A Matter of Respect

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In Merced, you might stand next to a Hmong shaman in the line at a supermarket and not know it. You might see him wearing a hospital badge on his way to visit a patient. Or you might hear signs of the shaman when passing a ranch-style home: the resonating chime of a gong, the jingling of bells, a sing-song like chanting.

If you're Hmong, his presence might make the difference between staying in the American medical system or avoiding it all together.

A small man with gray hair and gentle dark eyes, Xeng Koua Moua is among the shaman healers practicing religious healing ceremonies in Merced who are recognized as such by the local hospital. He became a shaman at 19, when he was living in a Hmong village in the Phuyai Mountains of Laos and fell ill with fever, tremors and tingling. That's when his grandmother's spirit came to him and told him that he would be a txiv neeb, Hmong for shaman healer. A txiv neeb's job is to vanquish the illnesses that plague members of the community. To the Hmong, illness is often a sign that a spirit has been wronged, is seeking revenge or wants to settle a favor bestowed in the past. Or, as in Xeng Koua Moua's case, it's a time when ancestral spirits imbue you with the power to heal others.

Today, Moua is more than half a century and thousands of miles from the village where he began his work as a shaman healer, often walking past thatched-roof houses made of wood and bamboo, a nearby river and herds of cows, water buffalo and goats on his way to see patients. There the young Moua would visit families, carrying with him the tools of his trade: a wooden plank, bells, a rattle, a sword, split horns from the water buffalo and a gong.

Moua still works near herds of grazing cows, but on a rainy Saturday in early March he has unpacked his tools in the cozy living room of his nephew Francis' ranch-style home. Moua, now a master shaman, is performing a healing ceremony for Francis' mother, Blan Thao. Thao is also a shaman, whose broken arm has prevented her from healing others. Although she has had Western-style surgery on her arm, which is now in a sling, she has sought the traditional healing ceremony to appease the powerful ancestral spirit she believes is angry with her.

Moua is dressed in a black silk ceremonial jacket and is poised on the wooden plank in front of altars with offerings of herb-infused liquor, eggs and rice for the ancestral spirits. The sound of Saturday morning cartoons drifts in from an adjoining room where a teenage girl holding a baby and two younger children are transfixed in front of the television. As Moua unfurls the blue fabric tucked into his shaman hat, letting it fall over his face, his wife and assistant, Joua Vang, stands behind him, rhythmically hitting a large brass gong.

To heal others, a Hmong shaman such as Moua goes into a trance. In that state, the wooden plank becomes a horse on which the healer travels to the other side and fights with evil spirits or negotiates the terms of forgiveness with a wronged good spirit. In this case, a pig and two chickens will be sacrificed to give up their spirits as payment.

Reducing fear, instilling trust

Almost 70,000 Hmong populate California's Central Valley. The majority of non-native-born families, including Moua's, left Laos about 30 years ago because they would probably have been killed for collaborating with the United States. Many of the men had fought side by side with U.S. soldiers in Laos and behind enemy lines in Vietnam.

Having been in the United States for about three decades, Hmong, like other immigrants, have become part of the community's fabric. In the Central Valley, Hmong can be counted among the ranks of architects, business owners, teachers, school principals, social workers and pharmacists, among other occupations.

Another wave of refugees arrived as recently as October, following the closure of a large refugee camp in Thailand, to which thousands of Hmong had fled after Laotian communists prevailed in Laos and destroyed their villages.

Being an immigrant in an unfamiliar land is always difficult, but probably more so in the case of the Hmong, who had lived in remote mountains as farmers and did not read or write in their language. Many Hmong beliefs are also at odds with the practices of Western-trained doctors. Besides a belief system that accords the role of healer to the txiv neeb, the Hmong language, which wasn't a written language until 1951, doesn't have words for many Western medical concepts. Many Hmong, particularly those in the older generation and recent arrivals, have little confidence in Western doctors and avoid going to them. As a result, Hmong with preventable complications from a host of illnesses have been showing up at the emergency rooms of the local hospitals.

Marilyn Mochel, a registered nurse and diabetes educator who worked in public health in Merced for years, said she and colleagues were appalled by how close to death many Hmong were when they came in. "We saw ruptured appendixes, complications from diabetes, hypertension, end-stage renal disease, many more strokes and people presenting with end-stage cancers," she says.

To turn the tide, Mochel and Hmong community leaders, including shaman and health-care professionals, reasoned that teaching the culture's healers about Western medicine could reduce fear within the community and help the shaman and doctors better understand how they can work together to heal people. Although hard to quantify, their efforts have paid off. To date, 89 shamans have graduated from a shaman-training program that requires 40 hours of Western medicine classes. After graduation, shamans are given hospital badges that allow them unrestricted access to the local hospital to visit patients. It's now more likely, program leaders say, that doctors and shamans in Merced view each other with respect rather than bewilderment.

As the wife of one of the Hmong clan leaders in Merced, Palee Moua is a pillar of the Hmong community and a leader in her own right. A high-energy woman with a warm, raspy voice and dark eyes, she trains health interpreters to communicate the subtle nuances of her culture to doctors. She was also one of the developers of the shaman-training program offered by the nonprofit organization she works with, Healthy House. In a recent survey, the organization surveyed the Hmong shamans to understand the kinds of healing ceremonies they practice and the reasons their clients seek help. Among the ills, conditions, or end-of-life problems for which they perform ceremonies were to, "Welcome a child's soul, offer a cow to dead parents, treat a woman to get pregnant, and send spirit of death to heaven," to name a few roughly translated reasons from the survey.

Moua is well versed in the reasons many Hmong are averse to Western medical care. Some, she says, are rooted in a different worldview about how the body functions and its purpose. "Hmong people believe that when they're born that's all the blood they'll have," she says. "If they're skinny and they get sick and the doctor wants to take a blood test, they believe they'll lose blood and are afraid they'll feel more weak and black out."

And although nobody would welcome the news from a doctor that they need an organ or part of the body removed, for Hmong, it also has religious significance. It means that in their next life they'll be born without that organ or body part. Hmong are also wary of surgery because one's soul could wander away while they're under anesthesia.

The invisible world of spirits is a complex but comprehensible world to a Hmong shaman. Much more challenging is deciphering and believing in the invisible world of germs, which is among the subjects taught to the shamans. Other sessions required for shaman certification by Healthy House include instruction on diabetes, basic human anatomy and tours of the operating room and local cancer center.

On a damp evening in Healthy House's storefront office in downtown Merced, eight men and three women, aged mid-20s to 60s, listen intently as Dr. Timothy Livermore, Merced County's public health officer, attempts through an interpreter to explain germ theory and how tuberculosis is spread. All 11 attendees are Hmong shamans and recent arrivals to the United States. They came from a refugee settlement in Thailand and most spend a good part of the day in English classes; some are simply trying to set up home in their new country.

"When you cough and it gets on your hands, it's wet. These are germs you can't see with the eyes. 'So how do you get TB?' " Livermore asks, rhetorically. "Through coughing."

"If we're in the same family," interjects Healthy House's co-founder and clinical director Mochel, "and you have TB and you cough, the TB could come into my lungs."

"How does it travel to a person?" asks one of the shamans taking the training.

"Saliva stays on your hands," Palee Moua says. "It travels through the air," adds Mochel, moving her hand in an arc toward her mouth."

"And the lung is like a sponge -- it's mostly air," Livermore says. Silence and puzzled stares follow. Palee Moua launches into another explanation, which elicits nods of acknowledgement from several of the shaman. "I had to explain to them why air goes to the lung and not the liver. I said it's like a filter. It cleans the air that goes into the body."

In the ensuing class germs are likened to seeds. A book of pictures of microscopic organisms is passed around the room. Two interpreters try explaining how a microscope magnifies. The shamans look through a microscope for the first time and view human hair mounted on a slide. "If this can make a hair as big as my finger, than I believe it could show a virus!" declares Ka Yeng Vue, a female shaman who appears to be in her early 30s.

Besides wanting to grasp a basic understanding of Western medicine as healers, some class members have had personal experiences with physicians in a refugee camp in Thailand that left them mistrustful of Western medicine. A 2004 report by the Southeast Asia Resources Action Program on Wat Thamkrobak, the camp many of the new refugees came from, described it as grim: Impoverished Hmong day laborers plagued by malnutrition and inadequate health care, fenced off by barbed wire and guarded by Thai military.

"My mother had tuberculosis and the doctor would come to her to give her the medicine accompanied by a soldier with a gun," says Doua Moua, a young man with pensive eyes, who uses his hands to emphasize his point as he speaks.

During a break in the class, Yer Thao, a woman with waist-length silky, black hair relays through Palee Moua a similar experience. "The Thai doctor we knew was a good doctor, and would treat people and give X-rays [to see if people had TB]. And then when Hmong started leaving, he knew he wouldn't make as much money. We had to pay more for an exam, and we would be frightened, because he wrote down the wrong results for people. He would say, 'You have TB, you can't leave.' "

"This is true," interjects Palee Moua, who visited the settlement with a group from Healthy House in 2002. "When we were there we saw this happen. Those who had money went to town and saw separate doctors, who'd say, 'You don't have TB.' ''

Although the shaman-training program began before the current class members arrived, the widespread fear and distrust of Western doctors helped spur Mochel to expand it. "By offering the shaman class," says Mochel, who has red hair, clear green eyes and a calm demeanor, "at a minimum, we're reducing fear within the community."

The program is gratifying to both doctors and the shamans involved in it; however, the clash of cultures also makes it challenging. Decisions about how to interpret information from doctors both in and out of the class are a constant balancing act.

"You have to be very careful," says Changvang Her, the director of language services for Healthy House. He has had to intercede on many occasions in his job as health interpreter in the emergency room at Mercy Medical Center Merced Hospital.

"While interpreting, if a doctor says, 'You have cancer, you have about six months to live,' I'd say, 'Are you sure you want to say that?' It's very offensive to Hmong," he says, explaining that it's seen as putting a curse on them.

"When you predict death, it means you're going to make death happen," agrees Mochel, adding that she would recommend telling the family in a less direct way.

But both sides agree that the training has led to more contact between shaman and doctor in-patient care. "If a patient is having nightmares, hallucinations or is screaming out, I'll get a call from the hospital," says Maxwell Moua, a previous graduate of the shaman training program who has lived in the United States for 30 years, and has owned a pizza parlor, janitorial franchise, mini-pantry store and worked with refugees. "I'll go to the hospital and bring khawr koob (magic healing) to chase the ghosts away," says Moua, who has retired from his other work in Fresno. "Hmong become afraid in the hospital because they think that because a lot of people die there that their ghosts stay there."

Not surprisingly, doctors and hospital staff have had to make adjustments in how they view what heals a patient. Dr. Pamela Roussos, who has taught sessions of the shaman-training program and attended shaman healing ceremonies as a guest, recalls standing with a more experienced colleague when she was a new resident at Mercy Medical Center Merced in 2001 and asking in astonishment, "Why are those people killing chickens in the parking lot?" Without missing a beat, she says, the colleague explained, "Because we told them they can't do it in the hospital. They do it as part of a ritual for very sick people."

Roussos, who is in private practice in family and osteopathic medicine in Merced, says that learning more about the shaman and Hmong culture has broadened her view of healing. "Sometimes a [Hmong] patient with diabetes may have it under control but wonders if there's anything more they can do. In that case, there's nothing wrong with referring them to a shaman," she says.

Mochel sees the shaman training program as a beginning step. Already, shaman have changed their advice following a presentation on how medication could reverse or prevent damage in someone having stroke symptoms. "They said, before we would do ceremonies and tell them to wait three days before sending a family to medical services. Now that we understand, we'll send them immediately to the emergency room."

Thoroughly assimilated

Back in the cozy living room of the ranch-style house where master shaman Xeng Koua Moua was working, the offended good spirit of Blan Thao appeared to be partially satisfied with the offering in the healing ceremony he had conducted. After he came out of the trance, Moua observed the response of the spirit in the tongues of the chickens that were sacrificed.

The kitchen is bustling with men and women preparing Hmong pork and chicken dishes from the sacrificed animals, and vegetables and rice, as more family members arrive for a feast. Moua is about to pose for a picture, but the shaman master has one important thing to do first. As the guests look on with interest, he pins on a small laminated card with a photo of himself in a pointed blue shaman's hat. It's the Merced hospital badge he received when he completed the shaman training program.

Healthy House is at www.healthyhousemerced.org.

Laurie Udesky is a San Francisco journalist. Her work has appeared in Salon.com, Lancet and the Dallas Morning News.