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)

5 Ways to Destroy a Nation’s Healthcare System

September 9, 2011 by Ryan · 3 Comments 

Whenever someone hears about our kids or reads about our work they almost always arrive at the same question: “How did Iraq get this way?” “What caused this?” “Who’s to blame?”

Well, after 4 years of working throughout this country we believe we can provide you with a concise answer to that incredibly complex question. This isn’t about guilting anyone or pointing the finger (there’s already too much of that going around), but it is a hard look at the answer to your question.

Based on Iraq’s history, here are 5 ways to destroy a nation’s healthcare system:

1. Limit a country’s ability to operate politically and economically
In 1990 the UN Security Council passed Resolution 661, which imposed broad, restrictive regulations upon Iraq. In a nutshell, these regulations stipulated that no country in the UN could import or receive any goods from the country.

Unfortunately, the sanctions did more than impede the political and military action of the Iraqi aggressors. The Iraqi economy, that had been so dependent upon oil exports and foreign trade, crashed as a direct result of the Resolution 661.

In 1989 Iraq’s gross domestic profit was over $66 billion. Just seven years later it was estimated as being $10.8 billion. In 1989, annual income per household was $3,510, and by 1996 had fallen to less than $500. Before the sanctions, 93% of the population had ready access to healthcare institutions, which were staffed primarily by physicians who had been trained in Europe or the United States.

This economic collapse primed the country for the health crisis it is in today, a health crisis that has lead to the death of inestimable millions over the last two decades.

2. Slash governmental healthcare funding
In the 1990′s Saddam Hussein cut spending on healthcare by 90%. Continued education, supplies of necessary equipment, and valuable public health programs all suffered without adequate funding research.

Without funding and governmental support, the healthcare system deteriorated.

3. Reduce the number of medical professionals in the country
In some areas, insurgents made it a practice of targeting medical professionals. Although many doctors were not individually targeted, they were still in danger. Ambulances were frequently robbed of their medical supplies, and it was not uncommon for gunmen to enter hospitals and force doctors to care for their injured family members or comrades.

Another blow was dealt to the stability of Iraq’s healthcare when many doctors and nurses, who were lucky enough to escape death, fled the country in a mass exodus, further damaging the quality of the Iraqi healthcare system.

The murder and exodus of Iraqi healthcare professionals is tragic. It has left many families broken and many patients without the care that they need. But the negative effects extend beyond their families and the patients they left behind. Without their mentor-ship, expertise, and knowledge, generations of students from universities and teaching hospitals will continue to have insubstantial educations.

4. Destroy physical healthcare infrastructure
In 2003 American and Coalition forces destroyed two primary public health laboratories and an estimated 12% of hospitals. While speaking about the state of the nation’s healthcare infrastructure, former Minister of Health of Iraq, Khudair Abbas, explained that of the remaining primary care centers, “15% have been looted. Even though 80% remain intact, 40% need extensive repairs…13% do not have clean water and one third are staffed primarily by paramedics rather than physicians”.

During the Gulf War, American and coalition forces destroyed key elements of Iraq’s infrastructure. “Bridges, communications, electricity supplies, water and sewage systems, weapons factories, healthcare facilities, administrative centers, warehouses” and homes were destroyed. While this may have been a strategy aimed at ceasing Iraq’s ability to make war, this strategy did far more than defeat the Iraqi military.

5. Overburden the healthcare system by creating too many patients

The above contributing factors deal primarily with political, structural, organizational, or educational deficits. Ultimately, however, it is the population of patients that compose the largest component of any healthcare system. And, regrettably, there is a vast population of patients in Iraq.

The demolition of water and sewage treatment plants lead to outbreaks of typhoid and cholera. In 1989, there were no cases of cholera per 100,000 people; just 5 years later there were 1,344 cases per 100,000 people.

According to studies, by 1996 31% of children under five were chronically malnourished. Just a year later, there were a million children under the age of five who were malnourished, and a year after that 70% of women were suffering from anemia. Another study, consistent with the information on malnutrition, found widespread, chronic stunting in school children as an indication of long-term malnutrition.

Poverty’s wide-spread negatively affects the livelihood of the Iraqi people. Low socioeconomic status is associated with lower levels of education, poorer nutritional intake, and higher risk of congenital heart defects.

Research shows that poor diet contributes to far more negative effects than weight loss, anemia, nutritional deficiency, and compromised immune system. Without the funds to afford healthier food, mothers with higher intake of saturated fats and lower intake of nicotinamide (vitamin B3) have increased risk of giving birth to children with congenital heart defects. 5, 8 Furthermore, low dietary intake levels of folic acid (vitamin B9) around the time of conception have been linked to higher risk of neural tube disorders.

But nutrition and education are not the sole arbiters of death and ill health. Many parts of the country still suffer from the chemical and biological attacks perpetrated by Saddam Hussein. Not only are individuals suffering from primary exposure, but research supports that children of those who were exposed suffer secondary effects in the form of birth defects.

The list of health problems and their contributing factors continues ad nauseam, and the patient-load continues to overwhelm doctors.

The evidence shows that the state of Iraq’s healthcare system has been nearly two decades in the making. The downward spiral began with sanctions in the 1990’s by making the nation more susceptible to economic collapse. It continued with a multitude of factors including military action by the US and Coalition forces, violence wrought by religious extremists, and a vast backlog of patients.

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The question remains, is it too late for Iraqis to rebuild their healthcare system?

Is Iraq too far gone?

Of course not! The restoration of Iraq’s medical infrastructure is happening now!

This November 5th will be our biggest surgical mission yet–lives will be saved, doctors will be trained and Iraq will be one big step closer to restoring what was broken!

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”

Practicing The Art (and Reviewing the Basics) Of Taking Care Of Sick Children

February 25, 2011 by Cody · 1 Comment 

“Heart surgery is an art.” Dr. William Novick, ICHF Heart Surgeon

If heart surgery is an art, then a Remedy Mission would be the art studio. It’s the place where teaching happens and inspiration is born. It’s a place where masterpieces are created alongside artists.

But it’s an art that everybody in the heart center gets to play a role in. Whereas an artist can create a beautiful piece on his own, a heart surgeon can’t perform a flawless surgery without a team around him. When they work together and finish their part, the piece is carefully passed along where it’s taken over by the nurses in the intensive care unit.

Without a strong nursing staff, the masterpiece would never be completed.

Teaching all of this is an art as well.

In the same day a local surgeon is having his skills refined as he patches a hole in a heart and the nurses in the ICU are being taught the foundations of nursing.

In the West, we have benefited from governments who have been able to spend BILLIONS on health care, education, and creating awareness about best practices, and things like hygiene from the time we were in elementary school.

At Iraq’s lowest point under Saddam, the Ba’ath regime spent less than one dollar per person on health care each year. While other parts of the world were thriving, Iraq’s health care system – along with their doctors and nurses – weren’t given what they needed to keep up.

Our Remedy Mission comes at a pivotal time in Iraq. A time where they now have the opportunity to be invest like never before.

It was sobering when we heard that little Alawi is trying to fight off a bacterial infection in his chest, something that is easily caused in an ICU which doesn’t even have a sink or soap with which to wash your hands. Don’t worry, we’re trying to work with local officials to get that retrofitted!

Through our Remedy Missions we’re helping raise up local health care systems that excel in the complex but also in the fundamentals of taking care of children.

All of it goes into creating a masterpiece.

We couldn’t do this without a coalition that cared as much about this as you do!

You’re a part of the masterpiece.

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.

Our Partners

Ahmed’s Surgery a Complete Success; Heart Stronger Than Ever Thanks to You!

August 21, 2010 by Cody · 2 Comments 

Ahmed is prepared for surgery with our visiting cardiologist, Dr. Sri Rao, of the International Children’s Heart Foundation. Photo by Heber Vega

Ahmed’s 5 year battle to obtain his much-needed heart surgery is now a thing of the past after a 5.5 hour surgery that successfully corrected all five major heart defects! He’s now resting in ICU with his uncle who hasn’t left his side since his parents were seriously injured in a car crash this past week. If you haven’t read Ahmed’s story be sure to read it here.

We’ve all fallen in love with Ahmed, there’s no denying it. Today our joy is through the roof as we celebrate Ahmed’s life and the good news that both of his parents are recovering with him a few hours away in their home city!

Ahmed’s heart can now give his body everything it needs to run, jump, and shout for joy, thanks to you!

It’s always an exciting journey to the hospital each morning to see our kids. But tomorrow morning the trip is going to be special.

We can’t wait to see our friend, Ahmed.

With you,

Remedy Missions are international pediatric heart surgery teams that we bring to Iraq to to perform lifesaving heart surgeries and develop the infrastructure for the future. If you’re on Twitter this week be sure to use the #Remedy or #RemedyMission hashtag to describe all the good news coming out of Iraq this week via @preemptivelove and @babyheart_org. If you’re on Facebook, “Share” this story with the button below.

Our Partners:

Current News Coverage of BSSL in Iraq

September 13, 2007 by Jeremy · Comments Off 

Thanks to all of the journalists and newspapers who have put out time and effort to promote healthcare to Iraqi children through Buy Shoes. Save Lives. Check out the articles below to hear what they had to say (assuming you know English, Kurdish, or Arabic).Thanks!

-BSSL