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Our library is the biggest of these that have literally hundreds of thousands of different products represented. When you asked for a hug you could always get one from Lia. So you kind of liked her because she was a character, even though you hated her because she was so frustrating and she caused you so much grief. Lips pursed tightly to prevent this med given.

Spits well. And even when Lia was co-operative, Foua and Nao Kao were often uncertain about exactly what they were supposed to give her. Over time, her drug regimen became so complicated and underwent so many revisions that keeping track of it would have been a monumental task even for a family that could read English.

For the Lees, it proved to be utterly confounding. The anticonvulsant medication originally prescribed by Peggy Philp was Dilantin, which is commonly used to control grand mal seizures. Three weeks after her first MCMC admission, after Lia had a seizure in the hospital waiting room that appeared to be triggered by a fever, Peggy changed the prescription to phenobarbital, which controls febrile seizures better than Dilantin.

Lia seized several times during the next two weeks, so since neither drug appeared to work adequately alone, Peggy then prescribed them both simultaneously.

Consulting neurologists later prescribed two other anticonvulsants, Tegretol which was originally to be used along with both Dilantin and phenobarbital, and then just with phenobarbital and Depakene which was to be used in place of all the previous anticonvulsants. Because these medications were prescribed in varying combinations, varying amounts, and varying numbers of times a day, the prescriptions changed twenty-three times in less than four years.

Several of the medications were available in different forms, and were sometimes prescribed as elixirs all of which were pink or red and came in round bottles and sometimes as tablets almost all of which were white and came in round bottles. Foua and Nao Kao, of course, had no idea what the labels said. Even if a relative or the hospital janitor was on hand to translate when a bottle was handed to the Lees, they had no way of writing down the instructions, since they are illiterate in Hmong as well as English; and because the prescriptions changed so frequently, they often forgot what the doctors told them.

Measuring the correct doses posed additional problems. Liquids were difficult because the Lees could not read the markings on medicine droppers or measuring spoons. Pills were often no easier. At one point, when Lia was two, she was supposed to be taking four different medications in tablet form twice a day, but because each of the pills contained an adult dose, her parents were supposed to cut each of the tablets into fractions; and because Lia disliked swallowing the pills, each of those fractions had to be pulverized with a spoon and mixed with food.

If she then ate less than a full helping of the adulterated food, there was no way to know how much medicine she had actually consumed. This was a dismaying realization.

The only way to determine the optimal type and amount of anticonvulsant medications for Lia was to observe the level of her seizure activity and repeatedly test the medication level in her blood, but the test results were inconclusive unless the doctors knew exactly what was going into her system. Neither doctor could tell how much of their inability to get through was caused by what they perceived as defects of intelligence or moral character, and how much was caused by cultural barriers.

She was the first of a succession of public health nurses who were to visit the Lees over the next four years. Febrile seizures, noncompliant mother, noncompliant mother, noncompliant mother, noncompliant mother, noncompliant mother. When Lia was taking elixirs, they tried drawing lines on the plastic syringes or medicine droppers to mark the correct doses.

When she was taking pills, they tried posting charts on which they had drawn the appropriate pie-shaped fractions. They tried taping samples of each pill on calendars on which they had drawn suns and sunsets and moons. They tried putting the pills in plastic boxes with compartments for each day. There they would be, a little stack of bottles in the kitchen next to the tomatoes and onions, sort of like a decoration in the corner.

Because Lia was on such high doses, she had an appointment with Dr. Philp or Dr. Ernst almost every week and had a blood level drawn two or three days before and maybe another blood level two or three days afterwards, and there were so many changes that it was just totally mind-boggling. My general impression was that they really felt we were all an intrusion and that if they could just do what they thought best for their child, that child would be fine.

They were courteous and they were obstinate. They told us what we wanted to hear. Parents state infant is doing the same. Were unaware of appt. Peds clinic for today. Were confused about proper dosage of medicine and which to give….

Several meds in refrigerator that are outdated included Amoxil and Ampicillin. Also one bottle of medication with illegible label. Ernst contacted concerning correct dosage of Phenobarb and Dilantin. Correct administration demonstrated. Outdated medication discarded. Mother states she went to MCMC as scheduled for blood test, but without interpreter was unable to explain reason for being there and could not locate the lab. Is willing to have another appt. States infant has not had any seizures.

Have finished antibiotic. Are no longer giving Phenobarb because parents insist it causes diarrhea shortly after administration. Mother states she feels intimidated by MCMC complex but is willing to continue treatment there.

Agree to have continued care at Peds clinic. Home visit made with interpreter. Mother has now decided to give mg. Phenobarb at night. Mother seems very agitated. Father out of house for rest of day—shopping. Assured mother that child can be seen in Peds clinic Monday even without the Medi-Cal card. Home visit by interpreter to discuss childs care with father. Mother states they just returned from hospital that AM…. Diagnosis for hospitalization unknown to mother but antibiotic prescribed.

Their faith in medicines had not been strengthened by two routine immunizations Lia had received against diphtheria, pertussis, and tetanus, to which, like many children, she had reacted with a fever and temporary discomfort. In some cases phenobarbital can cause hyperactivity—it may have been responsible for the riotous energy the nurses always noticed when Lia was hospitalized—and, in several recent studies, it has been associated with lowered I.

Dilantin can cause hair to grow abnormally all over the body, and gum tissue to bleed and puff out over the teeth. Too much phenobarbital, Dilantin, or Tegretol can cause unsteadiness or unconsciousness.

Doctors are used to hearing patients say that drugs make them feel bad, and indeed the unpleasant side effects of many medications are one of the main reasons that patients so often stop taking them. Doctors who deal with the Hmong cannot take this attitude for granted. John Aleman, a family physician in Merced, once hospitalized a Hmong infant with severe jaundice. After two or three samples, the parents said their baby might die if any more blood was removed.

The doctor explained through an interpreter that the body is capable of manufacturing new blood, and he poured one cc of water into a teaspoon to demonstrate what an insignificant amount was being taken. They said if the doctor drew any more blood against their will, they would both commit suicide. Fortunately, at this point Dr. The baby had the blood tests and was successfully treated with phototherapy. His parents, both teenagers who had attended American high schools and spoke and read English fairly well, consented, though reluctantly, to the surgical removal of the affected testis.

She handed the parents a piece of paper on which she had typed the names of the drugs he would receive and their possible side effects. Her predictions turned out to be accurate. Arnie, who had appeared perfectly healthy after his surgery, lost all his shiny black hair within three weeks after his first cycle of chemotherapy, and every time the drugs were administered, he vomited.

I say, Wait for my husband. I say, Please that you go away. I hold my son. I hold him so tight. I say, Give my son back. Two police, they hold my hand behind my back. I am scared. My two daughters are crying. The police hold my hand, they take my son away! I scream and cry. They were two long guns. We bought them to shoot squirrels and deer, not to shoot people. I just yell, Please bring my son back to me.

I say, Just bring! I want to hold my son! Finally some police officers brought Arnie back from the hospital, and when Dia Xiong saw him, she dropped the guns and was driven, in handcuffs, to the psychiatric unit of a local hospital.

She was released the next day, and no criminal charges were filed against her. Arnie is still in remission today. It is likely that the only Western drugs Foua and Nao Kao had encountered in Asia were fast-acting antibiotics. I felt they really cared for Lia, and they were doing the best, the absolute best they knew how as parents, to take care of the kid. That is what I felt about them. It was very foreign to me that they had the ability to stand firm in the face of expert opinion. And the other thing that was different between them and me was that they seemed to accept things that to me were major catastrophes as part of the normal flow of life.

For them, the crisis was the treatment, not the epilepsy. The parents report that they had discontinued the medications about 3 months ago because the patient was doing so well. At p. He therefore had to deal on his own with the most severe episode of status epilepticus Lia had yet suffered.

He administered two more massive doses of phenobarbital. First Dan gave her mouth-to-mouth resuscitation, and when she failed to resume breathing on her own, he decided that a breathing tube had to be placed down her trachea. This time I saw what I needed to see and the tube went right in and it worked perfectly and I felt really good. I thought, well, I guess I am becoming a doctor.

I remember that they were very upset about that. I remember that the mother just had a very displeased look on her face. She regained consciousness there, and was able to breathe on her own after twenty-four hours on a respirator. Lia spent nine days in Fresno, spiking high temperatures from aspiration pneumonia and gastroenteritis, but did not seize again. Through an English-speaking cousin who accompanied Foua and Nao Kao to Fresno, the admitting resident was told that Lia had been off medications for one week rather than the three months recorded by Dan Murphy because the prescription had run out and the family had not refilled it.

It is not surprising that a child who had seized as frequently and severely as Lia was beginning to show the first signs of retardation, but Neil and Peggy found the situation particularly tragic because they considered it preventable. Neil and Peggy perceived Lia as being more retarded though still only mildly so than the visiting public health nurses did. Unfortunately, the Lees had now decided that they liked phenobarbital, disliked Dilantin, and were ambivalent about Tegretol.

The mother brought a large sack full of medication bottles and on closer examination by myself there were 3 half empty bottles of Tegretol. The mother stated that she was unaware that these bottles were Tegretol. In addition, the mother also was unable to identify the Dilantin bottle and gave that bottle to me and said that she did not want it at home. On rereading this note many years later, Neil said he could still remember the rage he had felt when he wrote it.

A handful of times, Neil gave Foua a hug while Lia was seizing, but most of the time, while Lia was between the ages of eighteen months and three and a half years, he was too angry to feel much sympathy toward either of her parents. It was like banging your head against a wall constantly and not making any headway. There was the frustration of the nighttime calls and the length of time it took and the amount of energy and sorrow and lack of control.

I mean, every time I saw Lia I would just, you know, it was like—ohhhhh, you would just get so frustrated! When she came to the emergency room in status there would be sort of like a very precipitous peak of anger, but it was quickly followed by the fear of having to take care of a horribly sick child who it was very difficult to put an IV in. From our own fear. No other pediatricians practicing in Merced at that time were willing to accept Medi-Cal patients.

The Lees also never showed their doctors the kind of deference reflexively displayed by even their most uncooperative American patients. The worst aspect of the case was that as conscientious physicians and dedicated parents, they found it agonizing to watch Lia, as it would have been for them to watch any child, fail to receive the treatment they believed might help her lead a normal life.

And it seemed as if the situation would never end. However frustrated they were, they never considered abandoning the case. Unless Lia died, they could see themselves driving to the emergency room in the middle of the night until she was grown up and had graduated to the care of an internist, with whom they already felt an anticipatory bond of sympathy.

In June of , Neil and Peggy found out that Foua was pregnant again. They were appalled. This baby would be number fifteen; eight had survived.

We were just dreading how this baby might turn out, that it might have Down syndrome and heart problems and that we were going to have to deal with two sick kids in this family.

Just what we needed. Not that she would have aborted anyway. She continued to breast-feed Lia throughout her pregnancy. On November 17, , when Lia was two and a half, Pang Lee—a healthy, vigorous, completely normal baby girl—was born. After the birth, Foua breast-fed both Lia and Pang. In it, he also wrote that because of poor parental compliance regarding the medication this case obviously would come under the realm of child abuse, specifically child neglect….

It is my opinion that this child should be placed in foster home placement so that compliance with medication could be assured. It was also said that Hmong women were forced into slavery, forced to have sex with American men, and forced to have sex with animals.

Dinosaurs lived in America, as well as ghosts, ogres, and giants. With all this to worry about, why did the 15, Hmong who gathered on the Ban Vinai soccer field to voice their deepest fears about life in the United States choose to fixate on doctors? A year after I first read the account of that gathering, as I was attempting to deal out a teetering pile of notes, clippings, and photocopied pages from books and dissertations into several drawerfuls of file folders, I had a glimmering of insight.

There were hundreds of pages whose proper home I was at a loss to determine. Should they go in the Medicine folder? The Mental Health folder? The Animism folder? The Shamanism folder? The Social Structure folder? I hovered uncertainly, pages in hand, and realized that I was suspended in a large bowl of Fish Soup. Medicine was religion. Religion was society. Society was medicine. The Hmong carried holism to its ultima Thule. As my web of cross-references grew more and more thickly interlaced, I concluded that the Hmong preoccupation with medical issues was nothing less than a preoccupation with life.

And death. And life after death. Not realizing that when a man named Xiong or Lee or Moua walked into the Family Practice Center with a stomachache he was actually complaining that the entire universe was out of balance, the young doctors of Merced frequently failed to satisfy their Hmong patients. How could they succeed? All of them had spent hundreds of hours dissecting cadavers, and could distinguish at a glance between the ligament of Hessel-bach and the ligament of Treitz, but none of them had had a single hour of instruction in cross-cultural medicine.

To most of them, the Hmong taboos against blood tests, spinal taps, surgery, anesthesia, and autopsies—the basic tools of modern medicine—seemed like self-defeating ignorance.

They had no way of knowing that a Hmong might regard these taboos as the sacred guardians of his identity, indeed, quite literally, of his very soul. What the doctors viewed as clinical efficiency the Hmong viewed as frosty arrogance. And no matter what the doctors did, even if it never trespassed on taboo territory, the Hmong, freighted as they were with negative expectations accumulated before they came to America, inevitably interpreted it in the worst possible light.

Whenever I talked to Hmong people in Merced, I asked them what they thought of the medical care they and their friends had received. They do what they want to do.

Doctor want to look inside the woman body. She do not want doctor to see her body. But this country there is the rule. If you want to stay here you must let doctor examine the body.

They feel, maybe doctor just want to study me, not help my problems. They scary this. If they go one time, if they not follow appointment and do like doctor want, doctor get mad.

Doctor is like earth and sky. He think, you are refugee, you know nothing. Other people who are rich, they treat them really well and they do not wait. She say, no, I just need medication for pain only. And he say, I know more than you do. He completely ignore what she ask. But he say to me, I already sign everything and the doctor going to send me to jail if I change my mind. The student doctors just want to experiment on the poor people and they kill the poor people.

He takes people that are sick, he produces people that are healthy. If he do not produce, his economic will be deficit. But the Hmong, he will want the doctor to calmly explain and comfort him. That does not happen. I do not blame the doctor. It is the system in America. Nonetheless, their version of reality fails to match that of their doctors pretty much across the board. The young residents are all M. The Hmong spend a long time in the waiting area, but so does everyone else. Patients who change their minds about surgery do not go to jail.

The doctors do not experiment on their patients. Neither do they kill them, though their patients do sometimes die, and are more likely to do so if, like the Hmong, they view the hospital as a dreaded last resort to be hazarded only when all else fails. The residents may be exhausted since their shifts are up to twenty-four hours long, and until recent years were up to thirty-three hours long ; they may be rushed since many clinic appointments are only fifteen minutes long ; but they are not—and they know they are not —greedy or spiteful.

Most of them have chosen the field of family practice, which is the lowest-paying of all medical specialties, for altruistic reasons. It was he who first told me about the Hmong of Merced, whom he described as being such challenging patients that some of his fellow doctors suggested the preferred method of treatment for them was high-velocity transcortical lead therapy. He had politely declined.

When they undressed for an examination, the women were sometimes wearing Jockey shorts and the men were sometimes wearing bikini underpants with little pink butterflies. 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. Traces the history of the United States from the arrival of the first Indian people to the present day. Maps on lining papers Includes bibliographies and index Summary: Traces the history of the United States from the arrival of first Indian people to the present day. The 14th edition places an even greater emphasis on the global context of American history through a new feature, "Thinking Globally.

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