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Cultural and Medical Traditions
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Hmong Culture and Medical Traditions1
Who are they? The Hmong in the United States are a relatively small southeast Asian minority group who began living here at the close of the Vietnam war.
Where did they come from? They emigrated from northern Laos. Hmong also live in China, Burma and Thailand, but Hmong now in the United States came here from Laos. Hmong were self-sufficient farmers. Their farming practices were labor intensive.
How did they get here? Hmong in Laos were involved in Vietnam War. In the 1960s the American Central Intelligence Agency recruited, trained and armed Hmong soldiers to help stop the North Vietnamese incursion into Laos and South Vietnam through northern Laos (the Ho Chi Min Trail) where the Hmong lived. American protection ceased at the end of the war, leaving the Hmong vulnerable to retribution from the North Vietnamese and the Laotian central government who were sympathetic to the North Vietnamese cause. Faced with possible annihilation, an estimated 370,000 Hmong crossed Laos.2 Most of them entered Thailand to escape. Many were killed in the course of this mass migration. Hmong settled in large refugee camps in Thailand, and began learning the ways of an industrial society and new languages. The United States gave them preferential refugee status in the early 1980s. A sizable number immigrated to the United States and an estimated 150,000 live here now.3 Minnesota’s Hmong population may be as high as 75,000.
Language: The Hmong have their own language, called Hmoob (Hmong in English). It has many dialects. However, most Hmong speak either white or green Hmong. Hmong was not a written language until the late 1960s. It has few medical terms. Older Hmong sometimes communicate by using metaphors. As a result, non-Hmong need some knowledge of the culture to understand what the Hmong are communicating.
Clan social structure: Hmong are organized into clans, which are determined by ancestral lineage (great, great grandfather) and which traditional ceremonies they practice. Clans are not constituted by last name. Families have two special ceremonies to remember their ancestors. If families practice the same ceremony, then they probably belong to the same ancestor. Hmong families tend to be large and the extended family is considered to be part of the family.
Clan leader: Each clan has a leader. Hmong and the whole clan select leaders who are honest, respectful, and who will make wise decisions. The leader’s job is to make decisions and to help when there is a problem, such as a divorce, illness or death in the family. The leader decides whether to go forward with a surgery or whether to resuscitate a patient. He calls people together to discuss issues, then he decides4.
Role of father. The father is always the head of the household. Traditionally, he makes the decisions. Hmong families do not respect mothers less. The idea is that one person must have the power to decide. However, more and more today’s mothers can also be leaders and make decisions. In younger Hmong families, both the father and the mother make decisions.
Role of mother: Hmong mothers nurture and take care of the children. They are responsible for the household. Men have more respect than women do, as is the case in most cultures. However, succeeding generations are giving Hmong women increasingly more respect. Women will often have the conversation with a health care provider, but men usually make the decisions related to health care. Hmong women are increasingly asked for their advice, because they often know more about their children’s conditions.
Role of elderly Hmong: The elderly get the most respect of all members of the family. Elderly Hmong are consulted when decisions need to be made. They help discipline the younger children. The elderly remain with the family throughout their life.
Religious leader: The Hmong shaman or the clan leaders are the key persons for decision making and for conducting religious ceremonies. The Hmong shaman5 helps the clan leader make decisions. Some religious ceremonies are conducted in the home of the clan leader or the shaman. Some Hmong shamans6 are very powerful. They make all decisions related to spiritual healing.
Religion: Hmong practiced Hmong religious beliefs in their native land. Hmong in the United States have continued many of their traditional beliefs and religious practices. A number also have become Christians.
New Year’s Celebration: Hmong celebrate the New Year sometime between Dec. 1 and Jan. 15. They welcome the New Year at social festivities. Hmong welcome the New Year with a "Calling of the Spirit for the New Year" ritual. Boys and girls meet and get to know one another. Many marriages occur during this celebratory period. Hmong usually marry outside of their own clan because they believe two individuals with the same last name may somehow be related.
Verbal/ non-verbal communications. Hmong may not communicate dissatisfaction with the quality of health care. Instead, they will refuse care and go somewhere else for treatment. Older Hmong listen attentively to health professionals, but will avoid direct eye contact because it is rude.
Time: Traditionally, Hmong farmers organized their activities around the sun--sun up and sun down. Recent immigrants are unaccustomed to doing things at specific times, and this becomes an area of difficulty for them. As a result, information about appointment times, etc., needs to be written and carefully explained.
Caretaking: Usually females and grandparents are the caretakers of children. Grandparents participate in decisions about their grandchildren’s health care.
Health Care
Medical conditions due to refugee status: Older Hmong (30 years of age or older) may have long-term effects from "yellow rain" or other war zone chemicals and malnutrition. Many recent refugees seeking western treatment have intestinal parasites, tuberculosis, anemia, depression or post traumatic stress syndrome. Older Hmong may have trouble breathing (dyspnea). Constipation and diarrhea are more common due to the lack of roughage in the diet.
Experience with western medicine: Hmong have been exposed to western medicine since the 1950s.
Cause of illness: Traditional Hmong view illness from a holistic perspective. Perfect health is a balance between the spirit and the body. When someone is ill, Hmong will seek out the help of a shaman to determine if the cause of the illness is in the realm of the spirit. Spiritual causes require religious remedies. Hmong also recognize physical causation. Physical causes require an appropriate response such as medication, various Hmong treatments or seeking western medical care. Traditional spiritual causes of illness include evil spirits or because one’s own spirit has left the body. Someone may be ill because an evil spirit or an ancestor is unhappy with the individual or that individual’s family. Perhaps someone has done something to offend the family’s spirits or ancestors. An illness also can arise because someone has cursed the family. Some Hmong accept the western view of the cause of illness along with their traditional view.
Spiritual healing: Hmong practice spiritual healing. Good health comes from souls living within each person. Illness or an invasive procedure can cause soul loss. Spiritual healing involves retrieving the lost soul from another plane of existence. Hmong will conduct healing ceremonies in the hospital or in the home.
Health prevention: Older Hmong generally have not practiced it. Health prevention was not available to them in Laos. Many Hmong focus on treating illness when it occurs. Younger Hmong, however, are interested in discussing health prevention.
Death: Hmong who follow traditional religious views believe that death is merely a phase people go through when one is passing from this plane of existence to the next. Life is not seen from a western point of view as a journey with a beginning and an ending point. Rather, life is viewed from an eastern point of view as a continuous journey. People are destined to live to a certain age. When the age is reached, Hmong understand it is time for the person to depart.7 Hmong believe the spirit will reincarnate.
Dying: Hmong want to dress the dying person in fine Hmong clothes. Doing so tells the community the person has lived a good life, will be missed and can make a proper entrance into the next world. Religious ceremonies conducted on behalf of the dying person are intended to make the person happier.
Treatments and practices: Many Hmong continue to use traditional herbal treatments. Others will use herbal treatments as complements to western treatments. Still others are adopting western medical practices. Traditionally, someone who is sick is required to eat hot food and certain vegetables. Hmong prefer hot chicken and rice. They drink hot or warm water. Within 30 days of childbirth, Hmong mothers will usually only eat warm foods.
Pediatric treatments: Hmong parents will alter the child’s diet to help an ill child recover. A common practice is to restrict the diet to rice and chicken only, and no vegetables. Chicken must be boiled, not fried. However, Hmong vary the diet depending on the child’s medical condition. Herbal medicines are added to the meal in small amounts. Other treatments include cupping (suctioning on the skin over the affected area), pinching or wearing religiously symbolic items to protect from soul loss. Spiritual treatments involve religious ceremonies and food or animal sacrifices.8
Child illness and traditional Hmong treatments:9
Abdominal pain-- herbal remedies and massage.
Chicken pox, stomach ache or infection—herbal mixtures
Cuts and abrasions—herbs, plants and animal parts wrap,10 cold compresses
Diarrhea—herbs boiled with tea, massage, placing warm paper ashes over the abdomen. Fever—herbs, coining (scraping a coin over the child’s body), and cool compresses
Sprains and fractures—steamed leaf wrap, chicken and herb wrap, massage, bone twisting.
Nosebleeds—animal parts mixed with herbs, cool compresses
Burns—herbs (aloe vera) inhale smoke from burnt herbs, ginger, apply egg yolk and salt to burn, apply various herbs and animal parts to burn
Vomiting—herbs
Surgery: Surgery is usually not acceptable. However, if laboratory or other tests identify a disease, then Hmong are willing to consider surgery.
Immunization: This is traditionally not acceptable. Hmong believe it is not a good idea to put something into their bodies. If a person is immunized or has surgery, he/she will be reincarnated with less than a complete body or a body with something foreign in it. However, most Hmong parents will have their children immunized once they know it is required for school or other activities.
Organ donation/ blood transfusions: Traditionally, both are unacceptable. Younger Hmong, however, are more accepting of these medical procedures.
Tests: Hmong accept blood tests. But they may question why they have to have blood taken more than once in one visit or why a large volume of blood is needed.
Breastfeeding: Bottle-feeding is becoming the norm.
Circumcision: Not practiced.
Complementary medicine: Herbal medicine is widely practiced, and some Hmong will often exhaust this resource and other traditional practices before seeking western medical remedies. Hmong women pass their knowledge along to their female relatives.
Practical tips for treating Hmong patients:
- Find out what, if any, care is under way. Ask about herb treatments and the sources of the herbs. Find out what condition they are treating with herbs. Ask for a sample.
- Build trust. Health care providers need to establish a relationship with the Hmong family before care begins. Building trust is essential. Providers need to be open to the family’s suggestions. Respect those suggestions and show respect for the family.
- Keep it private. Hmong share information among certain clan members. All staff and all interpreters, whether on staff or available from outside the hospital setting, must honor the privacy of patients and their families. This policy needs to be communicated to the Hmong. Do not share information on terminally ill Hmong without first consulting the family.
- Hold a conference. Hold a care conference if there is a major problem or major surgery is needed. The location is important. Hold the session in a conference room, not in the patient’s room. Invite all the family’s decision-makers—not just the parents--to the conference. It is a very important event. Some participants may not speak English, even if the parents do. Direct your communications to the father.
- Provide a Hmong interpreter. Federal law requires the health care provider to have an interpreter available. Don’t rely on a child to interpret. The interpreter needs to act as a neutral party. Make sure a qualified interpreter attends. The Hmong may be fearful and distrustful at the outset. Be very clear and explain everything about the child’s condition and intended care. There will be a lot of questions asked afterwards as well.
- Use a normal tone of voice. Watch your body language. Hmong present who don’t speak English fluently will listen and learn from the tone of voice used and body language.
- Allow time to get consent forms signed. Doing so may involve discussion with Hmong elders and family members.
- Allow amulets.11 Allow Hmong to wear them, if possible.
- Address Hmong women properly. Traditionally, it is considered rude to call a Hmong woman by her first name. Refer to her as Ms. or Mrs.
- Remind Hmong about scheduled immunizations. Contact parents to remind them or to schedule the next immunization. Explain why many immunizations are needed.
- Be a patient listener. When you ask them how they got sick, Hmong are likely to give you a long answer.
- Repeat information about medicines. Doing so will help insure Hmong understand.
- Explain purpose of blood withdrawals. Explain what the test is and why so much blood is needed.
Endnotes:
1 General characteristics of the Hmong as a cultural group are summarized here. Factors such as how long the Hmong have lived in the U.S. and the strength of their personal identity with their Hmong roots will result in individual variation. Children’s Hospitals and Clinics, Minneapolis-St. Paul, Minnesota prepared this description. Representatives of the Hmong community in the Twin Cities of Minnesota reviewed and critiqued the information. Hmong representatives were Yao Lo, Koua Moua, Chong Moua, Debbie Thao, Leng Xiong, and Nancy Yang.
2 Hanners, David. Pioneer Press. April 25, 2000
3 Nyman, Lynette. Hard Work. www.newsmpr.org. March 8, 1999.
4 The leader consults with the family and elderly clan members before deciding what to do. In reality, the authority to decide is shared with elderly clan members.
5 The tus txiv neeb
6 The tus txiv neeb
7 Pao Saykao. Death and Dying. wwwhmongnet.org. undated.
8Nuttall, Patricia and Flores, Filomena. Hmong Healing Practices Used for Common Childhood Illnesses. Pediatric Nursing/ May-June 1997/Vo23/No.3. pp.247-251
9 Ibid. p.249.
10 The traditional practice of using animal parts as a wrap or in a broth is increasingly rare because it is difficult to obtain the ingredients in the United States.
11Items such as strings tied around the wrist or other ornaments that have spiritual significance.
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