1/25/13 Cross-Cultural Conflict Exam number 2043

The Conflict of the Lee Family

This paper discusses the cultural factors that played out in the conflict between Foua and Nao Kao Lee and the various doctors they consulted concerning the epilepsy of their daughter Lia Lee. This story largely plays out in the book The Spirit Catches You and You Fall Down, and thus is largely taken from the book. I. History and Background The Hmong people have a long history in Asia and more specifically China. For much of the last two millennia, they existed within China but not part of Chinese society, largely dwelling in remote villages in the mountains. After centuries of skirmishes with the Chinese, large groups of Hmong migrated to and settled in the highlands of modern day Burma, Laos, Vietnam, and Thailand.1 Wherever they settled, however, they maintained an inner homogeny and independence while being marginalized from their respective societies.2 In this marginalized and independent position, the Hmong have developed a reputation for refusing to take orders, that they would rather flee, fight, or die than surrender; that they are not intimidated by being outnumbered, and that they do assimilate very well to other cultures, even if they are much more powerful than their

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Hillmer, p. 25 Id. 1

own.3 These traits proved to be challenges for the assimilation of the Hmong in the United States when thousands fled Thailand in the years after the Vietnam War. During the war, the United States Central Intelligence Agency trained a secret guerrilla army of Hmong soldiers to support the prevention of the spread of communism.4 This side-war taking place in Laos was called the Quiet War in part because it was kept a secret from the outside world. It is reported that as part of the agreement to fight for the United States, the CIA promised that if Pathet Lao won the war, the United States would continue to provide them with aid.5 Many Hmong men fought and ultimately died under this engagement, and American support ultimately pulled out of Laos. With that withdrawal, many Hmong were left on their own to flee Laosincluding the Lee family and little aid was immediately available. Foua Lee and Nao Kao Lee carried their children on their long journey to Thailand, only to be captured and returned by gunpoint.6 For three years they and other Hmong were treated like fugitives in their own country. This was a time of running, hiding, and evading death.7 In Thailand, they spent a year in two separate refugee camps. Another one of their daughters died in the first camp. They were cleared to immigrate to the United States in 1980.8 In the United States, the Lees had a young three-month-old daughter who started suffering from epilepsy. Although this illness was well known to them, they viewed it as some sort of a call from spiritual beings to be a healer. However, as the seizures continued, Fadiman, p. 17 Hillmer, p. 8485 5 Fadiman, p. 201 6 Id. at 155. 7 Her and Buley-Meissner, p. 33 8 Fadiman, p. 156
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they took little Lia to the hospital in hopes that Western medicine might provide some help.9 Over a number of years, different doctors tried to provide medical treatment to improve Lias condition. But due to cultural difference and failures in communication, and conflict ensued between Lias parents and her medical providers. II. Analysis While there were obviously many cultural differences between the Lee family and Lias medical providers, the main cultural differences manifested through the book The Spirit Catches You and You Fall Down are (1) differing concepts of truth and law, (2) high and low context communication, (3) high and low individualism, and (4) external and internal locuss of control. A. Differing Concepts of Truth and Law Cultures can have different concepts of what is considered true and untrue. They can place emphasis on different aspects of truth or on important factors other than the truth. The Western world largely places emphasis on facts and data when considering a question. What scientific studies have been done? What evidence exists leaning one way or another? What actually happened and who is to blame is at the forefront of resolving the question or problem. The doctors and medical staff who treated Lia definitely came from this Western perspective. They were focused on studies, science, and evidence of what would work to cure her. When Foua and Nao Kao did not cooperate in the administration of medicine, the medical staff became very frustrated because they could not understand why someone would not follow what they were prescribing. Dwight Conquergood, and ethnographer
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Id. at 23 3

with experience in working with the Hmong, observed that the problem of this situation is that the healthcare providers view the relationship as one-sided, with the doctors possessing all of the knowledge.10 This perspective differs significantly from that of the Hmongthey did not see the doctors as the only source of truth or help, they had their own spiritual beliefs regarding her illness. Other cultures view truth through a different light. Where the western world focuses on evidence and who is right or wrong, other cultures focus on harmony and saving face. In the case of Lias parents, they seemed to focus on saving face and the harmony and protection of their family. For example, when Foua was filling out medical forms, she invented the year that she and her children were born because she did not know what it was.11 At the same time, she complied with the filling out of the form to save face. Because of these different views on truth, the doctors repeatedly prescribed medical treatment to Lia that Lias parents did not follow. Neil and Peggy (her principal pediatricians) could not fathom in the beginning that the parents were not following the prescriptions that they gave: [Foua and Nao Kao] viewed themselves and eminently reasonable and their doctors as incapable of compromise.12 Another doctor observed, I remember that I was just watching them and they looked very resolute, like, you know, we are doing what we thing is right.13 This same doctor also stated that he was in awe of how differently he and Lias parents looked at the world, and he was surprised at how they stood firm in the face of experts. Lias parents did not understand the obligatory nature of United States law governing the care of children and the duties owed by the parentsthis Id. at 7 Id. at 7 12 Id. at 110 13 Id. at 53
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is a place where the Western view of truth is enforced by law, even if means taking children away from their parents. The conflict between Lias parents and the medical staff also stemmed from differing cultural viewpoints on the law and authority. Some cultures associate the law with absolute truth, and thus it is fair and should always be respected. Other cultures have differing degrees in how much they trust the law and whether or not it should be respected. The Hmong do not inherently trust American law based off of their culture and their experience in coming to the United States. Many Hmong folktales tell of stories with virtuous actors who lie to authority figures in order to protect their family or friends.14 The Hmong have never really had a nation of their own, so their laws and ethical values revolved around those within their communitieswho were their family and friends. Additionally, the Lias parents generally distrust the American government based off of their history of being left in Laos to fend for themselves. These differing perspectives ultimately contributed to the climax of the conflict between the partiesthe removal of Lia from her home into government custody. Neil, the doctor who initiated this move, stated his reasons for making the decision: I felt that there was a lesson that needed to be learned . . . I felt it was important for these Hmongs 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.15 He also stated that he wanted to set a precedent among the communitymaking the Hmong realize that the consequences of disobeying the doctor were more serious than they realized.
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Id. at 242-243 Id. at 79 5

As is common with conflict, one partys move to strengthen their power is usually responded to in kind. Neils seemingly logical move to assert custody of Lia only resulted in greater distrust of the doctors in the Hmong community.16 With greater distrust, Neil would be less likely to see and treat other children because their parents would not bring them in to be seen. The cultural miscommunications not only initiated the conflict but also fueled its escalation. B. High and Low Context Communication To say that a lack of communication was part of this conflict would be a gross understatement. Not only did the parties use different communication styles, but also they usually had either a poorly trained translator or none at all. This dynamic, combined with the differing concepts of truth and law discussed above, at best would result in a severe misunderstanding. Traditional Hmong communication would likely fall on the side of high context communication. High context communicators exchange information in a culture that assumes that much of the actual communication taking place is implicit and assumed. They do not think it is necessary to formalize an agreement or go into long discussions about what should be done in a situation. This is especially true where the high context communicator is communicating with someone who is perceived to be in a higher power role. Harmony and saving face remain paramount. Thus Lias parents would have felt strong cultural pulls to agree and be cooperative with doctorsbecause they were see in a high power roleeven when they did not understand what was being communicated.

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Id. at 83 6

At one point in the book, the author explains the meaning of the Hmong phrase hais cuaj txub kaum txub, which means to speak all kinds of things.17 This phrase is often used when a storyteller begins a narrative to remind them that the world is full of things that may not seem to be connected but actually are; that no event occurs in isolation; [and] that you can miss a lot by sticking to the point.18 This type of mindset describes the communication style of the Hmong. The author experienced challenges with Hmong translators who would translate high-context communication to low context communication. She explained that with her first two translators she would ask interviewees a question, to which they would take about four of five minutes to respond. The translator, however, would take the long Hmong response and condense it down to what the person really means, i.e. He means no.19 This shows that the interviewee was trying to save face and not give a direct answer, while the translator who understood the culture figured he would save time and just communicate what was really being said. This is typical for a high-context communicator. Low-context communicators, on the other hand, strive for open and clear direct communication. Low-context communicators assume less from the situation and want straightforward say what you mean communication. Neil described himself as a motivated and direct person, I am a fairly driven and compulsive kind of person, he said. When Neil seemed unable to properly communicate what was expected of Lias parents in regard to her treatment, a nurse was sent to the Lee

Id. at 1213 Id. 19 Id. at 94

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home to try to improve the lack of compliance with Lias medication.20 The nurse was the first of many who tried to help the Lees understand the details of their daughters treatment. Over four years, the visiting nurses put stickers on bottles to make it easier to determine when the medication was supposed to be taken, drew lines on syringes to measure dosage, posted charts on walls, and put up detailed calendars with plastic compartments for the medication to be taken at each specific time.21 With all of this low context communication, the Lees still did not comply with the doctors orders. Neil said, It felt as if there was this layer of Saran Wrap or something between us, and they were on one side of it and we were on the other side of it . . . we were reaching and reaching . . . but we couldnt touch them.22 The lack of understanding that on the part of the doctors that when Lias parents were nodding and agreeing in their visits, it was only to save face. They did not really think they had to do what the doctors told them to do. This prevented the doctors from understanding how they could best help Lia. C. High and Low Individualism The cultures of the parties also differed in terms of the emphasis on individualism each of the parties exhibited. The Hmong come from collective familiallow individualismcultures where the family (or clan) is most important, and thus they (clan members) should be consulted for decisions. General Western society and Western medicine focuses on what is best for the individual patient and the patients health as opposed to what the community or leaders think should be done. Thus they are highly individualistic. Id. at 48 Id. 22 Id.
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Cultures that place a low emphasis on individualism have a communal conscience that is worried about what is best for the whole. Individual needs are placed at the mercy of the community, and individual gain is looked down upon. We is more important in a persons self-image than I. There is a high pressure to conform to the norms and ideals of the group, and there is a stronger ability of society to deter unproductive behaviors through social pressure. The individual going against the societal pressure could be dishonored and lose face. The Hmong culture easily fits within this category. When the Hmong lived in Laos and grew substantial amounts of opium for trade, individual addiction to the drug was not a large problem because addicts shouldered a heavy burden of shame . . . [and] not only had trouble finding brides themselves but blackened the marital prospects of their brothers and cousins.23 This unity is also displayed in medical decision-making. Doctors treating Hmong patients often struggle in obtaining consent for even life-saving procedures: Wives had to ask their husbands, husbands had to ask their elder brothers, elder brothers had to ask their clan leaders, and sometimes the clan leaders had to telephone even more important leaders in other states.24 An extreme amount of patience and understanding was required for doctors accustomed to only talking to individual patients about their treatments. The Hmong are not only collective, but they are lineal collectives in the sense that they see themselves through the perspective of family lines. Lineal collective cultures view their life through the perspective of their ancestors and their children. They are concerned about the well being and respect of their predecessors; where as other collective
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Id. at 122 Id. at 71 9

cultures are more concerned about those around them at the moment rather than their ancestors. In the Hmong culture, people care deeply about their ancestors. They pray to their ancestors, sacrifice animals to them, and refer to where they were born on the basis of their ancestry (i.e., I was born where my father was born).25 American society, in contrast, tends to be very individualistic. On the Geert Hofstede model of country dynamics, the United States has a very high individualism score of 91 (out of 100).26 This means that people in America tend to be focused on what individuals can accomplish as compared to a concern for what is best for the group. This played out in the conflict because no one ever asked the Lees what they thought was the problem with their daughter. Doctors who wrote Lias medical chart history wrote lines and lines about what they thought was wrong with her, but not a single word actually addressed what Lias parents thought was the best way to treat their daughter.27 This in part is because of the focus the doctors had on themselves and Lia in solving the problem. Their lack of inquiry into Foua and Nao Kaos opinions and concerns caused one problem after anotherfrom the parents not giving Lia her medication as was prescribed to ultimately Nao Kao attempting to take and run with Lia out of a hospital before the doctors gave their approval.28 D. External and Internal Locuss of Control Even if the doctors had made inquiry into what Lias parents thought about what the problem was and what should be done, it is highly unlikely that they would have agreed or adapted their treatment accordingly (although it might have helped the doctors Id. at 13 http://geert-hofstede.com/united-states.html 27 Fadiman, p. 259 28 Id. at 178
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understand how to better encourage the cooperation off Lias parents). This is because the doctors and Lias parents come from very different perspectives in terms of their cultural locus of control. The Lees culture, and the Hmong generally, come from a perspective of an external locus of control, while the medical staff, and the United States generally, come from a perspective of internal locus of control. Cultures that have an internal locus of control believe that the individual has control over what happens to them in life. They are activists who believe that they can influence and even control not only how they feel in the moment, but also how their future destiny will be shaped. On the other hand, culture that have an external locus of control believe that there is natural process of things, and that feelings, promotions, and luck will come when it is supposed to come. Individuals in cultures that have an external locus of control try to be at peace with what is around them rather than trying to change what is around them. The Lee family, and Hmong generally, believe in more of external locus of control than a typical American. For example, the Hmong believe that illness can occur due to the transgressions of an ancestor, the implantation of a stone in ones body by an evil spirit, the bumping into of a dab (spirit) who lives in a tree or a stream.29 The most common believed cause of illness is soul loss. Hmong believe that people have many souls (there is no accord as to exactly how many) and that a persons life soul, which is necessary for health and happiness, can just get lost at times and wander off.30 Most importantly, Hmong believe that the life-soul of a newborn baby is especially likely to disappear because it is so new from the realm of the unseen. This is the reason why Lias parents believe that Lia started
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Id. at 10 Id. 11

her epileptic seizuresshe was only three months old and her sister made a loud noise that scared her spirit away and she initiated her first seizure. While the Lees believed that Lia needed her life soul to return, the doctors believed that her condition could be changed and improved if she were able to get the proper treatment and care. This demonstrated a belief in an internal locus of control (it is difficult to imagine Western medical practitioners not have an internal locus of control, after all, the medical profession strives to solve the physical and psychological ales of the human race through its own work and research). The challenge was not only that Lias prescriptions were very specific (different medicine at different times of day, sometimes in pill form, other times in liquid), but also that the doctors were changing the dosage levels constantly to see if they could get the right fit.31 It is no wonder that this conflict between the doctors and Lias parents proved to be so difficult, not only were the instructions difficult enough for an illiterate person, but they were constantly changing, and Lias parents did not know the reason why their child was receiving the medicine in the first place. E. Conclusion It is hard to imagine how more of a perfect storm could have been created than the one presented in the treatment of Lia Lee. To say that what happened was a tragedy is an understatement. The Lees, who had already been subjected to so much due to consequences of the Vietnam War, were pushed beyond all borders of tolerance in watching their daughter slowly fade away into a vegetative state. What is an apparent lesson from this story is that cultural differences matter in a big way. This story demonstrated how differing concepts of truth, law, contextual
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Id. at 47 12

communication, individualism, and centers of control can create gross miscommunications and frustrate all parties involved. At its worst, it can result in a child not getting the best treatment to prevent a tragic illness from its full onslaught of symptoms.

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Works Cited
Fadiman, Anne. The Spirit Catches You and You Fall Down: A Hmong Child, Her American Doctors, and the Collision of Two Cultures. New York: Farrar, Straus, and Giroux, 1997. Kindle Edition. Her, Vincent K., and Mary Louise. Buley-Meissner. Hmong and American: From Refugees to Citizens. St. Paul, MN: Minnesota Historical Society, 2012. Print. Hillmer, Paul. A People's History of the Hmong. St. Paul: Minnesota Historical Society, 2010. Print. "THE HOFSTEDE CENTRE." United States. N.p., n.d. Web. 26 Jan. 2013. http://geert-hofstede.com/united-states.html

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