Anne Fadiman’s nonfiction book The Spirit Catches You and You Fall Down: A Hmong Child, Her American Doctors, and the Collision of Two Cultures chronicles the life of Lia Lee, a Hmong girl who lives with her family in Merced, California, in the 1980s and 1990s. The book examines the cultural misunderstandings and conflicting belief systems that result in Lia’s poor medical treatment after she is diagnosed with a severe form of epilepsy, Lennox-Gastaut Syndrome. The book won the National Book Critics Circle Award for General Non-Fiction in 1997, the year of its original publication by Farrar, Straus, and Giroux.

This study guide uses the 2012 edition, which includes an afterword updating the book 15 years after its original publication.

Summary

Lia Lee’s sister Yer slams a door in their home in Merced, California, and shortly thereafter three-month-old Lia has her first seizure. Lia is a child of Hmong refugees, and her parents, Foua and Nao Kao, believe Lia’s seizures are caused by her soul fleeing, scared away by the slamming door. They diagnose her condition as quag dab peg, “the spirit catches you and you fall down” in Hmong. Though Lia’s seizures frighten and concern her parents, they also believe the seizures make her special. In Hmong culture, episodes like Lia’s indicate she has a special soul; she might be chosen to become a shaman also known as txiv neeb in Hmong.

Foua and Nao Kao bring Lia to the Merced Community Medical Center (MCMC) for treatment for her seizures. The doctors at MCMC struggle to understand the Lees, as there is no Hmong translator on staff to provide more information. Because of this, Lia’s condition is initially misdiagnosed. Her primary doctors, Neil Ernst and Peggy Philip, are highly rationalist, Western doctors. They treat Lia’s condition as purely neurological, against the wishes of her parents, who believe that curing Lia requires a mix of Western medicine and Hmong traditional healing arts. Lia’s parents are concerned that too much Western medicine will negate the healing effects of their traditional healing arts, which includes the frequent interventions of txiv neebs.

A few months after Lia’s initial hospital visit, Dr. Ernst and Dr. Philip diagnose Lia with Lennox-Gastaut Syndrome, a serious neurological disorder that causes frequent seizures. They prescribe anticonvulsants for Lia, but her parents do not understand the necessity of giving Lia the medication and are wary of the side effects. The more seizures Lia has, the more she suffers. She begins to show signs of significant brain damage and developmental delays as a result of the seizures. Her parents’ inability or unwillingness to give Lia her prescribed medication worries her doctors, who call Child Protective Services (CPS) and have Lia put in foster care for a year in order to protect her and help her return to health. Lia’s foster parents are kind and considerate people, but her separation from her family has a traumatic effect on both her and her parents.

After Lia returns home to her parents, social worker Jeanine Hilt teaches Foua how to give Lia her medication, satisfying CPS requirements for reuniting Lia with her family. Unfortunately, four months after Lia returns home, she has a grand mal seizure. Medical professionals discover she is brain dead and suffering from septic shock. Eventually the doctors send Lia home to be with her family, expecting her to die shortly thereafter. However, Lia defies all medical expectations and lives for 26 more years. Every year, Foua and Nao Kao hire a txiv neeb to perform a ceremony to support Lia’s health and wellbeing.

The Spirit Catches You and You Fall Down is a book about the importance of cross-cultural communication, particularly in situations of life and death. For doctors to help their patients most effectively, they need to utilize a methodological approach of cultural relativism and understand the belief systems and practices of their patients from a non-judgmental stance. They also need to recognize that biomedicine is a cultural system too. This, of course, is not an easy feat, and Fadiman offers several solutions to help medical practitioners and their supporting institutions find common ground with patients to negotiate effective treatment plans.

Fadiman’s book is pivotal in the development of the idea of “cultural responsiveness” in medical training programs and is credited with many innovative approaches to patient care. Considered a work of medical anthropology, the book is one of the most widely-read volumes about the Hmong experience in America.