It was a no-cost chance to learn about the culture, religion, and communication of the Hmong people, as well as how the Hmong community approaches health care and end-of-life issues. The bring-your-own-lunch workshop took place June 25 at HospiceCare, Inc. and featured speakers Leon Bernido and Charles Vue. The presenters reviewed the history of the Hmong people, discussed values and beliefs Hmong people hold regarding health, and shared personal insights on how Hmong people view death and dying.
Leon Bernido is a masters degreed social worker and a registered nurse, whose training includes a health care concentration, gerontology certification, and cultural and linguistics concentration. Bernido, who has worked at the HospiceCare inpatient unit since 2004, began by discussing the diversity within Southeast Asian people, pointing out that Southeast Asia has a large population of Christians, Muslims, and Buddhists.
“We do not put all Southeast Asian people in one specific group…” he says. Bernido stressed that as health care providers, “I think we need to know something about this group of people” in order to be a good clinician, nurse, etc.
He briefly reviewed the heritage and history of people in Cambodia, Laos, and Vietnam. In the 1700s, the Hmong people were forced to migrate out of southern China and settle in several neighboring countries, including Laos. “As you can see, the Hmong, for the most part, did not have their own country or a sense of nationhood when they came to America.”
Bernido talks about what happened in the 1960s and 1970s and the vital role Hmong played in the “secret war.” In 1961, President Kennedy asked the government of Laos for their cooperation in containing Communism. Many historians have said that without the help of the Hmong, there would have been more U.S. casualties, he says. The C.I.A. visited Laos and recruited Hmong people to assist and disturb the moving of Communist supplies. He explains that Hmong people saved the lives of many American pilots shot down during the war, a fact that is not widely known.
The Hmong and the Meng in Southeast Asia suffered under Pathet Lao (Communist ruler in Southeast Asia.) The U.S. promised to help both the Hmong and the Meng people following the war. However, the Communists sought vengeance against the Hmong and the Meng because they were allies to the U.S. The Hmong people suffered as they attempted to flee and seek political asylum in refugee camps in Thailand. “About half trying to make this journey died,” he said, as the result of starvation, drowning, or being ambushed by Pathet Lao patrol.
Bernido stressed that many atrocities occurred during the time Hmong people escaped from Laos to refugee camps, and as health care providers, one has to think about PTSD (post-traumatic stress disorder.) Especially when working with the elderly Hmong, he advises, “think about the fact that this group of people have been through so much and they’re most likely very traumatized. “
Reasons for slower assimilation
Situated in isolated villages, few if any of the Hmong people received any kind of formal schooling. “For the most part, when Hmong people resettled here in Wisconsin and in (other parts of ) America, they tend to take longer to assimilate into the mainstream (than other groups),” he says. Lacking education, they are not exposed to technology and some do not speak English, Bernido adds, which contribute to it taking longer for them “to be up on their (own) feet in America.”
He compared the pathway of the Hmong people with the experiences Vietnamese people have had coming to America. Because of their association with Americans and servicemen and technology associated with the war, people from Vietnam tend to be more educated. Most of them did very well if you read the accounts, “unlike the Hmong; they did not do so well in the beginning.”
Unlike other Southeast Asian people, Hmong are generally not Buddhists and their culture doesn’t include written religion texts. They are animists, meaning they believe in souls or spirits and they pray to spirits. Most Hmong believe spirits cause illness if a misdeed occurs.
Hmong people believe, for example, that if the police stop them for a potential violation, the trauma of the police stopping them will cause their soul to leave their body. And as a result of their soul leaving their body, they believe, they will get sick.
The basis of the Hmong language is oral tradition, Bernido reports. In 1952, linguistic specialists in France first formalized the Hmong language, using the Roman alphabet. “As a result, it is unlikely that elderly Hmong we see would be able to read their language themselves,” he states. Middle aged and younger folks, yes.; they usually can read the Hmong language.
Why Wisconsin?
Individuals frequently inquire, ‘Why did all the Hmong people come to Wisconsin, or California, or Minnesota?’ It began with various churches sponsoring Hmong families. Word started getting around that Wisconsin had a very good support system, which made it possible for family reunification and also to settle in one area. “That’s basically why (Wisconsin),” he quips. “It wasn’t the weather.”
Bernido talks about the impact of poverty and social marginality on Hmong immigrants. In American society, older citizens are often pushed aside for those that are younger. This sharply contrasts the traditional Hmong elderly experience, where elders are valued, respected, and consulted. In the U.S., many elderly Hmong fear taking public transportation and are victimized by crime in low income areas. Consequently, many older Hmong men who have immigrated have lost their traditional role as the wise man that solved many problems. They often feel useless, bemoans Bernido, and spend much of their time sitting around watching television.
Bernido, however, cautions that each situation is different. When you meet a Hmong person, “do not (automatically) assume that they have, or have not, assimilated” to mainstream U.S. culture, he recommends.
Reaching out to Hmong families
Charles Vue, MSSW, is student services coordinator at UW-Eau Claire’s Office of Multicultural Affairs. He has served as a social worker in Eau Claire and as a multicultural consultant in Milwaukee and has also served on the Hmong Mutual Assistance Board of Directors.
So how can people be more effective in reaching out to families? Vue contends that people are doing their best. He encourages folks “to build relationships (first) and then establish the outcome, which is to help your patient.” In Asian cultures and sometimes in low-income families, the tendency is to emphasize effectiveness, he states, versus efficiency--money and time in Western culture.
He reminds attendees that Hmong people came to the U.S. relatively recently, only 30 some years ago, and they came with their own values and the things they owned on their back. They’re only two generations here, he reiterates. In the Hmong tradition, “family comes first,” and “if an individual is a success or a failure, the impact rests with the whole family. “ Families simultaneously give a lot and expect a lot, he indicates.
“We have a system that I consider quite different,” he elucidates, referring to a “make or break” situation. “I consider (it) ‘make,’” he attests. The philosophy: “An individual stick is easy to break, but if you have a bundle (of sticks), (it’s) hard to break.”
Approximately 18 different clans currently exist in the Hmong culture and some use the clan as a support system for themselves. Members of the same clan “have the obligation of reciprocating mutual support… because we are considered brother and sister,” Vue says, and as such, people cannot marry within their own clan.
Generally, if a person becomes ill, word travels fast throughout the clan. All the clan members in the area would visit him/her in his/her home, or in the case of hospitalization, would jam into a (Western) hospital room or in a family lounge in a hospital. “We’re talking 24/7,” he further explains.
He went on to discuss the way Hmong people typically eat when they are ill. “We drink hot or warm water,” which is especially important after a woman has given birth, in the belief that this will prevent harm or clogging of the blood. “Sick people eat mostly boiled chicken and pork and certain vegetables.” In the Hmong tradition, “the main way of healing and treating a person is to follow our religious practice.”
Vue discusses the role of shamans in the health and well being of Hmong people: “When a person is ill, they seek the help of a shaman to determine if the cause of the illness is within the realm of the spirit.” The Hmong shaman “acts as a medium between the visible world and an invisible world and practices rituals for healing and control over natural events.” A shaman can be a man, a child, or a woman. The frequency with which Hmong people use a shaman varies: For some, it’s on a daily basis, others it’s a couple of times a week, or a couple times a year. Most shamans collect a small fee for their services. “Before you can become a shaman, you have to be severely ill for a long time,” he says, necessitating an existing shaman to be called in to help. The assisting shaman determines that you need to become a shaman, which entails an established mentoring process. (Of the 3,000 to 5,000 Hmong individuals in Madison, about one-quarter are shamans.)
Khawv Koobs are deemed to be magic healers. When someone is sick, Hmong people request a Khawv Koob event, which takes place over a bowl, using water to sprinkle over the area they had surgery. “The belief is that (by so doing) they will recover faster after that surgery,” Vue says.
He details what happened when his mother-in-law required major surgery and his father-in-law wanted the healing to be perfect. He and his wife had to be “very diplomatic” in working with his in-laws and the surgeon, who was concerned about keeping the surgical site sterile and preventing infection. For the kagone ceremony, a cotton ball sprinkled “just enough (water) to wet the area, but not to soak the wound.” While they were able to achieve what they wanted, many Hmong folks may not be able to advocate for themselves in a health care situation, he says, citing such factors as ignorance or inexperience.
Today, about half of Hmong families have converted to Christianity; a church sponsored Vue’s family when they came to the U.S. and they quickly became Lutherans. How religious beliefs play out in terms of health care and healing varies; often, “we go back and forth in the (Hmong) community (between Western medicine and shaman healing), depending on how strong is your belief and how flexible you are.” Mixed faith families call for good communication skills when it comes to weddings, illness, funerals, etc. , Vue declares.
Seeking out a Western doctor
Often Hmong turn to Western medicine only “after we exhausted (care) in our way,” Vue says. What conditions would make a Hmong family seek out a Western doctor?
A broken arm, a broken leg, cancer, or a coughing-type ailment that can’t be cured with herbs, “we would agree, that’s a (that needs a) Western approach.” Or, in the event of an obvious emergency, the hospital is the first place to go.
Vue laments about his uncle, who had a bladder infection and didn’t go to the hospital or clinic for treatment. By the time he went, doctors told him he only had three months to live. He currently is in the process of dying and is very uncomfortable. He also speaks of his good friend, a well-known Hmong person and Wisconsinite who was told he needed heart bypass surgery for blockage. Instead of pursuing cardiac surgery, he went to Thailand and Laos, looking for herbal medicine and died in the process.
When Hmong people are unhappy with the care they receive, he says, they may not communicate their dissatisfaction to their care providers. Most Hmong may listen attentively to a health professional out of respect, but may not necessarily challenge or follow their advice. Rather, they may refuse care or turn to traditional treatment.
To communicate emotion to a stranger in the Hmong culture is to give away your strength, he discloses, with two exceptions —funerals and weddings. At Hmong funerals, there is a very public display of emotions, where moaning in sorrow for the deceased and other lost loved ones is common. When the bride leaves the family with her new husband, her mother and other family members often cry heavily.
Hmong perspectives on life and death
“We believe that life is a continuous process,” Vue says. “…In other words, when you die, you reincarnate…we believe you live to your oldest age, 120 years (old),” and that a permit to live is given by the Spirit.
Though Vue quickly points out that it’s very individual, “generally a Hmong person doesn’t want to talk about their death.” It’s typically seen as a curse to discuss death.
In the Hmong tradition, it is important that they wear their nicest clothes when they die, Vue says, as they believe in the afterlife, they’ll wear those same clothes. Christian and non-Christian Hmong people believe the same thing, he clarifies.
Non-Christian Hmong people believe it is vital to remove all non-decomposable objects, like golden/filled teeth, plastic buttons from clothes, even metal rods that have been surgically implanted to repair legs, before the funeral. Not doing so is thought to delay the person going back to carnate; also, a surviving or subsequent family member might have a birthmark or develop a medical problem if they fail to remove such items. The funeral director dressing the deceased can remove these things, he explains. (Some “even believe if you have an amputated arm or leg, you have to have that piece with you…”)
Q and A time
A number of attendees posed questions following the presentation. One individual asked how Hmong people view advance directives? Vue responded to the question with several statements, including, “generally, we don’t believe we’re going to die;” “we think the paperwork is way too complicated,” and “we think, ‘we’ll get to that (later).’”
A HospiceCare representative asked Vue, given that Hmong people don’t talk about death, what advice he would give to staff when the end is approaching, as to how to talk with the patient and family about what’s happening to the patient. “Every family has a spokesperson or someone who is known as a trusted individual.” he says.
So ask the patient, “Who is the head of the family? Who is the leader of the family? Or, “Who do you prefer us to talk to?” (He cautions that “just about every visitor will appear to be family.”)
“Then you leave the information with that person, delegate them to share it.”
Vue also advises that to serve effectively as a provider of care, not necessarily efficiently, listen.
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