Book Review

A Book Review: The Spirit Catches You and You Fall Down
Lycia L. Harris
Jacksonville State University

Book Review
Introduction

The Spirit Catches You and You Fall Down is a book written in 1997 by Anne Fadiman.
The book deals with cultural differences and the negative impact miscommunication and cultural
misunderstandings can have on a persons journey through the healthcare delivery system. The
purpose of this paper is to review the story of Lia Lee, an American born child of Hmong decent.
Though she had the luxuries of Western medicine to treat her seizure disorder, Western medicine
and all the brilliant doctors who practiced it would ultimately fail her. A hard lesson in cultural
awareness and diversity is learned by all of those who took part in Lias care that would change
each of their lives forever.
Authors Credentials
Anne Fadiman is a writer who was born in New York City, New York. She was raised in
both Connecticut and Los Angeles (Fadiman, 1997). She graduated from Harvard, and worked as
a wilderness instructor in Wyoming before deciding to return to New York to begin her writing
career (Fadiman, 1997). She worked as a staff writer at Life magazine, editor-at-large of
Civilization, and editor of The American Scholar (Fadiman, 1997). Fadiman is, of course, the
author of The Spirit Catches You and You Fall Down, winner of a National Book Critics Circle
Award, an L.A. Times Book Prize, and a Salon Book Award (us.macmillian.com). She is also the
author of two essay collections, At Large and At Small and Ex Libris, and the editor
of Rereadings: Seventeen Writers Revisit Books They Love (us.macmillian.com). Her essays and
articles have appeared in Harper's, The New Yorker, and The New York Times, among other
publications and she is the Francis Writer-in-Residence at Yale (us.macmillian.com). Fadiman

Book Review
wrote The Spirit Catches You and You Fall Down in 1988 after an encounter with Lia Lee, a little
girl of Hmong decent with severe brain damage and her family. This was Fadimans first book
and did surprisingly well, though she thought no one would be interested in it. It took Fadiman
eight years to write this book and as a result, its publication has had a huge impact on the cultural
sensitivity of American doctors as they practice medicine.
Summary of the Book
In The Spirit Catches You and You Fall Down, the story of Lia Lee and her family
unfolds. The book begins by painting a picture of the life Foua, Lias mother, and Nao Kao,
Lias father, who were also Hmong immigrants had in their home country of Laos. Lia was the
fourteenth of fourteen children born to Foua and Nao Kao. All of Lias brothers and sisters were
born in the highlands of Laos and delivered alone and in silence by Foua, as was the custom of
the Hmong people. The Hmong had many cultural and spiritual beliefs that were practiced over
hundreds of years.
The Hmong believe that everything that happens in the world occurs for a reason and all
circumstances, no matter how big or small are interrelated. The Hmong believe in dabs, which
are evil spirits, who are around essential just to steal souls. The Hmong also believe in shamans,
or tvix neebs, who were the spiritual connection between the living world and the spirit world.
To be recognized as a shaman was an honor among the Hmong people. The shamans were
believed to have the power to go into deep spiritual trances in which their bodies would sort of
convulse in appearance.
Many shamans suffered from qaug dab peg, which meant, the spirit catches you and you
fall down in Hmong. Qaug dab peg essentially means epilepsy, but the Hmong felt this was a

Book Review
spiritual gift, not an illness. Animal sacrifices were often a part of the shamans sacred
ceremonies and served as spiritual offerings on behalf of the family. Foua, when giving birth to
her other thirteen children had no complications but if she had, she would have turned to Hmong
remedies that were always used by the Hmong. In their homeland, the Lees and their children
lived in the highlands of Laos. They were farmers and lived a honorable, modest life.
Nao Kao built the house that they lived in which had only one room where the entire
family lived and slept. The floor was made out of dirt, but Foua kept her home and her children
very clean. The Lees had no running water and relieved themselves in the forest. The Lees
farmed their own land and kept their own livestock. Life in Laos was difficulty; however, it was
the only life the Lees knew. Their life in Laos would be turned upside down by war (mostly
over opium farming) when the Vietnamese took over their country and forced the Hmong into a
type of slavery.
The Lees, along with other Hmong families, fearing for the lives and safety of
themselves and their children, fled Laos for Thailand. In their escape to Thailand, many Hmong
were killed by the Vietnamese, left behind because of age or sickness or died in the strenuous
terrain. Upon reaching Thailand, the Lees spent some time in a refugee camp, but ultimately
would choose to come to the United States, first to Portland, Oregon; and then finally settling in
Merced, California. Before reaching the U.S. the Lees would endure losing their home, their
property, and some of their children. Foua and Nao Kao and their older surviving children
arrived in America not being able to speak or understand English. Merced was a good city for
the Hmong because there was a large population of Hmong immigrant living there; however,
very few people understood both English and Hmong.

Book Review
Lia Lee was born in an American hospital under Western American tradition.
Foua thought the American birthing practices were very strange. There was no family in
the room, she was draped with sterile cloth, she was lying on her back on a steel birthing
table and a strange man was viewing her most private areas. Though Lias birth was far
different than the births of her brothers and sisters, Lia was in essence a healthy baby and
there were no complications recognized at birth. From her beginning, there were no
interpreters to translate to Foua and Nao Kao the condition of their baby and at discharge
Foua signed instructions written in English that she did not understand.
No one at Merced Community Medical Center, which was a county hospital,
made any effort to make sure that Foua understood what she signed and thus, sent them
home with documentation that was essentially false. Because of poor reimbursement for
the uninsured and no funds set aside for interpreters, no one at Merced was remotely
interested in getting interpreters to serve the growing Hmong population. At three
months old, Lias sister Yer slammed the door of the apartment that the Lees now lived in
which coincidentally preceded Lias first seizure. The Lees believed that when Yer
slammed the door, Lias soul was frightened and fled her body. As a consequence, Lias
soul was caught by a dab.
In the next few months, Lia would continue to have seizures and at least twice
during that period, Foua and Nao Kao took her to the hospital for treatment in spite of
their reservations about American doctors and western medical techniques. When they
would arrive at the hospital with Lia, the seizure would be over and because many
American residents of Merced neither understood nor tried to understand the Hmong, the
Lees were sent back home with Lia as if nothing happened. Lia was most likely post-ictal

Book Review
when the Lees reached the hospital, and because she was coughing and congested upon
examination, she was quickly diagnosed with bronchitis or pneumonia after an x-ray. Lia
had aspirated secretions into her lungs during the seizure. These events began the vicious
cycle of misunderstanding and stereotypical blocks that would become the meat of Lias
life story.
Only when Dan Murphy was on call in the emergency room a night that Lia was
brought in, did the pieces of the puzzle begin to form a picture. Dan recognized
immediately that Lia had epilepsy and because the Lees brought a cousin with them that
could interpret, they were suddenly in on the big mystery as to what was going on with
Lia. The Lees, based on cultural beliefs did not feel that this was a bad thing, in fact, it
was divine. Maybe, someday, Lia would become a shaman. After a few days in the
hospital, where her parents never left her side, Lia was sent home on seizure medicine
written in English instruction which neither of her parents understood, thus, therapeutic
drug levels were never reached and Lias seizures remained uncontrolled.
Lia unfortunately became well known to residents and supervising doctors and nurses at
Merced due to her condition and as her epilepsy worsened, some even feared the idea of
her possible admission. Lia would be treated by a set of married doctors, Neil and Peggy
who alternated being the attending nightly in the ER. Both Neil and Peggy were good,
doctors who practiced good medical care, however, both felt that the reason Lias
epilepsy was not controlled was the fact that the parents were purposely being noncompliant. Neil and Peggy even instituted a plan where interpreters would go to the Lee
home to make sure that Lia was given her medicine correctly. The Lees of course, loved
their child and could not understand why she needed to take so much medicine and after

Book Review
observing some negative side effects of the medication, refused to give Lia certain drugs.
Lia would suffer a seizure that caused her to have difficulty breathing after not receiving
her medicine for three months, and thus, Neil and Peggy were infuriated.
Lia was eventually removed from the care of her parents and placed in foster care,
but, a curious thing happened; she continued to have seizures even when her medication
was given correctly. Interestingly, the American foster parents found Lias complex drug
regimen difficult to follow though they read and understood English. Lia would be
eventually returned to her parents after her caregivers recognized the negative effect
separation was having on both Lia and her parents. Lias return was fostered by Jenine
Hilt, a social worker that actually took interest in doing the right thing for Lia and her
family. Jenine, was empathetic, because she too suffered from a chronic illness, like Lia,
an often faced discrimination, just like the Lees, based on her homosexuality.
Jenine learned about the Lees culture by actually spending time with the Lees.
Lia would eventually have a prolonged grand-mal seizure where she went without
oxygen to her brain for a prolonged period of time because, undenounced to the medical
team that had grown used to Lias repeated admissions for seizures, Lia was septic. Dr.
Neil was called into the hospital, a night before he was to go on vacation because his
worst fear was coming to fruition. Lia Lee was having a big seizure that they could not
get under control. After many doses of meds, and several hours of continuous seizures,
Lias seizures stopped, but this time, she suffered irreversible brain damage.
Once again, there was miscommunication between the medical staff and the
family. Lia would need to be transferred to a different medical center who was better

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equipped to care for her in her current state and Dr. Neil, probably exhausted from the
nights events, miscommunicated to the anxious parents that Lia was being transferred to
another facility because he was going out of town. The truth was, he was trying to
communicate that Lia was being transferred because she needed a higher level of care
and the Lees would not hear from him in the immediate days following because he
would be on vacation. Lia would never recover from this injury and the parents were told
that all care should be withdrawn from Lia and they should just let her die. Lias family
stuck to their cultural beliefs and against medical understanding, Lia would live for
another 26 years fueled by the care of a loving, devoted, mother.
Authors Thesis
Fadiman wrote this book to highlight how cultural stereotypes can stand in the way of
good, effective healthcare. Fadiman confesses her own misconceptions related to the Hmong and
defines how her views changed after she actually got to know the Lees. Lias story shows how
tragic consequences can result when opposing sides both feel they are acting in the best interest
of a person, yet, not communicating with each other. Lias story stands as a roadmap for cultural
awareness in combination with western medicine. Both the positives and negatives of Lias story
are shared to provide insight.
Criticisms
The positive aspect of the book include description of how a mother and father will endure
unspeakable circumstances to help their children have a better life, in chapter ten, we learn of the
conditions the Lees escaped in Laos and the conditions they endured to get their family to
Thailand. There are also positive pictures painted of how much the Lees loved Lia and how, in

Book Review
spite of everything, they agonized over her care and suffered great pain in chapter 7 when Lia
was removed from the home. There are also positive pictures painted of Drs. Neil and Peggy.
How in spite of their cultural beliefs, they always thought they were doing what was in the best
interest of their patients. They were not afraid to admit when they were wrong, especially if they
felt someone could learn from their mistakes. Jenine Hilt worked hard to make sure Lia and the
Lees were treated fairly and did everything in her power to help them. Another positive is how
love kept Lia alive 26 years longer than western medicine said she would be.
Negatives in the book include the American doctors superiority complexes. Chapter 6
highlights this fact well. We see how detrimental stereotypes can be. Another negative is
knowing what the Lee family went through escaping Laos, just to have a situation Fuoa would
describe as much worse, occur in a country that is based on freedom and good will towards men.
Another negative in the book is the fact that Lia was not treated accurately in the end. They
assumed her fate was sealed by her epilepsy but with just a little more investigation, her sepsis
could have been revealed.
Conclusion
The Spirit Catches You and You Fall Down was a very interesting book. It is based on a true life
story, where unfortunately, the outcome may have been a little different if the parties involved
communicated better. This story is a good example of how cultural stereotypes, beliefs, and
misunderstanding can result in life changing, negative outcomes in the healthcare delivery
system. The story of Lia Lee and the treatment of her epilepsy is unfortunate, but, ultimately
serves to raise cultural awareness in both doctors and their patients.

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References

Fadiman, A. (1997). The Spirit Catches You And You Fall Down: A Hmong Child, Her
American Doctors, and the Collision of Two Cultures. New York, New York:
Farrar, Straus & Giroux.
unknown. (2015, 07 28). Anne Fadiman. Retrieved from MacMillian.com:
http://www.us.macmillian.com/author/annefadiman