Nursing Book Club

The Spirit Catches You and You Fall Down by Anne Fadiman

A Hmong Child, Her American Doctors, and the Collision of Two Cultures 

Cover of The Spirit Catches You and You Fall Down and Anne Fadiman sitting in a chair

Back in 1997, Anne Fadiman wrote The Spirit Catches You and You Fall Down, documenting the experience of a Hmong family in Merced, Calif., 10 years earlier. The book, which won the National Book Critics Award, was a wake-up call on the need for cultural sensitivity in medicine.

During the Vietnam conflict, many Hmong people in Laos fought on the side of the United States. After the U.S. withdrawal in 1975, these Hmong-Lao fled Laos for Thailand, ending up in overcrowded refugee camps. Thousands emigrated to the U.S. in the late ‘70s and ‘80s, often settling in California.

As this book clearly documents, many faced a collision course with American culture.

Good and Bad Spirits

The subject of this book, Lia Lee, was born in 1982, the 14th child of Four and Nao Kao Lee, and the first to be born in the U.S. After her birth, her family found they were unable to bury the placenta beneath her birthplace, considered an inauspicious sign.

Hmong believe in spirits — both good and bad — and that your health depends on evading the bad spirits while capturing the good to stay within your body. The book’s title, “the spirit catches you and you fall down,” is a literal translation of the Hmong term quag dab ped, a condition we call epilepsy.

Lia suffered her first epileptic seizure when she was only 3 months old, after her sister slammed a door. In the Hmong belief system, quag dab ped is a special disease — acknowledged as serious, but also carrying some distinction. A person chosen for this illness is believed to have intuitive sympathy for other sick people, making them well-suited to becoming a txiv neeb, a traditional healer.

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Although it takes years to master the teachings, this vocation confers great social status, so the Lee family’s attitude toward Lia’s seizures was what Fadiman describes as a mixture of “concern and pride.”

Irreconcilable Differences

Young Lia was well cared for, but her seizures continued, and her physicians feared an impending disaster. However, her family spoke no English, so they were unable to follow the instructions for her multiple medications, and for various reasons, not all of the large number of clinic and hospital visits were kept.

More seriously, the Lee family faced an irreconcilable conflict between their own religious healing customs and the expectations of Lia’s doctors. The Lees came to believe the medications were harming Lia, which led to the child being removed from her home by Child Protective Services at the age of 3.

Ultimately, the physicians had to admit that despite their hard work, Lia’s condition was not improving, nor was the doctors’ relationship with the family or the Hmong community. Although Lia was allowed to return home after a year in foster care, she suffered a grand mal seizure, which left her severely brain-damaged.

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The language barrier was only part of the problem. The medical community’s reluctance to recognize the importance of family, culture, and the trauma of war and relocation all contributed to what appears to have been very poor care on the medical side.

Cultural Sensitivity

The Spirit Catches You and You Fall Down is an example of how badly things can go wrong, and an outline for improvement. For 25 years, this book has informed and enlightened readers, and has gone through 15 printings.

The latest editions detail the changes in the Merced Hospital since that time, which have also been a part of the national trend toward cultural sensitivity. The Afterword also follows changes in the Lee family and their Hmong friends since the original publication. (Lia died in 2012.)

I’d like to think that the way we handle patients has improved since the period described in this book. We now accord patients the religious rituals and practitioners of their choice; we provide the food they request, or allow it to be brought in; and qualified interpreters (not just family members) are now required by the Americans with Disabilities Act. If we have not made these changes to our practice, shame on us.

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

CHRISTINE CONTILLO, RN, BSN, PHN, is a public health nurse with more than 40 years of experience, ranging from infants to geriatrics. She enjoys volunteering for medical missions.

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