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)

3 Reasons For “In A Word” Mid-Week Photos

June 12, 2011 by Liz · Leave a Comment 

For a month now we’ve posted mid-week photos titled “In a Word,” and we’ve received some great feedback from you guys.

We want you to know that these aren’t just pretty pictures, they’re tools to help as all build an understanding of Iraq through the artists who live here.

We know you care about the future of Iraq, the kids and the training of nurses and doctors, but we want to offer you even more perspectives.

So here are 3 reasons we believe “In A Word” matters:

1. Images can be used to promote peace.
“Peace is waged when a child is served, a voice is heard, a story is told, a dialogue is created, and a community is engaged.”

We’re waging peace when we LISTEN to and TELL a story about Iraq, kids with CHD, local healthcare, local solutions (i.e. politicians, donors, doctors, etc.), Muslim and Eastern perspectives, Christian and Western perspectives, the war, etc. These photos give us the opportunity to engage another community. They tell stories and create dialogue.
They’re opportunities for us to understand.

2. We live among the people here.
We work with them, care for them, argue with them – we love them. And many of you have expressed interest in what those things look like here, so “In A Word” is our way of helping you visualize our day-to-day. It helps our families, friends and supporters ‘come around’, and for a few seconds, that makes us feel like you aren’t an ocean away.

3. It’s a platform for artists.
These Iraqi and Kurdish artists are unsung heroes, and their work deserves to be showed off and shared. They show their people that beauty can bring hope and truth in the midst of devastation.

“In A Word” is a forum – a sounding board – where artists can show off their work and prove emphatically: we’re here, and we’re talented.

Do you have any photos that you’d like to submit for an “In A Word” midweek post? If so send to liz@preemptivelove.org, subject “In A Word”

Liz Jones is PLC's copy editing intern. For everything you've read on our site this summer, odds are she's read it at least thrice (or more). When not absorbed in her editing, she can be found reading every article on Copyblogger and doing horse gymnastics. Wait, you don't know what horse gymnastics is?! Click here immediately. Also her Twitter: @liz_bentley.

Finding Familiarity In An Unlikely Place | An Intern’s Perspective on Followthrough

June 10, 2011 by Adam · Leave a Comment 

Yusuf is a brave 1-year-old who underwent heart surgery this past March. When his family brought him to the hospital, Yusuf blood had low levels of oxygen that had already tainted his skin blue. The surgeon needed to fix four heart defects for Yusuf to survive.

But thanks to caring donors and local support, Yusuf is very much alive!

You helped Yusuf receive a heart surgery, and, because of you, I was able to visit and make sure his recovery is going well. This is what we call Followthrough. CLICK HERE to learn more on the importance of Followthrough.

As we sat down with Yusuf and his family I was overwhelmed with all the cultural differences around me, but there was a strange sense of familiarity as well.

Shortly after we sat and talked in Yusuf’s living room, his family rolled out a giant feast for us. We ate until we were full, and there was still enough left to feed us for dinner! Then we drank tea, and the refills seemed to be endless.

As we drank tea and took photos of Yusuf, his older sister played with him and entertained us with her hilarious faces. Yusuf’s grandfather would toss his phone across the living room floor while Yusuf would scoot across the room to return it again and again.

The familiarity I recognized during my visit was the same warm family dynamic and rejoicing I experience with my own family.

Even though we ate sitting down on a concrete floor, followed a completely different set of manners, and understood very little of the words spoken, the joy and relationship between these family members was the same as many American families I know.

We laughed and enjoyed the fact that their son’s life had been rescued. At this point in the visit I began to see these faces as my family and friends rather than as distant strangers.

This family was so grateful for us, for their son, for his surgery, and for a community willing to come together to provide a solution for their needs. I felt the warmth in their home through photos of Yusuf, endless cups of tea, a floor full of food, and a room bursting with smiles.

No matter how great the cultural barriers there are some values and moments humanity can rejoice in and enjoy together. These shared moments and values are the most significant puzzle pieces of our own identity.

Adam is spending his summer using words and writing to connect hearts and minds to children with CHD. That means poring over newsletters, blog posts, and photo captions to make sure these children are heard and that they get their shot at surgery. When not buried in metaphor, Adam enjoys playing the violin, hiking, and photography. He's also on Twitter @adamhallbrandt.

In a word: “Groceries”

June 8, 2011 by Lydia · Leave a Comment 

A Kurdish grocer flashes a big smile for the camera.

Lydia Bullock wrote and photographed for us during the 2010 summer internship and then again for 7 months in 2011. She documented surgical missions in northern and southern Iraq. See more of her excellent work on our Flickr stream, or follow her on Twitter: @lydiabullock.

Meet the Interns: Our First Impressions of Iraq

June 7, 2011 by Ted · Leave a Comment 

Ted is making the magic happen as PLC's videography intern this summer ('11). He'll be the first to tell you: he shoots and edits to the glory of GOD and the benefit of Iraqi kids. When he isn't panning his camera, well... just go here to read just a few of Ted's lovable idiosyncrasies. He's also an avid Tweeter: @tedvid.

Have You Ever Seen How Much It Costs To Save 20 Lives? Here Are The Numbers:

June 6, 2011 by Jeremy · 1 Comment 

As we’ve looked across the landscape of organizations working in Iraq and around the world we’ve found ourselves wanting to know more about how their money is spent. We figure you are the same way – and we think you deserve to know. The scandalous press and allegations surrounding big name do-gooders, their books, and their organizations have all caused us at PLC to ask honest questions about how we can be fully transparent with you about your donations and our management of them in Iraq.

So here are a few real-time financial notes that will remain here for posterity’s sake:

- PLC spent $41,068.38 for airfare and hotels for Remedy V

- PLC spent $30,000 to the International Children’s Heart Foundation (ICHF) to procure their surgical expertise for this mission

- ICHF made approximately $20,000 in in-kind medical gifts to the mission (directly to the hospital in southern Iraq; not on our balance sheet)

- We have not finished tallying the field expenses for Remedy V yet but we anticipate it will account for an additional $1,790-$2,000

- Our partners in southern Iraq budgeted $1,500 for educational instruction

- More than $1,620 in visa expenses were covered directly by the Iraqi Ministry of Health (MOH) in Baghdad

- Security and transportation was provided to us, free of charge, by the MOH (worth, perhaps $10,000 as an in-kind contribution)

- Food, housing, and all local accommodations were provided by the MOH (worth more than $20,000 as an in-kind contribution)

We estimate the total cost of this particular mission to run all parties approximately $133,361. Our agreement with the MOH will subsidize approximately 77% of those costs, with roughly $2,800 for this particular mission coming from PLC’s international donor pool.

Our next mission – Remedy VI – in southern Iraq is scheduled for June 25th.

Here’s the bottom line to all this: you are indispensable to our work. We cannot help Iraqis reach their desired vision for the future without you. We cannot eradicate the backlog of untold thousands of children waiting in line for lifesaving heart surgery. And we cannot create the systems they need to do this work on their own without you.

But….

You are not alone! This is not a “hand-out” program in which you unload your hard-earned money into a foreign country (no matter how poor or decimated), without calling on local families, organizations, and government to carry the majority of the financial burden. This is what we mean when we talk about development. This is what we mean when we talk about graduating a program from foreign aid.

They cannot do it without you. But hopefully in the next few years that will no longer be true. Stay tuned in the coming months as we begin publicly exploring our EXIT STRATEGY and what exciting promises that holds for our dear friends here in Iraq!

With you,

Our Partners:

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

Bubble-Blowing, A Work-Out? Moustafa’s Recovering Beautifully!

June 3, 2011 by Lydia · 1 Comment 

Did you know bubbles are a part of the routine for discharging children from ICU?

It’s because blowing bubbles is a fun way for kids to strengthen their lungs and improve their breathing after hours of being on a heart-and-lung machine. Don’t believe me? Go here to find out more on how blowing bubbles is beneficial to your health.

You may remember that I was looking forward to giving you good news about Moustafa’s surgery, and I got it! Moustafa passed his healthy heart and lung test and is ready to make the trip back to his hometown – praise God!

You helped send Moustafa to surgery, and because of your donations and prayers his once-broken heart is now mended.

Thank you for choosing to be a heart-mender, and thanks for helping to save Moustafa!

Our Partners:

Lydia Bullock wrote and photographed for us during the 2010 summer internship and then again for 7 months in 2011. She documented surgical missions in northern and southern Iraq. See more of her excellent work on our Flickr stream, or follow her on Twitter: @lydiabullock.

How Moustafa and His Soccer Ball Captured Our Hearts

June 3, 2011 by Lydia · 2 Comments 

Moustafa’s parents spent years scouring hospitals across Iraq in search of someone who could fix their little boy’s heart.

Doctors eventually told them that he had no hope in his home country and that they needed to go to India, which meant Moustafa would never receive surgery since his parents could never afford to send him abroad.

But thanks to you Remedy Mission is here, and Moustafa is finally receiving his heart surgery!

In many ways, Moustafa is pretty similar to the other 6-year-old boys I know. His father, mother (who’s always by his side), and older brother all love him very much. He’s energetic and loves to play – especially soccer. But unfortunately I didn’t get to meet Moustafa at the park, or at his school. My first glimpse of him was in the children’s ward of a hospital awaiting surgery.

But all that has the chance to be fixed starting right now, and I’m eager to hear good news of a successful surgery. Keep reading for updates!

Our Partners:

Lydia Bullock wrote and photographed for us during the 2010 summer internship and then again for 7 months in 2011. She documented surgical missions in northern and southern Iraq. See more of her excellent work on our Flickr stream, or follow her on Twitter: @lydiabullock.

In a word: “Change”

June 1, 2011 by Lydia · Leave a Comment 

In Sulaymaniyah, you pass your bus fare forward in hopes that you’ll get change back. It’s always an adventure.

Lydia Bullock wrote and photographed for us during the 2010 summer internship and then again for 7 months in 2011. She documented surgical missions in northern and southern Iraq. See more of her excellent work on our Flickr stream, or follow her on Twitter: @lydiabullock.

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OUR BLOGGERS

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

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

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