This is the kind of thinking that has begotten the cartoon-version M. D., who when presented with a problem, would rather medicate it, scan it, suture it, splint it, excise it, anesthetize it or autopsy it than communicate with it.

— The Spirit Catches You and You Fall Down, p. 273


The first time I heard the word, “Hmong” was in the late 70’s when a series of articles appeared in national magazines about the plight of a race of people in Laos who were being systematically exterminated by the North Vietnamese. According to the articles, the United States was making (belated) efforts to rescue some 500,000 Hmongs by transplanting them to America. A number of “colonies” were established in regions that resembled the highland plateaus of Laos. These “relocated” people ended up in areas as diverse as North Carolina, California and Minnesota.

There were immediate acculturation problems, and shortly afterwards, a spate of studies and publications appeared dealing with the history of this ancient race that had spent over 2,000 years struggling against all attempts to subjugate or “absorb” them. Traditionally, the Hmong have always disliked governments that demanded conformity; they invariably responded with a “flight or fight” stance — an attitude that made them (like the Jews) one of the most persecuted races in the world. After migrating from China to Laos in the 19th century, the Hmong lived in remote isolation until communism demanded their total submission. Again, they chose to die rather than submit — in fact, a resistance to coercion of any kind (regardless how subtle) is a primary Hmong trait.

When the United States military discovered that the Hmong were bitterly opposed to the spread of communism in Laos, a covert CIA-sponsored operation promised the Hmong that should America lose the Vietnam struggle, it would protect its allies (the Hmong). This promise resulted in the transport of thousands of Hmong families — first to Thailand and then to the United States. Although the relocations were widely spread, a significant number of Hmongs ended up in California where the small city of Merced became a kind of “Mecca” for this disenfranchised race.

The Spirit Catches You and You Fall Down is a remarkable analysis of the astonishingly complex problems attending the “relocation” of this diverse culture. By focusing on the fate of a single Hmong child, Lia Lee, who is afflicted with epileptic seizures, author Anne Fadiman creates a vivid paradigm of cultural conflict. In essence, this book illustrates the clash between traditional (religious) medicine and modern medical science. Journalists love to use the phrase “From Stone Age to Space Age” when describing the Hmong relocations. (They even repeat an oft-told tale that when Hmong farmers first saw airplanes, they crawled under the crafts to see if they were male or female. There are other “urban myths” about the Hmong in California). However the basic premise is valid: The cultural shock of relocation has left the Hmong confused and disillusioned. To paraphrase the poet A. E. Houseman, they are “strangers and afraid/In a land they never made.”

Lia was only three months old when she had her first epileptic seizure and her parents took her to the emergency room at Merced County Medical Center (MCMC). The medical staff gave the infant a variety of injections and X-rays and provided the parents with instructions for a daily regimen of prescription drugs. Unfortunately, the parents did not understand English and did not know American measuring systems (teaspoons, milligrams, hours, etc.) However, the lack of communications between health provider and patient was far greater than language and measurements. As time went on and Lia returned a dozen times in a few months, it became apparent that much more was at stake — perhaps the little girl’s life.

For example, in Hmong tradition, epilepsy is considered a “divine sickness” and epileptics are considered spiritually gifted — many become shaman. To the Lee family, Lia’s seizures were not abnormalities that needed curing. They felt that she had been attacked by a “dab” (an evil spirit) and they merely needed help in evicting him. Further, they had their own medicines and wished to treat their daughter with a traditional mixture of roots, herbs, chants and animal sacrifices. In addition, they found the doctors at MCMC to be rude, arrogant and “uncaring.” The doctors, in turn, were puzzled, angry and offended by Hmong behavior. As time passes, Lia’s condition becomes worse with both sides (medical professionals vs. Lia’s family) becoming more alienated. Before a year has lapsed, MCMC has Lia’s parents officially branded as “unfit parents” and Lia was placed in a foster home. The Lee family, deeply humiliated because their daughter has become “government property,” develop a profound dislike for doctors, medication and hospitals. The ultimate victim of this conflict was Lia who, following a massive seizure, became “brain dead” and lapsed into a coma. To her family, she had “lost her soul;” however, they felt that she might yet become normal if her soul can be “called home.”

By using the poignant story of Lia and her family as a crux, Anne Fadiman extends this exercise in miscommunication to embody the excessive number of misconceptions about the Hmong and their future in America. In areas that contain significant numbers of Hmong families, misconceptions and apocryphal myths abound. Certainly, their presence is resented by politicians who lament their dependence on government subsidies, hospitals that resent the drain on medical resources and the unemployed who must compete with Hmong for minimum wage jobs.

Certainly, it seems that what is referred to as the “American Dream” has little to offer this unique culture. When Anne Fadiman talked to them about the future, a persistent yearning to “return home” (Laos) was expressed by the elderly. There is also a deep sense of betrayal in many refugees when they talk about the “promise” that the CIA gave them which America seems reluctant to honor. The majority of Hmong are farmers and America appears to be unwilling to provide them with the opportunity to own land and till the soil, even though the few “experimental farming communities” have proved to be successful. A persistent governmental policy advocates “wide dispersal” to major cities where Hmong workers are expected to learn English, pursue factory and industrial work and become good citizens.

However, in the final analysis, Fadiman is optimistic. In recent years many hospitals, including MCMC, have demonstrated a willingness to change and have employed Hmong interpreters. There are even instances in which Hmong patients are treated by both their traditional shaman and medical specialists. A small number of psychiatrists are now conversant in “cross-cultural issues.” Governmental agencies are abandoning their efforts to “encourage” refugees to acculturate.

As of the writing of this book (1997) Lia Lee was still alive. At the request of the Lee family, all of her life support equipment had been cut off and the hospital had allowed the family to take her home to die. She didn’t. Each day, she is fed, washed, medicated and tended by the Lee family that still believes that she will eventually wake up — provided that they continue to conduct religious rituals designed to call Lia’s soul “home.”

(The Spirit Catches You and You Fall Down received the National Book Critics Circle Award and has been widely acclaimed as a basic text in training hospital personnel in dealing with minority cultures and “cross-cultural issues.”)

(Gary Carden is a writer, storyteller and lecturer whose book, Mason Jars in the Flood, was recently named Book of the Year by the Appalachian Writers Association. He can be reached at gcarden498@aol.com.)