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)

5 Ways to Destroy a Nation’s Healthcare System

September 9, 2011 by Ryan · 2 Comments 

Whenever someone hears about our kids or reads about our work they almost always arrive at the same question: “How did Iraq get this way?” “What caused this?” “Who’s to blame?”

Well, after 4 years of working throughout this country we believe we can provide you with a concise answer to that incredibly complex question. This isn’t about guilting anyone or pointing the finger (there’s already too much of that going around), but it is a hard look at the answer to your question.

Based on Iraq’s history, here are 5 ways to destroy a nation’s healthcare system:

1. Limit a country’s ability to operate politically and economically
In 1990 the UN Security Council passed Resolution 661, which imposed broad, restrictive regulations upon Iraq. In a nutshell, these regulations stipulated that no country in the UN could import or receive any goods from the country.

Unfortunately, the sanctions did more than impede the political and military action of the Iraqi aggressors. The Iraqi economy, that had been so dependent upon oil exports and foreign trade, crashed as a direct result of the Resolution 661.

In 1989 Iraq’s gross domestic profit was over $66 billion. Just seven years later it was estimated as being $10.8 billion. In 1989, annual income per household was $3,510, and by 1996 had fallen to less than $500. Before the sanctions, 93% of the population had ready access to healthcare institutions, which were staffed primarily by physicians who had been trained in Europe or the United States.

This economic collapse primed the country for the health crisis it is in today, a health crisis that has lead to the death of inestimable millions over the last two decades.

2. Slash governmental healthcare funding
In the 1990′s Saddam Hussein cut spending on healthcare by 90%. Continued education, supplies of necessary equipment, and valuable public health programs all suffered without adequate funding research.

Without funding and governmental support, the healthcare system deteriorated.

3. Reduce the number of medical professionals in the country
In some areas, insurgents made it a practice of targeting medical professionals. Although many doctors were not individually targeted, they were still in danger. Ambulances were frequently robbed of their medical supplies, and it was not uncommon for gunmen to enter hospitals and force doctors to care for their injured family members or comrades.

Another blow was dealt to the stability of Iraq’s healthcare when many doctors and nurses, who were lucky enough to escape death, fled the country in a mass exodus, further damaging the quality of the Iraqi healthcare system.

The murder and exodus of Iraqi healthcare professionals is tragic. It has left many families broken and many patients without the care that they need. But the negative effects extend beyond their families and the patients they left behind. Without their mentor-ship, expertise, and knowledge, generations of students from universities and teaching hospitals will continue to have insubstantial educations.

4. Destroy physical healthcare infrastructure
In 2003 American and Coalition forces destroyed two primary public health laboratories and an estimated 12% of hospitals. While speaking about the state of the nation’s healthcare infrastructure, former Minister of Health of Iraq, Khudair Abbas, explained that of the remaining primary care centers, “15% have been looted. Even though 80% remain intact, 40% need extensive repairs…13% do not have clean water and one third are staffed primarily by paramedics rather than physicians”.

During the Gulf War, American and coalition forces destroyed key elements of Iraq’s infrastructure. “Bridges, communications, electricity supplies, water and sewage systems, weapons factories, healthcare facilities, administrative centers, warehouses” and homes were destroyed. While this may have been a strategy aimed at ceasing Iraq’s ability to make war, this strategy did far more than defeat the Iraqi military.

5. Overburden the healthcare system by creating too many patients

The above contributing factors deal primarily with political, structural, organizational, or educational deficits. Ultimately, however, it is the population of patients that compose the largest component of any healthcare system. And, regrettably, there is a vast population of patients in Iraq.

The demolition of water and sewage treatment plants lead to outbreaks of typhoid and cholera. In 1989, there were no cases of cholera per 100,000 people; just 5 years later there were 1,344 cases per 100,000 people.

According to studies, by 1996 31% of children under five were chronically malnourished. Just a year later, there were a million children under the age of five who were malnourished, and a year after that 70% of women were suffering from anemia. Another study, consistent with the information on malnutrition, found widespread, chronic stunting in school children as an indication of long-term malnutrition.

Poverty’s wide-spread negatively affects the livelihood of the Iraqi people. Low socioeconomic status is associated with lower levels of education, poorer nutritional intake, and higher risk of congenital heart defects.

Research shows that poor diet contributes to far more negative effects than weight loss, anemia, nutritional deficiency, and compromised immune system. Without the funds to afford healthier food, mothers with higher intake of saturated fats and lower intake of nicotinamide (vitamin B3) have increased risk of giving birth to children with congenital heart defects. 5, 8 Furthermore, low dietary intake levels of folic acid (vitamin B9) around the time of conception have been linked to higher risk of neural tube disorders.

But nutrition and education are not the sole arbiters of death and ill health. Many parts of the country still suffer from the chemical and biological attacks perpetrated by Saddam Hussein. Not only are individuals suffering from primary exposure, but research supports that children of those who were exposed suffer secondary effects in the form of birth defects.

The list of health problems and their contributing factors continues ad nauseam, and the patient-load continues to overwhelm doctors.

The evidence shows that the state of Iraq’s healthcare system has been nearly two decades in the making. The downward spiral began with sanctions in the 1990’s by making the nation more susceptible to economic collapse. It continued with a multitude of factors including military action by the US and Coalition forces, violence wrought by religious extremists, and a vast backlog of patients.

—–

The question remains, is it too late for Iraqis to rebuild their healthcare system?

Is Iraq too far gone?

Of course not! The restoration of Iraq’s medical infrastructure is happening now!

This November 5th will be our biggest surgical mission yet–lives will be saved, doctors will be trained and Iraq will be one big step closer to restoring what was broken!

Ryan Rosenberry is spending his summer as a PLC intern (’11) compiling Remedy reports and researching CHD and prenatal care. When not citing sources, this pre-med California native can be found playing the guitar (or piano), partaking in a game of Ultimate Frisbee, or doodling his favorite animal: the pink sea slug.

3 Things I Could Have Only Learned From The Kurds

July 24, 2011 by Ryan · Comments Off 

1: Dressing up isn’t only about looking good

For the most part, in America, men don’t dress up to impress their platonic male friends in social settings. When going out somewhere, whether it’s a sporting event, coffee shop, fast food joint or just hanging out somewhere, men typically don’t dress to impress their male friends. We just don’t. If I showed up to have lunch with a friend wearing slacks, dress shoes and a button down shirt, he’d almost be sure to ask where I was coming from or where I was going, that required such attire.

Would you press your shirt and throw on a tie for an all-guys backyard barbecue? Would you shine your shoes and put on slacks to go watch a ball game at a friends house?

Let’s be honest. The answer is no, you wouldn’t.

But the Kurds do. Every weekend in the bazaar, at tea shops or just walking in the street I see Kurdish men wearing slacks, button-down shirts and the shiniest shoes I’ve ever seen in the dustiest place I’ve ever been. Here in Sulaymaniyah, dressing up is not all about looking good. It’s an expression of respect to the people around you as well as to the friend you are meeting for tea. Dressing up isn’t about demonstrating how dapper you can look. It’s about wordlessly saying, “The time I spend with you is a special occasion, and that is worth dressing up for.”

2: Hospitality isn’t just refilling the bowl of potato chips

I always try to be a good host when people come over. I’ve got the basics down – offer them food, offer them drinks, “is there anything I can get you?” – you know, the usual. But since coming to Kurdistan, I’m realizing that hospitality isn’t just refilling the bowl of potato chips; my hospitality should not be confined to guests at my house.

While being here, so many Kurds have gone to great lengths to show me hospitality: from physically leading me to my destination when I’m lost (despite it being in the opposite direction of their destination) to spending entire afternoons with me drinking tea, playing backgammon, teaching me Kurdish and talking about life. When was the last time you spent an afternoon with a stranger, let alone an acquaintence, just to show them a good time?

3: We all yearn for reconciliation

I entered Kurdistan harboring misunderstandings. Besides some brief reading of Kurdish’s history, most of my opinions of Kurdistan were shaped by mainstream media and ignorance. Let me tell you, that was a mistake. My Kurdish friends laughed as I explained the common perceptions of Iraq and Muslims in general, and grimaced soberly as they explained that Osama Bin Laden wasn’t a real Muslim because of the way he perverted, corrupted and twisted the teachings of Islam for violence and hatred.

My Kurdish friends laughed as I told them that not all Americans are like the people on Jersey Shore and that our nation isn’t entirely filled with debaucherous hedonists. They nodded disapprovingly as I spoke about the Westboro Baptist Church and their hateful and irreverent propaganda, and nodded in agreement as I said that we reject them as true representations of Christian theology and culture.

Many things became clear through these conversations, but the most profound epiphany I experienced was that we all yearn for reconciliation. We spoke about TV and culture, but what we were doing was reaching for common ground, understanding, and reconciliation. In discussing our differences and our misunderstandings, we found a common desire for peace between our cultures.

Ryan Rosenberry is spending his summer as a PLC intern (’11) compiling Remedy reports and researching CHD and prenatal care. When not citing sources, this pre-med California native can be found playing the guitar (or piano), partaking in a game of Ultimate Frisbee, or doodling his favorite animal: the pink sea slug.

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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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