The Spirit Catches You and You Fall Down

The Spirit Catches You and You Fall Down 

The delivery of healthcare is a complex process that must take into account the various factors that influence its effectiveness. While the technical clinical aspects of the process are vital to caring for patients, professionals must consider other equally important dimensions. One such factor is the culture of the patient, which refers to the shared values, assumptions, opinions, learned responses, and tolerated beliefs that define the fabric that holds together the community they hail from (Purnell, 2014). It is a critical element in the delivery of human care since it defines the manner in which people behave and perceive multiple practices including medical ones. For instance, it is a culture that provides the communication context for all interactions between doctors and their patients. Since medical professionals are obligated to deliver care to all people indiscriminately, the issue of culturally competent healthcare comes to the fore. It involves healthcare professionals and establishments’ capability to provide medical services effectively in line with patients’ socio-cultural and linguistic needs (Purnell, 2014). It serves as the subject of the essay examined in the context of The Spirit Catches You and You Fall Down, by Anne Fadiman. In the end, the essay demonstrates that culture is inseparable from healthcare as it provides the communication context and, hence, the attempts to separate the two lead to negative outcomes.

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The Spirit Catches You and You Fall Down: A Hmong Child, Her American Doctors, and the Collision of Two Cultures is the story of the medical journey of Lia Lee who is of the Hmong descent, born to immigrants from Lao, Vietnam, in Merced, California. At the age of three months, she was identified as being epileptic. However, the treatment process was hindered by the variance between the cultural beliefs of doctors and the patients’ family. For instance, the latter believed that the epileptic episodes were due to the escaping of her soul. As she grew older, the treatment was complicated by noncompliance of the parents with medical procedures as well as hardline positions on treatment taken by the doctors. Eventually, the healthcare professional ceased treatment when Lia’s brain died, blaming the parents for noncompliance (Fadiman, 1997). The family, on the other hand, proceeded to take care of their daughter, put the responsibility for her vegetative state on the doctors’ practices and disrespect for their cultural beliefs.

Underlying Issues

There were several underlying issues in the case of Lia, the first of which was the doctor’s lack of cultural competence, which requires that the medical professionals provide care in accordance with the culture of the patient including the understanding of the language and the beliefs of their patient (Betancourt, Green, Carillo, & Owusu, 2016). Thus, it is evident that the said competence among the professionals caring for Lia was absent. For instance, none of them understood the Hmong language despite treating this particular patient for years. It complicated the process of communication, which is vital for the effective treatment. For instance, the doctors did not take an interest in learning beliefs, practices, and the context within which they were interacting with patients. Gathering such knowledge would have provided them with insights into the characteristic traits of the Hmong. With such awareness, there would be an understanding of the communication framework, for example, the Hmong the stubborn nature of the Hmong. Consequently, doctors would have acted in a way likely to diffuse tense situations. In addition, the medical team at Merced County Medical Center (MCMC) adopted a patronizing attitude towards the Hmong. Therefore, they failed to listen to suggestions from Lia’s patients in, for instance, allowing her to sleep with them. This problem also stemmed from the unwillingness to understand the history of the Hmong who came from a background of perpetual oppression and abuse. It amounts to the lack of the communication context (Betancourt, et. al., 2016). Therefore, they were bound to be defensive in any situation they considered to be threatening or unreliable.

However, there were underlying problems caused by Lia’s parents as well. Particularly, they lacked faith and trust in the medical system and professionals. As such, they remained suspicious of all doctors, even when the latter were completely dedicated to helping them. Consequently, they were not completely honest with the medical team. For instance, though they took Lia to the hospital, they did not always comply with medical recommendations of the medical staff and lied about it. Thus, when Lia was visiting her parents after being admitted to the hospital, the latter tended to lie about administering the medicine and empty the vials. Such a lack of trust always compounds the patient’s care since it causes inconsistency in treatment (Purnell, 2014). Collectively, such behaviors of both the professionals and the family caused the tragic fate of Lia.

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There is also a considerable problem in the setup of the medical system, which contributed to the fatal failure of Lia’s treatment. Specifically, the hospital was insufficiently equipped to deliver care to all groups of the society. Given that the population of the Hmong community was approximately one-fifth of Merced’s population, it is difficult to explain why the hospital administration had not hired a single translator. It is especially disconcerting since the Hmong were more predisposed to illnesses than the native residents. Such a situation implies that many people only received suboptimal care. In addition, the delivery of services for the Hmong was insufficient. It is evident from the admissions of the educated members of this community interviewed by Fadiman. It is even clearer in Nao Kao’s decision not to take Lia to the hospital by himself but to wait for an ambulance, which was inspired by the observation that the poor coming by foot did not receive the appropriate level of care. Moreover, the system failed in Lia’s case as the ambulance took longer to arrive than it would have taken Nao Kao to walk. This systemic failure contributed to reducing the quality of care received by the patient.

Undesirable Outcomes

One of the main problems that resulted from the shortcomings of the people involved in Lia’s case lays in the diagnosis. The medical team depended on a translator since none of them understood the Hmong language. Therefore, there was the miscommunication as only a few people were available to translate and the hospital often lacked such a person. Even when present, these individuals were not professionals; thus, it was causing additional miscommunication. One such consequence was the misdiagnosis of the patient. For instance, Lia Lee was not treated for epilepsy until after two visits and four months. Similarly, after the final big seizure, the doctors lacked a translator and, hence, assumed the usual problem. Therefore, they administered the wrong treatment. The combination of the wrong medicine and the time lost between the wrong diagnosis and the correct one exacerbated Lia’s condition and, collectively, resulted in her final vegetative state.

The Blame

The ultimate fate of Lia was occasioned by various failures of medical care. The healthcare team and the caregivers at home failed equally in their responsibility towards the patient. The hospital administrators did not ensure that the institution is well-equipped and care is delivered equitably, as they are supposed to, according to Purnell (2014). Individual caregivers also failed. Thus, none of them took the initiative to learn the traditions of the Hmong, some of their most common patients. Similarly, they all presumed to know Lia’s problem after her big seizure and, hence, overlooked minor symptoms. As such, they were not prepared to deliver the competent and effective care. Fresno from Valley Children’s Hospital also shares the blame for possibly overreacting when presented with the case of Lia Lee. Though he took some steps to help, such as the replacement of blood, he also contributed to the damage incurred on the patient. Most significantly, he added a highly potent sedative to the excessive Valium already administered at the MCMC. In as much as the damage they incurred was involuntary, Lia’s parents also played a considerable role in her illness. Their rigidity and non-compliance with the medical directions issued by the doctors mean that the disease was not treated in a proper manner, which gave it time to affect their daughter even more. Besides, Nao Kao’s decision to take Lia to the hospital in time contributed significantly to her final state. Healthcare delivery is the responsibility of all stakeholders interested in the patient’s health. The unfortunate fate of Lia is the striking evidence of this fact. No single person can take all the blame for her tragic case; it is the individual actions of all people involved that collectively led to the patient’s condition.

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Alternative Recommendations

The overarching theme of the entire book is the clash between American and Hmong cultures, which should be the first challenge to alleviate. The difference in beliefs between the two communities directly resulted in the tragedy of Lia, and it should be addressed through increasing doctors’ cultural competence (Betancourt, et al., 2016). Medical professionals are only charged with delivering the best possible care to all patients, notwithstanding their beliefs. Therefore, they are obliged to learn how to adapt their care to the diverse cultures they are bound to encounter in their practice. It could be attained by respecting the tenets of culturally competent care abbreviated as LEARN (Betancourt, et al., 2016). It stands for following notions: Listening (L), where doctors must listen to comprehend the patients’ presentation of the problem, including the relevant cultural perception; Explanation (E) is the next principle whereby doctors explain their understanding of the problem; Acknowledgment (A) of all disparities and commonalities between the two points of view whereby professionals are advised to focus on commonalities; the professional must then provide Recommendations (R), namely the remedy they deem appropriate; and the final step is Negotiation (N) since doctors must take culture into account. It is also vital to respect the views of the patient and, as such, prompt healthcare professionals to negotiate the treatment plan to accommodate the patient’s concerns and address them sufficiently where it is not possible. In many cases, the patients are rigid, and it is upon the doctor to develop the plan and means to affect the condition (Purnell, 2014). Fadiman gives the example of the Dwight Conquergood who created a narrative in line with his patients’ beliefs to inspire them to accept rabies vaccines. Professionals must take initiatives to avail and deliver optimal healthcare. At the same time, the MCMC needs interpreters. The administrator could seek volunteers or provide training to some members of the staff in the Hmong language to avoid additional expenses. Consequently, it will be possible to communicate with the patients.


It is evident that culture is one of the subjects at the center of the healthcare delivery. As such, the cultural competence is required to avoid the culture clash and facilitate effective healthcare services. In Lia’s case, the cultural differences between parents and caregivers resulted in the breakdown in communication and, hence, complications in treatment. A missing vital part of the treatment plan was that the doctors did not seek to understand the cultural context of the Hmong community’s members. As such, the doctors failed in their responsibility to provide culturally competent care. On the other hand, the parents, in their ignorance, acted in contravention of medical practices thinking they were defending their daughter. The inequality and the inefficiency of the healthcare system also contributed to the failure in treatment. Therefore, the absence of the cultural competence resulted in Lia being in a permanent vegetative condition.

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