1/25/13Cross-Cultural ConflictExam 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

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.

1 Hillmer, p. 252 Id.3 Fadiman, p. 17

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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 Laos—including 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,

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

4 Hillmer, p. 84—855 Fadiman, p. 2016 Id. at 155.7 Her and Buley-Meissner, p. 338 Fadiman, p. 1569 Id. at 23

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improve Lia’s condition. But due to cultural difference and failures in communication, and

conflict ensued between Lia’s parents and her medical providers.

II. Analysis

While there were obviously many cultural differences between the Lee family and

Lia’s 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 locus’s 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

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

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possessing all of the knowledge.10 This perspective differs significantly from that of the

Hmong—they 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 Lia’s 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 Lia’s 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 Lia’s parents looked at the world, and he was surprised at how they

stood firm in the face of experts. Lia’s parents did not understand the obligatory nature of

United States law governing the care of children and the duties owed by the parents—this

is a place where the Western view of truth is enforced by law, even if means taking children

away from their parents.

10 Id. at 7 11 Id. at 712 Id. at 11013 Id. at 53

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The conflict between Lia’s 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 communities—who were their family and friends.

Additionally, the Lia’s 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 parties—the 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 community—making the Hmong realize that the

consequences of disobeying the doctor were more serious than they realized.

As is common with conflict, one party’s move to strengthen their power is usually

responded to in kind. Neil’s seemingly logical move to assert custody of Lia only resulted in

14 Id. at 242-24315 Id. at 79

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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 Lia’s parents would have felt

strong cultural pulls to agree and be cooperative with doctors—because they were see in a

high power role—even when they did not understand what was being communicated.

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

16 Id. at 8317 Id. at 12—13

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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 Lia’s parents in regard to her treatment, a nurse was sent to the Lee

home to try to improve the lack of compliance with Lia’s medication.20 The nurse was the

first of many who tried to help the Lee’s understand the details of their daughter’s

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

18 Id. 19 Id. at 9420 Id. at 48

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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 doctor’s 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

couldn’t touch them.”22 The lack of understanding that on the part of the doctors that when

Lia’s 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 familial—low individualism

—cultures 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 patient’s health as opposed to what the

community or leaders think should be done. Thus they are highly individualistic.

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

person’s 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

21 Id. 22 Id.

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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

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

23 Id. at 12224 Id. at 7125 Id. at 13

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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 Lia’s medical chart history wrote lines and lines about what

they thought was wrong with her, but not a single word actually addressed what Lia’s

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 Kao’s opinions and concerns caused one problem after another—from

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 Locus’s of Control

Even if the doctor’s had made inquiry into what Lia’s 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

understand how to better encourage the cooperation off Lia’s parents). This is because the

doctors and Lia’s 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

26 http://geert-hofstede.com/united-states.html27 Fadiman, p. 25928 Id. at 178

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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 one’s 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 Lia’s parents believe that Lia started

her epileptic seizures—she was only three months old and her sister made a loud noise

that scared her spirit away and she initiated her first seizure.

29 Id. at 1030 Id.

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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 Lia’s 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 Lia’s parents proved to be so difficult, not only were the instructions difficult enough

for an illiterate person, but they were constantly changing, and Lia’s 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

communication, individualism, and centers of control can create gross miscommunications

31 Id. at 47

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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.

Works Cited

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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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