Fadiman discloses that Lia neither died nor recovered. As her siblings aged and assimilated into American culture, Lia remained nonresponsive, growing only several inches. Meanwhile, Nao Kao gained weight and suffered from high blood pressure, while Foua felt constantly fatigued. At Jeanine Hilt’s suggestion, they re-enrolled Lia in the Schelby Center for Special Education, where Dee Korda (whose foster child was cognitively challenged) often saw her and was filled with sadness. Jeanine Hilt died in 1993 after having an acute asthma attack that sent her into hypoxic ischemic encephalopathy, depriving her of oxygen and causing her to lose brain function in the same manner Lia had. When Foua heard the news, she was distraught, explaining to Fadiman, “I cried because Jenny had told me […] she would help me raise my children. But she died, so she couldn’t do that, and I felt I had lost my American daughter.”
Foua’s strong reaction to Jeanine Hilt’s death shows her remarkable capacity to form relationships across social and cultural barriers (that is, if the circumstances are right and she respects the person in question). The fact that she liked the idea that Jeanine would help raise her children is significant, since for most of Lia’s medical history Foua and Nao Kao vehemently fought against Americans who tried to take control of their daughter’s life. It seems, then, that Foua’s experience with Lia turned her into a more compassionate, open, and accepting person.
Neil Ernst and Peggy Philp continued to practice, winning awards and gaining promotions. When their son was diagnosed with Leukemia, Foua—who had heard the news—expressed great concern, asking Peggy how he was doing. In a letter to Fadiman about this encounter, Neil wrote: “At the end of the visit Mrs. Lee was hugging Peggy and they were both shedding a few tears. Sorrows of motherhood cut through all cultural barriers.” When their son entered permanent remission, Foua continued to ask after him. In a later letter, Neil wrote: “Our contacts with [Foua] are very infrequent because her family provides excellent care for Lia, but they are special nonetheless.”
In framing the “sorrows of motherhood” as unifying forces, Neil finally hit upon something he and his wife had in common with the Lees: the love of family. Though it’s unfortunate that it took so long for the two parties to find an emotionally salient commonality, it’s evident that Lia’s demise ultimately enabled Neil to see beyond the narrow scope of Western medicine, understanding at last that the Lees took “excellent care” of Lia, despite the fact that this care did not fit his conception of what love and protection looks like.
In an effort to gain some clarity about the anticonvulsant medications prescribed to Lia, Fadiman visited Dr. Hutchinson at Valley Children’s Hospital. He explained that Lia’s final seizure was the result of the septic shock her brain suffered. When Fadiman asked if the Lees’ earlier noncompliance had affected this outcome, he assured her that the two matters were unrelated. “The only influence that medications could have had,” he told her, “is that the Depakene we prescribed might have compromised her immune system and made her more susceptible to the Pseudomonas [the bacterial infection that led to toxic shock].” Fadiman told Hutchinson that Foua and Nao Kao believed the problem was caused by too much medicine, to which he replied, “That may not be too far from the truth.” Fadiman stared at him, shocked. “Go back to Merced,” he said, “and tell all those people at MCMC that the family didn’t do this to the kid. We did.”
The fact that Hutchinson believed that he—along with Lia’s other doctors—were responsible for Lia’s final neurological crisis indicates his desire to assign blame to somebody, even if that means pointing the finger at himself. Indeed, both the Lees and the doctors they saw constantly tried to determine who was at fault for Lia’s various ailments and hardships, a fact that speaks to the human tendency to look for meaning in petty accusations rather than accept a difficult situation for what it is.
Fadiman repeated Hutchinson’s theory to Neil and Peggy, who pored through their notes before determining that it was indeed a possibility that the Depakene had made Lia especially vulnerable to infection. When Fadiman told Dan Murphy the same thing, he pointed out that Neil probably would have caught the infection if it hadn’t been for Lia’s history of seizures; “No one at MCMC would have noticed anything but her seizures. Lia was her seizures,” he told her. Taking a cue from this sentiment, Fadiman notes the way doctors talked about Lia after her neurological crisis. Hutchinson, Neil, and Peggy all continued to refer to her as dead, even after Fadiman would remind them that she was alive. She remarks that this isn’t an oversight so much as an “admission of defeat”; their care and medical treatments had failed, so Lia was dead to them.
Crushed by their feelings of culpability, Lia’s doctors used language to defend themselves against the pain of her neurological crisis. Furthermore, Dan Murphy’s statement that “Lia was her seizures” is a succinct summary of the unfortunate approach of Western medicine, an approach that all too often reduces patients to their illnesses without taking their humanity into account. In keeping with this, once Lia’s illness (which ultimately defined her in the hospital) reached its zenith and ceased to continue acting up, Lia effectively ceased to exist for her doctors.
In an attempt to postulate what could have happened differently in Lia’s medical history, Fadiman spoke to Dan Murphy, who expressed that he believed there was a “gulf” between the Lees and the doctors that was “unbridgeable.” Fadiman obsessed over the notion, wondering if it was truly the case that these two cultures were irreconcilable in this situation. She evokes an idea Blia Yao Moua presented to her that Hmong culture is not Cartesian, which is to say that it is nonlinear. Western medicine, on the other hand, is incredibly Cartesian, devoted as it is to logic and empirical data.
It is no surprise that Fadiman obsessed over the idea that the gulf between Hmong culture and Western medicine might be “unbridgeable,” since the very aim of The Spirit Catches You and You Fall Down is to examine the missed avenues of communication in a disastrous instance of cross-cultural misunderstanding. By suggesting that Hmong culture is nonlinear, she ultimately proposes a possible way to bridge this gulf: Western medicine must recognize the non-Cartesian logic driving Hmong patients’ beliefs.
Fadiman brings up a program of eight questions designed by Arthur Kleinman, a psychiatrist and medical anthropologist interested in cross-cultural medicine. The questions include: (1) What do you call the problem? (2) What do you think has caused the problem? (3) Why do you think it started when it did? (4) What do you think the sickness does? How does it work? (5) How severe is the sickness? Will it have a short or long course? (6) What kind of treatment do you think the patient should receive? What are the most important results you hope she receives from this treatment? (7) What are the chief problems the sickness has caused? (8) What do you fear most about the sickness?
These questions are concrete examples of the kinds of inquiries doctors could make in the hopes of successfully treating their Hmong patients. It’s worth noting that three out of the eight questions begin with the phrase, “What do you think…?” This subverts the idea that the doctors sit in a position of power from which they hold the objective truth, implying instead that the patient’s beliefs and opinions actually matter.
Fadiman answered these questions in the way she thought the Lees would respond and brought the results to Kleinman. In contrast to Neil and Peggy, who were baffled to learn what the Lees actually believed, Kleinman was excited and unsurprised by the answers. Fadiman then explained to him what happened to Lia and asked what he would have suggested. First of all, he told her that the term “compliance” (in the context of following medical regimen) should not be used because it “implies moral hegemony”; second of all, he suggested that somebody should have brought in a member of the Hmong community or a medical anthropologist who could help negotiate between the family and the doctors (this would have required deciding upon certain limits, sticking to those, and accepting compromise on everything else); and third of all, he said that the doctors needed to remember that even their own culture has its own “set of interests, emotions, and biases.”
When Kleinman used the term “moral hegemony,” he meant that Lia’s doctors unwittingly implied to the Lees that the set of ethical standards of Western medicine were superior to those of the Hmong tradition. This relates to Kleinman’s other idea that the doctors ought to have remembered that their own culture comes with biases—his prevailing argument, as he put it to Fadiman, was essentially that doctors must be aware of the implications of their own beliefs before they can hope to address any sort of cross-cultural divide.