Running head: THE SPIRIT CATCHES YOU AND YOU FALL DOWN !

The Spirit Catches You and You Fall Down:

The Roles of Social Determinants of Health and Cultural Competence

Rino Watanabe

University of Washington

Professor Christine Leibbrand

SOC 230

December 10, 2019


THE SPIRIT CATCHES YOU AND YOU FALL DOWN !2

Introduction: Lia Lee’s Experiences with Colliding Cultures

As the United States population is rapidly diversifying, the ability to effectively

communicate and gain perspective has become more critical. This holds true, especially in

regards to cross-cultural environments, because each culture has its own set of beliefs, values,

and practices that drive people’s thoughts and actions. It is pivotal to acknowledge and respect

these differences since the decisions people make based solely on their perspective can impact

lives such as Lia Lee’s in The Spirit Catches You and You Fall Down. Through Lia’s experiences,

the author Anne Fadiman investigates the impact of colliding cultures on health outcomes and

addresses two obscure issues in Western medicine - the lack of cultural competence and diversity

among health care professionals. Diagnosed with epilepsy, Lia Lee’s medical journey is

particularly affected by the clash of perspectives on causes of illness and proper treatment

between American physicians and her Hmong family (Fadiman, 1998). In addition to cultural

conflicts, the conflict between medical science and spiritual religion also contributes to the lack

of trust, empathy, and communication between them. The issues presented from this patient-

physician interaction are exacerbated by the biases and prejudices that Western and Eastern

groups hold against each other. As a result, the lack of cultural awareness in medicine - among

other social determinants like access to health care - limits the potential for better health

outcomes for ethnic groups, making them more marginalized and thus disadvantaged in Western

society. Through Lia’s story, this novel serves to not only reflect the consequences of social

factors on health outcomes but also advocate for social change in U.S. medical practices from its

generally one-sided, doctor-centered perspective to a more inclusive and patient-centered

perspective.
THE SPIRIT CATCHES YOU AND YOU FALL DOWN !3

Social Determinants of Health: The Roles of Ethnicity, Culture, and Religion

What are social determinants of health? Social determinants of health are “social factors

that have a direct or an indirect influence on health...including things like: education, income/

wealth, occupational status, neighborhoods, race/ethnicity, religion, etc.” (Leibbrand, 2019, slide

15). They play a vital role in Lia Lee’s health outcomes because social factors, such as ethnicity

and culture, fuel a majority of the miscommunication and mistrust between the Lee’s and Merced

County employees. For one, ethnicity is a social factor that affects Lia’s health, as she is one of

thousands of Asian refugees in Merced at the time. Because they were generally viewed as

financial burdens (due to their dependence on Medi-Cal benefits and translation services/

bilingual employees), Lia’s initial visit to the emergency room for seizures is routinely dismissed

under a misdiagnosis. One supporting explanation is that “Ethnic minority patients receive less

information, empathy, and attention from their physicians regarding their medical care than their

White counterparts” (Scharff, Mathews, Jackson, Hoffsuemmer, Martin, & Edwards, 2010). This

inequitable treatment ultimately impairs Lia’s health; similarly, culture is another factor that

impairs her health, since the clash between the Lee’s and Merced County employees, or more so

their beliefs and values regarding epilepsy’s causes and appropriate treatment, is rooted in

cultural differences.

To the Lee family, Hmong culture, specifically their spiritual religion, is integral to

their daily lives and beliefs. As a result, Lia’s parents Foua and Nao Kao have mixed reactions to

Lia’s illness: on the one hand, they worry about Lia’s health and want her to be healed because

the shaking symptom is a sign that a malicious spirit called a dab is ‘catching her’- thus, the

illness’ name, quag dab peg, means “the spirit catches you and you fall down” (Fadiman, 1998).
THE SPIRIT CATCHES YOU AND YOU FALL DOWN !4

On the other hand, their culture also views quag dab peg to be an illness of honor and a vocation

to be a txiv neeb, a distinguished shaman in Hmong culture (Fadiman, 1998). As this paradox

demonstrates, a key difference between Hmong and U.S. culture is that Hmong religion

attributes many illnesses and events to spiritual activity. Similar to Muslim cultures, in Hmong

culture, “religious values attach meaning to health and disease as well as health-related

experiences and influence cultural practices that manifest in health and healthcare-seeking

behaviors” (Padela, Gunter, Killawi, & Heisler, 2011). Furthermore, this quote supports how

because the txiv neeb also provides healing services, the Lee’s are accustomed to shamanistic

medicine, which entails entirely different processes for patient interactions, diagnosis, and

treatment than U.S. medicine. Their lack of trust in Western medicine is exacerbated by the

misinformation and biases that the Hmong already associate with American doctors (like how

doctors eat livers and brains of patients), as well as Hmong cultural/religious taboos of Western

practices including taking large amounts of blood, frequently consuming many pills, using

anesthesia, and having surgery, spinal taps, and autopsies (Fadiman, 1998, p.33). Other

minorities in the U.S. also harbor a mistrust against Western medicine: “Many [African

Americans] suggested that health care providers are dishonest, either by leaving out important

information when obtaining consent or by misinforming them” (Scharff et al., 2010). This shared

perspective reflects how the lack of communication can contribute to the growing health

disparity between minorities and more privileged groups.

However, to U.S. medical practitioners, epilepsy is viewed as a serious neurological

disorder, involving chaotic neural impulses and loss of consciousness. The doctors at Merced

County are driven by Western medical science rather than Hmong religious beliefs, which
THE SPIRIT CATCHES YOU AND YOU FALL DOWN !5

motivates them to prescribe treatments for Lia’s epilepsy that are based on Western practices and

thus a doctor-centered perspective. This one-sided culture of medicine fuels the mistrust between

doctors and minority patients, which is significant because “negative perceptions could alter their

[Black patients/other minority patients] behavior in ways that reduce adherence, return for

follow-up, or trust and thus contribute to disparities in care” (Chapman, Kaatz, & Carnes, 2013),

inevitably impairing Lia’s health outcomes as well. Furthermore, these doctors have their own

biases against the Lee family; as a result, Jeanine Hilt - a social worker who makes the effort to

communicate with the Lee’s - is the only one who asks Foua and Nao Kao for their perspective

on what is causing Lia’s illness. In contrast, the Merced County doctors have a “vague idea that

‘spirits’ are somehow involved” (Fadiman, 1998, p.22). Although both the doctors and the Lee’s

are doing what they think is “best” for Lia, because both the Lee family and Merced County

doctors are only aware of their own culture’s perspective and neither would acknowledge the

other culture’s perspective, Lia’s health outcomes are adversely affected.

Social Determinants of Health: The Roles of Access to Health Care, Immigration

Status, and Education

Lia’s health is also impacted by social factors such as limited access to health care,

immigration status, and education. These social factors are all interrelated because her health,

specifically treatment procedures, is impacted by her family’s background as Hmong refugees in

a foreign country. Thus, in addition to ethnicity and culture, miscommunication and mistrust can

be attributed to language barriers, for example. Not only did Merced County not have any

interpreters or Hmong-speakers but also Foua and Nao Kao did not speak English, so Lia’s

parents and doctors were unable to communicate with each other. In some instances, Foua and
THE SPIRIT CATCHES YOU AND YOU FALL DOWN !6

Nao Kao had to rely on English-speaking relatives or would be given complex instructions in

English to give Lia specific dosages of multiple medications at different times. Language barriers

in medicine occur quite often, as one study demonstrated, “no interpreter was used in 46 percent

of emergency department cases involving patients with limited English proficiency” (Flores,

2006). However, these language barriers are detrimental to improvements in health outcomes

because patients are less likely to return for follow-up appointments and experience higher rates

of hospitalization and drug complications (Flores, 2006), as demonstrated by Lia experiences.

Moreover, these relatives or “ad hoc interpreters” are more likely to commit errors and not be

familiar with medical terminology, which can result in dire health consequences (Flores, 2006).

The lack of sufficient resources, particularly language services, contributes to the health disparity

between immigrants and non-immigrants in the U.S. In Lia’s case, education is also a significant

social factor because no service or organization in Merced County or Laos informed her family

about the American health care system, follow-up appointments, treatment procedures, etc.

Therefore, accessibility is a key issue for the majority of immigrants and non-English speakers:

“At the individual level, flexible resources can be conceptualized as the “cause of causes” or

“risk of risks” that shape individual health behaviors by influencing whether people know about,

have access to, can afford, and receive social support for their efforts to engage in health-

enhancing or health-protective behaviors” (Phelan, Link, Tehranifar, 2010). Specifically,

accessibility tailed for cross-cultural communication is an obstacle in Lia’s health: “Community

needs are better understood and met by culturally sensitive healthcare accommodations and

structural modifications in healthcare delivery” (Padela et al., 2011). Because the Lee’s weren’t

informed about how to administer her treatment and the significance of it, and the doctors did not
THE SPIRIT CATCHES YOU AND YOU FALL DOWN !7

accommodate her treatment accordingly to acknowledge the cultural disparity, the Lee’s decide

to limit Lia’s medication, damaging Lia’s health.

Addressing the Social Factors: Would Outcomes have Changed?

Fadiman and others have investigated Lia’s experience at Merced County to speculate

if outcomes could have changed. Attending to these social determinants of health could have

potentially changed the health outcomes for Lia Lee. In particular, if the social factors were

addressed through increasing cultural competence and diversity in health care professions, the

collision of cultures may not have impaired Lia’s health, and there may have been more trust,

empathy, and communication between the Lee’s and Merced County employees.

Cultural competence is defined as “the ability to effectively engage in cross-cultural

interactions by behaving and acting in a way that shows awareness of and sensitivity to

culturally-specific practices” (Leibbrand, 2019, slide 66). Had the Merced County employees

been more culturally competent and provided interpreters, bilingual nurses to administer

medicine, or included a txiv neeb in Lia’s treatment, the Lee family may have trusted more, and

communication may have been more efficient, ultimately improving Lia’s health outcomes.

Because Western medicine is often doctor-centered and based on U.S. medical science, Lia’s

experiences demonstrate the importance of being more patient-centered and culturally-aware. In

other words, in order to mitigate inequity in health care and health outcomes, “cultural

competency programs along with patient-centered models of care ensure that patient values are

respected and that medical complications stemming from cultural differences are reduced

through reasonable healthcare accommodations” (Padela et al., 2011). Regarding patient-

centered medicine, Fadiman supports medical anthropologist Arthur Kleinman’s set of eight
THE SPIRIT CATCHES YOU AND YOU FALL DOWN !8

questions that physicians should ask their patients, such as the Lee’s, to hear their perspective on

causes and appropriate treatment for illnesses (Fadiman, 1998, p.260).

This support for cultural competent and patient-centered medicine is not to argue that

Western medicine/medical science culture is wrong or leading to negative health outcomes. As

Kleinman even cautions, “If you can't see that your own culture has its own set of interests,

emotions, and biases, how can you expect to deal successfully with someone else's

culture?” (Fadiman, 1998, p.261). Fadiman explains how cultural competence and Western

medical science are not mutually exclusive: “Western medicine saves lives...Until the culture of

medicine changes, it would be asking a lot of them to consider, much less adopt, the notion that,

as Francesca Farr put it, "our view of reality is only a view, not reality itself." However, I don’t

think that it would be too much to ask them to acknowledge their patients’ realities” (Fadiman,

1998, p.276).

Conclusion: Moving Forward in the Culture of Western Medicine

In essence, The Spirit Catches You and You Fall Down emphasizes the role of

communication, trust, and empathy in cross-cultural settings, particularly between patients and

physicians. Lia Lee’s health is impacted by several social determinants of health, or social

factors, including ethnicity and culture, education, and access to health care. These issues are

driven by the clash of cultures between Hmong and U.S. medicine, which raises the importance

of cultural competence and diversity in U.S. health care professions. By demonstrating how a

one-sided perspective can result in negative health consequences, Fadiman advocates for patient-

centered and culturally inclusive medical care in the U.S. to prevent health injustices like that of

Lia Lee’s. 

THE SPIRIT CATCHES YOU AND YOU FALL DOWN !9

References

Chapman, E.N., Kaatz, A., & Carnes, M. (2013). Physicians and Implicit Bias: How Doctors

May Unwittingly Perpetuate Health Care Disparities. J Gen Intern Med, 28(11), 1504–10.

doi: 10.1007/s11606-013-2441-1.

Fadiman, A. (1998). The Spirit Catches You and You Fall Down: A Hmong Child, Her American

Doctors, and the Collision of Two Cultures. New York, NY: Farrar, Straus and Giroux.

Flores, G. (2006). Language Barriers to Health Care in the United States. N Engl J Med, 355(3),

229-31. doi: 10.1056/NEJMp058316.

Leibbrand, C. (2019). SOC 230: Introduction to U.S. Health Disparities Weeks 1-2 [PowerPoint

slides]. Retrieved from https://canvas.uw.edu/courses/1342105/files/folder/

Class%20Powerpoints?preview=58661547

Leibbrand, C. (2019). SOC 230: Introduction to U.S. Health Disparities Week 5 [PowerPoint

slides]. Retrieved from https://canvas.uw.edu/courses/1342105/files/folder/

Class%20Powerpoints?preview=59233872

Padela, A.I., Gunter, K., Killawi, A., Heisler, M. (2011). Religious Values and Healthcare

Accommodations: Voices from the American Muslim Community. J Gen Intern

Med, 27(6), 708-15. doi: 10.1007/s11606-011-1965-5.

Phelan, J.C., Link, B.G., Tehranifar, P. (2010). Social Conditions as Fundamental Causes of

Health Inequalities: Theory, Evidence, and Policy Implications. Journal of Health and

Social Behavior, 51(S), S28-S40. doi: 10.1177/0022146510383498.

 !10

Scharff, D.P., Mathews, K.J., Jackson, P., Hoffsuemmer, J., Martin, E., & Edwards, D. (2010).

More than Tuskegee: Understanding Mistrust about Research Participation. Journal of

Health Care for the Poor and Underserved, 21(3), 879-897. doi:10.1353/hpu.0.0323.