A Mock Cultural interaction between a Hmong immigrant family and American Doctor
Lisa Pope Fischer
Social Science
ANTH 2000: Medical Anthropology
Activity Description: Provide a brief description of the activity
This is a teaching exercise, or module, that will lead up to a mock interaction between a Hmong patient and American doctor. Essential to Anthropology is the ability to be sensitive to cultural differences. In terms of understandings of illness, one culture may have a different interpretation of, and different treatment for particular illnesses. I designed this exercise by drawing on issues and concerns presented in Ann Fadiman’s work with Hmong immigrants (1997, 2000). The objective of this module is to teach students skills of perception and interpretation. The module begins with reviewing some basic anthropological concepts and key terms. The duration of the exercise requires preliminary preparation such as assigning the readings to the students. The in class activity should allow time to discuss and review the material. This exercise would be suitable for smaller class sizes no larger than 40 but perhaps could be modified for a lecture demonstration or online learning if students handed in written descriptions.
Learning Goals: What do you aim to achieve with this activity?
The General Education Outcomes that the assignment aims to achieve are: Intercultural knowledge and Competence.
This lesson addresses: Cultural self-awareness, knowledge of cultural worldviews, empathy, shared forms of communication, curiosity, and openness .The objective of this module is to briefly outline the anthropological concepts of “cultural relativism,” “worldview” and “emic/etic” as tools for understanding that different cultures may interpret illness differently. This is important in terms of making diagnoses as well as treating patients in a culturally sensitive manner. Cultural relativism is an approach in anthropology that tries to maintain a neutral non-judgmental stance, showing both “empathy” for cultural differences, as well as “openness” to see cultures that are different from our own without bias. This exercise looks at beliefs regarding health and illness from Hmong culture teaching “openness” to other perceptions of health. A young girl is misdiagnosed due to cultural misinterpretation causing dire consequences, so the aim is that students can imagine their perspective, to learn “empathy.” “Worldview” is a concept central to anthropology, looking at how individuals perceive their world and their place in it, which can be different in different cultures. Emic and Etic are common concepts in anthropology that try to show differences in perception, “cultural self-awareness,” the emic being the perspective of the people we study, and etic being the outsider’s perspective, the perspective of the anthropologist who analyzes the culture. This assignment in particular looks at an example where communication between cultures lead to a horrible outcome for one little girl, and the aim is to try to understand and create “shared forms of communication” to avoid such a tragedy again. As a mock patient and doctor interaction, the students learn “curiosity” and “critical thinking” as, they articulate responses based on two different cultural worldviews related to health and healing showing ability to see things from multiple cultural perspectives. In terms of High Impact Educational Practices (HIEP), this exercise uses collaborative learning. Diversity and global learning, and community based learning. It will become part of my Open Lab site for ANTH 2000: Medical Anthropology, and Blackboard.
Timing: At what point in the lesson or semester do you use this activity? How much classroom time do you devote to it? How much out-of-class time is expected?
The in class activity should allow time to present the concepts and themes, and have students perform the mock patient and healthcare practitioner scenario, followed by discussion of the issues raised in the reading and presentation. One standard hour –fifteen-minute class period would suffice but allowing a class period to view the film might expand the topic. This exercise would be suitable for smaller class sizes no larger than 40 but perhaps could be modified for a lecture demonstration if students handed in written responses to the discussion questions.
Film Suggestion:
“Split Horn: Journey of a Hmong Shaman” (2001, 56 minutes)
Logistics: What preparation is needed for this activity? What instructions do you give students? Is the activity low-stakes, high-stakes, or something else?
The module begins with reviewing some basic anthropological concepts and key terms. The Fadiman book The Spirit Catches You, wonderfully exemplifies issues of cultural difference and perceptions of illness, but she also has a short article that focuses on epilepsy that can also be used to illustrate cultural difference. A full-length film documents the story of a Hmong shaman, (Split Horn), but you can also use short video clips to illustrate the point of cultural difference. The duration of the exercise requires preliminary preparation such as assigning the readings to the students and handouts for the mock patient/healthcare practitioner interaction.
Fadiman, Ann. The Spirit Catches You and You Fall Down: A Hmong Child, Her American Doctors, and the Collision of Two Cultures. Farrar, Straus, & Giroux, 1997.
Fadiman, Ann. "The Spirit Catches You and You Fall Down": Epilepsy and the Hmong. Epilepsy & Behavior: E&B [Epilepsy Behav] 2000 Feb; Vol. 1 (1), pp. S3-S8.
Activity: Cultural Perceptions
I.Review the Anthropological concepts either using PowerPoint or in handouts. This exercise gets students to think about how we might be quick to judge other cultures (ethnocentrism), yet also understand how others might perceive us.
KEY TERMS/ CONCEPTS:
Cultural Relativism: Anthropologists attempt to be neutral non-judgmental observers that take into account the culture’s practices relative to their own cultural understandings.
Ethnocentrism: People might judge a culture’s practices in a negative manner simply because they might be different from their own. Anthropologists try not to be “ethnocentric” or “Western centric” as it is important to understand why a culture might perceive or do something rather than judge it in a prejudice manner.
Emic/Etic: Anthropologists use the concept “emic” to explain the perspective of the people one studies. How do the people perceive their culture? How do they interpret the world in which they live? In contrast, the anthropologist must also retain the “etic” perspective, the view of the scientific observer. The etic perspective allows the anthropologist to step back and analyze the culture using the various theories in which to interpret a culture’s practices (i.e. Cultural Marxism/social conflict theory, Functionalism, Practice theory, Reflexive Anthropology/writing culture, etc.)
Worldview: Refers to how a person views their world and their place within it. Whereas some people may define themselves and behave according to a religious worldview, an atheist can also have a worldview. Different cultures may have different types of worldviews that affect perceptions of time and space, feelings about moral behavior, how they think about and how they seem themselves within their society.
Culture Bound illnesses: These are illness that might be found within particular societies.
Mind/Body dualism: Western medicine tends to separate understandings of how illness in the body might be separated from the mind whereas many cultures see the two as closely related.
II. Give illustrative examples to spur discussion about ethnocentrism and cultural relativism. Encourage students to look at cultures in a culturally relative way by reminding them that people outside our own culture may view American practices as unusual as well.
1. Female brutality or beauty? Female circumcision is a practice in which elders cut off a young woman’s clitoris to prepare her for womanhood. Some refer to this as Female Genital Mutilation (FGM). This practice evokes much debate about brutality and mutilation of women, yet studies indicate that women from these societies may perceive this practice as a means to obtain purity and femininity (Gruenbaum 2006). Ask students in what ways do American women brutalize their bodies in the pursuit of femininity or beauty? To shock them you might show an image of the Cat lady who has had too many plastic surgeries, or a hyper thin anorexic looking fashion model. (See suggested short video clips from youtube below – following the bibliography)
2.Food delicacy or garbage? Students often cringe when they hear that in some cultures grub worms or monkey brains might be considered a delicacy, however, there are foods that Americans eat that other cultures might find repulsive. How, for example are grub worms similar to shrimp? For people outside the United States, peanut butter might look like mud or feces. People might perceive fine cheese as smelly rotten dairy. In the south, or even at the Coney Island Nathans, one can buy fried frog legs. Americans often perceive French food as elite fine food, yet they make “escargot” from common snails, and they perceive horsemeat as a healthy specialty.
III. Discuss how the above examples illustrate an understanding of “ethnocentrism,” but also connect to the idea of “emic” and “etic” as a matter of different cultural perceptions. Expand their understanding of emic /etic by connecting to an example of interpretations of cultural illness.
In Freed’s (1999) work, “Taraka’s Ghost”, a young bride in a strange new village experiences spirit possession, but is this a form of anxiety attack or depression? Would anti-depressants work if she truly believed she needed a shaman to remove the spirit? Several anthropologists have looked at the culture bound illness “Susto” prevalent among Mexican and other Hispanic communities in which they believe a person who has a sudden fright or trauma may develop loss of energy, loss of appetite, sleeplessness, and depression. Whereas from a Western medical perspective “susto” might be explained as a psychosocial illness in which the person becomes antisocial and uses the excuse of illness to withdraw, “susto” also has underlying physical symptoms that may be covering up serious illnesses such as diabetes (Poss & Jezewszi 2002) or tuberculosis (Rubel and Moore 2001), or hypoglycemia (Bolton 1981).
IV. Instigate discussion of the suggested Fadimon reading with a mock patient and doctor interaction exercise. You can have student volunteers improvise a discussion between an ill person and a healthcare practitioner or have the students all do the exercise in pairs. The exercise creates a scenario between a Hmong immigrant family with a sick daughter and a Western medical practitioner. Discussion should follow the exercise.
HANDOUT FOR STUDENTS:
Each student will improvise or act out a “scene” that depicts a Hmong patient with a healthcare practitioner. We will discuss the reading in light of themes that result from this mock patient/doctor exercise.
PERSON ONE: You are a Hmong immigrant whose baby daughter is sick. Based on what you read in Fadiman’s article or book, how might a Hmong patient describe and present their illness.
Consider the following:
The immigrants understanding of the illness or self-diagnosis: The spirit catches you and you fall down. Her older sister slammed the door so loudly that her spirit was scared out of her and she fell down. Illness may have many causes but can be due to a loss of the soul to a malevolent spirit. It might be a sign that she will grow up to be a high status Shaman who can go into a trance and see the spirits and in this regard this illness (epilepsy) is highly distinguished and should not be cured as it may lead to prestige later in life.
Cultural perception of illness and health:
• Will not take pills if the colors are inauspicious.
• Will refuse surgery, anesthesia, autopsies, blood tests, and spinal taps.
•May wear a white “spirit string” on wrist that can’t be cut off while they are ill as their soul might endlessly wander.
• Hmong traditional medicine may include herbs, amulets, and animal sacrifices.
PERSON TWO: you are a health care professional and you are trying to understand or interpret what the person is saying to develop a diagnosis. Based on what you read in Fadiman’s article or book, how might a Western Doctor describe and interpret the illness.
Consider the following:
Western Medicines cultural understanding of illness:
• Customs and traditions – desensitized empathy.
• Cultural taboos- perception that only Western medicine can cure and to look at “alternative” practices would be inappropriate. There may be legal rules or “taboos” in treating patients, especially children.
• Hierarchies—tend to be “rational” and controlling.
•Have their own language that an ordinary patient might not understand.
What type of questions does a typical healthcare practitioner ask?
• What is your name, your date of birth
• What brought you in today? What is your illness?
• What kind of symptoms are you experiencing?
• What is your medical history? Do you have prior ailments, surgeries, and/or allergies?
• What medications do you take?
• Is there a family history of illness? Does heart disease or diabetes run in your family?
• Can your occupation play a role in your illness?
•Review of systems: do you have headaches, vision troubles, trouble swallowing, nausea, etc.
How might a Western doctor interpret the Hmong explanation about a malevolent spirit causing the illness?
Symptoms /diagnosis from Doctor’s perspective: At first the doctors did not understand the parents and thought Lia had bronchitis or pneumonia and prescribed antibiotics. After the third time taking Lia to the hospital they saw she was suffering from a sudden attack of seizures or convulsions.
DISCUSSION QUESTIONS AFTER MOCK PATIENT/DOCTOR INTERACTION:
1. How might differences in language affect diagnosis and treatment? Why is it important to have access to skilled interpreters? What might be the challenges of having an interpreter?
2. How might cultural differences affect diagnosis and treatment? How might it be helpful to practice both allopathic and folk medicine? What are the challenges?
3. How did the patient interpret the doctor? What did they think about the doctor and his/her treatment of them?
4. How did the doctor interpret the patient? What did the doctor think about the patient? (I.e. “noncompliance” – patient’s refusal to disregard instructions)
5. What is the “culture of medicine”? How do Western doctors perceive health, illness, diagnosis and treatment?
6. How is Western medicine linked to legal practices (i.e. Child protective services/child endangerment, Brain dead = death) and how might this conflict with the patient’s perspective?
7. Why is the patient’s view of their illness important even if it is culturally different from the Western Medical perspective?
8. How might there be inequality between doctor and patient? How might a patient’s perception of doctor’s as authority figures impact their interaction with the doctor?
9. Why is it important, as Fadiman suggests, for health care practitioners to “develop certain habits of listening, empathy, and flexibility” (2000: 6).
10. Why does Fadiman suggest doctors to ask : What do you think caused this illness? What do you call this illness? What are you most afraid of?
Assessment: How do you assess this activity? What assessment measures do you use? Do you use a VALUE rubric? If not, how did you develop your rubric? Is your course part of the college-wide general education assessment initiative?
Assessment for Intercultural Knowledge and Competence:
Student Learning Outcomes (SLO): Cultural Self Awareness, Cultural Worldview, Empathy, Verbal and Non-verbal communication, Curiosity/critical thinking, Openness.
(SLO) Knowledge: Cultural Self Awareness.
Intercultural Experience.
“The experience of an interaction with an individual or groups of people whose culture is different from your own. Intercultural/cultural differences: The differences in rules, behaviors, communication and biases, based on cultural values that are different from one's own culture(AAC&U).”
Assessment of Cultural Self Awareness:
Emic and Etic are common concepts in anthropology that try to show differences in perception, “cultural self-awareness,” the emic being the perspective of the people we study, and etic being the outsider’s perspective, the perspective of the anthropologist who analyzes the culture. The exercise tries to get students to understand Hmong cultural beliefs from their perspective (emic) but also be able to analyze and interpret them from an etic perspective (The anthropologist or doctor)
(SLO) Knowledge: Knowledge of cultural worldview frameworks.
“Worldview is the cognitive and affective lens through which people construe their experiences and make sense of the world around them(AAC&U).”
Assessment of cultural worldview frameworks.
“Worldview” is a concept central to anthropology, looking at how individuals perceive their world and their place in it, which can be different in different cultures. This exercise looks at the worldview from American culture in contrast to Hmong culture.
(SLO) Skills: Empathy.
"Empathy is the imaginary participation in another person’s experience, including emotional and intellectual dimensions, by imagining his or her perspective (not by assuming the person’s position). (Bennett 1998)"
Assessment of Empathy.
Cultural relativism is an approach in anthropology that tries to maintain a neutral non-judgmental stance, showing “empathy” for cultural differences. This exercises looks at beliefs regarding health and illness from Hmong culture. A young girl is misdiagnosed due to cultural misinterpretation causing dire consequences, so the aim is that students can imagine their perspective.
(SLO) Skills: Verbal and nonverbal communication.
Articulates cultural understanding of verbal & nonverbal forms of communication and show ability to create shared understandings.
Assessment of Verbal and nonverbal communication.
This assignment in particular looks at an example where communication between cultures lead to a horrible outcome for one little girl, and the aim is to try to understand and create “shared forms of communication” to avoid such a tragedy again.
(SLO) Attitudes: Curiosity/critical thinking.
Able to question and articulate responses showing ability to see things from multiple cultural perspectives.
Assessment of Curiosity/critical thinking
As a mock patient and doctor interaction, the students learn “curiosity” and “critical thinking” as, they articulate responses based on two different cultural worldviews related to health and healing showing ability to see things from multiple cultural perspectives.
(SLO) Attitudes: Openness.
Suspends Judgment in valuing their interaction with culturally different others.
“Postpones assessment or evaluation (positive or negative) of interactions with people culturally different from one self. Disconnecting from the process of automatic judgment and taking time to reflect on possibly multiple meanings” (AAC&U).”.
Assessment of Openness.
Cultural relativism is an approach in anthropology that tries to maintain a neutral non-judgmental stance, showing “openness” to see cultures that are different from our own without bias. This exercises looks at beliefs regarding health and illness from Hmong culture.
Association of American Colleges and Universities. "Intercultural Knowledge and Competence VALUE Rubric." 2009. https://www.aacu.org/value/rubrics/intercultural-knowledge.
Bennett, J. 1998. Transition shock: Putting culture shock in perspective. In Basic concepts of intercultural communication, ed. M. Bennett, 215-224. Yarmouth, ME: Intercultural Press.
Reflection: How well did this activity work in your classroom? Would you repeat it? Why or why not? What challenges did you encounter, and how did you address them? What, if anything, would you change? What did students seem to enjoy about the activity?
I have not been able to run the ANTH 2000 “Medical Anthropology” class yet for lack of enrollment, but I hope to try to offer it in the Spring 2021. I am not sure how I could adapt this lesson for online learning if that should continue, but perhaps have students write response papers.
Additional Information: Please share any additional comments and further documentation of the activity – e.g. assignment instructions, rubrics, examples of student work, etc. These can be links to pages or posts on the OpenLab.
Materials needed
1) Anthropology key terms
2) Readings:
Book: Fadiman, Ann. The Spirit Catches You and You Fall Down: A Hmong Child, Her American Doctors, and the Collision of Two Cultures. Farrar, Straus, & Giroux, 1997.
OR
Article: Fadiman, Ann. "The Spirit Catches You and You Fall Down": Epilepsy and the Hmong. Epilepsy & Behavior: E&B [Epilepsy Behav] 2000 Feb; Vol. 1 (1), pp. S3-S8.
(Available thru City Tech library article database EBSCO)
3) Xerox of mock patient/healthcare practitioner scenario (https://openlab.citytech.cuny.edu/popefischeranth2000medicalanthro/files/2020/06/Intercultural-Knowledge-and-Competence-for-ANTH-2000-Medical-Anthro-.pdf)
4) Optional: Video “Split Horn: Journey of a Hmong Shaman”. Or you might show a short video clip from youtube that shows a Hmong Shaman doing a ritual cure (See suggestions below after bibliography of references and suggested reading).
Other Resources
Possible links:
•Pdf course notes
•Powerpoint slides
•List of online resources
• Google images are a good way to find pictures AND Youtube.com has a number of short video clips.
REFERENCES AND SUGGESTED READING:
Arntfield, Shannon L., Kristen Slesar, Jennifer Dickson, Rita Charon “Narrative medicine as a means of training medical students toward residency competencies” Patient Education and Counseling. Volume 91, Issue 3, June 2013, Pages 280–286
Bolton, Ralph (1981) “Susto, Hostility, and Hypoglycemia” Ethnology , Vol. 20, No. 4 (Oct., 1981), pp. 261-276.
Fadiman, Ann. The Spirit Catches You and You Fall Down: A Hmong Child, Her American Doctors, and the Collision of Two Cultures. Farrar, Straus, & Giroux, 1997.
Fadiman, Ann. "The Spirit Catches You and You Fall Down": Epilepsy and the Hmong. Epilepsy & Behavior: E&B [Epilepsy Behav] 2000 Feb; Vol. 1 (1), pp. S3-S8.
Freed, Stanley A. and Ruth Freed (1999) “Taraka’s Ghost,” Natural History, October 1999, pp. 84-91.
Gruenbaum, Ellen. “Sexuality Issues In the Movement to Abolish Female Genital Cutting in Sudan.” Medical Anthropology Quarterly, Vol. 20, Number 1, (2006) pp. 121-138
Hahn, Robert A. and Marcia Inhorn (eds.) (2010) Anthropology and Public Health, Second Edition: Bridging Differences in Culture and Society.Oxford University Press.
Kleinman A, Eisenberg L, Good B. Culture, illness, and care: clinical lessons from anthropologic and cross-cultural research. Ann Intern Med 1978;88:251–8
Oubre, Alondra. Shamanic trance and the placebo effect: The case for a study in psychobiological anthropology. PSI Research, Vol 5(1-2), Mar-Jun, 1986. pp. 116-144.
Poss, Jane and Mary Ann Jezewski (2002) “The Role and Meaning of Susto in Mexican Americans' Explanatory Model of Type 2 Diabetes” Medical Anthropology Quarterly , New Series, Vol. 16, No. 3 (Sep., 2002), pp. 360-377
Rubel, Arthur J. and Carmella C. Moore (2001)”The Contribution of Medical Anthropology to a Comparative Study of Culture: Susto and Tuberculosis” Medical Anthropology Quarterly, New Series, Vol. 15, No. 4, Special Issue: The Contributions of Medical Anthropology to Anthropology and Beyond (Dec., 2001), pp. 440-454
Thompson, Jennifer Jo Ritenbaugh, Cheryl Nichter, Mark. Reconsidering the placebo response from a broad anthropological perspective. Culture, Medicine and Psychiatry, Vol 33(1), Mar, 2009. pp. 112-152.
Suggested photograph images or videolinks:
Film Suggestion:
Split Horn: Journey of a Hmong Shaman
The spiritual healing of Hmong Shamanism (7:28)
https://www.youtube.com/watch?v=ymJnUHxqRpE
ASA Documentary: Second Generation Hmong Shaman (33:39)
https://www.youtube.com/watch?v=OrSZBsGn-4M
Anorexic Models: The curse of fashion modeling (2:47)
https://www.youtube.com/watch?v=ZK-Lhy-HqCs
Extreme Plastic Surgery (8:42)
https://www.youtube.com/watch?v=9R149OXxsGg
The link on Open lab includes the handout I would give students:
Click to access Intercultural-Knowledge-and-Competence-for-ANTH-2000-Medical-Anthro-.pdf
Please share a helpful link to a pages or post on the OpenLab
Click to access Intercultural-Knowledge-and-Competence-for-ANTH-2000-Medical-Anthro-.pdf
