Lia Lee: Hmong Culture

Being a Hmong-American in the United States was hard. Growing up in a community that was full of Americans, and being in a private school in my early years, (consisting mostly of Americans and little diversity) was difficult. In that kind of environment, I never saw each person differently. The characteristics that I saw were our skin color, and another distinction that I saw was our religious and cultural backgrounds. I started to lose touch of my own culture and identity as a Hmong-American girl. My family told me that in the stages of my toddler years, I used to be good at speaking my native tongue until I started school.

In addition, relying on a doctor who does not share the same beliefs as one does can become fearful. Trusting the doctor for full treatment is necessary but when from a different cultural background it can prevent them on trusting them. According to a research article, Cross- Cultural Medicine a Decade Later, clearly states “when the basic belief structure of biomedicine and another set of health beliefs differs radically, problems and frustrations almost inevitably arise” (Barker, 1992, p.249). The central purpose of the research was to show whether or not health beliefs between patient and doctor differs will they find it difficult to interpret the symptoms and treatment variations to accommodate their beliefs. However, the doctor having faith in one’s health beliefs can sometimes be beneficial for the patients because they’ll be fully understood and not misjudged as being crazy. As stated by the author, for the article Chinese Health Beliefs of Older Chinese in Canada, “the findings support the previous prescriptive knowledge about Chinese health beliefs and illustrate the intergroup socio-cultural diversity that health practitioners should acknowledge in their practice” (Lai, 2009, 38). Like the Chinese, Hmong’s too first go to their shaman for traditional treatment rather than going to the doctor; to them an illness and their healing is more of a spiritual thing that

Language barrier was a major factor that served to extend the boundary existing between the two cultures. Some of the utterances made by the doctors were interpreted right but were understood wrongly (Swartz 2). This resulted in a worsened discernment of the American doctors by the Lees and Hmong as an entity alike. In the case of an emergency, the Lees needed to contact an ambulance, but could not communicate with the hospital. This necessitated the involvement of their learned nephew, who would call an ambulance. The interpretation process would at times limit the effectiveness of the message intended by either party. For instance, when Lia was undergoing critical care in MCMC, the Lees needed to be comforted, a process which had to be done by an interpreter. Before the final discharge, miscommunication between Lia’s mother and the doctors had her think that the nurses disconnected medicine tubes off Lia in order to give it to some other patient; a mean act. In the same incident, Lia’s father was made to sign a letter of discharge for Lia, which would happen in two hours. However, he understood this as a letter to guarantee death in two

The doctors assuming the Lee were giving their daughter her medications, were surprised to not see levels of the medications in her blood. Dan Murphy who was one of Lia’s doctor questioned the parents and he learned that due to their cultural beliefs, Lia’s parents have not been administering her with the proper medicine. Where Lia’s mother believes she is doing the right thing for her daughter, Murphy has sympathy for the mother and told Fadiman “I remember having a little bit of awe of how differently we looked at the world”. A key feature of the Hmong is that they have no interest in being rule, do not like to be told what to do, and are rarely persuaded by the customs of other culture. The mistrust and open hostility between the medical staff and the Lee family seemed to overshadow Lia’s disease. Both side obviously loves Lia and wants her healthy but neither was willing to compromised and meet half way.

With the loud noise of a slamming door the family believed that Lia’s spirit had been frightened and left the body causing the sickness she was experiencing. The family saw the seizures as an illness of some distinction. In the Hmong culture epileptics often become shamans. The chapter goes on to tell the child’s story about multiple trips to the Hospital Emergency Room. It speaks about the lack of communication surrounding the child’s symptoms. The family is unable, and the medical team unaware of the lack of communication about medical dosages. The doctors have no idea about parental refusal to give certain medicines due to mistrust, misunderstandings, and behavioral side effects. The doctors do not attempt to develop more empathy with the traditional Hmong lifestyle or try to learn more about the Hmong culture. The dichotomy between the Hmong's perceived spiritual factors and the Americans' perceived scientific factors comprises the overall theme.

This prejudice is another strong concept, as the American doctors continued to underestimate, disrespect, and undermine Foua Yang (mother) and Nao Kao Lee (father) and their Hmong way of life. Vice versa, the Lees would refuse doctors’ orders in administering medicines. Ruane and Cerulo hit it right on the nail when describing prejudice,(20) which is a prejudgment directed towards members of certain social groups, as a feeling associated with immigrant groups, those that contain individuals who have left their homelands in pursuit of a new life in a new country. There is a clear indication of an in-group vs. an out-group, as it is noted from Second Thoughts, “an in-group carry unrealistically positive views of their group. At the same time…share unrealistically negative views of the out-group.” The cultural barriers are built due to “the one-sided relationship,” of knowledge only found in the unyielding West, with the prominent racial discrimination found among the white, English-speaking doctors and their intimidate dismissal of the existence of any Hmong medical practices/knowledge. The application of assimilation (20) is important to the in-group, as they simply believe that the immigrants will come to embrace the same values and customs of their new ‘homeland.’

Many live under the assumption that those who come to the United States want to become Americanized and assimilate to the melting pot our culture has formed into. This is the populations ethnocentric belief, which is the belief that the ways of one’s culture are superior to the ways of a different culture, that wants others to melt into the western ways. In Ann Faidman’s The Spirit Catches You and You Fall Down, Faidman fails to completely remain objective when demonstrating how cross-cultural misunderstandings create issues in the healthcare field, specifically between the Hmong and western cultures that created dire consequences between the Lee’s and their American doctors. Faidman uses her connections with the Hmong and the doctors who cared for them in order to disclose the different views, beliefs and practices the Hmong and Western cultures practiced. With her attempt to be culturally relative to the situation, Faidman discusses the series of events and reasons as to why the Lee’s faced the fate that they did and how it parallels to the ethnocentrism in the health care system.

1. The client system, in this case the Lee family, defines Lia’s seizures as both a spiritual and physical ailment. According to Fadiman (1997), “…the noise of the door had been so profoundly frightening that her soul had fled her body and become lost. They recognized the resulting symptoms as qaug dab peg, which means ‘the spirit catches you and you fall down’”(p.20). To the Lee family, Lia’s condition was as revered as it was frightening. While a person with qaug dab peg was traditionally held in high esteem in the Hmong culture, it was also terrifying enough that the Lee’s rushed Lia to the emergency room more than once in the first few months

The Lees, a Hmong family, came to the United States in the 1970s as refugees from Laos, and lived in Merced, California. Unlike most immigrants, the Hmong population was less amenable to assimilation. The traditional health beliefs and practices of the Hmong population were disputed by the practices of Western medicine. This became very event when the Lees took their three-month-old daughter, Lia Lee, to the emergency room in Merced. Lia was diagnosed with epilepsy a disease that had two different meaning among the Hmong population and Western medicine.

In a perfect world, race, ethnicity and culture would have no negative effect on the medical care we receive, yet problems do arise and it affects the quality of care the patient receives. Language barrier, poor socioeconomic status, and poor health literacy also contribute to health care disparity. For Lia, it was more than her skin color, it was all of the above, her parents did not speak English and they were illiterate. They had trouble understanding the American healthcare system, had trouble or little interest in adjusting to or understanding the American culture. They didn’t work, which in addition to cross cultural misunderstanding, helped contribute to animosity between the Hmong and the host community, because some in the Merced area did not like or appreciate the fact that some Hmong did not work and relied on welfare to make ends meet. All these factors, contributed to the poor quality of

The case study of Lia Lee is interesting and serves as a cautionary tale as it explores the consequences of cultural misunderstanding. In this case both the parents and medical staff sought the same thing; they both wanted Lia to have a positive outcome. Unfortunately, both groups had distinct ideas regarding how to achieve the common objective. This division was rooted in each sides individual cultural beliefs.

The story draws attention to the disadvantage that the language barrier caused in the Chapter titled “Take as Directed”. This chapter talks about how the parents don’t follow the doctor’s orders in giving Lia the proper dosing regimen. The staff and doctor’s didn’t know if her parents simply did not want to give her the medicine or if they basically didn’t know or understand what to do. Lia’s suffers a grand mal seizure during this chapter and gets intubated and placed on a ventilator to keep her alive. To make matters worse, the doctors start to believe that the seizures are causing retardation and that if Nao and Foua would give the child the medicine as directed she would be getting better. Finally a decision is made among medical staff that placing Lia under Foster care may be in her best interest in order to assure a proper dosing regimen.

We can see that there was a misunderstanding between the Lee’s and the doctor. Both parties explained the view on Lia’s case but from a biased perspective within their own culture. Lia's doctors strongly opinionated to treat her disease with medication, however her parents felt that being given medication would restrict with the spiritual healing given by a Hmong shaman.

Anne Fadiman wrote this book to document the conflict between cultural barriers and how they affect medical issues. In this book, Lia Lee is a Hmong child was has epilepsy and battles cultural medical differences. The main struggle in this story is the conflict between the doctors and parents because they cannot seem to get on the same page. While writing the book, Fadiman stated that there was a “clash of cultures”. (Fadiman, preface) Meaning, there are two different sides to the story and the problem has not be solved.

Obtaining information and understanding the culture of the patient can better help the nurse be a patient advocate. The nursing staff at MCMC did not advocate for the Lia or her family. Part of being an advocate is understanding what the barriers are for the patient and the staff and helping bridge the gaps. Involving family in decision making and assisting in making sure that the patient and family clearly understand what is being discussed is advocacy. I believe in the case of the Lee family that the nurses caring for Lia in the hospital and the visiting nurses, there was huge opportunity for the staff to learn about the belief of the Hmong culture. As Lia continued to be admitted to the hospital and struggle with medication administration, staff should pursue finding the reasons why and helping to facilitate meetings to help all the staff understands what the goal is for the patient as determined by the family and the physicians. The specific units could incorporate a cultural competence at monthly staff meetings and take turns educating the other staff about the people they may care for in their surrounding area. I believe there is also opportunity to include people from the different cultures and let them share with the staff the information they see important.