“When Lia was about three months old, her older sister Yer slammed the front door of the Lees’ apartment. A few moments later, Lia’s eyes rolled up, her arms jerked over her head, and she fainted. The Lees had little doubt what had happened. Despite the careful installation of Lia’s soul during the hu plig ceremony, the noise of the door had been so profoundly frightening that her soul had fled her body and become lost. They recognized the resulting symptoms as qaug dab peg, which means “the spirit catches you and you fall down”…On the one hand, it is acknowledged to be a serious and potentially dangerous condition…On the other hand, the Hmong consider quag dab peg to be an illness of some distinction.”
- Anne Fadiman, The Spirit Catches You and You Fall Down
If nothing else can be said about this book, it should be said that it will cause a reaction. Most books are a monologue. The author is telling you something and you listen. Anne Fadiman’s book is so engaging, and touches on so many sensitive subjects, that it’s more like a dialogue between author and reader. And I use the word dialogue literally. During the course of this book, I found myself audibly voicing my opinions at the page like a crazy person. My wife would ask me what I was saying, and I’d tell her “I’m not talking to you I’m talking to the book!” Sometimes I agreed with Fadiman. Sometimes I didn't. In any event, I was locked in, totally absorbed.
The Spirit Catches You and You Fall Down is a sad, beautiful, complicated story that is ostensibly about a tragedy that arose from a clash of cultures, but is really about the tragedy of human beings.
Lia Lee was three months old when she suffered her first epileptic seizure. Her parents, Nao Kao and Foua, were Hmong refugees from Laos who didn't speak any English. They took Lia to Merced Community Medical Center, a county hospital that just happened to boast a nationally-renowned team of pediatric doctors. None of those doctors spoke the Hmong language. From this initial collision – different languages, different religions, different ways of viewing the world – sprang a dendritic tree of problems that resulted in a medical and emotional catastrophe for Lia, her family, and her doctors.
When Lia first came to the hospital, the language barrier – an inability to take a patient history – caused a misdiagnosis. The next time she arrived, however, she was actively seizing. Thus, her doctors were able to determine her malady and come up with a game plan on how to treat it. For a variety of reasons (both spiritual and practical), the Lees did not follow the treatment plan, and Lia didn't receive the specific care her doctors ordered. Eventually, one of her doctors filed a petition with the court to have Lia removed from the home and placed into a foster home. This allowed for a rough sort of compromise to be reached. Lia’s treatment plan was simplified and made more palatable to the Lee’s wishes. On the other hand, the Lees promised to follow the new plan as prescribed. For a time, Lia seemed to thrive.
This détente looked good on the surface, but masked an unfixable wound to the relationship between the Lees and their daughter’s doctors. By the time the final seizure came for Lia Lee, her family actively distrusted the people working at the Merced Community Medical Center.
Fadiman intercuts her narrative of Lia Lee’s care with sections on the history of the Hmong in general and the journey of the Lees in particular. The Hmong people are an ethnic group who once lived in southern China. The Chinese pushed many of the Hmong from their borders, and they ended up living in Burma, Vietnam, Thailand, and Laos. During the Vietnam War, the CIA secretly recruited the Hmong to fight against Communism. When America pulled out of Vietnam, a Communist government in Laos persecuted the Hmong, and many fled the country in fear of their lives. The Lees left northwest Laos, spent time in a Thai refugee camp, and eventually ended up in California, where Lia was born.
Fadiman explores the complicated system of rituals and beliefs that govern traditional Hmong life. The Lees, like many Hmong, are animists, with a belief in a world inhabited by spirits. This faith dictated how the Lees understood Lia’s illness and how they wanted it treated. Ultimately, it led to problems.
I read The Spirit Catches You and You Fall Down for as part of my book club, the Eastern Nebraska Men’s Biblio & Social Club (formerly known as the Husband's Book Club, after we realized our wives were having all the fun. We later changed the name, because sometimes we just end up drinking). It came as a surprise pick from one of our quieter members, but proved to be one of our best choices. There are a lot of things to discuss. A veritable cornucopia of debate, dissention, and gentlemanly disagreement: Vietnam, CIA, Laos, and the debt owed the Hmong; refugee crises and how they are handled; the assimilation of refugees and immigrants; and even end of life decisions.
We met to discuss this book at a local brew pub where we could drink IPAs and eat pretzels with cheese. Most of us got pretty drunk. Usually, six drunks sitting around a table can solve most of the world’s problems. In this case, though, we mostly ended up in total divergence. I think that’s a testament to Fadiman’s willingness to take on every third rail in modern American life: religion, race, and the limits of government intervention.
(An aside: One of Fadiman’s chapters, called “The Life or the Soul,” posits the question of whether it is more important to save someone’s life – in which medical decisions trump all – or their soul – in which a person wouldn’t receive certain treatments that contradicted their deeply held beliefs. I’m not sure if it was the high alcohol content by volume in the beer, but the club somewhat surprisingly split 3-3 on the issue. Having known these guys for years, I was under the impression – wrong, as it turns out – that they were all secular humanists).
Judging from other reviews I’ve read, this is a book that angered people. Much of the vitriol is aimed at the Hmong who are accused, among other things, of being welfare mooches (this book was published right before Clinton signed the Personal Responsibility and Work Opportunity Act, gutting welfare); of ingratitude for the millions of dollars of free medical care they received; of parental negligence; and for their refusal to assimilate into American society. If you read this book and only feel anger…Well, I’d never tell someone they’re reading a book wrong, but in this case, you’re clearly reading this book wrong. These are difficult, fraught topics that Fadiman handles with grace. There are no heroes and villains. There are only individuals doing the best they can with what they have, based on who they are. It should also be noted that Fadiman is a beautiful writer, and in terms of sheer journalistic enterprise, I’ve rarely stumbled across a better example of diligent, on-the-ground research.
Fadiman isn’t out to piss people off. She does not structure her book to lay blame at anyone’s feet. Nevertheless, the central conflict of her story pits the Lees versus her doctors. Who was responsible for Lia’s fate? The parents who did not follow their doctors’ orders? Or the doctors, who never took the time to understand their patient, her family, and the context in which they lived their lives?
On this question, Fadiman is admittedly biased. It is a gentle bias. She faults the doctors for a lack of cultural curiosity, yet admits that – in order to gain the Lees’ trust – she spent hundreds and hundreds of hours with them, speaking to them through a handpicked interpreter. The time she spent allowed her to see the Lees as fully formed people, not the seemingly-ignorant, oft-mute “other” that presented at the hospital. She recognizes that it’s hardly reasonable for any doctor to spend hundreds of hours with a single patient just to understand how they view the world.
There are moments where, though, when I think that Fadiman is rather a bit too hard on some of her non-Hmong interview subjects. She gets intensely irritated with a waitress who says the Hmong are bad drivers. (I don’t know why this angered her. It’s perfectly rational to think that the Hmong, unable to understand American traffic signs, might be terrible behind the wheel. My dad and I once drove from Paris to Normandy. Neither of us speak French. We were honked at the entire time. Literally. The entire time. Don’t know why. To this day we don’t know why). Her sympathies lie with the Lees, and perhaps rightly so; yet she isn’t quite willing to extend the same empathy or generosity of viewpoint to others she comes across. I wonder if she’d have the same tolerance for a white anti-vaxxer who doesn’t have their kid inoculated for a deadly disease, or a Jehovah’s Witness who refuses consent for a child’s blood transfusion.
I like to think of myself as generally broadminded, with a liberal and accepting heart. Like Jesus, with more wine. As a parent, though, I found myself periodically raging against the Lees. This is your kid! Give her the correct prescriptions! Just do it!
At the same time, I recognize the need for doctors to better remember their patients are people. I’ve dealt with a chronic medical condition for the last couple years that has sent me on a semi-desperate search for a specialist who would listen to me. I’m a college-educated white male with health insurance who often wore a business suit to my appointments since I came straight from work. If I couldn’t get a doctor to give me five minutes of uninterrupted time, I can only imagine the experience of an indigent, non-English speaking patient who walks into the hospital with a life experience 180-degrees different from his or her physician.
One of the book’s final chapters, “The Eight Questions,” provides a nice roadmap for doctors. The titular questions, devised by a Harvard Medical School professor, are a deceptively simple, brilliant way of allowing the doctor and patient to share roughly-equal footing in the patient’s treatment. It shouldn’t be a binary question of the life or the soul, with the doctor standing in for God.
When I love a book, I talk to people about it. In doing so, I found that it’s on a lot of different curriculums. One of my friends read it for an undergrad ethics course. Another of my buddies, we’ll call him Dr. B, had it assigned while he was in medical school.
ME: Did you read it? It’s really good.
DR. B: No.
ME: Why not?
DR. B: Because I was studying medicine.
His answer is what I expected, and why I hope this book continues to get read.
(Final aside: The Spirit Catches You and You Fall Down was researched in the 1980s and published in the 10990s, meaning that the Hmong experience in America has changed, often drastically. I recommend getting the Fifteenth Anniversary Edition with a new Afterword by Fadiman. The Afterword provides a nice little update, as well as the cathartic tying of some loose ends).