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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]

Mohammed Malnourished in ICU – Doctors Marvel at Obstinate Refusal to Eat

July 30, 2009 by Jeremy · 1 Comment

mohammed-icu1 gaelan-faith-fear mohammed-in-foreign-hands

Follow 11-year-old Mohammed on Twitter: @mohammedgaelan. Subscribe to Mohammed’s updates via RSS here. Follow Mohammed’s thread of longer stories (with pictures) on the PLC blog here.

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: @Jeremy_Courtney.

Filed under: Anadolu Sağlık Merkezi, Heart Surgery, Misdiagnosis, Mohammed Gaelan, News, Our Kids, Partnerships, Peacemaking, Sad, Surgery Updates, TOF/DORV

Daryan Still Intubated in ICU with High Pressure in Lungs – Heart is Doing Well

July 30, 2009 by Jeremy · 19 Comments

daryan-icu-intube
daryan-icu-1
daryan-icu-3 daryan-icu-4

Daryan has had a difficult few days… more than a little baby should ever have to endure as far as we’re concerned. He was extubated the day after his surgery, but the pressure in his lungs began to rise too quickly so they had to reintubate him in order to keep everything under control. Today he is scheduled for another attempt at extubation in hopes that he can breath on his own AND that his pulmonary pressures will stay down.

PLC Family Services Director, Jessica Courtney, took Daryan’s mother out on Istanbul today for a day of shopping and change of scenery. It looks like Daryan still has some fight left in him, but it’s going to take a fight. We knew before bringing Daryan here that it was risky and that the aftermath of the surgery was going to be the most difficult part. Our hopes have risen and fallen this week with this child’s pressures…

We appreciate all you who have given sacrificially to Daryan’s surgery and other’s like him. We appreciate all of the buzz you’ve created on Facebook, Twitter, and your own blogs and websites. Please keep it up… as you’ve seen this week – and as we remember all too keenly with Daryan – there are real lives at stake and a five minute blog post really can change the world.

Follow 4-month-old Daryan on Twitter: @daryansalah. Subscribe to Daryan’s updates via RSS here. Follow Daryan’s thread of longer stories (with pictures) on the PLC blog here.

Filed under: Anadolu Sağlık Merkezi, Daryan Salah, Heart Surgery, News, Our Kids, Partnerships, Peacemaking, Surgery Updates, Volunteers

Walk On: Mazyar Traverses the Hospital Campus, Plays Ball Just Days Post-Surgery

July 28, 2009 by Jessica · 56 Comments

Walking and coughing – two of the most important things a child can do after receiving a very invasive heart surgery. And Mazyar is doing both stellarly!

When we went for a walk with Mazyar in the park today outside the hospital in Istanbul, Turkey, the coastal air was refreshing and it was perfect weather for Mazyar to strut his stuff – just four days after going in to repair a large whole between the two ventricles of his heart.

Follow 3-year-old Mazyar on Twitter: @mazyartahir. Subscribe to Mazyar’s updates via RSS here. Follow Mazyar’s thread of longer stories (with pictures) on the PLC blog here.

Jessica Courtney lives and loves in Iraq as a co-founder and Family Services Director of the Preemptive Love Coalition. She is also a mother of two children and is married to PLC's Executive Director, Jeremy Courtney. When not absorbed in caring for Iraqi children and sharing life with Iraqi families, she enjoys sewing and scrapbooking.

Filed under: Anadolu Sağlık Merkezi, Heart Surgery, Internship, Mazyar Tahir, News, Our Kids, Partnerships, Peacemaking, VSD, Volunteers

Ruzhan Has Landed in Iraq & is Now Driving Home to Her Village One Week After Leaving for Surgery

July 28, 2009 by Jeremy · 404 Comments

to-village

Ruzhan has landed in Iraq and is headed home by car to her village a few hours outside the city.

Until the Anadolu Sağlık Merkezi and Dr. Sertaç Çiçek partnered with PLC, children in need of life-saving heart surgeries would typically be required to leave Iraq for months at a time in order to receive the care they needed. Ruzhan will be at home resting exactly one week from departing from her village. And when a child is sick, there’s nothing like her mother and her home to help her heal.

Toward that end, we are excited to keep working with Anadolu Sağlık Merkezi and Dr. Çiçek in the Fall (and beyond) to perform more and more surgeries in Iraq, saving more money, more lives, and allowing children to recover in an environment of love that is most familiar to them.

Follow 8-year-old Ruzhan’s continued journey post-surgery on Twitter: @ruzhanferis. Subscribe to Ruzhan’s updates via RSS here. Follow Ruzhan’s thread of longer stories (with pictures) on the PLC blog here.

Filed under: ASD, Anadolu Sağlık Merkezi, AtlasJet, Heart Surgery, News, Our Kids, Partnerships, Peacemaking, Ruzhan Feris, Surgery Updates

Ruzhan Fit to Fly – Checking in at Airport Right Now for 11:30 Flight to Iraq

July 28, 2009 by Jeremy · 1 Comment

ruzhan-airport

Modern medicine and technology is simply amazing. One week ago today (to the hour) Ruzhan left Iraq in need of a life-saving heart surgery. She will be returning on the same flight she blew in on 168 hours later with a new heart, a new life ahead of her, and an unanticipated impact on her mother, father, five sisters, brother, extended family, neighbor, community, city, tribe, and country.

For families like Ruzhan’s that live on or near the Turkish border, there is often one narrative: Turkish oppression of Kurds. And while that narrative has a self-evident history, it is not the only story going on with regards to Turkish-Kurdish relations. Ruzhan’s family now returns to their home with a new story to tell – one of Turkish kindness, generosity, sacrifice, and service on behalf of their family and other Kurdish families like them. Through this new story and the telling of it, an entire family and community will have the opportunity to think differently about the black and white narratives that have often dominated and defined their lives.

Saving Ruzhan’s life was important enough. But thankfully, it’s not the only thing going on when you give to the Preemptive Love Coalition.

We are grateful to our partners in Turkey: the Anadolu Sağlık Merkezi and AtlasJet for their generosity to the people of Iraq. We could not do this well – and would not want to – without visionary partners like them.

Follow 8-year-old Ruzhan on Twitter: @ruzhanferis. Subscribe to Ruzhan’s updates via RSS here. Follow Ruzhan’s thread of longer stories (with pictures) on the PLC blog here.

Filed under: Anadolu Sağlık Merkezi, AtlasJet, Heart Surgery, Internship, News, Our Kids, Peacemaking, Ruzhan Feris, Surgery Updates, Volunteers

Daryan Alive & Well in ICU After Difficult Surgery – Soon to be Extubated

July 27, 2009 by Jeremy · 2 Comments

After one of the most obviously difficult set of problems we’ve ever seen, we are delighted to celebrate Daryan’s successful surgery, all of the nurses, doctors, and staff at Anadolu Sağlık Merkezi.

The recovery process is still a difficult process. I don’t think any of us will breath that final sigh of relief until Daryan is back in Iraq, gaining weight, and crawling around his house for the very first time. But thankfully, thanks to all your help, that day is much closer to being realized than it has ever been.

Follow 4-month-old Daryan on Twitter: @daryansalah. Subscribe to Daryan’s updates via RSS here. Follow Daryan’s thread of longer stories (with pictures) on the PLC blog here.

Filed under: Anadolu Sağlık Merkezi, Daryan Salah, Heart Surgery, Internship, News, Our Kids, Partnerships, Peacemaking, Surgery Updates, Volunteers

Daryan in Surgery Right Now Facing 20% Risk of Serious Complications

July 27, 2009 by Jeremy · 428 Comments

daryan-bed

Daryan’s empty bed. The sight keeps his mother out of the room for the duration of the surgery…

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Daryan is about half-way through his surgery with Dr. Sertaç Çiçek (above) and the team. After an estimated 20% risk of serious complications, we are all nervous and eager to hear some good news for Baby Daryan. Unlike the other children, Daryan’s surgery is not being conducted through the chest cavity, but rather through the back. And due to the complicated nature of Daryan’s condition, it’s highly unlike that the doctors will even touch his heart properly, opting instead to work primarily on the vessels coming and going from the heart today.

Another few hours and we should know some news… in the meantime, we wait.

Follow 4-month-old Daryan on Twitter: @daryansalah. Subscribe to Daryan’s updates via RSS here. Follow Daryan’s thread of longer stories (with pictures) on the PLC blog here.

Filed under: Anadolu Sağlık Merkezi, Daryan Salah, Heart Surgery, Internship, News, Our Kids, Partnerships, Peacemaking, Surgery Updates, Volunteers

Ruzhan Resting in Her Room & Cleared to Return to Iraq on Tomorrow’s Flight

July 26, 2009 by Jeremy · 1 Comment

Ruzhan has been resting in her sunny room over the weekend and was cleared to return to Iraq on tomorrow’s flight!

Follow 8-year-old Ruzhan on Twitter: @ruzhanferis. Subscribe to Ruzhan’s updates via RSS here. Follow Ruzhan’s thread of longer stories (with pictures) on the PLC blog here.

Filed under: Anadolu Sağlık Merkezi, Heart Surgery, Internship, Misdiagnosis, News, Our Kids, Partnerships, Peacemaking, Ruzhan Feris, Surgery Updates, Volunteers

Daryan Heads to Surgery in 8 Hours w/ Est. 80% Likelihood of Success

July 26, 2009 by Jeremy · 414 Comments

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After days of watching and waiting for other parents’ children to receive the life-saving heart surgeries they came to receive, Daryan’s turn has come. Daryan will be in surgery at midnight Central Time (just eight hours from the time of this posting).

Unlike most of the other surgeries, however, whose risk factors have been between 5-10%, Daryan’s surgery has a very sobering 20% amount of risk involved (in the surgery itself). Moreover, the ability for this little child to recover from a surgery of this magnitude…. that is something that only God knows.

PLC staff and summer interns have done their best to serve Daryan’s mother (and all of the families) during their wait. Above is PLC co-founder, Jessica Courtney, giving Daryan’s a much needed break from the non-stop responsibilities of motherhood. As Daryan goes to surgery in the morning and recovers in ICU for the following few days, those are no doubt responsibilities she will be happy to take up again as soon as she can.

One thing about this work we do – it helps us appreciate the things that matter in life.

Follow 4-month-old Daryan on Twitter: @daryansalah. Subscribe to Daryan’s updates via RSS here. Follow Daryan’s thread of longer stories (with pictures) on the PLC blog here.

Filed under: Anadolu Sağlık Merkezi, Daryan Salah, Heart Surgery, Internship, News, Our Kids, Partnerships, Peacemaking, Sad, Surgery Updates, Urgent, Volunteers

Mazyar Recovering Well in ICU Living Off of His Own Heart | Total Correction!

July 26, 2009 by Jeremy · Leave a Comment

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Before running out of the hospital Friday night to catch the last bus home we snuck into ICU and snapped these few shots of Mazyar resting right after admission to ICU. He’s doing well and it expected to return to his private room tomorrow. His father has been great to be around and we’ve learned a lot from him about faith and friendship.

Follow 3-year-old Mazyar on Twitter: @mazyartahir. Subscribe to Mazyar’s updates via RSS here. Follow Mazyar’s thread of longer stories (with pictures) on the PLC blog here.

Filed under: Anadolu Sağlık Merkezi, Heart Surgery, Internship, Mazyar Tahir, News, Our Kids, Partnerships, Peacemaking, Surgery Updates, Volunteers

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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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