The-Spirit-Catches-You-and-You-Anne-Fadiman1.pdf

Praise for

The Spirit Catches You and You Fall Down

“Fadiman describes with extraordinary skill the colliding worlds of
Western medicine and Hmong culture.”

—The New Yorker

“This fine book recounts a poignant tragedy…It has no heroes or villains,
but it has an abundance of innocent suffering, and it most certainly does
have a moral…[A] sad, excellent book.”

—Melvin Konner, The New York Times Book Review

“An intriguing, spirit-lifting, extraordinary exploration of two cultures in
uneasy coexistence…A wonderful aspect of Fadiman’s book is her even-
handed, detailed presentation of these disparate cultures and divergent
views—not with cool, dispassionate fairness but rather with a warm,
involved interest that sees and embraces both sides of each issue…
Superb, informal cultural anthropology—eye-opening, readable, utterly
engaging.”

—Carole Horn, The Washington Post Book World

“This is a book that should be deeply disturbing to anyone who has given
so much as a moment’s thought to the state of American medicine. But it
is much more…People are presented as [Fadiman] saw them, in their
humility and their frailty—and their nobility.”

—Sherwin B. Nuland, The New Republic

“Anne Fadiman’s phenomenal first book, The Spirit Catches You and You
Fall Down, brings to life the enduring power of parental love in an
impoverished refugee family struggling to protect their seriously ill
infant daughter and ancient spiritual traditions from the tyranny of

welfare bureaucrats and intolerant medical technocrats.”
—Al Santoli, The Washington Times

“A unique anthropological study of American society.”
—Louise Steinman, Los Angeles Times

“Some writers…have done exceedingly well at taking in one or another
human scene, then conveying it to others—James Agee, for instance…
and George Orwell…It is in such company that Anne Fadiman’s writing
belongs.”

—Robert Coles, Commonweal

“When the Lees hedged their bets in 1982 in Merced by taking Lia to the
hospital after one of her seizures, everybody lost. Fadiman’s account of
why Lia failed to benefit over the years from Western medicine is a
compelling story told in achingly beautiful prose.”

—Steve Weinberg, Chicago Tribune

“A deeply humane anthropological document written with the grace of a
lyric and the suspense of a thriller.”

—Abby Frucht, Newsday

“Fadiman’s meticulously researched nonfiction book exudes passion and
humanity without casting a disparaging eye at either the immigrant
parents, who don’t speak English, or the frustrated doctors who can’t
decipher the baby’s symptoms…The Spirit Catches You and You Fall
Down conveys one family’s story in a balanced, compelling way.”

—Jae-Ha Kim, The Cleveland Plain Dealer

“Fadiman’s sensitive reporting explores a vast cultural gap.”
—People Magazine

“Compellingly written, from the heart and from the trenches. I couldn’t

wait to finish it, then reread it and ponder it again. It is a powerful case
study of a medical tragedy.”

—David H. Mark, Journal of the American Medical Association

“The Spirit Catches You and You Fall Down is Fadiman’s haunting
account, written over a nine-year period, of one very sick girl in Merced,
California…What happens to Lia Lee is both enlightening and deeply
disturbing.”

—Kristin Van Ogtrop, Vogue

“Fadiman gives us a narrative as compelling as any thriller, a work
populated by the large cast of characters who fall in love with Lia. This is
a work of passionate advocacy, urging our medical establishment to
consider how their immigrant patients conceptualize health and disease.
This astonishing book helps us better understand our own culture even as
we learn about another—and changes our deepest beliefs about the
mysterious relationship between body and soul.”

—Elle

“The other day, I picked up a book I had no intention of buying. Eight
hours later, having lifted my head only long enough to pay for the book
and drive home, I closed Anne Fadiman’s The Spirit Catches You and You
Fall Down and started calling friends…This is an important book.”

—Wanda A. Adams, The Honolulu Advertiser

Contents

Preface

1 / Birth
2 / Fish Soup

3 / The Spirit Catches You and You Fall Down
4 / Do Doctors Eat Brains?

5 / Take as Directed
6 / High-Velocity Transcortical Lead Therapy

7 / Government Property
8 / Foua and Nao Kao

9 / A Little Medicine and a Little Neeb
10 / War

11 / The Big One
12 / Flight
13 / Code X

14 / The Melting Pot
15 / Gold and Dross

16 / Why Did They Pick Merced?
17 / The Eight Questions
18 / The Life or the Soul

19 / The Sacrifice

Note on Hmong Orthography, Pronunciation, and Quotations
Notes on Sources
Bibliography

Acknowledgments
Index

Preface

Under my desk I keep a large carton of cassette tapes. Even though they
have all been transcribed, I still like to listen to them from time to time.

Some of them are quiet and easily understood. They are filled with
the voices of American doctors, interrupted only occasionally by the
clink of a coffee cup or the beep of a pager. The rest of the tapes—more
than half of them—are very noisy. They are filled with the voices of the
Lees, a family of Hmong refugees from Laos who came to the United
States in 1980. Against a background of babies crying, children playing,
doors slamming, dishes clattering, a television yammering, and an air
conditioner wheezing, I can hear the mother’s voice, by turns breathy,
nasal, gargly, or humlike as it slides up and down the Hmong language’s
eight tones; the father’s voice, louder and slower and more vehement; and
my interpreter’s voice, mediating in Hmong and English, low and
deferential in each language. The hubbub summons a whoosh of sense-
memories: the coolness of the red metal folding chair, reserved for
guests, that was always set up as soon as I arrived in the apartment; the
shadows cast by the amulet that hung from the ceiling and swung in the
breeze on its length of grocer’s twine; the tastes of Hmong food, from the
best (quav ntsuas,* a sweet stalk similar to sugarcane) to the worst (ntshav
ciaj,* congealed raw pig’s blood).

I sat on the Lees’ red folding chair for the first time on May 19, 1988.
Earlier that spring I had come to Merced, California, where they lived,
because I had heard that there were some strange misunderstandings
going on at the county hospital between its Hmong patients and its
medical staff. One doctor called them “collisions,” which made it sound
as if two different kinds of people had rammed into each other, head on,
to the accompaniment of squealing brakes and breaking glass. As it
turned out, the encounters were messy but rarely frontal. Both sides were

wounded, but neither side seemed to know what had hit it or how to avoid
another crash.

I have always felt that the action most worth watching is not at the
center of things but where edges meet. I like shorelines, weather fronts,
international b s. There are interesting frictions and incongruities in
these places, and often, if you stand at the point of tangency, you can see
both sides better than if you were in the middle of either one. This is
especially true, I think, when the apposition is cultural. When I first came
to Merced, I hoped that the culture of American medicine, about which I
knew a little, and the culture of the Hmong, about which I knew nothing,
would in some way illuminate each other if I could position myself
between the two and manage not to get caught in the cross fire.

Nine years ago, that was all theory. After I heard about the Lees’
daughter Lia, whose case had occasioned some of the worst strife the
Merced hospital had ever seen, and after I got to know her family and her
doctors, and after I realized how much I liked both sides and how hard it
was to lay the blame at anyone’s door (though God knows I tried), I
stopped parsing the situation in such linear terms, which meant that
without intending to, I had started to think a little less like an American
and a little more like a Hmong. By chance, during the years I worked on
this book, my husband, my father, my daughter, and I all experienced
serious illnesses, and, like the Lees, I found myself spending a lot of time
in hospitals. I passed many hours in waiting rooms gnawing on the
question, What is a good doctor? During the same period, my two
children were born, and I found myself often asking a second question
that is also germane to the Lees’ story: What is a good parent?

I have now known the people in this book for much of my adult life. I
am sure that if I had never met Lia’s doctors, I would be a different kind
of patient. I am sure that if I had never met her family, I would be a
different kind of mother. When I pull a few cassettes from the carton
beneath my desk and listen to random snatches, I am plunged into a
pungent wash of remembrance, and at the same time I am reminded of
the lessons I am still learning from both of the cultures I have written
about. Now and then, when I play the tapes late at night, I imagine what

they would sound like if I could somehow splice them together, so the
voices of the Hmong and the voices of the American doctors could be
heard on a single tape, speaking a common language.

A.F.

1

Birth

If Lia Lee had been born in the highlands of northwest Laos, where her
parents and twelve of her brothers and sisters were born, her mother
would have squatted on the floor of the house that her father had built
from ax-hewn planks thatched with bamboo and grass. The floor was dirt,
but it was clean. Her mother, Foua, sprinkled it regularly with water to
keep the dust down and swept it every morning and evening with a broom
she had made of grass and bark. She used a bamboo dustpan, which she
had also made herself, to collect the feces of the children who were too
young to defecate outside, and emptied its contents in the forest. Even if
Foua had been a less fastidious housekeeper, her newborn babies
wouldn’t have gotten dirty, since she never let them actually touch the
floor. She remains proud to this day that she delivered each of them into
her own hands, reaching between her legs to ease out the head and then
letting the rest of the body slip out onto her bent forearms. No birth
attendant was present, though if her throat became dry during labor, her
husband, Nao Kao, was permitted to bring her a cup of hot water, as long
as he averted his eyes from her body. Because Foua believed that
moaning or screaming would thwart the birth, she labored in silence, with
the exception of an occasional prayer to her ancestors. She was so quiet
that although most of her babies were born at night, her older children
slept undisturbed on a communal bamboo pallet a few feet away, and
woke only when they heard the cry of their new brother or sister. After
each birth, Nao Kao cut the umbilical cord with heated scissors and tied it
with string. Then Foua washed the baby with water she had carried from
the stream, usually in the early phases of labor, in a wooden and bamboo

pack-barrel strapped to her back.
Foua conceived, carried, and bore all her children with ease, but had

there been any problems, she would have had recourse to a variety of
remedies that were commonly used by the Hmong, the hilltribe to which
her family belonged. If a Hmong couple failed to produce children, they
could call in a txiv neeb, a shaman who was believed to have the ability to
enter a trance, summon a posse of helpful familiars, ride a winged horse
over the twelve mountains between the earth and the sky, cross an ocean
inhabited by dragons, and (starting with bribes of food and money and, if
necessary, working up to a necromantic sword) negotiate for his patients’
health with the spirits who lived in the realm of the unseen. A txiv neeb
might be able to cure infertility by asking the couple to sacrifice a dog, a
cat, a chicken, or a sheep. After the animal’s throat was cut, the txiv neeb
would string a rope bridge from the doorpost to the marriage bed, over
which the soul of the couple’s future baby, which had been detained by a
malevolent spirit called a dab, could now freely travel to earth. One could
also take certain precautions to avoid becoming infertile in the first place.
For example, no Hmong woman of childbearing age would ever think of
setting foot inside a cave, because a particularly unpleasant kind of dab
sometimes lived there who liked to eat flesh and drink blood and could
make his victim sterile by having sexual intercourse with her.

Once a Hmong woman became pregnant, she could ensure the health
of her child by paying close attention to her food cravings. If she craved
ginger and failed to eat it, her child would be born with an extra finger or
toe. If she craved chicken flesh and did not eat it, her child would have a
blemish near its ear. If she craved eggs and did not eat them, her child
would have a lumpy head. When a Hmong woman felt the first pangs of
labor, she would hurry home from the rice or opium fields, where she had
continued to work throughout her pregnancy. It was important to reach
her own house, or at least the house of one of her husband’s cousins,
because if she gave birth anywhere else a dab might injure her. A long or
arduous labor could be eased by drinking the water in which a key had
been boiled, in to unlock the birth canal; by having her family array
bowls of sacred water around the room and chant prayers over them; or, if

the difficulty stemmed from having treated an elder member of the
family with insufficient respect, by washing the offended relative’s
fingertips and apologizing like crazy until the relative finally said, “I
forgive you.”

Soon after the birth, while the mother and baby were still lying
together next to the fire pit, the father dug a hole at least two feet deep in
the dirt floor and buried the placenta. If it was a girl, her placenta was
buried under her parents’ bed; if it was a boy, his placenta was buried in a
place of greater honor, near the base of the house’s central wooden pillar,
in which a male spirit, a domestic guardian who held up the roof of the
house and watched over its residents, made his home. The placenta was
always buried with the smooth side, the side that had faced the fetus
inside the womb, turned upward, since if it was upside down, the baby
might vomit after nursing. If the baby’s face erupted in spots, that meant
the placenta was being attacked by ants underground, and boiling water
was poured into the burial hole as an insecticide. In the Hmong language,
the word for placenta means “jacket.” It is considered one’s first and
finest garment. When a Hmong dies, his or her soul must travel back
from place to place, retracing the path of its life geography, until it
reaches the burial place of its placental jacket, and puts it on. Only after
the soul is properly dressed in the clothing in which it was born can it
continue its dangerous journey, past murderous dabs and giant poisonous
caterpillars, around man-eating rocks and impassable oceans, to the place
beyond the sky where it is reunited with its ancestors and from which it
will someday be sent to be reborn as the soul of a new baby. If the soul
cannot find its jacket, it is condemned to an eternity of wandering, naked
and alone.

Because the Lees are among the 150,000 Hmong who have fled Laos
since their country fell to communist forces in 1975, they do not know if
their house is still standing, or if the five male and seven female
placentas that Nao Kao buried under the dirt floor are still there. They
believe that half of the placentas have already been put to their final use,
since four of their sons and two of their daughters died of various causes
before the Lees came to the United States. The Lees believe that someday

the souls of most of the rest of their family will have a long way to travel,
since they will have to retrace their steps from Merced, California, where
the family has spent fifteen of its seventeen years in this country; to
Portland, Oregon, where they lived before Merced; to Honolulu, Hawaii,
where their airplane from Thailand first landed; to two Thai refugee
camps; and finally back to their home village in Laos.

The Lees’ thirteenth child, Mai, was born in a refugee camp in
Thailand. Her placenta was buried under their hut. Their fourteenth child,
Lia, was born in the Merced Community Medical Center, a modern
public hospital that serves an agricultural county in California’s Central
Valley, where many Hmong refugees have resettled. Lia’s placenta was
incinerated. Some Hmong women have asked the doctors at MCMC, as
the hospital is commonly called, if they could take their babies’ placentas
home. Several of the doctors have acquiesced, packing the placentas in
plastic bags or take-out containers from the hospital cafeteria; most have
refused, in some cases because they have assumed that the women
planned to eat the placentas, and have found that idea disgusting, and in
some cases because they have feared the possible spread of hepatitis B,
which is carried by at least fifteen percent of the Hmong refugees in the
United States. Foua never thought to ask, since she speaks no English,
and when she delivered Lia, no one present spoke Hmong. In any case,
the Lees’ apartment had a wooden floor covered with wall-to-wall
carpeting, so burying the placenta would have been a difficult
proposition.

When Lia was born, at 7:09 p.m. on July 19, 1982, Foua was lying on
her back on a steel table, her body covered with sterile drapes, her genital
area painted with a brown Betadine solution, with a high-wattage lamp
trained on her perineum. There were no family members in the room.
Gary Thueson, a family practice resident who did the delivery, noted in
the chart that in to speed the labor, he had artificially ruptured
Foua’s amniotic sac by poking it with a foot-long plastic “amni-hook”
that no anesthesia was used; that no episiotomy, an incision to enlarge the
vaginal opening, was necessary; and that after the birth, Foua received a
standard intravenous dose of Pitocin to constrict her uterus. Dr. Thueson

also noted that Lia was a “healthy infant” whose weight, 8 pounds 7
ounces, and condition were “appropriate for gestational age” (an estimate
he based on observation alone, since Foua had received no prenatal care,
was not certain how long she had been pregnant, and could not have told
Dr. Thueson even if she had known). Foua thinks that Lia was her largest
baby, although she isn’t sure, since none of her thirteen elder children
were weighed at birth. Lia’s Apgar scores, an assessment of a newborn
infant’s heart rate, respiration, muscle tone, color, and reflexes, were
good: one minute after her birth she scored 7 on a scale of 10, and four
minutes later she scored 9. When she was six minutes old, her color was
described as “pink” and her activity as “crying.” Lia was shown briefly to
her mother. Then she was placed in a steel and Plexiglas warmer, where a
nurse fastened a plastic identification band around her wrist and recorded
her footprints by inking the soles of her feet with a stamp pad and
pressing them against a Newborn Identification form. After that, Lia was
removed to the central nursery, where she received an injection of
Vitamin K in one of her thighs to prevent hemorrhagic disease; was
treated with two drops of silver nitrate solution in each eye, to prevent an
infection from gonococcal bacteria; and was bathed with Safeguard soap.

Foua’s own date of birth was recorded on Lia’s Delivery Room
Record as October 6, 1944. In fact, she has no idea when she was born,
and on various other occasions during the next several years she would
inform MCMC personnel, through English-speaking relatives such as the
nephew’s wife who had helped her check into the hospital for Lia’s
delivery, that her date of birth was October 6, 1942, or, more frequently,
October 6, 1926. Not a single admitting clerk ever appears to have
questioned the latter date, though it would imply that Foua gave birth to
Lia at the age of 55. Foua is quite sure, however, that October is correct,
since she was told by her parents that she was born during the season in
which the opium fields are weeded for the second time and the harvested
rice stalks are stacked. She invented the precise day of the month, like the
year, in to satisfy the many Americans who have evinced an
abhorrence of unfilled blanks on the innumerable forms the Lees have
encountered since their admission to the United States in 1980. Most

Hmong refugees are familiar with this American trait and have
accommodated it in the same way. Nao Kao Lee has a first cousin who
told the immigration officials that all nine of his children were born on
July 15, in nine consecutive years, and this information was duly
recorded on their resident alien documents.

When Lia Lee was released from MCMC, at the age of three days, her
mother was asked to sign a piece of paper that read:

I CERTIFY that during the discharge procedure I received my
baby, examined it and determined that it was mine. I checked the
Ident-A-Band® parts sealed on the baby and on me and found that
they were identically numbered 5043 and contained correct
identifying information.

Since Foua cannot read and has never learned to recognize Arabic
numerals, it is unlikely that she followed these instructions. However, she
had been asked for her signature so often in the United States that she had
mastered the capital forms of the seven different letters contained in her
name, Foua Yang. (The Yangs and the Lees are among the largest of the
Hmong clans; the other major ones are the Chas, the Chengs, the Hangs,
the Hers, the Kues, the Los, the Mouas, the Thaos, the Vues, the Xiongs,
and the Vangs. In Laos, the clan name came first, but most Hmong
refugees in the United States use it as a surname. Children belong to their
father’s clan; women traditionally retain their clan name after marriage.
Marrying a member of one’s own clan is strictly taboo.) Foua’s signature
is no less legible than the signatures of most of MCMC’s resident
physicians-in-training, which, particularly if they are written toward the
end of a twenty-four-hour shift, tend to resemble EEGs. However, it has
the unique distinction of looking different each time it appears on a
hospital document. On this occasion, FOUAYANG was written as a
single word. One A is canted to the left and one to the right, the Y looks
like an X, and the legs of the N undulate gracefully, like a child’s drawing
of a wave.

It is a credit to Foua’s general equanimity, as well as her

characteristic desire not to think ill of anyone, that although she found
Lia’s birth a peculiar experience, she has few criticisms of the way the
hospital handled it. Her doubts about MCMC in particular, and American
medicine in general, would not begin to gather force until Lia had visited
the hospital many times. On this occasion, she thought the doctor was
gentle and kind, she was impressed that so many people were there to
help her, and although she felt that the nurses who bathed Lia with
Safeguard did not get her quite as clean as she had gotten her newborns
with Laotian stream water, her only major complaint concerned the
hospital food. She was surprised to be offered ice water after the birth,
since many Hmong believe that cold foods during the postpartum period
make the blood congeal in the womb instead of cleansing it by flowing
freely, and that a woman who does not observe the taboo against them
will develop itchy skin or diarrhea in her old age. Foua did accept several
cups of what she remembers as hot black water. This was probably either
tea or beef broth; Foua is sure it wasn’t coffee, which she had seen before
and would have recognized. The black water was the only MCMC-
provided food that passed her lips during her stay in the maternity ward.
Each day, Nao Kao cooked and brought her the diet that is strictly
prescribed for Hmong women during the thirty days following childbirth:
steamed rice, and chicken boiled in water with five special postpartum
herbs (which the Lees had grown for this purpose on the edge of the
parking lot behind their apartment building). This diet was familiar to the
doctors on the Labor and Delivery floor at MCMC, whose assessments of
it were fairly accurate gauges of their general opinion of the Hmong. One
obstetrician, Raquel Arias, recalled, “The Hmong men carried these nice
little silver cans to the hospital that always had some kind of chicken
soup in them and always smelled great.” Another obstetrician, Robert
Small, said, “They always brought some horrible stinking concoction that
smelled like the chicken had been dead for a week.” Foua never shared
her meals with anyone, because there is a postpartum taboo against
spilling grains of rice accidentally into the chicken pot. If that occurs, the
newborn is likely to break out across the nose and cheeks with little white
pimples whose name in the Hmong language is the same as the word for

“rice.”
Some Hmong parents in Merced have given their children American

names. In addition to many standard ones, these have included Kennedy,
Nixon, Pajama, Guitar, Main (after Merced’s Main Street), and, until a
nurse counseled otherwise, Baby Boy, which one mother, seeing it written
on her son’s hospital papers, assumed was the name the doctor had
already chosen for him. The Lees chose to give their daughter a Hmong
name, Lia. Her name was officially conferred in a ceremony called a hu
plig, or soul-calling, which in Laos always took place on the third day
after birth. Until this ceremony was performed, a baby was not
considered to be fully a member of the human race, and if it died during
its first three days it was not accorded the customary funerary rites. (This
may have been a cultural adaptation to the fifty-percent infant mortality
rate, a way of steeling Hmong mothers against the frequent loss of their
babies during or shortly after childbirth by encouraging them to postpone
their attachment.) In the United States, the naming is usually celebrated
at a later time, since on its third day a baby may still be hospitalized,
especially if the birth was complicated. It took the Lee family about a
month to save enough money from their welfare checks, and from gifts
from their relatives’ welfare checks, to finance a soul-calling party for
Lia.

Although the Hmong believe that illness can be caused by a variety of
sources—including eating the wrong food, drinking contaminated water,
being affected by a change in the weather, failing to ejaculate completely
during sexual intercourse, neglecting to make offerings to one’s
ancestors, being punished for one’s ancestors’ transgressions, being
cursed, being hit by a whirlwind, having a stone implanted in one’s body
by an evil spirit master, having one’s blood sucked by a dab, bumping
into a dab who lives in a tree or a stream, digging a well in a dab’s living
place, catching sight of a dwarf female dab who eats earthworms, having
a dab sit on one’s chest while one is sleeping, doing one’s laundry in a
lake inhabited by a dragon, pointing one’s finger at the full moon,
touching a newborn mouse, killing a large snake, urinating on a rock that
looks like a tiger, urinating on or kicking a benevolent house spirit, or

having bird droppings fall on one’s head—by far the most common cause
of illness is soul loss. Although the Hmong do not agree on just how
many souls people have (estimates range from one to thirty-two; the Lees
believe there is only one), there is a general consensus that whatever the
number, it is the life-soul, whose presence …