PDF Summary:The Spirit Catches You and You Fall down, by Anne Fadiman

When a Hmong child named Lia Lee develops epilepsy in California, the clash between her family's traditional beliefs and Western medical practices leads to a heartbreaking outcome. In The Spirit Catches You and You Fall Down, Anne Fadiman examines this case to explore the challenges of providing healthcare across cultural divides. She explains Hmong spiritual concepts about illness and healing, including their views on blood tests, surgery, and the role of shamans in medicine, and shows how these beliefs conflicted with the treatment approach of Lia's doctors.

Fadiman discusses the sources of misunderstanding and mistrust on both sides, from language barriers to fundamentally different worldviews about health and medicine. She also offers pathways for improvement, including cultural competency training for healthcare providers and the integration of traditional healers into hospital settings. This guide provides insight into how cultural differences can affect medical care and what steps can bridge these gaps.

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Rituals and Manifestations in the Spiritual Domain

Fadiman states that the Hmong think epilepsy comes from a soul-stealing spirit. The Hmong word for epilepsy is qaug dab peg, which means “the spirit catches you and you fall down.” They think illness can stem from various origins, but soul loss is the most common reason. A life-soul might detach from the body due to being angry, sad, afraid, curious, or feeling wanderlust.

(Shortform note: In Calling in the Soul, Patricia V. Symonds explains that in the Hmong village where she worked, the hu plig (“calling in the soul”) ritual is one of the most ancient and central rites of the life cycle. She argues that the Hmong’s focus on soul-stealing spirits and soul loss as the cause of illness developed from the hu plig ritual, which was originally performed to protect infants and mothers during the dangerous transition of birth.)

Fadiman also notes that spiritual healers are seen as mediators between the physical and spiritual worlds, using rituals to restore balance and health. They’re called to their role through illness, which is interpreted to mean a spirit that heals has chosen them. Shamans undergo extensive training to learn rituals and incantations. Their work is entirely metaphysical, and they aren't resistant to prescription medicine or physical treatments because they see natural and supernatural healing as complementary.

(Shortform note: Medical anthropologists refer to this as medical pluralism, which is the coexistence of multiple medical systems or practices within a single society. In medical pluralism, different therapeutic worldviews are preserved and combined rather than replaced by a single, dominant model of care. This approach recognizes that people may seek care from various sources, including traditional healers, biomedical practitioners, and alternative therapies, depending on their needs and beliefs.)

Lia Lee's Case: Conflict, Misunderstanding, and Lessons for Cross-Cultural Care

Lia Lee's circumstances highlight the challenges of intercultural care and communication. Fadiman writes that Lia Lee suffered from epilepsy, and her case led to extreme turmoil at the Merced hospital. The Lees used herbal treatments, skin therapies, and animal offerings for Lia, while the doctors treated her with medicine to control seizures. The Lees didn't comply with the doctors' orders, and the doctors failed to grasp the Lees' beliefs. The doctors reported the Lees to social services, and Lia was taken from their custody. The situation was complex and harrowing for everyone involved.

From Cultural Competency to Structural Competency

Since the publication of The Spirit Catches You and You Fall Down, some medical training programs have shifted their focus from “cultural competency” to “structural competency.” In a 2014 article, Jonathan M. Metzl and Helena Hansen argue that “structural competency is the trained ability to discern how many issues defined clinically as symptoms, attitudes, or diseases also represent the downstream implications of a range of upstream decisions about such matters as health care and food delivery systems, zoning laws, urban and rural infrastructures, and the very definitions of illness and health.” In other words, Metzl and Hansen argue that clinicians should understand the institutional and political structures that shape intercultural care and communication. In the case of Lia Lee, a structural competency approach would have encouraged the doctors to understand the larger forces that led to the breakdown in communication between the Lees and the doctors.

Below, we will describe the sources of conflict in Lia's care and pathways to improved cross-cultural healthcare.

Sources of Conflict in Lia Lee's Care

Fadiman describes how cultural misunderstandings between the Lees and the medical community led to conflict in Lia's treatment. The Lees thought that American medicine had harmed Lia and lost trust in medical professionals. They believed that if they were still in Laos, they could have healed Lia with traditional medicine.

The medical professionals blamed the Lees for not following medical advice, while the Lees accused the doctors of not understanding their beliefs. The Lees' experience with the medical system reinforced the Hmong community's distrust of Western medicine, while the medical community's experience with the Lees reinforced their negative stereotypes about the Hmong.

(Shortform note: The conflict between the Lees and the medical professionals led to a breakdown in trust between the two groups. This is because people tend to form opinions about groups based on their experiences with individual members of those groups. When people have a negative experience with a member of another group, they often see it as evidence that confirms their existing stereotypes about that group. This is especially true when the experience is emotionally charged, as it was in Lia's case.)

Fadiman explains that Lia's treatment was affected by the Lees' distrust of Western medicine. They believed that the medicine Lia was given was making her sicker, so they didn't always follow the prescription directions. This distrust was reinforced by Lia's condition worsening despite the treatment she received.

(Shortform note: In The Patient’s Brain, Fabrizio Benedetti explains that the nocebo effect is driven by negative expectations, learning, and prior beliefs. When patients expect harm from a treatment, they’re more likely to misinterpret spontaneous fluctuations of the disease as being caused or worsened by that treatment.)

Additionally, Fadiman notes that healthcare providers' perception of the Lees as noncompliant parents contributed to the conflict. The Lees believed that the doctors were angry at them for not following medical advice and removed Lia from their care as punishment. Their failure to follow the medication schedule for Lia stemmed from their lack of trust in Western medicine and their belief in traditional Hmong healing practices.

From Noncompliance to Adherence

Since the publication of Fadiman’s book, the medical community has shifted away from the term “noncompliant” to describe patients who don’t follow medical advice. Instead, they use the term “adherence,” which recognizes that patients are active partners in their care and that treatment recommendations should be based on agreement rather than unilateral instruction. This shift in language reflects a broader understanding that nonadherence is often due to barriers in the healthcare system, rather than a lack of willingness or responsibility on the part of patients or their families.

Below, we will discuss conceptual and philosophical disparities, along with clinical actions and their unintended consequences.

Conceptual and Philosophical Disparities

Fadiman writes that medical practices in the West often prioritize clinical procedures over cultural understanding. Doctors learn to be emotionally detached from patients, which can make them insensitive to these individuals' feelings and beliefs. They may see medicine across different cultures as a challenge to their logical thinking and may not be open to the idea that their perception of reality is merely one perspective, not reality itself. This can cause gaps in their caregiving.

(Shortform note: One of the most influential advocates of emotional detachment in medicine was Sir William Osler, a Canadian physician and one of the founding professors of Johns Hopkins Hospital. In his 1904 address “Aequanimitas,” Osler argued that doctors should cultivate a calm, impersonal demeanor to maintain sound clinical judgment. He explains that this emotional distance is necessary for doctors to make objective decisions and avoid being overwhelmed by their patients’ suffering.)

Clinical Actions and Their Unintended Consequences

Fadiman argues that clinical actions can have unintended consequences due to misunderstandings between cultures. The Lees believed that Lia’s condition worsened because she was taken away from them and that the medical team was punishing them for not following their instructions. Conversely, the doctors thought Lia's situation worsened because her parents didn’t follow their instructions.

The doctors didn't grasp the Hmong's holistic approach to medicine, and the Hmong didn’t understand the American approach of dividing medicine into specialties. The Hmong thought that the doctors were arrogant and didn’t respect their beliefs, while the doctors believed the Hmong were ignorant for refusing modern medicine.

The Fundamental Attribution Error

In The Social Animal, Elliot Aronson describes the “fundamental attribution error,” which is the tendency to attribute other people’s actions to their character rather than their circumstances. For example, if someone cuts you off in traffic, you might think they’re a jerk, rather than considering that they might be rushing to the hospital. Aronson argues that this error is especially common when people from different backgrounds interpret the same events differently. This supports Fadiman’s argument that the Lees and their doctors each blamed the other for Lia’s condition, rather than considering that they were each responding to their own circumstances.

Pathways to Improved Cross-Cultural Healthcare

Fadiman suggests that programs designed to educate on cultural diversity can improve healthcare delivery. These programs can help healthcare professionals better understand and communicate with people from different backgrounds. They can include role-playing, case studies, and discussions on differences in culture. They can also teach healthcare professionals how to collaborate with interpreters, as well as how to ask patients about their beliefs and preferences. Ultimately, these programs can help healthcare professionals provide more respectful and effective care to people from different cultures.

The Pitfalls of Cultural Diversity Education

Cultural diversity education programs can sometimes backfire. For example, if they focus too much on specific cultural traits, they can reinforce stereotypes. For example, if a program teaches that all Hmong people believe in shamanism, it can lead healthcare professionals to make assumptions about their patients. This can make patients feel misunderstood and disrespected. To avoid this, programs should focus on teaching healthcare professionals how to ask open-ended questions and listen to their patients’ individual needs.

Fadiman additionally states that integrating traditional healers into medical care can enhance patient trust and outcomes. In 2009, Mercy Medical Center Merced became the first US hospital to formally incorporate shamans in the care of patients. The hospital partnered with a local community organization to train shamans in medical procedures and allow them to perform certain ceremonies at patients’ bedsides. This partnership has improved trust in the hospital within the Hmong community and reduced the frequency of problematic cases.

(Shortform note: A qualitative study by Carolyn M. Audet, Milton L. Wainberg, and Maria A. Oquendo found that when faith healers in rural Mozambique were brought into formal partnerships with mental-health clinicians, they began directing clients toward clinic-based treatment in new ways. This suggests that such partnerships can change the timing and setting of people’s help-seeking behavior. The authors argue that this shift occurred because the healers felt recognized as collaborators in the health system.)