Andrea Bennett Anthropology of Health and Healing November 5, 2010

Critical Review of The Spirit Catches You and You Fall Down Ann Fadiman's The Spirit Catches You and You Fall Down is a compelling portrait of what can happen when two cultures collide. The author does an incredible job of acquainting readers with the Hmong people of Laos, and a culture that is rich in traditions and paradoxes. It is truly ironic that such proud individualists would find themselves, and their child, in a position of such powerlessness and vulnerability. This book should be required reading for all medical students; it captures the severe ethnocentric that dominates Western medicine. Two of the books main medical characters, Doctors Neil and Peggy Ernst, struggle to care for a baby that is drenched in shamanistic traditions of which they know nothing about. The biggest strength of this narrative lies in its ability to bring the brain death of Lia Lee to life in the hearts of it readers. In a story that is shocking, compelling, and often poignant, Fadiman uncovers the weaknesses of Western medicine and leaves the reader struggling to make sense of the Lee family's suffering. Fadiman tirelessly reconstructs Lia Lee's roots in a war torn country that is as far away from Western Society as any country could be, and chronicles the war that brought them all to a Northern California community. The main question appears to be: Could Lia Lee have experienced a better outcome in a medical system that was less ethnocentric? Fadiman answers the question in no uncertain terms; and she does it throughout the book. Down deep, however, Fadiman shows that the rough individualism of Laos is really the base upon which Americanism is built, albeit in a different language and opposite cultural traditions. Americans, like Laotians, are used to doing things their own way. Western medicine had to rise above a plethora of other medical traditions, such a Ayurveda and Traditional Chinese Medicine in order to evolve into the industry it is today. This meant dismantling the mind-body connection in favor of a straight biological

mindset. While this outlook alleviated the responsibility for Western patients to use preventative measures in the area of health maintenance, it also made us prisoners of our own genes. At the opposite end of the spectrum, Laotians are captured by the mind. All it takes is the slam of a door for an errant dab to steal the soul of an innocent baby. Exorcising the bad spirit can only be accomplished by a trained shaman a txiv neeb. Herb baths, animal sacrifices, prayer, and other shamanic rituals are used to cure everything from seizures to perforated bowels. Fadiman makes it clear that it is indeed the ground in the middle of this vast spectrum, and not what lies on either side, that is probably the most efficacious position in which to deal with both health and illness. Fadiman also brings to light the very real problem created by language barriers. Neil and Peggy Ernst have a real problem communicating with Lia's parents, Foua and Nao Kao, which appears to exacerbate the problems with Lia's treatment for grand mal seizures. The Ernst's sterile world of an art that at times cannot comprehend the human needs of its patients is overturned by a family steeped in traditions they cannot see, let alone understand. After prescribing a rigorous and confusing course of treatment, one that appears to be difficult even for people who were born and raised in America, the Ernst's stubbornly, and with great professional determination, stick to a course of action that leads to suffering and loss. It is not until the end of the book that the reader finds out that the main culprit in Lia's brain death is not the seizure disorder for which she is being treated, but a septic infection that spiked her temperature so high that she never recovered. There were a few notable areas in which I as a reader was left wondering. First and foremost, Fadiman portrays Lia's treatment problems as something that were caused by a lack of communication, when in reality these events can and do happen with American patients as well. Iatrogenic injury causes over half a million deaths per year in America (Our Civilization). On page 117, Fadiman illustrates the problem with nosocomial infections, saying that these events are not something a doctor, or hospital, would want to emphasize; this is probably because a full 98,000 iatrogenic deaths each year are caused by such infections (Starfield). The fact that doctors can and do make mistakes is grossly under-explained

in the book. I feel that adding some background statistics would have only added to Fadiman's book because it would have forced the reader to bring the Lee's story right into his or her own back yard. What happened to the Lees could happen to anyone. The arrogance of Western doctors the idea that doctors always know what's best along with the complete dis-allowance of the processes of the psyche, separate doctors from their patients on the most deeply spiritual plane. However, Descartess I think, therefore I am, the mind-body split upon which Western medicine is built, could never be more deliberately exposed as in The Spirit Catches You and You Fall Down. Secondly, the Lee's struggles getting out of their war-torn country must have caused a great deal of traumatic stress. The fact that Fadiman left out the very real effects of such stress is a telling reminder that even in anthropology, the Descartes phenomenon is still very much alive. Outside of anecdotal stories, such as Jonas Vangay's summary about his parents on page 136, there isn't much in the book that explains the ravaging stress that people like the Lees endured. Post traumatic stress can cause a whole host of psychological and physiological imbalances. The Lee's reluctance to follow treatment for their daughter, although much of it cultural, could have also been a pathological response to the fear of losing their daughter after having carried her through both rice and mine fields during the Viet Nam War. My own mother, who was raised in Missouri, took me out of the hospital after I was prepped and ready for surgery because she lost a son just a few years earlier. Fadiman fails to address the issue of post traumatic stress disorder in any meaningful way. Again, fear of losing a child is a universal trait, not bound by individual culture. The Lees had already lost so much; the Ernst's failed to take the very real brutal after-effects of war into consideration. It is as if Neil and Peggy were numb to anything outside of being perfect doctors. When one is so focused on his or her own performance, it is hard to comprehend the needs of others. Even though Fadmian provides a chilling narrative on the effects of war, adding a short chapter, or at least a few pages, of the crushing effects of trauma could have only enhanced the story of Lia and her family. Lastly, in the area of constructive criticism, although Fadiman very eloquently illuminates the

very real shortcomings of Western medicine, she also minimizes the efficacy of other healing modalities by not looking into the very real physical process of belief not to mention herbal medicine. In the chapter, A little Medicine and a Little Neem, particularly in pages 108 through 110, the author talks a great deal about animal sacrifice, yet provides no background information on the two most important parts of Lia's home treatment by her parents. Studies have been conducted on the immune system, as well the neurological circuitry of the brain. There is information available on everything from spontaneous remission to dopamine receptors. Herbs like graviola and mistletoe (the latter being marketed under the brand name Iscador) have been clinically proven to cure some kinds of cancers. Including even a small amount of background material on these subjects would have made them look like more than just religious symbolism. She mentions the opinion of Kleinman, that ...the doctor cures the disease but the indigenous healer cures the underlying illness (p 266), but by not adding credible clinical statistics about the true healing capacity of of both belief and herbal preparations the two main tools in a shamans toolbox she relegates both to the the realm of the mysterious. In fact, this statement in and of itself puts mind/body healing completely out of Western medicine's reach because it infers that doctors will never be able to do what the shaman does, which is only true because of current educational paradigms. The more modern technology is able to look deeply into the biology of the brain and emotion, the more it realizes that objective results can be obtained through unorthodox processes. Furthermore, since many drugs today are still derived from plant constituents, there is little doubt that herbs do indeed hold huge healing roles in both Western and traditional medical systems. Fadiman does a wonderful job of showing her own values and beliefs. Her lines of evidence, throughout the book, add velocity to her central thesis that there is room in modern medicine for the power of belief. She makes the assumption that the situation can be changed, and supports her premise by coming back to Neil and Peggy Ernst, along with a host of other professionals in the last two chapters. I don't sense any falsity in her assumptions, and feel that in that respect Fadiman succeeded in helping me to understand a problem that is even further compounded by cultural and language barriers. All in all,

Ann Fadiman does a stellar job in underlining the importance of Kleinman's 'eight questions, devoting and entire chapter to the subject toward the end of the book. On page 259 the author asks, Instead of practicing 'veterinary medicine' what if the residents at in the emergency room had managed to elicit the Lee's trust at the outset or at least manage to not crush it by finding out what they believed, feared and hoped? One can only wonder what could have happened if the doctors at MCMC could have not only been patient and probing enough to ask about what Lia's illness meant to the Lee's, but also willing to take their opinions seriously. In the end, the Ernst's own child falling ill seemed to let them off the hook entirely, and Lia's transformation from a problem child into a docile, compliant patient exonerated her in the eyes of a hospital staff that at times seemed completely barren of empathy. While I have nothing against them they did the best they could with the education they received I find it disturbing that their training fell so short when it came to dealing with the humanity in their patients. This is truly a book I will remember. The backdrop of my own near-death illness as a child was occupied by a brother who died of febrile seizures, just like Lia Lee, just before I was born. Before my mom died, she told me the story of her and my dad, traveling by boat down a dark Mississippi River, feeling their way to the hospital after finding out that their son was ill again. I never realized how much they must have suffered until I read this book. I was always well aware of the undercurrent of sorrow that defined both my mothers' life and death. Now I understand why she never recovered.

Sources Cited: Table of Iatrogenic Deaths in the United States, Our Civilization, Web. 2010 Nov 05, http://www.ourcivilisation.com/medicine/usamed/deaths.htm

Starfield B., Is US health really the best in the world? JAMA. 2000 Jul 26;284(4):483-5.