1

ANNE FADIMAN BOOK REFLECTION

Gabriela Rivera
4/24/2015
The Spirit Catches You and You Fall Down Book Reflection
Community Systems
Two systems that I identified to be culturally insensitive and ineffective were the hospital
that Lia sought treatment from and the community in Merced, California that Lias family
resided in.
I think that the hospital was ineffective because they were not culturally competent. For
example, the doctors refused to give the placenta to Lias mother because the doctors thought the
family was going to eat it or that it was infected with hepatitis. They also continuously suspected
mistreatment of Lia when in reality in the Hmong culture mistreatment of children is looked
down upon.
An example of this with another hospital staff member that worked with Hmong in a
different area was provided in the book. In 1985, the International Rescue Committee chose
Dwight Conquergood to design a program for the Ban Vinai camp. He noted that the medical
staff at the Ban Vinai camp never tried to work in cooperation with the shamans, but instead did
everything they could to disconfirm them or undermine their authority. As a result, the Hmong
did not trust or utilize the hospital services.
Compared to the Hmong culture, a shaman would spend eight hours in a Hmong home
while an American doctor demanded the patient come to the hospital where the doctor might
only see the patient for twenty minutes. Shamans never asked personal questions compared to

ANNE FADIMAN BOOK REFLECTION

American doctors. Shamans could come up with an immediate diagnosis while the doctors had to
run many tests and then sometimes still didnt know what was wrong anyway. Shamans never
undressed their patients compared to American doctors placing their hands and fingers into the
body. Shamans knew you had to treat the soul as well as the body and they could not be blamed
for their patients not getting well, because it was the fault of the spirits while American doctors
were blamed for the patients death.
Furthermore, another community that was ineffective was the community that the family
resided in Merced, California. Merced failed in providing a safe haven for the Hmong. There was
no motivation to provide resources such as translators or ways to get healthcare. Also, there was
not an accepting environment in place to learn the culture of their host country. I think that if the
Hmong were more accepting of men and women that join with American men or women there
would be less of a divide and less miscommunication.
Richard Smith wrote in the British Medical Journal, Fadiman makes clear that
understanding and cooperation--let's call it concordance--doesn't come easily. It's not just a
matter of knowing a language and listening but also of understanding something of both the
ancient and near history of a people, their beliefs, and their culture--something that nobody
managed. Therefore, as social workers we have to make sure that translators do not solve
everything when two different people are trying to communicate. They also need to understand
and that can only be achieved when the history of culture of both people are known and
respected.
Strengths Perspective

ANNE FADIMAN BOOK REFLECTION

Lias main strength was the love she had for her family. She accepted everyone and
showed love physically with hugs and charmed anyone that played a role in her life. Also, Lia
had optimism despite her age. She faced various adversities such as being taken from home and
never completely understanding her disease because her family and the doctors viewed epilepsy
as two different things. Lias culture is a strength because Lias family cherished her and never
saw her as a burden when Lia sought treatment.
Interventions
I think the only helpful social work interventions that occurred in the book was Lias
foster family placement and Jeanine Hilts actions when Lia passed away. Lias foster family felt
that Lia did not need to be taken away from her family however, I think that the compliance with
the prescriptions and a nonexistent language barrier helped the doctors accelerate in determining
what to do for Lia and her epilepsy. Though Lias stay was very stressful for Lia, the foster
family, and Lias birth family.
I found a journal that explores the effect of stress on Hmong and Caucasian college
students. I felt that this was applicable because I am a college student and I wanted to relate to
the research I was completing. Also, Lia was a Hmong that was under high stress that could
match the levels of a Hmong college student. The hypothesis stated that there would be a
difference on internal subscales and no differences on chance and powerful-others subscales
between Hmong and Caucasian college students was supported. Results could be attributed to the
differences of cultures that Hmong college students retain from their communities and families.
Previous studies indicate that international students have less access to health care facilities and
viewed stress with an internal approach (Carpenter-Aeby, T., Xiong, D., & Aeby, V. G., 2014).

ANNE FADIMAN BOOK REFLECTION

Lia Lee
I felt like I didnt know Lia Lee. I knew of her because Anne Fadiman did a great job
recounting the descriptions that Lias family and doctors gave of Lia. However, I didnt get to
hear from inside Lias mind. I never got the chance to read how Lia felt when all these scary
things were happening to her. I never read what she thought about when her culture conflicted
with the western medicine she was receiving for her epilepsy. I understand that Lia was
incapable of explaining but if she were able to when she was alive today or capable while she
was I wouldve wanted that viewpoint in the book so I could get to know her more.
I consider Lia Lee to be a person of value. I think the many readers could think that she is
not because of the lack of knowledge of the Hmong culture. For example, it was very frustrating
for me as the reader to see that the family agreed to many things the doctor prescribed without
knowing what they were agreeing to. However, through my research I found that to show
respect for the counselor, in response to a power differential or because of trepidation regarding
the situation, Hmong clients may tend to be overly polite and agreeable, even when they do not
fully understand the question or task at hand or agree with it. Yes statements may be implying
that the client acknowledges a comment, but this does not necessarily mean that he or she agrees
with or accepts what is said. (Tatman, p.7, 2004)
What is a good doctor?
From the viewpoint of Anne Fadiman, a good doctor is defined as a person who
advocates for those who seek healthcare. Anne took special notice to those doctors that went
above and beyond to not only learn about the Hmong culture but to understand it and apply it
their Western medicine so it could be accepted by the Hmong. Fadiman described Dan Murphy

ANNE FADIMAN BOOK REFLECTION

as a man who needed to explain to the family what he had to do when they brought Lia seizing
but conflict arose because he knew that being invasive to the body was looked down upon.
Also, I think that Anne Fadiman considered Lias parents to be good parents. They gave
Lia unconditional love, took care of her physical needs, and gave Lia medical help in the Hmong
manner. Even though the medicine prescribed wasnt always followed I dont think Anne
Fadiman considered that action to be bad parenting. The parents saw that it would alter Lia
negatively and though it was unheard of to take matters into their own hand, going to the doctor
was not an option because they were met with confusion and aggression when given the
prescription.
I consider a good doctor to be a medical professional that provides the best care to get me
back to being healthy but also respecting what I am not comfortable with. I think an even better
doctor is one that is proactive to understand why I choose not to follow what they prescribe. I
think a good parent is one that loves, respects, encourages, seeks to connect and takes care of
their child. It can be difficult for a p parent to listen and agree with their child since the majority
of their lifetime the decisions for the child were made for them.
Jeanine Hilt
Jeanine Hilt was a successful social worker with the family because she advocated for
them therefore gaining their trust which encouraged progress. I think that Jeanine succeeded
because she worked hard to educate Foua to learn the medication regimen so the family could
regain custody. Compared to Sue Xiong, who was a Hmong, was not trusted because she married
an American and did not practice the Hmong culture. Jeanine validated Nao Kaos feelings of

ANNE FADIMAN BOOK REFLECTION

anger because she worked to make sure that his anger was not expressed with medical noncompliance.
At the end of the book I read that Jeanine visited Lia every day and worked hard to get
Lia to leave the hospital so she could pass away with her family. I learned from Jeanine that
despite a language barrier and cultural differences, validating a clients feelings can be
understood in all languages. I also learned that sometimes we have to be the resource for our
clients instead of finding a resource for them. Merced, California was a growing Hmong
population but there were no resources to learn how to adapt to living in the United States.
Jeanine herself became a resource for the family to learn the medication regimen so they could
get Lia to come back home.
Personal Reactions and Foster Family
Some of the issues I struggled with were Lias placement with a foster family and the last
chapter when Nao Kao was upset and tried to take Lia from the hospital. When Lia was placed
with a foster family she was well taken care of. What I struggled with specifically is that Lias
health got worse when the foster family was following the medication prescription exactly.
Furthermore, she suffered from a seizure when her family was given Lia back for a week because
the medication wasnt followed. I questioned whether anything being done for her was right or
wrong but the family was the one that had to suffer the consequences. I also struggled with Nao
Kaos reaction at the end of the novel trying to take Lia from the hospital because of a
misunderstanding. It was sad to read that he thought he was signing that Lia is going to die in 2
hours rather then he is taking her home in 2 hours.

ANNE FADIMAN BOOK REFLECTION

I think being placed with a foster family was to Lias benefit. Though she didnt improve
that much for her health and Lia didnt deal emotionally well with being separated from her
parents. The foster family followed every direction the doctor gave them and it helped rule out
what medication to use with Lia that could subside her seizures. I was surprised because the
foster family gave praise to the parents and Lia when all other comments from other people in
their life were negative. For example, the doctors complained that she was spoiled and fat
therefore it was difficult to put a needle in her but the foster family noted how positively loving
Lia was because of the way the parents raised her.
This book helped me resolve that translators are not the answer to clients that are not
from the United States. Cultural competence is also necessary to truly understand and help these
clients. Therefore, I question if social service agencies that have clients that are commonly
immigrants understand this concept and support it. This story affected me because my parents are
from Puerto Rico and they moved to California after they both graduated from high school.
Though Puerto Rico is a US territory, living in California was difficult because they had no
family and did not speak English. I thought about my background while reading this book and
wanted to connect it to the social work practice. Social work came into play for both Lia and my
family because people had to advocate for us since the language barrier was an obstacle for
communication.
Lee Memorial
The healthcare system failed the family because they were not culturally competent.
Given how signicantly Hmong beliefs, culture, and practices differ from those of mainstream
American cultureand other challenges they face as recent immigrants in a foreign land, a
variety of features of the ecological context in which Hmong are situated are creating a poor

ANNE FADIMAN BOOK REFLECTION

person-environment t and contributing to low utilization of preventive health care. (Sparks,
p.227, 2014)
After listening to our speaker, trainings should be more often and a requirement to attend.
We live in a dynamic society that is always changing. For example, a training about human
trafficking done a year ago would not be useful today because new tactics are always being
developed. Health disparities continue to exist because of language, financial/payment/coverage,
transportation, work/family demands, and other complicating factors barriers (Shippee, 2011,
p.2).

ANNE FADIMAN BOOK REFLECTION

References
Carpenter-Aeby, T., Xiong, D., & Aeby, V. G. (2014). Comparing the Health Locus of Control
among Caucasian and Hmong College Students. Journal Of Human Behavior In The
Social Environment, 24(5), 635-642. doi:10.1080/10911359.2014.914832
Shippee, N., & Shippee, T. (2011). Depression, Discrimination, and Unmet Health Needs
Among Hmong Enrollees of Public Health Care Programs in Minnesota. Conference
Papers -- American Sociological Association, 844.
Smith, R. (n.d). An extreme failure of concordance. BMJ: British Medical Journal, 327(7419),
818.
Sparks, S. A. (2014). Considerations of Culture and Community in the Production of Hmong
Health. Family & Consumer Sciences Research Journal, 42(3), 224-234.
doi:10.1111/fcsr.12057
Tatman, A. W. (2004). Hmong History, Culture, and Acculturation: Implications for Counseling
the Hmong. Journal Of Multicultural Counseling & Development, 32(4), 222-233.