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)

Congratulations to Jon Vidar for His Award-Winning Remedy Mission Photo!

November 26, 2010 by matt · Leave a Comment 

No amount of blog posts could quite communicate all the good that has come from our August Remedy Mission with the International Children’s Heart Foundation.

We saw partnerships formed and solidified, peace was forged between people who came in opposing one another, local involvement increased in Iraq, Kurdish and Arab doctors and nurses were trained and, of course, children’s lives were saved.

And now we’re pleased to congratulate Remedy Mission photographer, Jon Vidar, on his exceptional photo:

The above photo won the People’s Choice Award at FotoWeekDC 2010 and is now hanging in the Corcoran Gallery of Art. 6,500 submissions from over 35 countries made for some steep competition – congrats, Jon!

As PLC's Press Secretary, Matt Willingham is bent on leveraging words and media to connect hearts and minds to Iraqi children in need. On the side, he likes reading old books, devouring the great food his wife cooks up and dabbling in DSLR video work. He's also mildly obsessed with Twitter: @mehtin.

Interview with former Iraq War hostage, Nahoko Takato

November 18, 2010 by matt · 20 Comments 

In honor of the first annual Remember Fallujah Week we’ve interviewed a new friend and member of the Coalition, Nahoko Takato. She was instrumental in sending Baby Bakir out of the country for a lifesaving heart surgery, and her continued compassion for Iraqi IDPs and refugees even after being kidnapped and held hostage is inspirational to many world-wide.

PLC: To start, would you tell us a little about your work in and around Iraq?

Nahoko: In 2003, I went to Iraq for the first time to do emergency relief. I started to study the hospital situations in Fallujah and Ramadi and shared what I found with NGOs and the media. I also worked with some NGOs and distributed medicine and basic items. Meanwhile, I was also very involved with street children in Baghdad.

After my incident in April 2004, I traveled to Jordan every 2 months and continued to support Iraqis.

I have been doing medical support for Iraqi refugees in Jordan since 2007, working with Iraqi women who are also refugees, providing medication, supporting costs for surgeries and so on.

My Iraqi friends have sometimes taken very important footage, and I bring them to the media and the human rights organizations so they can share it with a much larger audience.

When in Japan I go on speaking tours and provide information by showing many photos and videos about Iraq. I really think that one of the most important things for the people is “media literacy.”

PLC: So what is it that motivates you to do this kind of work?

Nahoko: Love: I love all kinds of people, different cultures and ideas. I want to do more.

Responsibility: My country (Japan) has been involved in Iraq invasion, in spite of our Peace Constitution.

Guilt: My country sent troops (Self Defense Forces) to Iraq as “Humanitarian Aid” and was providing military support for US troops rather than supporting/helping Iraqis.

PLC: Could you tell us some of the biggest challenges of your work?

Nahoko: I am interested in reconciliation and peacemaking. Each of my projects or activities are about “repairing the relationship.”

I’ve met some Iraq veterans and interviewed them and then brought their messages to Iraqis in hopes of making peace.

Also, I had set up the opportunity for the talk between former- US soldiers and former Iraqi soldiers in the international conference and on a Japanese TV program.

Japan was really loved by Iraqis before, but we had lost their trust since the Iraq war. Actually, some Iraqis refused our aid because the Japanese supported the invasion and occupation. But we continued to give aid to Iraqis anyway without revealing our names. As a result, we were able to gain their trust and repair our relationship with our Iraqi friends.

Now I am preparing for “Peace Talks” between Baghdad University and Keio University in Tokyo. I am seeking for the actual way of reconciliation that leads to real peace.

PLC: It’s incredible that, even after being captured by Iraqis and held hostage, you’ve continued to serve the Iraqi people. How did you endure in the face of such opposition?

Nahoko: The first 3 days I was seriously thinking I might be killed. Firstly, the people of Fallujah surrounded me and demanded to know why Japanese troops came to Iraq to help US troops. And then armed men came and kidnapped us with rockets and hand bombs.

I explained to the kidnappers my humanitarian work in Fallujah and Ramadi and told them to ask the doctors in Fallujah general hospital who I am, but the hospital was besieged at that time and inaccessible. So I continued to explain why I came to Iraq and what I did for emergency aid and what I witnessed the victims in Fallujah. Then the armed group recognized I was not their enemy.

I never call those armed people “terrorists.” I know they are victims who had lost their loved ones for no reason. I know they were farmers and ordinary people, but they had made a decision to pick up weapons to get revenge on US troops.

Just before I was released, I was able to have a long, deep discussion with my kidnappers, and I told them :

“You’re wrong. You made big mistake. You are saying that Americans are bad and killers, but now you are doing the same bad thing to me and my family. I really understand your anger and sadness, I can understand why you picked up weapons and were resistant, but I do not agree with this way. This is just encouraging negative reactions. You might be asking for help from the international world, but you have lost many supporters. You’ve got more enemies now because of these kinds of responses.”

One of the kidnappers put his gun on the floor and asked me with tears, ”How can I be your friend?”

I answered,”I am your friend, that is why I shared my honest feelings with you.”

Right before being released our kidnappers gave us bottles of pure honey which is special gift to receive in Fallujah. They said it was for my family.

After I was released and was interviewed by Al jazeera I said that I was too tired and in shock, but I can not hate the Iraqi people.

On the other hand, I had many shocking treatments by US soldiers while I was in Iraq. They pointed machine guns at me many times, stopped my car with guns and shouted at me and forced me to lie face down on the road. These were also difficult experiences for me, but I have since contacted many Iraq veterans and have had deep, meaningful talks with them. I lived in America as a student and have many good friendships there.

Even when I was treated very badly or physically hurt, this is never enough reason to hate ALL Americans, ALL Iraqis, or ALL Muslims.

I am so honored to work with you, Matt and Jeremy, and with my many American friends, and I am so happy to introduce you to my wonderful Iraqi friends.

After the 2004 kidnapping incident, I was spurned by the Japanese government, media and society. That was what really hurt and “killed” me. The armed group in Fallujah could listen to me and did not kill me, but my own people who are not armed never listened to me and “killed” me. That might have been the biggest shock to me, and not really have a deep talk with Japanese people yet. Now I am trying to forgive… I do not want to hate my people, of course.

Last year, I came back to Fallujah and Ramadi for the first time since 2004, and that was the big turning point for me. A whole 5 years after my kidnapping and social rejection and I was facing Iraqis and speaking out for Fallujah victims. I could not communicate with my own people, and I avoided them.

I always felt the Fallujah victims were supportive of me and using my mouth to express their sadness. I always remembered the sounds of air strikes overhead during my captivity, and I know more than 700 civilian who were killed at that time. Eventually, I came back to Fallujah and prayed in front of their tombs. Since that moment, I had regained my life left behind in Fallujah.

PLC: This week is “Remember Fallujah Week” and I know you’ve had first-hand experiences in the city. Would you mind sharing with us about your relationship with the city of Fallujah and its residents? What do you envision for the future of Fallujah?

Nahoko: When I came to Iraq for the first time in May 2003, I met some young men who came to Baghdad to inform the international media what was happening in Fallujah. They were so angry and said the media never cared about the outlying cities like Fallujah and Ramadi. They demanded that we come to Fallujah and witness what US soldiers had done there. I went and saw the blood of the victims who were shot, and found many injuries in the hospital. People cried and told me that soldiers never listened to them and shot randomly.

Fallujah’s story is similar to many other cities during the Iraq War, but there are still a lot of secrets. Thousands of people were killed by a chemical called white phosphorus and by many other unknown chemicals there.

There are  big pressures on the people who are trying to investigate Fallujah, and the international world should commit to remembering and revealing the atrocities that happened in there.

PLC: Thanks Nahoko for taking the time to share your experiences with us (and in your 3rd language!). May your preemptive love for the people of Iraq galvanize us all to a similar compassion for “the other.”

As PLC's Press Secretary, Matt Willingham is bent on leveraging words and media to connect hearts and minds to Iraqi children in need. On the side, he likes reading old books, devouring the great food his wife cooks up and dabbling in DSLR video work. He's also mildly obsessed with Twitter: @mehtin.

Hope for Baby Bakir and His Ruined Hometown

November 15, 2010 by matt · 2 Comments 

Meet Baby Bakir (pronounced bah-ker). Thanks to the combined efforts of Nahoko Takato, the talented doctors and nurses at Anadolu Medical Center, and the Preemptive Love Coalition, this beautiful little boy is now recovering after receiving a lifesaving heart surgery in Istanbul, Turkey.

This is actually an exciting week for Bakir’s hometown of Fallujah as it’s the first annual Remember Fallujah Week. US veteran Ross Caputi launched the Justice for Fallujah Project to decry the atrocities committed against the citizens of Fallujah during the Iraq War.

US officials report that more than half of the city’s 39,000 homes were either damaged or destroyed in Operation Phantom Fury in 2004, and, like Bakir, many of the city’s children have continued to experience the lingering effects of chemical weapons in the form deadly heart defects.

Yet in the midst of so much destruction, we’re eager to offer you stories like Bakir’s. In a city of rubble, his is a bright story of hope and future.

As PLC's Press Secretary, Matt Willingham is bent on leveraging words and media to connect hearts and minds to Iraqi children in need. On the side, he likes reading old books, devouring the great food his wife cooks up and dabbling in DSLR video work. He's also mildly obsessed with Twitter: @mehtin.

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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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