Book Review: The Spirit Catches You and You Fall Down

The Spirit Catches You and You Fall Down: A Hmong child, her American doctors, and the collision of two cultures

Author: Anne Fadiman
Publisher: Farrar, Straus and Giroux (1997)
ISBN: 978-0-374-52564-4

In recent conversations about cultural sensitivity in healthcare, I found myself returning to a powerful and enduring piece of literature: The Spirit Catches You and You Fall Down by Anne Fadiman. First published in 1997, this extraordinary work explores the heartbreaking story of Lia Lee, a young Hmong child with severe epilepsy, and the cultural collision between her immigrant family and the American healthcare system tasked with her care.

More than two decades on, this book remains essential reading—not only for its compelling narrative, but for its unflinching examination of what happens when good intentions are not enough. In recounting Lia’s medical journey, Fadiman provides a case study in the limits of biomedical knowledge when divorced from cultural context, communication, and empathy.

A clash of cultures in clinical care

Lia Lee’s story is one of profound tragedy and painful miscommunication. Born to Hmong refugee parents in California, Lia developed symptoms of epilepsy as a baby. Her parents, Foua and Nao Kao, attributed her condition to spiritual causes—what they described as "the spirit catches you and you fall down"—while the American doctors saw it strictly as a neurological disorder. Both parties wanted the best for Lia, but their conflicting worldviews and deeply held beliefs about health and healing would soon create insurmountable barriers.

As Fadiman traces the events of Lia’s life—from early seizures and repeated hospital visits to the eventual brain damage that left her in a vegetative state—it becomes tragically clear that the true diagnosis might be "cultural disconnect." Western doctors struggled to comprehend, let alone accommodate, the beliefs of Lia’s family, while her parents felt disrespected, unheard, and alienated from their daughter’s care. Misunderstandings about medication compliance, medical terminology, and decision-making authority fed into a system that ultimately failed all involved.

Communication is not enough

What is perhaps most poignant—and troubling—about this case is that many of the healthcare professionals involved in Lia’s care considered themselves competent communicators. They were skilled, well-intentioned, and medically knowledgeable. But they were not prepared for the deep cultural divide between their own biomedical worldview and the Hmong cosmology of health, illness, and healing.

This is not a story about individual failings; it is a cautionary tale about systemic blind spots. Fadiman helps us see that communication is not merely about language fluency or explanation—it's about understanding, respect, and the willingness to see the world through another’s eyes. And in clinical practice, that perspective can mean the difference between healing and harm.

The explanatory model: A tool for bridging the divide

One of the most valuable contributions of the book is Fadiman’s discussion of Arthur Kleinman’s “Explanatory Model”—a framework designed to help clinicians explore a patient’s beliefs about illness. Featured on page 260 of the book, the model is based on eight simple but powerful questions:

1. What do you call the problem?
2. What do you think has caused the problem?
3. Why do you think it started when it did?
4. What do you think the sickness does? How does it work?
5. How severe is the sickness? Will it have a short or long course?
6. What kind of treatment do you think the patient should receive?
7. What are the chief problems the sickness has caused?
8. What do you fear most about the sickness?

These questions are not about undermining medical expertise—they are about enhancing clinical practice through empathy and understanding. They serve as a reminder that patients are not just bodies to be treated, but whole people with their own logic, values, and lived experiences.

As Kleinman aptly notes, "If you can't see that your own culture [biomedicine] has its own set of interests, emotions, and biases, how can you expect to deal successfully with someone else's culture?" (p. 261). This reflection sits at the heart of Fadiman’s book and is a vital lesson for healthcare professionals at every level.

Beyond cultural competency

Although The Spirit Catches You and You Fall Down is often championed as a foundational text for understanding cultural competence in medicine, it is more than that. It is a deeply human story about trust, power, and the moral obligations of healthcare systems. It teaches that cultural awareness is not a checklist item—it is an ongoing commitment to humility, curiosity, and collaborative care.

Fadiman’s writing is richly detailed, compassionate, and unflinchingly honest. She neither vilifies nor romanticises any party in the story, instead portraying a complex web of motivations and systems that together contributed to Lia’s fate. Her respectful and painstaking research into Hmong culture gives the book extraordinary depth and credibility.

A must-read for healthcare professionals

For anyone working in healthcare, The Spirit Catches You and You Fall Down is more relevant than ever. In an increasingly multicultural world, clinicians must not only diagnose disease but also navigate diverse beliefs and practices. This book is a reminder that excellent care requires more than clinical accuracy—it requires cultural insight, humility, and the courage to listen.

If you are passionate about healthcare communication, patient-centred care, or medical ethics, this book will challenge you, inspire you, and stay with you long after the final page.

Author: Kara Gilbert, KMG Communications