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)

New Houses, New Hearts—How Real Estate Is Saving Lives!

May 24, 2012 by matt · Leave a Comment 

Congratulations, Matt & Devin, on the new house!

Our friend Shane Blackshear is in the business of real estate. He’s also in the business of saving lives. Join the growing number of people who are using their business to help save the lives of Iraqi children—write us!”

As PLC's Press Secretary, Matt Willingham writes, reads, edits, tweets, updates, and works with a camera so as to connect hearts and minds to Iraqi children in need. On the side, he likes reading stories, devouring the great food his wife cooks up and exploring DSLR work. He's also mildly obsessed with Twitter: @mehtin.

“An Idea Worth Living”—Hear Jeremy Courtney Speak At TEDxAustin!

April 12, 2012 by matt · Leave a Comment 

“If we live skeptically and only by the principles of risk-management, I fear we’ll miss the opportunity to remake the world around us.”

On a recent trans-atlantic trip, Jeremy Courtney was invited to share about the concept of preemptive love at TEDxAustin’s 4th annual conference.

This talk differed from his TEDxBaghdad talk as he shared new stories and invited attendees to consider how they personally might “do preemptive love.” And the video presents the same question to you: what can you do—small or large—to remake the world today?

After watching the video, would you share it? Your ‘shares’ and support help make our work possible—they can help save lives!

As PLC's Press Secretary, Matt Willingham writes, reads, edits, tweets, updates, and works with a camera so as to connect hearts and minds to Iraqi children in need. On the side, he likes reading stories, devouring the great food his wife cooks up and exploring DSLR work. He's also mildly obsessed with Twitter: @mehtin.

Tragedy To Triumph—How Preemptive Love Shocked A City

March 8, 2012 by matt · Leave a Comment 

A week ago today our friend Jeremiah Small was killed in his classroom. His own student pulled a gun on him. If you haven’t read about it, see more here.

It happened here in our home city of Sulaymaniyah, and the entire community is still recovering from the shock of it all. Of course, the shock is about the violent death of an American in the oft-touted “the other Iraq” region of Kurdistan, to be sure, but the shock is also about much more than that.

When people in Sulaymaniyah heard that Small’s family was coming to Kurdistan to bury their son, rumors started to fly. Some thought they were coming for financial compensation, others for revenge. And in an eye-for-an-eye culture like this one, rumors like that aren’t crazy. If someone hurts you, you hurt them back. And that’s more than cultural, it’s human nature.

But that isn’t preemptive love.

Until someone is willing to absorb the pain rather than pass it on, violence will only continue to beget violence. Pain has to go somewhere.

So when Jeremiah’s family arrived and began blessing everyone they met, people were amazed! They were grief-stricken, to be sure, but through their great love the Small family proved to be bigger than anything most people had ever seen—they blessed rather than cursed, they sang rather than screamed; their love was furious. They even wore traditional Kurdish clothing in order to show solidarity with the culture.

This was their way of living out preemptive love. Just as Jeremiah worked to love his students first—no questions asked—his family came and loved Kurds preemptively. They were remaking a broken world by choosing to forgive rather than to yield to the endless downward spiral of hate and violence.

Perhaps the most compelling example of this love was at the funeral when both the family of Jeremiah and the family of the boy who killed him embraced (pictured above). They absorbed the pain—shared it even—rather than lashing out at each other.

This is preemptive love. This is the lifestyle we believe everyone can (and should) live by. This is the better way, and the Small family used Jeremiah’s death to show us that.

As PLC's Press Secretary, Matt Willingham writes, reads, edits, tweets, updates, and works with a camera so as to connect hearts and minds to Iraqi children in need. On the side, he likes reading stories, devouring the great food his wife cooks up and exploring DSLR work. He's also mildly obsessed with Twitter: @mehtin.

Her Name Is Zahraa, And She Probably Loves You

February 20, 2012 by matt · Leave a Comment 

We passed the midway point of Remedy Mission IX, and, for me, everything seemed to be moving in slow-motion.

It was the best problem any hospital could hope for: boredom.

When the alternatives are problems like drama between medical staff, complications in the ICU, or even death, I’ll take boredom any day!

I had already completed my morning rounds of photos and family meet-’n-greets, and I was back dozing in the break room, debating whether or not to eat an extremely unripe banana.

Then the break room door opened and in walked the little girl in the red coat. She was hugging a doll and squeaking something at me in Arabic.

Her dad poked his head into the room, apparently glad to have found her. He seemed embarrassed by her intrusion, but we invited them to sit and share their story.

I learned that the girl’s name is Zahraa, she is 6 years old, she has a beyond-your-typical-little-girl obsession with dolls, and she needs an urgent heart surgery.

While talking with her father, Zahraa leaned toward me from her dad’s arms and whispered something to me in Arabic.

“She says she loves you,” a translator explained.

Initiating heart meltdown.

As if that wasn’t enough, she proceeded to grab my head and kiss me on the cheek and then to tell everyone else in the room that she loved them, too. Her malformed heart certainly has no trouble expressing love! But she still needs an operation and, according to her father, it is scheduled to happen soon.

Come back tomorrow and I’ll tell you more about the little girl in the red coat and her (hopefully) lifesaving operation!

As PLC's Press Secretary, Matt Willingham writes, reads, edits, tweets, updates, and works with a camera so as to connect hearts and minds to Iraqi children in need. On the side, he likes reading stories, devouring the great food his wife cooks up and exploring DSLR work. He's also mildly obsessed with Twitter: @mehtin.

“His Surgery Would Be Five Years Away”—A Father Shares His Story!

February 15, 2012 by matt · Leave a Comment 

Doctors assigned little Nassir a number—119—and then told him to get in line.

“Should I get a hotel near the hospital for a few days?” his father asked. “No, come back in 5 or 6 years.” So Nassir’s father went home dejected with nothing to do but wait. But waiting could render Nassir inoperable, and then it would be too late.

But, thanks to you, Nassir and his family are getting another chance. Click here to listen to a father tell of his search for a surgery.

As PLC's Press Secretary, Matt Willingham writes, reads, edits, tweets, updates, and works with a camera so as to connect hearts and minds to Iraqi children in need. On the side, he likes reading stories, devouring the great food his wife cooks up and exploring DSLR work. He's also mildly obsessed with Twitter: @mehtin.

No More Crying—Hamma Is Going Home!

February 12, 2012 by matt · Leave a Comment 

I was a little worried when Hamma had to be carried from the ICU into the children’s ward. But the doctors said he is doing well and should be able to go home in a few hours. Then, sure enough, he perked up and now he’s walking all over the place!

After a sick heart, a smashed nose, and a surgery, I finally got what seems to be a smile out of this little boy. Isn’t he cute?

And he has reason to smile! His surgery was a complete success, and he is going home. Thank you for making Hamma’s surgery possible, and thank you for putting his best days ahead of him!

As PLC's Press Secretary, Matt Willingham writes, reads, edits, tweets, updates, and works with a camera so as to connect hearts and minds to Iraqi children in need. On the side, he likes reading stories, devouring the great food his wife cooks up and exploring DSLR work. He's also mildly obsessed with Twitter: @mehtin.

Hamma Is In Surgery!

February 11, 2012 by matt · Leave a Comment 

Remember super-sad-faced Hamma?! He’s getting surgery now!

I spent much of the day running in and out of the operating room to check on him. His father kept poking his head in from the hallway and whispering, “Psst! Mister! Photo Hamma?”

I felt like an image delivery boy with all the running back-and-forth, but letting Hamma’s dad ‘watch’ his son’s progress through surgery was extremely rewarding—at one point he even side-hugged me!

Here are a few of the photos I showed dad throughout the day:

(The boy isn’t alone here, the nurse just stepped away from the window)

As you can imagine, each picture I showed them brought on strong emotions, and by the end of the day his parent’s eyes were bloodshot from lack of sleep and crying. But the doctors report that the surgery is going well.

More to come…

As PLC's Press Secretary, Matt Willingham writes, reads, edits, tweets, updates, and works with a camera so as to connect hearts and minds to Iraqi children in need. On the side, he likes reading stories, devouring the great food his wife cooks up and exploring DSLR work. He's also mildly obsessed with Twitter: @mehtin.

Seatbelts Fastened & Tray Tables Upright—Remedy Mission IX Is Here!

February 9, 2012 by matt · Leave a Comment 

Remedy Mission IX is here!

This is our first surgical mission in the holy city of Najaf in southern Iraq, and the excitement is electric! The local doctors can’t imagine the extraordinary operations they’re about to see, and families can’t imagine the hope they’re about to find.

And you made that possible! You chipped in, you told your friends, you skateboarded, you ran marathons, and so much more, and now we’re flying south to embody that good will.

Here we go…

As PLC's Press Secretary, Matt Willingham writes, reads, edits, tweets, updates, and works with a camera so as to connect hearts and minds to Iraqi children in need. On the side, he likes reading stories, devouring the great food his wife cooks up and exploring DSLR work. He's also mildly obsessed with Twitter: @mehtin.

VIDEO: Watch Jeremy Courtney Speak At TEDxBaghdad!

February 1, 2012 by matt · Leave a Comment 

Iraq’s first-ever TEDx event happened in Baghdad and, as the only westerner to attend TEDxBaghdad’s inaugural conference, it was an honor for us to have Jeremy attend as a speaker.

Jeremy spoke on the concept of ‘preemptive love’ and its ability to heal, reconcile and restore people to right relationship with one another. If you’re having trouble loading the video above, just click here.

As PLC's Press Secretary, Matt Willingham writes, reads, edits, tweets, updates, and works with a camera so as to connect hearts and minds to Iraqi children in need. On the side, he likes reading stories, devouring the great food his wife cooks up and exploring DSLR work. He's also mildly obsessed with Twitter: @mehtin.

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.

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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 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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