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)

Reflections On Remedy Mission VIII And The Vision You’re Living Out

January 22, 2012 by Cody · Leave a Comment 

As I write this, I’m driving away from Remedy Mission VIII. Just hours ago, we were in the hospital waiting for our 16th child to come out of the operating room.

This mission’s last child was a little baby boy named Younis.

Younis came 400 miles to get to Remedy, but the drive took it’s toll and Younis—just 2 months old—came down with a fever. Every day we put him on the schedule for surgery, but every day we had to cancel because his fever wouldn’t break. Some days it would break in the middle of the night, but by the time we could rush to the hospital to operate the fever had returned. This continued until the very last day of the mission. This time his fever broke for good, giving us just enough time to give Younis the lifesaving surgery for which he had traveled so far.

These are the stories of Remedy.

I also had the privilege of telling Ali’s story this mission, but it wasn’t just Ali who you helped us save this mission. You saved Amjed, Zainab, Alawi, Zain, and so many more.

###

This past week I’ve been reflecting more on the lives of these children and the life and vision of Martin Luther King Jr. In between surgical days I re-listened to some of his sermons, trying to once again stir my heart for the things that stirred his.

I was humbled by the devotion and the vision that he carried throughout his life, right up until his assassination. He maintained an astounding vision of God and his fellow man, one that led to his unparalleled passion for justice and peace.

King reminded me once again that there comes a point when silence is betrayal.

And so he shouted out for justice, equality and love. He spoke up for the broken, the poor, the ones affected by unjust war and the ones who had no voice of their own.

And people listened. We’re still listening.

This week I’m profoundly grateful for the life of Martin Luther King Jr. And I’m also profoundly grateful for you.

You see, these Remedy Missions can’t happen without you. In our writings we use the word “I” and “we” a lot but truth-be-told, I can’t think of one thing “I’ or “we” have done apart from you.

Because of that, together we’re breaking the silence. You’re bringing Remedy Missions to cities all over Iraq and because of that you’re saying to the people of Iraq “You are not alone. We are in this together.”

And they’re listening.

Thank you for not reducing the vision and legacy of Martin Luther King Jr. to a yearly quote, but for committing to live it out by saving the lives of children like Ali and Younis. Thank you for Remedy Mission VIII!

We’re just two weeks away from our next Remedy Mission….stick with us!

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.

“Thank you for saving me!”—Ali Abdul, 12 Year-Old Future Heart Surgeon

January 21, 2012 by Cody · Leave a Comment 

If you’ve been following Ali’s story, you’ll be happy to know he is doing extremely well! Remedy Mission VIII is almost at an end, but Ali’s last words for the camera were expressions of gratitude—thank you for saving him!

In case you missed them, go check out more photos/videos of Ali and his friends on our Twitter stream.

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.

After Only 26 Hours, Ali Is Out Of The ICU!

January 20, 2012 by Cody · Leave a Comment 

Does this look like a boy who just had an open heart surgery 26 hours ago? I didn’t think so!

I got a phone call from Ali early this morning telling me not to bother looking for him in the ICU anymore. I walked into the hospital to find him walking around in the ward!

Not only that, but he was already asking me when he can go home. Ali still really wants to be a doctor, so maybe one day he’ll understand how important this time is in the hospital.

But I love that he’s still a 12 year-old boy who can’t wait to go home and play soccer with his friends. At this rate, who knows, he could even be home by tomorrow!

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.

Breaking News: Ali Made It Through Surgery!

January 19, 2012 by Cody · Leave a Comment 

Ali was just brought out of the operating theater and into the ICU—with a mended heart!

The next 24 hours will be absolutely crucial for Ali, though. The operation was a complete success, but now we have to wait to see how his heart and the rest of his body will respond.

I ran into the ICU so I could take the above photo of Ali and show it to his mother. She was ecstatic to see her little boy!

Who knows what will happen next—Ali could be up walking around as soon as tomorrow!

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.

Ali Is In Surgery!

January 18, 2012 by Cody · Leave a Comment 

I got to the hospital this morning only to find out Ali had just been wheeled into the operating room for surgery.

I went to see how Ali’s mother was doing and she was surrounded by a group of women—all with enormous smiles on their faces. I asked why they were all smiling and they said it’s because Ali is getting his heart fixed!

12 years of waiting for a lifesaving heart surgery…I’d be all smiles too!

Ali should be coming out of the operating room within the next few hours. We’ll let you know how it goes!

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.

Ali Calls His Dad To Tell Him He Is Getting His Heart Fixed Tomorrow!

January 17, 2012 by Cody · Leave a Comment 

Ali’s days in the hospital got a whole lot more exciting once the doctors told him that tomorrow’s his turn to get his heart fixed!

What’s the first thing he did when he heard that? He grabbed the phone and called Dad.

Ali is just hours away from getting his heart mended—get ready!

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.

Ali’s Heroes Join Together To Save His Life

January 16, 2012 by Cody · Leave a Comment 

Did you ever get a chance to meet one of your personal heroes?

Given Ali’s dream of becoming a heart surgeon, spending all day surrounded by heart doctors was like spending an entire day hanging out with his heroes. Ali has never wanted to be a doctor as badly as he does right now! But without a heart surgery within the next few days, Ali will never be able to grow up strong enough to make that a reality.

Today, Ali was taken in for more tests so the doctors can fully understand his rare heart defect. Essentially, part of Ali’s heart never completely formed, so his heart needs to be repaired in a way that will help him grow strong enough to go back to school and get back to being a kid.

Thankfully, a heart surgery exists that can do exactly that.

I asked Ali if he’s still excited for his heart surgery and he responded even more enthusiastically “Yes – YES!” Who wouldn’t want a surgery that could put all of their dreams back within reach?

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.

Meet Ali!

January 15, 2012 by Cody · Leave a Comment 

A lot of you met Ali already, when he welcomed you to Remedy.

Whether he’ll admit it or not, he’s the ringleader and the brains behind The Fantastic Five. When Ali and The Fantastic Five aren’t by my side, it usually means I’m in the OR or in a meeting, in which case Ali will patiently sit right outside the door separating us. Just last night he called me over a dozen times on my phone, asking how I was doing and exhausting all of the Arabic I know.

What excites me the most about my friend Ali, though, is what he wants to be when he grows up. He wants to become a heart surgeon.

Yesterday we sat down and talked about his heart defect and I asked him why he wanted to become a heart surgeon. He responded, “I want to save others like me.”

If all goes well, Ali is just days away from his lifesaving heart surgery, where he’ll be saved by a heart surgeon and his team. I asked Ali if he’s excited for his surgery and he gave me a thumbs up and said “Yes – Yes!”

Ali is one day closer to being saved and getting the chance to save others…stay tuned!

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.

Iraq Sees Its Second Arterial Switch—Ever!

January 14, 2012 by Cody · Leave a Comment 

Baby Ridha was born just 19 days ago. She may not be old enough to keep up with The Fantastic Five, but she was born at the perfect time for the surgeons to save her life. By the time Remedy arrived, Ridha’s heart was at the perfect developmental stage to be fixed, making her the 2nd (and the youngest!) baby to ever receive an arterial switch in Iraq!

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.

Meet The Fantastic Five!

January 13, 2012 by Cody · Leave a Comment 

Say hello to the Fantastic Five. They formed two days ago when I was meandering down the hall meeting the families in the ward.

Yousef, the little boy front-and-center stealing the spotlight, ran up and almost dislocated my shoulder by swinging from the bed to the ground on it.

Saif, the boy over his left shoulder, let out a screech as he thought that was just the funniest thing he had ever seen. Ameer, the taller boy peaking over Yousef’s head, made a grab for the camera and managed to squeeze off a few photos of himself until I could get ahold of him.

Then Zainab, the shy girl against the wall, slapped her balloon my way and hit me in the head. Ali, the big brother of the group, stood off to the side smiling, but I’m pretty sure he’s their ringleader!

Since this meeting in the hospital ward, I haven’t been able to separate them – literally. Every chance I have of taking a photo of just one of them is always sabotaged by the other four. So this is my best attempt to get them all to hold still long enough for a photo.

All five of them have a different kind of heart defect, and all five of them are here for a chance at a lifesaving heart surgery.

Over the next few days we’ll start doing the tests needed to know how we can best help each of them. In the meantime…something tells me that they’re going to keep the hospital staff and their mothers on their toes!

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.

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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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