Women & Children First

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Winner of the National Book Critics Circle Award for Nonfiction

When three-month-old Lia Lee Arrived at the county hospital emergency room in Merced, California, a chain of events was set in motion from which neither she nor her parents nor her doctors would ever recover. Lia's parents, Foua and Nao Kao, were part of a large Hmong community in Merced, refugees from the CIA-run "Quiet War" in Laos. The Hmong, traditionally a close-knit and fiercely people, have been less amenable to assimilation than most immigrants, adhering steadfastly to the rituals and beliefs of their ancestors. Lia's pediatricians, Neil Ernst and his wife, Peggy Philip, cleaved just as strongly to another tradition: that of Western medicine. When Lia Lee Entered the American medical system, diagnosed as an epileptic, her story became a tragic case history of cultural miscommunication.

Parents and doctors both wanted the best for Lia, but their ideas about the causes of her illness and its treatment could hardly have been more different. The Hmong see illness aand healing as spiritual matters linked to virtually everything in the universe, while medical community marks a division between body and soul, and concerns itself almost exclusively with the former. Lia's doctors ascribed her seizures to the misfiring of her cerebral neurons; her parents called her illness, qaug dab peg--the spirit catches you and you fall down--and ascribed it to the wandering of her soul. The doctors prescribed anticonvulsants; her parents preferred animal sacrifices.
Anne Fadiman is the editor of The American Scholar. Recipient of a National Magazine Award for reporting and a John S. Knight Fellowship in Journalism, she has written for Civilization, Harper's, Life, and The New York Times, among other publications. She lives in New York City.
Winner of the National Book Critics Circle Award for Nonfiction
Winner of the Los Angeles Times Book Prize for Current Interest
A Salon Book Award Winner
Boston Book Review Ann Rea Jewell Non-Fiction Award
A New York Times Notable Book
A Detroit Free Press Best Book of the Year
A New York Newsday Best Book of the Year
Finalist for the PEN / Martha Albrand Award for First Nonfiction

When three-month-old Lia Lee arrived at the county hospital emergency room in Merced, California, a chain of events was set in motion from which neither she nor her parents nor her doctors would ever recover. Lia's parents, Foua and Nao Kao, were part of a large Hmong community in Merced, refugees from the CIA-run "Quiet War" in Laos. The Hmong, traditionally close-knit, have been less amenable to assimilation than most immigrants, adhering steadfastly to the rituals and beliefs of their ancestors. Lia's pediatricians, Neil Ernst and his wife, Peggy Philip, cleaved just as strongly to another tradition: that of Western medicine. When Lia Lee entered the American medical system, diagnosed as an epileptic, her story became a tragic case history of cultural miscommunication.

Parents and doctors both wanted the best for Lia, but their ideas about the causes of her illness and its treatment could hardly have been more different. The Hmong see illness and healing as spiritual matters linked to virtually everything in the universe, while medical community marks a division between body and soul, and concerns itself almost exclusively with the former. Lia's doctors ascribed her seizures to the misfiring of her cerebral neurons; her parents called her illness, qaug dab peg—the spirit catches you and you fall down—and ascribed it to the wandering of her soul. The doctors prescribed anticonvulsants; her parents preferred animal sacrifices.

Anne Fadiman's compassionate account of this cultural impasse is literary journalism at its finest. The Spirit Catches You and You Fall Down moves from hospital corridors to healing cereomies, and from the hill country of Laos to the living rooms of Merced, uncovering in its path the complex sources and implications of two dramatically clashing worldviews. "This is a captivating, riveting book—a must-read not only for medical professionals, anthropologists, and journalists, but for anyone interested in how to negotiate cultural difference in a shrinking world. Fadiman's ability to empathize with the resolutely independent Hmong as well as with the remarkable doctors, caseworkers, and officials of Merced County makes her narrative both richly textured and deeply illuminating. Sometimes the stakes here are multicultural harmony and understanding; sometimes they're literally life and death—whether in wartime Laos or in American emergency rooms. But whatever the stakes and wherever the setting, Fadiman's reporting is meticulous, and her prose is a delight. From start to finish, a truly impressive achievement."—Michael Bérubé, author of Life As We Know It
"Ms. Fadiman tells her story with a novelist's grace, playing the role of cultural broker, comprehending those who do not comprehend each other and perceiving what might have been done or said to make the outcome different."—Richard Bernstein, The New York Times

"An intriguing, spirit-lifting, extraordinary exploration of two cultures in uneasy coexistence . . . A wonderful aspect of Fadiman's book is her evenhanded, detailed presentation of these disparate cultures and divergent views—not with cool, dispassionate fairness but rather with a warm, involved interest . . . Fadiman's book is superb, informal cultural anthropology—eye-opening, readable, utterly engaging."—Carole Horn, The Washington Post Book World

"If tragedy is a conflict of two goods, if it entails the unfolding of deep human tendencies in a cultural context that makes the outcome seem inevitable, if it moves us more than melodrama, then this fine book recounts a poignant tragedy . . . It is a tale of culture clashes, fear and grief in the face of change, parental love, her doctors' sense of duty, and misperceptions compounded daily until they became colossal misunderstandings. It has no heroes or villains, but it has an abundance of innocent suffering, and it most certainly does have a moral."—Melvin Konner, The New York Times Book Review

"So good that I want to somehow make it required reading . . . The Spirit Catches You and You Fall Down explores issues of culture, immigration, medicine, and the war in [Laos] with such skill that it's nearly impossible to put down."—Linnea Lannon, The Detroit Free Press

"This is a captivating, riveting book—a must-read not only for medical professionals, anthropologists, and journalists, but for anyone interested in how to negotiate cultural difference in a shrinking world. Fadiman's ability to empathize with the resolutely independent Hmong as well as with the remarkable doctors, caseworkers, and officials of Merced County makes her narrative both richly textured and deeply illuminating. Sometimes the stakes here are multicultural harmony and understanding; sometimes they're literally life and death—whether in wartime Laos or in American emergency rooms. But whatever the stakes and wherever the setting, Fadiman's reporting is meticulous, and her prose is a delight. From start to finish, a truly impressive achievement."—Michael Bérubé, author of Life As We Know It

"When a Hmong child and her parents encounter the American medical system, what takes place is a veritable explosion that reveals the weaknesses and rigidity of both systems. Ms. Fadiman's painstaking research and extraordinary writing skills make this into a compelling story that, once started, cannot be put down. And yet The Spirit Catches You and You Fall Down is also a unique anthropological study of our society, one that will endure and be referred to for years to come."—Abraham Verghese, author of My Own Country

"So extraordinary is this tale, no conventional label comes to mind. It is a story of the tragedy of an ill child, a debate between two improbably clashing cultures, an essay on the limits of reason and authority. Anne Fadiman has yoked all three forms into a remarkable book which touches on every aspect of human capability and makes one feel at once more and less in control of life. This is a beautiful and haunting piece of work."—Roger Rosenblatt

"In The Spirit Catches You and You Fall Down, Anne Fadiman tells the story of a Hmong family's experience with the American health care system and highlights many of the weaknesses of what some describe as the best health care system in the world. Fadiman writes beautifully and weaves the story of the Lees, their doctors, and the social and political history of the Hmong people and their unwilling immigration to the United States into a book that is difficult to put down once started. The Spirit Catches You will appeal to anyone interested in the culture of medicine and the interface between different cultures. It will also attract readers interested in the dynamics of power in the doctor-patient relationship and readers who can find inspiration in one family's devotion to a chronically ill child. Nao Kao and Foua Lee and their children came to the United States because they felt they had no other option. They could not return to their home in Laos because there they faced persecution, yet they had to leave their refugee camp in Thailand because it had been scheduled to close. They settled in a Hmong community in California, where their daughter Lia was born. The treatment of Lia's seizure disorder in the United States, both by her parents and by her health care providers, is the theme of this story. Fadiman takes the reader through the details of the treatment to paint a full picture of Lia's experience as a chronically ill Hmong child in America. We learn, for example, that long before the Lees even considered coming to the United States they had heard rumors about American doctors: doctors casually take blood from people, including children (the Hmong believe that the body contains a finite amount of blood that is not replaceable); doctors remove organs from their patients to eat or sell for food; doctors anesthetize patients and in so doing put their patients' souls at large, leading to illness or death; and when Hmong are admitted to the hospital, doctors cut the 'spirit-strings' from their wrists, thus disturbing their 'life-souls.' American doctors, in turn, often consider the Hmong to be ignorant, backward, and too reliant on animal sacrifices and other unacceptable practices. During Lia's treatment, the assumptions and beliefs that both parties brought to the patient-doctor interaction were never adequately explored. Doctors often took advantage of their powerful position, and along the way there was a lack of trust and respect between the family and the doctors. Much of Fadiman's book explores how each party blamed the other for the tragic outcome—Lia's severe mental and physical disabilities. In one of the book's final chapters, Fadiman suggests ways in which health care providers can improve their ability to care for patients whose background is different from their own. The chapter draws heavily on work by Arthur Kleinman and others who began exploring cross-cultural medicine before it became popular. Readers of Fadiman's book will understand, however, that to provide high-quality, appropriate care for the diverse populations using the U.S. health care system, health care providers and organizations must adequately assess the need for resources to address a wide range of cross-cultural issues. Holding a 'diversity' or 'multicultural' day in a hospital or medical school is a superficial and inadequate approach. More meaningful is participation by bilingual, bicultural, professionally trained interpreters, the lack of which played a major part in the miscommunication between the Lees and their physicians. Americans' lack of understanding of the hierarchy in the Hmong community and of how conflicts are resolved was also a major barrier that might have been addressed by a health worker representing the Hmong community. The Spirit Catches You illustrates how much time, energy, and commitment are necessary to understand another culture's perspective on health and wellness and to translate that understanding into the day-to-day practice of medicine."—JudyAnn Bigby, M.D., Journal of the American Medical Association

"A vivid, deeply felt, and meticulously researched account of the disastrous encounter between two disparate cultures: Western medicine and Eastern spirituality, in this case, of Hmong immigrants from Laos. Fadiman, a columnist for Civilization and the new editor of the American Scholar, met the Lees, a Hmong refugee family in Merced, Calif., in 1988, when their daughter Lia was already seven years old and, in the eyes of her American doctors, brain dead. In the Lees' view, Lia's soul had fled her body and become lost. At age three months Lia had had her first epileptic seizure—as the Lees put it, 'the spirit catches you and you fall down.' Lia's treatment was complex—her anticonvulsant prescriptions changed 23 times in four years—and the Lees were sure the medicines were bad for their daughter. Believing that the family's failure to comply with his instructions constituted child abuse, Lia's doctor had her placed in foster care. A few months after returning home, Lia was hospitalized with a massive seizure that effectively destroyed her brain. With death believed to be imminent, the Lees were permitted to take her home. Two years later, Fadiman found Lia being lovingly cared for by her parents. Still hoping to reunite her soul with her body, they arranged for a Hmong shaman to perform a healing ceremony featuring the sacrifice of a live pig in their apartment. Into this heart-wrenching story, Fadiman weaves an account of Hmong history from ancient times to the present, including their work for the CIA in Laos and their resettlement in the U.S., their culture, spiritual beliefs, ethics, and etiquette. While Fadiman is keenly aware of the frustrations of doctors striving to provide medical care to those with such a radically different worldview, she urges that physicians at least acknowledge their patients' realities. A brilliant study in cross-cultural medicine."—Kirkus Reviews

About the Author

Anne Fadiman is the editor of The American Scholar. Recipient of a National Magazine Award for reporting and a John S. Knight Fellowship in Journalism, she has written for Civilization, Harper's, Life, and The New York Times, among other publications. She lives in New York City.

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

"Ms. Fadiman tells her story with a novelist's grace, playing the role of cultural broker, comprehending those who do not comprehend each other and perceiving what might have been done or said to make the outcome different." --Richard Berstein, The New York Times

"So good I want to somehow make it required reading...The Spirit Catches You and You Fall Down explores issues of culture, immigration, medicine, and the war in [Laos] with such skill that it's nearly impossible to put down." --Linnea Lannon, The Detroit Free Press

"This is a captivating riveting book--a must-read not only for medical professionals, anthropologists, and journalists, but for anyone interested in how to negotiate cultural difference in a shrinking world. Fadiman's ability to empathize with the resolutely independent Hmong as well as with the remarkable doctors, caseworkers, and officials of Merced County makes her narrative both richly textured and deeply illuminating. Sometimes the stakes here are multicultural harmony and understanding; sometimes they're literally life and death--whether in wartime Laos or in American emergency rooms. But whatever the stakes and wherever the setting, Fadiman's reporting is meticulous, and prose is a delight. From start to finish, a truly impressive achievement." --Michael Berube, author of Life As We Know It