PHYSICIANS+ "THE SPIRIT" = FATAL MISUNDERSTANDING

When two cultures clash, the result can be fatal. But it doesn't have to be. Some extra legwork and a little understanding can go a long way in preventing a tragedy.

That was the basic message of a lecture given to first-year students at UMDNJ-Robert Wood Johnson Medical School this winter. It was sponsored by the school's Department of Family Medicine.

"The Challenge of Cross-Cultural Medicine" was presented by Anne Fadiman, a renowned journalist and author of the book, The Spirit Catches You and You Fall Down. The book is the true story of a severely epileptic Hmong child, Lia Lee, and her family, who migrated from the hills of Laos to California. It was the basis of her talk.

Lia was three months old when she had her first seizure and her parents carried her in their arms to a Merced County emergency room three blocks from their apartment. By the time they arrived, however, the seizure had stopped. Unable to communicate with the Lees, doctors couldn't make a diagnosis, and Lia was sent home. This happened several more times, until the Lees arrived at the ER with an English-speaking relative and with Lia still convulsing. She was finally diagnosed correctly and put on an anticonvulsant medication.

Meantime, the Lees believed that a dab, or spirit, had caught Lia and made her fall down. The cure, they thought, lay in animal sacrifices -- particularly chickens and pigs -- that would persuade the spirit to give Lia her soul back.

Completely unaware of what was taking place in the Lee home, doctors insisted on a complicated regimen of drugs for Lia. Some pills had to be cut in half, some given only with meals and still others at bedtime.

The Lees didn't understand the sophisticated directions and couldn't read the prescription labels; some bottles simply stated, "Take as directed." With every new drug, Lia's personality and energy level changed, sometimes drastically. They began losing confidence in the doctors and balked at giving her medication.

The physicians saw this noncompliance as child abuse. Feeling they had no other choice, they had Lia placed in foster care. She was terrified and miserable. After a torturous year, Lia returned home. But a few months later at the age of four, she suffered a massive seizure that virtually destroyed her brain. Now 16, Lia remains in a coma.

"Lia"s chart weighed 13 pounds and 5 ounces, but was filled with only one language," Fadiman told the students. "The doctors spent a huge amount of time learning all they could about epilepsy, but no time at all learning about the Hmong language or culture." She advised the students to take the extra time to find an interpreter who understands not only the language of a country but the culture as well. Among the Hmongs, she pointed out, there are clan leaders who are well educated and can communicate. One hospital in San Francisco maintains a list of Hmong clan leaders in their emergency room.

"Try to see the illness from the patient's point of view. This is vital to good care," she explained. "Ask the patient what he thinks is wrong. What does he call the condition? What caused it, and how long does he think it will last? What is he doing for it? Just these few simple questions can save everyone a lot of heartache."

"Form an alliance," Fadiman said. "You don't have to believe in a foreign method of treatment, just respect it. You can't practice good medicine without practicing culturally competent medicine."