Book Review: The Spirit Catches You And You Fall Down

            The Spirit Catches You and You Fall Down is based on a true incident that explores the cultural clash between a Hmong family and an American medical facility. The conflict occurs over the care of a Hmong baby girl, Lia Lee who was diagnosed with severe epilepsy. Lia’s parents and her doctors both wanted her to recover but a lack of communication and understanding between them led to the struggle. Anne Fadiman uses The Spirit Catches You and You Fall Down to convey the message that no matter how much the Western medicine has advanced, cultural factors are important for diagnosis, treatment and care.

            The Lees were a Hmong family that lived as refugees in Merced, California. They fled from their country, Laos due to warfare and political strains. They survived but half of their kids died during the escape. They also lost their identity as being self-sufficient, respectful and productive farmers and were forced to become dependents on Merced economy. Lia Lee was the 13^th child born to mother Foua and father Nao Kao Lee. She was suffering from epilepsy since the age of 3 months old. She was taken to the emergency room at Merced multiple times Due to a language barrier the parents could never communicate the symptoms correctly to the doctors. It was when she was taken into the emergency room during a convulsion that she was correctly diagnosed with epilepsy.

            Lia Lee was prescribed complex medications by the doctors. Her parents found it difficult to comply with the instructions. This resulted in Lia Lee being over-medicated, under-medicated or not medicated at all. Seeing no improvement in Lia Lee’s condition, her parents believed that huge amount of medicines was doing more harm to her than good. For them, “the crisis was the treatment, not the epilepsy” (53). Lia’s condition worsened to such an extent that one of her doctor’s recommended that she should be taken into foster care. While Lia was away, the parents went through a rigorous learning session to be able to give the right medications to their daughter. After they showed ability to comply with the prescription, Lia was returned to them. Despite being given the right medicines, Lia’s seizures did not stop. One afternoon, Lia went into status epilepticus, the situation that was feared by all her doctors in which her seizures continued one after another without any interval of consciousness. The parents believed that the child was returned to them in a “damaged condition” (110). The seizure and the septic shock resulted in Lia’s brain completely losing all its functions. She went into a comatose stage. Her seizures stopped since she was brain dead. Her doctors decided to take her off all life-saving treatments because they knew she was going to die. She had been living in the vegetative state for two years, much to the surprise of the doctors and was also lovingly cared by her parents, when Anne Fadiman first visited them.

            The Spirit Catches You and You Fall Down is a literal translation of a Hmong phrase, quag deb peg. In English, it is translated as epilepsy, a condition well known to every Hmong. The Hmongs receive this condition with both fear and gratitude. The condition is a burden on the individual undergoing the seizures and having hallucinations but the person is blessed spiritually. For the American doctors, diseases are caused due to changes in the normal functioning of the body and epilepsy was due to a malfunctioning in the brain activity. It had nothing to do with the soul.

            This book is an exciting story about the cultural aspect of practicing medicine. Other than this book, Fadiman has authored two essay books only. I would like to read them since I like her writing style. She is very clear in what she conveys that immediately gets into your heart. In Spirit Catches You and You Fall Down, Fadiman gives vivid descriptions of the war situation in Laos that resulted in the Hmongs escaping and transitioning into the Western world. She acts like a cultural broker. She interviewed everyone involved with Lia Lee’s case, listened to their stories, interpreted what they believed in and integrated their interpretations with one common goal, to save Lia Lee.

Despite many clashes of beliefs, Fadiman did a commendable job in presenting the correct viewpoints of both the Hmong parents and the American doctors. For instance, Lia’s parents considered her doctors, Neil Ernst and Peggy Philip guilty of Lia’s status epilepticus condition. It was not because the doctors had prescribed the wrong medications. It was because they went on a vacation and left Lia to be cared by other unskilled doctors. When Neil and Peggy heard this from Fadiman, they were completely shocked. Even when Lia was taken away into foster care, the parents had no clue why they were being separated from their child. They threatened to consider suicide so many times that Fadiman says, “Child Protective Services considered placing the entire family in a psychiatric hospital” (89). This sentence made me laugh as well as cry. The Lees were very loving and caring parents but they were legally declared as “abusive parents” due to their inability to follow the doctor’s instructions. At the end of the day, Fadiman concluded that everyone was striving hard to save Lia Lee. They were fighting from different sides but their ultimate goal was the same.

One of the most powerful incidents described in the book is when the child of Peggy Philip, one of the doctors of Lia Lee, was diagnosed with leukemia. Lia’s mother could identify her pain with that of Peggy’s. They were both hugging and shedding tears over their kids’ ailments despite all cultural barriers. This incident shows the humanitarian side of both the cultures. There are some feelings that are culturally universal. This motherly love surpassed any cultural judgments. With this I believe that Fadiman’s conclusion that the Hmongs are “differently ethical’ is contradictory. She said so because the Hmongs would cheat creatively on the written part of the driver’s test and lie about their age and marital status to gain benefits. This is just a way for the Hmongs to find a place for themselves in a place where they do not even understand the language. Every culture has a set of rights and wrongs but the ultimate cause for it is the human desperation to survive. It should not be considered differently ethical.

Although the book was very sad, I found it an interesting read. I learnt a lot about the Hmong culture. Also, being a pre-medical student, the book compelled me to consider the cultural aspect of medicine, which is usually taken for granted. It is very important for doctors to be sensitive to cultural differences and to try to provide care accordingly. In Lia’s case, a lack of a competent Hmong interpreter was a disadvantage but the Hmongs are so radically different from the Americans that even if a good translator were present, it would be difficult to find appropriate Hmong terms to explain the situations properly. The doctors should have at least tried to acknowledge the concerns of the Hmong parents. Cultural barrier in addition to illiteracy resulted in the parents giving wrong medications to their child. Due to deteriorating condition of Lia, the parents lost faith in the treatment plan. They believed that Lia needed some medications but she also needed chants, amulets and animal sacrifices. But for the doctors, Lia’s parents were the cause of her suffering.

The Spirit Catches You and You Fall Down is not really a “must read” book for premedical/pre-health students since it does not give a deep insight about the life and challenges in a medical school but it does enlist some chilling facts and personal experiences of doctors. It talks about cultural competence which people in the field of health care have to face in their careers. Winner of the National Book Critics Circle Award for Nonfiction, the book is based on well-conducted research about cross-cultural medicine with some very valuable lessons.