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The Many Worlds of Nozipo Maraire

Yale Medicine Magazine, 1999 - Summer


Most neurosurgical residents are happy just to learn their craft, help humanity and survive seven years of very long days. Zimbabwe’s Nozipo Maraire has other things on her mind as well.

A morning in December. The neurosurgeon and the ophthalmologist have searched for three hours without finding the tumor on the 15-month-old boy’s optic nerve, a glioma that has already blinded the toddler in one eye and threatens his sight in the other. Because it is the same pearl white as the surrounding tissue and lies hidden somewhere behind the eye, it is hard to find. Reluctantly, the two doctors decide they must drill farther into the boy’s frontal bones and orbital rim.

Nozipo Maraire has been watching this from the sidelines. As the chief resident neurosurgeon, she had begun by assisting with the procedure but ceded her place at the operating table when the ophthalmologist was called in to help. For the last three hours, Maraire has watched the surgery on a video screen linked to the operating microscope. Now she asks to take another quick look for herself. She steps onto the stool, peers into the microscope — and this time finds the tumor. She guides the stainless steel instruments with precision to free it from the nerve. After two hours of painstaking work, Maraire lifts out a glioma the size of a cherry.

For J. Nozipo Maraire, M.D., HS ’92-99, the operating room is a world apart, a place where little else intrudes as surgeons, nurses and technicians focus on the delicate work of opening the skull and fixing what’s wrong inside. “There’s a closeness you share with people here. It’s almost a kind of clandestine fraternity,” she says, wearing a blue surgical cap, her smooth black hair pulled back above a high forehead. “Part of the culture is the balance between the seriousness of the situation — how macabre it really is — and yet you’re able to talk about the baby you just had, your lives, your friends. Time is suspended.”

Amid the repartee of the operating room, Maraire concentrates almost single-mindedly on the work of her hands. She has used this ability to focus outside the OR as well, extending her influence far beyond hospital walls. In the little free time granted a surgical resident, she has written a critically acclaimed novel, served on the board of an international development agency, pursued her master’s degree in public health, and laid the groundwork for a partnership between Yale and the medical institutions of her native Zimbabwe.

When she returns there next year, the 34-year-old Maraire will be one of seven neurosurgeons in the southern African nation of 11 million people. (Her 77-year-old counterpart at Pariranyetwa Hospital in the capital city of Harare is “counting the days until I get there,” Maraire says.) She will be only the second woman to have completed neurosurgical training at Yale since its program began in 1925, and she believes she will be the first black female neurosurgeon on the African continent.

Maraire was five years old when she told her father she wanted to be a neurosurgeon. She had only the vaguest notion of what one did, but liked the idea because “it sounded like the most difficult thing I could find to do.” Her mother is a pediatrician; her father, now deceased, was a college professor, banker and tobacco farmer. Nozipo grew up in Harare, attended elite private schools, then earned her undergraduate degree at Harvard before studying medicine at Columbia. Though her choice of career originated as a dare to herself, it has proven satisfying to Maraire. She feels drawn to the intellectual challenge of working out the puzzle of what afflicts a patient: asking good questions, listening carefully, visualizing the neuroanatomy, doing research. She recognizes that the problems treated by neurosurgeons lie at the core of the patient’s identity.

“What is wrong with them, and what are you going to do about it? What do they want done? You know you are going to do something that affects their body and, worse yet — in our case — their brain, which is at the center of how they function,” Maraire says with a trace of a British accent. “If you affect someone’s memory, it affects their ability to interact with their children, to get around town, to find their way home, to remember what they left the house for. You almost have a dread when you first meet a patient because you know, initially, more than they do about how they will be affected.”

On a different day, writing notes in the recovery room, she glances toward a gurney where a curly-haired man in his 40s is stirring back to consciousness. She has just completed surgery to release fluid pressure caused by an inoperable brain tumor. She asks the man to squeeze her hand, then continues holding it.

“Surgery’s all done!” Maraire says in a loud voice. “You’re doing great. You just have to wake up.” She has to strain to keep a grip on his hand because she is very short. (“Say I claim to be five feet tall,” she teases jovially when asked her height on another occasion.) Watching the man drinking orange juice from a paper cup in the recovery room a half-hour later, she says, “I didn’t know him yesterday, and when he’s finished I may never see him again. It’s just for the moment. He trusts me completely. It’s amazing.”

For her part, Maraire throws herself into the process of diagnosing problems and working out a treatment plan. In the course of talking through these issues with patients, she says she has experienced “an intimacy you don’t encounter anywhere else.” She also recognizes, and tries to resist, the impulse to shield oneself from the patient’s pain. “There’s a vulnerability in really allowing yourself to feel things,” she says. “For me it wouldn’t be meaningful without it. It helps the quality of what I do. I can only hope it helps the patient.” With a few patients, she has had to overcome racial stereotypes. There was the patient who was on the phone when she entered his hospital room to introduce herself as his surgeon. The patient told the person on the other end, “Hold on. The cleaning lady just came in.”

Patients do respond to Maraire, and her medical colleagues clearly enjoy her company as well. She teases them by using exaggerated formality at times. (“Yes, doctor. Yes, sir.”) She laughs at their bad puns. She joins in the irreverent banter while maintaining her focus as she performs a procedure. Operating room nurse Paul Bruch, R.N., has spent years trying to sleuth out Maraire’s first name. (She uses only the initial “J.”) Bruch’s technique for venturing new guesses is intimately tied to the surgical process itself. At the end of each case, as Maraire dresses the patient’s incisions, Bruch uses Bacitracin ointment in a fine-tipped tube to write “J” names on the gauze he prepares for her.

“I’ve tried Juanita, Jebedia, Jessica, Jewel, Jacqueline. ... I’ve been doing it for seven years,” Bruch says in mock despair. Maraire smiles and keeps her own counsel.

Early evening. Maraire has spent 12 hours in surgery and the toddler’s case is still in progress. She leaves the OR, slips the paper surgical mask off her face, and walks briskly downstairs to pathology, carrying the child’s optic tumor in a sterile cup. Pathology will check to see that a margin of healthy brain tissue surrounds the glioma, showing that the entire tumor has been removed. As Maraire awaits the results, she notices stacks of glossy Christmas catalogs in the waiting area. She begins constructing a story in her mind. She imagines a play for children, in which a scholarship student in Zimbabwe visits the home of a wealthy classmate and recognizes the difference between material wealth and a rich family life. Maraire has no paper for making notes. She rehearses the ideas in her mind so that she will remember enough to record them when she gets home.

Ideas for stories often emerge when she is most consumed by her work as a doctor. “I’m so full of neurosurgery and it’s like a release valve that allows me to escape.” Writing provided this kind of liberation early in her residency, when she wrote Zenzele: A Letter for My Daughter (Crown, 1996; Delta paperback edition, 1997). She borrowed the key to an empty computer room, and at midnight, or 2 a.m., or whenever her day finally ended (and her call began), she wrote for two hours. She says her need to write outweighed her need to rest, and she often got by on three hours’ sleep. Zenzele, listed in the New York Times Book Review as one of the notable books of 1996, has been translated into 13 languages.

The book takes the form of a letter from a wise Zimbabwean mother to her daughter at Harvard. The mother uses her life story and stories of family and friends to illustrate the struggle of Shona people to preserve the strong aspects of their culture: respect for elders and a feeling of obligation to the community. She warns her daughter Zenzele of the perils of severing roots to her culture. In poetic language, the mother tells how the older generation suffered under and resisted colonial rule in Rhodesia (the name for Zimbabwe until independence from Britain in 1980).

“Since I’ve written the book,” Maraire says, “I’ve met a lot of young Africans who’ve told me it’s the first time they’ve read a book in which they recognize themselves, the generation of children who made the transition from pre-independence to the struggle for independence and the post-independence era, and the ensuing cynicism that inevitably followed.

“We remember apartheid, when we weren’t allowed to shop in certain stores. ... We’re lost between the traditional African culture and the modern culture. We don’t know how to incorporate them, and there are no role models. The world is so Western, and we want to retain our core identity.”

Maraire’s second novel, well under way, tells the story of a return from the West: a Zimbabwean woman orphaned by the brutal assassination of her family escapes to the United States. Years later, she goes back to Africa to confront her past and the meaning of home.

The struggle of Maraire’s fictional characters to reconcile African and Western values reflects Maraire’s own enduring interest in the analogous challenge facing Third World societies: how to adopt Western ideals and technologies selectively. While an undergraduate at Harvard, Maraire organized a campus group to place students with international agencies like Oxfam. She took a year off from college to work on AIDS education for the World Health Organization in Geneva. There she worked closely with the late Jonathan Mann, M.D., a visionary advocate for global AIDS policy. Now she serves on the board of directors of the Manhattan-based nonprofit group South North Development Initiative, which finds innovative ways to provide capital to African and Latin American businesses considered too risky by conventional investors.

Maraire has retained her connections to home during her surgical residency. She found grant money for a fellowship that will allow American neurosurgeons to visit Zimbabwe, and she is the only African serving on a committee, led by missionaries, hoping to establish a second medical school in Zimbabwe. When she was invited to speak at the Zimbabwe International Book Fair this summer, she used her honorarium to establish an award for a young female African writer.

It’s 10 p.m. when Maraire has completed the optic glioma case and “tucked the patient in.” The prognosis for the little boy is excellent: the tumor has been removed and biopsied, and it is not malignant. His physicians will need to watch him closely, but they don’t expect the tumor to recur. Maraire does rounds, checking on eight surgical patients on the neurosurgical intensive care unit and then another 32 on the neurosurgery ward. When she gets home, she writes until midnight, recording the ideas that struck her while she waited in pathology. Before sleeping, she phones her husband, Allen Chiura, M.D., a urologist in Delaware.

Allen Chiura was a childhood friend whom she met again by chance five years ago in Heathrow Airport in London. (He was traveling from Zimbabwe to Philadelphia; she from Ethiopia to New York.) Maraire had thought she wouldn’t be caught dead making the conventional choice by marrying someone from her upper-class social circle in Zimbabwe. But she and Chiura found that their common frame of reference gave them a deep understanding of each other. She says they “shared a time not too many people have shared, living in a country going through the transition from colonialism to a time of independence. We made sense to each other.” She saw that broadening her horizons by dating men from different cultures had, paradoxically, imposed limitations. She compared it to living in a single room of a mansion. “Meeting Allen, it was like the whole house was open. Light came in.”

Marriage to a Zimbabwean will make it easier for Maraire to transmit to her children what she most values in the Shona worldview: feeling linked to one’s ancestors. “There’s a sense that you have the benefit of other spirits. You’re not so alone. There’s a sense of some continuum. That continuum is with you and maybe — who knows — gives you wisdom and insights.”

Maraire and Chiura have celebrated two weddings. Their families gathered in May 1998 in a traditional Shona kuroora. The kuroora ceremony joins the extended families of bride and groom. This union is symbolized by ritualized gift-giving and role-playing in which the groom’s parents, siblings, aunts and uncles show appreciation to the bride’s family for raising her. Chiura’s family paid Maraire’s family a lobola, or dowry — a “hefty” one because Maraire is a well-educated professional. Then in April of this year, they were married in a large Roman Catholic wedding in Zimbabwe. The reception, attended by 1,600 guests and a writer for Martha Stewart Living, was held at the botanical gardens in Harare.

The wedding also solved the mystery that has plagued operating-room nurse Paul Bruch for the last seven years. Engraved on the invitation that arrived at his home in late winter was Maraire’s full name. The “J.” stands for Jacqueline.

At seven the next morning, on a warm day for December, Maraire arrives at Union Station in New Haven. Briefcase in hand, she is heading to Manhattan for the annual meeting of South North Development Initiative. She serves on the agency’s eight-member board, which includes bankers, business leaders, an environmental activist and a high-level United Nations administrator. Sitting in the conference room overlooking Rockefeller Center, they hear a report on a plum farm in western Argentina that South North is trying to save from bankruptcy. The discussion turns to South North’s social rationale for preserving the farm, the largest employer in a small town. Maraire raises some philosophical questions, asking whether the agency is doing enough to differentiate itself from conventional venture capitalists and lenders by emphasizing its mission of empowering poor people.

After the board meeting, Maraire takes a rare evening away to meet Chiura and attend a friend’s wedding reception in Philadelphia. By midnight she will be back in New Haven and on call. She seems almost embarrassed to admit that she will take a few months off before beginning a fellowship in New York in June. Not completely off — Maraire will be writing the thesis for her master’s degree in public health at Yale. She will develop a system for measuring quality of life for patients with cerebrovascular disease.

Maraire’s next big project would affect lives on a larger scale. She hopes to create a foundation that will “galvanize civil society” in southern Africa. Her aim is to build cultural centers, museums and theaters in the region (Zimbabwe, South Africa, Namibia, Botswana, Mozambique, Zambia, and Malawi). She sees the foundation as “an instrument to improve the quality of life for southern Africans” in the broadest terms: providing grants to support innovation in medicine, public health, the arts, engineering and scientific research. For lack of money to carry out their ideas, southern Africans “have become culturally impoverished when we are culturally rich.” Maraire has envisioned this project for a long time — she wrote her first proposal for a foundation while an undergraduate.

After Maraire completes her fellowship this December with pediatric neurosurgeon Fred J. Epstein, M.D., in New York, she and Chiura will return home. Many of their patients in Zimbabwe will have AIDS. (The United Nations estimates that at least one in five Zimbabweans between 15 and 49 is living with HIV or AIDS.) The epidemic has devastated people of every social class — Maraire says their parents tell her and Chiura that they attend as many as three funerals a week. She has no choice but to accept the perpetual risk that any patient could infect her. “You double glove. You take precautions. What are you going to do? You have to treat people,” says Maraire. “It’s not that it’s not scary. It’s scary.”

Settling permanently in the United States is “not even an option,” she says. She feels a strong tie to her home that she attributes in part to her parents’ example. They were always raising money or collecting clothes for the revolutionary forces fighting to overthrow the government of Rhodesian Prime Minister Ian Smith. Even when her father’s academic appointments took the family abroad to live, Maraire says, “it never occurred to my parents that they were not going home.”

The strength of her commitment to return home was important to the Yale neurosurgeons who chose her, over 100 other candidates, for a single slot in the residency program in 1992. The committee immediately recognized that “if we wanted to make a difference in the world, this is the person to take on,” recalls Alain de Lotbinière, M.D., associate professor of neurosurgery. “It was obvious that we had to take her. She’s an exceptional individual. I don’t expect to train anyone else like her in my lifetime.”

The department’s chair, Dennis Spencer, M.D., HS ’72-76, says that, in his experience, surgeons trained at Yale are often unwilling to return to places that lack the sophisticated technology they have come to rely on in the United States. Maraire’s challenge will be to adapt neurosurgical techniques to use the limited equipment in Zimbabwe. For instance, the university hospital in Harare just received its first operating microscope as a result of Maraire’s efforts.

Yale will help her to handle difficult cases by establishing a videoconferencing link between New Haven and Harare, allowing Maraire and colleagues to confer with Yale physicians even while doing surgery. (A video camera can be aimed through the microscope to show detail.) Spencer plans to visit Zimbabwe to help train surgeons in advanced techniques and to provide any other help Maraire requests. “Her promise when we brought her into the program was that she would bring her training back to the people of Zimbabwe,” Spencer says. “My promise to her was to make that dream happen and to continue to be a bridge between the United States and Zimbabwe.”

Spencer says that knowing Maraire has inspired him to make more effort to extend his work in epilepsy to developing countries, teaching medical and surgical approaches that do not require expensive equipment. He foresees that Maraire will have to choose between two routes: becoming the mainstay for neurosurgery in Zimbabwe, case by case, “living in the hospital,” or taking a broader approach by setting up programs to improve medicine in Zimbabwe and to train “more Nozipos.” He predicts she will choose the latter.

Maraire agrees. She imagines a life for herself that includes time in the operating room, time establishing her foundation, time with the children she hopes for. She plans for her future by picturing how she wants to live — what she calls “doing the visioning thing.” Observing that people often complain about their lives without recognizing that they are choosing those lives, Maraire recommends that people slow down and think: “I want my life to be like this. How can I construct the life I want?” This long-established practice of envisioning her goals has been confirmed by her experience in practicing medicine, in what she calls “this constant encounter with death.” She says, “I have a sense that at any time this moment could be cut short. I think, as a result, I live more fully. Time is so precious.”

Maraire says her drive and her ability to get things done derive from her assumption that she can accomplish whatever she chooses to undertake, even when she can claim no special expertise in a field. “I don’t feel, ‘I can’t do that. Somebody else should do that,’” she says. Maraire believes her lack of inhibition about tackling projects grows, in part, out of coming from the Third World, where fewer people have the education and the connections to get things done. “If you have the opportunity to do something, you have to seize it.”

Although Maraire has reached two of the goals she set in her twenties — becoming a surgeon and writing a book — she feels frustrated that she hasn’t accomplished more. “The more you do, the more you feel needs to be done,” she says. “I feel a responsibility because I’ve had so much opportunity. I’ve had a privileged life.”