Running head: THE SPIRIT CATCHES YOU AND YOU FALL
DOWN
The Spirit Catches You and You Fall Down: The Collision of Two Cultures
Kayla McDonald
Dixie State University
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The Spirit Catches You and You Fall Down: The Collision of Two Cultures
Many health care beliefs and behaviors are culturally based, when two different cultures
come together in the health care setting, a collision of expectations typically occur. The Spirit
Catches You and You Fall Down is a critically acclaimed novel that shares the story of a young
Hmong girl who suffers from being caught in the middle between the collision of Hmong culture
and western medicine. The book has many important themes, although the primary theme of this
paper will focus on the importance of culturally competent care. The story of the Lee family and
Hmong culture will be described in detail, then the book is connected to transcultural nursing
through the important theme of providing culturally competent care, and finally personal
opinions and thoughts of the book are expressed in the final paragraph.
Description of Book
Lia Lee was born on July 19, 1982 in Merced Community Medical Center to two loving
Hmong parents, Nao Kao and Foua Lee. Lia was described by her doctors as a healthy baby with
no abnormal complications present at birth. The Lee family however, was concerned for her
soul, because Lia’s placenta was incinerated rather than being buried in their home. Hmong
culture centers around the soul. Burring the placenta in the home allows the soul of the
individual to find its way back to the placenta after death, reuniting the soul with its original
clothing. Only then can the soul continue its journey in peace. On the other hand, if the soul
cannot find its placenta, the soul is destined for a life of wandering alone and naked.
When Lia was around three months old, she began to have epileptic seizures. The Lee
family believed her seizures were caused by Lia’s soul being scared out of her body from a door
being slammed shut. American doctors believed the seizures were caused by a chemical
imbalance in her brain. Lia began having more and more seizures and had been to the emergency
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room a few times, only to be sent home with antibiotics. The Lees had a difficult time
understanding western medicine and American culture. There was a lack of interpreters in the
Merced Community Medical Center emergency room, and very few health care providers were
familiar with the Hmong Culture. Lia had a grand mal seizure on her third admission to the
emergency room. Dan Murphy and his wife Peggy became interested in the Hmong culture and
became Lia’s physicians. A full workup was completed to try to determine the underlying cause
of Lia’s seizures, but the results were inconclusive. Lia was discharged with antibiotics and
Dilantin. Lia began to show developmental delays and her behavior became hyperactive. The
seizures continued and Lia became well known at Merced Community Medical Center.
One of the biggest barrier between the Lees and the hospital staff was medication
management. Nao Kao and Foua both were illiterate in English, keeping up with a frequently
changed medication schedule and dosage for something they believed was caused by the loss of
Lia’s soul, not a chemical imbalance, was not their number one priority! Lia was prescribed most
of the time to be on a combination of Phenobarbital, Dilantin, Tegretol, and Depakote. These
medications also required frequent blood work and frequently caused confusion because of the
nontherapeutic levels in Lia’s blood. It soon became apparent that Lia’s medications were not
being administered correctly. In hopes to improve medication compliance, home health nurses
started to visit the Lee home to give Lia her medications and help educate the parents. Nao Kao
and Foua viewed this help as more of an intrusion and felt they knew what was best for their
child. The Lees did not trust western medicine, and even believed the medications she was
prescribed caused her to have seizures and fevers. Lia’s parents soon stopped giving her
medications to her at all. As a result of stopping her medications, Lia had a massive grand mal
seizure on January 20, 1984 that required large doses of Phenobarbital, emergent intubation, and
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transport to a different hospital. A few months later, after it was obvious that Lia was not
receiving her medications at all at home, Lia’s physicians felt obligated to contact child
protective services to recommend foster care so that medication compliance would be met. Soon
after the recommendation, the request was granted and Lia was removed from her home. Lia was
placed in foster care to the home of Dee and Tokorda. Lia’s medications were administered as
prescribed, yet Lia’s seizures continued. In fact, Lia’s seizures started to get worse. Lia’s
developmental deficits became more pronounced and severe. Her medications were weaned just
to Depakote due to her hyperactivity. The social worker Jeanine Hilt became determined to help
the Lees become competent enough to care for Lia in their home. Jeanine spent countless
numbers of hours educating and working with Foua. Lia was finally able to return home to her
parents on April 30, 1986.
Despite Foua and Nao Kao’s beliefs of western medicine, they became compliant giving
Lia’s medications because they knew it was the only way to keep the government from taking
her away from them. Lia showed improvement by only having one seizure in the first four
months she was home. Lia even began going to special education classes three times a week.
Unfortunately, in September 1986, Lia fell out of a swig causing her to go into status epilepticus.
The Lees believed Lia’s teacher made her fall out of the swing, causing her to be afraid, resulting
in her soul leaving again, causing the seizures to return. During this hospitalization, Lia
contacted a terrible infection. Again, there were massive communication barriers between the
Lees and the hospital staff. Lia began to have terrible seizures and dangerous fevers, although
her Depakote levels were within normal range. This meant Lia’s condition was worsening and
medication management was beginning to fail. Lia’s physicians tried to communicate the
inevitable with Nao Koa and Foua, but it was unclear how much was understood. A few months
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later, Lia had a grand mal seizure lasting 2 hours. Lia was transported in critical condition to
Valley Children’s Hospital in Fresno. She began to seize again, resulting in her body to fail.
They ran multiple tests to try and find the source of infection, including a spinal tap. Her body
began to go into septic shock, then into DIC. Lia underwent an EEG and a brain CT, she was
found to be brain dead. The Lee family was very confused with Lia’s condition. Nao Kao
believed the spinal tap caused her soul to be lost. In his words he said, “They put a hole in her
back before we got to the hospital, I don’t know why they did it. I wasn’t there yet and they
didn’t give me a paper to sign. They just sucked her backbone like that and it makes me
disappointed and sad because that is how Lia was lost” (Fadiman, 1997). Foua’s explanation was
“They just took her to the hospital and they didn’t fix her. She got very sick and I think it is
because they gave her too much medicine” (Fadiman, 1997, 148). The physicians started to
discuss withdrawing life sustaining measures with Nao Kao and Foua. Nao Kao refused to listen
to any discussion of withdrawing life sustaining measures and demanded that she be returned
home. The court order was obtained to allow Lia to be transferred home. Lia still required
supportive care so it was agreed to transfer Lia back to Merced Community Medical Center for
further care.
Lia’s second day back at Merced Community Medical Center, Nao Kao demanded that
all of Lia’s invasive lines and medications be removed and that she would be allowed to go home
because he believed they were making her sicker. The health care team agreed to let Lia be
discharged home to die with dignity. The Lees were repeatedly told that once home, Lia would
die within a few hours. The Lee’s refused to listen, and took their daughter Lia home with them.
Once home Lia was bathed with herbs because she had been constantly sweating in the hospital.
After the bath, Lia stopped sweating, and did not die. Two years later Lia was still alive. Lia
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remained in a persistent vegetative state, she had gained some weight and grew taller. Her brain
damage ended her epilepsy. Nao Kao and Foua were viewed as excellent care givers. The Lee
family still described Lia’s condition as missing her soul, and they never lose hope that Lia’s
soul will someday return home.
Application to Course Content
The book The Spirit Catches You and You Fall Down has an important theme supporting
the necessity for culturally competent care. Providing culturally competent care is also a one of
the learning outcomes for the course Transcultural nursing. The Spirit Catches You and You Fall
down unfolds the story of a medical tragedy that debatably could have been medically managed
and prevented Lia from suffering as she did if health care providers at Merced Community
Medical Center would have provided culturally competent care to the Lee family. Andrews
describes cultural competence as one of the main ingredients in closing the health disparities gap
as health care services that are respectful and responsible to health care beliefs, practices,
cultural, and linguistic needs of diverse patients and can help bring our positive health outcomes
(Andrews, Boyle, 2012). Andrews also defines culturally competent care using Leininger’s early
definition. It is described as the contribution of “holistic care focused on the complex
interrelationship of lifeways, religion, kinship, politics, law, education, technology, language,
environmental context, and worldview” (Andrews, Boyle, 2012).
Personal Insights and Feelings
I really enjoyed reading this book. I like the style of writing the author uses. She was very
descriptive and I felt like I knew every essential detail of both sides of the story, which I believe
would be very challenging to accomplish as a writer. This book takes a medical tragedy and
turns it into an eye opening cultural experience. It helped me realize that providing culturally
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competent care isn’t just an ethical obligation to help the patient feel more comfortable, but has
the potential to have devastating consequences if ignored.
Conclusion
The importance of developing culturally competent care can literally mean the difference
of life of death. Lia Lee most likely suffered far more than she would have if only culturally
competent care would have been implemented from the beginning of her medical journey.
Cultural competence is one of the main ingredients in closing the health disparities gap. Health
care providers hold an obligation to listen to the patient’s views and concerns regarding care.
Compromise between cultural practices and western medicine used as a combination will lead to
better outcomes for the patient’s body and their soul.
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References
Andrews, M., & Boyle, J. (2012). Transcultural concepts in nursing care (6th ed.). Philadelphia,
PA: Wolters Kluwer Health/Lippincott Williams & Wilkins.
Fadiman, A. (1997). The spirit catches you and you fall down: A Hmong child, her American
doctors, and the collision of two cultures. New York, NY: Farrar, Straus, and Giroux.
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The Spirit Catches You and You Fall Down (1)
Criteria
Hook
(Introducto
ry
Paragraph
Ratings
Interesting opening:
Engages readers.
Clear introduction
of paper.
10 pts
Opening attracts readers
but lacks interesting
engagment or intrigue.
Vague introduction.
7 pts
/Thesis
Grammar
Descriptio
n of book
content
Applicatio
n to
course
Sentences well-built and
strong, and varied in
structure. Words convey
message in interesting
and natural way. Erors in
conventions tend to be
few; minor editing
required.
10 pts
APA
Format
Opening demonstrates an
attempt to interest, but
falls short.Needs engaging
component. No
introduction.
4 pts
Most sentences are
complete with some
variety; limited quotes;
language is ordinary;
errors in conventions
begin to impair
readability, moderate
editing required
7 pts
Sentence flaws;
writer uses limited
vocabulary;
extensive editing
required with errors
in conventions make
text difficult read
4 pts
Information is
presented in a logical
sequence. Transitions
are clear, connections
are made. Specific
examples are
provided. Book
content is clearly and
thoroughtly stated,
easily understood by
reader.
10 pts
Information is mostly
presented in logical
order. Transitions and
connections are made.
General examples are
provided. Reader
needs to make a few
inferences but is able
to understand the book
content.
7 pts
Clearly illustrates an
obvious connection
with course content.
10 pts
Reader is forced to make a
few inferences to see the
connection with course
content.
7 pts
Leaves the reader
with a strong, final
thought.
10 pts
Final statement made but isn't
as strong or unique as it could
be.
7 pts
content
Closing
Pts
Satisfies all specified
requirements. Headings,
running head, title page, in text
citations, etc...
10 pts
Organization is not
logical. Transitions are
inconsistent and often
weak or missing. Vague
examples or none at all
are provided. The reader
is left to "fill in the
blanks." More
information is needed for
the reader to understand
the book content.
4 pts
Follows some
specified
requirements.
7 pts
Little or no
relationship with or
mention of course
content.
4 pts
No attempt to
summarize ideas.
4 pts
Does not follow
specified
requirements.
4 pts
8 / 10 pts
Need to provide in text
citation for book. Need
hook to engage readers.
9 / 10 pts
Long and confusing
sentences. Quotes need to
have quotation marks to
begin and end quote.
10 / 10 pts
10 / 10 pts
10 / 10 pts
8 / 10 pts
Need in text citations
for specific information
from book. See APA
manual for correct format
of in text citations.
Personal
Interpretati
on of Book
Clearly describes new
insights/understandings gained
through the book
10 pts
General
description of
insights gained.
7 pts
No description
of insights
gained.
4 pts
10 / 10 pts
Total Points: 65
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