Examining Cultural Perceptions of Stroke: Spirits, Superstitions, and Steaming Pasta

I push the simmering sauce around in the pan. Tuna, oil, a few anchovy filets, and perfectly browned sautéed onions emit a rich smell that fills the apartment. I've sliced the cherry tomatoes; I admire their deep red and the beauty of the symmetry in the small heart-shaped fleshy center encased by the slightly green seeds. Like so many simple Italian dishes, the success of this fusilli al tonno is dependent upon the quality of the ingredients. But all of the produce for tonight's meal is from the local Moroccan souk. I have no doubt about the robustness of its flavor.

Correctly salting the pasta water is key, and -- in my experience -- friends without Italian family fail to add adequate salt. I call Aisha over who accepts my tutelage and we throw in the pasta. I step out onto the balcony, scanning the long strip of beach, which is dotted with a combination of jeans, sneakers and hijab, the traditional loose fitting Moroccan robe -- djellaba -- plus a few bikinis, all of which are sitting in the sand or splashing about in the water.

I return inside to taste the pasta, perfectly resistant to my teeth: al dente. There is no other option. I call Aisha over, -- "It's ready!" -- toss the colander into the sink, and start to pour in the pasta. I hear a scream.

"Stop it! Stop now!" Her shriek is terrifying.

A mess of words escape helplessly from my mouth as Aisha runs toward me, and -- to my surprise -- reaches over the sink to frantically jerk the handle of the faucet upwards. Cold water pours out onto the steaming hot pasta in the colander. I stand, aghast and befuddled, holding the pasta pot -- still half filled with pasta -- tilted over the sink, two towels wrapped around my hands as potholders. Aisha and I look at each other for a moment as the cold water continues to flow from the tap onto my once-steaming fusilli.

"Go ahead, pour the rest in", she instructs.

I hesitate. "You sure?"

"Yes."

I pour the rest of the pasta and boiling water into the colander and Aisha reaches over and turns the cold water off.

"What did I do?..." I ask tentatively.

"Well, it's more of a habit, really." She trails off. I continue to look at her questioningly.

"I never pour hot water into the sink without running the cold."

I have made so much pasta at this point in my life and not once have I run cold water over it while pouring in the hot... I am perplexed; Aisha clearly recognizes this and starts to explain.

"...It's just the way we do it here.... Here in Morocco, you won't find anyone pouring hot water into the sink without also running cold water."

"Why?"

"Well..." Aisha pauses for a moment. "Because of the spirits. Evil spirits can live in the sink and they're more likely to emerge and harm you if you don't try to prevent it by letting the cold water run when you pour the hot in."

I was shocked.

These evil spirits are called Jinn, and they are referenced in Koranic texts. At this point during my stay in Morocco, discussion of jinn was uncharted territory for me. Little did I know, I would have hundreds of conversations within the next few months about jinn as they relate to classic symptoms of stroke.

....Stroke?

I was in Morocco working on grant funded research that investigated perceptions of stroke symptoms, risk factors, and subsequent treatment-seeking behavior in different communities. For many of the Moroccans I spoke to, the jinn that can live in the sink and harm you during the pasta-making process can also cause stroke-like symptoms. Symptoms classic of stroke include paralysis or numbness -- especially on one side of the body -- likely of the face, arm or leg, difficulty in understanding or producing speech, a splitting headache often accompanied by dizziness or nausea. I soon discovered how intertwined the perception of stroke symptoms were with cultural stigmas, taboos, and accepted norms.

Stroke is a disease of global proportion, a leading cause of death and disability worldwide, and its incidence is increasing. Many countries, Morocco included, do not have the resources for ubiquitous neurosurgical stroke treatment, so prevention is paramount to reduce stroke burden.

Prevention is coupled with awareness. With an understanding of stroke symptoms so entrenched in religious beliefs and day-to-day practices as basic as draining pasta water, how can you "educate" about stroke without fundamentally disrupting the cultural milieu in which that belief exists? How do you appreciate interconnected, complex patterns of behaviors and understanding that involves spirits -- both conscious and unconscious -- and appropriately introduce the biomedical perspective? Initially I thought it would be feasible to isolate stroke as a case not caused by evil spirits, but by an anatomical, physiological issue... Moments like my pasta experience forced me to question this assumption.

Aisha had grown up in Morocco with a pharmacist father, went to an English-speaking school, and attended an elite college in the United States. Her reaction to her own "jinn reflex" elicited confusion and perhaps even embarrassment. She may question whether she truly believes in these spirits, but the superstitious practices accompanying this cultural belief are ingrained to the point of instinct. I was not expecting to see the tension between "biomedical modernity" and "cultural history" manifest in this manner. I wanted to teach Aisha how to make Italian pasta, but my pasta methods were inappropriate in her cultural context; Aisha's stress-reaction triggered by my lack of awareness of jinn was not such a big deal in the situation of two friends cooking pasta. But, what about a western doctor who is completely unaware of jinn and who is charged with treating and counseling a Moroccan community about stroke? What are the ramifications of that cultural impasse?

Such considerations are not restricted to health initiatives abroad: with immigrant and asylee-accepting states, and the influx of displaced persons across the globe due to turmoil, western physicians and systems will be increasingly confronted with differing cultural perceptions. Being conscious and sensitive to these disparate understandings of health will always be paramount to delivering culturally competent care.