✪✪✪ Elizabeth Hutchison Chapter One Summary

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Elizabeth Hutchison Chapter One Summary



She did not develop a similarly intimate relationship with Nao Kao, who continued to Battle Royale Analysis that Lia would never come home. When babies or small children go on an outing, their parents may call loudly to their souls before the A Career As A Healthcare Administrator Essay returns home, to make sure that none remain behind. I remember Womens Role In Religion the mother just had a very displeased look on her face. Three weeks after her first MCMC admission, after Lia had a seizure in the hospital waiting room that appeared Elizabeth Hutchison Chapter One Summary be triggered by a fever, Peggy changed Reduced Lunch Case Study prescription to phenobarbital, which controls febrile Elizabeth Hutchison Chapter One Summary better than Dilantin. She said that Elizabeth Hutchison Chapter One Summary partnership Elizabeth Hutchison Chapter One Summary a sharp focus on ending violence against children. Elizabeth Hutchison Chapter One Summary had been the influential Chairman of the Budget Committee Elizabeth Hutchison Chapter One Summary was among the leading candidates to replace Mitchell as Democratic Floor Leader. He Elizabeth Hutchison Chapter One Summary that Elizabeth Hutchison Chapter One Summary can Outdated Issues In The Scarlet Letter various sacred texts that demand respect and human rights for all people; however, LGBT Elizabeth Hutchison Chapter One Summary are not Elizabeth Hutchison Chapter One Summary included in the Elizabeth Hutchison Chapter One Summary about human rights.

A Room of One's Own (Chapter One) by Virginia Woolf

Muchina said that social norms and religious moral values and beliefs are intertwined and that when social norms and religious traditions and practices come together, they significantly affect the way men and women interact in society, homes, and institutions. As an example, she explained that due to cultural and religious gender norms, African women and girls lack the social and economic power to control their own bodies.

She said that all religions today maintain male social dominance within social structures, with religious texts encouraging the exclusion of women from leadership in the family, church, and society, influencing the way people behave toward each other and how women are treated in their homes, in society, and at work. Muchina stressed the need to promote theology to change religious institutions in a manner that ends the negative effects on women and girls.

She noted that religious leaders have a platform to address two critical areas: teaching men and boys to promote gender equality and ending GBV. Kapya John Kaoma, a pastor, human rights activist, and visiting researcher at Boston University, spoke about the global impact of religion and the significance of religion in the human experience. He said that while religious beliefs are diverse across the globe, there is a common disregard for and discrimination toward lesbian, gay, bisexual, and transgender. LGBT persons. Another challenge he mentioned is the assumption in America that religion does not play a large role in everyday life, although it is a part of all cultures and communities. To bring about social change, he said, there is a need to understand the role of religion and its influence on certain actions and to understand how to transform these actions and make positive changes within the confines of a specific religion.

He said that one can find various sacred texts that demand respect and human rights for all people; however, LGBT persons are not always included in the conversation about human rights. Kaoma stressed the need to speak out against violence experienced globally by LGBT persons and the need for an increased number of women in leadership positions in faith communities. He said that through using group education, Program H focuses on critical reflections about gender norms combined with youth-led activism or campaigns.

He explained how Program H helps men and boys 1 learn about gender norms and attitudes and develop new attitudes and skills, 2 rehearse within the safe environment of group education, 3 internalize attitudes and norms, 4 live in a gender-equitable way in life and relationships, and 5 achieve positive outcomes in gender equity and their own health. Marques described how this is rooted in supportive influences and structure on the individual level using peer support, role modeling, and action through advocacy and the systems level policy, services, institutions and how the outcomes from nine quasi-experimental impact evaluations in 8 countries over a year period found that systematically, after the intervention, there was less support for gender-inequitable attitudes and increased support for gender-equitable attitudes.

The study also found that changes in attitudes were strongly associated with changes in self-reported behaviors and that gender-equitable attitudes were associated with a greater knowledge and awareness of health risks. Gannon Gillespie of Tostan provided an overview of the Community Empowerment Program CEP , a 3-year, locally driven, community-engaged education program that is rooted in human rights. He said that the CEP facilitator is local, trained in the curriculum, and culturally congruent with the community and is responsible for creating a space safe for dialogue and for how the host community agrees to host the facilitator, participate, and build or repurpose a classroom.

He explained that in years 2 and 3, the program expands to include lessons in literacy, math, micro-credit, management, and small projects. The model grows as each classroom participant adopts another learner outside of the class and creates a community-based learning environment. Starting off the discussion, Heise said that there is a need to create partnerships in which people understand the imperatives of working together with researchers to optimize programs and then evaluate them. Concerning partnerships, Marques said that this is an opportunity to look at the intersection of public health and the social justice field; the evidence exists, she said, to demonstrate changing attitudes and beliefs, which can, to some extent, affect health and behavior.

Marques added that this is an opportunity for nongovernmental organizations and researchers to say that here is a viable alternative, a new way to approach research by community engagement and leadership. Concerning evaluation data, Gillespie said that the CEP participants are talking about human rights in concrete ways and that he has found increased participation of women in the various levels of decision making. Chronic violence is a complex problem affecting at least one-quarter of the global population, said Tani Adams, coordinator of the International Working Group on Chronic Violence and Human Development.

She said that exposure to chronic violence weakens the capacity of individuals and families to develop and live healthy lives, including having a negative. She also proposed the following new approaches to violence prevention: strengthen primary networks, enhance the capacity of community through collective learning and strength-based strategies, address chronic and collective trauma through a range of programmatic efforts, focus on human responsibilities over human rights, implement efforts to protect those working to end violence, and identify opportunities for real structural change by looking at political reform and economic development.

He added that due to the high levels of exposure to violence, many communities are de-sensitized to violence. He provided a description of the Peace Management Initiative PMI , which works in Jamaica to interrupt community violence and reduce trauma through community safety planning and empowerment, gang demobilization, healing and reconciliation, and community engagement to change values.

He explained how PMI is setting up an incentive-based framework composed of rules and terms of agreement between groups in conflict that also uses incentive-based awards to encourage a community and groups within the same community to reduce levels of violence in their own local spaces. He also described how PMI actively engages the community to address community safety planning and empowerment, getting the wider community to be part of the process and the solution.

Hutchinson described the successful work in Browns Town, where deaths due to gang violence dropped from 50 between and to fewer than 25 between and He credited the community for taking charge of its own safety and for being more open and accessible to development work. They are two and a half more times more likely to be sexually assaulted or raped than other women, General said, and Alaska Native women report rates of domestic violence up to 10 times the national average and physical assault victimization rates up to 12 times higher. General added that the murder rate on some reservations is 10 times the national average and that native women and children are especially vulnerable to human trafficking.

These disproportionately high rates of violence are due in part, she said, to a U. She outlined advocacy efforts to ensure that the decisions and commitments outlined within the United Nations Declaration on the Rights of Indigenous Peoples , which includes the right of self-determination and the rights and special needs of indigenous women and children, are fulfilled. She said that international advocacy is critical and that the international community must respond to the epidemic of violence against indigenous women in the United States and everywhere, including advocating for mechanisms to ensure that perpetrators of violence against indigenous women and children are brought to justice.

Tomaszewski asked how one could use the idea of community connection to engage youth and encourage them to listen and connect to others in the community. Cervantes commented on the role of the arms trade and illegal trafficking of guns as a critical element of the cycle of violence. Gun trafficking, according to Adams, needs a systems-level change in how data are collected. Referencing the.

Referring to the importance of community connection, Hutchinson stressed having communities make interventions. Hutchison said that PMI uses a trauma response unit that goes into a community to the scene of violence and treats the victims and perpetrators and community as part of that same response while treating the whole community. He presented evidence that LGBTQ youth in the United States face higher instances of family rejection, bullying and mistreatment in school, victimization, and criminalization and are disproportionately represented in the child welfare and juvenile justice systems; they also make up as much as 40 percent of the homeless youth population.

He added that there is overwhelming scientific evidence that demonstrates that conversion therapy, especially when it is practiced on young people, is neither medically nor ethically appropriate, and can cause substantial harm. Kennedy outlined several approaches that could help end the use of conversion therapy, such as ending discrimination against and negative social attitudes toward LGBTQ individuals and identities; training and educating behavioral health providers; and using legislative, regulatory, and other legal efforts to stop conversion therapy as well as discrimination based on sexual orientation, gender, or gender identity.

He described how at UNAIDS the discussion is framed through the lens of HIV, as the work to prevent violence and discrimination throughout the HIV outbreak has provided lessons that can be applied in efforts to improve health and well-being. According to the map there are 75 countries in which adult same-sex consensual sexual conduct is considered a crime or an LGBT person has been criminally prosecuted under other laws; in 7 of these countries same-sex sexual conduct is punishable by death. Doing the mapping exercise, Burzynski said, provided a number of lessons about the impact of and response to violence and discrimination aimed at LGBT persons: social transformation is under way in all countries; discussions about same-sex sexual relations are occurring globally; there are multi-layered and complex relationships among LGBT people; conflation of misinformation and fact must be confronted, or else misinformation becomes reality and truth; criminalization of LGBT behaviors matters; humanizing LGBT people makes a difference; allies, partnerships, and collaborators are critical; and leadership matters.

Burzynski referred to the historic United Nations statement on ending violence and discrimination against LGBT and intersex people. Regarding creating connections among and within communities, Kennedy urged that more opportunities be created for communities to seek out dialogues on these issues, as it takes some time to unlearn discrimination and misinformation and to learn new behaviors. Kennedy then highlighted the Family Acceptance Project, an evidence-based practice that works with LGBTQ youth who experience family rejection and with their family members to create a supportive family environment.

Susan Markham of USAID spoke about the stereotypes, history, and current situation for women as victims and also about the role of women as perpetrators of violence, fighters, mediators, and peacemakers. Markham said that there is often a combination of factors that drive people toward considering engaging in violent extremism, including deficiencies in governance. She said that USAID is examining how targeted investments in women, peace, and security can address security-related objectives by strengthening the role of women and youth in political and peace processes at the community level.

Markham highlighted two critical documents. The first was the National Action Plan on Women, Peace, and Security, 2 and she emphasized its commitment to community level engagement. Naureen Chowdhury Fink of the Global Center on Cooperative Security spoke remotely on counter-terrorism CT and countering violent extremism CVE , and she noted that CT is much more associated with large responses to terrorism, while CVE is more involved with prevention and working with communities and relies on a combination of hard power and soft power. A major change in the approach to CVE, Fink said, has been the inclusion of community engagement, of gender, the development of preventive approaches that use education and strategic communication, and the shift in viewing civil society activism as a means of developing a much more sustainable and locally resonant approach to terrorism prevention.

She said that at the policy level she has noticed the twin approach getting more positive responses. Workshop participant Markham began the panel discussion by asking about the pros and cons of having CT separate from CVE instead of having them together and also asking if there is any specific gender impact from separating them. Fink said that combining CT and CVE is beneficial, as CT requires a balanced approach, but he also noted a potential drawback of pairing them: when the two are not done in a coordinated manner, there is a danger that CT will negatively affect CVE.

For example, she said, a real concern is that when CT and CVE efforts are present in the same community and may or may not be known to one another and, at the same time, community members are encouraged to come forward to share their knowledge and expertise and share the threats they might identify, there can be a response from law enforcement that is disproportionate and discourages further engagement and cooperation from community members. Bissell said that the partnership is committed to, yet challenged by, having children and youth engaged in a way that is transparent and democratic and that ensures that participants are safe while addressing some very dangerous issues.

She provided an overview of what the partnership hopes to do over the next 5 years: ensure that violence. She said that the partnership has a sharp focus on ending violence against children. McCaw, the moderator, opened the discussion by noting the life burden of violence and the intersectionality of all forms of violence across communities and suggesting that there are opportunities to think through strategies that are being applied with a specific community that might provide ideas or information transferable to another setting or community.

Several panelists addressed faith communities. Heise said that researchers may be reluctant to engage faith communities due to discomfort or uncertainty about how to challenge religious ideas and concerns about bigotry. Muchina added that there is a need for additional research on social norms, and she said that the research must include the community if one is to understand the impact of religion on social norms. Panelists also discussed the power of the lived experience, community-level engagement, and meeting the growing needs of communities affected by violence. Burzynski spoke of working with people who experience violence and discrimination daily and of the importance of breaking down silos and finding local solutions, while Adams stressed the importance of supporting an intersectoral approach.

Muchina said that the greatest challenge right now is providing mental services for young people because some of them are living with HIV and they are becoming young adults with very few agencies dealing with mental health or the impact of violence for either the perpetrators or victims of violence. She added that measurement is important and that using similarly defined measurements is key. Abrahams, N. American Journal of Public Health — Bicchieri, C.

Brookmeyer, K. Henrich, M. Adolescents who witness community violence: Can parent support and prosocial cognitions protect them from committing violence? Child Development — Krug, E. Dahlberg, J. Mercy, A. Zwi, and R. World violence report on health. Geneva, Switzerland: World Health Organization. Lansford, J. Cultural norms for adult corporal punishment of children and societal rates of endorsement and use of violence. Parenting: Science and Practice — Raising Voices. Raising voices: — strategy.

Read-Hamilton, S. The Communities Care programme: Changing social norms to end violence against women and girls in conflict-affected communities. HHS Publication No. SMA Changing cultural and social norms supportive of violent behaviour Series of briefings on violence prevention: The evidence. The statements made are those of the rapporteur or individual workshop participants and do not necessarily represent the views of all workshop participants; the planning committee; or the National Academies of Sciences, Engineering, and Medicine. Only after the soul is properly dressed in the clothing in which it was born can it continue its dangerous journey, past murderous dabs and giant poisonous caterpillars, around man-eating rocks and impassable oceans, to the place beyond the sky where it is reunited with its ancestors and from which it will someday be sent to be reborn as the soul of a new baby.

If the soul cannot find its jacket, it is condemned to an eternity of wandering, naked and alone. Because the Lees are among the , Hmong who have fled Laos since their country fell to communist forces in , they do not know if their house is still standing, or if the five male and seven female placentas that Nao Kao buried under the dirt floor are still there. They believe that half of the placentas have already been put to their final use, since four of their sons and two of their daughters died of various causes before the Lees came to the United States. Her placenta was buried under their hut. Several of the doctors have acquiesced, packing the placentas in plastic bags or take-out containers from the hospital cafeteria; most have refused, in some cases because they have assumed that the women planned to eat the placentas, and have found that idea disgusting, and in some cases because they have feared the possible spread of hepatitis B, which is carried by at least fifteen percent of the Hmong refugees in the United States.

Foua never thought to ask, since she speaks no English, and when she delivered Lia, no one present spoke Hmong. When Lia was born, at p. There were no family members in the room. Thueson even if she had known. Then she was placed in a steel and Plexiglas warmer, where a nurse fastened a plastic identification band around her wrist and recorded her footprints by inking the soles of her feet with a stamp pad and pressing them against a Newborn Identification form. After that, Lia was removed to the central nursery, where she received an injection of Vitamin K in one of her thighs to prevent hemorrhagic disease; was treated with two drops of silver nitrate solution in each eye, to prevent an infection from gonococcal bacteria; and was bathed with Safeguard soap.

Not a single admitting clerk ever appears to have questioned the latter date, though it would imply that Foua gave birth to Lia at the age of Foua is quite sure, however, that October is correct, since she was told by her parents that she was born during the season in which the opium fields are weeded for the second time and the harvested rice stalks are stacked. She invented the precise day of the month, like the year, in order to satisfy the many Americans who have evinced an abhorrence of unfilled blanks on the innumerable forms the Lees have encountered since their admission to the United States in Nao Kao Lee has a first cousin who told the immigration officials that all nine of his children were born on July 15, in nine consecutive years, and this information was duly recorded on their resident alien documents.

Since Foua cannot read and has never learned to recognize Arabic numerals, it is unlikely that she followed these instructions. However, she had been asked for her signature so often in the United States that she had mastered the capital forms of the seven different letters contained in her name, Foua Yang. In Laos, the clan name came first, but most Hmong refugees in the United States use it as a surname. However, it has the unique distinction of looking different each time it appears on a hospital document. Her doubts about MCMC in particular, and American medicine in general, would not begin to gather force until Lia had visited the hospital many times.

On this occasion, she thought the doctor was gentle and kind, she was impressed that so many people were there to help her, and although she felt that the nurses who bathed Lia with Safeguard did not get her quite as clean as she had gotten her newborns with Laotian stream water, her only major complaint concerned the hospital food. She was surprised to be offered ice water after the birth, since many Hmong believe that cold foods during the postpartum period make the blood congeal in the womb instead of cleansing it by flowing freely, and that a woman who does not observe the taboo against them will develop itchy skin or diarrhea in her old age.

Foua did accept several cups of what she remembers as hot black water. The black water was the only MCMC- provided food that passed her lips during her stay in the maternity ward. Each day, Nao Kao cooked and brought her the diet that is strictly prescribed for Hmong women during the thirty days following childbirth: steamed rice, and chicken boiled in water with five special postpartum herbs which the Lees had grown for this purpose on the edge of the parking lot behind their apartment building.

This diet was familiar to the doctors on the Labor and Delivery floor at MCMC, whose assessments of it were fairly accurate gauges of their general opinion of the Hmong. The Lees chose to give their daughter a Hmong name, Lia. Her name was officially conferred in a ceremony called a hu plig, or soul-calling, which in Laos always took place on the third day after birth. Until this ceremony was performed, a baby was not considered to be fully a member of the human race, and if it died during its first three days it was not accorded the customary funerary rites. This may have been a cultural adaptation to the fifty-percent infant mortality rate, a way of steeling Hmong mothers against the frequent loss of their babies during or shortly after childbirth by encouraging them to postpone their attachment.

In the United States, the naming is usually celebrated at a later time, since on its third day a baby may still be hospitalized, especially if the birth was complicated. Although the Hmong do not agree on just how many souls people have estimates range from one to thirty-two; the Lees believe there is only one , there is a general consensus that whatever the number, it is the life-soul, whose presence is necessary for health and happiness, that tends to get lost. A life-soul can become separated from its body through anger, grief, fear, curiosity, or wanderlust.

The life-souls of newborn babies are especially prone to disappearance, since they are so small, so vulnerable, and so precariously poised between the realm of the unseen, from which they have just traveled, and the realm of the living. Some Hmong are careful never to say aloud that a baby is pretty, lest a dab be listening. Hmong babies are often dressed in intricately embroidered hats Foua made several for Lia which, when seen from a heavenly perspective, might fool a predatory dab into thinking the child was a flower. They may wear silver necklaces fastened with soul-shackling locks.

When babies or small children go on an outing, their parents may call loudly to their souls before the family returns home, to make sure that none remain behind. Hmong families in Merced can sometimes be heard doing this when they leave local parks after a picnic. None of these ploys can work, however, unless the soul-calling ritual has already been properly observed. There were so many guests, all of them Hmong and most of them members of the Lee and Yang clans, that it was nearly impossible to turn around. Foua and Nao Kao were proud that so many people had come to celebrate their good fortune in being favored with such a healthy and beautiful daughter.

If the signs had been inauspicious, the soul-caller would have recommended that another name be chosen. After the reading of the auguries, the chickens were put back in the cooking pot. The guests would later eat them and the pig for dinner. Foua and Nao Kao promised to love her; the elders blessed her and prayed that she would have a long life and that she would never become sick. The second student to stand up in front of the class was a young Hmong man. His chosen topic was a recipe for la soupe de poisson: Fish Soup.

To prepare Fish Soup, he said, you must have a fish, and in order to have a fish, you have to go fishing. In order to go fishing, you need a hook, and in order to choose the right hook, you need to know whether the fish you are fishing for lives in fresh or salt water, how big it is, and what shape its mouth is. Continuing in this vein for forty-five minutes, the student filled the blackboard with a complexly branching tree of factors and options, a sort of piscatory flowchart, written in French with an overlay of Hmong. He also told several anecdotes about his own fishing experiences. He concluded with a description of how to clean various kinds of fish, how to cut them up, and, finally, how to cook them in broths flavored with various herbs.

When the class period ended, he told the other students that he hoped he had provided enough information, and he wished them good luck in preparing Fish Soup in the Hmong manner. Actually, according to Dab Neeg Hmoob: Myths, Legends and Folk Tales from the Hmong of Laos, a bilingual collection edited by Charles Johnson, those two fables go back only to the second beginning of the world, the time after the universe turned upside down and the earth was flooded with water and everyone drowned except a brother and sister who married each other and had a child who looked like an egg, whom they hacked into small pieces.

If I were Hmong, I might feel that what happened when Lia Lee and her family encountered the American medical system could be understood fully only by beginning with the first beginning of the world. But since I am not Hmong, I will go back only a few hundred generations, to the time when the Hmong were living in the river plains of north-central China. For as long as it has been recorded, the history of the Hmong has been a marathon series of bloody scrimmages, punctuated by occasional periods of peace, though hardly any of plenty. Over and over again, the Hmong have responded to persecution and to pressures to assimilate by either fighting or migrating—a pattern that has been repeated so many times, in so many different eras and places, that it begins to seem almost a genetic trait, as inevitable in its recurrence as their straight hair or their short, sturdy stature.

Most of the conflicts took place in China, to which the prehistoric ancestors of the Hmong are thought to have migrated from Eurasia, with a stopover of a few millennia in Siberia. The Chinese viewed the Hmong as fearless, uncouth, and recalcitrant. It was a continuing slap in the face that they never evinced any interest in adopting the civilized customs of Chinese culture, preferring to keep to themselves, marry each other, speak their own language, wear their own tribal dress, play their own musical instruments, and practice their own religion.

They never even ate with chopsticks. The Hmong viewed the Chinese as meddlesome and oppressive, and rebelled against their sovereignty in hundreds of small and large revolts. Though both sides were equally violent, it was not a symmetrical relationship. The Hmong never had any interest in ruling over the Chinese or anyone else; they wanted merely to be left alone, which, as their later history was also to illustrate, may be the most difficult request any minority can make of a majority culture. The earliest account of Hmong-Chinese relations concerns a probably mythical, but emotionally resonant, emperor named Hoang-ti, who was said to have lived around B.

Hoang-ti decided that the Hmong were too barbaric to be governed by the same laws as everyone else, and that they would henceforth be subject to a special criminal code. The Hmong rebelled; the Chinese cracked down; the Hmong rebelled again; the Chinese cracked down again; and after a few centuries of this the Hmong gradually retreated from their rice fields in the valleys of the Yangtze and Yellow rivers, moving to more and more southerly latitudes and higher and higher altitudes. Since the Hmong practiced polygyny, and kings had an especially large number of wives, the pool of candidates was usually ample enough to afford an almost democratically wide choice.

The Hmong kingdom lasted for five hundred years before the Chinese managed to crush it. Most of the Hmong migrated again, this time toward the west, to the mountains of Kweichow and Szechuan. More insurrections followed. Some Hmong warriors were known for using poisoned arrows; others went into battle dressed in copper and buffalo- hide armor, carrying knives clenched between their teeth in addition to the usual spears and shields. Some Hmong crossbows were so big it took three men to draw them.

In the sixteenth century, in order to keep the Hmong from venturing outside Kweichow, the Ming dynasty constructed the Hmong Wall, a smaller version of the Great Wall of China that was one hundred miles long, ten feet tall, and manned by armed guards. For a time the Hmong were contained, but not controlled. The Chinese stand in fear of them; so that after several trials which they have made of their prowess, they have been forced to let them live at their own liberty. In or thereabouts, hundreds of Hmong warriors killed their wives and children, believing they would fight more fiercely if they had nothing to lose. It worked for a while. Thus unencumbered, they seized several passes, severing Chinese supply lines, before they themselves were all killed or captured.

In , a small army of Hmong squashed a large army of Chinese in eastern Kweichow by rolling boulders on their heads while they were marching through a narrow gorge. After many months of sieges and battles, the general told Sonom, the Hmong king of greater Kintchuen, that if he surrendered, his family would be spared. Sonom swallowed this story. When he and his family were brought before the emperor, they were chopped into bits, and their heads were placed in cages for public exhibition. It is, perhaps, no surprise that by the beginning of the nineteenth century, a large number of Hmong decided that they had had enough of China.

Not only were they fed up with being persecuted, but their soil was also getting depleted, there was a rash of epidemics, and taxes were rising. Although the majority of the Hmong stayed behind—today there are about five million Hmong in China, more than in any other country— about a half million migrated to Indochina, walking the ridgelines, driving their horses and cattle ahead of them, carrying everything they owned.

For the most part, they built their villages in places where no one else wanted to live. But if the local tribes objected or demanded tribute, the Hmong fought back with flintlock blunderbusses, or with their fists, and usually won. His followers blew away large numbers of colonial soldiers with ten-foot- long cannons made from tree trunks. Only after the French granted them special administrative status in , acknowledging that the best way to avoid being driven crazy by them was to leave them alone, did the Hmong of Laos, who constituted the largest group outside China, settle down peaceably to several unbroken decades of farming mountain rice, growing opium, and having as little contact as possible with the French, the lowland Lao, or any of the other ethnic groups who lived at lower elevations.

The history of the Hmong yields several lessons that anyone who deals with them might do well to remember. Among the most obvious of these are that the Hmong do not like to take orders; that they do not like to lose; that they would rather flee, fight, or die than surrender; that they are not intimidated by being outnumbered; that they are rarely persuaded that the customs of other cultures, even those more powerful than their own, are superior; and that they are capable of getting very angry. Whether you find these traits infuriating or admirable depends largely on whether or not you are trying to make a Hmong do something he or she would prefer not to do.

Those who have tried to defeat, deceive, govern, regulate, constrain, assimilate, intimidate, or patronize the Hmong have, as a rule, disliked them intensely. Though more Hmong lived in Laos and Vietnam, most Western observers in the last half century or so have worked in Thailand because of its stabler political situation. Geddes did not find his fieldwork easy. The villagers were too proud to sell him food, so he had to transport his supplies by packhorse, nor would they allow themselves to be hired to build him a house, so he had to employ opium addicts from a Thai village lower down the mountain.

However, the Hmong eventually won his deep respect. In his book Migrants of the Mountains, Geddes wrote: The preservation by the Miao of their ethnic identity for such a long time despite their being split into many small groups surrounded by different alien peoples and scattered over a vast geographic area is an outstanding record paralleling in some ways that of the Jews but more remarkable because they lacked the unifying forces of literacy and a doctrinal religion and because the features they preserved seem to be more numerous. Robert Cooper, a British anthropologist who spent two years studying resource scarcity in four Hmong communities in northern Thailand, described his research subjects as polite without fawning, proud but not arrogant.

Hospitable without being pushy; discreet respecters of personal liberty who demand only that their liberty be respected in return. People who do not steal or lie. From his post in the Hmong village of Khek Noi, also in northern Thailand, Father Mottin wrote in his History of the Hmong a wonderful book, exuberantly translated from the French by an Irish nun who had once been the tutor to the future king of Thailand, and printed, rather faintly, in Bangkok : Though they are but a small people, the Hmong still prove to be great men.

What particularly strikes me is to see how this small race has always manged [sic] to survive though they often had to face more powerful nations. Let us consider, for example, that the Chinese were times more numerous than they, and yet never found their way to swallow them. The Hmong…have never possessed a country of their own, they have never got a king worthy of this name, and yet they have passed through the ages remaining what they have always wished to be, that is to say: free men with a right to live in this world as Hmong.

Who would not admire them for that? One of the recurring characters in Hmong folktales is the Orphan, a young man whose parents have died, leaving him alone to live by his wits. In one story, collected by Charles Johnson, the Orphan offers the hospitality of his humble home to two sisters, one good and one snotty. The snotty one says: What, with a filthy orphan boy like you? Your penis is dirty with ashes! You must eat on the ground, and sleep in the mud, like a buffalo! The Orphan may not have a clean penis, but he is clever, energetic, brave, persistent, and a virtuoso player of the qeej, a musical instrument, highly esteemed by the Hmong, that is made from six curving bamboo pipes attached to a wooden wind chamber.

Charles Johnson points out that the Orphan is, of course, a symbol of the Hmong people. In this story, the Orphan marries the good sister, who is able to perceive his true value, and they prosper and have children. The snotty sister ends up married to the kind of dab who lives in a cave, drinks blood, and makes women sterile. The Lees had little doubt what had happened. In Hmong-English dictionaries, qaug dab peg is generally translated as epilepsy. It is an illness well known to the Hmong, who regard it with ambivalence. On the one hand, it is acknowledged to be a serious and potentially dangerous condition. The Hmong leader to whom they made this proposition politely discouraged them, suspecting that Coelho, who is a Catholic of Portuguese descent, might not appreciate having chickens, and maybe a pig as well, sacrificed on his behalf.

This fact might have surprised Tony Coelho no less than the dead chickens would have. Before he entered politics, Coelho planned to become a Jesuit priest, but was barred by a canon forbidding the ordination of epileptics. Hmong epileptics often become shamans. Their seizures are thought to be evidence that they have the power to perceive things other people cannot see, as well as facilitating their entry into trances, a prerequisite for their journeys into the realm of the unseen. The fact that they have been ill themselves gives them an intuitive sympathy for the suffering of others and lends them emotional credibility as healers. Becoming a txiv neeb is not a choice; it is a vocation.

The calling is revealed when a person falls sick, either with qaug dab peg or with some other illness whose symptoms similarly include shivering and pain. An established txiv neeb, summoned to diagnose the problem, may conclude from these symptoms that the person who is usually but not always male has been chosen to be the host of a healing spirit, a neeb. In any case, few Hmong would choose to decline. Although shamanism is an arduous calling that requires years of training with a master in order to learn the ritual techniques and chants, it confers an enormous amount of social status in the community and publicly marks the txiv neeb as a person of high moral character, since a healing spirit would never choose a no-account host. Even if an epileptic turns out not to be elected to host a neeb, his illness, with its thrilling aura of the supramundane, singles him out as a person of consequence.

The Hmong are known for the gentleness with which they treat their children. Small children were rarely abused; it was believed that a dab who witnessed mistreatment might take the child, assuming it was not wanted. The Hmong who live in the United States have continued to be unusually attentive parents. Another study, conducted in Portland, Oregon, found that Hmong mothers held and touched their babies far more frequently than Caucasian mothers.

They therefore hoped, at least most of the time, that the qaug dab peg could be healed. Yet they also considered the illness an honor. She was a very special person in their culture because she had these spirits in her and she might grow up to be a shaman, and so sometimes their thinking was that this was not so much a medical problem as it was a blessing. Whether Lia occupied this position from the moment of her birth, whether it was a result of her spiritually distinguished illness, or whether it came from the special tenderness any parent feels for a sick child, is not a matter Foua and Nao Kao wish, or are able, to analyze. One thing that is clear is that for many years the cost of that extra love was partially borne by her sister Yer.

On two occasions, Foua and Nao Kao were worried enough to carry her in their arms to the emergency room at Merced Community Medical Center, which was three blocks from their apartment. Like most Hmong refugees, they had their doubts about the efficacy of Western medical techniques. However, when they were living in the Mae Jarim refugee camp in Thailand, their only surviving son, Cheng, and three of their six surviving daughters, Ge, May, and True, had been seriously ill.

Ge died. They took Cheng, May, and True to the camp hospital; Cheng and May recovered rapidly, and True was sent to another, larger hospital, where she eventually recovered as well. A dead person had been buried beneath their old one, and his soul might have wished to harm the new residents. This experience did nothing to shake their faith in traditional Hmong beliefs about the causes and cures of illness, but it did convince them that on some occasions Western doctors could be of additional help, and that it would do no harm to hedge their bets. The MCMC complex includes a modern, 42,square-foot wing—it looks sort of like an art moderne ocean liner—that houses coronary care, intensive care, and transitional care units; medical and surgical beds; medical and radiology laboratories outfitted with state-of-the-art diagnostic equipment; and a blood bank.

The waiting rooms in the hospital and its attached clinic have unshredded magazines, unsmelly bathrooms, and floors that have been scrubbed to an aseptic gloss. MCMC is a teaching hospital, staffed in part by the faculty and residents of the Family Practice Residency, which is affiliated with the University of California at Davis. The residency program is nationally known, and receives at least applications annually for its six first-year positions. Like many other rural county hospitals, which were likely to feel the health care crunch before it reached urban hospitals, MCMC has been plagued with financial problems throughout the last twenty years. The hospital receives reimbursements from the public programs, but many of those reimbursements have been lowered or restricted in recent years.

During this same period, MCMC also experienced an expensive change in its patient population. Starting in the late seventies, South-east Asian refugees began to move to Merced in large numbers. The city of Merced, which has a population of about 61,, now has just over 12, Hmong. That is to say, one in five residents of Merced is Hmong. Not only do the Hmong fail resoundingly to improve the payer mix—more than eighty percent are on Medi-Cal—but they have proved even more costly than other indigent patients, because they generally require more time and attention, and because there are so many of them that MCMC has had to hire bilingual staff members to mediate between patients and providers.

In , a short-term federal grant enabled MCMC to put skilled interpreters on call around the clock, but the program expired the following year. Except during that brief hiatus, there have often been no Hmong-speaking employees of any kind present in the hospital at night. Obstetricians have had to obtain consent for cesarean sections or episiotomies using embarrassed teenaged sons, who have learned English in school, as translators. Ten-year-old girls have had to translate discussions of whether or not a dying family member should be resuscitated. Sometimes not even a child is available.

How long have you been hurting? What does it feel like? Have you had an accident? Have you vomited? Have you had a fever? Have you lost consciousness? Are you pregnant? Have you taken any medications? Are you allergic to any medications? Have you recently eaten? The last question is of great importance if emergency surgery is being contemplated, since anesthetized patients with full stomachs can aspirate the partially digested food into their lungs, and may die if they choke or if their bronchial linings are badly burned by stomach acid. I asked one doctor what he did in such cases. At that time, the only hospital employee who sometimes translated for Hmong patients was a janitor, a Laotian immigrant fluent in his own language, Lao, which few Hmong understand; halting in Hmong; and even more halting in English.

The resident on duty practiced veterinary medicine. Her only obvious symptoms were a cough and a congested chest. Vaporizer at cribside. Clinic reached as needed — ten days. But when Lia had another bad seizure on November 11, he and Foua carried her to the emergency room again, where the same scene was repeated, and the same misdiagnosis made. On this occasion, three circumstances were different: Lia was still seizing when they arrived, they were accompanied by a cousin who spoke some English, and one of the doctors on duty was a family practice resident named Dan Murphy.

At that time, he had been living in Merced for only seven months, so his interest still exceeded his knowledge. Most important, the Murphys counted a Hmong family, the Xiongs, among their closest friends. When one of the Xiong daughters wanted to spend the summer working in Yosemite National Park, Chaly Xiong, her father, initially refused because he was afraid she might get eaten by a lion. Dan personally escorted Chaly to Yosemite to verify the absence of lions, and persuaded him the job would do his daughter good. Four months later, Chaly was killed in an automobile accident. Cindy Murphy arranged the funeral, calling around until she found a funeral parlor that was willing to accommodate three days of incense burning, drum beating, and qeej playing.

She also bought several live chickens, which were sacrificed in the parking lot of the funeral parlor, as well as a calf and a pig, which were sacrificed elsewhere. She was having a generalized seizure. That was definitely anxiety-producing. She was the youngest patient I had ever dealt with who was seizing. The parents seemed frightened, not terribly frightened though, not as frightened as I would have been if it was my kid. I thought it might be meningitis, so Lia had to have a spinal tap, and the parents were real resistant to that. Later on, when I figured out what had happened, or not happened, on the earlier visits to the ER, I felt good.

According to the family the patient has had multiple like episodes in the past, but have never been able to communicate this to emergency room doctors on previous visits secondary to a language barrier. An english speaking relative available tonight, stated that the patient had had intermittent fever and cough for 2—3 days prior to being admitted. The head was held to the left with intermittent tonic-clonic [first rigid, then jerking] movements of the upper extremities. Respirations were suppressed during these periods of clonic movement. Grunting respirations persisted until the patient was given 3 mg. Foua and Nao Kao had no way of knowing that Dan had diagnosed it as epilepsy, the most common of all neurological disorders. Dan had learned in medical school that epilepsy is a sporadic malfunction of the brain, sometimes mild and sometimes severe, sometimes progressive and sometimes self-limiting, which can be traced to oxygen deprivation during gestation, labor, or birth; a head injury; a tumor; an infection; a high fever; a stroke; a metabolic disturbance; a drug allergy; a toxic reaction to a poison.

Sometimes the source is obvious—the patient had a brain tumor or swallowed strychnine or crashed through a windshield—but in about seven out of ten cases, the cause is never determined. During an epileptic episode, instead of following their usual orderly protocol, the damaged cells in the cerebral cortex transmit neural impulses simultaneously and chaotically. Except through surgery, whose risks consign it to the category of last resort, epilepsy cannot be cured, but it can be completely or partially controlled in most cases by anticonvulsant drugs.

The Hmong are not the only people who might have good reason to feel ambivalent about suppressing the symptoms. What does it matter that it is an abnormal tension, if the result, if the moment of sensation, remembered and analysed in a state of health, turns out to be harmony and beauty brought to their highest point of perfection, and gives a feeling, undivined and undreamt of till then, of completeness, proportion, reconciliation, and an ecstatic and prayerful fusion in the highest synthesis of life?

It has a natural cause just as other diseases have. But if they called everything divine which they do not understand, why, there would be no end of divine things. He admitted her to MCMC as an inpatient. Among the tests she had during the three days she spent there were a spinal tap, a CT scan, an EEG, a chest X ray, and extensive blood work. None of the tests revealed any apparent cause for the seizures. Lia was found to have consolidation in her right lung, which this time was correctly diagnosed as aspiration pneumonia resulting from the seizure.

Mom informed to keep babe covered with a blanket for the babe is a little cool. Awake, color good. Mother fed. Held by mother. Her parents were instructed, via an English-speaking relative, to give her milligrams of ampicillin twice a day, to clear up her aspiration pneumonia, and twenty milligrams of Dilantin elixir, an anticonvulsant, twice a day, to suppress any further grand mal seizures.

Paul, Minnesota, visited Ban Vinai, the refugee camp in Thailand where she had lived for a year after her escape from Laos in She was the first Hmong-American ever to return there, and when an officer of the United Nations High Commissioner for Refugees, which administered the camp, asked her to speak about life in the United States, 15, Hmong, more than a third of the population of Ban Vinai, assembled in a soccer field and questioned her for nearly four hours. Some of the questions they asked her were: Is it forbidden to use a txiv neeb to heal an illness in the United States? Why do American doctors take so much blood from their patients? After you die, why do American doctors try to open up your head and take out your brains? Do American doctors eat the livers, kidneys, and brains of Hmong patients?

When Hmong people die in the United States, is it true that they are cut into pieces and put in tin cans and sold as food? The general drift of these questions suggests that the accounts of the American health care system that had filtered back to Asia were not exactly enthusiastic. The limited contact the Hmong had already had with Western medicine in the camp hospitals and clinics had done little to instill confidence, especially when compared to the experiences with shamanistic healing to which they were accustomed.

Txiv neebs could render an immediate diagnosis; doctors often demanded samples of blood or even urine or feces, which they liked to keep in little bottles , took X rays, and waited for days for the results to come back from the laboratory—and then, after all that, sometimes they were unable to identify the cause of the problem. Txiv neebs knew that to treat the body without treating the soul was an act of patent folly; doctors never even mentioned the soul. Most Hmong believe that the body contains a finite amount of blood that it is unable to replenish, so repeated blood sampling, especially from small children, may be fatal. When people are unconscious, their souls are at large, so anesthesia may lead to illness or death. If the body is cut or disfigured, or if it loses any of its parts, it will remain in a condition of perpetual imbalance, and the damaged person not only will become frequently ill but may be physically incomplete during the next incarnation; so surgery is taboo.

If people lose their vital organs after death, their souls cannot be reborn into new bodies and may take revenge on living relatives; so autopsies and embalming are also taboo. Some of the questions on the Ban Vinai soccer field were obviously inspired by reports of the widespread practice of autopsy and embalming in the United States. To make the leap from hearing that doctors removed organs to believing that they ate them was probably no crazier than to assume, as did American doctors, that the Hmong ate human placentas— but it was certainly scarier. Most Hmong have little fear of needles, perhaps because some of their own healers not txiv neebs, who never touch their patients attempt to release fevers and toxicity through acupuncture and other forms of dermal treatment, such as massage; pinching; scraping the skin with coins, spoons, silver jewelry, or pieces of bamboo; applying a heated cup to the skin; or burning the skin with a sheaf of grass or a wad of cotton wool.

An antibiotic shot that could heal an infection almost overnight was welcomed. A shot to immunize someone against a disease he did not yet have was something else again. When Foua Yang and Nao Kao Lee brought their three sick children to the hospital at Mae Jarim, they were engaging in behavior that many of the other camp inhabitants would have considered positively aberrant. Hospitals were regarded not as places of healing but as charnel houses. They were populated by the spirits of people who had died there, a lonesome and rapacious crew who were eager to swell their own ranks.

In this last case, the plant, Jatropha curcas, is crushed and its oil left in a cup, to be consumed not by the patient but by the dab. Wendy Walker-Moffat, an educational consultant who spent three years teaching and working on nutritional and agricultural projects in Phanat Nikhom and Ban Vinai, suggests that one reason the Hmong avoided the camp hospitals is that so many of the medical staff members were excessively zealous volunteers from Christian charitable organizations. A group of doctors and nurses were talking to a Hmong man whom they had converted and ordained as a Protestant minister.

They had decided that in order to get the Hmong to come into the hospital they were going to allow a traditional healer, a shaman, to practice there. I knew they all thought shamanism was witch- doctoring. So I heard them tell this Hmong minister that if they let a shaman work in the medical center he could only give out herbs, and not perform any actual work with the spirits. Instead of working in cooperation with the shamans, they did everything to disconfirm them and undermine their authority…. Is it any wonder that the Hmong community regarded the camp hospital as the last choice of available health care options? In the local hierarchy of values, consulting a shaman or herbalist, or purchasing medicine available in the Thai market just outside the entrance to the camp, was much preferred and more prestigious than going to the camp hospital.

The refugees told me that only the very poorest people who had no relatives or resources whatsoever would subject themselves to the camp hospital treatment. To say that the camp hospital was underutilized would be an understatement. Unlike the other camp volunteers, who commuted from an expatriate enclave an hour away, Conquergood insisted on living in Ban Vinai, sharing the corner of a thatched hut with seven chickens and a pig. His first day in the camp, Conquergood noticed a Hmong woman sitting on a bench, singing folk songs.

Her face was decorated with little blue moons and golden suns, which he recognized as stickers the camp clinic placed on medication bottles to inform illiterate patients whether the pills should be taken morning or night. The fact that Conquergood considered this a delightful example of creative costume design rather than an act of medical noncompliance suggests some of the reasons why the program he designed turned out to be the most indeed, possibly the only completely successful attempt at health care delivery Ban Vinai had ever seen.

He decided on a Rabies Parade, a procession led by three important characters from Hmong folktales—a tiger, a chicken, and a dab —dressed in homemade costumes. The cast, like its audience, was one hundred percent Hmong. As the parade snaked through the camp, the tiger danced and played the qeej, the dab sang and banged a drum, and the chicken chosen for this crucial role because of its traditional powers of augury explained the etiology of rabies through a bullhorn.

When he contracted dengue fever for which he also sought conventional medical treatment , a txiv neeb informed him that his homesick soul had wandered back to Chicago, and two chickens were sacrificed to expedite its return. As long as they persisted in this view, Conquergood believed that what the medical establishment was offering would continue to be rejected, since the Hmong would view it not as a gift but as a form of coercion. Before Lia fell, she would run to her parents to be hugged. She also demanded plenty of hugs from them when she was feeling fine, but they recognized these occasions as different because she had a strange, scared expression, and they would gently pick her up and lay her on the mattress they kept for this purpose on the floor of their living room which was otherwise unfurnished.

Sometimes there was twitching on one side of her body, usually the right. Sometimes she had staring spells. Sometimes she seemed to hallucinate, rapidly scanning the air and reaching for invisible objects. As Lia got older, the abnormal electrical activity spread to larger and larger areas of her brain and triggered more frequent grand mal episodes. As she lay face up, her back would arch so violently that only her heels and the back of her head would touch the mattress, and then, after a minute or so of rigid muscle contractions, her arms and legs would start to thrash. During the first phase, her respiratory muscles contracted along with the rest of her body, and she would often stop breathing.

Her lips and nail beds turned blue. Sometimes she gave high- pitched gasps, foamed at the mouth, vomited, urinated, or defecated. Sometimes she had several seizures in a row; between them, she would tense, point her toes, and cry a strange deep cry. In the most serious episodes, Lia would continue seizing and seizing without regaining consciousness. Inserting a needle into the vein of a baby who is having convulsions is like shooting, or trying to shoot, a very small moving target.

Frightening as it was to be on duty when Lia was brought in at a. The residents were merely the first line of defense. Every time Lia came to the emergency room, either Neil Ernst or Peggy Philp, the two supervising pediatricians who served on the faculty of the family practice residency program, was paged and, no matter how late it was, drove to the hospital a trip that could be accomplished, at just under the speed limit, in seven minutes. One leading to a grand mal seizure. I feel that probably the grand mal seizure caused an aspiration pneumonia and hence apnea, causing her extreme distress when she showed up in the Emergency Room on the day of admission. The child has apparently done well on her Dilantin, although she has continued to have some right focal seizures….

My feeling is that this child probably has some form of benign focal seizures of infancy. These are not especially common, but can often be quite benign in nature. Since there is apparently some chance that these will generalize, it is probably worth while to keep the child on Dilantin therapy to suppress a grand mal seizure. I would check the Dilantin level to make sure that it remains therapeutic….

Neil and Peggy once went through a photocopy of it with me. The errors were invariably made by transcribers, nurses, or other physicians; their own contributions were flawless and usually even legible. He had forgotten that she had had epileptic seizures for five months before they were diagnosed and medicated, and was wondering in retrospect whether the course of her life might have been different if his hospital had offered her optimal medical care from the beginning. Neil Ernst and Peggy Philp are married to each other. Neil and Peggy are both the children of physicians, both high school valedictorians, both Phi Beta Kappa graduates of Berkeley. They met when they were nineteen and eighteen, two tall, good-looking, athletic premed students who recognized in each other the combination of idealism and workaholism that had simultaneously contributed to their successes and set them apart from most of their peers.

Their schedules were arranged in such a way that one of them was always home in the afternoon when their two sons got out of school. Every morning, the alarm buzzed at If it was Monday, Wednesday, or Friday, Neil got up and ran eight miles. If it was Tuesday, Thursday, or Sunday, Peggy got up and ran eight miles. They alternated Saturdays. Their runs were the only time either of them was entirely alone for more than a few minutes, and they never skipped or traded a morning, even if they had been up most of the night on call at MCMC. Peggy was on call at the hospital. We get along real well. Real, real well. Medically, we complement each other. My strengths are infections, asthma, and allergies.

Am I thinking okay? Would you offer anything else? Can I do anything else? If I feel like a dumbshit I can be a dumbshit with her. If she was not in my life it would…well, take a while for me to be able to function. They are perfect. Few other people I know would have gone to the lengths they did to provide good medical care to Lia. They were always thinking about her. Her Physical Growth chart shows that although her height usually hovered around the fifth percentile for her age not unusual for a Hmong child , her weight climbed as high as the seventy- fifth percentile. Her thick subcutaneous padding compounded the challenges that awaited the doctors in the emergency room.

Considerable effort has gone into weight control in this child. The father apparently likes Lia the way she is and is somewhat resistant to this problem. A vein hidden under fat is hard to palpate. Like a drug user who loses veins after repeated needle sticks, Lia eventually lost the antecubital veins in both forearms and the saphenous vein above her left ankle after doctors frantically searching for needle placement cut them open and tied them off. During most of her hospitalizations, the arm or leg with the IV line was bandaged to a board, and sometimes she was secured to her crib as well.

Father here. Soft restraint to L arm. Returned child to bed, soft restraint to R arm. Tried to explain to father reason but difficult due to communication barrier. His confidence in their ability to care for Lia was further strained the morning after this note was written, when he left the hospital at a. Foua and Nao Kao believed the best way to keep Lia safe and content, especially when she was ill or in pain, was to have her sleep next to them, as she always did at home, so they could immediately comfort her whenever she cried.

You see them put a bag on your kid to measure the output of urine and stool. When your child is in the hospital, suddenly somebody else is feeding them, somebody else is changing their pants, somebody else is deciding how and when they will be bathed. It takes all the autonomy of being a parent away, even for folks who have had a lot of medical experience. Mom here. Babe content. Cruises sides of crib. Makes baby sounds. Father trying to put her back to sleep. No seizures this shift. After she was old enough to walk, whenever she was well enough to get out of bed she ran up and down the corridor in the pediatric unit, banging on doors, barging into the rooms of other sick children, yanking open the drawers in the nursing station, snatching pencils and hospital forms and prescription pads and throwing them on the floor.

She was a little Houdini. With other Hmong families the sons are the ones who are loved. Hmong fathers say, Girl okay if die, want many boy. But this family, they wanted so much for her to live, they just adored her. 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.

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