The Spirit Catches You and You Fall Down (34 page)

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
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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

Case No. 9

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 includes 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
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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
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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
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’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:

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.”