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The Collision of Two Cultures – Implications of Cultural Values and Beliefs on Caring Concepts Abstract This paper is a personal response to Anne Fadiman’s book The Spirit Catches You and You Fall Down. The paper includes a summary of the book, an overall impression of the reader, a discussion of three major themes evident in the book, and a description of a situation from the book and how the situation could be handled differently using references and material learned in 3020 Transcultural Nursing.
Keywords: culture, cultural barriers, values and beliefs, language barrier, assimilation process The Collision of Two Cultures – Implications of Cultural Values and Beliefs on Caring Concepts After I finished my second summer semester this year I had 3 weeks break before starting fall semester, where I enrolled for this class. I had acquired my books already from a fellow student and went home to enjoy my three weeks of not studying; just working.
As I was putting the books away at home, I started reading the back of Anne Fadiman’s book “The Spirit Catches You and You Fall Down” where a journalist of The Washington Post referred to the book as utterly engaging, readable, and a superb piece of writing. Instead of storing the book I carried it upstairs and put it on my night table. That evening after I snuggled up in my bed I got to know Lia Lee, her parents, her doctors, and I learned about the struggles that were involved in caring for an ill child that sat between two cultures; the Hmong culture and the culture of American health care professionals.
Anne Fadiman takes the reader on a cultural journey where she describes the case of Lia Lee, a Hmong infant that suffers from epilepsy. As she tells the story of Lia and her immigrant family that had to flee from their home country and eventually gained entrance into the United States, she reveals the history and cultural traditions of the Hmong people. Moreover, she describes how her parents and the medical community of Merced Medical Center in California strive to help Lia as they try to treat and care for the epileptic child each in their own way.
The values and beliefs that both sides hold seem to be irreconcilable at the time because the two sides do not know enough about each other to even try to understand that both sides mean well and try their best to help Lea in her struggles to regain her health or control the condition. Fadiman details the misunderstandings that arise when two cultures come face-to-face but cannot understand each other. Lia arrives in the hospital with epileptic seizures which her parents blamed on a slammed door, a spirit catching Lia, and subsequent soul loss.
To the western doctors, who know little about the Hmong people and their culture, Lia’s seizure was caused by dysfunction in her brain which can be treated with medication. The doctors are unaware of the fact that the Lee’s diagnosed Lia with “qaug dab peg” which is the Hmong word for epilepsy, though considered potentially dangerous in Hmong culture it also distinguishes a person and may be indicative of a possible future as a shaman. The Hmong, like American Indians, are circular thinkers who see universal connections in all things.
The Hmong, unlike Americans, don’t split the mind and the body. To the Cartesian, linear thinking doctors, medical health cannot be restored by bargaining with spiritual powers and offering animal sacrifices. The book also touches on historical and political events which have shaped the character traits of Hmong and Americans. For centuries the Hmong have resisted persecution, manipulation, and domination by other Asian groups. They are a proud people and cherish their independence.
The Hmong’s challenge of authority frustrated the American doctors who aren’t used to having their authority questioned. The Lees non compliance with the western medical treatment was rooted in their belief that the family makes the decisions for their children which in their culture is in the best interest of the child. The Lees were convinced that the medication regimen only made Lia more ill and refused or altered the medication regiment. The doctors retaliated and showed their power by removing Lia from her parent’s home to foster care where they hoped Lia’s condition would stabilize.
However, there was that fear that lingered over the medical community in the Merced hospital that Lia would one day come in “with the big one”, the doctors called a grand mal seizure that would deprive the child of vital oxygen to her brain and either take her life or leave her in a vegetative state. Inevitably the day came that Lia suffered a grand mal seizure. Since, her higher brain function has ceased and she was left in a state that the western doctors described as dead, however, for the Lees it was the soul that had now left her body with no return.
Lia was taken home from the hospital where the medical team thought she would die soon after. However, the Lees loving competent care kept her alive, a life that in western value and belief system is not worth living, whereas the Hmong see it as a variation of nature and care for Lia even more, still hoping that her soul may return to her body one day. After finishing the book, I caught myself thinking that maybe Lia’s soul would one day return to her body. I truly enjoyed reading this cross-cultural account that is full of knowledge and derives wisdom from people of different life-ways.
Somehow, the book allows the reader to step out of one’s own culture and look at the world like a Hmong. Recognition of cultural differences is important in a country that consists of mostly immigrants. As people of one country we want to take care of each other, understand each other, and live with each other. Therefore, people need to get to know each other and understand the cultural backgrounds, value and belief systems. That is my opinion as a person. Looking at the book from the perspective of a nurse makes it even more valuable.
I have always liked the idea of culturally congruent care and have tried to incorporate it in my daily practice as a nurse. After reading this book, however, my perception of cultural care has changed. Anne Fadiman has spent years on her research on Hmong culture and her goal to make people understand the vast differences in values and beliefs of people from cultures that are different than main stream culture here in America. Her efforts make it possible for other people to embrace the knowledge she has collected and hopefully people are able to use the knowledge to make a difference in somebody else’s life; somebody else, like Lia.
Fadiman’s book illustrates how much time, commitment, and energy is necessary to understand another culture’s perspective on health and wellness and to translate that understanding into the day-to-day practice of medicine and caring. Incorporating cultural beliefs into medical care can go a long way to help people cope with illnesses. “A little medicine and a little neeb”, is what Nao Kao, Lia’s Dad said. In these simple words is hidden much of the truth that would have helped the Lees to cope better and comply more with Lia’s medication regimen.
If the outcome would have been different is questionable, however, the cultural aspect of Lia’s care was disregarded by the medical staff, both nurses and doctors and led to more complication than necessary. The involvement of a twix neeb would not have harmed Lia’s medical treatment; it would have enhanced it. The twix neeb, a shaman conducts his work on a metaphysical plane. He usually mediates between the earthly and the spiritual world, however, there is no evidence that this treatment hurts anybody (Fadiman, 1997, p. 267).
According to Dwight Conquergood, who has seen medication bottles on the altars of neebs, they do not resist medications, rather they incorporate it in the heeling process (Fadiman, 1991, p. 268). The book delivers much food for thought for whom ever is hungry for it, but it is especially useful for medical staff and doctors who dedicate their work to helping others. Anne Fadiman makes clear that we treat people and not diseases or body parts. On that note, she quotes William Osler who said “Ask not what disease the person has, but rather what person has the disease” (Fadiman, 1997, p. 75). The major theme in Fadiman’s book is cultural barriers. Language, cultural values and beliefs, and immigration status play an extensive role in assimilation and acculturation to a new society. The language barrier that the Lee’s experienced along with their different values and beliefs made it difficult for the Lees and the Merced medical staff to communicate with each other to navigate the treatment for Lia. Through Fadiman’s book, it becomes clear that language is an expression of cultural beliefs.
In Hmong language epilepsy is explained in spiritual terms and is, therefore, an expression of their culture that is rooted in the natural and spiritual world. In English epilepsy is explained as a disturbance of brain function, which expresses western values and beliefs that are based on knowledge derived from science. The use of translators only added to the miscommunication of the two sides, especially the use of unskilled people like a janitor or an aid which they used in this case. Fadiman states that cultural brokers are needed to help a situation where the divide between cultures is extensive.
In one of his interviews with Fadiman, Neil Ernst, the pediatrician involved in Lia’s care describes the cultural barrier as being a layer of saran wrap between the Lee’s and the medical staff of Merced Medical Center. He states that, you could get somehow into the area where you thought you reached them but you could never be sure that they understood. In 1980 when the Lee’s came to America cross-cultural medicine and care concepts were perceived by the medical community as form of political bamboozlement.
Physicians felt that these ideas were an assault on their rationality rather than a potentially lifesaving therapy (Fadiman, 1997, p. 273). Fadiman’s book was a necessity to open the road for cultural congruent care concepts. It serves as a testimony that ethnocentrism on behalf of a majority culture could prohibit people from seeking care or negatively influence the outcome. The description of birth practices and beliefs in Hmong culture is a good example for inhibiting people to seek care.
Prenatal care is highly valued in western culture, however, in Hmong culture where our understanding of medical care is nonexistent women take care of their needs. Even in the process of giving birth, as Fadiman describes in the first chapter they deliver their babies by themselves. If help is needed, the husband is utilized to aid in the birth of a Hmong baby. The Hmong women came to the hospital to give birth only because they had heard that if they do not deliver the baby in the hospital it will not be accepted as American citizen and they could not collect money from the government.
If it wasn’t for this misconception, the women would have avoided the hospitalization. The Hmong people were political refugees. Fadiman pictures the Hmong as extremely different from typical immigrants who are grateful and happy to have landed in America, the land of opportunity and freedom. As a group, the Hmong have a history of vehemently resisting assimilation. The Hmong refugees were not here because they wanted to be; they were here because they had no other choice.
The CIA-led “quiet war” in Laos had destroyed their homeland villages and made life as they knew it impossible. The life that the refugees found in the United States was strikingly different from their life in the mountains or in the refugee camp in Thailand. The culture shock caused many to cling more zealously to the old ways and to one another. This explains, at least in part, why after being in the United States for a number of years, the Lees appeared to speak virtually no English. Fadiman claims that Lia’s mother, even after being in the U.
S. for several years, had no idea how to operate the family telephone. In Transcultural Concepts in Nursing Care, Andrews and Boyle list many factors that affect the process of assimilation and acculturation to a new culture. As first generation immigrants, the Lees came to this country as a middle aged couple with their children. Whereas, Foua, Nao Kao and their peers had many difficulties getting used to the new life the book reveals that their children embraced the new experience and grew up to be bicultural.
As involuntary immigrants the first wave of Hmong people clung more to their cultural traditions as voluntary immigrants would do. Fadiman chronicles migration patterns of Hmong people inside the United States. After landing here the Hmong were dispersed across many states to divide the financial burden among the communities. However, the Hmong did not want to live apart from each other in this strange new environment. So against governmental plans they settled in large groups to practice their traditions and help each other.
Therefore, the assimilation to the new culture was slowed and delayed. Educational status is another factor that slows assimilation. The Hmong’s educational level was not comparable to western standards. As an indigenous mountain tribe who lived off their land knowledge was limited to what was necessary to survive in that environment. However, when the Hmong came to the United States the pattern of knowledge that was needed to survive changed drastically. To gain entrance into a society different than your own a new set of knowledge needs to be acquired to compete for resources.
Caring for people from a culture that has a different set of values and beliefs takes understanding and knowledge on the behalf of the professional that delivers the care. In nursing delivering cultural congruent care is a concept that was established by Madeleine Leininger who developed the theory of Cultural Care Diversity and Universality (George, 2010, p. 404). In their care practice nurses need to consider the interrelationship of cultural care, well-being, health, illness, and death as it is viewed by people from different cultures (George, 2010, p. 11). The approach should be holistic and explore multidimensional ways of caring. The nurse should seek to discover cultural care universalities and diversities and be able to apply it. Cultural care preservation, accommodation, and restructuring are key concepts of cultural congruent care delivery. Applying my knowledge from this class to the care of Lia I would have tried to establish a working relationship with the family and their twix neeb to preserve and maintain their values and beliefs.
The involvement of the neeb would have shown Lia’s family that their values and beliefs were acknowledged and not disregarded. Moreover, the twix neeb could have acted as negotiator to ensure that the Lee’s adhered to the medication regiment. Fadiman describes situations in the hospital where Lia was put in restraints to not interrupt her medical treatment by pulling on tubes and IV lines. The Lees were enraged about the restraints and tried to free her from the coercion of force that was administered by the medical professional at Merced Medical Center.
Involving a cultural broker like Fadiman terms it would have helped to concert the different views of treatment. The Lees wanted to care for her daughter by holding her and having her close, however, the medical staff wanted to maintain their treatment modalities to get Lia the medical treatment that she needed. A holistic approach is of utmost importance and maybe some agreement could be made to how the parents could have held and be close to Lia without interfering with the treatment modalities.
Restructuring Lia’s environment and treatment would have been a matter of more sensitivity on behalf of the medical professionals involved. Foster care did not improve Lia’s condition and the coercion of power on the Lee’s did not improve their compliance or strengthen their beliefs in western medicine and treatments. A more sensitive approach through home care services might have been more effective in the treatment of Lia’s epilepsy. Teaching the Lees how to read a clock, how to use the Gregorian calendar, would have been a useful approach to improve Lia’s condition.
Community classes on western values and beliefs would also be of interest to help people from different cultures to assimilate to main stream culture. The tragedy is that both the doctors and the family genuinely wanted to help Lia, but their lack of communication and inability to understand each other, culturally, and linguistically, made mutual efforts impossible. Anne Fadiman’s research effort created a valuable resource for people in curing and caring professions. Understanding the importance of incorporating cultural values and beliefs in the deliverance of care can make a difference in somebody else’s life.