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)

An Update on Sozyar, Five Months After Surgery

July 12, 2010 by Sophia · Comments Off 

At last week’s home visit, two-year-old Sozyar puckered her lips and blew me a kiss as I was walking out the door.

Sozyar, who has a much more delayed development and a much longer medical history chart than most other children her age, is doing remarkably well given where she was less than half a year ago. When Sozyar went to surgery in February, she only knew how to lie down and bat her big, beautiful eyes. Now, five months later, she has grown tremendously and is attempting to pull herself up and crawl. If she continues developing at this rate it won’t be long until she is walking!

With a healthy appetite (she ate from everyone else’s dishes at lunch) and a feistiness for asserting herself, she has begun to reach milestones in her recovery.

Sophia is passionate about living, loving and saving lives. While in Iraq, Sophie enjoys wandering the bazaar, trying local foods and playing with the kids.

Yahya – One Week Before Surgery

July 12, 2010 by Sophia · Comments Off 

The hot desert sun beams down upon wreckage from the days of Saddam’s rule; and big houses, now broken down into cement blocks, line the dusty streets.

A modest white home is nestled in the midst of the rubble. And coming from the house were the sounds of dishes clanking in the kitchen, a TV blaring, a little boy’s laughter.

That little boy is 5 year-old Yahya, one of my favorites who is about to make the trip to Istanbul this Saturday for heart surgery. Much awaits Yahya. He is getting a new valve put into his heart, a new lease on his young life.

But for now, he is at home. While visiting him and his family in their home last week, I noticed Yahya in the living room playing a soccer-themed video game and giggling with his best friend, Ahmed.

Yahya loves video games. Normally very shy and reserved, his demeanor was relaxed and comfortable when he pretended to be the famous Argentinian soccer player, Lionel Messi. Yahya told his father that when he grows up, he wants to be Messi.

Yahya’s upcoming surgery gives us hope that one day he will overcome his disease and put aside his soccer video games in order to play like a real soccer star outside under the Iraqi sun.

Sophia is passionate about living, loving and saving lives. While in Iraq, Sophie enjoys wandering the bazaar, trying local foods and playing with the kids.

Family Advocate Connecting with a Two-year-old Waiting for Heart Surgery

July 11, 2010 by Sophia · Comments Off 

On a house visit last week I noticed Chro’s tiny bright-pink fingernails and toenails as she sat squeamishly on her father’s lap. Chro is one of five children going to surgery on July 18.

Her father is a policeman, a civil servant in charge of protecting their village; but right now he is focused on protecting his little girl by sending her to surgery. At 2 years old, Chro is battling the heart disease inside her chest.

As I sat with her family on the knit rugs that lined their living room floor, Chro’s eyes anxiously looked around. She started to whimper a faint cry because her lungs can hardly provide enough oxygen for the deep breaths that are required to shed many tears.

She was scared.

I could only imagine what might be going through Chro’s head. She is a little girl, who will soon be getting on a plane and flying to a foreign country only to have her small heart cut open and restored. Can she possibly grasp the magnitude of lifesaving heart surgery? I cannot possibly understand what it feels like to be a scared two-year-old with shortness of breath and probing doctors.

After I asked Chro’s family about her likes, her mother, a sturdy Kurdish woman with a protruding pregnant belly, smiled and said, “Dolls, lollipops and ice cream.”

I realized that Chro is a normal little girl. In spite of facing a disease that threatens to take her life, she is a little girl who likes lollipops, rainbows, baby dolls and bright pink. I think we have more in common than I first thought.

Sophia is passionate about living, loving and saving lives. While in Iraq, Sophie enjoys wandering the bazaar, trying local foods and playing with the kids.

Revisiting Nivar Helped PLC Family Advocate Refocus on PLC Goals

June 27, 2010 by Sophia · Comments Off 

It is often difficult to measure the level of success of our work here in Iraq. Working with kids and families, donors and budgets is all sometimes daunting.

On a recent visit to see 9 year-old Nivar, I was reminded of how precious life of an Iraqi child with a heart disease is. With little energy to play outside and unable to run around with her younger brothers, Nivar spends her days watching TV and lying down in her family’s home. Her condition is significant and according to her father, she often feels tired and bored now that school is out for the summer.

Nivar is one of the sweetest girls I have had the privilege of meeting here in Iraq. Big green eyes and a smile that captures your heart, she is the epitome of why we here at PLC work to send children to surgery.

We work to see kids outside playing once again. We work to stop sick days and sad childhoods. We work to see smiles and healthy pink cheeks instead of blue ones that show a lack of oxygen.

We work because we love, and we hope that love can be shared with everyone who donates to a child.

I can’t help but think that if we can help save at least one little girl like Nivar, our job will be a success.

Sophia is passionate about living, loving and saving lives. While in Iraq, Sophie enjoys wandering the bazaar, trying local foods and playing with the kids.

UPDATE on Three PLC Kids Three Months After Surgery

June 20, 2010 by Sophia · Comments Off 

Driving the dusty highways of Iraq, past kids selling water on the side of the road and through security checkpoints, I’ve found that the journey to visit PLC patients is one of joy. These family visits after a child has been sent to surgery are used to see the child’s progress and their health condition post-surgery.

Last week I had the pleasure of visiting three children who have already undergone surgery. Mohammed, Deelan, and Sara received successful, life-saving heart surgeries earlier this year, and what a joy it was to see them doing well only a few months after!

Eleven-month-old Mohammed entered the reunion screaming his head off – a wonderful sign of healthy lungs and a healthy heart! Mohammed has been gaining weight since his return home and can happily entertain himself with a cell phone on his father’s lap, not unlike many babies his age.

Deelan, now one and a half years old, has had tremendous improvement in his condition. Before surgery Deelan was a very weak and frail little boy, but he is now feisty and pushing over tables and chairs!

As Jessica, the family services director for PLC, recalled, “Deelan was so weak and tired on the way to surgery… his mother just didn’t know what to do with him.” That doesn’t seem to be a problem for Deelan’s mother now since it appears she spends some of her time chasing Deelan as his tiny legs run in circles around the room.

Sara, who is 14 years old, had her surgery in March. Ever so polite, she carries herself with confidence and maturity. When asked what she hopes to be in the future, Sara said proudly that she wants to study medicine, because her doctors were, in her own words, “so good.”

Revisiting kids like these three that inspires us at PLC to continue our work here in Iraq. Some days the stories of sick children are hard to handle, but when we are able to see tired and defeated faces turn into healthy and smiling ones, it certainly gives us strength.

Sophia is passionate about living, loving and saving lives. While in Iraq, Sophie enjoys wandering the bazaar, trying local foods and playing with the kids.

Yahya’s Playtime with a Preemptive Love Family Advocate

June 5, 2010 by Sophia · 1 Comment 

The first time I wandered onto the Preemptive Love Coalition website, I was drawn to the images. The poignant photos of sick children laughing and playing made their personalities come to life. Delicately illustrated stories depicted the reality of their conditions and the urgency to help them. Already a very maternal person, I instantly wanted to pick them up, talk to them, play with them, comfort them, and ultimately help save their lives. Before this summer, I could only imagine how beautiful an encounter with one of these children would be.

Just the other day, I experienced the first of what I hope to be many encounters with PLC kids. Shy and nestled under the skirt of his mother’s headscarf, five year-old Yahya came into the PLC office. His sweet smile was masked by a veil of bashfulness and uncertainty, and I was eager to make him giggle. Bouncing balls, coloring pictures and shooting a rubber band gun helped me break the ice. I was essentially making myself look like a fool in order to get him to laugh, but it was all worth it to see the look on his face when he realized that he could relax; that he could play.

I didn’t speak the unique Kurdish-Arabic blend of his family when I played with Yahya, but I didn’t need to in order to communicate with him. Sharing the qualities of just about every child I have ever met, Yahya wanted nothing more than to feel comfortable and at ease so that he could goof around and enjoy himself. It takes few language skills to have playtime with a preschooler.

At five years old, Yahya’s short life has been filled with little playtime. Born with some of the most complex heart problems, Yahya’s grave condition set him on a path filled with physical malformations and potential social setbacks. But while we were playing, he was just a normal little boy waiting for a lifesaving surgery.

I can honestly say that my short time with Yahya is one of the most rewarding things I have done since coming to Iraq. Yahya is a very ill little boy, and I know that my loving him cannot save him. But playtime can do wonderful things for a child!

Our goal for Yahya today is to raise an additional $1,500 for airfare, food, housing, translation services, remaining surgery expenses and additional contingencies. Whether you’ve seen Yahya around before or this is your first time, help us go beyond meaningful play times to get Yahya the surgical therapy through which he will benefit so much.

Sophia is passionate about living, loving and saving lives. While in Iraq, Sophie enjoys wandering the bazaar, trying local foods and playing with the kids.

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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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