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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?"

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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]

Baby Leah is Developing Nicely as We Anticipate a July Surgery Outside Iraq

April 30, 2010 by Jessica · Leave a Comment

Visiting Leah’s house this week was so much fun. She is developing well and her parents continue to work with her everyday to help her struggle through her Down Syndrome. We gave her some stacking rings, which she picked up and chewed and wore as bracelets while playing with her older sister, Dia, who is two years old.

A few weeks ago Leah’s mom watched me with a careful eye taking in everything I was doing with Leah. She then repeated it all after me to get Leah to engage in play rather than just lay still – which is going to be such a critical part of her development. Now, thanks to this simple modeling session and her mother’s diligence to practice and work with her, Leah can now roll over, sit up with little support, grab and hold toys and giggle about it all.

She is gaining weight steadily and should be just the right size for her surgery in July.

Jessica Courtney lives and loves in Iraq as a co-founder and Family Services Director of the Preemptive Love Coalition. She is also a mother of two children and is married to PLC's Executive Director, Jeremy Courtney. When not absorbed in caring for Iraqi children and sharing life with Iraqi families, she enjoys sewing and scrapbooking.

Filed under: Delayed, Development, Family Participation, Featured, Go Blog It!, Heart Surgery, Leah Ibrahim, News

Mohammed Goes to Surgery After Days Fighting Fever

January 13, 2010 by Jeremy · 538 Comments

After days waiting, watching, and being anxious about her son’s well being, Mohammed’s mom is relieved to finally send him off to surgery. It’s been a rough week in Istanbul – mixed with joy and sorrow – so we know that that her anxieties are heightened as she hands him over to foreign nurses and doctors.

But this surgery is the strongest chance Mohammed will ever have at living a healthy life. And that’s why the hospital is such fertile ground for peacemaking and changing the way we think about each other. As these Turkish nurses and doctors love her family, it’s not just Mohammed’s heart that is changed; it’s her heart and her family’s collective worldview that is affected as well – giving a real chance at mitigating some of the hatred that between Turks and Kurds after decades of active struggle.

Mohammed is headed to surgery right now… more to come.

Isn’t it amazing to watch life-saving in progress? We are able to do this because thousands of people like you have given $10, $25, and $50 – or whatever they could – to impact the future of kids in Iraq.
Have you helped out yet? Would you give what you can today below?

Follow Mohammed on Twitter: @MohammedUmed. Subscribe to Mohammed’s updates via RSS HERE. Follow Mohammed’s thread of longer stories (with pictures & video) on the PLC blog HERE.

Jeremy Courtney lives and loves in Iraq as a co-founder and Executive Director of the Preemptive Love Coalition. He's also the father of two spectacular children, and married to the lovely Jessica Courtney. When not absorbed in PLC work he can be found writing songs and singing about hope and future. Follow Jeremy on Twitter: @JCourt.

Filed under: ASD, Anadolu Sağlık Merkezi, Delayed, Fever, Heart Surgery, International Guild of Visual Peacemakers, Mohammed Umed, News, Our Kids, Partnerships, Surgery Updates, dTGA

Soma Selected for Surgery After Days of Considering Surgery’s Potential Impact

January 8, 2010 by Jeremy · 1 Comment

Soma is a 7 month old little girl from a small village in Iraq.

Preemptive Love Coalition’s Jeremy Courtney plays with Soma as mom awaits surgery decision.

Soma’s dad was tortured by Saddam Hussein a few years before 2003. It’s an honor to care for his child in Istanbul, Turkey while he remains with his other children in Iraq.

Difficult discussion about the post-operative course for Soma after announcing her selection for surgery.

The Preemptive Love Coalition is not a heart surgery organization. Heart surgeries come and go. You can even get a heart surgery and die because of it. Heart surgeries are not the point.

The Preemptive Love Coalition is a children’s organization. The point is impacting children’s lives. We make hard decisions every day about how we can most impact children. Sometimes that means we end up passing on children whose likelihood to benefit from surgery is actually quite small. For days now, we’ve been wondering if Soma might end up being one of those children.

But the Preemptive Love Coalition is also a hope bank – a place where Iraqi families come for a chance at a better life for their kids; a place they come for a hope transfusion. And being a people of hope has compelled us to accept Soma to surgery.

Soma will be dead in two years without surgery. If there is any error to be made with her, we want to err on the side of giving hope and a future. And this isn’t just a field decision – time and time again we’ve heard from you that this is the organization you want us to be and that this is, overwhelmingly, how you want your money spent.

Soma goes to surgery today. Stay tuned…

The most critical factor in our decision to help Soma was our own personal presence in Iraq and our team’s commitment to ongoing followthrough with Soma’s family in their village three hours away. If you love what we do, please consider contributing to our travel and Followthrough fees to see Soma in her village.

Follow baby Soma on Twitter: @SomaSalah. Subscribe to Soma’s updates via RSS HERE. Follow Soma’s thread of longer stories (with pictures & video) on the PLC blog HERE.

Filed under: Anadolu Sağlık Merkezi, Delayed, Ebstein Disease, Heart Surgery, International Guild of Visual Peacemakers, LTGA, News, Our Kids, Partnerships, Peacemaking, SomaSalah, Surgery Updates, Tricuspid Valve Atresia

Mohammed’s Mom Waits Anxiously for Fever to Subside; Surgery Delayed until Monday

January 7, 2010 by Jeremy · 1 Comment

A fever presented itself today in Mohammed Umed. As a precautionary measure doctors have delayed his surgery to observe and investigate what may be causing the fever. In the interim period, his mother is understandably anxious as she has now sat by while two other kids have had their chance before hers. Of course, they are all in this together, but it’s easy enough to relate to her desire to be “first” and not “last” in a critical scenario like this.

So this Kurdish mother from Iraq waits in Turkey while her husband serves as a soldier in Baghdad and the rest of her family is at home. Together we are all hoping the fever will not prove to be the result of anything serious; hoping that Mohammed’s chance at surgery is not delayed any further.

Imagine you’re in a foreign land without the language to acquire safe shelter, privacy, and quality food. You can donate below today toward the cost of one day’s room & board so future kids receive excellent hospitality even through medical delays.

Follow Mohammed on Twitter: @MohammedUmed. Subscribe to Mohammed’s updates via RSS HERE. Follow Mohammed’s thread of longer stories (with pictures & video) on the PLC blog HERE.

Filed under: ASD, Anadolu Sağlık Merkezi, Delayed, Fever, International Guild of Visual Peacemakers, Mohammed Umed, News, Our Kids, Partnerships, Sad, Surgery Updates, dTGA

Six Teeth Pulled

December 2, 2007 by Jeremy · 789 Comments

We learned today that because of the emergent need for surgery for another child, Hussein’s surgery will be postponed. The dental work he needed was finished on Friday – six teeth pulled! - and the doctors hoped to perform his surgery immediately afterwards. When I visited the Save A Child’s Heart house this evening, his mother wondered why the surgery was changed, and as she understood that without surgery tomorrow the other child might not live, she was able to accept the need to wait.

Filed under: Delayed, Heart Surgery, News, Our Kids, Surgery Updates

Surgery Delayed for 30 Days

November 8, 2007 by Jeremy · Leave a Comment

Hedi was happily drinking a bottle when I arrived at the hospital today and found him and his sweet mother sitting in their room in the children’s ward. We visited for a bit, and I gave Hedi an inflatable fish toy which had been sent in a ”goody box” to us from someone in the US — thanks from Hedi!! He loved it.

Yesterday while at the hospital with the student group, we found out that Hedi would be treated with steroid medication commonly given for asthma associated with allergies. Today, he was not wheezing when I was there, and did not cough much either.

When I spoke to the doctor yesterday, we also talked about Hedi’s surgery. Dr. Katz informed me that Hedi would probably not have his surgery for about 30 days. This was a big disappointment for his mother, but we trust that the doctors know the best timing for each child’s surgery to be scheduled. There are several cases which are more urgent than Hedi, and the surgeon will be out of town to train doctors in another country next week. He cannot perform some of the most complicated surgeries and leave town, because he must monitor these patients closely, so the surgeries must be scheduled accordingly. Hedi’s is tenatively scheduled after some of the extreme cases, and this adds up to about one month. Had he not had the problem with the cough, maybe it could have been done more quickly.

Filed under: Delayed, Heart Surgery, News, Our 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 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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Baby Leah is Developing Nicely as We Anticipate a July Surgery Outside Iraq

Mohammed Goes to Surgery After Days Fighting Fever

Soma Selected for Surgery After Days of Considering Surgery’s Potential Impact

Mohammed’s Mom Waits Anxiously for Fever to Subside; Surgery Delayed until Monday

Six Teeth Pulled

Surgery Delayed for 30 Days

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