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LISA L. CAPPS Division of Nursing North Park College Chicago, Illinois

Change and Continuity in the Medical Culture of the Hmong in Kansas City

The Hmong in the United States have undergone radical culture change through their recent experiences of the war in Laos, refugee resettlement, and Christian conversion. This article analyzes the influence of these changes on the health ideas and practices of the Hmong in Kansas City, the primary study population. Although shamanism andancestor worship have been abandoned, attenuated concepts of spirit illness and soul loss exist in health beliefs and patterns of illness, notablyfright illness (ceeb). Their eclectic set of ideas and practices is derived fiom several systems, including Chinese medicine, Protestant Christiania, and biomedicine. To explain the varied health ideas and practices, Last’s concept of medical culture is usefit1 because it provides a framework for understanding medical traditions drawn from differing cultural systems. The Hmong have created a unique medical culture through their incorporation of new therapies as well as the use of some traditional methods of healing. [Hmong refugees, medical culture, Southeast Asia, Christianity]

he Hmong refugees of Kansas City have an eclectic set of health beliefs and practices variously influenced by their long history of migration and contact T with other ethnic groups, their relatively recent adoption of Protestant

Christianity, and their interaction with Western biomedicine. Concepts of health and the treatment of illness have undergone dramatic change with the abandonment of shamanism and ancestor worship. Christian practices, such as individual and group prayer, now play a large role in the Hmong response to illness; Hmong herbalists and Western biomedicine remain vital to community well-being. Never- theless, certain continuities of Hmong beliefs regarding illness causation, patterns of response, and treatment remain. The Hmong of Kansas City draw ideas and practices from biomedicine, Chinese traditions, and Christianity selectively, ac- cording to a variety of circumstances.

To examine the eclecticism in Hmong health ideas, I apply Murray Last’s concept of medical culture (198 1, 1992). The concept of “medical culture” offers

Medical Anthropology Quarterly 8(2): 161-177. Copyright 0 1994, American Anthropological Asso- ciation.

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a looser and more general framework for understanding the health traditions of an ethnic group such as the Hmong than does that of medical system. Medical culture has been defined by Last as “all things medical that go on within a particular geographical area” (1981:388) or “composed of competing systems derived from distinct cultural groups” (1992:M). This definition originates from his work with the Maguzawa Hausa of northern Nigeria, where a wide range of therapies and ideas developed following contact with reform Islam, the introduction of Western medicine, and the loss of various traditional health practices (Last 1981).

The salient idea of a medical culture is the lack of a consistent body of theory of medical ideas and practices (Last 198 1); a significant aspectof a medical system, on the other hand, is the coherence of its theories (Leslie 1976a:ll) and the organization and power of its practitioners (Last 1992). For medical beliefs and practices to form a “system,” the following must be present: (1) a group of practitioners who adhere to acommon, consistent body of knowledge and practice according to logic deriving from that theory; (2) patients who recognize such a group of practitioners and such a consistent body of knowledge; and (3) theory that explains and guides treatment of most illnesses in the society (Last 1981:389).

In the medical culture of the Hmong of Kansas City, parts of different systems are incorporated and intertwined, yet not attached to any overarching theory. Health ideas and practices are adopted from Hmong traditional culture, Chinese medicine, Christianity, and Western biomedicine. Hmong practitioners apply similar concep- tions of body functioning and pathology recognized in patient treatment; however, Hmong healers do not have associations, licensing, or exams to provide consistency to their work. Like many in the general population, the Hmong have difficulty accepting the logic of the theories that form the base of biomedicine, although they seek care from biomedical practitioners. With relocation to Western countries, the Hmong are exposed to new concepts when chronic illnesses, such as cancer, stroke, and diabetes, are diagnosed by biomedical practitioners. Conversion to Christianity has alsocontributed to changes in ideas about illness causation. The new ideas about causation and diagnosis pose difficulties in treatment because traditional theory and methods now cannot explain or heal such illnesses. Given the fragmented borrow- ing of health traditions among the Hmong in Kansas City and absence of practitio- ner organization, Last’s medical culture concept is particularly relevant.

The Hmong health setting represents a type of medical pluralism, which entails the presence of differently designed and conceived medical systems in a single society (Janzen 1978:xviii). Janzen found in Kongo society that separate, yet complementary, systems exist and are integrated in various illness episodes. Ideo- logical dichotomies of illness, namely illnesses “of God” and illnesses “of man,” determine the therapies (Janzen 1978:8; see also Leslie 1976b on medical plural- ism).

Crandon-Malamud (1991) builds upon Janzen’s earlier work in medical pluralism (1 978) by demonstrating the historical and political-economic context in which marginalized Aymara and mestim residents of Kachitu, Bolivia, choose and manipulate therapy systems to deal with change and to affect social relationships outside the medical context. In this setting, the experience of alienation gives rise to different therapies.

In the case of the Hmong in this study, medical pluralism evolved from historical patterns of war and migration and from recent experience as Christian

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converts and refugees in Western society. Hmong medical culture reflects their long history of migration and interaction with different traditions. Like the Kachitufios (Crandon-Malamud 1 9 9 1 ) . the Hmong choose among different therapeutic ideolo- gies to alter social relationships and to create access to secondary social and economic resources (see Unschuld 1975). For example, by becoming Christians and changing religious medical ideology and practice, Hmong gained access to valued social and economic resources, primarily literacy and material benefits, by forgoing expense of traditional ritual practices (Tapp 1989b94,IOl).

In the Kansas City setting, Christianity provides a means for the Hmong to reinforce their cultural identity as they gather in their own churches and at the same time to “fit into” mainstream U.S. society. Ethnic and clan solidarity is enhanced at times of illness and misfortune when relatives, healers, and the Hmong church community gather for support. Through contact with other Christian religious groups, the Hmong expand their social networks both within and outside Kansas City. The Hmong in Kansas City also include ideas and practices from Western biomedicine, but, in many cases, Hmong ways of healing are seen as superior, enhancing their sense of membership in a distinct ethnic group. The varied ideas and practices in their medical culture provide diverse health and social resources essential to a people who have undergone significant change and experienced trauma as refugees.

This article addresses the relevance of Last’s medical culture concept in explaining the changes and continuities in the medical culture of the Protestant Hmong in Kansas City. My analysis gives attention to the historical events that led to the development of present health ideas and practices and the juxtaposition of Hmong health culture and Western biomedicine.

Christianity and Medical Pluralism in Hmong History

History of the Hmong

The Hmong have a long history of migration, culminating in movements as refugees during the later half of this century. This history has exposed them to a variety of ideas and practices related to health and healing from Asia and from the West.

The Hmong lived along the fertile plains of both the Yellow River and Yangtze River between 2700 and 2300 B.C. (Geddes 1976:5).’ Numerous conflicts with the Chinese occurred during the various dynasties in China, resulting in frequent migrations of the Hmong. Following the uprisings of 1698,1732,1794, and 1855, the Hmong began migrating southward into Vietnam and later into Laos, Thailand, and Burma (Quincy 1988:61; Wiens 1954:90). Today, some five million Hmong remain in China (Tapp 1989b 18).

The Hmong in China and Indo-China live in mountainous areas at altitudes of 3,000 to 6,000 feet. They are a patrilineal society practicing clanexogamous marriage. Beginning in 1962, the Central Intelligence Agency of the United States (CIA) recruited them for assistance in the so-called “secret army” during the war in Laos (Branfman 1970:243). This set in motion a series of events that eventually led to their resettlement in the United States.

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The Hmong of Xieng Khouang province in Laos, where the majority of Hmong now living in Kansas City originate, were particularly affected by the Indo-China war. The death toll was heavy, not only because of fighting, but also because of starvation and disease during forced migrations within the country. After the fall of Laos in May 1975, thousands fled to Thailand where they lived in refugee camps until their resettlement in various countries, including the United States, Canada, France, French Guyana, and Australia. Since their move to primarily urban and highly technological environments in the United States, the Hmong have undergone further change as refugees.

Christianity in Hmong History

In the late 16OOs, a Jesuit in China was one of the first missionaries to have contact with the Hmong (Radley 198636). In 1895, James Adam of the Protestant China Inland Mission lived with the Hmong in Y U M ~ Province and learned their language (Hudspeth 1937:32). By providing the Hmong quinine and other simple medicines, he was able to interest them in Christianity. Clarke (1911:172-174) reports that by 1900, Hmong began coming from 250 villages for biblical instruc- tion. At this same time, Methodist missionary Samuel Pollard constructed a mission station and a school to which the Hmong flocked in numbers. In response to epidemic smallpox, Pollard began vaccination of the villagers and “brought hun- dreds toChristianity”(Kendal1 1954:142-143; Pollard 1919:191).PoIlard invented the first Romanized script for the Hmong language in which the Bible was later printed.

In northern Laos, the first Protestant mission station was opened by the Christian and Missionary Alliance in February 1929 (Ekvall et al. 1939:242). Later, during the 1940s and 195Os, Protestant missionary activity brought about a large number of Hmong conversions, particularly in the province of Xieng Khouang (Barney 1978[1957]; Smalley 1978[1956]).

By 1954, there were 4,000 Hmong Christians in 96 villages in Xieng Khouang, with 42 percent of the villages professing to be entirely Christian (Barney 1978[1957]:472). Many of these conversions happened during a time when the North Vietnamese were launching attacks throughout Laos (Menger 197012). At the same time, the Hmong were increasingly coming in contact with Westerners as the war escalated. Western medicine was proving effective against disease. The Hmong became engaged in millenarian activities bringing attempts at synthesis of indigenous ideals and newly imported concepts (Menger 1970:196; Tapp 1989x78).

During the war, because of frequent moves from areas of fighting and the lack of domestic animals for sacrifice, shamanism and ancestor worship became diffi- cult, and many abandoned these traditional practices (Kuhn 1956236).3 When people converted to Christianity, Protestant missionaries required that traditional practices be given up and that protective neck rings, shamans’ drums, and spirit implements be destroyed (Clarke 1911:180-181; Tapp 1989b:lOO). In contrast, Catholic missionaries have been more tolerant of Hmong traditional beliefs and practices, such as shamanism and ritual soul calling (hu p l i g ) , and have allowed such practices. Tapp (1989b: 100) cites this as a reason for the association of Hmong messianism with Protestant, as opposed to Catholic, forms of Christianity.

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The Study Populations and Research Methods

I collected information for this study in Kansas City, Kansas, and in Mae Sa Mai village in north Thailand, but the primary focus is on the Hmong community in Kansas City. In January and February 1990, I lived in Mae Sa Mai to observe and interview people in a community similar to the Kansas City Hmong.4

Hmong have lived in Kansas City, Kansas, since February 1976. At the time of the study in fall 1989, the community had 632 people, including three families that lived in Kansas City, Missouri. The Hmong in Kansas City are d l Protestant Christians. Those who desire to maintain the traditional practices of ancestor worship or shamanism generally do not stay long in Kansas City because they find little community support for traditional practices. Rather, they settle in other, more heterogeneous Hmong communities in the United States, such as those in Fresno, California; Minneapolis-St. Paul, Minnesota; and Providence, Rhode Island.

The majority of the Hmong in Kansas City are members of the First Hmong Christian and Missionary Alliance Church; a smaller number are members of the First Hmong Baptist Church. Loyalty to previous religious affiliation or to reset- tlement sponsors are the reasons for the maintenance of the two separate churches.

Hmong in both Kansas City and Mae Sa Mai are mainly of the Blue or Green Hmong (Hmoob ntsuab) dialect group. The Hmong village of Mae Sa Mai is located 30 miles north of Chiang Mai in northern Thailand. Mae Sa Mai has a population of 1,076. Most people practice the traditional religion, although there is a Protestant church offering services for the approximately 100 Christian Hmong.

I first became involved in the Hmong community in Kansas City through my work as a nurse practitioner from 1980 to 1982. My role as a nurse was apparent in later fieldwork when community members requested that I accompany them to visit hospitalized relatives and attend clinic appointments to facilitate communica- tion or to provide support in negotiation of biomedical treatments.

In Kansas City, research methods included participant observation and open- ended interviews with Hmong community leaders, church pastors, herbalists (kws rshuaj], and others. I was able to speak Hmong on an elementary level but was assisted by interpreters for Hmong who did not speak English. 1 followed several families through illness episodes in hospitals, at clinic visits, and at home during their illness and recovery. I also visited women in hospitals or homes who had recently given birth.

Traditionally, there is a wide range of healers in Hmong society, including the shaman (rxiv neeg), the sorcerer-magician (khawv b o b ) , the fortune-teller (saib yaig), herbalist (kws tshuaj), and bone ~ e t t e r . ~ The different kinds of healers may show some similarities in practice. For example, a shaman may also have a broad knowledge of herbal medicines. In Kansas City, one sees in practice only herbalists (kws tshuaj), who specialize in herbal and massage treatments. The four Hmong herbalists in Kansas City were women who had learned their craft from relatives who were healers and who were thought to have a gift for curing. They allowed me to observe their treatment of patients in their homes. I observed a total of 20 patient cases in which illness was dealt with by biomedical, Hmong, or combined methods of healing.

In addition, I attended Hmong church services bi-weekly, including both the weekly prayer session and sermon. Sermons were taped, translated by a Hmong

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interpreter, and analyzed for key concepts relevant to health. Prayer sessions provided an understanding of individual and community concerns, illnesses, and misfortunes, and how these events were dealt with by the Hmong community. Life histories of six individuals were recorded to provide a perspective on illness management in Laos, on experiences during the war and the refugee camp intern- ment, on reasons for conversion to Christianity, and on the transition to American life.

In Mae Sa Mai in north Thailand, I interviewed members of 15 Christian households regarding reasons for conversion to Christianity and how this affected their health practices. Three shamans (fxiv neeb) allowed me to observe their healing rituals; one shaman and one sorcerer-magician (khawv koob) allowed an interview. An interpreter helped me with interviews and the interpretations of ceremonials and translations of three recorded church sermons by Hmong lay pastors. This field experience provided information on life in a Hmong village, traditional religion, religious conversion, and health care.

Change in Health Ideas and Practices as a Result of Christian Conversion

One focus of this article is changes and continuities in Hmong health ideas and practices. Continuity in idea systems has been demonstrated in other groups in which millenarian activities developed following contact with Western culture and Christianity (Burridge 1969; Frankel 1986; Janzen 1977, 1979; Worsley 1986). Frankel found that the adoption of Christianity among the Huli of Papua New Guinea occurred in response to European influence and the concordance of Chris- tian beliefs to their own (1986:37). Similarly, Hmong in Kansas City demonstrate certain continuities in ideas about illness, particularly its moral and spiritual dimensions, despite the loss of many ritual practices, including shamanism and animal sacrifice, as a result of Christian conversion.

The Hmong in Kansas City have responded to abrupt culture change by incorporating specific elements of Protestant Christianity and biomedicine. At the same time, they disregard some concepts from their traditional medical culture, such as soul loss and spirit illness; however, elements of these concepts remain for some in ideas about illness and misfortune.

Because of these changes and the varied repertoire of ideas in health and illness, the concept of medical culture, as opposed to medical system, is useful in providing a framework with which to comprehend the fragmented borrowing from differing systems.

Abandonment of Shamanism and Ancestor Worship

Of the many changes following conversion to Protestant Christianity among the Hmong in Kansas City, the loss of shamanism and ancestor worship are the most dramatic. The costly burdenof animal sacrifice in the practice of the traditional religion has been a major reason for conversion. Cooper (1984 198) found that the poorer Hmong in Thailand, who lived isolated from family and kin networks, found that Christianity enhanced their survival by relieving them of expensive ceremonial ritual. Lack of effectiveness of shamanistic ritual in curing illness was also a reason for many conversions. One man in Kansas City told me that a shaman had been

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unable to cure three of his children who died of sickness. After his third child died, he became a Christian. Another man mentioned the difficulties of carrying out traditional ceremony during wartime: “In Laos, during the war, people had to move many times. There were no pigs or chickens for ua neeb [ritual shamanic healing]. If one became Christian, no one would have to sacrifice or do the Devil-way again.” Protestant Christianity offered a powerful alternative that afforded protection and healing.

The conversion to Christianity has brought a complex interweaving of Hmong indigenous ideas and practices with Christian traditions. In part, this has been influenced by missionaries who drew from applied Hmong traditional cosmology in their attempts to convert the Hmong, showing that Hmong beliefs align with Christian doctrine and deities. The devil is referred to as dluab (spirit), suggesting that all spirits associated with the traditional religion are now evil. In the traditional religion, relationship to the spirit world is critical to social life and well-being, and this relationship is also important in Protestant Christianity.

The Hmong in Kansas City say that because they are Christian, ancestral (dluab m m dlaab rxiv) and nature (dluab qus) spirits are no longer influential in health or illness. People believe they are protected by a more powerful spirit, the Holy Spirit of the Christian Trinity. There is, however, ambiguity surrounding the idea of spirit illness, and this is evident in several cases. For example, a Kansas City man believed his daughter’s death may have been related to some wrongdoing and the influence of ancestors. Even in Mae Sa Mai, a young Protestant man attributed his frequent headaches to an attack by a wild jungle spirit (dlaab qus).

In another case, a 72-year-old woman living in Kansas City complained of back pain, which she attributed to sorcery in Laos. The cause of her pain was a “devil rock” (dluab pob zeb), placed by the sorcerer (khawv koob), which moved around in her body causing pain in her legs, arms. head, and neck. Since coming to Kansas City, she had seen several physicians who gave her pills that provided no relief. Because she had converted to Christianity, she said she could not seek help from a shaman or khawv koob to reverse the sorcery. To relieve pain, she applied melted beeswax or a topical Asian menthol preparation and prayed. I later asked my interpreter why the woman did not see a shaman for treatment (a shaman can remove the stone by sucking it from the painful area). He was aghast and responded, “Can you imagine how the Hmong community would respond if she went to the shaman? Everyone is Christian here and she would be rejected from the community.” He went on to explain, “If she did seek help from a shaman, who has a connection to the devil, she may get worse or die because Satan has more power.” By taking recourse to non-Christian ways, one has less protection from God and could be more vulnerable to Satan. In some Hmong communities where there are no practicing shamans, a shaman living in another community may be contacted by telephone for intervention in illness (Bruce Bliatout, personal communication); however, I did not find this among the Hmong in Kansas City.

For the Hmong in Kansas City, the orientation to and interaction with the spiritual domain influences health and well-being. In traditional society, improper behavior may provoke ancestral spirits to withdraw their protection, allowing evil spirits to attack. Despite conversion to Christianity, continuity of ideas is evident in Protestant Hmong beliefs that sin displeases God, who withdraws his protection, allowing the devil to cause illness and misfortune.

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In the Protestant view, the pastor is the mediator between God or Jesus and man. The shaman, who in traditional Hmong cosmology is the mediator between the spirit and human worlds, is viewed by the Hmong of Kansas City as the mediator between the humans and the devil. Any association with the traditional spirit world is evil. These viewpoints pose a conflict between traditional and Protestant Hmong.

For the Hmong in Kansas City, belief in Christianity is integral to the response to illness and to maintaining the health of the individual and community. Bi-weekly prayer sessions at the churches help the Hmong deal with illness and crises such as job loss, infertility, or family conflict. In group prayers, people express their despair over illness and misfortune and request healing. Prayer helped one young Kansas City man who attributed his chronic stomach pain to his life in the jungles of Laos while he was trying to escape. Although he had an extensive medical evaluation and treatment, he felt his successful recovery was the result of prayer and treatment from a Hmong healer. In another case, prayer and biomedical care were deemed significant in saving the life of a young boy who suffered a serious accidental injury. Prayer is believed to resolve misfortune and illness and secure future blessings of health and well-being. Through public prayers at critical periods of illness and misfortune, people receive personal support and the community strengthens its sense of ethnic solidarity.

Change in the Idea of the Soul

A significant change for the Hmong of Kansas City following conversion to Christianity is in the notion of the soul. Traditional belief says that each person has multiple souls, which may wander or leave from fright or illness. According to different reports, there are varying numbers of souls (ntsuj or plig), generally ranging from 3 to 12 (Bernatzik 1970:219; Bliatout 1986:351; Chindarsi 1976:30). The Christian Hmong consider one soul to be bound to the body, not wandering or leaving during illness. Only at death is the soul sent to live forever in heaven or hell. Kunstadter discusses these conceptual changes regarding the soul among the Christian Lua’ and Karen in Thailand, whose beliefs are similar to those of the Hmong in Kansas City:

Christians may believe in souls, but not in soul loss as a cause o r concomitant of illness, nor in wrist binding as a therapeutic activity. They are allowed to believe in devils, but are not allowed to believe that forest spirits can be propitiated by direct animal sacrifices; thus traditional techniques depending on communication with these spirits are no longer relevant, nor is consultation with native specialists, except for symptomatic relief by use of herbs, or other physical or material techniques. [Kunstadter 1978:207]

Despite the adoption of the Christian idea of the soul, some Hmong continue to grapple with the contradictory notions of the soul in Christianity and the traditional religion. The persistence of certain illnesses, notably fright illness (ceeb), is related to this ambiguity.

In Kansas City, rituals for calling the soul (hu plig) at critical life junctures, including birth and serious illness, have been replaced by prayer. Protective neck, ankle, and wristbands, which hold in the souls and act as symbolic protective barriers, have been discarded along with the spirit implements used in ritual

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ceremonies. Animal sacrifice as a ritual exchange for soul loss no longer plays a role in these events, but animals are still killed and eaten at marriage and funeral ceremonies, as well as at the New Year (see also Symonds 1991:66). In Mae Sa Mai, I observed Christian families helping with ritual healing when a non-Christian family member was ill. Thus, the integration of certain traditional beliefs and practices continues despite Christian conversion, adding to eclecticism in the medical culture.

The Adoption of Biomedicine

Biomedicine is included in the plurality of resources in Hmong medical culture. Although biomedical resources were available in Laos, such health care was scarce, located primarily in the lowland areas, and not easily accessible to the Hmong. In Laos, the Hmong became familiar with biomedicine from their contact with Westerners during the Southeast Asian war. In Thailand, there are a number of resources available, including mobile clinics, some locally based clinics, and hospitals in Chiang Mai and Chiang Rai. Biomedical services are also available to the Hmong in the refugee camps in Thailand.

Biomedicine is part of the diversity in Hmong medical culture. It plays a minor role in Hmong ideas about health and illness but is used for the treatment of certain illnesses and injuries. Although biomedicine has its place in Hmong health care, in some cases it is thought to be potentially dangerous (Hurlich eta]. 1986:427; Kirton 1985: 135). Resistance to invasive biomedical procedures, such as venipuncture, is common among Southeast Asian refugees for several reasons including fear of causing humoral imbalance between hot and cold, as well as the absence of such techniques in traditional medical practice (Muecke 1983). For example, some of the Hmong in Kansas City were concerned that giving blood for laboratory testing may cause weakness or illness or that blood could be sold for American use. Surgery or autopsy is feared by those who practice the traditional religion because the disfigurement of the body may prevent the reincamation of the soul (Finck 1984). Among the Hmong in Kansas City, religious conversion and changes in the idea of the soul have resulted in less conflict surrounding necessary surgeries. Neverthe- less, biomedicine is used with some reluctance and ambivalence, in part, because the theoretical practice base is unfamiliar.

The Hmong of Kansas City seek biomedical care for a variety of health problems including local and systemic infection, traumatic injuries, acute illness, and chronic illnesses, such as hypertension and diabetes. They also purchase various over-the-counter medications such as aspirin or decongestants. These medicines are said by some Hmong to be more effective than Hmong herbs. Lack of health insurance or money to pay for preventive, as well as curative, biomedical care is a barrier for many. Women seek prenatal care and routine immunizations for their children; other preventive services, such as for routine physical examinations, are rarely used. Though not recognized as constituting a system, biomedical treatments function as alternative health care methods for the Hmong.

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Continuities in Health Ideas and Practices

Chinese Medical Ideas

Hmong traditional medical culture, albeit uniquely Hmong, includes elements of Chinese medicine. Historically, the Hmong have selectively borrowed from the Chinese. This pattern has been, in part, related to their marginal status as minorities in China and their migratory response to social pressure. One Kansas City Hmong man explained that because the Hmong were so highly migratory in China, they did not have time to acquire the system of Chinese medicine and gathered only bits and pieces of it. The adoption of Protestant Christianity has also changed some ideas integrated from the Chinese, including soul loss and spirit illness. For example, among the traditional Hmong, angry spirits may cause stomach pain, diarrhea, or vomiting (Westermeyer 1988:774); whereas, theHmong in Kansas City may attribute such symptoms to improperly prepared food.

Hmong medical culture includes a fragmentary representation of the Chinese medicine of systematic correspondence (1028 B.C. to 257 B.C.), which integrated several paradigmatic worldviews that today are associated with traditional Chinese science in general (Unschuld 198551).

Similar to use in Chinese medicine, massage and herbal medication is used by Hmong herbalists (kws tshuaj), as well as by others, for treating family members. Other elements of Chinese medicine include the treatment of fright illness with massage and liniments (Topley 1970; Veith 1966:211) and the belief that the circulation in the arteries and veins ceases with fright (Veith 1966:211). Fright may also precipitate soul loss among the Chinese (Topley 1976:255). The Chinese humoral concept that excessive emotion can cause illness and alter biological processes (Leslie 1 9 7 6 ~ 1 ) resembles Hmong ideas on emotions and health.

Massage for fright illness (ceeb) generally begins at the head and extremities, moving toward the center of the body. When massage is done in this manner by a shaman, it is symbolic of gathering the lost soul back into the body. At the same time, the shaman calls for the soul (Thao 1984325). Hmong healers in Kansas City, on the other hand, may offer a prayer after the massage treatment. Coin-rubbing (kaav), a type of dermabrasive massage, is applied to treat a variety of symptoms, including myalgia, headache, and fever. It brings to the body’s surface internal disease represented by the ecchymotic area on the skin or blackening of the silver bar or coin used in rubbing the skin.

The Hmong practice of needling (nkaug) is similar to that of the Chinese; the Hmong did not, however, develop or apply the complex techniques of acupuncture practiced by the Chinese (Bliatout 1986:358). In Chinese thought, needling releases bad blood, evil air, or may stimulate the flow of ch’i influences (Unschuld 198596; Veith 1966:65). The Hmong view needling as releasing bad blood or air: but they do not have a concept similar to ch’i. Needling is used by the Hmong in Kansas City for a number of ailments, including stomach ache, headache, and fright. It appears to be a highly significant technique in dealing with health emergencies as well. I observed this treatment in the case of a woman who had become quite angry and “fainted” as a result of her daughter’s insulting comment. Several Hmong attending to the woman vigorously massaged her upper and lower extremities with Tiger Balm ointment and sprinkled a menthol and camphor lotion on her body. A

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church elder firmly patted her skin (creating an ecchymotic area) starting at the anterior of the elbow on both arms. He then pricked (nkaug) the ecchymosis with a sewing needle and squeezed the skin to insure release of the “bad blood” that had accumulated from the anger. The same technique of vigorous massage and needle- stick was used on the fingers of both hands, back of the knees and toes, and the sides of the patient’s neck. Throughout this treatment, the woman remained immobile and rigid. Following the crisis, the pastor led the group in prayer for the woman. A few minutes later, she opened her eyes and moved her extremities. I was told that the treatment of massage and needle-stick was done to “help get the blood moving again” and to “prevent a heart attack or stroke,” which could have been the outcome of her anger. I was told that for this case Western medicine would not be useful. One man said, “The American doctors would only put in an IV, and she could still have a stroke.” He also commented that the treatment was like acupunc- ture the Chinese use and was learned by the Hmong from the Chinese.

Humoral medical concepts derived from Chinese medicine are not systemati- cally represented in Hmong ideas of health and illness, but are notable particularly within the context of childbearing. With the exception of the postpartum period, humoral qualities of food or medicines do not seem to play a large part in treating illness or maintaining health. In one case of infertility in a Kansas City couple, however, a difference in hot and cold qualities of the blood of the couple was thought to have caused their inability to have a child.

Postpartum practices include specific dietary and activity restrictions. For at least 30 days after delivery, the mother is vulnerable to illness and must eat hot foods, drink warm liquids, and avoid food symbolically or actually cold in tem- perature. Drinking warm fluids also prevents the congealing of postpartum blood flow (as well as monthly menstrual flow) and sickness (Thao 1986:370). The postpartum woman sits by a warm fire or heater and wears warm clothing, including a head cover. Scarves worn by postpartum women (and the elderly) are said to prevent headaches and osteoporosis in old age (Hahn and Muecke 1987; La Du 1985; Nyce and Hollinshead 1984; Symonds 1991).

Other similarities to Chinese health beliefs are seen in specific Hmong illnesses, such asfuab illness (illness caused by offensive odor or food resulting in an “allergic reaction”), in which fried foods (symbolically associated with heat) are avoided to prevent worsening of the illness and possible death. Among both the Chinese (Topley 1970) and the Hmong, fried foods are also avoided when measles or chicken pox occur. Thus, there are a number of similarities between Hmong and Chinese beliefs about health and illness, yet Chinese ideas in Hmong medical culture are neither highly developed nor systematic.

Fright Illness and the Concept of Soul Loss

Significant in the continuity of Hmong health ideas and practices is the persistence of specific Hmong illnesses, in particular fright illness (ceeb), which is common in the Hmong community in Kansas City. Commonly stated causes of fright illness are sudden immersion in cold water, a startling noise, a car accident, and being chased by adog. Fright illness is viewed as most common among children because of the traditional concept that their souls are less firmly attached to their bodies. In fright illness, elements of traditional concepts of soul loss and regenera-

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tion are maintained, albeit in a different form. Rather than citing soul loss as the etiology of the illness (Thao 1986:367-368; see also Kunstadter et al. 1986:62), the Hmong in Kansas City describe ceeb as a physiological problem primarily affecting the flow of blood by slowing the blood flow and pulse rate. They say the veins are too tight and clamp down, resulting in the slower blood flow and cold extremities. Cooled blood is seen as dark, thick, and bad (Munger 1986:393). People say that the cooling of the extremities may be progressive, and if it reaches the trunk and heart, the result can be fatal.

Whereas the traditional Hmong may use the soulcalling ritual or treatment by a shaman for ceeb, the Hmong in Kansas City use massage and prayer. Massage opens the veins, and it is often used with a warming ointment such as Tiger Balm or with chopped ginger. One young woman in Kansas City, whose 4-month-old baby was hospitalized because of a fever, told me her baby had ceeb, yet Hmong healers were not allowed by the medical and nursing staff to do massage therapy. Although the baby’s mother used biomedicine, she did not know the biomedical diagnosis or understand the medical treatments. She took her baby to a Hmong healer after hospital discharge for treatment of fright illness (ceeb).

In Kansas City, one case was reported in which soul loss was said to have occurred. Mai, a widow, developed ceeb after she dreamed of a puj ntmog, an ominous spirit that can take away the souls of the living.’ This occurred after the death of two Hmong males in Kansas City. When Mai came to the emergency room after developing chest pain and shortness of breath, she was diagnosed with esophageal reflux and depression and sent home with antacid and antidepressant medication. Shortly thereafter, Mai went to a Hmong herbalist for massage for fright. Mai’s dream was interpreted by some to mean that the ancestors were returning to take Mai to the other world or that they desired food. Although Mai never gave such interpretations, she stated that massage and prayer were most helpful in her recovery. This case demonstrates continuity of traditional Hmong ideas in illness and the salience of Hmong therapies for healing.

Although the concept of soul loss does not assume a central role in Protestant Hmong worldview, fright illness remains a valid diagnosis in the Hmong commu- nity. The persistence of this illness preserves central themes in Hmong medical culture and provides a base for maintaining illness as identity (Hawood 1981; McClain 1977; Press 1978; Schwartz 1969).

Conclusion

The medical culture of the Protestant Hmong of Kansas City contains health ideas and practices that derive from differing systems. Through significant events of war, migration, Christian conversion, and the exposure to biomedicine, Hmong medical culture has been transformed, yet at the same time, maintains continuities. Murray Last’s (1981, 1992) concept of medical culture provides a way of under- standing the medical pluralism of the community by moving beyond the assump- tion of a system and providing a framework that takes eclecticism into account as a central feature. Within the constellation of influences from biomedicine, Christi- anity, and Chinese medicine, the Hmong in Kansas City have developed a medical culture that uniquely reflects their ethnic identity.

MEDICAL CULTURE OF THE HMONG I N KANSAS CITY 173

Significant for the Protestant Hmong in Kansas City is the abandonment of shamanism and ancestor worship and the disregard of the central notion of soul loss in illness. Nevertheless, continuity exists in the notions of soul loss in the mainte- nance of fright illness (ceeb) and traditional therapies of massage and herbal medicine. The relationship to the spirit world continues to be important although it is transformed. People believe they are now protected by the Christian Trinity. Nevertheless, some community members view ancestral or nature spirits as influ- ential in well-being. Traditional religious practices have been substituted by prayer or medical therapy in response to misfortune and illness.

Confronted with the changes brought about through migration and sedentary life in industrial society, the Hmong have incorporated from U. S. biomedicine new patterns of illness and treatment, which they have interwoven with traditional ideas and therapies. Although they recognize the value of biomedicine in treating certain health emergencies and acute illnesses, they continue to consider Hmong therapies most effective when Hmong-specific illnesses are identified.

As Crandon-Malamud (1991) found in Bolivia, medical pluralism in Kansas City provides access to various secondary resources. By embracing Christianity, the Hmong in Kansas City have expanded social networks and received medical resources through contact with other Christian groups (for example, church spon- sorship assistance in accessing health care). At times of illness or misfortune, the gathering of relatives, healers, and the Hmong church community provides crucial social and economic support. Church membership and various religious ceremonies bring the Hmong together, enhancing social solidarity and the sense of ethnic community. In the face of uncertainty and tension, plural systems of thought and action will coexist (Kunstadter 1978396). The adoption of a plurality of medical ideas and therapies is a response by the Hmong to the experience of drastic change and tenuous life circumstances.

NOTES

Acknowledgments. Appreciation is extended to the following persons who assisted in making this study possible: John M. Janzen, Donald D. Stull, Linda J. Redford, Marjorie A. Muecke, Patricia V. Symonds, Bruce Thowpaou Bliatout, Xeng Djoua Xiong, Pastor Dan Yang. Niyaphan Wannasiri, and the Hmong of Kansas City and Mae Sa Mai Village. Special thanks goes to John M. Janzen, Donald D. Stul1,PatriciaV. Symonds, and Xeng Djoua Xiong for their review of this manuscript at various stages in its development.

Correspondence may be addressed to the author at 1092 Alden Lane, Buffalo Grove, Illinois 60089.

1. In Chinese writings, the Hmong are referred to as “Miao.” In Laos and Thailand they are known as “Meo.” The Hmong prefer the term “Hmong,” which is interpreted as “free man” (Bliatout 1982:3). Because of Hmong preference and their view of other terms as derogatory, the name Hmong is used throughout this article.

2. For further discussion of missionary Christianity among the Hmong in Southeast Asia, see Tapp 1989a, 1989b. On the importance of writing systems in Hmong society. see Smalley et al. 1990 and Tapp 1989b.

3. Among Hmong practicing the traditional religion in the United States, shamanism and animal sacrifice are often difficult due to the nature of the Living space in an urban setting. Some have claimed this as a reason for Christian conversion.

174 MEDICAL ANTHROPOLOGY QUARTERLY

4. Because of the political and technical difficulties in gaining enay into Laos, I choose to study the Hmong in Thailand, who within the past 50 years have migrated from Laos. For similar reasons, Symonds and others pursued research among the Hmong in Thailand.

5. The shaman (txiv neeg) can negotiate with spirits and retrieve souls lost with illness. In trance, the shaman travels to the spirit or ancestral other world (yeeb ceeb) to make an offering to the spirit god ( N u ~ j Nyoog) for the return of a person’s soul (plig) (Radley 1986:262). The khawv koob is a person who can perform “magic” (Heimbach 1969) and, like a sorcerer, is capable of causing harm. Some khawv koob practice to benefit others and can cure certain illnesses. For example, in Thailand, I observed a khawv koob treat a baby’s eye infection by blowing into the eye and giving some medicated eye drops. In these techniques, the shaman and sorcerer differ from the herbalists (kws tshuaj) in Kansas City who specialize in herbal and massage therapies. In Kansas City, thert: were no practicing shamans or khawv koob.

6. Westemeyer ( 1 988:775) states in his study of the traditional Hmong in Laos that in addition to promoting the release of bad blood, the needle puncture may allow an undesirable spirit to escape from the body.

7. The sighting of a puj ntxoog is common among the traditional Hmong and greatly feared because of the implication of possible s o u l loss and death. In traditional belief, protection may be conferred if a shamanic ritual is performed (Munger 1986388). The Protestant Hmong in Kansas City feel that God will protect them from puj ntxoog attack, and many deny that the puj ntxoog even exist. Some say that Mai’s (Mai is a fictive name in this case study) lengthy stay in Thailand is the reason her traditional beliefs remain.

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