Cultural Barriers and Different Approaches to Wellness

Chapters 6-7 describe the linguistic and cultural barriers between the Hmong patients and their American doctors.  The older Hmong immigrants in Merced typically don’t speak English, and the translators have difficulty translating medical terms (that don’t exist int the Hmong language) for their patients.  The biggest barrier, however, is cultural.  Patient-physician relations are difficult because the Hmong don’t wish to disrespect their physicians by asking questions, so patients often leave the visit without any understanding of what their doctor said, what the recommended treatment was, or how to comply with it.  The Hmong have no concept of the different internal bodily organs (except for the heart), as they don’t practice autopsy.  Shaman training involves rituals to appease the spirits, not anatomy and physiology. 

The gap between patients and physicians Fadiman discusses in this section reminds me of my discussion last week of the medical profession’s approach to death.  Physicians, by nature of their profession, do their best to avoid death.  Some physicians see acquiescence to death as a sign of complete failure, and think about death in terms of which procedures they could have done to save their patient’s life.  Death is the enemy, in part because it reminds them of medicine’s limitations: they can fight death but ultimately cannot overcome it.  Christianity, in contrast, offers an alternative.  Through the cross, Christ overcame death forevermore.  Those who believe in His sacrifice are granted eternal life in Him.  From this perspective, death is not the enemy, but a part of life we accept when the time comes.  Earthly death does not have the same sting, because it has lost its finality in the face of eternal life.  Physicians coming from this perspective do their best to alleviate their patient’s suffering and encourage them to fight, but do not try to avoid death at all costs.

That being said, if one of my loved ones was suffering from an illness, the last thing I would want his/her physician to say is, “They may be suffering, but don’t worry- it’ll ultimately make them stronger.  Plus, they have eternal life, so their earthly death isn’t all that bad.”  I don’t mean to suggest that all suffering ought to be held as valuable, or that we ought to seek it out, but rather that when we are inevitably faced with it, we allow ourselves to feel the pain it brings.  Christianity also allows people to recognize that in our suffering also lies the possibility of growing in understanding and closeness to God; it can teach us about ourselves, our loved ones, life, or God Himself.  The question, then, is how to practically apply this idea.  How much suffering do we let it as a way of recognizing it as a natural part of life? Conversely, how much do we shut out so that we don’t end up wallowing in it? How do we allow it to be a source of instruction without wallowing in it or welcoming it in all circumstances in attempt to ascribe meaning to something that may simply be painful? Can all instances of suffering be used for instruction? Is it even entirely healthy to try to make it so?

This alternate approach to death reminds me Fadiman’s quotation of Dostoyevsky’s Prince Myshkin.  It points to an alternate way of looking at disease.  He asks, “What is a disease? What does it matter that it is an abnormal tension, if the result, if the moment of sensation, remembered and analyzed in a state of health, turns out to be harmony and beauty brought to their highest point of perfection, and gives a feeling, undivined and undreamt of till then, of completeness, proportion, reconciliation, and an ecstatic and prayerful fusion in the highest synthesis of life?” (29)  If we approached disease in this way, what implications would this have for medicine and the people it seeks to return to wellness?  

Chapters 3-5: Dealing with Suffering and Death

Chapters 3-5 opened with an event from Lia’s infancy.  When she was three months old, her sister slammed the front door of their home very loudly.  The Lee family believes (in accordance with Hmong tradition) that the loud sound of the slamming door startled Lia’s spirit so much that it left her body and became lost.  In Hmong, this is represented by the phrase “qaug dab peg”, which means “the spirit catches you and you fall down”.  For the Hmong, the “spirit” is a soul-stealing being whose displeasure one ought to avoid incurring.  Fadiman explains that children are regarded very highly by the Hmong, as they are the most treasured possession a person can have.  Fadiman also gives an account of Lia’s admission to a hospital in California.  Her physician, Dr. Dan Murphy, approaches her case rationally, as any physician immersed in American medical culture would.  He treats her, and prescribes drugs to cure her pneumonia and prevent further seizures. 

This section also marks the beginnings of the tension between Hmong culture and American medical culture.  Dr. Murphy later prescribes phenobarbital for Lia, but due to a misunderstanding, Lia does not receive the medication as instructed.  Lia’s nurse and doctor are frustrated by what they see as the parents’ unwillingness to comply with physician instructions, even when it involves their daughter’s health.

The Hmong’s valuation of children highlights how difficult it will be for Lia’s parents to make the decision they do concerning her medical care.  Lia’s epileptic condition, in fact, is considered to be a blessing.  The spirits chose to reside in her, indicating Lia has the capability to one day become a shaman.  Because of this, she is regarded much like a member of royalty. 

These chapters reminded me of ideas about suffering in Christianity.  Suffering, while it is painful, can be purposeful.  While we don’t seek it out, it can still be a source of instruction.  As Paul says, “Three times I begged the Lord about this, that it might leave me, but He said to me, ‘My grace is sufficient for you, for power is made perfect in weakness.’ I will rather boast most gladly of my weaknesses, in order that the power of Christ may dwell with me.  Therefore, I am content with weaknesses, insults, hardships, persecutions, and constraints, for the sake of Christ; for when I am weak, then I am strong.” -2 Cor. 12:8-10.  While it may seem contradictory, from this perspective, God uses our weakness to form our strength.  Moreover, weakness allows our strength to be elevated and “perfected”. 

As a future healthcare professional, I will certainly do everything in my power to ease my future patients’ suffering.  Whether a physician embraces suffering as painful and inevitable (but possibly valuable) or tries to avoid it at all costs can have huge implications for how he/she sees and treats patients.  We can examine this idea through the lens of attitudes toward death, particularly in the field of healthcare.  Like suffering, we can embrace or try to reject death. 

We read an essay by William Mays in my Bioethics class dealing with this topic.  Mays labels western society’s approach to death the “pornography of death”.  This refers to society’s two-fold approach to the subject of death: much like pornography, we simultaneously label it taboo and obsess over it.  It is a positive feedback loop.  Because it is taboo, we avoid it for the sake of “propriety”, yet we also obsess over it because we are never allowed to engage with it regularly in some way.  We end up engaging with death indirectly, as in the case of violent video games.  Thus, discussion of death is relegated to the realm of the morbid and morose.  As a result, we are not comfortable enough with death to see it as a sad but natural part of life, or see that it can be healthy to openly discuss it. 

For Lia’s family, suffering is not seen as a means of sanctification or instruction, but much like in Christianity, it is not something one tries to avoid at all costs.  Christianity and Hmong culture both see value in suffering, albeit for different reasons.  If we were to follow the Christian model of suffering and death, what implications would this have for interactions between patients and their physicians? I don’t know the details of the tragedy Fadiman alludes to on the book’s back cover, but I’m sure applying this model would have completely changed the tone of the clash between these two cultures.

Introduction to Hmong Culture, Perspectives in Ethics

The Spirit Catches You and You Fall Down centers on a young Hmong girl, named Lia Lee, and her medical treatment.  The treatment her doctors deem necessary to save her life violates certain Hmong beliefs concerning Lia’s spirit (similar to a soul) and the afterlife.  The story chronicles the clash between American medical culture and Hmong culture, and the implications this has on Lia’s life (both earthly and otherwordly).

In the opening chapters, Fadiman gives the reader some insight into Foua Yang’s (Lia’s mother) upbringing in Laos.  Foua, as per Hmong custom, births almost all of her fourteen children by herself.  Lia, in contrast is born in the United States, in a hospital in Merced, California.  Her family moves to the U.S. to flee conflict in their homeland.  Traditionally, a child’s placenta is saved after their birth and buried either under the parents’ bed or under the family home.  It is believed that the placenta is a kind of “jacket” for the soul.  After death, the soul travels to all the places the person lived in during their life, and eventually settles back into its placental jacket.  Once it has done this, the soul can reach “heaven”, where it reunites with ancestors and may later be reborn as the soul of a new baby.  If the soul does not find its placental jacket, it is doomed to wandering alone for eternity.  According to Hmong belief, illness can be caused by eating the wrong foods, doing wrong, or the interference of evil spirits, among other things.  For Lia and her family, then, her medical care not only has implications for her earthly life, but also her eternal life.  As the story progresses, this idea will certainly be the focal point of the clash between American medical culture and Hmong culture.

Fadiman posits that the best vantage point from which to examine an issue is not in the center of things, but at the edges, where the opposing sides meet.  As she puts it, it is here that there are “interesting frictions and incongruities” where you can “see both sides better than if you were in the middle of either one” (vii).  In other words, the ideal position is to be an involved third party observer: a part of the conflict, but not so involved as to be directly in the middle. 

In this novel, the two opposing cultures are American medicine and the Hmong culture.  Fadiman comes into the situation not knowing much about either culture, which gives her a unique point of view.  She is directly involved in the clash between these two cultures, but she does not identify with either side at the outset. Her vantage point is important to consider in examining her depiction of events, because it influences the account the reader is given.  Although I have only read the first couple of chapters so far, I agree that this is the ideal vantage point.  The reader is given a relatively objective account, but due to her direct involvement in the events, she understands the situation and the motivations of everyone involved in a way that a third-party (completely removed from the situation) could not.

While my own particularity as a Christian will influence my discussion of this novel, (Thank you, Kant, for pointing this out to me.  Sic ‘em World Cultures III.) I think discussing this from a Christian perspective is exactly the kind of “involved third-party” vantage point Fadiman believes is ideal.  Christians are called to be in the world, but not of it.  In other words, to live in the world and be directly involved in it (ie to not seclude oneself from the world), but to not let worldly values influence and distort your Christian values.  As a Christian pre-health student, I am not yet directly involved in the American medical culture, and I have not come into direct contact with anyone from the Hmong culture.  I hope coming from this perspective (and analyzing the issue from this perspective) will help me remain an  “involved-but-objective” third party.