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)

Delshad Now Fully Funded!

November 19, 2007 by Jeremy · Leave a Comment 

Delshad, 5 years old

Delshad has a hole between the ventricles of his heart, and was singled out by doctors at the October screening in Jordan as a child who needs surgery in the near future, before pulmonary hypertension would leave him inoperable. His visa for travel has already been approved, and thanks to your continued advocacy and purchases, BSSL contributed almost 40% of the necessary funds and he will be headed to surgery this week! Sometimes we cannot believe this is actually working!

Introducing James Peel

November 15, 2007 by Jeremy · Leave a Comment 

James Peel is an early adopter of the Buy Shoes. Save Lives. vision. Through his music recordings, live concert events, and cooperative projects with Buy Shoes. Save Lives. , James is getting the word out and we’re happy to partner with him in the effort for a better Iraq. Check James out on iTunes or at virb.com/jamespeel.

But Sometimes They Die

November 6, 2007 by Cody · 1 Comment 

This morning I (Cody) went and saw three families with a social worker from Kurdistan Save the Children. My emotions are all worked up… I love these kids more than ever.

I went to four homes but only saw three children because one little girl had just died before we could even tell her story. One child’s dad works as a guard for the local hospital…he guards a hospital that can’t even help his son. That’s not ironic… it’s sick.

One of the boys is 4 years old and he has until he’s 6 before he won’t be able to walk because of his heart condition (unless he has surgery.)

I am now more passionate than ever about telling their story and putting together some sort of photo book….but it’s really up to KSC and whether or not they can consistently send a social worker with me. I need them to take me to these homes and help me tell their story. I’m up for it though… we will just pray that they see the value of telling these stories.

Everyone deserves a voice.

Anonymous Donor Partially Funds Two Children for Buy Shoes. Save Lives.

November 6, 2007 by Jeremy · Leave a Comment 

Hedi, 8 months old

Thanks to an anonymous gift directly to our partner organization on behalf of Buy Shoes. Save Lives., Hedi will be able to have the operation he needs to fix the hole between the ventricles of his heart. Your advocacy among your friends is apparently working! Keep it up!

Hussein, 3 years old

Hussein is from one of the few Arab (non-Kurdish) families who made it safely to the October screening. Doctors singled him out as urgent, as he periodically runs out of breath and cries. Our partners at Brothers Together took him across the Jordan River Monday with Hedi (above), and thanks to an anonymous gift on behalf of Buy Shoes. Save Lives., his sponsorship was completed at three minutes to midnight the same day!

Three-Way Partnership Signed

November 4, 2007 by Jeremy · Leave a Comment 

Cody Fisher with Dr. Noaman and Dr. Muhammad upon signing a three-way partnership deal between Buy Shoes. Save Lives., Kurdistan Save the Children, and Rayalla.

As of this afternoon KSC has a database of 1,617 children who need some sort of emergency medical attention. Over 700 of those cases are heart problems.

Estimations say more than 1,000 unregistered children have various kinds of urgent congenital heart diseases which will leave the children dead or paralyzed within weeks if not treated. The blood disease Thalassemia is also hitting children hard, with more than 508 cases in Sulaimanyia and 450 cases in Kirkuk. There is no cure in Iraq, and without help from abroad, these children are just waiting for death.

That’s why we’re so grateful for these partnerships and for your help!

Sincerely,

BSSL

Differentiating BSSL and TOMS Shoes

November 3, 2007 by Jeremy · Leave a Comment 

One of the most frequent responses I receive after visioncasting for Buy Shoes. Save Lives. is this: “Oh… so you’re like TOMS Shoes?”

We’re honored to be numbered with TOMS Shoes in anyone’s mind. They would be great company to keep.

On the other hand, we think it’s important to highlight a few differences between Buy Shoes. Save Lives. and TOMS – not because one way is inherently better, but because we have slightly different goals and methods and we think it’s preferable not to have the two conflated. The following three categories represent some of the ways in which TOMS and Buy Shoes. Save Lives. are different.

ECONOMIC DEVELOPMENT

BSSL is doggedly committed to using our access to American and international markets to develop the economy of Northern Iraq by never farming out the production of our shoes to cheaper production regions of the world. BSSL klash are made entirely by hand by shoe artisans at 35 hours per pair in a non-factory setting by apprenticed workers. We know the name of every shoe maker with whom we work. We believe exporting production is exporting economic development and therefore, our shoes will remain “Made in Iraq” and cost $100. Some of TOMS shoes are made in China and cost much less at $38/pair. TOMS shoes are made in sweatshop-free conditions in Argentina, Peru, and China, but many Americans have commented that it is increasingly difficult to find TOMS shoes that are made somewhere other than China.

BUSINESS MODEL

BSSL is a non-traditional for-profit business that gives every cent of profit to children in Iraq who need heart surgeries. All of our staff have raised independent financial support and therefore volunteer for BSSL. TOMS is a traditional for-profit business excercising a highly accute social conscience.

SCOPE

BSSL has two full-time volunteers, two part-time volunteers, and a handful of activists like you. BSSL grossed $12,000 in our first quarter and has helped two children whose names and families we know increasingly well. TOMS has 16 full-time employees, a building, recently went on a nation-wide tour sponsored in part by Ford, and has grossed nearly $2 million dollars or more in two years. TOMS has delivered over 50,000 shoes to children in Argentina and various places in Africa!

CONCLUSION

The things listed above are things to which we want to draw attention so as to not be misunderstood in our particular posture on these issues. We are not attempting to set ourselves against TOMS. We are merely saying that our context warrants a different approach. It would be problematic for one to assume that we’ve unscrupulously copied TOMS approach without considering the ways in which our situation demands differentiation.

Aras Now Fully Funded!

October 29, 2007 by Jeremy · 1 Comment 

Aras, 12 years old
Halabja, Iraq

Aras should have had surgery as an infant, and thanks to your thoughtful buying practices and great compassion Aras will now inshallah, LORD willing, get that surgery he needs. This surgery was co-sponsored by Buy Shoes. Save Lives. and other private donors with BSSL paying over 68% of the $7,000 base. With surgery Aras is expected to lead a normal life! doctors have accepted him as a surgery candidate, and we will attempt to send him as soon as possible.

more photos…

BSSL in Los Angeles Fri/Sat Oct 19 & 20

October 19, 2007 by Jeremy · Leave a Comment 

We’re boarding a plane for Los Angeles. We are standby for a flight to Los Angeles. In a quick turn of events we are planning an impromptu gathering in Los Angeles on Saturday to promote Buy Shoes. Save Lives. and call people to ACTIVATE LOVE on behalf of Iraq’s beautiful people.

Even if you don’t live in Los Angeles, you might know someone who lives within 2 hours. Would you mind calling them and alerting them to this important event? Send out a Facebook message. Blog about it. These degrees of separation are smaller than ever and the info could get out there fast enough for us to have a significant small group of people.

We really need pockets of passionate people in major cities and at major campuses around the States. As details come together I will post again, but immediate action on your part via phone or web could help us mobilize a group of people who are ready to step up, move beyond eloquent inactivity or blithe optimism about the war in Iraq, and actually make a difference.

THANKS FOR YOUR HELP! Even if you don’t know anyone in LA and know for certain that no one who reads your blog is in LA, you never know that someone who reads your blog doesn’t know someone in the area… ! Gotta love the web…

Saturday, Oct 20th, 2007
1 p.m.
Buy Shoes. Save Lives. ACTIVATE LOVE (Small Group Event)
Information drop only – no commitments or cover charge.
FINAL LOCATION T.B.A.

Repeater Tshirt Added to Store – $12 PREORDER SALE ENDS SOON!

October 17, 2007 by Jeremy · Leave a Comment 

Top 5 Reasons We Added Another TShirt to the Store

1. Some people don’t look good in baby blue!

2. Text based shirts don’t engender conversation as much, but they convey the message more immediately.

3. We almost ran out of the other shirt and needed a new shirt immediately.

4. We love activists like you who want to continue to support the movement toward a peaceful Iraq by serving her people.

5. We are close to two major articles being published and our first full heart surgery and thought we’d help you celebrate with us!

Cool New Web Banners Added

October 16, 2007 by Jeremy · 124 Comments 

User submitted artwork… we love it! Thanks again to designer Carissa Phillips for her superrad, simplistic design on these web banners. If you haven’t grabbed a Buy Shoes. Save Lives. viral marketing web banner in awhile, go grab one and attach it to your face – I mean your Facebook – myspace, blog, and email. Because ultimately only you can tell the people we can’t reach about the stuff you now know that they don’t know regarding the ways in which together we can make a more peaceful Iraq by wearing clothing that builds bridges and tears down misconceptions.

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