Stanley Malonza is a physiotherapy supervisor at CVT Kakuma.

Our clients have survived extreme circumstances. When they come to the Kalobeyei settlement, they have escaped from torture and atrocities. They’ve made harrowing journeys to find themselves in a new community, with new challenges and dark, disturbing memories. This is where CVT comes in – we bring them into the community.

Even though we are now facing the COVID-19 pandemic, our services have stood the test of time. Inspired by the resilience in our clients, we have had to adapt. We have continued to reach out to our clients and others who are in need of our services remotely. The incentive workers and community advisory members provide constant feedback on what is happening in the field. This information helps us to modify and adapt our service delivery to meet the changing trends.

Before the pandemic, one of my clients here was a man who had been beaten, captured by militia, and had his parents and relatives assassinated. He was forced to watch his beloved wife being raped. After the horrific abuse, they untied him and commanded him to run. As he was running he was shot. He was meant to be killed. He fell and lost consciousness, waking to find himself in the very hands of the perpetrators.

He described to me how he did not know where he was, the time and day, or the length of time he had been in that motionless state. He thought to himself he must be dreaming as he could not remember what had happened. His body was full of pain. He tried to move his legs but was not able to. His left leg felt as if an anchor had been tied to it.

The room was dark and he could only hear footsteps come and go. He said the pain in his body was gnawing on his flesh and burning like acid the moment he tried to recollect the last memories. So he shut his eyes and did not want to ever open them again.

“Bring the pickup.” Those are the only words he remembered hearing. He had no idea where they were taking him and only wished he could see his wife for the last time and say goodbye. They drove for a long time among the woods he once enjoyed. The road was very rough and as they drove he realized the vehicle was slowing down. Great fear engulfed him and he wanted to go back to the unconscious state – it was safe there. It was raining heavily so he knew this was their perfect time to take him to his maker.

They pulled over, dragged his body out of the car, disposed him on the road, and drove off.

He woke up in hospital. His leg was in a huge white cast. He did not know what was happening. He told me his survival instincts at that moment were very strong; the moment he could walk, limping with the cast on, he escaped from the hospital. He had no idea how long he walked but he just kept on walking and walking.

He said he was able to rejoin with his wife after several months. He said they had no words for each other, just tears and the warmth of the hug they gave each other. He told me they felt empty, and in a society where one is often judged by physical appearance, they felt like walking wreckage beyond salvage.

He asked me, “Could a walking skeleton command you to enjoy life?” He was traumatized physically and emotionally, and he had a lot of pain. When they come to the Kalobeyei settlement, a new challenge awaited them with dark and disturbing memories. In nearby Kakuma, he didn’t get better care. He roved from one hospital to another but many times he walked out because nobody believed him or wanted to listen to his story. He said they thought he was paranoid, and in turn he became violent and aggressive towards people. It was hot and very dusty in Kakuma camp but having escaped from the glaring eye of death from his country, that did not deter him. He found his way to us at CVT and came for an intake appointment.

I took him to a quiet and safe place for privacy, where he chose where he wanted to sit, and I introduced my role and the work of CVT. He seemed disengaged. He asked me, “Is this going to take long?” I could see by the look on his face this was not going to be easy. I put down my pen and told him I was not here to fill out the form but to listen to him. I told him to feel free to be in charge of the time and everything we discuss here. He said to continue and gazed straight forward.

As I asked the questions, he answered with very few words. He paused and told me “Stanley, my story is very long.” He paused again, held his chin with one hand on his face. I saw tears were flowing like a waterfall. This happens with clients who have survived traumatic experiences. I reassured him and gave him a glass of water and tissues.

I paused the intake process and suggested an activity to help him compose himself. We did a grounding exercise focused on his breathing and body sensations while taking deep and slow breaths. I explained to him it may feel difficult at first and this is very normal. We did this together while focusing on our feet planted firmly to the ground, listening to our heart beat and observing our shoulders rise and melt away from the ears.

After that he seemed more trusting, calm and composed. So then he narrated his story. He was shot in his knee as he was running away and his kneecap (patella) was shattered. Without any medical attention, his tormentors locked him in a de facto prison so he would experience both physical and emotional pain before killing him.

After he was rescued, a surgery was done to fix his broken knee. An intramedullary nail was inserted through his knee, from the lower shaft of femur to tibia, and as a result he could not bend his knee. This inhibited him from performing important functional movements like squatting during toileting, bathing, fastening shoe laces, and picking up items the floor. His walking had also been affected, and he was limping.

He showed me his scar where the metal implant was inserted, and I noticed some striking features: a large scar above the knee and small wound were still present. The knee appeared swollen and tender and there was clear fluid oozing out from the wound. Then he said “I don’t think I will benefit from CVT’s care. What I need is surgery. I have been like this for the last three years since I came to the camp. All they give me is painkillers!”

During my medical training and having worked in an orthopedic hospital, I had not seen such a procedure. Intramedullary nails are used in comminuted fractures of long bones such as the femur. But for patella fractures, in this case where gunshot would have shattered the patella bone, another surgical management is more common, using pins and wires. I wondered if his knee was surgically fused.

These were questions which lingered in my mind as I observed his knee carefully. He had escaped from the hospital in fear for his life and did not have any discharge summary or documentation of the past medical care. I needed to get an x-ray film to augment my clinical diagnosis and plan for his knee.

But I said there were other things we could do that could help. We set very realistic goals and agreed to do both group and individual sessions. He came the first day of group physiotherapy, but he sat in the corner and didn’t speak to anyone. After some time, though, he realized there were people from his neighborhood there, people who could be his friends. So he started to participate. He could not do some of the exercises, however, so I did individual work with him for his leg. He became committed to group sessions and in only two weeks he said there was more that he had not told me. He started to open up. He had other problems and became very open to me. I listened.

His friends in the group encouraged him through all ten sessions, and even though his joint range of motion did not change, he had a lot of other improvements. He became aware of his body and pain pattern. He was able to sleep well and use new coping strategies to deal with pain and flashbacks. His body posture and walking greatly improved.

After he had completed the group sessions, visiting orthopedic surgeons from Nairobi came to Kakuma. When they reviewed him and the x-ray, they confirmed he had implants (screws on the patella) that were supposed to be temporary. These were never removed and were the cause of chronic infections on his knee. They did surgery for him to remove the pins. It went okay. Intensive physiotherapy was recommended. He did not want to attend physiotherapy anywhere else apart from CVT even though he had completed CVT’s 10 sessions. We agreed to have further individual sessions with him.

We did intensive physiotherapy to improve the range of motion, now being sure the exercises were safe. Initially the knee was locked in extension at 180 degrees, but after every week we were able to get more than 5 degree reductions. By the 6^th individual session, his knee flexion could go to 125 degrees and this enabled him to perform most of his functional activities again. He could squat, take a bath, sit on chairs, and motorbike comfortably.

He became a very good ambassador for CVT – he spoke out in his community and they all came to CVT. Now he is part of his community and he is bringing CVT into it.

I have been here in Kakuma for over two years. I trained as a physiotherapist and have over 10 years’ of healthcare in various hospitals, faith-based organizations (FBOs), and as a lecturer in medical college. My focus has been on lecturing and clinical work. During my work in one of the orthopedic hospitals, I focused on rehabilitation after surgical correction for congenital or acquired injuries from accidents and trauma. I also trained in assistive devices and am a member of the International Society of Wheelchair Professionals (ISWP). In my work, I saw that there are a lot of barriers, negativity and stigma to people living with disabilities. Often, they have limited access to basic facilities and face discrimination. They are deprived of their liberty and often isolated and locked up.

I have a passion for people who are less fortunate – I have a value in my life to help people who cannot ever give back. Because of that compassion I have unwavering passion to seek more knowledge and face new challenges. I moved here to Kakuma out of Nairobi because I wanted to be challenged. Working with CVT has changed my perspective on medical care. I have learned to pay attention to a client’s narrative even if I cannot find their symptoms on standard clinical tests. For example, in some cases, what a client says doesn’t match the clinical symptoms – tests don’t elicit symptoms. I’ve found that especially true with post-traumatic stress disorder (PTSD). I work very closely with psychosocial counsellors to be able to provide holistic approach.

And the results we achieve are quite impressive. It motivates me. In my role, I oversee a team of physiotherapists and incentive workers. I support them in capacity building and we share knowledge together. I also handle assessments and make sure the environment is welcoming and safe, especially now with the pandemic, when we are very limited in any in-person work.

Of the clients who have been to CVT many found value in their life and became ready to move on. They have been able to get jobs; they are empowered. They go on to be very productive people in the society. One is a teacher; another is a receptionist at the hospital. All of them felt they were not accepted in society but now some are becoming productive in their lives. They feel they have value. This lifts me up.

From working with clients, I see that there is hope for everyone – they can see the world is still a good place to live. There is no reason to give up. They tell me they have found an oasis of hope in organizations like CVT. They find meaning in life. Because life is a gift.