1: What are you trying to accomplish?
2: What's your evidence that you can accomplish it?
3: How is it possible that you can provide an open heart surgery in Iraq for less than $1,000? Is that the full cost?
4: So is that the same thing as saying that my donation doesn't really make a difference? That the "up to 85%" funded locally by those inside Iraq is all that is really necessary to make this work?
5: Any other costs?
6: What is the bottleneck to more surgeries: money or skilled labor?
7: I'm skeptical of non-profits and charities because they always seem to be asking for more money. How can I be sure that Preemptive Love Coalition has "room for more funding" and that I'm not paying into a huge savings account, "Rainy Day Fund", or something similar?
8: Do you have enough volunteer surgeons available for unfunded Remedy Missions? (i.e., are there trips that you could fund if you had more money, or is there a labor bottleneck?)
9: Many heart surgeries require follow-up treatment (including additional surgeries). Do you have a way of providing these to patients?
10: How do you assess whether surgeries are completed competently and appropriately?
11: What is the rate of complications during and following surgery?
12: How do you assess whether surgeons are performing additional surgeries that they would have not had the funding or motivation to perform otherwise?
13: How do you assess whether surgeons are charging their patients for the surgeries you fund?
14: Do you follow up with the surgeons you've trained to assess whether they are correctly applying their training?
15: What information is available on the activities - and competence - of the surgeons you've trained?
16: Where do surgeons work after completing training? Do they serve poor patients?
17: How much do you spend each year on "program" expenses and how much on "overhead?"


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 Q: What are you trying to accomplish?

A: Train Iraqi heart surgeons and nurses so they can eradicate the backlog of tens of thousands of Iraqi children waiting in line for lifesaving heart surgery. [Back to Top]

 Q: What's your evidence that you can accomplish it?

A: Each year we continue to increase Iraq's total number of pediatric cardiac surgeries with new surgeries in Iraqi centers that would not - indeed could not - have been accomplished otherwise. Ministry of Health (MOH) officials speculate 500 surgeries were accomplished in 2009 (of which we provided 23 - 4.6% - outside the country). The addition of our 82 surgeries in FY 2010 - to the 500 baseline - for a total of 582 approximated surgeries, represents an increase created by PLC of 14% over 2009. In FY 2011 we anticipate increasing Iraq's total number of pediatric cardiac surgeries to at least 719 (or another 19% over FY 2010 directly attributable to our surgeons and our training).

Each year the local teams with which we work will become more proficient, and each year they will independently take on a larger case load than they could have the year before. None of these figures yet account for that additional output.

In March 2010 the Iraqi Ministry of Health asked us to expand our work to three additional sites. In May 2010 we began additional discussions about establishing a fellowship program in which international surgeons and nurses would take up residence in the Iraqi system to train locally for 40 weeks out of the year.

Our model does not rely strictly on volunteers because the level of need in Iraq outstrips what we could reasonably supply through volunteer labor alone. Accordingly, we set our budgets so as to actually contract the international surgical and nursing staff we need to accomplish our mission.

Sure, this increases the cost-per-mission (and thereby, cost-per-child) over early "mission" models in which volunteerism was idealized and training was not necessarily prioritized. But our contract labor + volunteerism model is inarguably the only way to create a nationwide quarterly training program and fellowships inside Iraq with international experts across approximately 6-8 surgical sites. Moreover, our model does not face the same sluggishness of learning that other surgery organizations suffer because we do not have the same rates of turnover; we have incredible consistency across our programs and missions. [Back to Top]

 Q: How is it possible that you can provide an open heart surgery in Iraq for less than $1,000? Is that the full cost?

A: The "less than $1k" numbers we routinely publish represent the amount in "program costs" we spend from our international donor money. The figure does not necessarily account for every single management, overhead, or fundraising expense.

Our total expenditures for FY 2010 were $188,919. We performed 82 surgeries during the same period for a per child total of $2,304 (though this data is a bit moot moving into 2010-11 as we abandon our very expensive "surgery exports" program(s) in Turkey, etc. and focus henceforth on more cost-effective in-country surgeries alone).

When all of our Remedy Mission partners are taken into consideration - including the Iraqi Government, medical companies that donate medicines and supplies, and local organizations - the real Remedy Mission cost to all donors is in the range of $5,400 - $7,000. Put another way, up to 85% of the total cost of a single surgical/training mission is now subsidized by local, Iraqi constituent institutions. [Back to Top]

 Q: So is that the same thing as saying that my donation doesn't really make a difference? That the "up to 85%" funded locally by those inside Iraq is all that is really necessary to make this work?

A: There is not a single site across Iraq for which our Remedy Missions are fully funded. If we fail to provide our 15-19% of the overall budget, Remedy Missions fail, surgeons and nurses do not get trained regularly, on-site audits from our international team do not happen, up to 20 children are delayed from receiving surgery, and a few may even die or become inoperable. Your role in funding the remaining 15-19% is as critical in the short term as any other entity. A single Remedy Mission is binary - it either happens or it doesn't. Your money makes it happen. But our goal is to continue to graduate all our programs so they are 100% funded locally in the next 5-10 years. [Back to Top]

 Q: Any other costs?

A: Our numbers per Remedy Mission do not account for "indirect costs," such as the cost (or value) of our volunteer medical staff from around the world, costs to local healthcare systems, the cost of a family to travel to the surgery site, the opportunity costs of lost income for families as they wait for surgery, etc. The reason we think it's important to note this here is because lifesaving is actually quite difficult. Building a pediatric cardiac surgery system for the entire country of Iraq is laborious and full of complexities. [Back to Top]

 Q: What is the bottleneck to more surgeries: money or skilled labor?

A: People often assume that the biggest need is more Iraqi heart surgeons. We could use a few more, but the real bottleneck is skilled nurses, technicians, and non-surgical physicians. A surgeon is only as good as his support staff. One of our biggest challenges is training pediatric cardiac intensive care nurses. To date, we haven't found a better model than our Remedy Missions through which we bring quarterly hands-on training to local nurses (and surgeons) in Iraq. Rather than exporting the nurses to Europe or the USA for training (whose medical systems barely resemble the Iraqi system), we train them with what they have on hand in their local environment. [Back to Top]

 Q: I'm skeptical of non-profits and charities because they always seem to be asking for more money. How can I be sure that Preemptive Love Coalition has "room for more funding" and that I'm not paying into a huge savings account, "Rainy Day Fund", or something similar?

A: For the record, we are skeptical of non-profits as well! In 2012 PLC needs $350,000 on hand at any given time to cover our cash flow needs for up to three Remedy Missions per quarter. We are still 30% under-funded against that goal. In addition to cash flow needs, we still require 15-19% funding on most of our missions after local sources contribute their portion; we have un-funded pilot programs in new cities where local doctors have been requesting our help (but where weve yet to woo local philanthropists or health directors); and we have research and social service initiatives through our Followthrough program that require funding at present because we have not yet sought local funding for those initiatives (seeing as how they relate mostly to our Monitoring & Impact Evaluation objectives). Please see our "Funding Gap" page to look deeper into our anticipated program costs, the sources of funding we are counting on, and the funding gap between the two for the next few years. [Back to Top]

 Q: Do you have enough volunteer surgeons available for unfunded Remedy Missions? (i.e., are there trips that you could fund if you had more money, or is there a labor bottleneck?)

A: Great question! We use a hybrid volunteer/staff model. Roughly 25-30% of any one of our Remedy Mission teams is employed by the International Children's Heart Foundation (typically the surgeon, scrub nurse, anesthesiologist, ICU doctor, and often a part-time ICU nurse). The remainder of the team typically comprises volunteer physicians, technicians, and nurses from across the world. Because the hardest-to-come-by positions are contract labor for us and NOT volunteers, we have never failed to run a mission for lack of personnel. We have only cancelled or turned down a request for a future mission due to lack of funding. [Back to Top]

 Q: Many heart surgeries require follow-up treatment (including additional surgeries). Do you have a way of providing these to patients?

A: Yes, we do. Our model dictates quarterly visits to each program site (a hospital inside a regional hub). Our reliance on local cardiologists ensures that the local team prioritizes and almost entirely sets the agenda for patient selection (within a development curricula) - after all, Iraqi doctors are the ones who are most intimately connected to the patients and their daily progress! When a local cardiologist sees a child who has either (1) deteriorated and requires another intervention or (2) advanced as expected to the next step of a complex, staged intervention, the child is prioritized for follow-up treatment. [Back to Top]

 Q: How do you assess whether surgeries are completed competently and appropriately?

A: Because we are a broker and play a combination administrative and financier role in the coalition of partners working in Iraq to develop pediatric cardiac care, we are able to stand in-between the local surgical team and the international surgical team (whom we contract as a third-party to train and perform surgeries in Iraq). If the local team or health directorate suspects a lack of competence in the international team, a cavalier attitude, or a single poor judgement call, our role is to be the go-between - to be the advocate for the local healthcare providers vis-a-vis the international surgical team.

Similarly, if the international surgical team feels pushed by the local surgical team to perform procedures with which they are uncomfortable or for which they think the local system is ill-prepared, they are able to refuse children for surgery and/or use us (PLC) as a go-between.

The checks-and-balance between the two teams helps us ensure surgeries are performed in a competent, appropriate manner. [Back to Top]

 Q: What is the rate of complications during and following surgery?

A: We report our in-hospital and 60-day mortality after each Remedy Mission. You can finds those numbers here. We also produce reports after each Remedy Mission detailing the trip, including data on intraoperative complications, post-operative complications, and mortality. You can find those reports here. We are also deliberately raising the funds necessary to help us bring our various heart hospitals into compliance with the International Quality Improvement Collaborative for Congenital Heart Surgery in Developing Countries. If this kind of quality improvement and reporting initiative interests you, we are currently looking for financial partners for our Followthrough program. [Back to Top]

 Q: How do you assess whether surgeons are performing additional surgeries that they would have not had the funding or motivation to perform otherwise?

A: Pediatric heart surgery in Iraq is almost nonexistent without our work. There are two active programs for relatively simple surgeries (one in Erbil and one in Baghdad). Local surgeons claim that combined they perform no more than a few hundred pediatric surgeries a year. In every location where we work, pediatric heart surgery is effectively nonexistent. Therefore, every surgery performed at our program sites (both when we are present and when we are not) are "additional surgeries" that they would not have had the SKILL to perform without the FUNDING we employed to train them in their local environment. [Back to Top]

 Q: How do you assess whether surgeons are charging their patients for the surgeries you fund?

A: Because we work in public (government) hospitals - and because healthcare in Iraq is provided almost entirely free of charge - it is widely known that any cardiologist, surgeon, or administrator seeking compensation for services is acting outside of Iraqi law. [Back to Top]

 Q: Do you follow up with the surgeons you've trained to assess whether they are correctly applying their training?

A: We see them quarterly in their local environment and perform real-time audits of their skills, recollection of past training, application of new techniques, etc. Additionally, our international surgeon remains on call at any time via phone, Skype, or email for consultation. [Back to Top]

 Q: What information is available on the activities - and competence - of the surgeons you've trained?

A: Because our Remedy Mission training program only began in late 2010 - and pediatric heart surgery at our sites across Iraq is the same age - there is still relatively little independent practice to report, and therefore little data on the activities and competence of our surgeons and their teams. But as they begin performing more surgeries independently, we are trying to align each site/surgical team with the International Quality Improvement Collaborative for Congenital Heart Surgery in Developing Countries (a data collection and tracking initiative of Children's Hospital Boston and Harvard University). [Back to Top]

 Q: Where do surgeons work after completing training? Do they serve poor patients?

A: As of Q2 2011 there was only one private hospital in Iraq (to our knowledge) providing pediatric heart surgery (and those surgeries were on the lower end of the complexity scale). Our work does not necessarily mean to exclude private hospitals as they continue to come online and become viable options, but at present the government system has a better equipped foundation for training local surgical teams. As we look to fully graduate our local surgical teams in the next 5-10 years, we imagine that most of them will stay in the public sector for all of the stability, pensions, and benefits of loyalty provided to those who stick with it. But, undoubtedly, some will seek positions at private hospitals (assuming private hospitals are willing to invest in the requisite capital purchases necessary to establish a credible program). In the public sector, rich and poor are served alike. In the private sector, poorer patients would be at an obvious disadvantage. [Back to Top]

 Q: How much do you spend each year on "program" expenses and how much on "overhead?"

A: As a rule, we do not adhere to the model that claims that "overhead" is somehow bad and "program" is somehow good. There are very bad program expenses. There are overhead expenses that are excellent investments. We agree with Paul Brest, President of the Hewlett Foundation, when he said, "Achieving a low overhead ratio drives many charities to behaviors that make them less effective and means more, not less, wasted dollars." Therefore, we spend as much on overhead as we need to accomplish our mission. The mission itself is our North Star - not arbitrary (even harmful) standards about overhead-vs-program expenditures. For the record, however, you can find a current pie chart of our expenditures here (and if you're into that sort of thing, you'll probably be impressed!). [Back to Top]

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)

Trip to see Aras in Halabja

March 25, 2008 by Ruth · 326 Comments 

Last week I made my first visit to one of ‘our kids’ – Aras, the start of what I hope to spend much time doing here as ‘Director of Rehabilitation & Family Relations’ for BSSL.  

Aras was the first kid that was mostly funded for his surgery through BSSL . When we arrived in his neighborhood we first spotted him out playing on the street with his friends – running around, laughing, having fun! It was my first time to meet him and I definitely would not have suspected that he had been through so much in the past few months!  

I had a wonderful time with Aras and his family. They thanked us over and over again for all that we had done to help Aras. His mom had put together an extensive photo album telling Aras’s story during his time in Jordan. It was fun having Aras talk me through all the photos from him lying on his bed immediately following surgery through all the various stages of recovery. He’s a real sweet kid!  

Thank you for making it possible for kids like Aras to have the life saving operations that they need!  Arya and Rebar just returned on Saturday so I’m also hoping to be able to visit them soon. This week I’ll also be visiting Baveel so check in again soon to see an update on how he’s doing.  

Headed Home With New Hearts

February 1, 2008 by Jeremy · 1 Comment 

Today both Aras and Delshad dashed through snow in Jerusalem, loaded into a bus with their mothers, and began the journey to travel back home to Iraq. This day marks a very eventful journey for these 2 boys!
Just a few months ago both boys were plagued with heart problems that were holding them back from living the normal life of a rowdy young boy (not to mention threatening their very lives!) and burdening their families greatly with worry. Here they are today with healthy, healed hearts, heading home to start a new chapter in life.
We’re speechless, really, to be involved in restoring health (and so much more!) to these children. Keep spreading the word, because, as you can see with your own eyes- it’s so worth it!

Aras Leaves Snowy Jordan

January 31, 2008 by Jeremy · 303 Comments 

 

As I pulled up to the Shevet house, Aras, Hardi, and Dilshad dashed through the newly fallen snow with unrestraint. Once they were all piled in the van, their destination was the Al Aqsa mosque where each family spent some time in prayer. Then it was time for lunch before saying final goodbyes and heading for Jordan.

 

During the two hour drive, the boys practiced the many English words they learned during their stay. Aras and Hardi amazed me with their newfound skill of counting to 100 and pointing to parts of their face, saying “nose, mouth, ears”….. they now were showing off and we all began to laugh!

Aras heading home after successful surgery!

January 23, 2008 by Jeremy · Comments Off 

On January 3rd Aras received heart surgery and has been succesfully healing and recovering since then. He has now been given a clean bill of health and was released from the hospital in Jordan on January 21st. He and his mother will be returning to their home in Iraq to begin a new phase of life- free from worry about Aras’s heart. We’re really excited to welcome him back to Iraq and to watch how much more he can enjoy life now!

Delshad is also recovering from his heart surgey that took place on December 30th. Due to some further problems he had to undergo a second surgery on January 3rd. This took quite the emotional toll on Delshad’s mother who has been at his side every step of the way. Delshad has shown great improvement however after both surgeries, giving his mother much hope! Delshad will receive his last echocardiogram on Thursday, January 24th and hopefully be released after that!

A Clean Bill of Health, Free to Go Home

January 21, 2008 by Jeremy · 327 Comments 

Aras has been discharged from the hospital as he continues strengthening after his open-heart surgery. His heart is doing so well that doctors today gave Aras a clean bill of health and the green light to go home to Iraq and a bright new future!

Aras has a virus

January 6, 2008 by Jeremy · 159 Comments 

 

Aras moved out of ICU today,  he was watching basketball in the corner bed of the intermediate ICU ward, with his mother at his side. He was not doing much eating, she told us, and it was clear he was still not back to his usual “chipper” attitude yet. He did perk up a bit when he learned that his new friend Hardi was now being admitted for surgery. After Hardi’s pre-op necessities, he came down to visit Aras. He and Baveel, as well as all of the mothers who just arrived last week, had been asking about him.

 

Aras was glad to see Hardi and they talked a little while, as did their mothers. They were glad their boys were going to have surgery within a few days of each other.

 

Aras was moved to another ward today. He began throwing up this morning from a virus, and was still not eating. I saw his mother in the hall, and followed her down the hallways until we found Aras’ new room. He was very subdued, and was on an IV for fluids. His mother was worried, but thankful that he was ok. 

Aras comes through surgery today

January 3, 2008 by Jeremy · Comments Off 

 

Today it was finally time for Aras’ surgery. Accompanying an older child for their surgery is very different than going with one of the toddlers or pre-school aged children. Patients here are not given any sedation before they go to the operating room, so Aras was fully alert, and knew exactly what was about to happen, and couldn’t hide his fear in those final moments. Seeing him cry made his mother cry too. Seeing Diyka Aras’ distress as we walked out into the hallway, one of the medical personnel asked us to wait while she went to check on how long it would be before he would come upstairs. The answer we were given was that it would be a long surgery of about five hours.

 

 Five hours later. Dr. Sasson, the surgeon who performed the operation, came by and told us that everything went very well. Diyka Aras was very relieved, yet as is always the case, she wasn’t able to be sure all was well until she saw her son for herself. When we saw two men wheeling his bed down the hall to the ICU, she cried and thanked God as we walked with them until they were inside. 

Aras waits again

January 2, 2008 by Jeremy · 269 Comments 

 

Aras’ surgery was postponed until tomorrow because of an emergency which required his slot.  This time they did not look so disappointed, and in fact seemed accepting because of the reason things were happening this way. Aras’ mother was also attempting to encourage Mustafa’s mother when she approached and began to shed tears as she talked about Mustafa’s condition. This good natured boy must be getting anxious about all the times he’s had to go through the pre-op essentials, and fast from foods after midnight. We will update you tomorrow about the status of Aras after his surgery.  

Aras and Dilshad in Jordan Awaiting Heart Surgery

December 17, 2007 by Jeremy · Comments Off 

What do little boys with heart problems do while waiting for heart surgery? Apparently they ride their bikes much like other little boys do… The boys are sick and need help… but they don’t let that stop them from having fun and living a full life while they can. It’s so fun to see the way they just go for it and live it up; emotionally uninhibited by the setbacks they face! Would that we all were so vivacious and resilient!Thanks for all you do. Soon these boys won’t have to monitor the duration of their bike rides quite so closely, inshallah (God willing)!

Catheterization Delayed

December 5, 2007 by Jeremy · Comments Off 

 

Aras was prepped for his catheterization today, waiting for his turn, playing with a small brass dreidel (or top) in his bed. All week the patients have been receiving gifts and candy from visiting school children and other volunteer groups, and this was one of his treats from a Hanukkah gift. It was quiet entertainment while he waited. However, because the catheterization lasted much longer than usual for the first child this morning, and he was to be the third one of the day, Aras’s cath had to be delayed.  Since Aras could not have his catheterization today, he was dismissed back to the Save A Child’s Heart house. It is likely he will be rescheduled for next Wednesday, the day the caths are performed. 

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