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 Tips To Help You Beat The Iraqi Heat

August 15, 2011 by Adam · 1 Comment 

Iraq is hot.

This isn’t Texas-hot or even Mexico-hot. This is a mouth-so-dry-you-can-barely-talk kind of hot. I’ve never craved water as much as I do here.

It’s completely normal for temperatures to stay up around 115 degrees Fahrenheit in the summer, so how do you beat the heat? Well, until Bear Grylls decides to brave this desert, here are a few tips from yours truly on how you can beat the Iraqi sun:

1. The locals have an efficient method for staying cool and they’ve been doing it for centuries–they stay inside!

As my Kurdish friend told me, when it gets hot enough to fry an egg on the street and there isn’t a pressing need to go anywhere, stay indoors and wait for the sun to go away.

2. But, as much as you’d like to hide inside, sometimes that just isn’t possible. Cabin fever sets in, and, once the walls start closing in, you’ll risk the eyeball-melting heat for a little air. So what do you do?

Scout out any and every bit of shade to walk under. This may mean moving to the other side of the street and under the shadow of buildings or considering a new route through the shady (in both senses of that word) alleys or underground passages through the bazaar to reach your destination.

3. In some places, you beat the heat by drinking something cold, like iced tea. Here, the idea of icing a tea or coffee is absurd. Iraqis continue to drink boiling hot tea–even when the weather is the same temperature as the drink.

However, they do have smoothie stands on almost every busy street corner. Here you can drink freshly blended cantaloupe, kiwi, carrot or orange juice. It’s pure fruit, it’s cold and it’s usually less than 25 cents a cup!

So there you have–3 ways to stay cool and beat the Iraqi heat! Hope that helps!

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.

The Most Disappointing Thing About My 10 Weeks In Iraq

August 1, 2011 by Adam · 2 Comments 

Remember Jenga? That crazy game where you pull blocks out of the wooden tower, hoping it doesn’t tumble over? Making plans often feels like a game of Jenga. You build a tower of ideas piece-by-piece, then life pulls at pieces of your plan, and sometimes our tower of plans comes crumbling down…

About a month ago, we received some disappointing news, and the PLC staff had to make a difficult decision. The Remedy Mission we all hoped to experience in our city, was canceled. For many of the interns, this Remedy Mission was the biggest reason we fought so hard to get the PLC internship. From the start of our internship process, we wanted to meet the families and kids who would be on the receiving end of lifesaving surgeries. Some of the intern’s assigned work even revolved around there being a Remedy Mission.

To make a complicated situation simple, the hospital and a local nonprofit partner didn’t prepare enough for the impending surgical mission. The hospital wasn’t as equipped to handle these complex surgeries as it should have been and funding was withheld. Surgical missions always have some risk involved, but PLC won’t dive into a Remedy Mission with unnecessary risks that could cost children their lives.

PLC could have provided more funds to make the surgical mission happen and just hoped the hospital’s current equipment was sufficient, but this is about long term solutions over short term gain. The problem could have been temporarily fixed with a handout, but we would much rather empower local organizations and hospitals to take ownership and responsibility for their community–for saving the lives of their children.

We don’t ram solutions down people’s throats. We’re here to aid local desires and local initiatives. So when local preparations fall or local enthusiasm wanes, we don’t force it. Part of creating long term solutions lies in ensuring that this is something local doctors, government officials and parents of sick babies really want–without our patronage.

Thankfully, PLC was still able to host a Remedy Mission, but it was relocated to a partnering city which was better-prepared, in a place most interns were unable to go.

When the rug is pulled out from under us, we can’t help but feel disappointment. However, we must come to the realization that GOD will reconcile our plans. Even when our Jenga tower crumbles to the floor, GOD is still in control.

Now Remedy VI is finished in southern Iraq, and we can praise GOD for each of the 18 kids who received a successful heart surgery and for zero fatalities!

The internship is now over and–Remedy Mission or not–each of us experienced so many valuable events and lessons. Our plans never really work out quite how we anticipate, but we’ve seen that GOD is trustworthy and will work everything out for the best.

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.

Never Have I Ever Spent An Entire Afternoon At A Tea Shop… Until I Came To Iraq

July 17, 2011 by Adam · 1 Comment 

Kurdish men spend a lot of time drinking tea, playing games, and socializing at tea shops. A Kurdish tea shop is completely different from how I imagined a tea shop, since I only had Starbucks and Teavanna to compare it to.

Please allow me to describe my first experience at a legitimate Iraqi tea shop buried in the center of the bazaar.

A returning 2010 intern, Alex, likes to call this tea shop “the catacombs.” So when he proposed the idea of revisiting his favorite place in Sulaymaniyah, another PLC intern and I were excited to visit this mysterious, catacomb-like teashop.

Alex led us through the winding streets of the bustling bazaar, when out of nowhere he dove into the small entrance of “the catacombs.” We walked through the narrow seating area and tea stand and then the room opened up to a huge floor filled with a mess of tables crowded with men.

The sights and sounds of the catacomb tea shop were awesome! The noise of dominoes slamming against tabletops, dice rolling across wooden boards and men’s laughter and conversation filled the room. The walls were lined in dirty, beige brick. These brick walls held pictures of Iraqi politicians and famous figures that seemed to transcend their canvas and stare creepily at you no matter where you moved.

The tea shop is a place where they can invite total strangers or friends to play games and drink cha (the Kurdish word for tea). The workers went around delivering tea, handing out games or repositioning cheap plastic chairs and metal tables to accommodate more Kurds. Every so often the old owner of the shop would come by to sweep up the endless amounts of cigarette butts scattered across the floor.

We found a small spot near the AC, and immediately our white skin and American-ness attracted eyes of friendly patrons eager to practice their English and help us out in our attempts to play backgammon. Anytime I play backgammon, a Kurd either playing or just watching, would move my pieces for me if I wasn’t quick enough to move them myself.

That day I spent over three hours in the tea shop losing almost every game I played, drinking tea and laughing with new friends. In Iraq, it’s normal to sit down and help strangers or foreigners with anything, even something as simple or insignificant as a board game.

And this friendliness isn’t just occasional. It’s a quality they practice daily. The Iraqi people really understand the value and importance of relationships. The culture here is saturated with qualities of hospitality and friendliness to strangers and friends, and I’ve recognized this level of love and friendliness as something I hope to adapt in my own life.

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.

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

June 10, 2011 by Adam · Comments Off 

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.

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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 children in pursuit of peace between communities at odds. We offer the untold thousands of Iraqi kids 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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