In 1982, Mao Thao, a Hmong woman from Laos who had resettled in St. Paul, Minn., visited Ban Vinai, the refugee camp in Thailand where she had lived for a year after her escape from Laos in 1975. She was the first Hmong-American ever to return there, and when an officer of the United Nations High Commissioner for Refugees, which administered the camp, asked her to speak about life in the United States, 15,000 Hmong, more than a third of the population of Ban Vinai, assembled in a soccer field and questioned her for nearly four hours.

Some of the questions they asked her were: Is it forbidden to use a txiv neeb [a shamanistic traditional healer] to heal an illness in the United States? Why do American doctors try to open up your head and take out your brains? Do American doctors eat the livers, kidneys, and brains of Hmong patients? When Hmong people die in the United States, is it true that they are cut into pieces and put in tin cans and sold as food?

The general drift of these questions suggests that the accounts of the American healthcare system that had filtered back to Asia were not exactly enthusiastic. The limited contact the Hmong had already had with Western medicine in the camp hospitals and clinics had done little to instill confidence, especially when compared to the experiences with shamanistic healing to which they were accustomed. A txiv neeb might spend as much as eight hours in a sick person's home; doctors forced their patients, no matter how weak they were, to come to the hospital, and then might spend only twenty minutes at their bedsides.

Txiv neebs were polite and never needed to ask questions; doctors asked many rude and intimate questions about patients' lives, right down to their sexual and excretory habits. Txiv neebs could render an immediate diagnosis; doctors often demanded samples of blood (or even urine or feces, which they liked to keep in little bottles), took X-rays, and waited for days for the results to come back from the laboratory — and then, after all that, sometimes they were unable to identify the cause of the problem.

Txiv neebs never undressed their patients; doctors asked patients to take off all their clothes, and sometimes dared to put their fingers inside women's vaginas. Txiv neebs knew that to treat the body without treating the soul was an act of patent folly; doctors never even mentioned the soul. Txiv neebs could preserve unblemished reputations even if their patients didn't get well, since the blame was laid on the intransigence of the spirits rather than the competence of the negotiators, whose stock might even rise if they had had to do battle with particularly dangerous opponents; when doctors failed to heal, it was their own fault.

Threats to Health To add injury to insult, some of the doctors' procedures actually seemed more likely to threaten their patents' health than to restore it. Most Hmong believe that the body contains a finite amount of blood that it is unable to replenish, so repeated blood sampling, especially from small children, may be fatal. When people are unconscious, their souls are at large, so anesthesia may lead to illness or death. If the body is cut or disfigured, or if it loses any of its parts, it will remain in a condition of perpetual imbalance, and the damaged person not only will become frequently ill but may be physically incomplete during the next incarnation; so surgery is taboo. If people lose their vital organs after death, their souls cannot be reborn into new bodies and may take revenge on living relatives; so autopsies and embalming are also taboo.

(Some of the questions on the Ban Vinai soccer field were obviously inspired by reports of the widespread practice of autopsy and embalming in the United States. To make the leap from hearing that doctors removed organs to believing that they ate them was probably no crazier than to assume, as did American doctors, that the Hmong ate human placentas — but it was certainly scarier.)

The only form of medical treatment that was gratefully accepted by at least some of the Hmong in the Thai camps was antibiotic therapy, either oral or by injection. Most Hmong have little fear of needles, perhaps because some of their own healers (not txiv neebs, who never touch their patients) attempt to release fevers and toxicity through acupuncture and other forms of dermal treatment, such as massage; pinching; scraping the skin with coins, spoons, silver jewelry, or pieces of bamboo; applying a heated cup to the skin; or burning the skin with a sheaf of grass or a wad of cotton wool. An antibiotic shot that could heal an infection almost overnight was welcomed.

A shot to immunize someone against a disease he did not yet have was something else again. In his book Les naufrages de la liberte, the French physician Jean-Pierre Willem, who worked as a volunteer in the hospital at the Nam Yao camp, related how during a typhoid epidemic, the Hmong refugees refused to be vaccinated until they were told that only those who got shots would receive their usual allotments of rice — whereupon 14,000 people showed up at the hospital, including at least 1,000 who came twice in order to get seconds.

Something Inhospitable When Foua Yang and Nao Kao Lee brought their three sick children to the hospital at Mae Jarim, they were engaging in behavior that many of the other camp inhabitants would have considered positively aberrant. Hospitals were regarded not as places of healing but as charnel houses. They were populated by the spirits of people who had died there, a lonesome and rapacious crew who were eager to swell their own ranks. Catherine Pake, a public health nurse who spent six months working at Phant Nikhom (a camp where refugees from Laos, Vietnam, and Cambodia came for their final "processing" before they were sent to a country of permanent asylum), concluded from a study of the hospital log that "in comparison to refugees of other ethnic groups, the Hmong have the lowest per capita rate of visits." (Pake also discovered, not coincidentally, that the Hmong had an extremely "high utilization rate" of indigenous healing arts: shamanism, dermal treatments, herbalism. She published an article in the Journal of Ethnobiology identifying twenty medicinal plants she had collected under the tutelage of Hmong herbalists, which, in various forms — chopped, crushed, dried, shredded, powdered, decocted, infused with hot water, infused with cold water, mixed with ashes, mixed with sulphur, mixed with egg, mixed with chicken — were indicated for burns, fever, weakness, poor vision, broken bones, stomach aches, painful urination, prolapsed uterus, insufficient breast milk, arthritis, anemia, tuberculosis, rabies, scabies, gonorrhea, dysentery, constipation, impotence, and attacks by a dab ntxaug, a spirit who lives in the jungle and causes epidemics when he is disturbed. In this last case, the plant, Jatropha curcas, is crushed and its oil left in a cup, to be consumed not by the patient but by the dab.)

Wendy Walker-Moffat, an educational consultant who spent three years teaching and working on nutritional and agricultural projects in Phanat Nikhom and Ban Vinai, suggests that one reason the Hmong avoided the camp hospitals is that so many of the medical staff members were excessively zealous volunteers from Christian charitable organizations. "They were there to provide medical aid, but they were also there — though not overtly — to convert people," Walker-Moffat told me. "And part of becoming converted was believing in Western medicine. I'll never forget one conversation I overheard when I was working in the hospital at Ban Viani. A group of doctors and nurses were talking to a Hmong man whom they had converted and ordained as a Protestant minister. They had decided that in order to get the Hmong to come into the hospital they were going to allow a traditional healer, a shaman, to practice there.

"I knew they all thought shamanism was witch doctoring. So I heard them tell this Hmong minister that if they let a shaman work in the medical center he could only give out herbs, and not perform any actual work with the spirits. At this point they asked the poor Hmong minister, 'Now you never go to a shaman, do you?' He was a Christian convert, he knew you cannot tell a lie, so he said, 'Well, yes, I do.' But then their reaction was so shocked that he said, 'No, no, no, I've never been. I've just heard that other people go.' What they didn't realize was that — to my knowledge, at least — no Hmong is ever fully converted."

Ties Broken to Spirits In 1985, the International Rescue Committee assigned Dwight Conquergood, a young ethnographer with a special interest in shamanism and performance art, to design an environmental health program for Ban Vinai. He later wrote:

I heard horror story after horror story from the refugees about people who went to the hospital for treatment, but before being admitted had their spirit-strings cut from their wrists by a nurse because "the strings were unsanitary and carried germs." Doctors confidently cut off neck-rings that held the life-souls of babies intact. Instead of working in cooperation with the shamans, they did everything to disconfirm them and undermine their authority. . . . Is it any wonder that the Hmong community regarded the camp hospital as the last choice of available healthcare options?

In the local hierarchy of values, consulting a shaman or herbalist, or purchasing medicine available in the Thai market just outside the entrance to the camp, was much preferred and more prestigious than going to the camp hospital. The refugees told me that only the very poorest people who had no relative or resources whatsoever would subject themselves to the camp hospital treatment. To say that the camp hospital was underutilized would be an understatement.

Unlike the other camp volunteers, who commuted from an expatriate enclave an hour away, Conquergood insisted on living in Ban Vinai, sharing the corner of a thatched hut with seven chickens and a pig. His first day in the camp, Conquergood noticed a Hmong woman sitting on a bench, singing folk songs. Her face was decorated with little blue moon and golden suns, which he recognized as stickers the camp clinic placed on medication bottles to inform illiterate patients whether the pills should be taken morning or night.

The fact that Conquergood considered this a delightful example of creative costume design rather than an act of medical noncompliance suggests some of the reasons why the program he designed turned out to be the most (indeed, possibly the only) completely successful attempt at health care delivery Ban Vinai had ever seen.

Going to the Dogs Conquergood's first challenge came after an outbreak of rabies among the camp dogs prompted a mass dog-vaccination campaign by the medical staff, during which the Ban Vinai inhabitants failed to bring in a single dog to be inoculated. Conquergood was asked to come up with a new campaign. He decided on a Rabies Parade, a procession led by three important characters from Hmong folktales — a tiger, a chicken, and a dab — dressed in homemade costumes. The cast, like its audience, was one hundred percent Hmong.

As the parade snaked through the camp, the tiger danced and played the qeej, the dab sang and banged a drum, and the chicken (chosen for this crucial role because of its tradtional powers of augury) explained the etiology of rabies through a bullhorn. The next morning, the vaccination stations were so besieged by dogs — dogs carried in their owners' arms, dogs dragged on rope leashes, dogs rolled in on two-wheeled pushcarts — that the health workers could hardly inoculate them fast enough. Conquergood's next production, a sanitation campaign in which a parade of children led by Mother Clean (a huge, insanely grinning figure on a bamboo frame) and the Garbage Troll (dressed in ragged clothes plastered with trash) sang songs about latrine use and refuse disposal, was equally well received.

During Conquergood's five months in Ban Vinai, he himself was successfully treated with Hmong herbs for diarrhea and a gashed toe. When he contracted dengue fever (for which he also sought conventional medical treatment), a txiv neeb informed him that his homesick soul had wandered back to Chicago, and two chickens were sacrificed to expedite its return. Conquergood considered his relationship with the Hmong to be a form of barter, "a productive and mutually invigorating dialog, with neither side dominating or winning out."

In his opinion, the physicians and nurses at Ban Vinai failed to win the cooperation of the camp inhabitants because they considered the relationship one-sided, with the Westerners holding all the knowledge. As long as they persisted in this view, Conquergood believed that what the medical establishment was offering would continue to be rejected, since the Hmong would view it not as a gift but as a form of coercion.

"Do Doctors Eat Brains?" and jacket design from THE SPIRIT CATCHES YOU AND YOU FALL DOWN by Anne Fadiman. Copyright ©1997 by Anne Fadiman. Reprinted by permission of Farrar, Straus & Giroux, Inc. Fadiman, editor of The American Scholar, was introduced by a friend to the Hmong population in Merced County, Calif. He told her that these refugees from Laos gave birth by squatting on the floor, wore amulets containing odd-smelling herbs, and sacrificed pigs when a family member or friend had a serious illness. They also had taboos against blood tests, surgery and anesthesia and autopsies. The title of the book comes from the Hmong term for epilepsy (quag dab peg or "the spirit catches you and you fall down.") As Fadiman explains, "The spirit referred to in this phrase is a soul-stealing dab; peg means to catch or hit; and quag means to fall over with one's roots to the ground, as grain might be beaten down by wind or rain." In contrast to the way epilepsy is sometimes viewed in the West, the Hmong view it as an illness "of some distinction." Fadiman adds, "Hmong epileptics often become shamans. Their seizures are thought to be evidence that they have the power to perceive things other people cannot see, as well as facilitating their entry into trances, a prerequisite for their journeys into the realm of the unseen." The book focuses on the case of Lia Lee, a little Hmong girl with a seizure disorder, her parents, and their collision with Western medicine. (339 pages; hardcover $24).