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Culturally Competent Care in The Spirit Catches You and You Fall Down
Melissa Kiesel
Dixie State University
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The Spirit Catches You and You Fall Down
“The Spirit Catches You and You Fall Down”, by Anne Fadiman, is a tragic story of a
young girl and her family’s experience with medical care within the United States. The book
discusses the experiences and conflicts experienced by a Hmong family living in California
while their daughter under go’s various courses of treatment for epilepsy. The story highlights
the importance of medical ethics and cultural competence within the United States. It illustrates
the significance of providing culturally competent care and it’s continuous need for
improvement. This true story of Lia Lee and her family has paved a way to the importance of
incorporating culture, language, tradition, religion and individual health beliefs into each element
of healthcare. This paper will examine the impact of providing culturally competent care as it
relates to nurses, doctors, and various healthcare members who manage patient care.
Background
The story illustrates the struggle between the Lee’s family and Merced Community
Medical Center . Lia’s parents, Nao Kao and Foua, were immigrates to the U.S. from Laos. Their
Hmong culture was imbedded deep into their roots. Nao Kao and Foua could not speak English
and could not read or write in any language. At the age of 3 months, Lia developed a seizure
disorder. A medical resident at Merced Community Medical Center misdiagnosed her disease,
and MCMC was incapable to provide any information due to the lack of Hmong interpreters.
After Lia was discharged, her parents refused to give her medications as prescribed because they
believed that Lia seizures demonstrated a sense of spiritually. At the age of three, Neil And
Peggy Ernst, the medical doctors treating Lia, had Lia placed into foster care. Over the course of
one year Lia Lee was admitted seventeen times with over one hundred outpatient doctor visits.
After experiencing a year in foster care, the Lee family regained custody of Lia. At the age of
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seven, Lia was pronounced brain dead. The doctors as Merced Community Medical Center were
not longer able to provide the care Lia required so Lia was transferred to Valley Children’s
hospital in Fresno. Lia became septic and remained unconscious. No further treatments could be
performed so she was again sent back to MCMC to die. Lia was sent home with her parents
where Lia’s body healed but she never woke up from her vegetative state (Fadiman, 1997).
Hmong People
Before discussing culturally competent care, we must first examine the impact of culture
on the Lee family. In the Hmong culture, the thoughts adjoining health and illness are vastly
different from American medical beliefs. The American healthcare culture focuses on a
biological and scientific approach when examining illness and disease. The Hmong culture has
more of a magico-religious paradigm approach in explaining sickness (Andres & Boyle, 2011).
Dabs, or evil spirits, are believed to be the causes of illness. The Hmong believe in praying to
their ancestors, natural herbs and teas, shaman, and making sacrifices. They also believe in
identifying several sources of infection/illness, including soul loss, supernatural or spiritual
causes, magical spells, or the death of a “life via” or “mandate of life” (Helsel, etal, 2004). The
American cultures views labs tests, blood work, complex medication regiments, etc as ways of
providing medical care. Because of the vast differences between these two cultures, it’s easy to
see why the Lee family and healthcare team at Merced Community Medical Center did not agree
on Lia’s treatment.
Culturally Competent Care
Culturally competent care is defined as a complex integration of knowledge, attitudes,
beliefs, skills, and encounters with those from other cultures different from one’s own that
enhances cross cultural communication and appropriate and effective interactions with others
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(Andres & Boyles, 2012). As a nurse, we are taught throughout nursing school the importance of
nonmmaleficence or, the duty to do no harm. In order to do no harm; we must take into account
the entire scope of nursing, and healthcare practice, which includes providing culturally
competence care as defined above (Andres & Boyles, 2012).An. Taking the time to value our
patient’s personal beliefs and getting to know the importance of understanding and respecting
various cultural belief systems. As medical professionals, we must learn to never judge for we
have never walked in their shoes and know not where they have been.
From the birth of Lia, we see how important it is to provide culturally competent care.
Lia’s birth was vastly different from that of the traditional Hmong births. Foua gave birth on a
solid metal counter with sterile drapes and no medications. Foua recounts the birth as a bizarre
experience, yet she didn’t complain. Foua recalls squatting over a dirt floor, catching her babies,
and making certain not to let the baby touch the floor. Nao Kao would then cut the umbilical
cord, tie it with a string, and place the baby back with the mother. Foua wasn’t able to make any
sounds so not to wake the other children (Fadiman, 1997). Providing care for the Lee family
would be challenging for any member of the healthcare team. Belief systems, cultural difference,
language barriers, medical practices and social organizations can all play a large role in patient
and family care (Andrews & Boyle, 2012).
The Lee’s believed that Lia’s seizures were caused by Lia’s soul being “frightened” and
lost when Lia’s older sister, Yer, slammed the front door of their apartment triggering the Lia’s
first seizure. The resulting symptoms were seen as “quag dab peg” or “The Spirit Catches You
and You Fall Down” otherwise known as epilepsy in the American culture. In the Hmong culture
epilepsy is regarded with “ambivalence, acknowledged as dangerous and potentially life
threatening, yet consider to be an illness of distinction, reserved for shaman and other influential
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Hmong “ (Fadiman, 1997). Over the next several years, cultural differences would consume
Lia’s life. In the end, everyone involved in Lia’s care was ill equipped to properly care for this
little girl. By the time Lia was transferred to Valley Children’s Hospital, no one even spoke to
Foua and Nao Kao Lee. She was sent home to pass away but some argue even though her heart
was beating, she never fully lived again. Foua wished her child would walk and talk but often
found herself waking up to a silent sober child. It wasn’t just the Lee family that suffered through
this experience, but the entire healthcare community.
Cultural differences, communication barriers and many misunderstanding led to the
terrible events that chased the Lee family through the many torturous years of medical treatment
for Lia. If nonmaleficence had truly been taken into account, I personally feel that Lia’s outcome
may have been different.
Conclusion
The medical professionals in “The Spirit Catches You and You Fall Down” had a strong
misunderstanding of the Hmong culture and beliefs that ultimately lead to the death of a child.
Fadiman herself even seemed to struggle with the cultural system of the Lee family at the
beginning of the book. As she continued through her journey to better understand the Hmong
culture, she was able to express her revelations that the Hmong are “differently ethical”
(Fadiman, 1997).
The Hmong may have some eccentric and exclusive medical practices but, there is no
doubt that their children are cared for and loved. According to Hugo Adolf Bernatzik, a German
ethnographer, observation of the Hmong community he noted, “ a child is the most treasured
possession a person can have” (Fadiman, 1997). He continues noting that most of the Hmong
children have shown signs of maturity and advance development because of their bonding with
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their mothers and overall community support. The Hmong community merged with cultural
traditions seems to collide with the medical doctors throughout the book. The physicians at
MCMC could witness that the Lee family was caring, yet they could not comprehend why the
Lee’s would not follow medical advice to heal Lia. This fundamental trouble with the American
method to Lia’s healing was the lack of community and cultural support in regard to the
Hmong’s cultural values. If the medical team at MCMC would have taken a more culturally
competent care approach, Lia’s and the Lee’s family experience would have been vastly different
and much more positive.
References
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Andrews, M., & Boyle, J. (2012). Transcultural concepts in nursing care. (6th ed.). Philadelphia,
Pennsylvania: Lippincott Williams & Wilkins.
Fadiman, A. (1997). The spirit catches you and you fall down. New York: Farrar, Straus, and
Giroux.
Helsel, D. G., Mochel, M., & Bauer, R. (2004). Shamans in a Hmong American Community.
Journal Of Alternative & Complementary Medicine, 10(6), 933-938.
doi:10.1089/acm.2004.10 .933