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)

Kisses, Crayons, And Bubbles—A Look Back On Our Week In Fallujah

August 21, 2012 by Kendelyn · Leave a Comment 

Uncertainty is a way of life here.

When it comes down to it, the answer to questions is often “I don’t know.” This was the answer I got when I asked whether or not I’d be going to Fallujah for Remedy Mission X last July. The problem wasn’t the lack of communication, the real challenge, for me, was the inability to create expectations (and therefore plans) of any kind. It’s often difficult to gauge what a mission is going to look like, especially when the mission is a first-of-its-kind in a new city. And, since Fallujah was a first-ever, it was guaranteed to have bumps along the way. Embracing this fact, I made sure to walk into the week with an open mind.

I’d heard a lot about Fallujah over the years, but most importantly I knew that the city had experienced a lot of pain and difficulty, and all I wanted to do was make it better—somehow. But how? How could I, a 20 year old from America, be able to make any difference in such a big, broken place so far from home?

The more I pondered this question, the more my response made sense to me: I can make a difference by endeavoring to love everyone I come into contact with. But that begs the question: “how do I show my love for these people when I’ve barely just met them?” I strived to find an answer to this question all week.

And the week was a blur!

Children were in and out of the operating room faster than I thought possible. But with the intention to love in the back of my mind at all times, I moved forward in my interactions with the children and their families filled with as much purpose and love as I could muster. I made sure not to let my fatigue and frustration show, and I made sure to have a smile on my face at all times. I was there to be a friendly face and bearer of joy as I documented the mission with my camera.

Looking back, I can barely recall how exhausted I was that week as the experiences of love and joy stand out far more prominently in my mind. The doctors loved the children, the children loved their parents, and the parents loved the doctors.

As love is put into the world, love circles back around. It begets itself.

In the course of a week I took hundreds of photos. Photos of everything from the children hanging out in pre-op to the doctors working in the cath lab. But out of all the images that I took in the course of the week the ones that stand out the most to me are the ones of kisses, crayons, and bubbles—not because they’re the cutest images of the week, but because they best exemplify the love that filled the hospital. The very same love that I tried to foster all week.

But all of that effort made by our team and the local doctors is just a drop in the bucket. Fallujah is still a broken city in need of attention and love, and the past still matters. But if we can continue to push ourselves toward selflessness over and over and over again, mission after mission, then I believe we’ll be able to create a future filled with love towards one another.

I believe we can reshape old perceptions previously founded on hate.

Our Partners:

Kendelyn is a 2012 summer intern who LOVES taking photos, and you can find her strolling the streets snapping shots of anything from flowers to friends to googly-eyed stuffed goats. She's excited to be working in Iraq this summer as PLC's photography intern and looks forward to learning more about its culture and people.

How A Boy With A Marker Captured My Heart!

August 14, 2012 by Kendelyn · Leave a Comment 

All kids are cute. It’s a fact of life.
But some kids have the ability to steal your heart. Meet Jasem, the captor of my heart. I had the pleasure of getting to spend time with him as he waited for his catheterization.

Now, pre-op can be a rather boring place. It usually entails an hour or more of just waiting around for the doctors to finish their current case so they can move on to the next child. But in Jasem’s case, we kept things interesting.

When I first came to hang out with Jasem, he had his shirt on and was coloring a picture quietly on his bed. He was a little hard to engage, but adorable nevertheless. I would talk to him, he would look at me, and then he would go back to his coloring. Apparently I’m not as funny as I think I am.

The second time I hung out with him, he had his shirt off and had managed to procure a marker from one of the nurses. And, doing what all 6 year-old boys seem to do well, he colored on himself, which only upped the adorableness factor. We bonded some more over his artistic endeavors, bubbles, and the pictures of him on my camera’s display screen.

Before we knew it, Jasem’s turn for catheterization came. So into the operating room he want, and an hour and a half later he came out with his heart completely healed!

As he lay sleeping in recovery, I couldn’t help but feel overwhelmingly happy. Here was a little boy who had spent his life restricted by his heart defect, and although he didn’t know it yet, he was healed. He can now run, jump, and play with the best of them, and I got to be there to see him through it all!

Our Partners:

Kendelyn is a 2012 summer intern who LOVES taking photos, and you can find her strolling the streets snapping shots of anything from flowers to friends to googly-eyed stuffed goats. She's excited to be working in Iraq this summer as PLC's photography intern and looks forward to learning more about its culture and people.

PHOTOS: Lining Up And Weighing In—Let The Operations Begin!

July 13, 2012 by Kendelyn · Leave a Comment 

Before a child hops up on the operating table, they must take their turn on the scale so the anesthesiologist can know the correct dosage to administer so they can sleep safely during their operation. Below are a few of the children who are lining up for their shot at a healed heart.

Come back over the next few days to meet these children and to hear their stories!

Our 85 suture kits are FULLY funded — Thank you for helping fund $765 worth of medical supplies!

Our Partners:

Kendelyn is a 2012 summer intern who LOVES taking photos, and you can find her strolling the streets snapping shots of anything from flowers to friends to googly-eyed stuffed goats. She's excited to be working in Iraq this summer as PLC's photography intern and looks forward to learning more about its culture and people.

Revved Up, Ready To Go—Remedy Mission X Is In Fallujah!

July 10, 2012 by Kendelyn · Leave a Comment 

Remedy Mission X is finally here!

We just started working in Fallujah, and I couldn’t be more excited. As PLC’s photography intern, I’ve already been a part of some exciting stuff, like my trip to Dohuk last May. But nothing has me more excited than this trip to Fallujah!

The mission is a first-of-its-kind in the Anbar province, and I have the privilege of documenting it all and sharing it with you.

The press are swarming, and doctors from all over the region are arriving to be a part of the groundbreaking work that YOU’VE made possible, so join me as I take my camera on our first-ever lifesaving Remedy Mission to Fallujah!

More to come…

Our Partners:

Kendelyn is a 2012 summer intern who LOVES taking photos, and you can find her strolling the streets snapping shots of anything from flowers to friends to googly-eyed stuffed goats. She's excited to be working in Iraq this summer as PLC's photography intern and looks forward to learning more about its culture and people.

How Newborn Babies in Dohuk Are Helping Us Shed Light On The Backlog

June 5, 2012 by Kendelyn · Leave a Comment 

I wasn’t sure what to expect when I got in the car and drove five hours north to the Kurdish city of Dohuk.

I was told we would be screening children for congenital heart disease (CHD), but since I’m not in the field of medicine and am a newcomer to PLC, I wasn’t exactly sure what that would look like. All I knew was that this was going to be a first-time experience for me and that I was excited.

I walked into the experience with an open mind and an open heart, and I walked away with a new understanding of what it means to screen babies for CHD and why that has everything to do with understanding and fighting the backlog of children waiting in line for lifesaving heart surgery here in Iraq.

In the end, we spent the week screening newborns using two echo machines. Dr. Kirk (whom we’ve partnered with before) preformed an echo using a V-scan, a pocket-sized ultrasound device while Dr. Serdar—the local Kurdish cardiologist who we partnered with for the mission—used a full-size echo machine.

Each morning we walked into the hospital and screened the children who were born that day as well as the children who were born the previous night. More often than not, grandmothers would carry in children who were barely minutes old. Their vibrancy and freshness to life continually brightened the room.

Along with the spirited children, we saw timid mothers, brand new fathers, and bashful siblings—all of which were hoping to hear good news about their brand new family member. It was such a joy to be able to see the relief and joy on many of the families’ faces as they heard the words “healthy heart!”

In addition to performing two screenings per a child, we conducted interviews with parents and close relatives of the babies. The interviews make up a collection of data on the parents of the child, which will later be analyzed by Dr. Kirk as he searches to better understand the conditions that lead to CHD.

By the close of the week, Dr. Kirk and Dr. Serdar felt well on their way to being able to make a more solid assessment of the CHD situation in the Dohuk region of Iraqi Kurdistan – and a more solid assessment is exactly what we need if we’re going to eradicate the backlog.

I feel truly blessed to have been a part of this screening mission. Not only did I learn a ton, but I forged new friendships and had an amazing time.

Kendelyn is a 2012 summer intern who LOVES taking photos, and you can find her strolling the streets snapping shots of anything from flowers to friends to googly-eyed stuffed goats. She's excited to be working in Iraq this summer as PLC's photography intern and looks forward to learning more about its culture and people.

Old Welcomes New—Meet the Amazing Grandmothers of Northern Iraq (Kurdistan)!

May 29, 2012 by Kendelyn · Leave a Comment 

Grandmothers; they’ll pinch you, they’ll squeeze you, and they’ll always hold you tight.

Our recent screening mission in Dohuk saw a constant stream of grandmothers caring for their newborn grandchild as the weary mothers rested. And for that, I salute them. They are truly fantastic women!

A Kurdish grandmother poses with her grandchild after learning the child was free of any heart defects.

A Kurdish Yazidi grandmother rewraps her grandchild after the child’s screening—no heart defect found!

These grandmothers were incredible at caring for the newborns. This one kept her grandchild distracted during the screening.

Kendelyn is a 2012 summer intern who LOVES taking photos, and you can find her strolling the streets snapping shots of anything from flowers to friends to googly-eyed stuffed goats. She's excited to be working in Iraq this summer as PLC's photography intern and looks forward to learning more about its culture and people.

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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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