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)

Baby Noor Continues Healing Post Surgery; Fluid Around Chest Only Concern

August 27, 2010 by Jeremy · 1 Comment 

Photos by Heber Vega

[ ABOVE ] Baby Noor arrives in the Intensive Care Unit all smiles for her morning check-up. Dr. Sri Rao and Kathryn Frazier, RN from the International Children’s Heart Foundation care for her tenderly and take in her joy as our time together in Iraq draws near an end. Noor doesn’t yet know that the procedure to come is going to replace her smiles with tears…

[ ABOVE ] But the tears come loud and the screams come fast as the ICHF and local doctors and nurses begin working together to drain the fluid from inside her chest cavity. Nonetheless, that scream is a sign of a kid with a healthier heart than when she arrived!

[ ABOVE ] ICHF Intensivist Marc Anders administers positive pressure ventilation to Baby Noor during the procedure. The Intensive Care Unit is the area of greatest concern for children in the local hospital. While surgeons and cardiologists locally continue to improve in their training at encouraging rates, local nurses are thrown into the mix without proper training, tools, or respect. The ICHF team feels a strong desire to increase the level of respect, knowledge, and engagement among local staff in the Unit.

[ ABOVE ] Mom waits downstairs in the ward for news as to how Noor is progressing and an estimate as to when they might be allowed to return to their home in the southern most part of Iraq near Basra.

[ ABOVE ] After all is said and done, Baby Noor rests in the Unit with her baby seal, fluids, and a bit of sedation. The procedure goes well, prevents infection, and hastens the day when Baby Noor, her mom, and her dad return home… hopefully in time for the Eid al-Fitr holiday at the end of Ramadan in few days.

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:

Ahmed Leaves the Hospital; On His Way Home with a Healthy, Happy Heart Thanks to You!

August 25, 2010 by Cody · Comments Off 

This morning as I walked into the hospital I almost ran right into Ahmed. He was walking around the hospital ward all by himself; something he wasn’t able to do just a few days ago!

The doctors took one last echo of Ahmed’s heart and found nothing but good news so they let him and his uncle head back home to Nasiriyah.

We miss Ahmed and the several others that have already gone home but it’s an exciting feeling to walk through the hospital and see empty beds that once held sick kids.

They are empty, thanks to you!

As with all the surgeries we facilitate, this is only the beginning of our journey with each one of these children. We stay connected with each family and continue to follow through with each child to make sure they’re continuing to progress in every way. We’ll stop by their homes, go visit them at school and continue to invest in them and their local communities.

The surgery is only the beginning of our work.

We couldn’t be doing any of this if it weren’t for YOU.

Thank you for giving and sacrificing so that others can live. We love standing alongside you.

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:

Ahmed is Doing Great, Out of ICU and One Day Closer To Seeing His Parents

August 24, 2010 by Cody · Comments Off 

Ahmed is now one day closer to seeing his parents. His days of fighting against a completely broken heart are over! What’s ahead of him? Everything! His family, his home, his friends, his school, soccer and anything else any normal four year old with a strong heart would look forward to.

Today, I’m pretty sure I caught Ahmed daydreaming about all of those things as he just spent time relaxing before heading home sometime this week.

I remember meeting Ahmed just last week, with his knees to his chest because that was the only position in which he could breath properly. Now he’s sprawled out on his bed with candy wrappers all around him.

We are looking forward to our last few days with Ahmed and his uncle. Will we miss them? Of course! But we can’t wait for his parents to see him with a healthy, happy heart thanks to you!

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:

Hussein’s Story

January 8, 2009 by Jeremy · 7 Comments 

Hussein, a 3 year old with bright brown eyes, has been one of our more urgent cases and one we’ve been trying to raise funds for very quickly. You may have seen the banner “Save Hussein”. Here’s his story:

November 2nd- Hussein is often short of breath, and although his adorable smiles in these pictures do not show it, he will occasionally simply run out of energy and cry as his mother holds him awhile. His case is quite urgent; the diagnosis is DTGA, meaning he will undergo an operation to switch his great arteries of his heart. His mother is very anxious for him to get the surgery done. As we talked tonight about what it will be like for them at the treatment center, such as the food, and the room where they will stay, she humbly and with tears in her eyes said, “I don’t care if I have only tea and bread, just help my son have his operation.”

November 6th- During one of Hussein’s initial exams, while the doctors asked for some family medical history, his mother shared that her oldest daughter had died of a heart problem in Iraq, as the doctors there could do nothing for her. We can’t really imagine what she must be going through as Hussein is now also approaching treatment.

December 17th- Hussein undergoes a 7 hour surgery, but the surgeons weren’t able to complete the artery switch. Stress is high for his mother and she hasn’t been sleeping at night.

December 18th- Hussein’s 2nd surgery is successful. As soon as his mother sees him recovering in the ICU she notes how pink his skin is and how high his oxygen levels were reading. His heart is finally working properly!

December 24th- Hussein is blooming before our eyes! He’s playing with his mom and making great progress in healing. Now that Hussein is on his way to full recovery, the relief and joy in his mom is so evident.

January 13th- Hussein and his mother finally depart the treatment center and make their way back home to Iraq. What a long road this has been for them and their family. They return to Iraq with very joyful news and a very healthy son!

Thanks for helping us “Save Hussein”. For this 3 year old- it meant everything.

Shkar returning to Iraq

September 8, 2008 by Jeremy · Comments Off 

Shkar, who underwent heart surgery on August 6th, has been healing rapidly and is already on his way back home to Iraq with his mother. The doctors cleared Shkar to return home after they had conducted the final echo-cardiogram and removed the last stitches. The surgeons reported that Shkars heart surgery was relatively easy, compared to other cases, so his recovery has been pretty fast. We’re excited for Shkar to return home and start living life with a strong heart!

Hussein’s heart strong, while mother worries about unrest in Iraq

April 24, 2008 by Jeremy · 1 Comment 

Last week Hussein was given the official clearance to head back home to Iraq! He had a bit slower recovery than the other kids have and required a pacemaker to maintain the health of his heart- but he’s pulled through like a champ! Hussein and his family are excited about his healthy heart, but are also bearing a great weight of concern about the safety of their city in Iraq. Our partner staff in Jerusalem wrote about Hussein’s mother:

“She had an emotional departure from our house in Jerusalem two days ago, and it was obvious when we visited them last evening in the apartment here in Amman that her heart was still full of conflict about leaving the people and the place where Hussein had received the help he needed. She spoke of how wonderful the people are, that there are many good people in Jordan, and how thankful she is for the help they have received. And it is clear to those of us who first met her at the echocardiogram screening in October that the experiences they’ve had have changed the heart of both the mother as well as the son.”

The day Hussein and his mother flew back to Iraq:

“Hussein’s mother was quietly emotional during the time we spent together this day. They return to a very dangerous area of Iraq, and it is beyond the comprehension of most of us the extreme contrast she is experiencing at this time. While with us, she so enjoyed the freedom to go about the city and know she was safe… now she returns to the reality of a life I honestly cannot imagine. She was carrying so many things in her heart! I felt as we rode home from the airport it was as if a revolution was being birthed within her, one which perhaps represents the desires of many others in her nation who have not had the opportunity to experience the things she has. Please join me in praying for this beautiful mother and her son, and their family, as well as for the peoples in the land in which they live, to fulfill the good purpose God had when He created them.”

 

Arya

April 16, 2008 by Ruth · 599 Comments 

Last week Kanar (my translator) and I visited Arya and his family in their home. We had a wonderful time with them! Arya is doing amazing – he’s a two and a half year old boy with Down’s Syndrome. He had a hole in his heart repaired plus an extra thumb removed and arrived back in Kurdistan a few weeks ago. Ayra has one of the the biggest smiles I’ve ever seen and he’s so sweet! His family are over the moon with how he is progressing. He’s even been able to learn how to walk in these past two months since having his heart fixed! Before he often had pneumonia and just not enough energy to motivate him to learn how to walk. His family are so thankful for the way which we have been able to help them. We’ve been invited to their home today for lunch as a way for them to show their gratitude to us. I’ll let you know how that goes and hopefully I can post some pics too!