by Anne Fadiman
Shamans are, first and last, quintessential mediators. They are threshold crossers, endowed creatures who can go between the earth and the sky. Grand articulators, shamans’ special gift and mission is to bring opposites together—to bring the physical and moral worlds into meaningful conjunction. That is why they are identified with archetypal connectors such as images of ladders, bridges, ropes, and cosmic trees that sink roots into the earth while branching towards the sky….
It is the special responsibility of the shaman to celebrate and actualize the coincidences between these two kingdoms and to amplify their resonances, one into another. Perhaps that is why shamans do not resist prescription medicine and physical treatments. These forms of medicine do not directly compete with the shamans’ manipulation of symbols and management of belief. Indeed, I saw bottles of prescription medicine resting without contradiction on shamans’ altars inside thatched huts in Camp Ban Vinai….
They see the two modes of healing, natural and supernatural, as complementary rather than contradictory.
Conquergood should know, having been a txiv neeb’s patient himself when he had dengue fever. He has described his soul-calling ceremony, which was attended by most of his friends at Ban Vinai—and which he claims was truly restorative—as a festive and affectionate drama that was “saturated with care and humankindness.”
Lemoine has commented that a txiv neeb is far more like a psychiatrist than like a priest. However, there is a crucial distinction:
Comparing his work to psychiatric procedure, I noticed that while the analyst tries to provoke self-analysis by scratching the wounded part of the self, a Hmong shaman will provide an explanation which avoids all self-involvement of the patient. [The patient] is always represented as a victim of an assault from outside powers or of an accidental separation from one part of his self. When this situation has been identified and overcome by the shaman, health is recovered. At no point has there been a feeling of guilt associated with suffering.
When I read this, I thought of how often the Hmong react to threat or blame by fighting or fleeing, which in the medical arena translate to various forms of noncompliance. The txiv neeb’s exclusion of guilt from the transaction dovetails perfectly with the Hmong temperament. The doctor’s standard message (“If you don’t take these pills/have this operation/see me again next Tuesday, you’ll be sorry!”) does not.*
During the mid-eighties, the Nationalities Service of Central California in Fresno received a short-term federal grant of $100,965 to establish what it termed “an integrated mental health delivery service utilizing Hmong healers and western mental health providers.” Eight txiv neebs were hired as consultants. They treated 250 patients, most of whom had complaints that transcended the usual boundaries of “mental health.” The resulting project report, which contains descriptions of eighteen healing ceremonies, including Ceremony to Dispel Ogre Spirits, Ceremony to Separate This World from That of the Afterlife, and Ceremony to Appease the Spirit Above the Big Stove, is one of the most amazing documents ever financed by American taxpayers. “Sometimes the ceremony by itself was enough,” it concluded. “In other cases, once such a ceremony was performed the client was more amenable to recommended medical procedures, such as surgery or medication, administered by licensed health care providers.” Here are the report’s summaries of two cases that had different, though equally positive, resolutions:
Case No. 3
Complaint/Symptomatology—Gall Bladder Problem (mob tsib): The client suffered from a sharp pain on the right side of the chest extending to the back. He reported inability to engage in any activity other than passive relaxation.
Assessment: A licensed physician diagnosed the condition as a gall bladder problem requiring surgery for correction. The Neng [txiv neeb] was consulted following this diagnosis.
Treatment Plan: The Neng performed a ceremony during which healing powers [were] bestowed on water which was then used to wash the painful area in order to release the pain. However, the pain persisted and the client accepted that it was not a spiritual problem. He then returned to the physician and consented to surgery.
Result: The surgery was successful and the client reported that his illness was cured.
Case No. 9
Complaint/Symptomatology: The client’s penis had been swollen for about a month. He reported that he’d been treated by licensed physicians, but that the treatment had only given intermittent relief from pain and swelling.
Assessment: The Neng determined that the client had offended the stream spirits.
Treatment Plan: The Neng called upon the Neng spirits to effect a cure and release the pain. The Neng used a bowl of water to spray from the mouth over the infected area. The offended spirits were offered payment of five sticks of incense to release the pain and relieve the swelling.
Result: The client got better after the ceremony.
After fourteen months, the grant for the program expired, and, as far as I know, that was the first and last penile exorcism to be sponsored by the Department of Health and Human Services. However, in many less recondite ways, the medical establishment appears to be waking up to the fact that since 1990, more than half the population growth in the United States has come from immigrants and their children—and that many of these immigrants, even if they can get to the hospital and pay for their treatment, may find mainstream health care culturally inaccessible. The 1992 edition of the Merck Manual of Diagnosis and Therapy, the world’s most widely used medical text, included, for the first time, a chapter called “Cross-Cultural Issues in Medicine.” The chapter was allotted only three pages out of 2,844, and it was not cross-referenced in the chapter on “Patient Compliance,” or indeed in any other chapter. However, merely printing such phrases as “spirit attack,” “trance state,” and “cultural relativism” granted them an ex cathedra legitimacy. Where Merck went, others could follow without fear of sounding like cranks.
Ten years ago, hardly any medical-school or residency curricula included cross-cultural training. In 1995, for the first time, the national guidelines for training psychiatry residents stipulated that they learn to assess cultural influences on their patients’ problems. In 1996, the American Academy of Family Physicians endorsed a set of “Recommended Core Curriculum Guidelines on Culturally Sensitive and Competent Health Care.” Among the resources suggested by the guidelines’ authors was BaFá BaFá, a simulation game in which the participants are divided into two mythical cultures, each assigned a different set of manners, conventions, and taboos. Each group inevitably misperceives the other by applying its own cultural standards; each inevitably offends the other; and each, until the groups meet at the end of the game to discuss the pitfalls of ethnocentrism, is inevitably certain that its culture is superior.
Today most medical students at least brush shoulders with cross-cultural issues, and some form more than a glancing acquaintance. The University of Wisconsin recently developed an “integrated multicultural curriculum” that includes panel and group discussions, case conferences, student interviews, role-playing exercises, and home visits. At Harvard, all first-year students are required to take a course called “Patient-Doctor I” (significantly, not “Doctor-Patient I”), in which they learn to work with interpreters, study Kleinman’s eight questions, and ponder such conundrums as “Can an American pediatrician truly explain a surgical consent form to newly arrived parents of a Southeast Asian baby?” and “Is it ethical to use psychotherapy when therapist and patient are ethnically unmatched?” Some residency programs are evolving along the same lines. At San Francisco General Hospital, all family practice residents are required to do a rotation at the Refugee Clinic, in which, since 1979, more than 20,000 refugees, speaking dozens of languages, have received health screenings. (Francesca Farr, who persuaded the Hmong man to let his wife take her isoniazid, was a social worker at the Refugee Clinic.) In addition to briefings on hepatitis B, thalassemia, and intestinal parasites, the residents’ orientation manual inclu
des an article on assessing symptoms in Southeast Asian survivors of mass violence and torture; a set of guidelines for working with interpreters; and an eight-page chart that compares the social and cultural customs of the Vietnamese, Cambodians, Lao, and Hmong.
Highmindedness in the big leagues is all very well. But how much of this kind of thing was likely to trickle down to a place like Merced? As it turns out, a lot more than I expected. In 1996, the Merced County Health Department invited a Seattle-based cross-cultural education program called “Bridging the Gap” to train its nursing, administrative, and interpreting staffs in advocacy skills and “cultural competence.” The health department now produces a segment for the local Hmong cable channel that features a tour of MCMC and answers, in Hmong, some commonly asked questions, including “Why are doctors so rude?” At MCMC, a fifty-five-year-old Hmong man nearly died recently from a perforated bowel after his family took three days to consent to surgery. Because he stayed in the hospital for more than two months, and every resident either cared for him or debated his case in the corridors, he galvanized interest in such questions as: Could txiv neebs be certified, like clergy, to visit MCMC patients?* Could Hmong serve as cultural brokers?† If MCMC employed certified interpreters instead of lab assistants and nurse’s aides who translated on the side—a plan that had previously been dismissed as too expensive—would hospital stays be shortened and costs thereby reduced? (This last question was particularly germane, since managed care had drastically eroded MCMC’s referrals and hospitalizations, and the county was so nervous about the resulting deficit that it was planning to lease the hospital to a large health-care corporation.)
But change comes hard, especially in the trenches. It is one thing to read in medical school that the ideal doctor-patient-interpreter “seating configuration” is a right triangle, with the patient and interpreter forming the hypotenuse, and another to recollect the diagram in a roomful of gesticulating Hmong toward the end of a twenty-four-hour shift. When I heard of Merced’s latest cross-cultural efforts, I remembered an elderly Hmong woman with stomach cancer whom I had once met at MCMC. Her family, unable to understand either the resident’s English or his drawings of the digestive system, had refused to consent to surgery. I had expected the resident to move heaven and earth to bring in a decent interpreter. Instead, I found him in the Preceptor Library, his head bowed over four articles on poorly differentiated gastric adenocarcinoma. I also remembered a Morbidity and Mortality Conference during which Dan Murphy presented the case of a middle-aged Hmong woman rendered comatose by a stroke. Her family had staged an insurrection at her bedside, demanding that her intravenous and nasogastric tubes be removed and that a txiv neeb be permitted in the Intensive Care Unit. (MCMC had acceded, and she had died.) Every time Dan tried to steer the discussion toward cultural issues, the residents yanked it back to a debate on the relative merits of labetalol and hydralazine as antihypertensives.
This is the kind of thinking that has begotten the cartoon-version M.D., the all-head-no-heart formalist who, when presented with a problem, would rather medicate it, scan it, suture it, splint it, excise it, anesthetize it, or autopsy it than communicate with it. Fortunately, most real-life doctors, including MCMC’s, are not automatons. However, they often seem myopically overreliant on what Kleinman calls “the culture of biomedicine” (which, when he says it, sounds every bit as exotic as the culture of the Ainu or the Waiwai). Their investment in this culture does not make them resist change on general principle; quite the contrary. They eagerly embrace new drugs, technologies, and procedures as soon as clinical trials prove their effectiveness. Yet they may not feel the same way about Kleinman’s eight questions (“But diseases aren’t caused by spirits. Why should I indulge delusions?”) or his proposition that ethnographic methods should be part of every doctor’s job description (“But I’m not an anthropologist, I’m a gastroenterologist!”). The same doctors who listen to Continuing Medical Education audiocassettes on their car stereos, intent on keeping up with every innovation that might improve their outcome statistics, may regard cross-cultural medicine as a form of political bamboozlement, an assault on their rationality rather than a potentially lifesaving therapy.
On the wall above my desk, flanked by pictures of Lia and her family, are two Xeroxed passages that, in a jaundiced mood, I once captioned THE HMONG WAY and THE AMERICAN WAY. THE HMONG WAY is the page from the Fresno mental health report that summarized the txiv neeb’s successful treatment of his patient’s swollen penis. THE AMERICAN WAY is a page from the Journal of the American Medical Association. It was excerpted from an article called “Doctors Have Feelings Too.” Its author, a Harvard Medical School instructor named William M. Zinn, posited that because doctors may be busy “doing multiple other tasks,” “maintaining a clinical distance,” or harboring guilt about negative reactions to their patients, they run the risk of overlooking their feelings. So, if you’re a doctor, how can you recognize that you’re having a feeling? Some tips from Dr. Zinn:
Most emotions have physical counterparts. Anxiety may be associated with a tightness of the abdomen or excessive diaphoresis; anger may be manifested by a generalized muscle tightness or a clenching of the jaw; sexual arousal may be noted by a tingling of the loins or piloerection; and sadness may be felt by conjunctival injection or a heaviness of the chest.
I first read this article at Bill Selvidge’s house. Every night, while I waited for Bill to come home from MCMC, I alternated between his old anthropology texts and his piles of medical journals, and pondered which was the more arcane. I remember sitting on the dilapidated sofa, thinking that if any of my Hmong friends heard that American doctors had to read an article in order to learn how to tell if they were angry, they would never, ever return to MCMC. In lurched Bill, nearly ataxic from fatigue after a thirty-three-hour shift. I read him the paragraph that is now on my wall. We both laughed so loud we probably woke his fundamentalist neighbors, the ones who had smashed their TV set and danced a jig around it.
Bill assured me that he was so remarkably in touch with his feelings that he could tell if he was anxious or sad without benefit of diaphoresis or conjunctival injection. I believed him. Bill was a G.P. of the old school, the sort of doctor who relieved his stress by going to MCMC’s newborn nursery, selecting a crying baby, and walking back and forth with it until it quieted down. Yet I feared that Dr. Zinn had a point. Medicine, as it is taught in the United States, does an excellent job of separating students from their emotions. The desensitization starts on the very first day of medical school, when each student is given a scalpel with which to penetrate his or her cadaver: “the ideal patient,” as it is nicknamed, since it can’t be killed, never complains, and never sues. The first cut is always difficult. Three months later, the students are chucking pieces of excised human fat into a garbage can as nonchalantly as if they were steak trimmings. The emotional skin-thickening is necessary—or so goes the conventional wisdom—because without it, doctors would be overwhelmed by their chronic exposure to suffering and despair. Dissociation is part of the job. That is why doctors do not treat their own relatives (feelings would handicap their effectiveness); why, beyond routine issues of sterility, the heads of open-heart patients are screened from the surgeon’s view (individuality would be a distraction); and why Neil Ernst avoided Lia Lee after she returned from Fresno with irreparable brain damage (he couldn’t bear it).
At Stanford Medical School, in an admirable attempt to fight this trend, students are informed during the first semester that their empathy may already have peaked; if they succumb to the norm, it will plunge steadily during their four years of medical school and their first year of residency. “What changes?” an appalled student once asked. His professor answered, “As you get more skilled, you belittle what you had before you started.”
Stanford, like several other medical schools, is trying to bring back what has been called the “whole doctor-whole patient” model, in which the doctor brings his or her full
humanity (not just the part that aced the MCATs) to the hospital, and the patient is viewed as a complete person (not just the appendix in Room 416). This model is nothing new; in fact, it is what all doctors used to be taught. As William Osier once said—or is said to have said—“Ask not what disease the person has, but rather what person the disease has.” Between 1992 and 1995, the percentage of medical-school seniors who chose to become generalists—internists, general pediatricians, and family physicians—nearly doubled: a trend that may help bring Osier’s charge back into circulation. Some of these choices have been influenced by economic factors (managed care plans prefer primary to sub-specialized care because it’s cheaper), but others are surely idealistic. If there were more Osler-type generalists around, the Hmong, among others, would stand to benefit. The anthropologist Elizabeth Kirton has commented that a Hmong patient she knew, referred to a specialist for further treatment, did not ask the referring physician to find someone skilled or famous. He asked, “Do you know someone who would care for me and love me?”
It was probably unfair of me to caption Dr. Zinn’s article THE AMERICAN WAY. Once, several years ago, when I romanticized the Hmong more (though admired them less) than I do now, I had a conversation with a Minnesota epidemiologist at a health care conference. Knowing she had worked with the Hmong, I started to lament the insensitivity of Western medicine. The epidemiologist looked at me sharply. “Western medicine saves lives,” she said. Oh. Right. I had to keep reminding myself of that. It was all that cold, linear, Cartesian, non-Hmong-like thinking which saved my father from colon cancer, saved my husband and me from infertility, and, if she had swallowed her anticonvulsants from the start, might have saved Lia from brain damage. Dwight Conquergood’s philosophy of health care as a form of barter, rather than a one-sided relationship, ignores the fact that, for better or for worse, Western medicine is one-sided. Doctors endure medical school and residency in order to acquire knowledge that their patients do not have. Until the culture of medicine changes, it would be asking a lot of them to consider, much less adopt, the notion that, as Francesca Farr put it, “our view of reality is only a view, not reality itself.” However, I don’t think it would be too much to ask them to acknowledge their patients’ realities—to avoid the kind of blind spot that made a Merced health department employee once write, about a child from a family that views the entire universe as sacred: