by Anne Fadiman
Before receiving clearance to be admitted to the United States, all Hmong, like other refugees, undergo medical screenings by physicians employed by the International Organization for Migration. The physicians must sign forms indicating that they have specifically examined the visa applicants for, and found them free of, eight contagious diseases (leprosy, tuberculosis, five venereal diseases, and, since 1987, positive antibodies for HIV) and eight mental conditions, including “Sexual Deviation,” “Psychopathic Personality,” and “Previous Occurrence of One or More Attacks of Insanity.” Paul DeLay, the former director of the Refugee Clinic at San Francisco General Hospital, explained to me, “You get the impression that these problems are being carefully screened for back in Thailand. In fact, the exam takes approximately ten seconds. All you get is a blood test for syphilis and HIV, a quick skin check for leprosy, and a chest X ray for TB. Early on, you could buy a clear X ray on the black market. In ’81 it got a little harder because the immigration officials started stapling a photo of the person to the X ray, but it was still possible. And despite what it says on the form, there’s absolutely no screening for ‘mental conditions.’ In the early days, some medical person would walk down the aisle of the airplane and if somebody looked psychotic they’d be thrown off. So if a family was worried about their crazy relative they’d just load him up with opium so he’d fall asleep.” DeLay pointed out that although few refugees are rejected for medical reasons, it is a terrible crisis for the ill person’s family when this does happen, especially because once an applicant is “medically excluded” by one potential country of asylum, he is unlikely to be accepted anywhere else. “All of this means that the refugees have one more reason to be afraid of doctors,” said DeLay.
Once a refugee arrives in the United States, post-immigration screening is not legally required, so although most states have refugee health programs, many Hmong choose not to be screened and thus encounter the medical system for the first time during an emergency. In Merced, new arrivals are voluntarily processed through the county’s public health department, which checks primarily for tuberculosis and intestinal parasites. Though funding is too meager to allow more than a cursory examination during which the patient undresses only from the waist up, refugees who are pregnant or have glaringly evident medical problems are referred to the hospital or clinic.
Merced’s health department is also responsible, according to its former director, Richard Welch, for “dealing with the problems no one else in the community wants to get their hands dirty dealing with.” For example, when a rumor circulated in Merced that a Hmong family was raising rats to eat, a public health worker paid a call. “One of the children in the family had diarrhea, so the question was, did the rats have salmonella or shigella?” recalled Karen Olmos, a nurse in the health department’s communicable disease program. “I told the worker, For God’s sake, don’t just barge in and tell them you want to see the rats! So she went over there on some other pretext, and there were the rat cages. She could see the rats were from the pet store, not the gutter—they were big whoppers. Instead of making the family feel bad about the rats, she simply suggested that they raise rabbits instead. Low start-up cost, high yield, high protein.” On another occasion, the health department launched an investigation after sixty Hmong with diarrhea arrived at the MCMC emergency room. It turned out that for a major feast on a hot summer day, a pig infected with salmonella had been butchered, ripened in the sun for six hours, and served in various forms, including ground raw pork mixed with raw blood.
Although by the mid-eighties the regular staffs of the health department and the hospital had become inured, if not resigned, to dealing with the Hmong, each year brought a fresh crop of family practice residents who had to start from scratch. Avid for exotic medical experiences and hoping that, with its large refugee population, Merced might be sort of like the Peace Corps (but with good hamburgers), these new arrivals were deeply disappointed to find that their Hmong patients spent most of the time staring at the floor and speaking in monosyllables, of which the most frequent was “yes.” After a while, they began to realize that “yes” simply meant that the patients were politely listening, not that they agreed with or even had any idea what the doctor was talking about. It was typically Hmong for patients to appear passively obedient—thus protecting their own dignity by concealing their ignorance and their doctor’s dignity by acting deferential—and then, as soon as they left the hospital, to ignore everything to which they had supposedly assented.
When no interpreter was present, the doctor and the patient stumbled around together in a dense fog of misunderstanding whose hazards only increased if the patient spoke a little English, enough to lull the doctor into mistakenly believing some useful information had been transferred. When an interpreter was present, the duration of every diagnostic interview automatically doubled. (Or tripled. Or centupled. Because most medical terms had no Hmong equivalents, laborious paraphrases were often necessary. In a recently published Hmong-English medical glossary, the recommended Hmong translation for “parasite” is twenty-four words long; for “hormone,” thirty-one words; and for “X chromosome,” forty-six words.) The prospect of those tortoise-paced interviews struck fear into the heart of every chronically harried resident. And even on the rare occasions when there was a perfect verbatim translation, there was no guarantee that either side actually understood the other. According to Dave Schneider, who served his residency in Merced in the late eighties, “The language barrier was the most obvious problem, but not the most important. The biggest problem was the cultural barrier. There is a tremendous difference between dealing with the Hmong and dealing with anyone else. An infinite difference.” Dan Murphy said, “The Hmong simply didn’t have the same concepts that I did. For instance, you can’t tell them that somebody is diabetic because their pancreas doesn’t work. They don’t have a word for pancreas. They don’t have an idea for pancreas. Most of them had no concept that the organs they saw in animals were the same as in humans, because they didn’t open people up when they died, they buried them intact. They knew there was a heart, because they could feel the heartbeat, but beyond that—well, even lungs were kind of a difficult thing to get into. How would you intuit the existence of lungs if you had never seen them?”
Hmong patients might not understand the doctors’ diagnoses, but if they had summoned the courage to visit the clinic, they wanted to be told that something was wrong and to be given something, preferably a fast-acting antibiotic, to fix it. The doctors had a hard time meeting these expectations when the Hmong complained, as they frequently did, of vague, chronic pain. “I have a particular series of diagnostic questions I usually ask when a patient complains of pain,” said Dave Schneider. “I ask what makes it better and what makes it worse? Is it sharp? Dull? Piercing? Tearing? Stinging? Aching? Does it radiate from one place to another? Can you rate its severity on a scale from one to ten? Is it sudden? Is it intermittent? When did it start? How long does it last? I would try to get an interpreter to ask a Hmong patient these questions, and the interpreter would shrug and say, ‘He just says it hurts.’”
It has been well known since the aftermath of the Second World War that because of the enormous psychological traumas they have suffered, refugees of all nationalities have an unusually high incidence of somatization, in which emotional problems express themselves as physical problems. After dozens of gastrointestinal series, electromy-ograms, blood tests, and CT scans, the Merced doctors began to realize that many Hmong complaints had no organic basis, though the pain was perfectly real. Because so little could be done for them and because they were so depressing to be around, Hmong with “total body pain” were among the clinic’s least popular patients. I once heard a resident try to persuade a physician’s assistant to take over one of his cases. “No, Steve,” said the assistant. “No, I do not want to see an elderly Hmong woman with multiple complaints and depression. I will take your coughs and your back problems, but don’t giv
e me one of those!” In order to show they were taking the complaints seriously, some doctors prescribed what they called “the Hmong cocktail”—Motrin (an anti-inflammatory), Elavil (an antidepressant), and vitamin B12. But the patients did not usually get better. “For the underlying problems,” explained Bill Selvidge, “there was no treatment that it was in my power to offer.”
If Hmong patients left the Family Practice Clinic without a prescription (for example, if they had a cold or flu), they sometimes felt cheated and wondered if they were being discriminated against. But if they were given a prescription, no one knew if it would be followed. “You’d say, take a tablespoon of that,” said Mari Mockus, a nurse at the clinic. “They’d say, ‘What’s a tablespoon?’” One patient refused to swallow a pill because it was an inauspicious color. Long-term therapy—for example, the doses of isoniazid that must be taken every day for a year to treat tuberculosis—was always problematic, especially if the illness was asymptomatic. Whatever the prescription, the instructions on pill bottles were interpreted not as orders but as malleable suggestions. Afraid that medicines designed for large Americans were too strong for them, some Hmong cut the dosage in half; others double-dosed so they would get well faster. It was always frightening for the doctors to prescribe potentially dangerous medications, lest they be misused. In one notorious case, the parents of a large Hmong family en route from Thailand to Hawaii were given a bottle of motion sickness pills before they boarded the plane. They unintentionally overdosed all their children. The older ones merely slept, but by the time the plane landed, the infant was dead. The medical examiner elected to withhold the cause of death from the parents, fearing they would be saddled with an impossible burden of guilt if they learned the truth.
When a Hmong patient required hospitalization, MCMC nurses administered the medications, and the doctors could stop wondering whether the dose was going to be too high or too low. There was plenty else to worry about. When they walked into a hospital room, they often had to run a gantlet of a dozen or more relatives. Decisions—especially about procedures, such as surgery, that violated Hmong taboos—often took hours. 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. In emergency situations, the doctors sometimes feared their patients would die before permission could be obtained for life-saving procedures. All too often, permission was refused. “They won’t do something just because somebody more powerful says do it,” said Dan Murphy. “They will sit back and watch and sort of mentally chew it over, and then they may or may not do it. That attitude has been very culturally adaptive for the Hmong for thousands of years, and I think that it is still culturally adaptive, but when it hit the medical community, it was awful.”
Teresa Callahan once saw a patient in the emergency room who had an ectopic pregnancy that required the immediate removal of a Fallopian tube. “I told her over and over again that if the tube ruptured at home she might die before she could get to the hospital. I called her husband and her mother and her father and her grandparents, and they all said nope. All that mattered to them was that she would have one less tube and she might not be able to have kids after that, and when they heard that, it was no, no, no, no. She’d rather die. I had to watch her walk out the door knowing she had something that could kill her.” (Several days later, the woman consented to the surgery after consulting a Thai doctor in Fresno. Teresa does not know how he persuaded her.) Another Hmong woman, examined shortly before she went into labor, was told that because her baby was in a breech position, a cesarean section was indicated. Although breech births in Laos often meant death to both mother and child, the woman attempted to give birth at home rather than submit to the surgery. The attempt failed. Dave Schneider was on call when an ambulance brought her to the hospital. “I got paged at 3:00 or 4:00 a.m.,” he recalled. “‘Dr. Schneider, stat to the emergency room, there’s a lady coming in with a breech baby that won’t come out.’ The paramedics came in wheeling this Hmong woman on a gurney. She was making no noise, just moving her head around in panic. There was a blanket partly over her. I have a very clear visual memory of lifting the covers to reveal a pair of little blue legs, not moving, hanging out of her vagina.” Dave delivered the baby vaginally by manually stretching the cervix over its head. The mother recovered, but the baby died of oxygen deprivation.
Most Hmong women did go to the hospital to give birth, erroneously believing that babies born at home would not become U.S. citizens. Doctors were more likely to encounter them on the Labor and Delivery floor than in any other medical context because they had so many children. In the mid-eighties, the fertility rate of Hmong women in America was 9.5 children, which, according to one study, was “at the upper limits of human reproductive capacity,” second only to the Hutterites. (The fertility rate of white Americans is 1.9 children, and of black Americans, 2.2.) This rate has undoubtedly decreased—though it has not been recently quantified—as young Hmong have become more Americanized, but it is still extraordinarily high. The large size of Hmong families is the inevitable result of two circumstances: Hmong women usually marry during their teens, sometimes as early as thirteen or fourteen, thus allowing their reproductive years to extend nearly from menarche to menopause; and, as a rule, they are highly suspicious of contraception. In 1987, when Donald Ranard, a researcher on refugee issues at the Center for Applied Linguistics in Washington, D.C., visited Ban Vinai, he learned that in an effort to curb the exploding birthrate of the camp’s inhabitants, the administrators had promised free cassette recorders to women who volunteered to take contraceptive pills. Many women accepted both the tape recorders and the pills, but they soon discovered a marvelous paradox: the contraceptives, which they had probably never intended to swallow in the first place, were a superior fertilizer. So the pills ended up being ground up and sprinkled on Hmong vegetable plots, while the gardeners continued to get pregnant.
The Hmong have many reasons for prizing fecundity. The most important is that they love children. In addition, they traditionally value large families because many children were needed to till the fields in Laos and to perform certain religious rites, especially funerals; because the childhood mortality rate in Laos was so high; because so many Hmong died during the war and its aftermath; and because many Hmong still hope that their people will someday return to Laos and defeat the communist regime. In the refugee camps, Hmong newborns were often referred to as “soldiers” and “nurses.” The frequent appearance at MCMC of Hmong women on the Merced public assistance rolls who were about to give birth to their eighth, tenth, or fourteenth child did not endear them to those staff members who have strong ideas about family planning. “I am totally disgusted by the breeding rate,” said Robert Small, an obstetrician who is well known for his clinical proficiency, his unapologetic contempt for the Hmong, and his propensity for mixed metaphors. “The Hmong breed like flies as if the golden goose of welfare will continue to lay eggs forever.”
According to Dr. Small, the Hmong are highly uncooperative obstetrical patients. “They don’t do a damn thing you tell them,” he said. “They just come in late and drop it out. In fact, they wouldn’t come at all if they didn’t need to get the birth certificate so they could get more welfare. You or I, we can’t conceive of the degree of ignorance. They’re almost a Stone Age people. Hell, they never went to a doctor before. They just had a baby in the camp or the mountains or wherever the hell they came from.” Because they were approximately as fond of most doctors as Robert Small was of them, Hmong women who arrived in Merced in the refugee influx of the early and mid-eighties tended to avoid prenatal care.* They were particularly frightened of pelvic exams performed by male doctors. (In the Hmong healing system, txiv neebs and herbalists, who do not touch their patients, may treat people of the opposite sex, but in the more intimate sphere of dermal therapy—massage, acupuncture, pinching, coin rubbing—me
n usually treat men, and women women.) Once they were in labor, the women preferred to wait until the last minute to arrive at the hospital. They often gave birth in the parking lot, the emergency room, or the elevator. Wheelchairs at MCMC were called “Hmong birthing chairs” because so many Hmong babies were born in them en route to the Labor and Delivery floor.
Even if they got to the hospital on time, the women made so little noise during labor that the hospital staff, not realizing birth was imminent, often failed to transfer them from labor beds to delivery tables. A few doctors found this forbearance admirable. “We were told in medical school that childbearing is one of the three or four most painful things that can happen to a person,” said Dave Schneider. “Most women scream. Hmong women don’t make any sound at all. They are just remarkably, unbelievably stoic.”
The obstetric nurses were less impressed by the silence of their Hmong patients. Dan Murphy explained, “The nurses’ attitude was more, ‘Why didn’t they tell us they were about to deliver? What are they, stupid?’ I think it was kind of a displaced anxiety. I don’t think that they were angry at the Hmong so much as they were anxious because the Hmong didn’t fit the pattern they had been trained to deal with.” Some other ways in which Hmong women failed to fit the pattern included squatting during delivery and refusing permission for episiotomy incisions to enlarge the vaginal opening. Although Lia’s mother, when she lived in Laos, had preferred to go through labor alone, many Hmong women were used to being held from behind by their husbands, who massaged their bellies with saliva and hummed loudly just before the baby emerged. The husbands made it very clear what they expected from the doctors. “One father slapped my hand when I was controlling the progress of the baby’s head,” recalled Kris Hartwig. “The nurses got very upset because he violated the sterile field. Then, as I was clamping the umbilical cord, he reached down and touched the cord and said, ‘This is how long it has to be.’”