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Hmong Refugees and the US Health System

Although many Americans would prefer to forget about the Vietnam conflict, many of today's controversial issues stem from that era. One of these issues is the increased Southeast Asian refugee population in the U.S.

One of the major problems refugees face upon their arrival to this country is conflict with the US medical system. This conflict arises from misunderstanding and mistrust from both health professionals and refugee patients. With refugee children, misunderstandings can escalate. A more comprehensive understanding of Southeast Asian peoples and their cultures, especially their views regarding illness, can help make this transition much easier both for refugees and health care providers.


The Hmong, the largest of the hill tribes of Laos, are considered Laotian nationals but very much separate from the lowland Laotians. Originally river farmers from the southern portion of China, the Hmong fled the advances of the Han invaders to their north. They migrated to the mountains of southeastern Asia, settling in the present-day countries of Vietnam, Laos and Thailand. The Chinese labeled them Miao, which means "barbarians". In Laos they are called Meo, with basically the same translation and connotation. These Southeast Asian people use the term Hmong (also spelled h'Mong), which means "free man," as their real and preferred name.

A minority among the lowland Lao, the Hmong have fiercely struggled to maintain their independence and ethnic culture. They are aided, in part, by the extreme geographical isolation of the Laotian mountains and jungle in which they had established their homeland. The Hmong largely worked as farmers, utilizing the slash-and-burn method. Their primary cash crop, opium, was encouraged by both the Laotian and French regimes. In 1971, under pressure from the US, the Laotian government declared opium cultivation and sale to be illegal. Their previous pattern of subsistence farming had been barely adequate simply for survival before; with this change in their economy in 1972, survival had, for some Hmong, become nearly impossible. Many of the farmers continue to deal illegally in the supply side of the opium market simply because they have no other choice.

During the Indochina war the country of Laos held an officially neutral position. The Hmong, however, fought of both sides in this political struggle. The Communist faction of Laos, the Pathet Lao, was aided by the USSR and China, supported by the North Vietnamese. The US-backed, pro-Western Royal Lao government recruited Hmong General Vang Pao's guerrilla army, which included the largest part of the Hmong population, to fight the Pathet Lao and the North Vietnamese. The 1975 Pathet Lao victory cost the Hmong an estimated 30,000 lives, approximately 10 percent of their total population. The position for the surviving US-allied Hmong was politically very sensitive because of the role they had played against the Pathet Lao. Not anticipating defeat, the US government had no provisions for evacuating the stranded Hmong. From 1975 on, the Hmong fled Los for Thailand.

Since the mid-1980s, a large portion of Hmong refugees have immigrated to the US. In the relocation process, efforts are made to keep the nuclear family intact, but not necessarily the extended family. Because the Hmong give such importance to the extended family, many "secondary" migrations have occurred in order to reunite that extended family. Socially, the Hmong practice a patrilineal clan system. All of the people are divided into social groups referred to as clans, of which there are approximately 20 in their entire population. All of the clan share the same last name. These secondary migrations have led to several "impacted communities." Most US cities have been unable to handle the physical, financial and psychological ramifications of this sudden, large influx of refugees. More than 15,000 Hmong live in Fresno, California, today. This is believed to be the largest clustering of Hmong outside of Asia. It is on my experiences as a nurse in Fresno that I base my observations.

One of the most difficult areas of assimilation for the Hmong has been within the US health system. This article will first examine the traditional Hmong health system and then relate it to that of the US. The rest of the article will focus on the pediatric Hmong population.

The Traditional Hmong Health System

The Hmong view illness as a supernatural event, caused by spirits, called tlan. These animistic beliefs cloud their conception and perception of illness and also give "validation" to many of their cultural practices.

The Hmong spiritual world is composed of several tlan. One is the txi neng, or the shaman spirit. The txi neng is thought to give a severely ill person the ability to serve as an intermediary between the spirit world and the physical world, and thus survive the illness. After being trained by the spirit and a senior shaman, that person becomes a shaman (also called tu-ua-neng or trix neeb). The shaman can ten diagnose and treat villagers' illnesses, using magical powers to summon benevolent spirits.

Another form of tlan is the body spirit, which consists of three basic types: ancestors, dead friends and animals. If a person passes out, the good body spirits can escape. If a shaman cannot restore the good spirits to the body in time, the Hmong believe the person will die. A string, sometimes containing gold or silver charms, is tied to a bay's neck, hands, feet and/or waist at birth. This works as a promoter of good health, keeping the good spirits in and the bad spirits out. These strings are tied in position during a ceremony known as Baa and should not be removed.

Sometimes the body spirits are believed to cause illness because they want an animal sacrifice. If the correct animal is sacrificed, the victim will recover.

Following is a description of a traditional shaman treatment.

The "cure" varies little regardless of the disease. A tuua-neng pays a house call. He chants with the ardor and the exaggerated gestures common to faith healer anywhere. All the while a black mask over his head closes out this world.

Jangling a ring of noisemakers with a clippety-clopp rhythm, he "rides off on a horse" to find the soul. Along the way the tu-ua-neng gathers a posse of friendly spirits; one of these may bring field glasses, another an airplane. The villains may be lurking at the bottom of a pond, in the clouds, or far beyond China.

Once the spirit doctor meets them, excited haggling ensues. Leaping, dancing, sweating, he is driven by a trance that defies exhaustion. Tirelessly he bargains for the captive. Finally, the spirits demand a sacrifice - a pig if the family, can afford it, a chicken if not.

An assistant dispatches a chicken or pig and burns paper "spirit money" on the carcass. With luck the homeward journey from the vale of the spirits requires only another hour or so, long enough to cook the sacrifice.

Family, friends, and tu-ua-neng then sit down to a pork or chicken dinner, hoping the patient will recover. More and more the patient does, partly because on family altars you will now often find bottles of antibiotics among the holy artifacts. It would be a foolish tu-ua-neng who turned his back on such powerful allies.

Another type of healer is the kws tshuaj, who uses nonspiritual methods - herbs and plants - to cure the sick. These healers practice from personal choice, not "divine appointment." Therefore, a shaman could choose to learn kws tshuaj, but a kws tshuaj could not choose to become a shaman.

The Hmong view illness in terms of symptomatology, that is, through pain, weakness, fever, coldness in extremities, injury, change in color or anything else that is out of the ordinary. Once a person is diagnosed as being ill, the observers then have to decide the cause of the illness. The chosen treat-medicine, or a combination of both. Western medicine is often in the form of drugs; many pharmaceuticals available only by prescription in the US are readily available over the counter in Indochina. If all else should fail, the patient might be taken to a hospital, although this is a fairly uncommon occurrence.

Entering the US Health System

The Hmong refugee is understandably confused by the difference between traditional Hmong health Practices and those of the US medical system. On observer described the Hmong plight as follows: "The have jumped 2,000 years in a matter of a few days. It's like cryogenics and they've awakened from a days. It's like cryogenics and they've awakened from a deep sleep for centuries".

The Hmong who enters the us medical system often does so only when all traditional curing methods fail. At this point, the patient is usually extremely ill, sometimes critically. This emergency health care entry reflects the pattern practiced in their homeland. Their extreme geographical isolation during pre-refugee times prevented them from regularly seeking more sophisticated medical care, which was available only - if at all - in the more urban communities. A family member usually had to be close to death before the arduous trip could even be considered or justified by the clan. This learned behavior about when to enter the health system has persisted in the US, even though the element of geographical isolation has been removed.

Apart from the spiritual dimension, other cultural differences make Southeast Asians more reluctant to enter the US medical system. The intense cultural shock of relocation, for one, serves to further confuse the Hmong. They lose their sense of socioeconomic identity. The significant language barrier sometimes seems nearly impossible to overcome. The typical Hmong is very shy, conditioned by Hmong culture to remain closed, not revealing fears and anxieties.

Overview of Hmong Health Problems

Once in the US system, the Hmong refugees still have many obstacles to overcome. Chronic malnutrition, previous poor health and lack of medical care all serve to intensify their illnesses. Preventive medicine is virtually unheard of within the Hmong culture in Laos. Immunizations are seldom up to date, if even administered at all. Anemia is prevalent, mostly due to poor diet and parasitic infections Lactose intolerance has been documented. Parasitic disease is endemic with a high prevalence for Plasmodium species, Giardia lambia, Clonorchis sinensis and Paragoniumus westernani. Due to antibiotic overuse and abuse, a number of these organisms often become resistant to the more commonly used antibiotic overuse and abuse, a number of these organisms often become resistant to the more commonly used antibiotics. Scabies and lice are also quite common. Respiratory conditions include pneumocystis carinii pneumonia (an often threatening fungal infection) and tuberculosis, which is more of a public health threat than a truly dangerous threat than a truly dangerous threat to an individual. Hepatitis, which is also common in Indochina, is also considered mostly along the lines of communicability and the need for infection control.

Lifestyle Differences

The Many lifestyle differences in the US give rise to significant difficulties for the Hmong people. One involves the mechanization and industrialization of the more advanced technology found here. The typical Hmong has never seen a stove or refrigerator and has no idea of how or why to use them; perishable foods often spoil sitting beside an empty refrigerator. Many foods are not indigenous to Laos - for example, frozen goods - and when eaten after incorrect storage or preparation can cause illness. Not understanding potential hazards, Southeast Asians sometimes grill with open stoves on the wooden floors in their home, risking carbon monoxide poisoning and fire.

The attitude of the Southeast Asian refugees toward their children reveals another cultural difference. Because of the high infant and child mortality - morbidity rates in Laos, large families were necessary; therefore Hmong did not practice birth control. With the more advanced medical treatment available in the US, the Hmong mortality rate has declined significantly. With such large families, living conditions can become extremely crowded, increasing the chances of exposure to and communicability of disease within the clan.

Socially, too, US and Hmong cultural taboos differ. For example, tousling a child's hair is absolutely forbidden. Hmong consider the head sacred because the soul of the individual lives there. Patting the head could startle the soul out of the body.

Other Hmong cultural traditions can lead to cultural misunderstanding and even charges of child neglect or abuse in the US - both of which have been documented. The first involves the preference of Southeast Asians for flat heads posteriorly. The infant is placed supine, propped with pillows on either side of the head and/or body to keep the head posteriorly flush to the floor or surface. Continual pressure does yield a flat head, but the position of the pillows also prohibits free sideways or rolling movements, which can delay development. The flat head findings and significant developmental delay have provided the basis for questions concerning neglect.

Another Hmong custom, called "coin rubbing", has actually led to several charges of child abuse. This traditional method of healing, also known as Cao Gio, or "coining," is administered to the area where the illness is manifested. For example, for a chest cold, oil is spread on the back and chest with cotton swabs. The skin is then massaged until it is warm. A spoon or coin is stroked firmly up and down on the oiled skin until it is bruised. Pinching the skin is another method sometimes practiced. Another dermal therapy is called "cupping'; heat is injected into a cup which is then placed on a part of the skin; suction adheres the cup firmly in place, producing a symmetrical bruise when it is removed. A fourth traditional skin therapy is moxabustion. A plant called moxa is set afire; the flaming plant is then placed directly against the skin. Sometimes, a cigarette is used. Each of these four dermabrasive techniques can be used as treatment for "wind illnesses," manifested by symptoms of cold, flu or headache. These techniques allow the toxins or excess energy or "wind" to escape. The following story provides an example of the tragic consequences of misinterpretation of these healing techniques.

An oft repeated story in the Southeast Asian community is one of a well-educated Vietnamese man who was placed in jail for child abuse. This man had practiced coin rubbing to help relieve the fever of his child. The child's fever was not relieved so the father brought the child to the hospital, where he was accused of child abuse. The man was so embarrassed that people had thought he had beaten his child that he killed himself while in jail.

Health care professionals need to take special care to ascertain if any of these four dermabrasive practices are being used to heal the Southeast Asian child before child protective services is notified. The ecchmoses, or blotches, caused by coin rubbing, cupping and pinching can be identified by their symmetry and well-defined borders, as well as their location: the markings are generally located at the site of the disease. Although moxabustion presents more of a challenge in identification, is should be considered.

Yet another potential child abuse charge relates to a skin condition, but one that is a normal skin pigmentation for noncaucasian children: rather large black-and-blue spots on the feet and/or buttocks. These spots usually disappear within a few years of birth. However, they have been mistaken for signs of physical trauma to children.

Hmong Misconceptions of US Health Practices

* Fear of Drawing Blood and Other Invasive Procedures. Because a hole is being established into the body, the Hmong believe the good spirits can escape, causing death.

* Shots and Medicinal Cures. Due to the ease in obtaining over-the-counter medications in Laos, Southeast Asians have become accustomed to the availability of drugs. They expect a prescription with a doctor visit. The overuse of antibiotics has also led to drug-resistant organisms, causing less acute disease pathology to take on increased severity in these patients.

* Surgery. The Hmong have a widespread fear of mutilation. They believe the soul also could leave the body through any surgical incision, which could lead to death. They view almost any invasive procedure as having long-lasting and multiple effects. This fear extends itself to a person even after death. For this reason, few Asians will consent to an autopsy.

Case Studies

These three short case studies involve actual incidents with patients I have cared for as a pediatric intensive care nurse. These incidents illustrate US and Hmong cultural differences and misconceptions.

* Premature Baby. A newborn infant of Hmong parentage was admitted to our neonatal intensive care unit. This child had many congenital defects, including anacephaly, extensive facial abnormalities and other internal defects. The child had been transferred to our facility by our staff. Before leaving the referring hospitals, then nurse talked with the father concerning his child. He listened politely to all of her explanations, then quietly said, "Baby no good; throw away." The child was kept comfortable in our institution and died within 24 hours of admission. The incident illustrates that Hmong value and quality of life above quantity. The father's answer might sound harsh and callous, but it is also valid. We did allow the baby to die, but in a way we considered culturally acceptable by our standards.

* Balloon Incident. Paramedics were dispatched to a residence to transport a six-year-old poisoning victim. When they arrived, they found a large Hmong family with no English speakers. The paramedics found a child close to the age of the supposed victim and began their assessment. Ten minutes passed before an English-speaking neighbor arrived. The parents had sat by passively while the paramedics examined the wrong child. Due to the language barrier, Southeast Asian passive behavior and their respect for authority figures, a tragedy occurred. The patient was not a six-year-old but a six-month-old. The father had held him in his arms, with a blanket covering him. The baby, who had been given a balloon to play with and had put it in his mouth, choked on it and suffocated to death. This child could probably not have been saved, but the incident tragically illuminates language and cultural barriers.

* Anti-Birth Control. A child was admitted to our intensive care unit with a diagnosis of respiratory distress. I recognized the parents from a previous admission; another child of theirs had been a patient in our unit and had, in fact, died there. The parents had not mentioned this to the emergency room doctor when he questioned them concerning this child. This family carries an inherited muscular wasting disease known as Werdnig Hoffman Syndrome. The father had insisted with the previous child, and still did in this instance, that his babies got this disease from the birth control pills his wife was taking. He had not allowed her to take them since the death of the first baby. They have 11 children alive currently; five others had died. The mother probably has at least 15 more childbearing years left.


Of the many differences between the US and Hmong cultures, those between the two health systems are critical ones. Having an increased awareness of the Hmong historical and cultural heritage can aid the health professional in understanding the situation of the Hmong within the US health system. In many situations, a combination of therapies from both cultures can easily be used if the client so desires. This "partnership" of methods should be encouraged and should not be used only in exceptional cases. Sensitivity to other cultures and their traditional value system is critical in health care. If one can bypass one's own ethnocentricity, caring for anyone who is culturally different can be a positive experience. Attempts are being made in this direction with the creation of a new health field called transcultural medicine and nursing. The transcultural model stresses compromise, emphasizing the patient's own culture without insisting he or she fit into ours because ours is the "right" one. The understanding and acceptance of the cultural values and traditions of a population is crucial in effectively caring for that patient as a whole person.

Article copyright Cultural Survival, Inc.

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