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)

The Preemptive Love Coalition covered by NEED Magazine

February 16, 2009 by Jeremy · 60 Comments 

Thanks to Michael Duffield and NEED Magazine for covering Kadeeja’s stories and lending your voice in support of the effort to help Ahmad and the others from the Great Eight whose surgeries we are funding in Turkey right now.

Click here to read the article online.

BSSL Photo Shoot

April 8, 2008 by Jeremy · 898 Comments 

Shots from the recent BSSL Photo Shoot…

3 heading home with healed hearts!

March 31, 2008 by Jeremy · 8 Comments 

Aria, Juliana and Rebar all returned to their homes and families in Iraq on March 23rd after having successful heart surgeries and recoveries in Jordan!

These kids are returning home as totally new little people! The blue tinge to their skin is gone. They can run and play like all the other kids. They can breathe normally and have boundless energy! The outlook for their future is bright!

We’re all part of something huge here- bringing hope for life to kids and their families and a whole country that desperately needs it. Thanks for being on board with us! Who ever thought shoes could be part of something this amazing?

Trip to see Aras in Halabja

March 25, 2008 by Ruth · 447 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.  

$16k and 21 Children to Heart Screening

March 12, 2008 by Jeremy · 443 Comments 

Buy Shoes. Save Lives., Rayalla Organization, and Kurdistan Save the Children and other local partners recently raised and distributed over $16,000 to 21 children and their families so they could travel to Amman, Jordan for heart screening. 

 

Some of these children will likely go straight to surgery due to the severity of their case. Others will be placed in line until funds are available to fund their surgeries – whether through donations or the revenues from our online store. 

In Search of Shoes

March 9, 2008 by Jeremy · Leave a Comment 

You’ve heard that bit about the Iranian border, terrorist crossings, tea smugglers, porous trails in between security checkpoints, etc? Apparently it’s all true. 

 

We went  to Hawraman in search of shoes yesterday. Hawraman is a typical border town, having been arbitrarily divided and thereby having been forced to grow up on two sides of the border. We didn’t go into Iranian Hawraman; but Iraqi Hawraman was phenomenal. 

 

We did indeed see tea smugglers, with their mules packed down, weaving the windy roads into the Iranian mountains. Supposedly the donkeys know the trail by heart and can still deliver the tea (or whatever else they smuggle) if the Iranian officials get too close and the human guide has to abandon the cargo. 

 

Hawraman is built into the mountains in a terraced manner. We climbed 540 “stairs” to one guy’s house just to buy 7 pairs of shoes. We trekked another kilometer to a roof top patio where we inspected some 200 shoes and walked away with 28. But the net result was money saved and more control over the product compared to buying in the larger city markets; not to mention greater economic impact. 

 

We were there at the behest of a former regional commander of the Kurdish peshmerga, whose guests for the day included a few scraggly Americans (that would be us), business men decked out in Western suits and ties, a parliamentarian for the Regional Government, the former 20-year mayor of Halabja, and a number of armed guards. And though it was entirely unnecessary, he sent one of his guards with us to traipse through the city “just in case.” 

 

As with all the former peshmerga with whom I’ve sat, I found it funny that a man would swear on the Qur’an while downing whisky shots and gambling over poker. Nice guy… but what does swearing on the Qur’an really amount to in that context?

 

Part of his agenda for the day was to connect us with the poorest klashmakers in the community. In this way, this protector of the people was acting as a conduit for foreign investment directly into the lives of the city’s poorest – without skimming anything off the top for himself. 

 

The same could not be said for the parliamentarian. He tried to horn in on our bulk purchase and buy a pair of shoes at our significantly discounted mass-meets-mercy prices. To my astonishment, the klashmakers stood their ground and told him he could afford a full-priced pair!

 

We left Hawraman about 5:30 p.m., feeling completely at home, but having been previously warned that “it is not a safe place at night.” I’m guessing it’s not because of the tea smugglers. 

 

We arrived back in our city a couple hours later, completely worn out from the “up-hill-both-ways” drive. For the first time in my life, I can actually conceive of my father’s “when I was a child” stories. 

 

We’ve made some preliminary arrangements for the klashmakers to visit our office next week to make a delivery according to our specifications. We’ll be eager to see how that goes, and excited to continue on partnership with them in the event that all goes well. 

 

Thanks for reading… over and out.

 

The BSSL  Peeps

The Embassy

February 29, 2008 by Jeremy · 449 Comments 

The Embassy

Today we had a meeting with US Embassy brass working in the North. We initiated the contact a few weeks ago while seeking out funding for an art exhibition we are hosting here in April through Buy Shoes. Save Lives.

Since we’re committed to keeping all our profits for heart surgeries, we needed to seek outside funding for the art gallery – the primary purpose of which is to raise awareness of Kurdish art and mobilize civil society to play a helping role in the reconstruction process.

We were very encouraged by the response of the Embassy’s team to Buy Shoes. Save Lives. in general, and the proposal for the art exhibition in particular. The only two criticisms they had was that our budget was too small and that our venue was too small.

We are specifically asking for the Embassy to send a delegation to the installation, so I think the security concerns surrounding a high profile diplomat entering a crowded bazar for a photo op was on their minds.

The best hint of their approval for the project came when they requested a second meeting with us a few hours later to reformat the proposal into beuarocrat-speak and further discuss the implications of USAID funding for a for-profit business.

In our off hours between meetings we beefed up our marketing budget and will likely be pursuing an even higher profile for the event as a result.

Among the most exciting things was their eagerness to lend their name to the event and their insistence that they help us deliver invitations to all the appropriate ministers and diplomats on our list.

On a personal level, one of the suits was interested to hear more due to the fact that his son suffered from a hole in his heart as a child and was adversely affected by the limited healthcare available in East Asia where they were living at the time.

In other BSSL news, the Relevant Magazine interview we did is finishing its run on stands this week and has single-handedly produced almost $10,000 in sales!

Thanks for tracking with us!

J

Close February with Some Love…

February 29, 2008 by Jeremy · 1 Comment 

The month of February has been a month of love for Buy Shoes. Save Lives. Thanks to Relevant Magazine and the journalism of Jason Boyett, February is likely to be our first $5,000 month in online sales! We’ve been hovering in the $4,000/month range for a while, but this month we’re trying to push it over the top. We currently lack $43.00 to reach our (completely arbitrary!) goal.We just thought we’d let you know in case you had been pining for two shirts before the end of the month!

For the Kids of Iraq,

Cody and Jeremy 

Shy Yet Brave In Initial Tests

January 6, 2008 by Jeremy · 1 Comment 

A shy Tarza and her mother began the admissions process today for her heart surgery. Even though she is beginning to warm up to those of us on staff, she is still very quiet and shy. Because of this, I rather expected her to be fearful of the tests which had to be done today prior to her admission. What a surprise that she was such a trooper when it came her turn for the dreaded blood test!  She only made a small whimper when the needle was inserted, and was very brave the rest of the time for every test.

The doctor found in the echo that Tarza has an ASD, which can be repaired by a simple and short heart surgery (relatively speaking of course!) It is hoped that her surgery can be scheduled soon, and after the surgical team meets on Sunday we should have a better idea about just how soon. Naturally all of us hope they do not have to endure a long wait to get the treatment they came for.

On Sunday Tarza and her mother will return to the hospital to be checked after the standard test for tuberculosis.  One father was a great help to them and us at the hospital by translating and explaining what to expect, and another father has been a great help here at the house.

BSSL in Covered in Austin Monthly

December 13, 2007 by Jeremy · Leave a Comment 

Austin Monthly‘s coverage of BSSL as some sort of “philanthropic superhero” doing “cool” things to change the world is on news stands now in the Austin area. We think we are outshone by the other 4 coverstory profiles ($100 laptops for kids in Africa!?!?!?!), but we are so grateful to have been included!

Thanks to Melissa, Robyn, and Lynn at Austin Monthly for all of your hard work. Photography by the phenomenal Matthew Rainwaters can be considered here.

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