Staff at most hospitals would be baffled by an instruction like this on a bedside chart: to prepare patient for surgery, provide 15 minutes of soft chanting and tie a red string around the neck.
It's different at Mercy Medical Center in Merced. There, nurses know they must call a shaman.
Mercy is the nation's first hospital with a formal policy for Hmong shamans, allowing the traditional healers, working alongside doctors, to help patients recover.
Hospitals around the country are paying attention as they seek to accommodate cultural beliefs of diverse patient populations.
In the San Joaquin Valley, the Hmong are one of a few ethnic groups including some indigenous Mexican cultures that practice shamanism. For those with traditional beliefs, calling on a spiritual healer is as important to good health as making an appointment with a doctor. They may go without care if they can't have a shaman nearby, sometimes with devastating consequences.
Unlike most religious rites performed by mainstream clergy, which provide a sense of comfort, shaman ceremonies go further: They are intended to heal.
Traditionally, the Hmong believe a soul can become lost or captured by spirits. The spirits can affect the person's health and well-being, and until the soul is restored, the Hmong believe, the body won't heal. The shaman, in a trance, negotiates with spirits for the return of the soul.
Other valley hospitals may allow shaman healing ceremonies, but only Mercy guarantees the right in writing. The Hmong Health Collaborative a group of area agencies hopes the other hospitals will follow Mercy's lead.
That remains to be seen. Not all the hospitals are sure they want to single out one group of spiritual healers. But since Mercy adopted its policy in June, the hospital has been receiving calls from as far as Malaysia from people who want to know how it works.
Mercy's policy is "quite amazing," said Jacqueline Voigt-Dieball, cultural-competency manager at the University of Michigan Health System.
Janice Wilkerson, director of mission integration at Mercy, said reaction to the policy has been "very, very positive." But she's a little surprised by all of the attention.
The hospital, owned by the national nonprofit chain Catholic Healthcare West, is licensed for 174 beds and sees an average of four Hmong patients a day. Caring for patients' spiritual health as well as their physical health is part of the hospital's mission, she said.
Chants and string
Mercy's policy lists nine healing ceremonies that shamans are allowed to perform.
Most involve soft chanting to promote healing, strengthen the body, keep the body safe or call the soul back to the body.
Shamans can tie strings around a neck and wrist. A red string around the neck helps in healing, and a white string around a wrist maintains a soul during hospitalization.
A shaman, or "txiv neeb" in Hmong, can ask Mercy hospital staff for permission to do ceremonies that go beyond chanting. An example would be a request to sprinkle water over incisions. According to Mercy's policy, hospital staff are to try to make accommodations.
The ceremonies can occur in patient rooms, in the emergency department or in surgery preparation areas.
The hospital ceremonies are brief 10 to 15 minutes. By contrast, healing rituals conducted in private homes can last hours and typically involve a drum, bells and the rattling of rings.
Before the policy, Hmong healing ceremonies were occurring, but the hospital gave shamans only tacit, informal consent.
A written policy "recognizes the value of this complementary healing service," said Marilyn Mochel, clinical director at Healthy House, a Merced nonprofit multicultural health organization that pushed for the formal guidelines.
While many Hmong have excelled in college, become professionals and embraced Western beliefs, Mochel estimates that 70 percent of Hmong in the valley follow traditional beliefs and can benefit from a shaman healing policy.
A long road
There are more than 55,000 Hmong from Sacramento to Bakersfield; about 7,000 live in Merced County. In the decades since they fled the remote mountains of Laos after Communist takeover in 1975, they have had to reconcile traditional healing practices with Western medicine.
Unfamiliarity with Western medicine has led to distrust among the Hmong refugees who settled in the valley. Some of the biggest fears surround surgery that the removal of body parts could affect them in the next life after reincarnation.
In 1990, for example, parents of a Fresno boy refused to agree to surgery to repair his club feet. The case went to court, with a judge ruling that the medical need wasn't pressing enough to require surgery against the parents' will.
In 1994, police removed a Hmong girl from her Fresno home for chemotherapy after surgery for a cancerous ovary. The parents said they opposed the procedure because of side effects and because doctors could not guarantee her survival. A shaman had been consulting with the family.
Author Anne Fadiman wrote about the Hmong cultural conflicts in "The Spirit Catches You and You Fall Down: A Hmong Child, Her American Doctors, and The Collision of Two Cultures." The 1997 book detailed the case of a young Merced girl who suffered from seizures, and the effect of the clash of cultures on her health care.
By that time, health professionals and Hmong community leaders in Merced had applied for funding to start Healthy House to bridge the cultural divide. In 2000, Healthy House created a 40-hour certificate program called "Partners in Healing" that brought Hmong spiritual healers together with Western doctors and pharmacists.
During evening classes, the shamans looked through microscopes, learned about prescription drugs, X-rays and blood tests, and toured the hospital, including stops inside empty operating rooms.
Shamans invited doctors to their homes, where the physicians learned about Hmong healing beliefs and witnessed traditional spiritual healing ceremonies.
All told, 89 shamans received Partners in Healing certificates.
They were given special badges identifying them as graduates of the program. They wear them in the hospital.
Among the graduates is Fai Pah Chang. A short, sturdy man who farms vegetables in Merced, Chang, 65, fought on behalf of the United States in its secret war in Laos. He came to Merced four years ago from Thailand.
Before the classes, Chang had reservations about surgery being safe. A tour of an operating room at Mercy eased his mind.
"It is a place with safe tools, a safe place to keep the patient," he said.
Leading the way
Healthy House's certificate program paved the way for the hospital policy on Hmong shaman healing ceremonies.
Shamans learned what they could and could not do because of patient safety and infection-control reasons. And doctors became more knowledgeable of Hmong spiritual healing ceremonies, Mochel said.
A similar education program has been started by the Hmong Health Collaborative, a group of nine Hmong-serving organizations in Fresno, Merced, San Joaquin and Sacramento counties.
Last year, the collaborative trained 13 shamans at a class at Children's Hospital Central California in Madera County.