R373 -biomedical vs. biopsychosocial model

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					       The Spirit Catches You and You Fall Down, written by Anne Fadiman, is entirely centered on

the existing dichotomy between two models of medicine, these being the Western biomedical and

the holistic, biopsychosocial model. The biomedical model is based on a conceptual model of illness

which includes all the biological factors of a person in order to determine and understand a medical

disorder, with the exclusion of any psychological and/or social factors. These factors are not

viewed as contributing to the previously mentioned disorder/illness. However, the holistic

approach of the biopsychosocial model, would disagree. It is based on the principles of the social

cognitive theory with the conclusion that the treatment of a disorder/illness must be done so in a

manner which addresses the biological, social, and psychological (thoughts, emotions, and

behavior) factors as collectively responsible for the clinical diagnosis. In this novel these two

models clash when the Hmong of Laos meet the doctors of Merced, California when dealing with the

case of Lia Lee, an infant whom has epilepsy or an infant whom has been anointed to become a twix

neeb (a shaman healer). The focus of this paper is to convey the differences between these models

exhibited in the novel and the solutions suggested by the author as well as my own sentiment

toward the solutions.

       The first instance, in which the existing division is made evident, begins on the opening

page of the first chapter. The traditional birth of a Hmong infant born in Laos is described. The

mother stood over the dirt floor of her home, built by her husband with the help of the clan. She

labored in silence, with the belief that screaming and moaning would oppose the birthing process.

She and her clan’s men all held the belief that the birthing of the infant was to be done in her own

home so that a dab could not cause harm. If difficulty during the delivery arose, the husband was

permitted to bring in drinking water which had a key boiled in it, as long as he did not look upon his

wife. The key which had been boiled in the water was believed to unlock the birth canal and ease

the difficulty. The mother reached between her legs to ease out the head while the rest of the

infant’s body slid into the bent forearms of its mother. The infant was washed in spring water
which had been collected by his mother during the early stages of labor and the responsibility of

cutting the umbilical cord was left to the father. The cord was the tied with string and buried in a

place of reverment, which depended on the sex of the child. The burial of the placenta is essential

because is believed to be a jacket, the first article of clothing that a person enters with into this

world. It is believed that the soul must return to its placenta in order to be reincarnated.1

        In contrast, the birth of Lia Lee in the U.S. is characterized by the coldness of Western

medicine. “When Lia was born, at 7:09 p.m. on July 19, 1982, Foua was lying on her back on a steel

table, her body covered with sterile drapes, her genital area painted with a brown Betadine

solution, with a high wattage lamp trained on her perineum.2" The difference of the birthing

experience in America is furthered by the inclusion that there was no artificial rupture of the

amniotic sac necessary, which is sometimes done to speed the delivery. It was also made clear that

neither an epidural nor an epistomy (a surgical cut enlarging the vaginal opening) were necessary.

While I believe the initial motive of narrating this separation is to magnify the differences between

the two systems it also serves a purpose of undermining American women. While Hmong women

are idealized for their strength in childbirth and their lack of desire for the easement of delivery,

American women are criticized for not sharing this same absolution against and tolerance of child

birthing. The holistic Hmong approach is contrasted further by describing how Lia is immediately

taken by the nurses to clean her as well as determine her APGAR scores (heart rate, respiration and

color, reflexes rated on a scale from 1-10, 10 being the best), her weight, length, head

circumference, and shoulder width. Foua was given a standard IV dose of Pitocin to constrict her

uterus and the placenta was weighed and then cast aside into a biomedical hazard labeled trash

receptacle. 3 After all these foreign requirements to the Hmong have been conducted,

immunizations are given, and a birth certificate, identification bracelets for both mother and infant

are drawn up, and a signature on official documentation stating that the correct infant was given to

the Lee’s (Lia’s parents) is required before returning home from the hospital.
        From this book, I cannot help but get the sense that Fadiman expects more than just a

simple understanding or compromise of the biomedical and holistic Hmong approach to the

treatment and care of illness. While I do agree that western medicine must be relevant to the lives

it is saving, otherwise becoming insignificant, a peaceful unity of the two models cannot exist. This

is not just a situation in which there is a clash of medical models, but also of different cultures,

languages, and religious backgrounds. I believe that a coexistence of the models should exist in a

manner of mutual respect and understanding of each model, as being different from the other with

different goals, methodologies, and beliefs. I feel that the two models can run concurrently in a way

that both the biomedical approach as well as the holistic approach can treat the individual

separately, but have an awareness of the other models goals and progression in an area. However,

a blending of these two models cannot happen, because eventually, there will come a time when

Western medicine must administer a form of medicine or perform an emergency, necessary

procedure that would be in conflict with the holistic approach. An example of this situation is when

Lia’s parents fail to administer her proscribed medication. However I feel that the best illustration

of the Hmong’s consternation to the biomedical model is described in the following passage. “It

was typically Hmong for patients to appear passively obedient—thus protecting their own dignity

by concealing their ignorance and their doctor’s dignity by acting deferential—and then, as soon as

they left the hospital, to ignore everything to which they had supposedly assented.”4 A point of

concern which should be brought out from this quote is the fact that the Hmong were ignorant to

the kind of treatment the doctor’s were attempting to provide them. This an area in which I agree

with Fadiman and the fact that it need to be made clear to the Hmong, or those following the

biopsychosocial model, the intentions and goals of the medical doctors and the reasoning it is so

important to them (as should be to the patient), according to the Western model, that the patient

follow the directions given.
        I feel that the Lee’s expectations of the doctors for the health care and healing of their

daughter is completely different from the goals of the Merced doctors, Peggy and Neil. The Merced

doctors are in the business of treating the illness and saving lives. While the Hmong believe that

illness can be caused by a variety of conditions, not all of these are shared by the medical realm as

causality of illness, especially illness due to soul loss. The Hmong believe that a person can have

anywhere from one to thirty-two souls, but that there is a most powerful life-soul, whose presence

is necessary for health and happiness.5 While some western medical doctors may believe in a soul,

some do not at all, while others who do believe in a soul have contrasting views. The most common

view of a soul, this viewpoint held by most Catholic hospitals, is the belief that the soul exists as the

mind, will, and emotions (some also consider it to be like a conscience) of a person, which is a

separate from the body. A popular culture quote of the same belief was expressed in a recent

episode of the popular television series, House; “I am no more the body, muscles, nor bones beneath

them”. Being that the soul is viewed as separate from the body, it also held that a spiritual or

religious leader is responsible for the healing of the soul.

        Not only is Fadiman suggesting that Western medicine become aware and familiarize itself

with the spiritual belief of the Hmong, she is also stating that the course of medical treatment cater

to the religiosity within the care for the illness. To suggest that a blending of Western medicine and

the biopsychosocial model should occur is impossible. This violates a separation that was put in

place so that medical care is not compromised. By making an effort to familiarize themselves with

the culture, the doctors lose their ability to analyze the situation as professionals and their efforts to

provide appropriate medical care are hindered. An example of becoming overly familiarized with a

case, not even regarding religious preferences, was during Lia’s final grand mal seizure. Neil was so

familiar with Lia’s case that his medical care for her was compromised because he did not cover the

basics, as was later stated by Bill Slevidge.6 To suggest that the sole responsibility of improving the
health care of the Hmong rests upon the physicians is unfair and inaccurate. There must be

compromise and mutual understanding/respect for growth and advancement to occur.

        While her most evident suggestion for the improvement of Hmong health care was the

blending of both models, which she suggested to be the responsibility entirely of the health care

professionals, she also made some suggestion as to using the eight question model of Arthur

Kleinman. Kleinman’s explanatory model is centered around questioning the patient about his/her

belief of what the illness is called and what it means to have this illness; what causes the illness;

when and why it started, as well as how it works; the type of treatment the patient hopes to receive

as well as his/her goals of the treatment; the problems which the illness has caused; and finally the

biggest fear caused by the illness.7 I feel that this suggestion is an excellent avenue to determine the

goals of the patient and come to a mutual understanding and respect for his/her expectations. I feel

that if the patient is given the opportunity to express his/her opinion on the matter that the patient

will not only be more receptive of the medical professional’s explanation of the illness and the

expectations for the treatment that he/she hope to provide. In following this model not only is

mutual respect and trust in the medical professionals assessment formed, it is also an excellent way

for a compromise to be made based upon some religious beliefs that will not complicate nor hinder

the level of care necessary to treat the illness. It also allows the doctor to acknowledge the patient’s

beliefs and suggest that he/she seek a spiritual healer to treat the soul as a concurrent treatment to

that of the Western medicine.

        While I do feel that ultimately Fadiman’s suggestion is to follow the models concurrently,

there is a noted bias throughout the book for the holistic, cultural approach of the Hmong as well as

the delegation of responsibility to the medical professionals as being obligated to fix the clash as is

especially noted when it is suggest that medical school return to the teaching of the “whole

doctor—whole patient” model.8 I whole heartedly agree with addressing the issues concurrently as
the best solution for the problem, nonetheless, the clash will always be in existence; For in the

instance when a life is on the line, the biomedical model will win out over the biopsychosocial

model, because doctors are in the business of saving lives; this is their sole responsibility, their

oath, their duty as physicians.

1Fadiman’s    description of a traditional birth p.3-5 of Chapter 1, entitled Birth.

2   Bottom of p.6 in Chapter 1.

3   Fadiman’s continuing description of Lia’s birth on p.7 of Chapter 1.

4   Page 68 of Chapter 6, High-Velocity, Transcortical Lead Therapy

5   Chapter 1, page 10, Fadiman’s description of what Hmong believe illness to be

6 Page 254-255 of Chapter 17, The Eight Questions, based upon Kleinman’s explanatory model of

7 Specifically,   the eight questions of Kleinman listed verbatim on page 260 of Chapter 17.

      of Chapter 18, on changing the medical school system, or reverting back to its original
8 p.275

methods of teaching.

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