Chapter 18 - The Life or the Soul

The author begins this chapter with the assertion, “I do not know if Lia would be able to walk and talk today had she been treated by Arthur Kleinman instead of by Neil Ernst and Peggy Philp. However, I have come to believe that her life was ruined not by septic shock or noncompliant parents but by cross-cultural misunderstanding.” (pg. 262) She goes on to state that she had come across perhaps one hundred Hmong medical cases over the years. The imbalance that is still there is disquieting. For example, a child with a harelip did not receive the corrective surgery that she needed, because her father had killed, in Laos, a bird, but had not done so cleanly.

The bird had suffered, and the Hmong believed that the spirit of the bird had caused the harelip in his child. To refuse to accept that punishment would be a grave insult. There were other bad outcomes, but there were also some good outcomes. For example, a Hmong man was hospitalized for an infection. He was asked on the general consent form, if he died, was he willing to donate his organs. As a result the man became highly agitated that the doctors were going to let him die and steal his organs. He wanted to leave immediately. When an interpreter was brought in and convinced the man that the doctors were honorable, he stayed and received successful treatment. After that, the hospital administrator fought to have the organ donation box removed from the consent form.

Francesca Farr did a number of things that generally weren’t done at MCMC: making a house call; taking along a cultural broker; working within the family’s belief system; not carrying her own belief system into the negotiations; never threatening, criticizing, or patronizing; and saying hardly anything about Western medicine. She truly like the Hmong and as a result worked successfully with them. However, the author learned that for doctors like Neil and Peggy, “their choice was morally satisfying, but whenever a patient crossed a compliance line, thus sabotaging their ability to be optimally effective doctors, cultural diversity ceased being a delicious spice and became a disagreeable obstacle.” (pg. 265)

Bruce Thowpaou Bliatout has suggestions for doctors such as these: female doctors should treat female patients and vice versa; involve the patient’s families; use bilingual or bicultural interpreters; enlist the support of family and community leaders; minimize blood drawing; allow relatives and friends in the room; allow shamans to perform ceremonies; encourage Hmong traditional arts; acknowledge the Hmong contribution to US military operations in Laos; promote clan reunification, never undercut the father’s authority; give refugees more opportunities; fuss over them less; and most importantly, integrate Western medicine with traditional healing arts. It was found when physicians followed this course, it actually improved the outcome. Bliatout actually felt that the shaman was the ideal collaborator. No one was better qualified to span the gap between the medical and spiritual. He would always recognize the patient as a victim of an assault from outside powers or of an accidental separation from one part of his self. When this situation has identified and overcome by the shaman, health is recovered. So noncompliance could then be labeled as a form of the Hmong reaction to threat or blame: fighting or fleeing.