The Spirit Catches You and You Fall Down by Anne Fadiman
Cultural competence is a defining aspect in the provision of medical care to people of different cultures. In “The spirit catches you and you fall down” by Anne Fadiman, the story of a family of Hmong immigrants in the United States illustrates the consequences of the cultural insensitivity of medical personnel. Mistrust in the healthcare system on the part of ethnic minorities and language barriers are significant obstacles to providing quality care and access to it.
The book describes both the personal story of the characters and the events associated with the whole folk. They both merge into a discussion of the dangers that a lack of cross-cultural competence among medical personnel poses to many people. First of all, the reader learns about the Hmong people, who were forced to live in the mountains of Laos, as they were expelled from China for their inability to assimilate into the local culture.
Further, the representatives of the people are forced to take military action on the side of the United States during the Vietnam War. Thus, the communist forces are destroying the Hmong communities, forcing them to move to the United States. This backstory helps the reader understand the cultural background, which further plays an important role in the perception of the personal history of the characters.
Nao Kao and Foua Lee are Hmong refugees affected by the tragic events described. In search of a quiet life, they come to the United States and settle in the quiet town of Merced, California. After some time, they give birth to Lia, but she is diagnosed with epilepsy, which is expressed as infrequent seizures. However, the treatment process is complicated by the cultural characteristics of the family. First of all, they do not speak English, which is an obstacle for many doctors. The author emphasizes that even the obstetrician Dr. Robert Small with extensive medical experience has “unapologetic contempt for the Hmong” (Fadiman, 1998, p. 73).
The main reason for his attitude is the inability of the representatives of the people to understand what is required of them. The language barrier irritates the doctor and creates a bias in him. This circumstance becomes the basis for the events unfolding in the book.
Despite the fact that parents have a special explanation for their daughter’s seizures since they associate her disease with traditional beliefs, they seek medical help. They go to the Merced Community Medical Center (MCMC) but also apply alternative medicine practices which are common among their people. They believe in the effectiveness of “a little medicine and a little neeb” (Fadiman, 1998, p. 106). Neeb refers to the traditional Hmong shamanic practices with which both parents associate their daughter’s seizures. However, they also fear that an excess of conventional medicine could harm her health.
Doctors Neil Ernst and Peggy Philp treat epilepsy solely as a neurological disease and take a rational approach. However, due to the language barrier and the lack of translators, they are not even able to correctly diagnose the girl’s issue. The regimen recommended by the doctors is complex, so the parents either cannot or do not want to follow their instructions. They do not understand the link between physiology and seizures and find the effects of drugs excessively harmful.
Eventually, the situation deteriorates, and Lia begins to show signs of mental retardation. Concerned doctors contact the Child Protection Service (CPS), and the girl is placed in a foster home, which becomes traumatic for both her and her parents. Social worker Jeanine Hilt tries to educate the family to follow doctors’ directions and take medication. However, upon returning home, Lia has several seizures and septic shock, which may lead to brain death. The doctors expect her to die; the family takes her home. However, the girl lives for another 26 years and participates in shamanic ceremonies every year.
Fadiman, in her book, describes the dangers posed by the lack of cross-cultural sensitivity to the health of many patients. Hebenstreit (2017) notes that Lia “experiences a host of negative outcomes resulting from her Hmong parents’ and American doctors ’mutual failure to understand and respect the worldview of the other” (p. 103). In this case, both hidden or overt racism among healthcare workers and fear of others on the part of the Hmong family is a causes for misunderstanding.
In particular, the situation is presented as a clash of traditional shamanistic beliefs and rationalistic Western medicine. The author emphasizes the influence of factors such as “literacy, language, education, social integration, community engagement and cultural discrimination and competency for the reader” (Uy & Dimaano, 2019, p. 74). Thus, the book addresses the issue of the importance of considering cultural differences in the healthcare setting. The problem can be the primary barrier to timely and appropriate care for many people.
Cultural Competence in Healthcare
I would support the main claims of the book because the modern world is characterized by an increasing degree of globalization, and medical personnel needs to help people regardless of their beliefs, ethnicity, and language. First of all, the language barrier impedes communication, which “can result in diagnostic errors and inappropriate treatments and challenges with health literacy” (Stern & Rosenthal, 2019, p. 138).
Cultural competence consists of many factors which depend on the level of interaction between healthcare providers, patients, and their families. Henderson et al. (2018) underline that the concept “implies self-awareness, knowledge and the skills required of healthcare practitioners and their ability to apply them in practice” (p. 601). These aspects are key to providing effective care for patients of different cultures, but not always medical specialists utilized.
For the healthcare professional, the first priority is to show cultural sensitivity, which consists of respect for other cultures and perception of differences. However, in the book, the author often describes situations where people do not seek to understand the culture of the Hmong, condemn them or treat them with contempt. The Lee family’s refusal to follow conventional therapies is also a result of the low cultural sensitivity of doctors (Lin, Lee & Huang, 2017). Although they could not explain the importance of the recommendations due to the language barrier, they were reluctant to overcome it.
Cultural knowledge is also the basis of competence and comes from the previous aspect. Health care providers should strive to learn and appreciate the beliefs of other cultures. In particular, by assessing the Hmong’s perception of epilepsy, they would be able to choose both a communication approach and treatments which take shamanism into account. This circumstance would help to avoid the psychological trauma which both Lia and her family have suffered.
Cultural skill refers directly to the ability of medical professionals to apply their knowledge and awareness to practice. As part of cultural competence, healthcare providers need to adapt treatment to suit the patient (Lin, Lee & Huang, 2017). In this case, the attempt was made by a social worker who educated the family to follow the doctors’ instructions properly. However, the efforts of one person are not enough; cultural competence must be developed systematically since it is essential to manifest it at all levels of assistance.
The experience of the Hmong family described in the book can also be compared with the manifestations of structural racism, which are often characteristic of United States medical care. These episodes have a historical basis and have a negative impact on the development of cultural competence in the healthcare system. In particular, Black and Hispanic residents face the greatest difficulties accessing adequate and effective assistance (Bailey et al., 2017).
This circumstance is often motivated by the socio-cultural conditions of local communities, which are also represented by less qualified medical professionals. In particular, a doctor’s low level of cultural competence may cause people to refuse help because of shame or fear of discrimination. Fadiman emphasizes that the Hmong live in a neighborhood that also has a fairly low socioeconomic level. In particular, violence and condemnation towards them are widespread in the community. Perhaps this fact is also decisive for the family’s distrust of the methods which doctors offer them. Other ethnic minorities may also experience social pressures and are wary of the healthcare system.
The language barrier is also a serious problem for many people, especially migrants. The Hmong family experienced difficulties, not the ability to communicate with doctors. This problem is also relevant to the Hispanic population, as about 25 million people in the United States have limited English proficiency (Steinberg et al., 2016, p. 1318). This circumstance results in dissatisfaction with the medical care received and a decrease in the availability of care for members of the community. This is explained by the fact that “when people migrate, they tend to follow immigrant networks and start recreating communities in their new country” (Squires, 2018, p. 21).
Thus, a significant part of the country’s population speaks exclusively Spanish, while there are few representatives of the community among the medical workers. Other groups experiencing language barriers to help include Mandarin and Cantonese Chinese, Russians, and Italians (Squires, 2018). Thus, distrust of health professionals due to possible discrimination and language barriers are important issues for culturally sensitive care, not only for Hmong people but for other groups as well.
Bailey, Z. D., Krieger, N., Agénor, M., Graves, J., Linos, N., & Bassett, M. (2017). Structural racism and health inequities in the USA: Evidence and interventions. Lancet 389(10077), 1453-1463. Web.
Fadiman, A. (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.
Hebenstreit, H. (2017). The National Association of Social Workers Code of Ethics and cultural competence: What does Anne Fadiman’s The spirit catches you and you fall down teach us today? Health & Social Work, 42(2), 103-107. Web.
Henderson, S., Horne, M., Hons, R. B., & Kendall, E. (2018). Cultural competence in healthcare in the community: A concept analysis. Health & Social Care in the Community, 26(4), 590-603. Web.
Lin, C. J., Lee, C. K.,& Huang, M. C. (2017). Cultural competence of healthcare providers: A systematic review of assessment instruments. The Journal of Nursing Research, 25(3), 174-186. Web.
Steinberg, E. M., Valenzuela-Araujo, D., Zickafoose, J. S., Kieffer, E., & DeCamp, L. R. (2016). The “battle” of managing language barriers in health care. Clinical Pediatrics, 55(14), 1318-1327. Web.
Stern, D. F., & Rosenthal, R. (2019). Clinical education in physical therapy. Burlington: Jones & Bartlett Learning.
Squires, A. (2018). Strategies for overcoming language barriers in healthcare. Nursing Management, 49(4), 20-27. Web.
Uy, T., & Dimaano, C. (2019). Lessons learned from The spirit catches you and you fall down: Student perspectives on how cultural differences can lead to health disparities. Health Education Journal, 79(1), 73-81. Web.