Prior to the advent of the hospice movement which began in Zimbabwe in 1979, care was given by herbalists and traditional healers. An ill person would be moved to a musasa²⁷ on the outskirts of the village. The traditional healer would direct care which was mainly provided by elderly women in the form of hygiene, nutrition, psychosocial and spiritual support. Modern nursing was introduced to Zimbabwe in 1890. Only acute care was offered, however, until the advent of Island Hospice in 1979.²⁸ Traditional healers are still an important part of the culture and many patients will alternate between these and allopathic health services.²⁹

Island Hospice. In 1977, Maureen Butterfield and her husband watched helplessly as their daughter, Frances, died of cancer. The inadequate levels of care that Frances and her parents received caused a grieving Maureen Butterfield to source something better for others in a similar position. She travelled to St. Christopher’s Hospice ( London) where she learned more of the services and facilities, and considered the concept ‘well suited, with slight adaptations, to the needs of the section(s) of the population which were most familiar to me’.³⁰ She returned to Zimbabwe eager to pursue ways of establishing a hospice service. A crowded public meeting in May 1979 resulted in the establishment of Island Hospice Service – the first of its kind in Africa - that developed 17 regional branches by 1997.³¹ The name was taken from the words of John Donne:

 ‘No man is an island, entire of itself. Every man is a part of the continent, a piece of the main, and each man’s death diminishes me because I am involved in mankind.’³²

In a country which became independent from Britain in 1980, the developing service operated in a receding colonial framework where whites still held social and financial power. Yet over the next 24 years, the organisation changed from ‘a charitable institution, relying on volunteers, initially with patients who were elderly, middle class and mostly white’³³ to something more attuned to the wider population of Zimbabwe. David McElvaine, a former Senior Administrator of Island Hospice writes:

‘Zimbabwe’s pre-independence history also had a marked effect on public opinion regarding death and bereavement. The bloody and protracted struggle for independence had personally affected hundreds of thousands of people. The need for skilled bereavement care was at its zenith when Island Hospice was formed. These large-scale events, coupled with our early focus on public relations and education were strong contributory factors to our successful establishment and have remained crucial to our continued functioning.’

At the outset, Island Hospice was a specialised unit with qualified and experienced staff who delivered care to a relatively small number of people. As the reputation of the service spread, ‘the patient profile changed. There were more black patients and they tended to be younger (conforming to the pattern of cancer in Africa), lived in small, overcrowded houses and spoke Shona’.³⁴

As the effects of HIV/AIDS became apparent, Island Hospice broadened its base to include patients with AIDS. Speaking at Island’s 25 th anniversary celebrations in January 2004, social worker Rona Martin recalls the impact of the AIDS epidemic on the service:

‘Twenty five years ago who could have known how the spread of HIV/AIDS would change the face of hospice care in Africa? Our first AIDS patient was in 1986 and we continued to take patients with HIV referred in the usual way. However, as with the rest of the country, we were slow to realize and respond to the full impact of the pandemic. It became clear, however, that in order to reach our increasing numbers of families in need, we would have to change the way we work. Carla Lamadora, former Director and now Director of HOSPAZ, the new umbrella organization, was instrumental in getting us into community based work. Island had always worked in the community with its home based care, but now with the increased need it became necessary to partner with other groups committed to home care. Our first base in the community was Mabvuku. Training, always a part of our work with medical students, nurses and caregivers, became increasingly important. Our separate training department was formed in 1996 to respond to demand. Spreading skills in palliative and home based care through training and mentoring continues to be seen as the way forward’.³⁵

Family AIDS Caring Trust (FACT). This NGO was founded in 1987 by Geoff Foster, a paediatrician at the government hospital in Mutare. As he saw some of the earliest cases of HIV/AIDS, he realised that Zimbabwe's limited health services were becoming overwhelmed. At the same time, AIDS prevention programmes and office-based counselling for HIV-positive people were largely ineffective. Consequently, Geoff Foster developed an alternative vision – of an organisation which would work with local communities, develop culturally appropriate models of prevention and home care, address religious beliefs on disease causation, and decrease the stigma associated with AIDS.

FACT began by engaging local church, political, health and business leaders and built up a broad volunteer and funding base within the local community. Issues of sexuality, female subordination and other taboo topics were confronted and openly discussed. Programmes were directed towards target groups, including: sex workers; single women; truckers; youth; rural inhabitants and people living with AIDS.⁶

 Mashambanzou Care Trust. Sister Noreen Nolan of the Little Company of Mary founded the Mashambanzou Care Trust in 1989. She had spent time in the rural areas and saw the impact AIDS was beginning to have on Zimbabwean society. Consequently, she founded a ward for terminal care at St. Anne's Hospital - a private centre in a well-to-do neighbourhood of Harare. Yet it became clear that pressing need for care existed in the high-density areas where the majority of people live. With the assistance of the Norwegian aid association, NORAD, Mashambanzou purchased a property on the outskirts of Harare to respond to the epidemic from a broader base.¹¹

The Mildmay Centre opened an outpatient clinic at Harare Hospital in April 2003; the day care centre opened the following month. The project is designed to be a model of care for children affected by HIV/AIDS, and focuses on intensive rehabilitation after diagnosis/ illness. Children who have been referred for intensive support in the day care centre are transported from their homes to the centre and then taken home at the end of the day. Where necessary, children are admitted to a ward in the hospital. Anti-retroviral drugs (ARVs) are not currently available, but it is planned to begin an ARVs programme during 2004. Nevertheless, many children have been able to return to school.³⁶

Morgenster Mission Hospital. Dr Breugem founded the palliative/ home care service in 2003 after receiving training from Island Hospice. She subsequently trained a body of volunteers (now around 400) who work in homecare and orphan care programmes and also distribute care kits, bandages, gloves and bleach. There is close liaison with district nurses (10) based at five clinics, where patients can also access medical support. Although the programme is weighted towards physical care, and as yet there are no social workers or nurses, Dr Breugem is mindful of incorporating psychosocial care as the service becomes established.