety of circumstances such as immense stress, profound grief, or poor fluency in a language, as in the case of Lia’s parents, can all impact a patient’s ability to interact with their physician. Still, we can’t simply throw the doctor under the bus anytime something goes wrong. It is important to analyze this issue of miscommunication due to cultural differences from their perspective as well.

Starting at Lia’s birth, the doctors already went against Hmong tradition by incinerating her placenta, which was common practice in the United States. Although there was clearly a lack of communication, as in numerous other cases of Hmong mothers, Foua only wanted to bury the placentas. The doctors, however, were simply following their training and trying to prevent the spread of disease. In chapter three, the doctors had no idea Lia had had a seizure when her parents brought her in and therefore only diagnosed her with “early bronchiopneumonia or tracheobronchitis”. Is all of this simply because Lia’s doctors were bad at their jobs? In my opinion, no. They were taught in medical school to use American methods for treating diseases and were probably accustomed to patients who spoke English. It is difficult for me to blame the American doctors who were never educated on the traditions of foreign refugees. How can they be expected to know if they can’t ask the Hmong and no one tells them? I feel that the US government should have established a program to educate healthcare workers in Merced on the Hmong culture and hired translators if they wanted doctors to actually be able to serve this population. In short, I feel that the difficulties the Lees faced are primarily due to a systemic failure.

In conclusion, I believe that the first four chapters of The Spirit Catches You and You Fall Down, along with the rest of Fadiman’s compelling narrative, depict the tragic effects of a culture clash compromising the United States healthcare system. The doctor-patient relationship is at the core of medical care, and when it is impacted by unchecked cultural barriers, there can be devastating consequences. In my opinion, we must hold the healthcare system largely responsible instead of individual doctors and patients. Lia’s heartbreaking story should inspire us to make the necessary modifications to our healthcare system to ensure that cultural differences don’t get in the way of providing quality healthcare for every patient.

Works Cited

Fadiman, Anne. The Spirit Catches You and You Fall Down, Farrar, Strauss, and Giroux, 2012

Butler Beaudoin

Summary

Disease is a complicated subject and can be discussed from the standpoint of how the medical community defines it as well as how it affects one’s everyday life. There are several distinct viewpoints which attempt to define disease.  Naturalism focuses solely on malfunctioning physiological systems, normativism focuses on generally disvalued states, and hybridism is a combination of both viewpoints. In contrast, eliminativism states there is no need for a clear-cut definition of disease.  Much like the topic of health, most disagreement regarding disease involves treating it as a decidedly concrete and objective concept versus treating it as a somewhat fluid and subjective concept.  As acknowledged in our class discussion, disease and health are deeply interconnected, so it is difficult to discuss disease without first considering health. Health, unlike disease, is examined through the lens of only two primary viewpoints: naturalism and normativism.  Naturalism claims health is simply the absence of disease while normativism regards it as a state of well–being.  Much like their counterparts which attempt to define disease, naturalism is rather objective, while normativism takes a more subjective approach with a particular focus on mental health.

Furthermore, disease can also be examined from a phenomenological standpoint by observing and assessing how it pervades numerous aspects of one’s life. I believe this practice can be highly beneficial for healthcare professionals today.  Utilizing Engel’s biopsychosocial (BPS) model of health and illness, we now understand biological, psychological, and social factors can all contribute to the presence or growth of a disease.  To further complicate matters, various interrelationships exist between the factors which can play a crucial role in promoting overall health.  I believe one practical application of this BPS model is to evaluate mental health and psychological disorders. For example, sustained stress brought on by social factors can influence biological and psychological factors (S–>B and S–>P), and, as mentioned in the discussion of neuroplasticity, psychological factors like learning new motor skills can influence biological factors such as neural pathways.  Both the negative relationship and the positive relationship can pertain to one’s mental health and are significant to the phenomenological discussion.  I feel that mental health is largely more susceptible to social and psychological factors, and, consequently, I believe mental health disorders can more easily be attributed to disvalued states, as normativism suggests.

These are the discussion questions for my presentation.  Although I was unable to address each one directly, I attempted to apply them to the discussion and was able to initiate interesting dialogue as a result.

• I thought it was interesting how Stegenga addressed four viewpoints concerning disease but only two on health. Why do you think that is?

• Do you believe we should have hybridism and eliminativism in reference to health?

What would that look like?

• Do we need a general concept of disease (Hesslow’s car mechanic analogy) or should we focus more on the phenomenological standpoint? (Using the car analogy, that would be like the mechanic asking how her driving experience is being affected by the car malfunctioning instead of arguing about whether the car is defective or not)?

• In my presentation, I really highlighted how I felt there should be a separation between physical and mental health when considering the topic of disease. Do you feel there should be a separation or are they one in the same?

• Do you feel that mental disorders should be viewed from the standpoint of normativism?

• All six potential pathways in the BPS model can potentially contribute to subjective well-being and to objective physical health outcomes. Which of these do you feel is most important in the medical field today?  (For example, I believe B–>S is very important right now.)

Class Discussion and Response

The discussion was largely dominated by the subject of mental illness.  Initially, it was somewhat challenging to reach a mutual agreement concerning the definition of disease in the context of mental health.  However, by utilizing hypothetical examples and actual cases in our discussion, we were able to approach the topic from a phenomenological perspective.  To clearly illustrate how some people who suffer from poor mental health claim to be healthy, one classmate referred to Hesslow’s car analogy discussed in Care and Cure, arguing that it was like driving with flat tires, either unknowingly or apathetically.  At another point, a classmate returned to another hypothetical situation from Care and Cure which discusses a monk who meditates inside a cave on a mountain and refrains from eating and sleeping.  It would appear this monk is unhealthy from the standpoint of modern medical practices, but he is content and highly functioning.  The case of the hypothetical monk presents us with an important question: how can we distinguish between healthy and sick people?  Several classmates felt that a person is sick when they have a condition which is harmful to them, in the sense that an unknown condition which is not impacting a person does not constitute a disease.  The argument was also made that unless a disease is communicable, implying it possesses potential to bring harm to others, many illnesses of both physical and mental varieties strictly affect the person with the condition.  In my opinion, a person is healthy when there is an absence of all mental and physical conditions.  If the lack of shelter, food, and sleep is causing the monk harm, I would say he isn’t healthy; however, he is also not diseased.  The class eventually arrived at the conclusion that we tend to treat physical ailments differently than mental disorders.  A person suffering from depression, for instance, may receive a prescription from a physician, but they will also likely be referred to a therapist for additional treatment.  While this isn’t a necessarily inappropriate step, the concern is whether doctors in the medical field today have completely isolated issues which pertain to mental health from physical disease.  In conclusion, I believe medical doctors should more frequently employ therapeutic practices.  This is not to say either physicians or psychologists are ineffective in their respective fields, but merely to suggest that the strategies of therapists and psychologists may be beneficial if implemented more widely in the modern medical field.

Works Cited

Stegenga, Jacob. “Disease” Care and Cure – The University of Chicago Press, 2018

Karunamunia, Nandini, Imayamab, Ikuyo Goonetilleke, Dharshini. “Pathways to well-being: Untangling the causal relationships among biopsychosocial variables” Social Science and Medicine, https://doi.org/10.1016/j.socscimed.2020.112846