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)

Loving by Covering—How Gender Frustrations Showed Me The Real Meaning Of Preemptive Love

August 9, 2012 by Monique · Leave a Comment 

One of the most well-known Muslim values is modesty.

Foreigners, however, often have a hard time adapting to the culture because they simply weren’t brought up in it. Women especially are expected to dress and carry themselves modestly, which I really appreciated throughout my internship. I learned a lot from women who saw my head covering as a sign of self-respect rather than oppression.

Needless to say, because this culture values modesty so highly, foreigners are generally perceived to be very loose. Something I didn’t expect before I got here was the local stereotype of Chinese women. It’s no secret to any of the locals that many Chinese women come to work at “massage parlours,” and that many of these establishments act as a front for prostitution. When I discovered this stereotype, I decided it was even more important for me to fight against these preconceptions by dressing and behaving modestly.

Despite the fact that Iraq arguably has some liberal cities, it is still very much a patriarchal society. Anything “shameful” between genders is usually put on the woman, and men are afforded much more flexibility. For instance, when a man and a woman shake hands (a rarity), it’s more likely to be viewed as shameful for the woman than the man. Obviously this means lots of leering and inappropriate comments, which we girls have to learn to ignore.

I felt like developed pretty thick skin to the men’s heckling, but one day when I was alone at the downtown bazaar, I had an entirely different experience. I definitely felt more targeted and men would come up behind me saying, “Massage? Massage?”, “How much?”

After several advances, I could feel my blood beginning to boil. It took all my willpower to avoid turning around and lashing out at them. As I was seriously contemplating yelling at someone, I asked myself, “What would that achieve?” Acting in anger would only make them think that foreigners are uncivilised. But what else was I supposed to do?

As I thought about this more, I realized it was ignorant for me to expect a perfect culture that required no adjustments and had no issues. Like every other culture in the world, Iraq is far from perfect. How hypocritical of me to say I want to care for these people and yet only include my girl friends and children with heart defects in that group.

But how do you respond in (the appropriate kind of) love to brazen advances from men? How do you even begin to love people who reduce you to little more than an object or idea? And what difference would it even make to them? Yet this is a perfect example of what “preemptive love” means. I cannot count the number of times our Executive Director, Jeremy Courtney, has reiterated the meaning of preemptive love. As a part of this organization, preemptive love should go beyond my work. It is a love of initiative; it is unconditional. If we cannot show preemptive love in our daily lives and difficult circumstances, how can we claim that our love is genuine? I should not demand respect from people in order to love them.

It sounds simple in theory, but in practice it is still beyond me. Dressing modestly and covering are obvious ways, but these are just starting points for me to adjust the lens through which I view people. Living in Iraq for the summer has made me more aware of my circumstance and interactions with people, and the lessons I’ve learned here about modesty and love will stay with me for the rest of my life.

Hailing from Hong Kong, Monique's background in film and communication make her the perfect choice for our Video Intern position. She is spending her summer documenting life in Iraq through writing and videography, helping with office administration, and—inshallah—teaching the entire PLC staff how to make delicious Chinese dumplings!

Ramadan—The Spirit of Giving

July 25, 2012 by Monique · Leave a Comment 

The month of Ramadan is an important time in the Muslim world with its emphasis on communing with God through fasting, praying, and giving to the poor. As a group based in Iraq, most of the people we interact with
here—friends, neighbors, coworkers, surgery kids, etc.—are Muslim, and most of them observe and celebrate Ramadan.

With that many people caring about it around us, it’s no surprise that we have grown to care about the month as well. We see it as an opportunity to reestablish what we have in common: a love for God and a desire to care for needy children and their families. This video offers a unique glimpse into our community here and why we want to partner with you this Ramadan in saving children’s lives.

To join us in caring for these children, please consider helping us save a life this Ramadan by funding medical supplies below!

Donate a surgical supply kit to save a child’s life this Ramadan.

Hailing from Hong Kong, Monique's background in film and communication make her the perfect choice for our Video Intern position. She is spending her summer documenting life in Iraq through writing and videography, helping with office administration, and—inshallah—teaching the entire PLC staff how to make delicious Chinese dumplings!

In a Word: “Call”

December 21, 2011 by matt · Comments Off 

A view from the minaret of a local mosque as the call to prayer sounds.

As Communication Director, Matt Willingham spends most of his time trying to get the word out on PLC's work in Iraq. On the side, he likes reading stories, devouring the great food his wife cooks up, and DSLR camera work. He's also mildly obsessed with Twitter: @mehtin.

In a Word: “Juice-in-a-Bag”

August 31, 2011 by matt · 1 Comment 

A local boy sells juice for the end of Ramadan and Eid al-Fitr.

As Communication Director, Matt Willingham spends most of his time trying to get the word out on PLC's work in Iraq. On the side, he likes reading stories, devouring the great food his wife cooks up, and DSLR camera work. He's also mildly obsessed with Twitter: @mehtin.

In A Word: “Pastime”

August 24, 2011 by Lydia · 2 Comments 

Sisters, Samu (14) and Shayhan (17) spend the long afternoons during Ramadan napping and reading.

For more great Ramadan photos, check out the 30 Days Of Forgiveness series by our very own photographer, Lydia Bullock.

Lydia Bullock wrote and photographed for us during the 2010 summer internship and then again for 7 months in 2011. She documented surgical missions in northern and southern Iraq. See more of her excellent work on our Flickr stream, or follow her on Twitter: @lydiabullock.

Understanding Ramadan, or Why My Fingers Are Crossed For A Sheep

August 12, 2011 by Lydia · 368 Comments 

The streets were absolutely silent. No kids running around, no mothers yelling after them. It was a little after one on the first day of Ramadan and the whole neighborhood seemed to be telling me, “For goodness’s sake, get out of this heat, go back inside and preserve what few bodily fluids you have.”

But I had a specific mission this day. Having been raised a Christian in the Midwest of the United States, I have very little first-hand experience with Islam. So on this day I was headed to a friend’s home to learn more about this Ramadan business.

Medya and her family welcomed me into their quieted home. The soporific atmosphere had already gotten to her older brother, who lay sleeping on the couch, while other family members wandered around in their house clothes alternating between reading the Koran and staring into space. So this is it? I wondered.

Thirty days devoted to inactivity and religious texts? If there’s one thing I’ve picked up on about my Muslim friends its their whole-hearted love and respect for God’s will. They are intensely devoted to knowing it, following it and furthering it. I soon discovered that the scene in this room demonstrated no less than this.

For the next hour and a half Medya and her siblings (and Google Translate) walked me through the ins and outs of Ramadan. I learned that any good deed done during these 30 days will count for many times over during the rest of the year. They explained people will be more generous, more kind and more caring during this time than any other.

Ramadan is “the month of forgiveness”—a time of fasting and petition before the Most High. A sin forgiven during Ramadan is a sin forgiven 100 times over for the next year. And as Medya reminded me, “God is at all times merciful.” Similarly, if you read the Koran during these 30 days it will be to God as if you’ve read it 30 times. (Medya and her sisters will each read the Koran twice this year—to build a credit of 60 times).

As the afternoon wound down (if that’s possible) they began explaining the concept of “Zikat”. It’s a percentage of all your “saved” assets that must be given to the poor. Any money you’re not using, gold you’re not wearing, or livestock you shepherd must be accounted for. 1 oz of silver for every 140 oz you have, 2.5% of your gold, 1 sheep for every 40. This rule instated by the prophet Muhammed himself has changed some over time.

In most Muslim countries, there is no longer a “Ministry of Zikat” to monitor and distribute these offerings. Instead each family brings their personal percentage of wealth directly to a family in need. “In need” ranges anywhere from abject poverty to refugees to those people displaced because of volunteer work or schooling.

As we covered this last category, Medya’s brother looked at me and laughed, “Lydia—that’s you! Maybe you will get a sheep.”

Lydia Bullock wrote and photographed for us during the 2010 summer internship and then again for 7 months in 2011. She documented surgical missions in northern and southern Iraq. See more of her excellent work on our Flickr stream, or follow her on Twitter: @lydiabullock.

In A Word: “Ramadan Preparation”

August 10, 2011 by Lydia · 20 Comments 

Young Kurdish girls in a mosque adjust each other’s veils during evening prayer.

Lydia Bullock wrote and photographed for us during the 2010 summer internship and then again for 7 months in 2011. She documented surgical missions in northern and southern Iraq. See more of her excellent work on our Flickr stream, or follow her on Twitter: @lydiabullock.

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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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