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They wore amulets around their necks and cotton strings around their wrists the sicker the patient, the more numerous the strings. They smelled of camphor, mentholatum, Tiger Balm, and herbs. When they were admitted to the hospital, they brought their own food and medicines.

Hmong patients made a lot of noise. Sometimes they wanted to slaughter live animals in the hospital. Finally we had to talk to them. No gongs. And no dead chickens. They looked like burns. Some of the lesions had healed and others were still crusty, suggesting that the skin had been traumatized on more than one occasion. Neil and Peggy immediately called the Child Protective Services office to report that they had identified several cases of child abuse.

The father hanged himself in his cell. The story is probably apocryphal though it is still in wide circulation , but Dan and the other doctors believed it, and they were shaken to realize how high the stakes could be if they made a tactical error in dealing with the Hmong.

And there were so many ways to err! When doctors conferred with a Hmong family, it was tempting to address the reassuringly Americanized teenaged girl who wore lipstick and spoke English rather than the old man who squatted silently in the corner. Yet failing to work within the traditional Hmong hierarchy, in which males ranked higher than females and old people higher than young ones, not only insulted the entire family but also yielded confused results, since the crucial questions had not been directed toward those who had the power to make the decisions.

Doctors could also appear disrespectful if they tried to maintain friendly eye contact which was considered invasive , touched the head of an adult without permission grossly insulting , or beckoned with a crooked finger appropriate only for animals.

The young residents at MCMC did not enhance their status by their propensities for introducing themselves by their first names, wearing blue jeans under their white coats, carrying their medical charts in little backpacks, and drinking their coffee from Tommee Tippee cups. On the other hand, bending over backwards to be culturally sensitive did not always work.

Bill Selvidge once examined a depressed middle-aged Hmong woman with severe headaches. Surmising that some of her problems stemmed from cultural dislocation and that her spirits might be buoyed by traditional treatment, he recommended that she see a txiv neeb. She may have tried this in the past because she indicates a previous landlord told her to leave home after police were called when some members of her family were just about to sacrifice a pig.

Compared to the other patients that frequented Merced Community Medical Center, the Hmong were not only trickier but sicker. They had a high incidence of high blood pressure, anemia, diabetes, hepatitis B, tuberculosis, intestinal parasites, respiratory infections, and tooth decay.

Some of them had injuries or illnesses they had acquired during the war in Laos or its aftermath: gunshot wounds, chronic shoulder pain from carrying M rifles, deafness from exploding artillery shells. Before receiving clearance to be admitted to the United States, all Hmong, like other refugees, undergo medical screenings by physicians employed by the International Organization for Migration.

In fact, the exam takes approximately ten seconds. Early on, you could buy a clear X ray on the black market. Once a refugee arrives in the United States, post-immigration screening is not legally required, so although most states have refugee health programs, many Hmong choose not to be screened and thus encounter the medical system for the first time during an emergency. Though funding is too meager to allow more than a cursory examination during which the patient undresses only from the waist up, refugees who are pregnant or have glaringly evident medical problems are referred to the hospital or clinic.

So she went over there on some other pretext, and there were the rat cages. She could see the rats were from the pet store, not the gutter—they were big whoppers. Instead of making the family feel bad about the rats, she simply suggested that they raise rabbits instead. Low start-up cost, high yield, high protein. It turned out that for a major feast on a hot summer day, a pig infected with salmonella had been butchered, ripened in the sun for six hours, and served in various forms, including ground raw pork mixed with raw blood.

Although by the mid-eighties the regular staffs of the health department and the hospital had become inured, if not resigned, to dealing with the Hmong, each year brought a fresh crop of family practice residents who had to start from scratch. When an interpreter was present, the duration of every diagnostic interview automatically doubled. Or tripled. Or centupled. Because most medical terms had no Hmong equivalents, laborious paraphrases were often necessary.

The prospect of those tortoise-paced interviews struck fear into the heart of every chronically harried resident. And even on the rare occasions when there was a perfect verbatim translation, there was no guarantee that either side actually understood the other. The biggest problem was the cultural barrier.

There is a tremendous difference between dealing with the Hmong and dealing with anyone else. An infinite difference. They knew there was a heart, because they could feel the heartbeat, but beyond that—well, even lungs were kind of a difficult thing to get into. How would you intuit the existence of lungs if you had never seen them? The doctors had a hard time meeting these expectations when the Hmong complained, as they frequently did, of vague, chronic pain.

Is it sharp? Does it radiate from one place to another? Can you rate its severity on a scale from one to ten? Is it sudden? Is it intermittent? When did it start? How long does it last? After dozens of gastrointestinal series, electromy- ograms, blood tests, and CT scans, the Merced doctors began to realize that many Hmong complaints had no organic basis, though the pain was perfectly real. But the patients did not usually get better.

But if they were given a prescription, no one knew if it would be followed. Whatever the prescription, the instructions on pill bottles were interpreted not as orders but as malleable suggestions.

Afraid that medicines designed for large Americans were too strong for them, some Hmong cut the dosage in half; others double-dosed so they would get well faster. It was always frightening for the doctors to prescribe potentially dangerous medications, lest they be misused. In one notorious case, the parents of a large Hmong family en route from Thailand to Hawaii were given a bottle of motion sickness pills before they boarded the plane.

They unintentionally overdosed all their children. The older ones merely slept, but by the time the plane landed, the infant was dead.

The medical examiner elected to withhold the cause of death from the parents, fearing they would be saddled with an impossible burden of guilt if they learned the truth. When a Hmong patient required hospitalization, MCMC nurses administered the medications, and the doctors could stop wondering whether the dose was going to be too high or too low.

There was plenty else to worry about. When they walked into a hospital room, they often had to run a gantlet of a dozen or more relatives.

Decisions—especially about procedures, such as surgery, that violated Hmong taboos—often took hours. 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. In emergency situations, the doctors sometimes feared their patients would die before permission could be obtained for life-saving procedures.

All too often, permission was refused. That attitude has been very culturally adaptive for the Hmong for thousands of years, and I think that it is still culturally adaptive, but when it hit the medical community, it was awful. All that mattered to them was that she would have one less tube and she might not be able to have kids after that, and when they heard that, it was no, no, no, no.

I had to watch her walk out the door knowing she had something that could kill her. Teresa does not know how he persuaded her. Another Hmong woman, examined shortly before she went into labor, was told that because her baby was in a breech position, a cesarean section was indicated. Although breech births in Laos often meant death to both mother and child, the woman attempted to give birth at home rather than submit to the surgery. The attempt failed. Dave Schneider was on call when an ambulance brought her to the hospital.

She was making no noise, just moving her head around in panic. There was a blanket partly over her. I have a very clear visual memory of lifting the covers to reveal a pair of little blue legs, not moving, hanging out of her vagina.

The mother recovered, but the baby died of oxygen deprivation. Most Hmong women did go to the hospital to give birth, erroneously believing that babies born at home would not become U. Doctors were more likely to encounter them on the Labor and Delivery floor than in any other medical context because they had so many children.

In the mid-eighties, the fertility rate of Hmong women in America was 9. The fertility rate of white Americans is 1. This rate has undoubtedly decreased—though it has not been recently quantified—as young Hmong have become more Americanized, but it is still extraordinarily high. Many women accepted both the tape recorders and the pills, but they soon discovered a marvelous paradox: the contraceptives, which they had probably never intended to swallow in the first place, were a superior fertilizer.

So the pills ended up being ground up and sprinkled on Hmong vegetable plots, while the gardeners continued to get pregnant. The Hmong have many reasons for prizing fecundity. The most important is that they love children. In addition, they traditionally value large families because many children were needed to till the fields in Laos and to perform certain religious rites, especially funerals; because the childhood mortality rate in Laos was so high; because so many Hmong died during the war and its aftermath; and because many Hmong still hope that their people will someday return to Laos and defeat the communist regime.

Small, the Hmong are highly uncooperative obstetrical patients. Hell, they never went to a doctor before. They just had a baby in the camp or the mountains or wherever the hell they came from. In the Hmong healing system, txiv neebs and herbalists, who do not touch their patients, may treat people of the opposite sex, but in the more intimate sphere of dermal therapy—massage, acupuncture, pinching, coin rubbing—men usually treat men, and women women.

Once they were in labor, the women preferred to wait until the last minute to arrive at the hospital. They often gave birth in the parking lot, the emergency room, or the elevator. Even if they got to the hospital on time, the women made so little noise during labor that the hospital staff, not realizing birth was imminent, often failed to transfer them from labor beds to delivery tables.

A few doctors found this forbearance admirable. They are just remarkably, unbelievably stoic. What are they, stupid? The husbands made it very clear what they expected from the doctors. But what if a patient or her husband or father or brother, who was more likely to make the decision refused an episiotomy that her doctors believed would prevent an imminent fourth-degree laceration—a laceration that the husband or father or brother might then forbid the doctor to stitch up?

I asked Raquel Arias—by common consent, the MCMC obstetrician with the most dazzling combination of skill and empathy—what she did when the wishes of her Hmong patients conflicted with the standard of medical care she was accustomed to providing. So I give them suboptimal care. Sometimes you can find middle ground and try to understand where they are coming from, which is hard, but not impossible. Sometimes you can persuade them to do what you want.

When that happens, it is an unbelievably terrible situation to be in. It is awful. It is not the kind of tension you feel when you get mad at someone from your own background who is doing something they know is bad, like smoking or drinking while they are pregnant.

According to their beliefs and principles, they are trying to protect the mother and the baby and their way of life. And what you think is necessary happens to be exactly the opposite of what they think is appropriate.

During Hmong labors that were going badly, Raquel bit her fingernails which were impeccably polished with Purple Passion enamel to the quick.

Sukey Waller, a psychologist at Merced Community Outreach Services who was highly regarded in local Hmong circles, went through a period of throwing up before going to work each morning. Thao into a little tape recorder while he drank cup after Tommee Tippee cup of coffee and reflexively picked at his eyelashes. I think that is why some young doctors go through the roof when Hmong patients reject what we have to offer them, because it intimates that what Western medicine has to offer is not much.

Roger Fife happened to espouse a philosophy that carried more weight with the Hmong than any degree of knowledge, intelligence, or technical skill. It would have gone completely against his grain to apply two different standards of care to his patients: a higher one for the Americans, a lower one for the Hmong.

But might Lia Lee have been better off if her family had brought her to Roger Fife? That latter question still bothers him. Which would have been more discriminatory, to deprive Lia of the optimal care that another child would have received, or to fail to tailor her treatment in such a way that her family would be most likely to comply with it?

A decade ago, that is not the way Neil looked at the situation. He never seriously considered lowering his standard of care. Lack of compliance constituted child endangerment, which is a form of child abuse. He and Peggy had both heard, and believed, the rumor about the Hmong father in Fresno who hanged himself in his prison cell after being unjustly arrested for child abuse.

Neil finally decided that he had no choice but to request that Lia be placed in foster care. I mean, you always do. And there was another part—and here I am speaking for myself, not for Peggy—which is that I felt that there was a lesson that needed to be learned. I wanted the word to get out in the community that if they deviated from that, it was not acceptable behavior. Failure to report child abuse is a prosecutable offense in forty-four states, including California.

Because physicians — along with other health care workers, teachers, day-care employees, and police officers—are especially likely to come across evidence of abuse, all fifty states have immunity clauses in their child welfare laws that protect these groups from civil or criminal charges after they file abuse reports, even if they are found to be wrong.

If a child had not been involved, things would have been different. All he wanted was to get Lia out of their hands and into the stewardship of someone who would administer her medications exactly as he prescribed them. On May 2, , she was placed temporarily in a foster home run by two Mennonite sisters who, whenever she became hyperactive, strapped her into an infant car-seat on the living room floor. After two weeks, she was returned home and her parents were given one last chance.

Blood tests continued to show that they were giving her less than the prescribed dose of Tegretol. A, Merced, California. Said minor is an epileptic with a complex seizure disorder, and the parents are administering sub-therapeutic medication levels.

The doctor states that said minor needs to be removed from the parental home at this time to preserve the life of said minor.

On June 26, Lia was removed from her home again, this time for a placement of at least six months. When the CPS workers arrived, Foua was out of the house, visiting relatives. Several years later, Nao Kao told me, through an interpreter, what had happened. He was under the impression that the social workers, who were accompanied by a Hmong interpreter named Sue Xiong, were police officers. I was very angry. I almost killed the translator. I said, This is my child and I love her.

The police said for six months Lia is government property. I cried so much that I thought my eyes would go blind. When they heard about it, every one of them disagreed with his decision, though none of them could suggest a better alternative.

Neil had not deliberately concealed what had happened. It was simply not his habit to discuss emotionally charged topics, especially ones about which he felt apprehensive or ambivalent, with anyone but his wife. Long after the event, I asked Kia Lee and Koua Her, two Hmong interpreters who worked for the public health department, what they had thought of the matter. Kia is a woman and Koua a man. They both remembered it well. The parents not want to hurt the child.

They try very hard to be good parents. They lost many child in Laos and they love this child very very much. In Laos, the parent have one hundred percent responsibility over the child. How can you say you can take it away unless it is orphan?

The mother was crying and crying all the time. The father he was not crying, he was very angry. Hmong men do not cry even if you feel sad. In Laos, I never heard of this happening in my life. Because family members love the child and are part of the family, they can assist the parents in making decisions about the optimal actions. Respected family lineage leaders also assist parents in making difficult decisions about serious conditions.

But as physicians are not family members, they cannot make decisions for the child…. If the child dies, it is their fault; and how will they repay the parents? Indeed, how will they pay for the life? As long as doctors and parents continue to negotiate, even if they disagree, the conflict is confined to differences in belief systems.

The differences are about power. Doctors have power to call the police and to access state power which Hmong parents do not have. We do understand like anyone who is a human being. We are just refugees but we are human beings like any doctor too. Nao Kao Lee appeared in court on June 28, , accompanied by a public defender. No one remembers whether an interpreter was there as well.

The plan detailed in the Disposition of Case called for Lia to remain in foster care for six months, the minimum time that Neil estimated would be needed to stabilize her seizure disorder. Child Protective Services was to work with them to increase that likelihood. If the court did not decide within a year that Lia could safely return to her family, the Lees would permanently lose custody. It was the responsibility of CPS to find Lia an appropriate foster home. As we sat in the living room, Dee simultaneously showed me a small scrapbook full of pictures of Lia she keeps one for every child she has cared for and dispensed hugs to children of various sizes and races who wandered in and out.

After Lia arrived in the Korda house, she cried continuously for ten days. Because the Kordas spoke no Hmong, they had no way of comforting Lia verbally. The only thing that seemed to help was constant physical contact.

During the day, Dee simultaneously carried Lia in a backpack and her own youngest child, who was nine months old when Lia arrived, in a frontpack. When Lia was inconsolable, Dee, guessing correctly that she had never been weaned, breastfed her alongside her own baby.

Her family let her rule the roost at home because she was the special child, the princess. Oh, Lia could be ornery and strong-willed, but she was a sweetie too. She was so beautiful. She knew how to love and how to let people love her. We were blessed to have Lia. Cries constantly. Real disruptive, real anger. Will cry non-stop 2—5 a. Family is on edge.

Withholds food. Looks at Dee, takes off her panties and pees. Pooping on floor now. Bit herself on lip. Lia crying 4 days straight. Smearing feces. Intense crying again. Stripped herself, peed on the floor, went on a wave of destruction.

Had to sedate her. It was degrading. According to Dee, the new regimens had fewer side effects. The Korda children lent the Lee children bathing suits, and they all swam together in the backyard pool. Foua embroidered a nyias, a Hmong baby carrier, for Dee. After a few months went by, Dee started leaving her own baby with Foua when she took Lia to medical appointments—perhaps the first instance in the history of Child Protective Services that a foster mother has asked a legally abusive parent to baby-sit for her.

They never should have been in the system. Lia was the only one for whom she had ever recommended reunification. We missed her too. I do not know how to describe how we missed her. I cried every night when I got in the bed and she was not there. Four months after that, Nao Kao came home to find Foua pointing a knife at herself. He took the knife away. Child Protective Services considered placing the entire family in a psychiatric hospital, but decided against it.

Lia did not return home after six months, as the Lees had expected her to. The CPS petition against reunification noted: The parents were again instructed, via interpreter, on the proper method of administering the medications.

Color coded graphics were also utilized to reinforce the instructions. The parents stated they understood and indicated that they would follow through immediately. During this visit the parents were allowed to have the minor treated by a Shamin [sic] from the Hmong culture. Home calls by social workers were completed during the time the minor was at home and the medications were checked and it appeared as though the medications were being administered.

The parents report no seizures. Lia was returned to the foster home on September 9, and was hospitalized later that day. The medication vials were returned empty by the parents. Jeanine Hilt wrote in her case log that when Lia returned to the Kordas, her chest was covered with coin-rubbing lesions. The petition stated that language delays were noted, her motor skills regressed, she would not eat or maintain eye contact, and she engaged in repeated head- banging behavior.

Lia also became encopretic [fecally incontinent], engaged in a variety of self-abusive behaviors such as scratching and biting, could not sleep, was abusive to other children, and lost all ability to recognize safe situations. These regressive behaviors have continued. Jeanine spent dozens of hours working with Foua. Hutchison decided that Depakene, used alone, was the drug of choice. Neil and Peggy had considered Depakene but had decided against it because it can cause liver failure; once Lia was started on it, they wished they had prescribed it themselves.

Pediatric Depakene is a liquid that tastes pleasantly of cherries, and it was far easier to administer than the complicated combinations of bitter ground-up pills Lia had previously been taking. Jeanine felt that Foua was slowly learning to trust her and was making good progress. She did not develop a similarly intimate relationship with Nao Kao, who continued to fear that Lia would never come home. He was wary of Jeanine, but he was not angry at her. Intermarriage is rare among the Hmong.

At that time, I was ready to hit Sue, and I got a baseball bat right there. My son-in-law was with me, and he grabbed me and told me not to do it. And then Sue said that she had a lot of work to do, so she left. I told the supervisor, This person is not good. Do not bring her here anymore. Blood tests showed they had administered adequate levels of Depakene. The undersigned provided extensive supervision three times daily while the minor was in the home. Supervision decreased as the Lees demonstrated their willingness to maintain the medication regime….

The undersigned has worked with the Lees on maintaining a daily schedule including proper diet, naps, and discipline…. Lee are to be commended for their cooperation and positive efforts in working with the undersigned in spite of their divergent cultural beliefs. Lia returned home on April 30, Even if they agreed to meet me, I was assured that I would find them silent, obtuse, and almost pathologically lacking in affect.

I was ready to be discouraged. Take off your shoes. If a man offers to shake hands with you, indicate your lower status by placing your left hand under your right wrist in order to support the weight of his honored and important hand.

If you walk with a Hmong leader, stay behind him and to his left. Use an older male interpreter to compensate for your lack of status as a younger woman. It did not seem a promising sign that my friend Bill Selvidge, the doctor who had invited me to Merced to meet his Hmong patients, had bookshelves jammed with ethnographic monographs on the Ik, the!

Indeed, my first few Hmong encounters proved disastrous. Later, however, she married him. I also had bad luck with my first two interpreters. My experiences with them were identical. I would ask a question. The interpreter would translate. The Hmong I was questioning would talk animatedly to the interpreter for four or five minutes. Everything is a spiritual problem. The only danger is that they might think I do open- heart surgery.

That would certainly make them run in the other direction. Two of them became irreplaceable sources and, over time, valued friends. I have an anarchist sub-personality. I also believe that the long way around is often the shortest way from point A to point B. In my opinion, consensual reality is better than facts.

So I just threw it all out. Now I have only one rule. Before I do anything I ask, Is it okay? For one thing, she informed me that even though there were thousands of Hmong living in Merced, not a single American in town spoke Hmong. For another, in her opinion, someone who merely converted Hmong words into English, however accurately, would be of no help to me whatsoever. They teach me. You should go find yourself a cultural broker. Her name means Opium Poppy. I figured that if she was the third-most-poised Hmong woman in the United States, she had as good a chance as anyone of being able to deal with the Lees.

That turned out to be an advantage. If anything, I needed less status. Being belittled is the one thing no Hmong can bear. When Laos was under French colonial rule, the Hmong were required literally to crawl whenever they were in the presence of a Lao official, forbidden to raise their heads until they were acknowledged.

With May Ying at my side, I was not an official, not a threat, not a critic, not a person who was trying to persuade the Lees to do anything they did not wish to do, not even someone to be taken very seriously. My insignificance was my saving grace. Meeting a Hmong is like getting into a speakeasy: everything depends on who sent you. My appointment with the Lees had been arranged by Blia Yao Moua, one of the Hmong leaders to whom Sukey had introduced me, a man fortuitously unconnected to the hospital or any other American institution.

Within thirty seconds, I could see I was dealing with a family that bore little resemblance to the one the doctors had described.

The Lees struck me as smart, humorous, talkative, and energetic. I wish I could say that it was my skill as an interviewer that brought out these excellent qualities.

In truth, I repeatedly embarrassed May Ying by asking her to translate questions of such surpassing ignorance that after I got to know the Lees I began to feel my primary role in their household was as a source of mirth.

Once, when I asked in which part of their house in Laos the family had relieved themselves, Foua laughed so hard she almost fell off her bamboo stool. The Lees were a good-looking couple.

Foua looked about forty-five and Nao Kao about ten years older; they had never learned their birth dates. They were both short, and although neither was fat, they looked well-rooted, as if it would take a gale force wind, or maybe even an earthquake, to knock them over. For an outline of the Librivox audiobook production process, please see The LibriVox recording process.

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