The Spirit Catches You and You Fall Down By Anne Fadiman

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Review by Catherine R. deVries, M. D.

Why does a soul take flight and leave a person, never to return? For many reasons - a blood drawing, a spinal tap, an improper dose of medicine, an operation. How can a person be attacked by an evil spirit, or dab? How can the terrible consequences be ameliorated? In an environment where peaple fear that doctors will eat their patient's livers, kidneys and brains and cause other unspeakable harm these are serious concerns. In 1982, 15,000 Hmong refugees in Thailand gathered in a soccer field to voice their anxieties about Western medicine. Most then subsequently moved to the United States, and by the 1990's, a large population had settled in Merced County, California.

In The Spirit Catches You and You Fall Down, Anne Fadiman details the story of a Hmong girl with epilepsy and the conflict between the Hmong community and the Western-trained medical personnel over how to treat her. The difficulties encountered by her doctors were not merely those of language. Explanation and translation of doctor's orders had no effect on "compliance" by the patient's parents. The problems centered on conflicting belief systems about causation of disease and a means to "cure". The Western system holds that disease has a biological basis while the Hmong hold that disease is primarily spiritual. Because neither party understood the other's intentions, mutual distrust and hostility evolved. Ultimately, the confusion contributed to the brain-death of the child. Anne Fadiman meticulously lays out the course of nine years of care and the efforts of her family to retrieve her wandering soul, from the sacrifice of a pig in the apartment living room to the intervention of a Tvix neeb, or Hmong shaman.

The story is sobering for those of us trained in Western medicine who try to provide good medical care for patients from other cultures. Why are these patients not grateful? Why do they think we caused the problem? To what extent do we as doctors actually exacerbate patients' problems? Can we convince them that our medicine or our surgery helps rather than harms them? When is noncompliance equivalent to child endangerment? By what means can we communicate? The answers, such as they are, seem to lie not in translation but in "cultural brokering" - the act of interpreting and educating both patients and doctors about the issues in terms of cultural context. Further, they require an active interest by care givers to understand the patient's view of the problem.

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