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)

Our Animated Manifesto

August 5, 2011 by Ted · 1 Comment 

Allow me to introduce PLC’s newest video!

If you’re unfamiliar with our work, we consider this our manifesto. Everything we do boils down to this belief: reconciliation happens through healing.

With your help, that which has been destroyed and ‘unmade’ can be rebuilt. It can be healed.

—

For all you video connoisseurs, what did you think? Give us some feedback in the comments section below, or connect with us on Vimeo.

VIDEO: Remembering Saddam Hussein’s Chemical Attacks on Halabja

September 5, 2010 by Jeremy · 4 Comments 

A sobering remembrance of the 1988 chemical attack on Halabja in Iraqi Kurdistan and the repercussions still felt by residents today.

Pondering Available Responses to Genocide and Its Effects

June 10, 2010 by Lauren · Leave a Comment 

On March 16, 1988, toward the end of the Iran-Iraq War, the Iraqi military used chemical weapons on the city of Halabja. The attack was meant to erase all Halabja inhabitants off the map: plants, animals and humans. A total of 5,000 men, women and children were killed in the attack, and of the survivors, 11,000 were injured.

As we walked through the memorial, I recalled an ancient Hebrew poem:

By the rivers of Babylon, we sat and wept
When we remembered Zion.
There on the poplars we hung our harps,
For there our captors asked us for songs,
Our tormentors demanded songs of joy

The poem is about the Hebrew people who were exiled in the land of Babylon, present-day Iraq. They cried because they missed their homeland; they cried because they were expected to be happy and play songs for their captors. But they couldn’t.

I wonder if that’s how the survivors of Halabja felt. They didn’t want to sing songs. Their families died. Their neighbors died. Like the Hebrews, some Iraqis living in Halabja had to leave their land and flee to Iran.

I’m trying to make sense of what happened in Halabja. I’m trying to make it mean something to me. We are bombarded with images of war and genocide on the news, making it easy to forget that Halabja was a reality. We forget that congenital birth defects caused by this and similar chemical attacks are a reality.

O, Daughter of Babylon, doomed to destruction,
happy is he who repays you
for what you have done to us

I hate how the Hebrew poem ends. Instead of offering hope for a people, it speaks of revenge against the tormentors. Hate is so easy. It is our job to choose not to hate.

Many children here need surgeries and medication and therapy to address their congenital birth defects. And some of them probably need this help as a result of the chemical attacks in Halabja and other attacks similar to it. As a newcomer and summer intern, I love that the Preemptive Love Coalition response to genocide is not to seek revenge on behalf of victims, but to work alongside Iraqis to bring healing to suffering children.

Mohammad’s family had $6,000 in-hand on loan from a friend to get their son the heart surgery he needed. Then the creditor decided to build a new house and took his loan back before Mohammad received surgery. Now the family is trying to find surgical solutions. Donate the amount of your choice by entering it in the field below to help send Mohammad to life-saving heart surgery.

Valentine’s Day Focus: The Great Eight (Ahmad’s Condition)

February 2, 2009 by Jeremy · 1 Comment 

Ahmad’s situation is one of the more dire we’ve seen.

His great arteries are switched around and in the wrong places. He has two holes in the wall of his ventricle, a hole in the wall of his atrium. Effectively, his heart is a big balloon without properly functioning walls and chambers like yours.

This alone results in exhaustion, frequent fainting, and the blue discoloration in his lips, hands, and feet from a lack of oxygen.

You remember oxygen? That stuff that we pretty much need to live. Ahmad needs it too, but his body cannot process it correctly due to the holes in his little heart.

You can follow Ahmad’s progress on Twitter (twitter.com/ahmadbakhtiyar) or via RSS.

Giant Need

See Ahmad’s campaign page on our website to make a contribution to his surgery.

Small Voice

His brown-booted feet hung limply from the chair. Most children wouldn’t be able to resist swinging their suspended legs back and forth in the quiet room surrounded by the seven dwarfs’ familiar faces, the Kurdish curls presumably spelling the names of Dopey and Sneezy and the rest, scattered among painted forest animals on all four walls of Dr. Aso’s combined office, waiting room and examination room. When the doctor was ready, the practiced hands of his mother removed his jacket from his tiny body, his boots from little clubbed blue feet which matched his hands, tormented eyes watching her above his oxygen deprived lips the shade of blueberries.

The doctor’s eyes widened and his brow furrowed as he looked at the Echo, turned to us and said, “This is a very serious case.” When we asked if he was inoperable the doctor shook his head and simply said again, “It is a very serious case…. I don’t know.” Whether she understood English or not Ahmad’s mother read all our expressions easily. She tipped her head to the heavens, possibly to pray, and more practically to give her eyes the opportunity to swallow the tears threatening to escape.

After the picture we snapped of him standing in front of a Kurdish Snow White & the Seven Dwarves, he hid his little face in his mother’s leg and wiped tears from his eyes…

Liz searched her purse for the third time looking desperately for something to give this poor child. She hoped a matchbox car or at least some stickers had magically appeared since she’d last checked, but her hands came up empty again. Her mind slowly absorbed the fact that even if a toy might have brought a temporary smile to his sad eyes, it would do nothing for his frail body. Instead she prayed for the Turkish doctor who will soon undergo the difficult task of setting to rights all that is wrong in Ahmad’s little Iraqi frame.

We’d like to ask you to be a part of Ahmad’s transformation. Of course, these are hard times. But if you can, please consider sacrificing that Ahmad might live.

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

Aras Arrives in Amman, Jordan!

November 28, 2007 by Jeremy · 681 Comments 

A few weeks ago Buy Shoes. Save Lives. took stock of our assets, our debts, our inventory, and our projected future needs and determined that it was time to give a significant chunk of our money to a child named Aras from the Kurdish city of Halabja in Iraq.

Halabja now stands as an emblem of suffering for the Kurdish people; the site of Saddam Hussein’s March 16, 1988 gas attack against Kurds in which 5,000 died in one day.

It felt significant and symbolic to make our first child the child of the city whose scars are carried on today by children who suffer heart disease – nearly 20 years later – because of the gas attacks of that day.

We were nine and younger in 1988, and yet we feel our hands are dirty and that we am somehow complicit in the problems and pains of Aras’ people. $5,000 cannot repair decades of hurt – and decades to come – but as far as feelings go, it felt good to give our money away to Aras and his family.

Today Cody escorted a very nervous Aras and his mother to the airport, where they flew for the first time, and landed many delayed hours later in Amman, Jordan. They were greeted by one of the many partners in this endeavor, Brothers Together. Aras should be headed on to Jordan later this week for surgery.

We are nearly speechless at how amazing this has been. And we’re fairly certain we’ve received new hearts in this process, as well.

Jordan to Jordan

November 28, 2007 by Jeremy · Leave a Comment 

The group of children ready to travel to Jordan was completed tonight when Aras and his mother arrived in Jordan. They had to leave home this morning to get to the airport for their flight which we were told would arrive at 6 pm. We were notified by our partners in Iraq that they were very nervous and didn’t know what to do, so we were planning quite carefully to be sure there were friendly faces on the ground to meet them at the airport.

Aras, is from the city of Halabja, where 5000 were killed in a notorious chemical attack in 1988, probably the most potent symbol of Kurdish suffering. Tomorrow Aras and his mother will cross into Jordan tomorrow for his long-sought treatment for this heart condition.

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…