Cultural and geographical differences between groups of people are believed to create boundaries that limit similarities between those on opposite sides. Contrary to the belief that the qualities of one side do not merge with those of the other, however when cultural awareness is exhibited, certain characteristics can become shared by different groups of people. In the book The Spirit Catches You and You Fall Down by Anne Fadiman, the story shows the tragic consequences of a lack of cross-cultural communication and reveals a major weakness in western medicine when caring for patients with beliefs that are different from that of their physicians.
The Lee family came to the United States with their own set of beliefs and customs and did not speak or understand the English language, which was often challenging and frustrating for both the Lees and the health care providers involved in Lia’s care. The Hmong believe that many diseases and ailments have a spiritual cause which differs drastically from the biomedical basis of western medicine. Some traditional Hmong remedies and practices include the shamanic rituals performed by a “txiv neeb.” Lia’s parents believed that, for Lia, the best treatment was a combination of “a little medicine and a little neeb” (Fadiman, 1997, p. 100). Health care providers knowledgeable about the Hmong culture and well-versed in cross-cultural medicine and cultural sensitivity may have led to a more favorable outcome for Lia and her family.
Author Anne Fadiman (1997) was able to learn a great deal about the Hmong culture and the Lee family with the help of May Ying Xiong, who she referred to as a “cultural broker” (p. 95). Xiong not only translated for Fadiman, but also educated her about the Hmong culture and explained what she should or should not do or say in the presence of the Hmong. This proved beneficial for Fadiman and she gained the trust of the Lees and a better understanding of the Hmong culture. If the providers in Lia’s case had around-the-clock access to translators and “cultural brokers,” the cultural and language barrier between the Lees and the providers might have been lessened to some extent. The physicians likely would have diagnosed Lia’s epilepsy sooner and, with proper translation and understanding of the Hmong culture, might have been able to compromise and identify a plan of care that Lia’s parents understood and agreed with.
Merriam-Webster Dictionary (n.d.) states that the definition of compliance “is the act or process of complying to a desire, demand, proposal, or regimen or to coercion”. An example of this in the medical profession would be a diabetic taking his medication as prescribed. As a result, his hemoglobin A1C would start to decline with follow up checks. It is very difficult to assess another culture’s level of compliance when one has not been educated on a particular culture. This similar situation was described in Fadiman’s book. She describes the time when Lia was discharged home from the hospital to the care of her parents. Before leaving the hospital, they were educated on the proper dosage, route, and frequency for administering Lia’s anticonvulsant medication. A home health nurse was also sent to the home for further education. When Lia was brought back into the emergency room with another seizure, serum drug levels were drawn that showed subtherapeutic levels, meaning Lia’s parents were not giving the medication as prescribed. They were then labeled as “noncompliant” by the emergency room staff (Fadiman, 1997). Throughout the book, questions were constantly brought up. Were Lia’s parents noncompliant? Did they simply not understand due to a language barrier? Did they want to use their own culture’s medical treatments? Using their own culture’s treatments instead of what the physicians suggested, to someone not educated to the Hmong culture would see the family as not complying with medical treatment.
Dr. Neil Ernst had a great understanding of how the human body should function accompanied with knowledge of important medications and how they can help with essential operations of the body. He was extremely committed to improving Lia’s ailments. Dr. Ernst was full of anger when contemplating why Faou would not administer Lia’s medication regimen as he had prescribed. Through all this, the Lee family had a mixture of emotions. When they initially discovered that Lia suffered from the disease known as epilepsy, they were fearful for her from a physical standpoint, but they were also gratified, believing that this illness could heighten her spirituality. The Lees also struggled with infuriation as their child was taken from them by CPS to live with someone else.
Dr. Ernst’s feeling on the issue can be seen in the following quote from him.
I felt it was important for these Hmong’s to understand that there were certain elements of medicine that we understood better than they did and that there were certain rules they had to follow with their kids' lives. I wanted the word to get out in the community that if they deviated from that, it was not acceptable behavior (Fadiman, 1997, p. 79).
The harsh comments made by Dr. Ernst were a result of knowing that Lia hadn’t received adequate amounts of medication. He truly felt that she was in harm’s way by being with her family. However, after Lia had been with the foster family, who had administered her medication religiously, Fadiman (1997) reports from Lia’s caseworker that she not only continued to seize, but her seizures occurred more often than when she was home. Fadiman (1997) recounts that following an attack and referral to a new physician, Lia’s medication regimen was simplified and limited to one medication. Following this, it was noted by the caseworker and Lia’s providers that Faou was much more consistent with giving Lia her medication. This led to her ultimate return home. Had cultural barriers been removed, Lia may have had an improved quality of life. Instead of removing Lia from her home because of her parent’s “non-compliance,” a home health nurse could have visited the home to administer Lia’s medication daily. A culturally competent home health nurse along with a Hmong “cultural broker” might have been able to teach the Lees the importance of Lia’s medications and how to administer them correctly. Starting with the simplest medication regimen, with the least amount of side effects, might have been the best strategy to ensure Lia’s parents would follow through with the treatment plan.
Cultural awareness, or “the self-examination and in-depth exploration of one’s own cultural background”, is essential to personally reflect on in order to provide competent care (Campinha-Bacote, 2003). Our future practice as Family Nurse Practitioners (FNPs) will consist of treating people from many walks of life; hence the importance of cultural awareness and acceptance. A provider’s personal beliefs and biases can positively or negatively impact the patient-provider relationship, thus having the chance to affect the level of care a patient receives. Campinha-Bacote (2003) reported that “without being aware of the influence of one’s own cultural values, there is a risk that the nurse may engage in cultural imposition”. Instead of imposing our beliefs and values on a patient, it is essential that we, as primary providers, recognize and respect the differences. By participating in a daily ‘self-check’ of one’s own values providers will remain aware of cultural differences, and will be able to provide culturally aware and accepting care; thus, having a greater impact on our patient-provider relationships.
Gallaher (2007) stated that by “understanding the point of view of the other, you are more likely to respond with compassion rather than judgment”. In order to understand the view point of others, it is critical that you are able to recognize and understand your own beliefs and values. As a future FNP, it is essential to evaluate and recognize one’s own self-beliefs, cultural practices, and cultural biases. By recognizing one’s own beliefs and values, it is easier to put yourself in another person’s shoes; ultimately allowing you to better understand their reasoning for certain decisions. By practicing culturally competent care, a provider will more than likely gain the trust from a patient that is needed in order to have an effective patient-provider relationship. There were countless instances where Lia’s providers nor her parents could see one another’s point of view concerning her illness. With a small amount of education about the Hmong culture combined with a certain level of longsuffering, Dr. Ernst may have been able to better reach the Lees and even be able to see the quality care that the Lees did provide for Lia. Likewise, had the Lees been provided with better interpreters form the hospital and community, they may have been able to understand more about Lia’s illness and express their beliefs to Dr. Ernst early on.
The collision of two cultures provided an interesting conflict of what is considered right and what is considered wrong. Fadiman does a good job empathizing with both sides and communicating their intentions with compassion and humanity, and carefully weighing the consequences of their actions objectively.