Kameko Washburn, Fall 2019
Program in Public Health, University of California Irvine
Anthro 215A / “Ethnographic Methods” / Professor Kim Fortun
The Spirit Catches You and You Fall Down: A Hmong Child, Her American Doctors, and The Clash of Two Cultures By Anne Fadiman / Farrar, Straus and Giroux; Later Printing, 2012
What is the text “about” -- empirically and conceptually?
What modes of inquiry were used to produce it?
How is the text structured and performed?
How can it circulate?
What is the text about – empirically?
What phenomenon is drawn out in the text? A social process; a cultural and political-economic shift; a cultural “infrastructure;” an emergent assemblage of science-culture-technology-economics?
A look into the integration of Hmong culture into “western” society specifically with respect to navigating and understanding the health care system.
Where is this phenomenon located – in a neighborhood, in a country, in “Western Culture,” in a globalizing economy?
1980’s Merced, CA
What historical trajectory is the phenomenon situated within? What, in the chronology provided or implied, is emphasized -- the role of political or economic forces, the role of certain individuals or social groups? What does the chronology leave out or discount?
Many Loatian individuals became refugees who came to the U.S. (usually through Thailand) following the shift in power to communist forces following the Laotian Civil War. As refugees they came to the U.S. seeking safety and many did not feel a need or desire to assimilate into American culture. Tension existed between the community of Merced, CA and the Hmong refugee population who were numerous throughout the community. This tension was apparent within the healthcare system where nurses, doctors, and other care providers often did not want to interact with the Hmong people because of the likelihood they would not follow medical advice/direction (although they largely did not consider why this may be). However, the text also highlights how the Hmong people have had to historically flee persecution and have been repeatedly been forced to migrate or fight causing them to continually be faced with the notion of assimilation and belonging.
What scale(s) are focused on -- nano (i.e. the level of language), micro, meso, macro? What empirical material is developed at each scale?
The text really works on all of these levels. It addresses the nano level through the discussion of language as a barrier to communication between providers and the Lees and also with regards to whom the providers address (the white step-parents, the much younger nephew brought in to translate) furthering the Lees distrust of the medical system. It works on the micro level by looking at the ways the various players address the issues at hand. How they see their role and what they feel is the appropriate course of action. The meso level is presented in the geopolitical relations between Laos and Vietnam, and the U.S. The U.S. medical system as an organization is also a major player. At the macro level, the way the legal system treated this family, through the use of social workers and forced foster care for their child, is a major portion of understanding the disconnect displayed throughout the text.
Who are the players in the text and what are their relations? Does the text trace how these relations have changed across time – because of new technologies, for example?
“Western” doctors and other health care providers and Hmong refugees. The text examines how the two negotiate their relationship with one another.
What is the temporal frame in which players play? In the wake of a particular policy, disaster or other significant “event?” In the general climate of the Reagan era, or of “after-the-Wall” globalization?
The individuals within this text are living in a post-refugee crisis, newly integrated community, which has undergone changes to it’s demographics following the war in Laos. The varying ‘sides’ within the community must face one another in order to try and save a young girl from the ‘outside’ group. This text follows her throughout her illness and describes the unfolding of that relationship.
What cultures and social structures are in play in the text?
The text examines Hmong culture and the way this is understood (or not understood) in the community of Merced, CA. Hmong cultural beliefs regarding world view and interconnectedness as a whole is highlighted with regards to its influence on their decision making and point of view when it comes to illnesses. In addition, with regards to the specific affliction discussed throughout the narrative, epilepsy, the Hmong people do not traditionally view this as an ailment so much as a sign of a higher status making individuals fit for highly respected shamanistic roles. Social power structures are in play between the ‘native’ and ‘other’ individuals and between the level of the patient and the provider as well as the state and the individual.
What kinds of practices are described in the text? Are players shown to be embedded in structural contradictions or double-binds?
Individuals of focus in the text are, regardless of their “side” of things (Hmong cultures vs. western medicine) caught between the two an trying to negotiate how they can be combined/integrated while still preserved.
How are science and technology implicated in the phenomenon described?
Science and technology play a role in this text primarily through the utilization of medicine in western society. The ability to utilize science and technology also links to the power that care providers have over the family in treating their daughter and also in depreciating the views, beliefs, and priorities of the family when it comes to their daughters care.
What structural conditions– technological, legal and legislative, political, cultural – are highlighted, and how are they shown to have shaped the phenomenon described in this text?
All of the above. This text examines historical and current political issues (the war in Laos, the welfare programs of Merced, CA being overwhelmed with the influx of Hmong people), legal and legislative issues (CPS becoming involved with Lia’s care), technological conditions (western medicines role in Lia’s care despite what her family believed was the best way to take care of her), and cultural conditions (opposing views of how to care for Lia, what was best for her, and what was causing her ailments in the first place. As well as the larger cultural identity clash with the community and historically for the Hmong people).
How – at different scales, in different ways – is power shown to operate? Is there evidence of power operating through language, “discipline,” social hierarchies, bureaucratic function, economics, etc?
Power plays a huge role in this text and exists at multiple levels. There is the initial interpersonal play of power between the family and the providers which is true for any patient-provider relationship but furthered here due to differences in culture and language. There is also the power in place at the level of bureaucratic function which is expressed primarily through the state entering in the care/treatment of the Lia (the young daughter) who is taken into foster care after Child Protective Services deems her parents unfit to care for her after they struggle to give her the proper medication regimen. There is also the larger scale focus on power over what creates refugees, how refugees are treated/who is responsible for them, and how they are required to behave in a new nation-state where they did not want to live in the first place. Historically, the text also looks at the power played between the U.S. and the Hmong people in Laos during the Laotian and Vietnam Wars showing that the U.S. utilized Hmong people as soldiers to fight a battle for them: a reason also used to describe why Hmong are so reluctant to assimilate because they feel it is owed to them after their people were used in this way.
Does the text provide comparative or systems level perspectives? In other words, is the particular phenomenon described in this text situated in relation to similar phenomenon in other settings? Is this particular phenomena situated within global structures and processes?
The text does not explicitly describe the phenomena examined within other settings however, it is one that is replicated in many situations and the same kind of approach/questions/analysis could be implemented in various settings.
What is the text about – conceptually?
Is the goal to verify, challenge or extend prior theoretical claims?
This book provides a situational example of the challenges of and need for cultural competence within the healthcare setting (a now widespread term and phenomena throughout medicine/public health) however, this is a concept that was relatively novel at the time of the texts original publication (1997). Therefore it is working to verify previous theoretical claims which were not as widely accepted/recognized at the time.
What is the main conceptual argument or theoretical claim of the text? Is it performed, rendered explicit or both?
Lack of cultural competence among U.S. medical providers resulting in decreased ability to care for the totality of their patients. This is both explicitly and implicitly shown and described throughout the text.
What ancillary concepts are developed to articulate the conceptual argument?
Stories of other situations in which the difference of worldview/understanding is shown
How is empirical material used to support or build the conceptual argument?
The text utilizes interviews, historical texts, and a case-study
How robust is the main conceptual argument of the text? On what grounds could it be challenged?
This is hard to discern for the time in which it was originally published. It is only one primary story arc showing these phenomena however, as it is now a widley accepted concept it feels to be a strong demonstration.
How could the empirical material provided support conceptual arguments other than those built in the text?
Additional examination of the relationships between staff and families (this is a recurring issue, even the smaller cases should be built into the text in order to more soundly build the argument)
Modes of inquiry?
What theoretical edifice provides the (perhaps haunting – i.e. non-explicit) backdrop to the text?
The authors expressed her own struggles with her health as well as with her daughter and demonstrates that the text is written in the larger scope of what is a good patient? And, what is a good parent?
What assumptions appear to have shaped the inquiry? Does the author assume that individuals are rational actors, for example, or assume that the unconscious is a force to be dealt with? Does the author assume that the “goal” of society is (functional) stability? Does the author assume that what is most interesting occurs with regularity, or is she interested in the incidental and deviant?
Fadiman assumes that the Hmong culture is something that is static and over generalizes the beliefs and views of the people.
What kinds of data (ethnographic, experimental, statistical, etc.) are used in the text, and how were they obtained?
Interview data from those closely involved as well as historical information regarding the past of the Hmong people
If interviews were conducted, what kinds of questions were asked? What does the author seem to have learned from the interviews?
Questions regarding why individuals believed what they did, how they acted on these beliefs, and what they thought of opposing viewpoints was primarily what was asked during interviews. Specific questions regarding the case-study were also asked.
How was the data analyzed? If this is not explicit, what can be inferred?
Analysis of interview data between the two varying “sides” placed within a historical framework
How are people, objects or ideas aggregated into groups or categories?
Cultural identity of Hmong vs. American. Also grouped by power: doctors, CPS vs. Hmong families
What additional data would strengthen the text?
Visuals, more focus outside of the specific case study (other occurrences)
Structure and performance?
What is in the introduction? Does the introduction turn around unanswered questions -- in other words, are we told how this text embodies a research project?
The introduction does position the text within the authors understanding that there were continually “strange misunderstandings” occurring between medical staff and Hmong refugees. Her research question is therefore centered around the desire to understand what was causing these misunderstandings. This in her description is something that was based on theory and not so much the problem.
Where is theory in the text? Is the theoretical backdrop to the text explained, or assumed to be understood?
As mentioned above, the author bases her inquiry on theory. She explains that
What is the structure of the discourse in the text? What binaries recur in the text, or are conspicuously avoided?
“Western” vs. “the other”, patient vs. provider, outsider vs. insider
How is the historical trajectory delineated? Is there explicit chronological development?
While the story of the case is given chronologically the story of the historical drivers used to explain and supplement the case are given sporadically throughout the narrative
How is the temporal context provided or evoked in the text?
The temporality is utilized to build a compelling narrative making the ‘dosing’ of the more technical discussions lesser in order to make the text approachable by the general population
How does the text specify the cultures and social structures in play in the text?
The discussion of the culture is somewhat troubling as it is discussed as a static phenomenon however the social structures are discussed in relation to power, community structure, and assimilation
How are informant perspectives dealt with and integrated?
The interviews are really what build the story and provide the bulk of the narrative. They are heavily relied on throughout the text.
How does the text draw out the implications of science and technology? At what level of detail are scientific and technological practices described?
Science and technology are discussed as they relate to the discipline of Western medicine and their
How does the text provide in-depth detail – hopefully without losing readers?
The whole text is written as a pretty reader-friendly piece meant to go into these details while relating them back to a narrative that has you invested in the ideas being presented.
What is the layout of the text? How does it move, from first page to last? Does it ask for other ways of reading? Does the layout perform an argument?
The text is laid out in chronological order of events surrounding Lia’s condition. However, it does sometimes skip back in time to discuss the Hmong people as a whole within Laos or the Lee family’s personal experience during their time in and fleeing from Laos. The layout does not, in my opinion, aid in it’s argument however, as it is largely meant to be a narrative of this one story it does make it easy to follow and potentially available to a larger audience who are used to reading texts in this format.
What kinds of visuals are used, and to what effect?
No visuals are used other than the one on the cover of the book, which is a simple image of a young Lia Lee in traditional garb.
What kind of material and analysis are in the footnotes?
This text has no footnotes
How is the criticism of the text performed? If through overt argumentation, who is the “opposition”?
This text is a criticism of the lack of integrated cultural care in U.S. medicine.
How does the text situate itself? In other words, how is reflexivity addressed, or not?
Fadiman is not reflexive in her text.
Who is the text written for? How are arguments and evidence in the text shaped to address particular audiences?
This text is written for the general public. It is not super technical in it’s terminology and it’s story based narrative most likely encourages readers who may otherwise not pursue texts focused on health care or cultural differences/assimilation.
What all audiences can you imagine for the text, given its empirical and conceptual scope?
Just about anyone honestly - although those already interested in medical anthropology/public health/cultural anthropology are probably most likely to engage with the text
What new knowledge does this text put into circulation? What does this text have to say that otherwise is not obvious?
Cultural identity among the Hmong people within this new setting and the influence of culture on their process of understanding new/different norms. Post-refugee navigation of a new place/system. Issues of power, specifically within the medical field and patient(or patient's family)/provider interactions
How generalizable is the main argument? How does this text lay the groundwork for further research?
Several different peoples from various cultures have sought refuge in the U.S. In several instances, their need to flee their home land/country/nation was not entirely unrelated to U.S. military actions/engagements. The investigation into the ways a peoples history/culture influences their desire to assimilate is applicable across multiple groups. In addition, understanding how these factors influence outcomes within the medical setting are important to investigate especially when trying to understand the “immigrant paradox”, often cited in public health research.
What kind of “action” is suggested by the main argument of the text?
For local health systems (and in turn entire communities) to be more understanding, and even adopting, of various cultural beliefs held by their clients.
Other modes of expression?
Describe how the material and arguments of this text could be presented in a form other than that of a conventional scholarly book -- as a graphic novel, museum exhibit, activist stunt, or educational module for kids, for example?
This material could easily be adapted into a movie or play. (I’m actually kind of surprised it hasn’t been). Seeing as it is meant to reach a broad audience this would further that reach.
This sketch was done for UCI Anthro 215A, Ethnographic Methods, Fall 2019.