Saturday, January 21, 2012

The importance, and limits, of cross-cultural understanding

Anne Fadiman's gripping book, The Spirit Catches You and You Fall Down: A Hmong Child, Her American Doctors, and the Collision of Two Cultures (1997), is a powerful demonstration of the value of cross-cultural sensitivity. It's clear from her book that dedicated, expert American doctors treating a very young Hmong girl for epilepsy and loving, attentive Hmong parents raising her in Merced, California could have engaged with each other far better than they did. More translators would have helped. More interest by the health providers in the parents' perceptions and understandings would have too. Less aura of authority on the part of the providers might also have elicited more trust and candor.

Had the health institutions and professionals managed all this -- in the midst of the many pressures of budget, workload and emotion that were part of their daily life -- communication would have been better. The parents would have better understood what they were being asked to do and why. The health providers, for their part, would have realized more quickly that the parents were profoundly loving and attentive, rather than essentially evasive and noncompliant (though they were these things too).

But even then the distance between the parents and the doctors would have been daunting. The Hmong parents believed that their daughter’s epilepsy was caused by her soul leaving her body and getting lost, evidently with the aid of a soul-stealing spirit, a
dab  -- hence the Hmong term for epilepsy, quag dab peg, or “the spirit catches you and you fall down.” (20) Hmong people find many familiar Western medical interventions -- spinal taps, emphatically, but also lesser intrusions such as drawing blood -- a threat to the body and soul.  (33, 61) “The only form of [Western] medical treatment that was gratefully accepted by at least some of the Hmong in the Thai camps [to which they had fled as they escaped from persecution in Laos] was antibiotic therapy, either oral or by injection.” (34)

Fadiman speaks only briefly (76-78) about the Merced doctor who had the most Hmong patients. The other doctors in town didn't think this one was very skilled. In the few words of his that Fadiman quotes, he does not come across as deeply reflective. But it does appear that what his Hmong patients like is that he doesn't try to push them to accept treatments they don't like – to be precise, he “doesn’t cut.” (76) And he has a reason for this stance, quite a good one -- that “It’s their body.” (77)

One way to understand this statement is that this doctor is truly patient-centered, and that may be so. The principles of nondomination captured in the idea of patient-centeredness – the medical analogue to lawyers’ client-centeredness -- are powerful ones.

But I wonder if this physician was reflecting an insight more sociological than ethical. Fadiman never offers any formula for what the health providers should have done for the little girl who is the center of the story -- that's not her point in the book. But she does express the hope that someday the voices of the American doctors and Hmong family members will merge into one conversation. (ix) Someday, yes. But perhaps we should accept that that may take generations. In the meantime, what the doctor popular with the Hmong offered might be called "peaceful coexistence" -- an acceptance that some gaps can't yet be bridged, some goals can't be accomplished, and that we should try to work together with mutual respect but relatively limited ambitions while the passage of time slowly brings us closer together.

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