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?"


----------

 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]

Jeremy Courtney Founder, Executive Director Twitter: @Jeremy_Courtney

“I'd love to hear any critique or questions you might have!”

DROP A NOTE OR DONATION BY MAIL: Preemptive Love Coalition 1300 Darbyton Dr. Hewitt, TX 76643 GIVE BY PHONE: To make a gift over the phone, using your credit card (Visa, MasterCard, American Express, or Discover), please call +1 (806) 853-9131 during normal business hours. IRAQ OFFICE: +964 770-355-6298 (local)

Adventuresaurus Collective – Advocates of the Week

May 19, 2010 by Joshua 

Meet Kelly Nowels and the Adventursaurus Collective.

Ironically, I’m introducing to you to the very one who introduced me to the Preemptive Love Coalition. Kelly and I both went to Cedarville University where, given the small nature of the campus, we eventually met. I remember him one day wearing a shirt that caught my eye. It read very simply: Buy Shoes. Save Lives.

I was intrigued. I asked him what it was about and it was then I first heard about the work of the organization I find myself working with today.

Kelly and two friends – Sammy Starr and Michael Beight – are preparing to bike through Europe to raise money to save the life of Mohammad Fwad. It’s a pretty big undertaking, so we were eager to name them our ADVOCATES OF THE WEEK. Here is my interview with Kelly:

PLC: Who is Kelly Nowels?

Kelly Nowels: I’m an ordinary man but I have an extraordinary maker.

PLC: What is the Adventuresaurus Collective?

Kelly Nowels: The Adventuresaurus Collective formed in the spring of 2009 when Sammy, Michael, and myself started brainstorming our next big adventure. We would ride our bikes down to the town bakery every week and eat doughnuts and muffins while we dreamed of the possibilities. We joined together because we couldn’t stand the thought of living an ordinary life. We wanted to squeeze all the energy out of youth and smear today on our faces until the stories run down to our feet and the setting sun is extinguished by the distant mountains.

The cool thing was, as soon as we decided we were going to ride bikes across Europe, that was it. There was no uncertainty about our commitment. Nobody said “well that sounds fun let me check my schedule.” It was more like, “Yes we’re going, done. I’ll build my schedule around this.”

This journey will be our first official project, but we’ve had plenty of adventures together before. Sammy and I have camped at the bottom of the Grand Canyon in a thunderstorm and driven across the country in a car with a broken window. For New Years eve the three of us ventured to the eastern-most point in Maine, shot fireworks over the ocean, slept in a collapsed tent under six inches of snow and woke up for the sunrise.

Michael Beight is [the] thoughtful and resourceful member of the group. I love his easygoing nature about things. Sleeping on park benches doesn’t faze him and I think I’ve never heard him complain about the circumstances, even when they might be pretty crummy. Mike worked 12 hour graveyard shifts at a factory last summer to save up for this trip. A picture of the Alps taped up at his work station was sometimes the only thing keeping him going. I can’t get enough of Mike’s enthusiasm.

Sammy Starr is our wonderful engineer friend. He’s the kind of guy who makes you mad because he’s good at everything he picks up. Sammy might come off as shy but don’t let the quietness fool you. His wit is razor sharp and his subtle humor has had the whole room laughing more than a few times. I love Sammy because he’s always up for a scenic detour. Take the long way round to see Devil’s Tower? [Y]es. Stop at an overlook to see an epic view of the Grand Tetons? Absolutely. Of the 43 states I’ve been to, I’ve been to 35 of them with Sammy.

PLC: Why choose the Preemptive Love Coalition?

Kelly Nowels: It’s an investment in the future. To me it’s like a man who plants a tree. An Oak tree takes 50 years to reach full size. The man who plants it won’t get to enjoy it, even his kids won’t be able to climb it, it will be too small. But his grandchildren will see the benefit. They’ll hang a swing from its branch and climb to the top. That Oak tree might live 500 years and generations of kids will enjoy its shade but the man who planted it never lived to see the fruition of his work.

With every kid the PLC saves, they’re planting little trees. Who knows how those trees are going to grow up or if any of us are even going to live to see their fulfillment? Each kid who lives grows up with a story of peace and love. It would be great to see those stories outlive us.

PLC: How did you first learn about the Preemptive Love Coalition?

Kelly Nowels: A couple years ago I found myself at Cody Fisher’s first gathering for PLC in California after he returned from Iraq. I was struck by the way PLC was showing love on a personal scale to these children and their families while spreading the message of peace on a global scale. Cody was fresh from his trip to Iraq and really fired up. I was inspired to see a recent graduate engage his world and dream big. I knew I wanted to be that fired up about something after college too.

I love the way PLC encourages people to think outside the box and get creative. It’s all about doing what you love and doing it for the kingdom [of God]. You want to ride bicycles across Europe? Sail around the world? Climb Everest? Good. Go do it to save a kid’s life.

PLC: How has your news to bike across Europe for the children of Iraq been received by friends, family, local news, etc?

Kelly Nowels: It’s been great for the most part. I love seeing people come out of the woodwork finding ways to get involved. It’s so encouraging. Our families are behind us, churches, and dear friends… with that, we can do anything.

The other thing is we get a lot of people saying “I wish I could do that” or “I’m so jealous.” And I always want to say “then do it!” Seriously, I don’t think there’s as much holding us back as we think there is. Trade a little of that comfort for experience, trade some of that security for a risk, trade that new TV for a plane ticket, and see what you end up with. I doubt it will be regret.

PLC: What would you say to Mohammad if he asked why you were helping him?

Kelly Nowels: “You are loved. There is so much bad in this world but your creator is good. He saved my life and I want him to save yours. You are living in the middle of a spectacular story. I want you to have a shot at living long enough to share that story with everybody you meet. Together we’ll create a story that will change hearts and minds and bring peace and love to a broken world.”

Donate the amount of your choice by entering it in the field below. All donations will help send Mohammad (and any others in his group) to life-saving heart surgery. Donation: We did not choose this picture to make you sad… it’s just the only picture we could capture of Mohammad during his recent trip to our office in Iraq and he wasn’t very happy that day. We hope to post more pictures soon!

You can learn more about the Adventuresaurus Collective at their website on on Twitter.

Joshua Gigliotti is a PLC Summer Intern ('09) turned short-term staff who spends a majority of his time with PLC taking exceptional photos of children in Iraq in an effort to humanize Iraqis and portray them as people full of dreams and hope. When his camera is not in-hand, Josh is often found in local tea houses with friends and also enjoys traversing the great outdoors. Follow Joshua on Twitter: @JoshGigs.

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	Matt Willingham is the PLC press secretary and writes primarily on politics, history, general updates and visual peacemaking through photography and film.
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	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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