Merced Community Medical Center
Cross-cultural Care & Representation
Introduction
Merced Community Medical Center (MCMC) located in Merced, California was built in 1952. The 176,000-square-foot facility was built with space for 120 patients, and a vast variety of medical services, including cardiac, critical care, emergency, family birthing, orthopedic, rehabilitation, surgical and respiratory care.
In 2010, MCMC fell into blight due to no longer meeting earthquake building standards in the state of California. A new replacement hospital, Mercy Medical Center Merced, was built just three miles north. It is currently owned by Dignity Health.
Map of (1) Old Merced Community Medical Center and (2) New Mercy Medical Center Merced
After undergoing renovations in 2016, the former county hospital now serves the community as the Merced County Behavioral Health and Recovery Services building. Today, the behavioral health location provides a consolidated resource center for the treatment of mental health and substance abuse. By appropriating the former county hospital, it preserves a piece of Merced's public history.
Part of this public history includes the legacy of cross-cultural care that occurred at MCMC after the Vietnam War. As one of the early county hospitals in the United States that faced the influx of new Hmong refugees, it is important to mark its place in history as a site of disability and cross-cultural significance.
This was a historic landmark for many people. People were born here, families work here, it is a tremendous community landmark...– Yvonnia Brown, Merced County Behavioral Health and Recovery Services Department Director, KFSN, 2018.
The interactive sliding image feature shows an image of MCMC when it was closed down in 2010 compared to the new renovation completed in 2018.
Cross-Cultural Care
Hmong Population by state from U.S. 2010 Census
The first Hmong people arrived in the United States in November of 1975. By the 1980's about one in five people living in Merced, California were Hmong. (1)
During this time Lia Lee, the subject of journalist Anne Fadiman's 1997 book, The Spirit Catches You and You Fall Down (The Spirit), was treated at MCMC.
A child of Hmong refugee immigrants, Lia’s disability history is one of many that occurs at the intersection of medical, racist, patriarchal, and colonizing systems of authority. This means that Lia’s story is not only framed by the medical model, where people with disabilities are treated as sick and need to be cured in order to be normal, but also that the systems mentioned above, simultaneously debilitated her and her family’s access to the care and resources they needed.
“Lia is doubly de-humanized: first by her illness and then by her classification as Asian...”– Monica Chui, Ph.D., Hmong Studies Journal, 2004-05 (3)
About Lia Lee & Family
After enduring tremendous adversity in Laos during the Vietnam War, Lia's family re-settled in Merced, California alongside 12,000 Hmong refugees. Lia had her first seizure at three months old. Three blocks away from MCMC, her father carried her to the emergency room where a veterinarian medicine resident misdiagnosed her due to lack of interpretation services. At this time, interpreters were not legally mandated and so providers often had to rely on young family members and non-medical staff for medical translation. The same misdiagnosis occurred a second time.
When her family rushed her in, a third time, this time still in seizure, the doctor ultimately diagnosed Lia with epilepsy. Meanwhile, Lia’s family saw her as spiritually gifted and called her condition quag dab peg, spirit loss, where the soul becomes separated from the body. For those that practice Hmong shamanism, txiv neeb, or shaman is asked for spiritual help in reuniting one's body and soul.
Hmong shamanism is a practice of maintaining communication with the spiritual world. When spirits of nature cause physical and psychological harm in the guise of illness, shamans are asked to heal the sickness through varying ceremonies. One does not decide to become a shaman, rather they are called to the role by healing spirits. (4)
Examples of some of the Hmong shaman tools used to create vibration during rituals. From left to right the objects are Lub ruas: a metal gong with warm tones of patina and mallet; Txiab Neeb: A metal hoop with metal coins to rattle, with red fabric wrapped around; Tswb neeb: A pair of donut like finger bells with red fabric tied through it; Twj Kum: a set of split horns.
Due to the lack of translation, cultural misunderstanding, and negative side effects from prescription medications, Lia’s family did not administer the full doses or frequencies of the prescribed treatments. As Lia’s seizures became more severe, the cross-cultural challenges resulted in the doctor’s calling Child Protective Services to take Lia from her family for almost a year, despite her family’s tireless care and devotion to Lia. Although Lia was eventually reunited with her family, her health continued to decline. When Lia was four, she suffered a tonic-clonic seizure, leading to septic shock, and leaving her in a persistent vegetative state. Lia lived until the age of 30. Her family cared for her at home until she died.
Cross-cultural Representation
The New York Times reports that The Spirit is required reading at the Yale School of Medicine. Credit: Farrar, Straus & Giroux
For the last 20 years, Lia’s early disability journey has been mostly understood through the perspective of journalist Anne Fadiman in The Spirit.
Seven years in the making, Fadiman drew from interviews with Lia's mother and father, Foua and Nakao Lee, her siblings, members of the Hmong community as well as the health and medical professionals who treated Lia at MCMC. The literary work exemplifies the desire to rationalize cultural collisions. Due to the novelty of it during its release, the book has become a required text in many medical schools across the United States. While it is used to teach about cross-cultural nuances of the medical system, the book certainly has its critiques.
Circumscribed by the author's Western perspective and white readership, the book overlooks the unethical, disabling, and debilitating history of Western medicine and also misrepresents the Hmong culture. For instance, Hmong scholar Monica Chui argues how the work perpetuates stereotypes of racialized, problematic, and non-compliant patients . (5) Evidence of how these stereotypes permeate popular knowledge can be found in book summaries on various study guide websites . (6)
Lia's medical regimen was complicated and her parents were either unable to follow the doctors' instructions, unwilling to do so, or both. They were unhappy with the side effects of the medication and may not have understood the connection between a seizure and its effect on the brain, nor the necessity of giving anticonvulsants. – via GradeSaver.com
Cross-cultural Architecture
While architecture is not critically considered in Fadiman's book, analyzing the spatial descriptions through a disability history lens reveals the forces that not only shape the container in which the two cultural narratives collide, but also how physical space serves as an omnipresent reinforcement of those social dynamics.
In the third chapter of The Spirit, the author makes a point of comparison that MCMC is not like other “dingy, crowded, dilapidated county hospitals.” Rather it is,
“a modern 42,000-square-foot complex that looks sort of like an art moderne ocean liner - that houses coronary care, intensive care, and transitional care units; 145 medical and surgical beds, medical radiology laboratories outfitted with state-of-the art diagnostic equipment; and a blood bank. The waiting rooms...have unshredded magazines, unsmelly bathrooms, and floors that have been scrubbed to an aseptic gloss.”
Shortly after, Fadiman reveals to the reader that, “the only employee who translated for Hmong people was a janitor, a Laotian immigrant fluent in Lao, which few Hmong understand.” These excerpts show how space reinforces which bodies get treated with dignity and urgency. It speaks to public health versus private medical institutions and the treatment of the different demographics they serve. At the same time it touts the superiority of MCMC’s facilities.
The architectural and literary evidence also exhibits how the custodian is economically and unethically exploited by MCMC. This reveals how the hospital can afford state of the art facilities and equipment, but did not afford to seek out and hire a Hmong interpreter for Lia and her family. Comparing how the Lee's were treated to the treatment of space demonstrates how architecture works in tandem with authoritative power.
Image on the left is of an old MCMC county hospital room. The mirrored plan, windows, electrical outlets, shelving, and ceiling rails suggest a room that could accommodate two patients with fabric curtains as a space divider. Some rooms accommodated four patients to a room with minimal space. Image on the right is a patient room in the new county hospital. The new hospital has individual patient rooms with furniture for visitors and family members. These images show the improvement of public health spaces.
A Call to Act
New York Times article on Mercy Medical Center's new Hmong Shaman Policy
Lia’s story raises the importance of eradicating the systemic inequities and injustices that impact cross-cultural care in the United States medical system. Her story is a story of so many others. Acknowledging this history is also a call for the advocacy of cross-cultural programs to widen our understanding of what wellness is and how to make it equitable.
Three years after The Spirit was published, Healthy House Merced started the country's first Hmong shaman policy at Mercy Medical Center. The policy acknowledges the cultural role of traditional healers and allows the performance of nine approved ceremonies in the hospital.
Additionally, Dignity Health now offers free medical interpreters for Spanish, Hmong, Laos, Portuguese, Mien and Punjabi. While these actions have moved the field of public health in a positive direction, the systemic forces that weigh on cross-cultural care in the United States are ever present. As we have learned from Lia's story and MCMC, change is not only a matter of language, but of soul.
