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)

A Dream Made Reality—The Remedy Fellowship Serves Nearly 300 Kids (And Counting)

June 18, 2013 by Alexis Allison 

One thing we constantly tell Iraqis is that their world is our world.

When violence unmakes their world, our world is unmade, too. So when we partner with doctors to provide a child with a lifesaving heart surgery, we’re not only mending a little heart—we’re working through stereotypes, geographic borders, and cultural barriers to remake the world through healing.

The Remedy Fellowship in Nasiriyah is helping us carry out this vision.

Ten months since its launch, Remedy Fellowship continues to be the number one surgical training program inside Iraq. Through the work of our partners at Living Light International and the International Children’s Heart Foundation, Remedy Fellowship has already provided nearly 300 operations and over 5,000 hands-on training hours for local medical teams.

The result is simple: our world is healing. The work we pursue is becoming a reality!

More and more, Iraqi families are finding medical care within their own borders. Local doctors at the Nasiriyah Heart Center are diagnosing and operating on heart defects that were inaccessible just a year ago.

We still have a long way to go, but we are moving in the right direction.

As the world around us continues to be remade, we give thanks: to you, who donated despite the uncertainties of beginning a new program, to our partners, who worked locally and nationally to make the vision hold together, and to the Iraqi doctors and nurses whose hands have helped mend nearly 300 little hearts.

Together, we celebrate the healing that has happened with the help of Remedy Fellowship—and the healing yet to come.

Alexis Allison is an almond-butter-lovin’ writing enthusiast with a penchant for allegories, Ray Bradbury, and studying Mandarin Chinese. Originally a farm girl from Amarillo, Texas, she studies creative writing at Pepperdine University, and her current adventure involves collecting and sharing stories as PLC’s copywriting intern.

Happy Father’s Day To Local Heroes!

June 16, 2013 by Alexis Allison 

“Dads are the most ordinary men turned by love into heroes, adventurers, story-tellers, singers of songs.” —Pam Brown

Happy Father’s Day from Iraq.

Help save a child in honor of your father today!

Alexis Allison is an almond-butter-lovin’ writing enthusiast with a penchant for allegories, Ray Bradbury, and studying Mandarin Chinese. Originally a farm girl from Amarillo, Texas, she studies creative writing at Pepperdine University, and her current adventure involves collecting and sharing stories as PLC’s copywriting intern.

How My Sister’s Heart Defect Led Me to Iraq

June 13, 2013 by Meredith Toering 

“Why heart defects? Why Iraq?”

Friends and family asked me these questions over and over again when I applied for an internship with Preemptive Love, and over and over again I answered:

Because of Cai Wei.

I met Cai Wei, or “Brooke” (her given English name), while interning for a special-needs orphanage in China. She was 18 months old, and, on my first day of work, I was assigned to work one-on-one with her.

Immediately, I fell head-over-heels in love.

She, however, was not so quick to love—distrustful and guarded due to emotional trauma in her past. Born with only half a heart—along with four other complicated defects—Brooke arrived at this orphanage when she was only 10 months old. Soon after, she received her first open heart surgery.

As the summer wore on, she gradually began to trust me. However, I still worried every day about her physical heart, knowing how much she needed another surgery. I left China and “my” Brooke Cai Wei at the end of the summer with my own heart broken, and I returned home resolved to find her a family.

Only God could have orchestrated the events that followed: eight months after I said goodbye to Brooke in China, my family flew back to bring her home—forever ours.

Seven weeks later, we placed Brooke into the arms of a capable surgeon, and she went in for yet another lifesaving open heart surgery. While Brooke’s heart can never be “fixed,” this surgery gave her a chance for a future.

Because of Brooke, I see hope for children all around the world with heart defects—children waiting for their chance at life.

I remember the despair I felt, knowing the child I loved needed a miracle to survive. Here in Iraq, I hurt with other families as they bravely hand their precious children over for surgery, uncertain of the outcome. I read the stories of children whose hearts have been repaired, and I know in my soul the relief their families feel because their children have hope for life.

This is why we’re here. This is why I am here. For me, heart defects are no longer just a statistic, just another medical condition. Brooke Cai Wei gave them a face, and her heart-story has rewritten my own.

Every child, like Brooke, deserves the gift of hope.

Your donations do exactly this—give real children a chance to live! Do you know a loved one who has dealt with CHD? Make a donation in honor of your loved one here:

Give children like Brooke hope for a future!

Meredith is a popcorn devotee from Oklahoma with Chinese-language skills and a desire to learn more about congenital heart defects in Iraq. Though she spends most of her American hours adventuring with her adopted little sisters—a 7-year-old and a 3-year-old from China—she will be working this summer on internal audits for PLC.

From Korea to Iraq—Yunus Comes Home for Surgery

June 11, 2013 by Alexis Allison 

Three months in a Korean ICU.

That’s what Yunus faced last year when he traveled abroad looking for a lifesaving heart surgery.

As a one-year-old with Down syndrome, Yunus journeyed to South Korea with his daddy, four complex heart defects, and the hope that their nearly 5,000-mile quest would end in healing.

But then his Korean doctor described the length of the post-op recovery period.

Unwilling to remain so far away for so long, Yunus and his dad turned around and flew back home—without surgery.

But as a little boy with a dying heart, Yunus’s opportunities for medical care in Iraq were also scarce.

That is, until his family discovered the Remedy Fellowship program in Nasiriyah.

This program, which began in August 2012, is the result of a collaboration between us, Dr. Novick’s team from the International Children’s Heart Foundation, Living Light International, and local surgeon Dr. Akeel.

The 48-week-long training course instructs Iraqi doctors so children like Yunus can receive care from local, well-equipped surgical teams.

And in February, he did. Yunus and his family traveled south to Nasiriyah, where he received the lifesaving medical care he needed and drove home to recover.

We saw him again two weeks ago in northern Iraq, visiting Dr. Kirk’s team from For Hearts and Souls for a follow-up screening—his local doctor had noticed a dangerous amount of fluid filling in around Yunus’ heart and advised his family to see the international team. Dr. Kirk confirmed that the fluid needed to be drained, so he sent Yunus and his family down to Nasiriyah—back to Remedy Fellowship—to receive care once more.

Yunus is back home now, and doing well.

He won’t need to travel across the world for surgery or checkups anymore—no one will ever ask him to spend three months in an ICU thousands of miles from home—because heart surgery shouldn’t require world travel.

The Remedy Fellowship program gives Iraqi children like Yunus the gift of high-quality medical care in their own country—so when they get sick, they won’t have to travel the world in search for healing.

Alexis Allison is an almond-butter-lovin’ writing enthusiast with a penchant for allegories, Ray Bradbury, and studying Mandarin Chinese. Originally a farm girl from Amarillo, Texas, she studies creative writing at Pepperdine University, and her current adventure involves collecting and sharing stories as PLC’s copywriting intern.

Committed to Care—Dr. Kirk Returns to Iraq

June 7, 2013 by Alexis Allison 

Author’s note: Last week, our partners at For Hearts and Souls—the medical organization founded by Dr. Kirk Milhoan and his wife—came independently of PLC to screen children at the Fountain of Love center in Chamchamal, Iraq. The team graciously allowed me, as well as other members of PLC, to accompany them in their work, and I received my first glimpse into developmental pediatric cardiology in this country.

###

Last Tuesday, a family brought their 21-day-old son to Dr. Kirk’s medical team, fearful. A local doctor had told them earlier in the day that their baby’s heart was sick, but they didn’t know how to help him.

The mother, father, and aunt knew they didn’t have enough money to send him out of the country for surgery. They needed another option to save their baby.

The family found Dr. Kirk in Shoresh, in the middle of screening nearly 1,000 children in just five days. He and his team had recently arrived from the US to check the hearts of children like this tiny boy.

But then the doctors confirmed the news: their baby had a complex heart defect that would require surgery.

The family’s options were limited, expensive, and only available abroad, until one of our staff heard the story and offered a more accessible location: a hospital inside Iraq associated with this year’s Remedy Fellowship program.

When we heard the news, we celebrated; this opportunity wouldn’t have been possible two years ago.

The next day, the baby and his family drove to receive help.

But then the phone call to our office came. Fifteen minutes after they had arrived at the hospital, the baby’s heart stopped. He passed away before he could receive medical care.

We—Dr. Kirk’s team, our team, local doctors, Fountain of Love, and our medical partners at the International Children’s Heart Foundation—did everything we could, but his little heart still stopped.

In the office that afternoon, processing how a family who had been given hope had just as quickly lost it, we were confronted with this reality:

Not every child’s story results in healing. Some end too quickly, too painfully. And when we see hurt, it can be difficult to press onward.

But even so, Dr. Kirk and his teams keep coming to Iraq.

Knowing they can’t save everyone, knowing that some stories don’t turn out the way we hope they would, they keep coming.

They practice disciplined love—committing to return to this place and these people in the hope that these kids might receive the best medical care possible, and that their stories might include healing.

Such faithfulness encourages us—and give us reason to be thankful—as Dr. Kirk and his teams continue to serve families across the country.

Alexis Allison is an almond-butter-lovin’ writing enthusiast with a penchant for allegories, Ray Bradbury, and studying Mandarin Chinese. Originally a farm girl from Amarillo, Texas, she studies creative writing at Pepperdine University, and her current adventure involves collecting and sharing stories as PLC’s copywriting intern.

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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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