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)

Failure Report: Year 2011 (Part 3 of 3)

June 19, 2012 by Jeremy · Comments Off 

The only bad failure
is the one from which we fail to learn.

Most organizations put a premium on celebrating successes at the end of every year—we certainly do!

But we also believe that we have a great deal to learn from our failures, so we endeavor to share them and the lessons we’ve learned in hopes of avoiding those same mistakes in the future.

When seeking to tackle intractable problems in an environment like Iraq, missed opportunities, missteps, false starts, and failures are par-for-the-course. There will be no improvement in the political situation in Iraq, in the economy, in healthcare, or in the pursuit of peace without a number of flops and failures along the journey. If we already knew what worked, we all would’ve implemented it by now and moved on.

The truth is, neither the American government nor the Iraqi—neither international nor local NGOs—truly know what works in Iraq. Most of us are making educated guesses and seeking to rightly adapt programs and principles that have proven successful at other times in Iraq or in other parts of the world.

From this point forward, I want to provide you with an annual (and sometimes real-time) assessment of our failures. In absence of such previous reports, I will use a few minutes to highlight our most meaningful setbacks, failures and lessons learned to date.

The three major failures of 2011, to be covered in this report are:

Let’s get started…

Failure #3: The Loss of Our Sulaymaniyah, Iraq Surgery Site as a Major Developmental Partner

Unfortunately, it became obvious in May 2011, after completing two Remedy Missions to the Sulaymaniyah Center for Heart Disease, that local organizations and hospital leadership were not committed to the partnership. In-fighting over child selection, credit sharing and cost sharing dogged the nascent partnership from day one.

We struggled for one year to make the partnership work. But ultimately, we failed to keep it all together. What we deemed to be petty lines in the sand gave us deep concerns over the ability of local players to see our program through to the 5-year completion that we had all discussed and envisioned.

Our March 2011 Remedy Mission IV was a huge disappointment in many ways. We went back to the drawing board and made a few required upgrades before our international team would agree to work again in the hospital.

By May 2011, as we tried to put the final touches on our next mission to the center, the local hospital had failed to made requisite upgrades in hardware, medications and supplies.

In consultation with our international partners, we ultimately issued a vote of “no confidence” and cancelled the pending mission.

In many ways this felt like a waste—a waste of nearly 8,000 of cumulative training hours; a waste of financial resources on a program that apparently lacked the willpower to see commitments through to the end, etc. All we had to show for our two missions in the city were 42 operations—including a few ground-breaking, inspirational cases; some amazing stories of peace and reconciliation; and eight deaths.

Within six months, we heard that the heart center was moving forward with an Italian team along a contract similar to the one we had originally proposed. The Italian mission in the Fall 2011 was deemed a success, and many surgeries were performed, but after the mission was completed rumors again circulated about local politics and an apparent inability to mobilize the center toward a long-term contract with the Italian team.

In a January 2012 meeting with the Director of Health for the province, we inquired about the number of surgeries that had been performed since our team and the Italian team had conducted three surgical missions to the city. To our great disappointment, the health director laughed and asked if we were joking, saying that the hospital’s surgical capacity had not improved in the previous year, in spite of the three missions. He laid the blame at the feet of local staff and the politics and health and not at the feet of the international teams that had attempted to help.

Lessons Learned: 



I’m not entirely sure we’ve learned all there is to learn from this yet. Our inability to woo or influence the hospital leadership into making the necessary upgrades was frustrating, but it is still unclear how we could have sweetened the deal or foreseen it coming prior to the May 2011 deadline that we set.

I am grateful that we made the decision to pull the plug on the program rather than continue to invest valuable resources (from all parties) into a stagnate program. The cumulative work done by international teams in the Center over the course of one year should have led to a measurable increase in surgical capacity. That is how our programs are designed and we are seeing an increase in capacity in other cities.

One question that we have contemplated is the idea of exclusivity in our contracts with a hospital. Should we insist on exclusive rights to train in a hospital, in an effort to increase commitment, decrease the opportunity for communication breakdowns and competing interests, etc? In the southern cities of Iraq where we work (where security risks are a much greater concern and where development is further behind the northern cities), we do not have competing interests. This appears to have created a greater loyalty and a healthier trust between our international and local teams than anything we were able to achieve in Sulaymaniyah. Our inclination continues to be against such exclusivity demands, but the question has come up as we seek to understand what went wrong and how we can avoid it in the future.

We cut our losses before running a mission in a dangerous environment. Perhaps most importantly, we cut our losses on a program that showed little organizational leadership and, in the words of the health director himself, zero increase in surgical output resulting from our educational, material, and infrastructural inputs. While the loss itself is a huge disappointment and I feel a personal sense of failure for my inability to cobble together a solution, it could have been so much worse.

Conclusion:

It has been an exhilarating year in so many ways. But the above failures have been sobering. Yes, children are alive that may not be if we had not intervened. But it is undoubtedly true that children have died because we intervened. If our mandate is primum non nocere—first, do no harm—then it is cleared that we have failed on that front at least a few times this year. At least one was related to indecisiveness—a leadership failure on my part. Some of the other deaths were to be expected given the risks that were clearly communicated to the family.

 But we do not only seek to “do no harm.” We have another object in view: we seek to do good. And we did not attain the good that we desired in our now defunct partnership. For reasons to which we are not privy, they have failed to increase their surgical output as a result of our efforts. We made the right decision walking away from the partnership for the time being. We will remain open to reengaging in the future if local conditions change.

I am most impressed and proud of our team’s willingness to confront and respond to failure on a trip-by-trip basis. When it became obvious that a mission could not run without an international cardiologist, we responded. When the local conditions required staggering the deployment of extra nursing staff so that ICU care could extend in a professional manner beyond the duration of the official trip itself, we responded. And when we were urged to move ahead with a mission in spite of conditions that we believed to be unsafe, we responded by canceling the trip.

There are at least a few viable philosophies as to how one should develop a pediatric cardiac care program. Some progressive; some conservative. Some are boring and more predictable; others are inspiring and innovative. We are proud to work with professionals who employ different methodologies and adhere to different philosophies of development. We will no doubt continue to face difficult days as we face down death and attempt to eradicate the backlog of Iraqi children waiting in line for lifesaving heart surgery. But we envision a day in the future when every child across the country has access to the care they need within a 3 hour car ride. And we will continue to labor toward that end.

If you have any questions or concerns about this report, the decisions we’ve made, or the direction we are going, please email me at your convenience. I would love to hear from you.

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.

Failure Report: Year 2011 (Part 2 of 3)

May 22, 2012 by Jeremy · Comments Off 

The only bad failure
is the one from which we fail to learn.

Most organizations put a premium on celebrating successes at the end of every year—we certainly do!

But we also believe that we have a great deal to learn from our failures, so we endeavor to share them and the lessons we’ve learned in hopes of avoiding those same mistakes in the future.

When seeking to tackle intractable problems in an environment like Iraq, missed opportunities, missteps, false starts, and failures are par-for-the-course. There will be no improvement in the political situation in Iraq, in the economy, in healthcare, or in the pursuit of peace without a number of flops and failures along the journey. If we already knew what worked, we all would’ve implemented it by now and moved on.

The truth is, neither the American government nor the Iraqi—neither international nor local NGOs—truly know what works in Iraq. Most of us are making educated guesses and seeking to rightly adapt programs and principles that have proven successful at other times in Iraq or in other parts of the world.

From this point forward, I want to provide you with an annual (and sometimes real-time) assessment of our failures. In absence of such previous reports, I will use a few minutes to highlight our most meaningful setbacks, failures and lessons learned to date.

The three major failures of 2011, to be covered in this series of reports are:

Let’s get started…

2011 Failure #2: High-mortality Remedy Missions in February/March 2011
In February and March we ran two back-to-back Remedy Missions. One was our second in the southern city of Nasiriyah; the other was our second in the northern city of Sulaymaniyah.

Over the course of four weeks of surgery, mortality rates between the two cities reached 20.5% (7 deaths out of 34 operations).

A few of the losses were very surprising to many on the local and international team and had an extremely demoralizing effect on the team (particularly in Sulaymaniyah). The loss of momentum undoubtedly had a qualitative impact on the care provided as the trip progressed.

Some of the factors were anomalous, such as our lead surgeon contracting an infection in a wound on his ankle that resulted in impromptu surgery inside Iraq to save his leg. But other factors were almost certainly preventable, beginning with case selection and moving to fundamental deficiencies in the hospital equipment and protocols themselves.

A lack of warming blankets, portable oxygen units, a ready blood bank and several other fundamentals led to a less-than-ideal environment for the teaching of pediatric cardiac care. As a result of all these factors and the inherent difficulties of open-heart surgery, mortality rates in the Sulaymaniyah mission reached 22% (four deaths)—unacceptably high by any standard.

None of the deaths were considered “surgical” deaths, in the sense that the child did not die on the operating table, but rather in the post-operative intensive care unit, ward, or—in one case—in the car on the way home after being prematurely discharged by a local nurse the day the international team left the country.

Lessons Learned:

Our international team was very impressed with the local cardiologist for Remedy Mission II in the southern city of Nasiriyah. When it came time to schedule Remedy Mission III in that city, the decision was apparently made to not send a cardiologist on the mission, believing that the local team could handle it. This may have contributed to the imbalanced case selection in RM III and may have led to the situation in which three children died during the course of the mission.

Since that mission, an international cardiologist has been present on every Remedy Mission in an effort to help with case selection and create a balanced schedule of surgeries.

In Sulaymaniyah for Remedy Mission IV, case selection was complicated by the number of stakeholders in the mission. Children were formally and informally (that is, “politically”) put into the mission by the Preemptive Love Coalition, local cardiologists and surgeons, Kurdistan Save the Children (a local NGO), and the Health Directorate.

With regard to Yahya’s case, as described before, I can certainly say that my judgement was impaired when it came to case selection. I can speculate that other entities, in an effort to do right by the friends and patients on their lists, made similar errors in judgement that ultimately skewed the balance of the surgery schedule and its complexities.

When two children died in Sulaymaniyah after the international team left for the airport, we realized for the first time how ill-equipped the local team was to handle relatively simple post-operative care (one child had a positive prognosis in the ICU and the other was already out of ICU and recovering in the ward).

In our post-mission Impact Evaluation Report, we published the following statement:

Our post-mission conferences and deliberations on the matter resulted in the following protocols: 


1. A mandatory reduction in “RACHS-1 scores” presented to the international team by the local team


2. A mandatory international ICU team to be left behind after surgeries stop to stave off post-mission ICU deaths and errant discharges


3. A postponing of our next planned mission to the Sulaymaniyah Center for Heart Disease due to lack of preparation of materials, equipment, staff, and protocols

If you have any questions or concerns about this report, the decisions we’ve made, or the direction we are going, please email me at your convenience. I would love to hear from you.

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.

Failure Report: Year 2011 (Part 1 of 3)

May 3, 2012 by Jeremy · Comments Off 

The only bad failure
is the one from which we fail to learn.

Most organizations put a premium on celebrating successes at the end of every year—we certainly do!

But we also believe that we have a great deal to learn from our failures, so we endeavor to share them and the lessons we’ve learned in hopes of avoiding those same mistakes in the future.

When seeking to tackle intractable problems in an environment like Iraq, missed opportunities, missteps, false starts, and failures are par-for-the-course. There will be no improvement in the political situation in Iraq, in the economy, in healthcare, or in the pursuit of peace without a number of flops and failures along the journey. If we already knew what worked, we all would’ve implemented it by now and moved on.

The truth is, neither the American government nor the Iraqi—neither international nor local NGOs—truly know what works in Iraq. Most of us are making educated guesses and seeking to rightly adapt programs and principles that have proven successful at other times in Iraq or in other parts of the world.

From this point forward, I want to provide you with an annual (and sometimes real-time) assessment of our failures. In absence of such previous reports, I will use a few minutes to highlight our most meaningful setbacks, failures and lessons learned to date.

The three major failures of 2011, to be covered in this report are:

Let’s get started…

Failure #1: Leadership Indecisiveness on the Case of Six-Year-old Yahya

This was a major lesson in leadership that potentially affects every area of our organizational and team life, couched in the saga of one very specific family.

I was walking home from work one night in Iraq in early 2010, when my phone rang. On the other end of the line was a man, knocking on the door back at my office, in hopes of meeting me and presenting the case of his nephew, Yahya, to me for surgical consideration. 

I asked if we could meet tomorrow, but he was insistent and there seemed to be great urgency in his voice. Instead of postponing the meeting, I gave him directions to my home and met with him over tea.

From early on, the situation was less than ideal. Yahya had already received one charitable heart surgery and the second one that was being requested was bound to be difficult.

In our 2007-2010 Failure Report, I noted our decision to restrict the complexity of children we sent abroad for surgery after a series of deaths caused us to reconsider our risk tolerance. Yahya was definitely on the high end of our new risk tolerance.

I chose to refuse surgery to the family based on our new priorities.

Months later, after a new check-up, Yahya’s mother and father brought him into our office to inquire again about the possibility of surgery. I’ll never forget sitting with them in my office explaining our decision to decline surgery funding for Yahya.

Then, with all the persistence that you would expect from a mother, she appealed to me again not to turn away their little boy.

I think one thing that non-profit directors and program directors fail to say often enough is this: “I am a human. I’m swayed by the kindness or brashness of our patients and, at times, it heavily influences how I make selection decisions.”

I could not continue to say “no” any longer. I said “yes” (with conditions).

Our surgeon in Istanbul was clear from the beginning that his surgery would require a “valved conduit” (an additional $5,000 expense or more) and licensing agreements in Turkey at the time had caused a shortage of such devices.

Cody Fisher (Development Director) did a great job reaching an agreement with Medtronic providing Yahya with a donated conduit, but the timing of receiving the conduit was still beholden to the licensing agreements that were being worked out in Istanbul.

All these factors together ultimately led to Yahya missing our July 2010 surgery group to Istanbul. We refunded the family’s portion of the money they had contributed for his surgery.

Shortly thereafter, in August 2010, we conducted our first Remedy Mission inside Iraq—our new programatic focus on localized training and development. The mission was such a huge success, I became convinced that we needed to cease all funding for outside surgeries and focus solely on development work inside the country.

But I also felt a sense of commitment to Yahya and his family, who were basically caught in the transitional period between one programatic focus and another.

What I should have done at that point was send Yahya to surgery in Turkey, finish our commitments there, take the free valved conduit from Medtronic, and finish our work in Turkey strongly. What I did instead was place Yahya on an upcoming Remedy Mission and take the Turkey option off the table for the family.

What I didn’t account for very well in that decision was how the complexity of Yahya’s case would fare in a development setting; a setting in which local capacity was far below that which he would have received in Istanbul.

In the chaos of Remedy Mission IV, a number of things went badly. Among them, Yahya’s family probably did not receive the proper explanations that they should have about the risks of his surgery and they probably felt very vulnerable about the decision to go forward with the risky surgery or forever miss their opportunity.

It was difficult to assess all this in real time, in part because I was so hopeful for Yahya and his family. In my optimism, I did not see or recognize a few red flags. But even that is not the whole truth… I remember hesitations—“red flags”—even as I sit here today. I willingly suppressed anything that was not hopeful and optimistic. It seemed noble, brave and right.

But he wasn’t my child.

Yahya’s surgery presented many complications that ultimately required doctors to operate through the night. When Yahya arrived in ICU around 5 or 6 a.m. the next morning, he was deemed stable enough for the surgical team to go to the hotel for a few hours of sleep. Before their bus even arrived at the hotel, though, Yahya had passed away in ICU.

I would not normally include a single death in a year-end Failure Report. My point is not that I feel bad and need catharsis. It’s just that Yahya was different, and not only because he had a name or because his family hosted us for dessert in their home and shared tea in mine. No, Yahya was different because I flipped-flopped on the family so many times. I said “no.” Then “yes.” Then “no” again. And then “yes.” And then he died.

Organizationally, the failure was related to a lesson we were just beginning to identify in our 2007-10 Failure Report: we are not the best qualified to select children for surgery. The suggested way forward at that time is still right: we have handed child selection over to a committee of local healthcare providers and our international surgical team. There will still be deaths that we regret deeply, but they will be less a function of our role and influence in the child selection process.

Personally, the failure was related to my inability to make a decision and stick with it. I always had a bad feeling about Yahya’s likelihood to endure surgery. That was why I denied funding more than a year prior to his death. I had good reason to deny funding. But I went back on my hunch. Fair enough… I wanted to give a family a chance. But I never really got over my fears of his death and that made me unwilling to go all in with the family. I hedged over spending extra money on his expensive valved conduit. And even when the conduit was donated, I found other reasons to delay surgery for fear of spending a lot of money (including the family’s) on a surgery about which I was always suspicious.

Lessons Learned: 


1. It’s OK to change one’s mind; but a leadership “Yes” or “No” should mean something. It hurts everyone involved to say one thing, give the impression of support, and never fully get behind one’s own decision. In this case, it played a role in Yahya’s death. 

He may have died in Istanbul just the same. The death itself is not the failure here. The faulty, character-flawed process by which I made life-altering decisions is.

I said “no.” I should have stood my ground. Or I said “yes” and I should have given that family my fullest “yes” ever. Instead, I said “yes” and stayed on the fence. I won’t do that again.

2. We are not qualified to select children. We are too emotionally attached and we do not possess the knowledge to make a right decision about a patient’s candidacy for surgery. We have handed child selection over to a collaboration between local cardiologists and our international surgical teams.

If you have any questions or concerns about this report, the decisions we’ve made, or the direction we are going, please email me at your convenience. I would love to hear from you.

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.

Tragedy To Triumph—How Preemptive Love Shocked A City

March 8, 2012 by matt · Comments Off 

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 in the 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 “other Iraq” region, to be sure, but the shock is also about much more than that.

When the community heard that Small’s family was coming 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 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 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 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.

Apart From Us Interrupting Her Nap, Deeya Is Doing Great!

October 25, 2011 by matt · 1 Comment 

Look who we just visited!

Deeya’s scar is now over 14 months old, and her mother happily reported that her daughter has started school and is doing extremely well. She used the Kurdish phrase joolay zora, meaning “she moves a lot” to describe how active her daughter has become.

We missed out on that activity during our visit, though, because we arrived in the middle of Deeya’s nap. I’d love to show you a photo of her sweet smile, but sometimes kids just don’t feel it.

Our inclination is to show you extremes: big, beaming smiles or desperately needy faces. But we all know that isn’t a true representation of most kids on most days. We have good days and bad days, but the important thing is the fact that now, thanks to you and our capable doctors, Deeya will actually live to have days, both good and bad!

Her life has been saved, and she is now healthy to be as joyful and irritable as any other child. Thank you for making that possible, and thank you for loving these children with us – even when we show you their groggy photos.

###

Our upcoming Remedy Mission VII will give you the opportunity to love even more sick children. Join us in counting down to the first day of surgery on Nov 6th!

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.

17 Heart Felt Thank You’s Coming Your Way From Iraq!

March 20, 2011 by Cody · 1 Comment 

We’re just now wrapping up our fourth Remedy Mission in Iraq and we have 17 heart felt thank you’s to send your way from the families who got the chance to see their children receive the heart surgery they’ve been waiting for!

(Go ahead, you can stand up and celebrate. We did!)

Now what?

Now we do it all over again! All over Iraq. Until every heart is mended!

Why?

So that girls like Ala can receive the surgery that she needs to be a strong and healthy little girl!

Ala was on the schedule for this past Remedy but she had to go home because there wasn’t enough time to save her, like we all had hoped.

Now we’re doing everything we can to turn that hope into a reality.

YOU can help us save Ala by joining us and helping bring Remedy back to her!

It’s easier than you think. Just click HERE!

If you’re on Twitter this week be sure to use the #RemedyMission hashtag to describe all the good news coming out of Iraq this week via @preemptivelove.

With help from our friends:

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.

Parzheen Heads Home!

March 11, 2011 by Cody · 1 Comment 

We have a list of over 3,000 local children that are waiting in line for a life-saving heart surgery but today we watched as 3 more walked right off the list!

…and one of those was Parzheen!

Her name is now on another list that’s growing each day.

It’s not a backlog.

It’s not for kids who need to be sent out of the country.

It’s a list of all the children that have been able to receive the remedy here in Iraq! In the past month, over 30 names have been added to that list!

Parzheen’s heart is responding beautifully to the remedy and today, the doctors cleared her to go home.

Thanks for giving Parzheen the Remedy.

Thanks for your relentless love for the hearts of Iraq.

We love doing this alongside you!

If you’re on Twitter this week be sure to use the #RemedyMission hashtag to describe all the good news coming out of Iraq this week via @preemptivelove.

With help from our friends:

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.

Mohammed Returns For A Check Up!

March 10, 2011 by Cody · 1 Comment 

Mohammed was the first to go home with a healthy heart and now he’s the first to get his post-op check up! 

We were a whole lot more excited to see Mohammed than he was to see us though.

When we say goodbye to each child we always love that soon we’ll get to see them at their school or at home, anywhere but the hospital.

Echo machines and doctors didn’t bring back fun memories for Mohammed, but for us, we love them because they showed us just how GREAT his heart is doing!

For the other parents, it was a sweet reunion and reminder that all this time in the hospital will be worth it!

For Mohammed, he made off with a hand full of cookies and candy so everybody had something to smile about!

If you’re on Twitter this week be sure to use the #RemedyMission hashtag to describe all the good news coming out of Iraq this week via @preemptivelove.

With help from our friends:

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.

Parzheen’s Strong Heart Takes Her From The ICU To The Hospital Ward!

March 9, 2011 by Cody · Comments Off 

Parzheen barely had time to get comfortable in the Intensive Care Unit before they told her she was well enough to go down to the hospital ward!

The nurses asked her if she wanted her father to carry her down to the hospital ward and she said “NO!”

She wanted to walk downstairs on her own.

She just couldn’t wait to put her new heart to the test.

Parzheen is now beginning physical therapy which is only going to help get her to the point where she can run and play for the first time with a healthy heart!

Today she invited us to her house and we said “YES!”

We’re spending as much time with her as we can but it’s always fun knowing that these relationships are only just now beginning!

How do you keep following her story?

Just keep following us on Facebook and Twitter!

If you’re on Twitter this week be sure to use the #RemedyMission hashtag to describe all the good news coming out of Iraq this week via @preemptivelove.



With help from our friends:

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.

Yasna Wraps Up Her Time In The Hospital Ward And Says Goodbye!

March 8, 2011 by Cody · 1 Comment 

It’s all hands on deck for us at the hospital as we not only continue to follow children into surgery but now out the door, as children are beginning to go home each day!

Today we said goodbye to little Yasna (pictured right) as her family was learning from the nurses and cardiologists how to best take care of her once she’s at home.

After that, her bags were packed and they walked through the hospital ward saying goodbye to all the friends that were made over the past few days.

The lucky ones got a smile out of her!

We love that we got to meet Yasna this Remedy Mission.

Even though it was a heart defect that brought us together we love that it didn’t have to end at that.

We love that today she was proudly carried out of the hospital after receiving the remedy!

The hospital ward already seems incomplete without her, but we know that her home is finally complete now that she’s there!

YOU made that happen!

If you’re on Twitter this week be sure to use the #RemedyMission hashtag to describe all the good news coming out of Iraq this week via @preemptivelove.



With help from our friends:

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.

Filed under: Amazed, Go Blog It!, International Children's Heart Foundation, Living Light International, News, Our Kids, Partnerships, Remedy Mission, Sulaymaniyah

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