The sharp edge of gratitude

It is relatively easy to see and raise a red flag on humanitarian programming where complaints roll in from those on the receiving ends of assistance. However, the dominance of gratitude in humanitarian relations might raise its own red flags.

“Beggars can’t be choosers!” 

The man speaks these words through a smile, leaning on his homemade crutches. I am in rural Nicaragua, in a community of about 300 people and a month into a study of Nicaraguan perceptions of humanitarian healthcare missions. This community had hosted such a mission from the U.S. for 6.5 hours the week before. The one-day event had been a rare opportunity to see a specialist, such as a gynecologist or a pediatrician, without several costly, time-consuming and thus for most impossible trips to the city.

My conversation partner, a man in his late 40s, has no complaints about the group from a U.S. medical school, many of them learners. The group had been friendly. They treated patients with respect. 

This man, like many of his neighbours, is particularly pleased that everyone who showed up on “mission day” was seen. His comment, “Beggars can’t be choosers,” is in response to my regrets that he has not received the walker he had been hoping for. I know Ronald (not his real name) has managed his twisted legs with home made crutches for years. And yet, that phrase, “Beggars can’t be choosers,” sticks with me. 

Ronald’s apparent satisfaction with the work of the humanitarian healthcare mission that had descended on his community was not unique. Again and again, in the course of the Nicaraguan perceptions of humanitarian healthcare study I was leading, I met Nicaraguan physicians, nurses, patients and community members who emphasised the many ways the foreign healthcare missions were “doing good”. They shortened long waiting lists for surgeries, provided free specialist consultations to the rural poor, and filled hundred of otherwise unaffordable prescriptions. Many patients and relatives of patients praised the foreign clinicians’ smiles and gentle touch: humanising treatment they claimed they were routinely denied in the public healthcare system because of their poverty. 

In speaking to Nicaraguans like Ronald about medical mission programmes in their communities, the limitations of feedback gathering exercises are hard to ignore. I have worked in Nicaragua since 2000, on projects related to poverty and health. I have asked sensitive and potentially politically loaded questions in all my work. While I recognise that the results of any feedback gathering may be skewed by norms of politeness, lack of trust, or even fear, it seems such exercises can also be at serious odds with the lived reality of those they involve. 

Where individuals and groups are routinely excluded from decision-making processes, asking them to comment critically on programmes that are delivering resources they want and need may elicit less than frank answers. Such exercises might strike some who are asked as absurd, but it might also produce a sort of false positive. Many Nicaraguans sincerely experience themselves as lucky to have received anything over nothing through the “good will” of foreign medical volunteers. People like Ronald do not always get what they hope for or need in this system, but they have no buying power to go elsewhere. 

Feedback gathering exercises can accomplish many instrumental goals, but as this last year of ALNAP activities has emphasised, engaging communities throughout the programming cycle is also an ethical project. Where humanitarian organisations carve out time and space to ensure those on the receiving end of aid can be heard, these individuals are recognised as valuable knowledge holders and potential partners, rather than as passive victims. 

Recognition is not the same as power, however. The humanitarian system continues to be experienced by many as a system of beggars and choosers. On the side of a dusty Nicaraguan road, one man leaning on his crutches reminded me that asking those on the receiving end of aid to provide input and even critiques on programming does not shrink the gap between those positions.