The Spirit Catches You and You Fall Down (3 page)

Robert Cooper, a British anthropologist who spent two years studying resource scarcity in four Hmong communities in northern Thailand, described his research subjects as

From his post in the Hmong village of Khek Noi, also in northern Thailand, Father Mottin wrote in his
History of the Hmong
(a wonderful book, exuberantly translated from the French by an Irish nun who had once been the tutor to the future king of Thailand, and printed, rather faintly, in Bangkok):

One of the recurring characters in Hmong folktales is the Orphan, a young man whose parents have died, leaving him alone to live by his wits. In one story, collected by Charles Johnson, the Orphan offers the hospitality of his humble home to two sisters, one good and one snotty. The snotty one says:

The Orphan may not have a clean penis, but he is clever, energetic, brave, persistent, and a virtuoso player of the
qeej
, a musical instrument, highly esteemed by the Hmong, that is made from six curving bamboo pipes attached to a wooden wind chamber. Though he lives by himself on the margins of society, reviled by almost everyone, he knows in his heart that he is actually superior to all his detractors. Charles Johnson points out that the Orphan is, of course, a symbol of the Hmong people. In this story, the Orphan marries the good sister, who is able to perceive his true value, and they prosper and have children. The snotty sister ends up married to the kind of
dab
who lives in a cave, drinks blood, and makes women sterile.

When Lia was about three months old, her older sister Yer slammed the front door of the Lees’ apartment. A few moments later, Lia’s eyes rolled up, her arms jerked over her head, and she fainted. The Lees had little doubt what had happened. Despite the careful installation of Lia’s soul during the
hu plig
ceremony, 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.” The spirit referred to in this phrase is a soul-stealing
dab; peg
means to catch or hit; and
qaug
means to fall over with one’s roots still in the ground, as grain might be beaten down by wind or rain.

In Hmong-English dictionaries,
qaug dab peg
is generally translated as epilepsy. It is an illness well known to the Hmong, who regard it with ambivalence. On the one hand, it is acknowledged to be a serious and potentially dangerous condition. Tony Coelho, who was Merced’s congressman from 1979 to 1989, is an epileptic. Coelho is a popular figure among the Hmong, and a few years ago, some local Hmong men were sufficiently concerned when they learned he suffered from
qaug dab peg
that they volunteered the services of a shaman, a
txiv neeb
, to perform a ceremony that would retrieve Coelho’s errant soul. The Hmong leader to whom they made this proposition politely discouraged them, suspecting that Coelho, who is a Catholic of Portuguese descent, might not appreciate having chickens, and maybe a pig as well, sacrificed on his behalf.

On the other hand, the Hmong consider
qaug dab peg
to be an illness of some distinction. This fact might have surprised Tony Coelho no less than the dead chickens would have. Before he entered politics, Coelho planned to become a Jesuit priest, but was barred by a canon forbidding the ordination of epileptics. What was considered a disqualifying impairment by Coelho’s church might have been seen by the Hmong as a sign that he was particularly fit for divine office. Hmong epileptics often become shamans. Their seizures are thought to be evidence that they have the power to perceive things other people cannot see, as well as facilitating their entry into trances, a prerequisite for their journeys into the realm of the unseen. The fact that they have been ill themselves gives them an intuitive sympathy for the suffering of others and lends them emotional credibility as healers. Becoming a
txiv neeb
is not a choice; it is a vocation. The calling is revealed when a person falls sick, either with
qaug dab peg
or with some other illness whose symptoms similarly include shivering and pain. An established
txiv neeb
, summoned to diagnose the problem, may conclude from these symptoms that the person (who is usually but not always male) has been chosen to be the host of a healing spirit, a
neeb
. (
Txiv neeb
means “person with a healing spirit.”) It is an offer that the sick person cannot refuse, since if he rejects his vocation, he will die. In any case, few Hmong would choose to decline. Although shamanism is an arduous calling that requires years of training with a master in order to learn the ritual techniques and chants, it confers an enormous amount of social status in the community and publicly marks the
txiv neeb
as a person of high moral character, since a healing spirit would never choose a no-account host. Even if an epileptic turns out not to be elected to host a
neeb
, his illness, with its thrilling aura of the supramundane, singles him out as a person of consequence.

In their attitude toward Lia’s seizures, the Lees reflected this mixture of concern and pride. The Hmong are known for the gentleness with which they treat their children. Hugo Adolf Bernatzik, a German ethnographer who lived with the Hmong of Thailand for several years during the 1930s, wrote that the Hmong he had studied regarded a child as “the most treasured possession a person can have.” In Laos, a baby was never apart from its mother, sleeping in her arms all night and riding on her back all day. Small children were rarely abused; it was believed that a
dab
who witnessed mistreatment might take the child, assuming it was not wanted. The Hmong who live in the United States have continued to be unusually attentive parents. A study conducted at the University of Minnesota found Hmong infants in the first month of life to be less irritable and more securely attached to their mothers than Caucasian infants, a difference the researcher attributed to the fact that the Hmong mothers were, without exception, more sensitive, more accepting, and more responsive, as well as “exquisitely attuned” to their children’s signals. Another study, conducted in Portland, Oregon, found that Hmong mothers held and touched their babies far more frequently than Caucasian mothers. In a third study, conducted at the Hennepin County Medical Center in Minnesota, a group of Hmong mothers of toddlers surpassed a group of Caucasian mothers of similar socioeconomic status in every one of fourteen categories selected from the Egeland Mother-Child Rating Scale, ranging from “Speed of Responsiveness to Fussing and Crying” to “Delight.”

Foua and Nao Kao had nurtured Lia in typical Hmong fashion (on the Egeland Scale, they would have scored especially high in Delight), and they were naturally distressed to think that anything might compromise her health and happiness. They therefore hoped, at least most of the time, that the
qaug dab peg
could be healed. Yet they also considered the illness an honor. Jeanine Hilt, a social worker who knew the Lees well, told me, “They felt Lia was kind of an anointed one, like a member of royalty. She was a very special person in their culture because she had these spirits in her and she might grow up to be a shaman, and so sometimes their thinking was that this was not so much a medical problem as it was a blessing.” (Of the forty or so American doctors, nurses, and Merced County agency employees I spoke with who had dealt with Lia and her family, several had a vague idea that “spirits” were somehow involved, but Jeanine Hilt was the only one who had actually asked the Lees what they thought was the cause of their daughter’s illness.)

Within the Lee family, in one of those unconscious processes of selection that are as mysterious as any other form of falling in love, it was obvious that Lia was her parents’ favorite, the child they considered the most beautiful, the one who was most extravagantly hugged and kissed, the one who was dressed in the most exquisite garments (embroidered by Foua, wearing dime-store glasses to work her almost microscopic stitches). Whether Lia occupied this position from the moment of her birth, whether it was a result of her spiritually distinguished illness, or whether it came from the special tenderness any parent feels for a sick child, is not a matter Foua and Nao Kao wish, or are able, to analyze. One thing that is clear is that for many years the cost of that extra love was partially borne by her sister Yer. “They blamed Yer for slamming the door,” said Jeanine Hilt. “I tried many times to explain that the door had nothing to do with it, but they didn’t believe me. Lia’s illness made them so sad that I think for a long time they treated Yer differently from their other children.”

During the next few months of her life, Lia had at least twenty more seizures. On two occasions, Foua and Nao Kao were worried enough to carry her in their arms to the emergency room at Merced Community Medical Center, which was three blocks from their apartment. Like most Hmong refugees, they had their doubts about the efficacy of Western medical techniques. However, when they were living in the Mae Jarim refugee camp in Thailand, their only surviving son, Cheng, and three of their six surviving daughters, Ge, May, and True, had been seriously ill. Ge died. They took Cheng, May, and True to the camp hospital; Cheng and May recovered rapidly, and True was sent to another, larger hospital, where she eventually recovered as well. (The Lees also concurrently addressed the possible spiritual origins of their children’s illnesses by moving to a new hut. A dead person had been buried beneath their old one, and his soul might have wished to harm the new residents.) This experience did nothing to shake their faith in traditional Hmong beliefs about the causes and cures of illness, but it did convince them that on some occasions Western doctors could be of additional help, and that it would do no harm to hedge their bets.

County hospitals have a reputation for being crowded, dilapidated, and dingy. Merced’s county hospital, with which the Lees would become all too familiar over the next few years, is none of these. The MCMC complex includes a modern, 42,000-square-foot wing—it looks sort of like an art moderne ocean liner—that houses coronary care, intensive care, and transitional care units; 154 medical and surgical beds; medical and radiology laboratories outfitted with state-of-the-art diagnostic equipment; and a blood bank. The waiting rooms in the hospital and its attached clinic have unshredded magazines, unsmelly bathrooms, and floors that have been scrubbed to an aseptic gloss. MCMC is a teaching hospital, staffed in part by the faculty and residents of the Family Practice Residency, which is affiliated with the University of California at Davis. The residency program is nationally known, and receives at least 150 applications annually for its six first-year positions.

Like many other rural county hospitals, which were likely to feel the health care crunch before it reached urban hospitals, MCMC has been plagued with financial problems throughout the last twenty years. It accepts all patients, whether or not they can pay; only twenty percent are privately insured, with most of the rest receiving aid from California’s Medi-Cal, Medicare, or Medically Indigent Adult programs, and a small (but to the hospital, costly) percentage neither insured nor covered by any federal or state program. The hospital receives reimbursements from the public programs, but many of those reimbursements have been lowered or restricted in recent years. Although the private patients are far more profitable, MCMC’s efforts to attract what its administrator has called “an improved payer mix” have not been very successful. (Merced’s wealthier residents often choose either a private Catholic hospital three miles north of MCMC or a larger hospital in a nearby city such as Fresno.) MCMC went through a particularly rough period during the late eighties, hitting bottom in 1988, when it had a $3.1 million deficit.

During this same period, MCMC also experienced an expensive change in its patient population. Starting in the late seventies, South-east Asian refugees began to move to Merced in large numbers. The city of Merced, which has a population of about 61,000, now has just over 12,000 Hmong. That is to say, one in five residents of Merced is Hmong. Because many Hmong fear and shun the hospital, MCMC’s patient rolls reflect a somewhat lower ratio, but on any given day there are still Hmong patients in almost every unit. Not only do the Hmong fail resoundingly to improve the payer mix—more than eighty percent are on Medi-Cal—but they have proved even more costly than other indigent patients, because they generally require more time and attention, and because there are so many of them that MCMC has had to hire bilingual staff members to mediate between patients and providers.

There are no funds in the hospital budget specifically earmarked for interpreters, so the administration has detoured around that technicality by hiring Hmong lab assistants, nurse’s aides, and transporters, who are called upon to translate in the scarce interstices between analyzing blood, emptying bedpans, and rolling postoperative patients around on gurneys. In 1991, a short-term federal grant enabled MCMC to put skilled interpreters on call around the clock, but the program expired the following year. Except during that brief hiatus, there have often been no Hmong-speaking employees of any kind present in the hospital at night. Obstetricians have had to obtain consent for cesarean sections or episiotomies using embarrassed teenaged sons, who have learned English in school, as translators. Ten-year-old girls have had to translate discussions of whether or not a dying family member should be resuscitated. Sometimes not even a child is available. Doctors on the late shift in the emergency room have often had no way of taking a patient’s medical history, or of asking such questions as Where do you hurt? How long have you been hurting? What does it feel like? Have you had an accident? Have you vomited? Have you had a fever? Have you lost consciousness? Are you pregnant? Have you taken any medications? Are you allergic to any medications? Have you recently eaten? (The last question is of great importance if emergency surgery is being contemplated, since anesthetized patients with full stomachs can aspirate the partially digested food into their lungs, and may die if they choke or if their bronchial linings are badly burned by stomach acid.) I asked one doctor what he did in such cases. He said, “Practice veterinary medicine.”

On October 24, 1982, the first time that Foua and Nao Kao carried Lia to the emergency room, MCMC had not yet hired any interpreters, de jure or de facto, for any shift. At that time, the only hospital employee who sometimes translated for Hmong patients was a janitor, a Laotian immigrant fluent in his own language, Lao, which few Hmong understand; halting in Hmong; and even more halting in English. On that day either the janitor was unavailable or the emergency room staff didn’t think of calling him. The resident on duty practiced veterinary medicine. Foua and Nao Kao had no way of explaining what had happened, since Lia’s seizures had stopped by the time they reached the hospital. Her only obvious symptoms were a cough and a congested chest. The resident ordered an X ray, which led the radiologist to conclude that Lia had “early bronchiopneumonia or tracheobronchitis.” As he had no way of knowing that the bronchial congestion was probably caused by aspiration of saliva or vomit during her seizure (a common problem for epileptics), she was routinely dismissed with a prescription for ampicillin, an antibiotic. Her emergency room Registration Record lists her father’s last name as Yang, her mother’s maiden name as Foua, and her “primary spoken language” as “Mong.” When Lia was discharged, Nao Kao (who knows the alphabet but does not speak or read English) signed a piece of paper that said, “I hereby acknowledge receipt of the instructions indicated above,” to wit: “Take ampicillin as directed. Vaporizer at cribside. Clinic reached as needed 383–7007 ten days.” The “ten days” meant that Nao Kao was supposed to call the Family Practice Center in ten days for a follow-up appointment. Not surprisingly, since he had no idea what he had agreed to, he didn’t. But when Lia had another bad seizure on November 11, he and Foua carried her to the emergency room again, where the same scene was repeated, and the same misdiagnosis made.