Book Review by Luxin Yin
More than two decades after its publication in 1997, Anne Fadiman’s The Spirit Catches You and You Fall Down is frequently required reading in medical schools and used to train future practitioners on the importance of cross-cultural communication. The book concerns the difficulties faced by a young Hmong epileptic, Lia Lee, who ultimately lands in a coma because of miscommunication between her immigrant parents and her doctors—a conflict, Fadiman suggests, caused by either implicit racism or cultural hegemony on the part of the medical establishment. Fadiman strove to cultivate a more inclusive medical atmosphere and a shared language among health practitioners, nurses, administrative personnel and patients, goals the medical profession still seeks today. However, today’s readers might find the book’s claims problematic: it romanticises patients and the Hmong community, and therefore may not present an effective way of realistically cultivating empathy in medical settings. After reviewing these shortcomings, I provide a perspective on medical empathy that focuses on patient-doctor collaboration rather than practitioners’ cultural competence.
Fadiman argues that cultural differences were the primary source of Lia’s medical failure. While Lia’s parents approached her illness through Hmong religious beliefs, physicians approached Lia with a perspective shaped by American medical culture. Consequently, these two communities both recognised Lia’s symptoms but ascribed them to different causes; for example, one doctor, Dan, could not understand Lia’s parents when they described her seizures as, “where the spirit catches you, and you fall down.” Where Dan saw epilepsy, Lia’s parents saw a loss of soul that, for the Hmong, is “necessary for health and happiness” (18). This dispute around soul, or life, is discussed between Sukey Waller, a psychiatrist familiar with shamanism, and Bill Selvidge, a medical practitioner. Their discussion highlights the child’s agency during treatment. While Lia’s parents have reservations about curing her epilepsy, as her seizures make “her noble in our culture, and when she grows up she might become a shaman” (260), the medical establishment interprets this view as depriving the child of the agency to make decisions regarding her own health. Bill expresses the medical establishment’s perspective: “if the child dies, she won’t get the chance to decide twenty years down the road if she wants to accept her parents’ beliefs or if she wants to reject them. She’s going to be dead” (27). Thus, the medical establishment sees itself as making life-or-death decisions in the name of patients themselves, particularly those it considers too young or too feeble to understand their condition.
In addition to recounting Lia’s story, Fadiman delves into Hmong folklore, religion, ethnomedicine and history in her attempt to describe Lia’s family’s and the medical professionals’ social backgrounds. Fadiman has explicitly stated that cultural differences must be resolved within medical settings to ensure fair treatment to minority patients, her preface encouraging cooperation between cultures so that “the Hmong and … American doctors could be heard on a single tape, speaking a common language” (ix). While Fadiman believes this commonality can be achieved by elevating doctors’ “cultural competency” (271) and empathy, recent empathy research shows us how difficult this is in practice. Cultural theorist Ann Albright (2016) argues that complete empathy for the other is unattainable, as each interaction brings new layers of feeling, resulting in new dimensions and predicaments. Fadiman’s goal of speaking a common language is therefore too idealistic in ways that can be seen in her own narrative, as she frequently romanticises Hmong culture and, in turn, creates unrealistic treatment expectations. Hmong immigrants are depicted as having a symbiotic relationship with their culture, which defines their identities in a circular, self-perpetuating and ultimately static way. They are destined to take actions to protect their culture, and those who do not align with this identity may be considered non-Hmong.
What would the merging of two essentialist cultures such as the Hmong and the American medical establishment look like? Fadiman seems to expect the two to merge in America’s melting pot in a shift toward an unknown greater cultural understanding, rather than toward the atomised view of doctors and experts. This assumption, however, is too optimistic and even orientalist. Lee and Farrell (2006) argue that a stress on “cultural competence” may be a “backdoor to racism” in its reification of trait-based cultural differences (9). Even more critically, Fadiman’s view may hinder the direct medical communication required to provide all communities with adequate health care. Today’s medical humanities researchers argue that culture must instead be considered fluid rather than fixed, allowing for greater interaction between patients and doctors rather than placing the onus on doctors’ “cultural competency” (10).
Fadiman forgets that communication between doctors and patients must be mutual. In portraying the Hmong community’s lack of compromise with doctors as heroic and embedded in Hmong history, an extension of their resilience in travelling to the United States after the Vietnam War, Fadiman romanticised lack of compromise as cultural integrity. Therefore, she portrayed them as people who hate “coercion” (44, 100, 255). Given Lia’s coma by the end of the book, this scepticism toward authorities appears justified and Fadiman’s approach has successfully aroused readers’ sentiments. However, considering her rich cultural and historical introduction to the Hmong people, she gave no comparable background on the development of Western medicine, itself a long story of persecution and resilience. Perhaps this lack of balance is easier to see now than it was two decades ago.
Lia’s parents and her doctors could be both right and wrong. A Chinese saying goes, “If someone is at the last stage of cancer, Western doctors will tell them to try Chinese traditional medicine or Shaman.” The statement has two meanings: when Western medical practitioners have tried everything but nothing has worked, the patient must either pray for a metaphysical miracle, or, more realistically, prepare for impending death. My own uncle, in the final stages of brain cancer, took a regimen of herbal remedies recommended by both my father and grandfather, traditional Chinese medicine practitioners. As with Lia’s family, our house was filled with herbal smells over the summer until he passed away—nothing worked, including our beliefs, herbs and family love.
Albright, Anne Cooper. 2016. “Feeling In and Out: Contact Improvisation and the Politics of Empathy.” In Zwischenleiblichkeit Und Bewegtes Verstehen – Intercorporeity, Movement and Tacit Knowledge, edited by Undine Eberlein, 289-298. Bielefeld: Verlag. https://doi.org/10.14361/9783839435793-011.
Fadiman, Anne. 1998. The Spirit Catches You and You Fall Down: A Hmong Child, Her American Doctors, and the Collision of Two Cultures. New York: Farrar, Straus and Giroux.
Lee, S. Agnes and Michelle Farrell. 2006. “Is Cultural Competency a Backdoor to Racism?” Anthropology News 47, no. 3: 9–10. https://doi.org/10.1525/an.2006.47.3.9.