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)

Heartmender Tour Takes on L.A.

September 22, 2010 by Cody · Leave a Comment 

Photo Mike Smith // All Rights Reserved

After four days in San Francisco, kicking off our Heartmender Tour (and only receiving one parking ticket!) we’ve made the trek down south to Los Angeles. Sunday marked our first full day in the “City of Angels” but only after a long day spent in deep discussions in restaurants, on high school campuses, and in local churches, where we continued our Heartmender Tour about postures of peace and cooperation between peoples at odds Iraq and around the world.

We’ve run into social workers, actors, doctors, engineers, business men, hipsters, friends we haven’t seen since 3rd grade, former travel companions, and people from just about any background you can think of.

What I love most about the Heartmender Tour is the fact that just a couple weeks ago, few knew the story of Ahmed or Mohammed. Now, people all over the West Coast have been able to hear their story, see them on film, and in some way become a part of their story.

Their stories are speaking up on behalf of thousands of other kids just like them in Iraq, waiting for surgery. Their stories are mobilizing entire communities here on the West Coast to take up action by becoming monthly sponsors. Their stories are mending hearts.

To join their story and become a part of ours here in Los Angeles, be sure to reach out to us while we’re in town! We leave Friday and we would love to see you!

Write us at info@preemptivelove.org or find us on Facebook (http://facebook.com/preemptivelove) or Twitter (http://twitter.com)!

To make a donation or become a monthly heartmender, click here.

With You,

Cody Fisher is the co-founder and Development Director of the Preemptive Love Coalition. He moved to Iraq in 2007 where he met his wife and since then they've been waging peace and mending hearts across Iraq. His passions are photography, peacemaking, and food that doesn't come out of a can. You can follow him on Twitter: @candmfisher.

Reclaiming Hearts in San Francisco on our Fall Heartmender Tour

September 13, 2010 by Cody · Leave a Comment 

Last night was our first stop in San Francisco for our Heartmender Tour and we couldn’t think of a better place to kick it all off! It was hosted by our wonderful new friends from the Mission District where we feasted on the city’s finest local food and shared great dialogue on issues of justice, peacemaking, reconciliation, and creating postures of preemptive love that stretch from San Francisco to Sulaymaniyah, Iraq.

It was a night centered around stories: our stories, their stories, and stories of Iraqi children and their families; all in the pursuit of peace. Through film, photography, and by sharing our hearts with each other we began a journey towards reclaiming the practice of peacemaking and reconciliation.

We’ve always loved the Mission District, but last night it was taken to a deeper level for me. I fell in love again with the people and the mosaic comprising so many backgrounds, histories, faiths, and perspectives.

And thanks to the generosity of all those who attended, hearts were mended – both in our group and in Iraq!

Could a night be better spent? We don’t think so!

We will be in San Francisco until Wednesday morning before we head down to Los Angeles. If you’re in the city and want to meet up, give us a call or send us an email at http://scr.im/heartmender.

With You,

Cody Fisher is the co-founder and Development Director of the Preemptive Love Coalition. He moved to Iraq in 2007 where he met his wife and since then they've been waging peace and mending hearts across Iraq. His passions are photography, peacemaking, and food that doesn't come out of a can. You can follow him on Twitter: @candmfisher.

You Just Helped More Kids in 12 Days Than Any 12 Month Period in Our History… for Less!

September 13, 2010 by Jeremy · Leave a Comment 

Deeya is alive and doing well at home today because of the surgery you provided for her in Iraq!

Wow! What a phenomenal trip it has been these last few weeks as you have brought a new remedy to the children of Iraq through the surgical and nursing team of Dr. William Novick. It’s high time we update your impact to help Iraqis make a better future for themselves and their children.

The total expense for our first Remedy Mission was approximately $90,000. This amount was further subsidized by the Director of Health in our city and the Kurdish Regional Government in Washington D.C., and the International Children’s Heart Foundation. The balance was underwritten by you!

This family was not yet chosen for surgery… they are still waiting for our next Remedy Mission.

Locally, Remedy Mission was a great success. We ended the week at dinner with the governor and the health director where they invited us to start our next Remedy Mission as quickly as possible. When we suggested May 2010 as a next date, all the surgeons and the health director rallied together to urge us to begin again in February instead.

Our current proposal is a five year plan comprising four trips per year to make the Sulaymaniyah Cardiac Center a premier facility in the region that is able to perform 12-14 surgeries per week without foreign assistance. We estimate that this will cost $1.5m and we are currently talking with the local authorities in hopes that they will choose to shoulder the majority of that expense.

During Remedy Mission ICHF and local surgeons performed 25 corrective cardiac procedures. Put differently, we helped more kids in 12 days than we have in any 12 month period to date… at a massive savings compared to our work in Iraq… with hands-on training for Iraqi doctors and nurses! A typical all-inclusive surgery in Istanbul costs us $10,000 (after subsidies). That expense is usually shared among the family of the child, local and international donors. The typical PLC international donor portion of a surgery in Turkey is $3-5k.

Cody Fisher reviews the list of kids who received surgery and kids still in line for February 2011.

The numbers for Remedy Mission look much different. Not only are we able to work in partnership with others more during Remedy Missions, but every surgery represents a local development and training opportunity. The all-inclusive price for all partners was approximately $3,600 per child (compared to $10k in Istanbul and much more in the States or Europe).

Remedy Mission has taught us a lot about being fiscally and developmentally responsible. Therefore, in an effort to redouble our commitment to long-term local solutions, we will be increasing our Remedy Mission funding in hopes of facilitating four Remedy Missions in our current city in 2011.

The following families are still waiting in line for our help…. Will you be the remedy? Donate the amount of your choice below to get our next Remedy Mission off to a strong start!

With you,

Remedy Missions are international pediatric heart surgery teams that we bring to Iraq to to perform lifesaving heart surgeries and develop the infrastructure for the future. If you’re on Twitter this week be sure to use the #Remedy or #RemedyMission hashtag to describe all the good news coming out of Iraq this week via @preemptivelove and @babyheart_org. If you’re on Facebook, “Share” this story with the button below.

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.

The Good & The Bad: A Report On One of Our Remedy Kids Who Did Not Make It Through

September 7, 2010 by Jeremy · Leave a Comment 

Video by Jon Vidar

We strive for transparency here; not marketing or public relations fluff. At the beginning of our Remedy Mission we chose a few children to feature on the website. At that time, we did not know which ones would survive and which ones would die; who would have an easy course and who would have a most difficult course. We chose them for reasons of timing, dramatic tension, and relational connectivity.

One of the families that was NOT chosen for feature, was actually concurrently featured by a photographer friend that we hired for some of the other work on Remedy Day #1. Jon Vidar had been out to meet Samal and her family weeks before Remedy Mission formally began. Jon was eager to see Samal get the surgery she needed. When he began her story for his personal project, we all had assumed and hoped that she would be one of the ones who benefited greatly from the surgery.

Unfortunately, it didn’t work out that way. Push play above to watch Jon’s excellent piece above to learn more about the situation in Iraq, our Remedy Mission solution, and Samal’s story in particular.

The one thing the ending slide does not capture with enough nuance is the bitter fact that Samal’s brain probably died before a knife was ever laid to her chest after her oxygen levels crashed to 10% for approximately 12 minutes. In that 12 minutes the O.R. team prepared her for surgery, opened her chest, and put her heart on the bypass machine, but she was without oxygen for far too long before they could intervene; they feared she was brain dead. They proceeded with the surgical correction for her heart and took precautionary measures after surgery to give her the greatest chance at recovery, but Samal never pulled through; she was probably too far gone before the surgery technically began.

There are no words or stories, prayers or personal presence that makes a loss like this more palatable. It’s dark and horrifying for the family; and, to a lesser degree, for those of us who invested a tiny bit of ourselves in Samal and her well-being.

There are no good words to wrap up a post like this… but there are more stories of hope to come.

With you,

Remedy Missions are international pediatric heart surgery teams that we bring to Iraq to to perform lifesaving heart surgeries and develop the infrastructure for the future. If you’re on Twitter this week be sure to use the #Remedy or #RemedyMission hashtag to describe all the good news coming out of Iraq this week via @preemptivelove and @babyheart_org. If you’re on Facebook, “Share” this story with the button below.

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.

VIDEO: Remembering Saddam Hussein’s Chemical Attacks on Halabja

September 5, 2010 by Jeremy · 4 Comments 

A sobering remembrance of the 1988 chemical attack on Halabja in Iraqi Kurdistan and the repercussions still felt by residents today.

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.

VIDEO: The World I See is the World You See by The Tiziano Project

September 3, 2010 by Jeremy · Leave a Comment 

Tiziano | 360° Kurdistan presents the journalistic efforts and personal accounts of Iraqi citizens in the Kurdish north alongside the stories of their professional multimedia mentors.

The Tiziano Project provides new media tools and training to community members in conflict, post-conflict and developing regions.

For more insights into the world in which we work, from the eyes and hearts of those who live here, visit http://360.tizianoproject.org.

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.

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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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