Reaction and Learning From Fadiman's 1998 Book Term Paper

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Spirit Catches You

The world including the United States is becoming increasingly culturally diverse. Over the next couple of decades, the demographics in the U.S. will be changing significantly, with a major increase in the population numbers of Hispanic and Asians in relationship to the amount of black and white citizens. The white population accounted for only 18.5% of the country's population increase between 2000 and 2004. The U.S. Hispanic population accounted for 14% of the population, but 49% of the four-year population increase. Looking at the age gap, one can see this difference even more: Among whites, 15% are age 65 and over, for Hispanics, it is 5%. Between 2000 and 2004 both African-Americans and Asian-Americans contributed about 29% of U.S. population growth. For Asians, however, immigration made up a much larger proportion of their share of population growth. In short, America is experiencing significant demographic change, growing more and more "minority" and less "majority." Considering that the U.S. is supposedly a "melting pot," and has always been culturally diverse, it should have the services in place to handle multiculturalism. Unfortunately, that is not the case. As exemplified by the book the Spirit Catches You and You Fall Down by Anne Fadiman, the U.S. has to make considerable changes in cultural understanding in regard to healthcare in medical institutions.

Fadiman's book recounts the tragedy of three-month-old Lia Lee, from Laos, who suffered from present-day cultural misunderstandings. Fadiman, a freelance writer, was introduced to the Hmong community through a friend working at a California hospital. It took her several months to be allowed to talk with the Hmong leaders, where she heard Lia Lee's tragic story. As a journalist, she shows the point-of-view of both the patient and her family and the healthcare professions, since cultural medicine is such a complicated issue. Fadiman demonstrates the challenges, frustrations and misunderstandings from both these perspectives. That is makes her book so well received by educators, literary critics and the medical field: Although becoming emotionally involved with the Lia Lee family, she remains an objective writer and explains the many problems associated with multiculturalism and medical care.

Going to go to the emergency ward with a family member who is injured or ill is a very stressful time, even when speaking the same language as the staff. Before even being admitted, the hospital asks for insurance information and injury/illness history and, during this time, the person who needs to see the doctor is waiting in pain. The stress mounts and communication becomes harder. This same scenario becomes even more difficult when someone in the ER does not speak the language or know the patient's culture. It not only exacerbates the process, but also can endanger the individual requiring the care.

When Fadiman first met the Lees in 1988, seven-year-old Lia was being cared for, although she was pronounced brain dead two years earlier by American doctors. Her story consists of miscommunication after miscommunication. She was only three months old when she had her first epileptic seizure and the Lees brought her to the hospital. The Lees, recently immigrated to America, could not speak any English, especially with the medical team about Lia's illness. It was the Lees' belief that Lia's illness stemmed from spiritual causes. It was not until the doctors saw Lia actually convulsing that they finally diagnosed her as suffering from epilepsy. The doctors explained that Lia's condition was biological and could be helped with medicine. During the following four years, her anticonvulsant prescriptions changed nearly 25 times, a communication horror in itself. The Lees doubted the treatment of all these many prescriptions and would not administer all of them. As a result, the doctor inaccurately concluded the parents unfit and placed Lia in foster care. A few months later, she had a massive seizure and was left brain dead. She continued to live, being cared for by her parents, despite doctors' expectations.

A major cause of this unfortunate situation was that the hospital did not hire enough translators, nor did it have enough staff to send home a nurse to Lia's house in the very beginning. The parents should have been told what was being done and why and what would happen if their directions were followed incorrectly or not at all. Then, if they did not listen to the doctors, they would have assumed the responsibility for what happened. How could the doctors expect the medicine to be taken correctly when the parents did not read, did not know mathematical symbols and were given change after change? These medical professionals were used to having others follow them unquestionably. Nor can the doctors be excused for not understanding the Hmong culture. Reading National Geographic (pg. 57), as the doctor did, is not the way to learn about a society. Similarly, Dr. Murphy's comment that "[p]eople in the early years of their medical careers have invested an incredible amount of time and energy and pain in their training, and they have been taught that what they've learned in medical school is the only legitimate way to approach health problems" does not excuse these physicians, either.

When the Spirit Catches You was published it created quite an impression. Medical schools and healthcare facilities began looking at their own way of communicating or not communicating with people of other cultures. That was two decades ago. How much progress has been made since then? Gladwell (2002) reports that since the book was published, an "explosion" of programs have been developed particularly to support the multicultural needs in the U.S.'s increasingly diverse population. Multicultural and lingual competence programs have been introduced at the systems, organizational, and clinical levels in numerous institutions. A growing number of grants and financial awards are being made available by federal agencies, foundations, and private organizations to educational, research, and service delivery organizations. For instance, the U.S. Health Resources and Services Administration established the Centers for Excellence to finance a curriculum guide to integrate cultural and linguistic competency content, methods and evaluation with the institution's existing academic programs (HRSA, 2005).

Despite these "explosive" programs, enough is not being done to prepare for the changing demographics. For instance, a study of 60 hospitals across the country, "Exploring Cultural and Linguistic Services in the Nation's Hospitals," (Wilson-Stronks & Galvez, 2005) analyzed 1) the challenges these healthcare organizations face when providing care and services to culturally and linguistically diverse populations 2) the ways to address these challenges and 3) the practices that may be helpful for best sharing. The top-rated challenges were language, culture and staffing, and financial stress, because it is often difficult to locate professionally trained staff who have the desired cultural or linguistic competency and to finance service of diverse populations.

Similarly, many medical schools now offer cultural competencies for clinical interaction for medical students. Metzyl and Poirier (2004), however, report the medical system with its diagnostic focus continues to define problems through disease. For example, medical students learn that African-Americans are at higher risk of sickle-cell anemia, women have a higher risk for the bone disease osteoporosis, and the poor are more challenged by schizophrenia. Metzyl and Poirier find that this training is not enough. It is essential to understand the cultural factors in conjunction with both physiology and disease. Although women have a greater tendency for osteoporosis, for instance, this cannot be completely explained by pathology. Other influences include nutrition, cultural dietary practices, and employment. The authors cite Fadiman's book regarding the different viewpoints regarding religion, wellness, disease, spirit and soul.

The social services are also having difficulty meeting specialized needs and often seem contradictory in their approach. Dr. Ernst reported Lia's parents to Child Protective Services (CPS), because they were not properly giving her the prescribed medication. This was considered child abuse, which was against the law. Medical staff is legally required to report any inkling of child abuse; a medical license may be taken away. The doctor, therefore, is caught between the patient's personal needs and the U.S. legal system. Child Protective Services placed Lia in a foster home in order to ensure she was receiving proper care.

Child Protective Services' bureaucratic and investigative approach is frequently in conflict with the social workers because of their separate charges. CPS professionals are responsible for safeguarding children from harm, but core social work values stress choice and self-determination for clients. The National Association of Social Work has a Code of Ethics with the primary mission "to enhance human well-being and help meet the basic human needs of all people, with particular attention to the needs and empowerment of people who are vulnerable, oppressed, and living in poverty." A major feature of social work is its stress on individual well-being in a social context and of society as a whole.

It is the hope of social service workers to develop long-lasting relationships that are based on trust and openness, in addition to becoming a valued partner with parents. Simultaneously, they continually have to make judgments, command authority, and take action… [END OF PREVIEW]

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