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1: What are you trying to accomplish?
2: What's your evidence that you can accomplish it?
3: How is it possible that you can provide an open heart surgery in Iraq for less than $1,000? Is that the full cost?
4: So is that the same thing as saying that my donation doesn't really make a difference? That the "up to 85%" funded locally by those inside Iraq is all that is really necessary to make this work?
5: Any other costs?
6: What is the bottleneck to more surgeries: money or skilled labor?
7: I'm skeptical of non-profits and charities because they always seem to be asking for more money. How can I be sure that Preemptive Love Coalition has "room for more funding" and that I'm not paying into a huge savings account, "Rainy Day Fund", or something similar?
8: Do you have enough volunteer surgeons available for unfunded Remedy Missions? (i.e., are there trips that you could fund if you had more money, or is there a labor bottleneck?)
9: Many heart surgeries require follow-up treatment (including additional surgeries). Do you have a way of providing these to patients?
10: How do you assess whether surgeries are completed competently and appropriately?
11: What is the rate of complications during and following surgery?
12: How do you assess whether surgeons are performing additional surgeries that they would have not had the funding or motivation to perform otherwise?
13: How do you assess whether surgeons are charging their patients for the surgeries you fund?
14: Do you follow up with the surgeons you've trained to assess whether they are correctly applying their training?
15: What information is available on the activities - and competence - of the surgeons you've trained?
16: Where do surgeons work after completing training? Do they serve poor patients?
17: How much do you spend each year on "program" expenses and how much on "overhead?"

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Q: What are you trying to accomplish?

A: Train Iraqi heart surgeons and nurses so they can eradicate the backlog of tens of thousands of Iraqi children waiting in line for lifesaving heart surgery. [Back to Top]

Q: What's your evidence that you can accomplish it?

A: Each year we continue to increase Iraq's total number of pediatric cardiac surgeries with new surgeries in Iraqi centers that would not - indeed could not - have been accomplished otherwise. Ministry of Health (MOH) officials speculate 500 surgeries were accomplished in 2009 (of which we provided 23 - 4.6% - outside the country). The addition of our 82 surgeries in FY 2010 - to the 500 baseline - for a total of 582 approximated surgeries, represents an increase created by PLC of 14% over 2009. In FY 2011 we anticipate increasing Iraq's total number of pediatric cardiac surgeries to at least 719 (or another 19% over FY 2010 directly attributable to our surgeons and our training).

Each year the local teams with which we work will become more proficient, and each year they will independently take on a larger case load than they could have the year before. None of these figures yet account for that additional output.

In March 2010 the Iraqi Ministry of Health asked us to expand our work to three additional sites. In May 2010 we began additional discussions about establishing a fellowship program in which international surgeons and nurses would take up residence in the Iraqi system to train locally for 40 weeks out of the year.

Our model does not rely strictly on volunteers because the level of need in Iraq outstrips what we could reasonably supply through volunteer labor alone. Accordingly, we set our budgets so as to actually contract the international surgical and nursing staff we need to accomplish our mission.

Sure, this increases the cost-per-mission (and thereby, cost-per-child) over early "mission" models in which volunteerism was idealized and training was not necessarily prioritized. But our contract labor + volunteerism model is inarguably the only way to create a nationwide quarterly training program and fellowships inside Iraq with international experts across approximately 6-8 surgical sites. Moreover, our model does not face the same sluggishness of learning that other surgery organizations suffer because we do not have the same rates of turnover; we have incredible consistency across our programs and missions. [Back to Top]

Q: How is it possible that you can provide an open heart surgery in Iraq for less than $1,000? Is that the full cost?

A: The "less than $1k" numbers we routinely publish represent the amount in "program costs" we spend from our international donor money. The figure does not necessarily account for every single management, overhead, or fundraising expense.

Our total expenditures for FY 2010 were $188,919. We performed 82 surgeries during the same period for a per child total of $2,304 (though this data is a bit moot moving into 2010-11 as we abandon our very expensive "surgery exports" program(s) in Turkey, etc. and focus henceforth on more cost-effective in-country surgeries alone).

When all of our Remedy Mission partners are taken into consideration - including the Iraqi Government, medical companies that donate medicines and supplies, and local organizations - the real Remedy Mission cost to all donors is in the range of $5,400 - $7,000. Put another way, up to 85% of the total cost of a single surgical/training mission is now subsidized by local, Iraqi constituent institutions. [Back to Top]

Q: So is that the same thing as saying that my donation doesn't really make a difference? That the "up to 85%" funded locally by those inside Iraq is all that is really necessary to make this work?

A: There is not a single site across Iraq for which our Remedy Missions are fully funded. If we fail to provide our 15-19% of the overall budget, Remedy Missions fail, surgeons and nurses do not get trained regularly, on-site audits from our international team do not happen, up to 20 children are delayed from receiving surgery, and a few may even die or become inoperable. Your role in funding the remaining 15-19% is as critical in the short term as any other entity. A single Remedy Mission is binary - it either happens or it doesn't. Your money makes it happen. But our goal is to continue to graduate all our programs so they are 100% funded locally in the next 5-10 years. [Back to Top]

Q: Any other costs?

A: Our numbers per Remedy Mission do not account for "indirect costs," such as the cost (or value) of our volunteer medical staff from around the world, costs to local healthcare systems, the cost of a family to travel to the surgery site, the opportunity costs of lost income for families as they wait for surgery, etc. The reason we think it's important to note this here is because lifesaving is actually quite difficult. Building a pediatric cardiac surgery system for the entire country of Iraq is laborious and full of complexities. [Back to Top]

Q: What is the bottleneck to more surgeries: money or skilled labor?

A: People often assume that the biggest need is more Iraqi heart surgeons. We could use a few more, but the real bottleneck is skilled nurses, technicians, and non-surgical physicians. A surgeon is only as good as his support staff. One of our biggest challenges is training pediatric cardiac intensive care nurses. To date, we haven't found a better model than our Remedy Missions through which we bring quarterly hands-on training to local nurses (and surgeons) in Iraq. Rather than exporting the nurses to Europe or the USA for training (whose medical systems barely resemble the Iraqi system), we train them with what they have on hand in their local environment. [Back to Top]

Q: I'm skeptical of non-profits and charities because they always seem to be asking for more money. How can I be sure that Preemptive Love Coalition has "room for more funding" and that I'm not paying into a huge savings account, "Rainy Day Fund", or something similar?

A: For the record, we are skeptical of non-profits as well! In 2012 PLC needs $350,000 on hand at any given time to cover our cash flow needs for up to three Remedy Missions per quarter. We are still 30% under-funded against that goal. In addition to cash flow needs, we still require 15-19% funding on most of our missions after local sources contribute their portion; we have un-funded pilot programs in new cities where local doctors have been requesting our help (but where weve yet to woo local philanthropists or health directors); and we have research and social service initiatives through our Followthrough program that require funding at present because we have not yet sought local funding for those initiatives (seeing as how they relate mostly to our Monitoring & Impact Evaluation objectives). Please see our "Funding Gap" page to look deeper into our anticipated program costs, the sources of funding we are counting on, and the funding gap between the two for the next few years. [Back to Top]

Q: Do you have enough volunteer surgeons available for unfunded Remedy Missions? (i.e., are there trips that you could fund if you had more money, or is there a labor bottleneck?)

A: Great question! We use a hybrid volunteer/staff model. Roughly 25-30% of any one of our Remedy Mission teams is employed by the International Children's Heart Foundation (typically the surgeon, scrub nurse, anesthesiologist, ICU doctor, and often a part-time ICU nurse). The remainder of the team typically comprises volunteer physicians, technicians, and nurses from across the world. Because the hardest-to-come-by positions are contract labor for us and NOT volunteers, we have never failed to run a mission for lack of personnel. We have only cancelled or turned down a request for a future mission due to lack of funding. [Back to Top]

Q: Many heart surgeries require follow-up treatment (including additional surgeries). Do you have a way of providing these to patients?

A: Yes, we do. Our model dictates quarterly visits to each program site (a hospital inside a regional hub). Our reliance on local cardiologists ensures that the local team prioritizes and almost entirely sets the agenda for patient selection (within a development curricula) - after all, Iraqi doctors are the ones who are most intimately connected to the patients and their daily progress! When a local cardiologist sees a child who has either (1) deteriorated and requires another intervention or (2) advanced as expected to the next step of a complex, staged intervention, the child is prioritized for follow-up treatment. [Back to Top]

Q: How do you assess whether surgeries are completed competently and appropriately?

A: Because we are a broker and play a combination administrative and financier role in the coalition of partners working in Iraq to develop pediatric cardiac care, we are able to stand in-between the local surgical team and the international surgical team (whom we contract as a third-party to train and perform surgeries in Iraq). If the local team or health directorate suspects a lack of competence in the international team, a cavalier attitude, or a single poor judgement call, our role is to be the go-between - to be the advocate for the local healthcare providers vis-a-vis the international surgical team.

Similarly, if the international surgical team feels pushed by the local surgical team to perform procedures with which they are uncomfortable or for which they think the local system is ill-prepared, they are able to refuse children for surgery and/or use us (PLC) as a go-between.

The checks-and-balance between the two teams helps us ensure surgeries are performed in a competent, appropriate manner. [Back to Top]

Q: What is the rate of complications during and following surgery?

A: We report our in-hospital and 60-day mortality after each Remedy Mission. You can finds those numbers here. We also produce reports after each Remedy Mission detailing the trip, including data on intraoperative complications, post-operative complications, and mortality. You can find those reports here. We are also deliberately raising the funds necessary to help us bring our various heart hospitals into compliance with the International Quality Improvement Collaborative for Congenital Heart Surgery in Developing Countries. If this kind of quality improvement and reporting initiative interests you, we are currently looking for financial partners for our Followthrough program. [Back to Top]

Q: How do you assess whether surgeons are performing additional surgeries that they would have not had the funding or motivation to perform otherwise?

A: Pediatric heart surgery in Iraq is almost nonexistent without our work. There are two active programs for relatively simple surgeries (one in Erbil and one in Baghdad). Local surgeons claim that combined they perform no more than a few hundred pediatric surgeries a year. In every location where we work, pediatric heart surgery is effectively nonexistent. Therefore, every surgery performed at our program sites (both when we are present and when we are not) are "additional surgeries" that they would not have had the SKILL to perform without the FUNDING we employed to train them in their local environment. [Back to Top]

Q: How do you assess whether surgeons are charging their patients for the surgeries you fund?

A: Because we work in public (government) hospitals - and because healthcare in Iraq is provided almost entirely free of charge - it is widely known that any cardiologist, surgeon, or administrator seeking compensation for services is acting outside of Iraqi law. [Back to Top]

Q: Do you follow up with the surgeons you've trained to assess whether they are correctly applying their training?

A: We see them quarterly in their local environment and perform real-time audits of their skills, recollection of past training, application of new techniques, etc. Additionally, our international surgeon remains on call at any time via phone, Skype, or email for consultation. [Back to Top]

Q: What information is available on the activities - and competence - of the surgeons you've trained?

A: Because our Remedy Mission training program only began in late 2010 - and pediatric heart surgery at our sites across Iraq is the same age - there is still relatively little independent practice to report, and therefore little data on the activities and competence of our surgeons and their teams. But as they begin performing more surgeries independently, we are trying to align each site/surgical team with the International Quality Improvement Collaborative for Congenital Heart Surgery in Developing Countries (a data collection and tracking initiative of Children's Hospital Boston and Harvard University). [Back to Top]

Q: Where do surgeons work after completing training? Do they serve poor patients?

A: As of Q2 2011 there was only one private hospital in Iraq (to our knowledge) providing pediatric heart surgery (and those surgeries were on the lower end of the complexity scale). Our work does not necessarily mean to exclude private hospitals as they continue to come online and become viable options, but at present the government system has a better equipped foundation for training local surgical teams. As we look to fully graduate our local surgical teams in the next 5-10 years, we imagine that most of them will stay in the public sector for all of the stability, pensions, and benefits of loyalty provided to those who stick with it. But, undoubtedly, some will seek positions at private hospitals (assuming private hospitals are willing to invest in the requisite capital purchases necessary to establish a credible program). In the public sector, rich and poor are served alike. In the private sector, poorer patients would be at an obvious disadvantage. [Back to Top]

Q: How much do you spend each year on "program" expenses and how much on "overhead?"

A: As a rule, we do not adhere to the model that claims that "overhead" is somehow bad and "program" is somehow good. There are very bad program expenses. There are overhead expenses that are excellent investments. We agree with Paul Brest, President of the Hewlett Foundation, when he said, "Achieving a low overhead ratio drives many charities to behaviors that make them less effective and means more, not less, wasted dollars." Therefore, we spend as much on overhead as we need to accomplish our mission. The mission itself is our North Star - not arbitrary (even harmful) standards about overhead-vs-program expenditures. For the record, however, you can find a current pie chart of our expenditures here (and if you're into that sort of thing, you'll probably be impressed!). [Back to Top]

Roshna to leave next week

February 11, 2009 by Ruth · Leave a Comment

Today I had the privillege of visiting Roshna in her home. Roshna is a sweet 16 year old girl. She has three older brothers who care deeply for her and a sister that she’s very close too. Even though her sister is a couple of years younger they’re in the same grade at school as Roshna has ben held back beause of her heart problem. They love being able to go to school together!

Roshna’s condition is very serious so she will have to undergo some tests so that the doctor will know how to proceed. Hopefully the tests will go well and she will be able to have surgery and come back with a healthy heart.

I’ll keep you updated in her progress over the next few weeks.

Ruth Simpson was a Family Advocate for the Preemptive Love Coalition in Iraq (2008-2010) and a certified physio-therapist. Ruth hails from Ireland, though she's slowly losing her amazing accent amongst all the Americans. When not sharing her life with PLC's kids in Iraq, she served other constituent groups with her rehabilitative skills and compassion.

Filed under: Heart Surgery, Our Kids, Surgery Updates

Kurdistan Save the Children Comes through in the Clutch!

February 11, 2009 by Jeremy · Leave a Comment

We’ve been getting ready to send a group of Iraqi kids to life-saving heart surgeries in Turkey next week. After crunching the numbers, we thought that we could stretch and send six kids this month. But we had eight who desperately needed urgent surgeries.

Enter our local partner, Kurdistan Save the Children.

Normally, KSC helps contribute to the funding of a couple of kids each month. But they really stepped up to the plate and quadrupled their commitment for February.

Instead of helping two kids this month, they’re helping eight, contributing $2,500 towards each of their surgeries!

That’s $20,000 (or doo defter, as we like to say here in Sulaymaniyah)!

That means that instead of sending just six kids, we can now send eight over the next week, probably saving two extra lives in the process.

It also means that we’re seeing our vision of local solutions to local problems become a reality.

We know that the only hope for sustainable development is when people are empowered and encouraged to tackle the challenges they face together. That’s why we ask for a child’s extended family to contribute something to the cost of their surgery: we don’t want our generosity to rob them of their dignity or their responsibility. Instead, we want to strengthen families as a constructive element of civil society here in Iraq.

And it’s why we’re increasingly looking to form partnerships with Iraqi NGOs and businesses to support their efforts to care for the lives of their own people.

This month, we’re seeing it happen. Local contributions will cover almost half the cost of these eight surgeries. We’ve still got a long way to go, but it’s great to see how far we’ve come.

Jeremy Courtney lives and loves in Iraq as a co-founder and Executive Director of the Preemptive Love Coalition. He's also the father of two spectacular children, and married to the lovely Jessica Courtney. When not absorbed in PLC work he can be found writing songs and singing about hope and future. Follow Jeremy on Twitter: @JCourt.

Filed under: Amazed, Giving Away Money, Heart Surgery, Partnerships

Meet Taban

February 10, 2009 by Ruth · 461 Comments

Two days ago Erin & I made a trip about an hour out of the city to visit Taban in her village. Taban is 13 years old, she’s the youngest of 8 siblings! Taban’s a sweet but shy girl. Her family live on a small wheat farm. When you walk out of the back of their house all you see are fields all around, very different from the city where we are living. Taban helped her older sister and her mom serve us drinks. We ended up having lunch with them too as they said that they couldn’t let us leave without feeding us! Her family can hardly believe that the time has finally come for her to have her heart surgery. She said that she’s not afraid and is looking forward to having a good heart.

Taban leaves along with 3 other kids on Sunday morning – Hunyar, Ranu and Ahmed. Taban and her mom, who will accompany her, haven’t spent much time out of their small village so I think that seeing the sites of Istanbul could be quick a shock for them! I’ll blog again soon to keep you updated on her progress.

Filed under: Go Blog It!, Heart Surgery, Our Kids

Follow us on Twitter

February 3, 2009 by Jeremy · Leave a Comment

The Preemptive Love Coalition has been too busy saving lives to maximize our Twitter account. But we’re ready to dive in fully!

With regular tweets from around the world [Texas, California, Iraq, Istanbul & Ankara (Turkey)] plus travel tweets as we hit up Europe & the UK for more preemptive love for people of Iraq, we hope we can connect with you and learn from you in our collective effort to increase dialogue – and love – between international communities at odds.

Filed under: Uncategorized

Valentine’s Day Focus: The Great Eight (Ahmad’s Condition)

February 2, 2009 by Jeremy · 1 Comment

Ahmad

Ahmad’s situation is one of the more dire we’ve seen.

His great arteries are switched around and in the wrong places. He has two holes in the wall of his ventricle, a hole in the wall of his atrium. Effectively, his heart is a big balloon without properly functioning walls and chambers like yours.

This alone results in exhaustion, frequent fainting, and the blue discoloration in his lips, hands, and feet from a lack of oxygen.

You remember oxygen? That stuff that we pretty much need to live. Ahmad needs it too, but his body cannot process it correctly due to the holes in his little heart.

You can follow Ahmad’s progress on Twitter (twitter.com/ahmadbakhtiyar) or via RSS.

Giant Need

See Ahmad’s campaign page on our website to make a contribution to his surgery.

Small Voice

His brown-booted feet hung limply from the chair. Most children wouldn’t be able to resist swinging their suspended legs back and forth in the quiet room surrounded by the seven dwarfs’ familiar faces, the Kurdish curls presumably spelling the names of Dopey and Sneezy and the rest, scattered among painted forest animals on all four walls of Dr. Aso’s combined office, waiting room and examination room. When the doctor was ready, the practiced hands of his mother removed his jacket from his tiny body, his boots from little clubbed blue feet which matched his hands, tormented eyes watching her above his oxygen deprived lips the shade of blueberries.

The doctor’s eyes widened and his brow furrowed as he looked at the Echo, turned to us and said, “This is a very serious case.” When we asked if he was inoperable the doctor shook his head and simply said again, “It is a very serious case…. I don’t know.” Whether she understood English or not Ahmad’s mother read all our expressions easily. She tipped her head to the heavens, possibly to pray, and more practically to give her eyes the opportunity to swallow the tears threatening to escape.

After the picture we snapped of him standing in front of a Kurdish Snow White & the Seven Dwarves, he hid his little face in his mother’s leg and wiped tears from his eyes…

Liz searched her purse for the third time looking desperately for something to give this poor child. She hoped a matchbox car or at least some stickers had magically appeared since she’d last checked, but her hands came up empty again. Her mind slowly absorbed the fact that even if a toy might have brought a temporary smile to his sad eyes, it would do nothing for his frail body. Instead she prayed for the Turkish doctor who will soon undergo the difficult task of setting to rights all that is wrong in Ahmad’s little Iraqi frame.

We’d like to ask you to be a part of Ahmad’s transformation. Of course, these are hard times. But if you can, please consider sacrificing that Ahmad might live.

Filed under: ASD, TGA, Urgent, VSD

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OUR BLOGGERS

	Matt Willingham is the PLC press secretary and writes primarily on politics, history, general updates and visual peacemaking through photography and film.
	Cody Fisher is a PLC cofounder and writes primarily on program development and peacemaking by giving us a lens into the lives of the real people we love.
	Jeremy Courtney is a PLC cofounder and writes primarily to emphasize our vision and values, including organizational and financial transparency.

Preemptive Love Coalition provides lifesaving heart surgeries for Iraqi kids in pursuit of peace between communities at odds. We offer the 30,000 Iraqi children suffering from life-threatening heart defects a chance at the surgery they need to save their lives. With our world-class international surgical partners we create long-term solutions by training local Iraqi doctors and nurses so they can sustainably save lives without our help.

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