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)

MY TAKE—”Immigrants A Key Step Toward Peaceful Coexistence In Iraq”

March 23, 2012 by Behar Godani · Comments Off 

For millions of immigrants in America,
a sense of belonging and successfully handling their dual cultural identity is one of the most difficult and challenging of tasks. On the one hand, your heart is tied back to a land that was once your home—as is the case with my parents—or at least a place that feels a lot like home—as is the case with my siblings and I.

Yet no matter how many times we go back there or insist that we want to spend the rest of our days here, there never seems to be a perfect fit. There moved right past my parents and the memories they could have made had they not been forced to leave thirty years ago, and here feels much more familiar.

As a result, we’re stuck between here and there, never completely belonging anywhere.

But perhaps the beauty in the limbo that so many immigrant families find themselves in is that they are able to understand and exist in both places at once.

And perhaps that’s where the secret to truly co-existing beside one another lies as well.

There are immigrants who have walked in our shoes, but there are plenty more back there—in Iraq—who, like my parents, were forced to leave and if they survived were likely to be internally displaced. And that’s where so much of the current resentment lies. It was never truly an ‘us’ vs. ‘them’ mentality in the sense that entire groups of people became alienated from one another. No matter how bad things became in Iraq, there was always a recognition that the majority of its citizens were good people.

Now, many wonder if the country and its people—in light of recent political developments—will ever live up to the potential that so many of its own politicians boast about and so many in the West had initially hoped for.

The key lies not in government policies, per se—which I yield, can at times favor one group over another and further disenfranchise other groups who already don’t feel welcome in the political system—but in all-natural and real human connections. When people can put a face on families affected by violence, when a doctor from a different faith or ethnicity saves a child’s life, when a Muslim breaks bread with a Christian who’s just as Iraqi as anyone else, the concept of “preemptive strikes” and bombings will become just as foreign and distant a concept as they were all those years ago. Then “preemptive love” and a true sense of commitment to the success and prosperity of the Iraqi state for the sake of its people will begin to emerge.

No more will bureaucrats, insurgencies, or fringe groups attempt to dominate the hearts and minds of the people as much as they have in the past because the people, like my parents, will come to learn the importance of existing in the now. They’ll learn that yes, you may have been displaced and you may have lost loved ones like so many innocent Iraqis have, but our humanity and our hopes for a better future must transcend the easy way out which often involves blaming an entire people or religious group for why things are currently the way they are.

Most immigrants face the challenge of simply reconciling their ethnic identities with their American ones, but families who hail from conflict zones—both those who had an opportunity to escape and those who were forced to stay behind—face the added difficulty of not only staying true to the identity that various groups have tried to wipe out, but also of keeping the anger and sadness in their hearts from ultimately skewing how they view “the other.” That of course can only happen with social projects and movements that focus on bringing different groups together so that individuals can begin to put a face on “that religion” or “that ethnic group.”

Eventually, they’ll come to find—as we all eventually must come to find as human beings—that religion, ethnic identity, the types of clothes a person wears, or the color they choose to dye their hair quickly falls away once that connection is made and “that” person becomes a friend.

3 Reasons For "In A Word" Mid-Week Photos

June 12, 2011 by Liz · Comments Off 

For a month now we've posted mid-week photos titled “In a Word,” and we've received some great feedback from you guys.

We want you to know that these aren't just pretty pictures, they're tools to help as all build an understanding of Iraq through the artists who live here.

We know you care about the future of Iraq, the kids and the training of nurses and doctors, but we want to offer you even more perspectives.

So here are 3 reasons we believe “In A Word” matters:

1. Images can be used to promote peace.
“Peace is waged when a child is served, a voice is heard, a story is told, a dialogue is created, and a community is engaged.”

We're waging peace when we LISTEN to and TELL a story about Iraq, kids with CHD, local healthcare, local solutions (i.e. politicians, donors, doctors, etc.), Muslim and Eastern perspectives, Christian and Western perspectives, the war, etc. These photos give us the opportunity to engage another community. They tell stories and create dialogue.
They're opportunities for us to understand.

2. We live among the people here.
We work with them, care for them, argue with them – we love them. And many of you have expressed interest in what those things look like here, so “In A Word” is our way of helping you visualize our day-to-day. It helps our families, friends and supporters 'come around', and for a few seconds, that makes us feel like you aren't an ocean away.

3. It's a platform for artists.
These Iraqi and Kurdish artists are unsung heroes, and their work deserves to be showed off and shared. They show their people that beauty can bring hope and truth in the midst of devastation.

“In A Word” is a forum – a sounding board – where artists can show off their work and prove emphatically: we're here, and we're talented.

Do you have any photos that you'd like to submit for an “In A Word” midweek post? If so send to liz@preemptivelove.org, subject “In A Word”

Alawi Receives His Much Needed Heart Surgery!

February 21, 2011 by Cody · Comments Off 

This morning Alawi got the heart surgery we’ve all been waiting for!

Local doctors and nurses – alongside the ICHF team – took a minimalistic approach to his repair, seeking to do as little “trauma” to his heart as possible. Unfortunately, after surgery, it seemed the minimalist approach wasn’t holding as well as they hoped. They decided to perform an even more robust correction that would make Alawi even stronger than he already was.

So Alawi went yet again into the operating room just as bravely as he went into his first operation.

Alawi’s a reminder of what we’re committed to – we will do whatever it takes to make each child and each Iraqi doctor and nurse into the healthiest child and most-skilled doctor or nurse they can be.

Hoping for the best still never makes it easy to watch a child go in for surgery.

We could not do this without you! You are our heroes and you inspire us to keep going so much! Stay tuned to get the latest update on Alawi from the ICU via our Facebook Page!

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Meet Ali. He Finally Got His Lifesaving Surgery on Our Second Trip to Southern Iraq

February 17, 2011 by Jeremy · Comments Off 

Ali gets his surgery from Dr. Novick and the ICHF during our February 2011 Remedy Mission to southern Iraq.

An interview with Cody Fisher about his first encounter with Ali and the journey to where he is today.

Push play above to meet little Ali….

With you,

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

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