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)

Photo of the Day

June 4, 2010 by Lydia · Leave a Comment 

Kids gathered in parks to play, dance, fly kites, and eat ice cream here in Sulaymaniyah to celebrate International Children’s Day on June 1! What a great way to celebrate life.

“There are Few Things More Satisfying” – Reviewing a Year of Family Advocacy in Iraq

May 27, 2010 by Joshua · Leave a Comment 

For those of you who have been following our blog this last year, you’ll remember this little guy! We went to visit him last summer in Chamchamal (the border city of Kirkuk) to talk through what was, at that point, his prospective surgery. Well, he had his surgery this past November and he’s doing great! We went to visit him the other day to check up on him and to visit with the family. Man, I love this little guy!

There’s something really beautiful about being here for a longer period of time− longer than the two-month summer internship which first brought me here in 2009. Now, almost a year later, I feel much more like a father, or an older brother, to these kids. I’m with them when they’re sick. I’m in their homes. I see them off to surgery. I welcome them home when their hearts are no longer broken. But what’s really important to me is that I watch them grow up, watch them as they live out the lives their repaired hearts now afford them. Kids like Danar really hit me.

He’s one of the ones I’ve been able to track the entire time. I was there when his family first brought him to our office. And I was there when we first visited his home.

And now, I’m here as he grows up finally able to do the things his heart once prevented him from doing. And there are few things more satisfying than this! I am part of a coalition. The coalition is not just the people in Iraq; it’s all our supporters.  We’re all doing it. I am here because of our shared vision for the future of Iraq and on behalf of the Danars of this country.

The ability to track these kids through the whole process  pushes me on − to see them back in their homes running and jumping after their hearts have healed. This is why we work.

For more information on how we plan to create this sort of impact in the lives of 30 children this August, please click to learn more about our Remedy Mission – a team of surgeons, doctors, and nurses we’re bringing into Iraq to perform surgeries and training this August.

Super Bowl Winner Malcolm Jenkins Speaks Up (A Few Months Ago!) For Iraqi Kids

February 10, 2010 by Jeremy · Leave a Comment 

Our congratulations to the New Orleans Saints and the Indianapolis Colts for a great game and a hard season. Special congratulations, however, go to cornerback Malcolm Jenkins for using his platform as an athlete to speak up on behalf of those whose voice is scarcely heard or heeded. Malcolm – along with many others who never won the Super Bowl – is like a megaphone for the kids of Iraq…

What about you? What are you up to for the kids of Iraq? If you’re a college student or post-college student, might we suggest our Summer Internship? There are still a few weeks left to apply!

Let us hear from you!

Banquet & Carnival in Iraq Celebrates Hope & A Future for Twenty of Our PLC Alumni Kids

August 20, 2009 by Jeremy · 24 Comments 

Eight year old Ahmad was on the brink of death when we met him. Now he’s rambunctious and carries his little sister all around the place!



Turkey Director, Scott Bertrand, with Hospitality Coordinator, Abby Bertrand, and Rezhin’s family.



Physical Therapist and Family Advocate, Ruth Simpson, at the banquet.



Executive Director, Jeremy Courtney, with Roman and his father amidst the fun and games.



PLC 2009 Summer Intern, Joshua Gigliotti, and Mohammed

Dear Preemptive Lovers,

In the midst of our most recent series of life-saving surgeries being conducted in Istanbul, Turkey for Iraqi kids we wanted to pause on the drama and reflect for a moment on what you’ve helped us do in the past year together. To date you’ve helped us give 44 children the surgeries they so seriously needed and we’ve raised/given away over $250,000.

In celebration of this we hosted our second annual PLC Alumni Kids Banquet on July 17, 2009 in Iraq for all of the children we’ve served between August 2008 and June 2009. We had over twenty families in attendance, a small team of volunteers from a church in Texas that helped fund the banquet, and 8 summer interns from all over the U.S. We also had special guests from the local community, including renowned artists, political players, and medical professionals.

But the stars were, of course, the children themselves. What a joy it was to see little boys with brand new soccer balls – a gift that would have previously been something of a cruel joke for most of these boys. The girls came decked out in the party attire and the children were showered with thousands of dollars in gifts from supporters in the States.

It’s been a great year (we just missed announcing our second organizational birthday amidst the flurry of activity) and it’s hard to believe that we’re able to live out this dream. And we wouldn’t be able to without you… So here’s to you and the kids you’ve helped. It’s a joy to be a facilitator of your love and kindness in the world.

For Hope & Future,

Jeremy Courtney
Executive Director

Two Great Pictures of Mohammed’s Surgery by 20-year-old PLC Summer Intern

July 24, 2009 by Jeremy · 6 Comments 

A few pictures from the middle of Mohammed’s surgery with Dr. Sertaç Çiçek and Dr. Ahmed Arsalan taken by one of PLC’s summer interns, Benjamin Landis.

Follow 11-year-old Mohammed on Twitter: @mohammedgaelan. Subscribe to Mohammed’s updates via RSS here. Follow Mohammed’s thread of longer stories (with pictures) on the PLC blog here.

Preemptive Love Coalition Summer Internship 2009

July 20, 2009 by Jeremy · Leave a Comment 

This post has been a long-time coming… We are excited to introduce you to the PLC Internship class of 2009!

This year’s interns have been phenomenal and have brought a lot of thoughtfulness and passion to work each day. They’ve put in long hours and gone the extra-mile in nearly every way imaginable. To hear them talk about the ways in which their previously held perceptions of Iraq, Islam, Kurds, Arabs, etc have changed has all been very refreshing. But more than changing the way they think about others, it seems this summer has helped us all change the way we think about ourselves.

PLC is extremely grateful to Ben, Josh, Jeremy, Nathan, Christin, Audrey, Ashley, and Angel for all of their hard work this summer. We’re better people for knowing you. And we’re especially excited that our journey together doesn’t need to end here.

Looking forward to years of friendship and journey together…

Preemptive Love Coalition Staff

Shwana Better Than Ever At Home in His Village Once Destroyed By Saddam Hussein

July 9, 2009 by Ruth · 4 Comments 

Qaladzya is a village in northern Iraq that was completely destroyed by Saddam Hussein in the late 1980′s as part of his Anfal Campaigns against the Kurdish population. This and the destruction of 4,000 other similar villages prompted a mass exodus of Kurdish families to the Turkish and Iranian borders at the close of the decade.

Shwana’s parents are survivors of Saddam’s terrible attacks. Today they live in a small two room house where they raise Shwana and his three brothers and sisters. Shwana’s father is a science teacher.

In spite of their meager monthly earnings, when PLC executive director, Jeremy Courtney, and Family Advocate, Ruth Simpson, visited Shwana’s family along with two of PLC’s summer interns on Tuesday we were treated to a feast of rice, beans, chicken, beef, stuff tomatoes, onions and peppers, and banana pudding. Plus loads of tea! Shwana received his heart surgery in May and has been recovering quite well every since.

It was a celebration to behold as we enjoyed the gift of life that so many of you around the world have worked to give nine year old Shwana. The food was great, but it was the smiles and the obvious gratitude that give us such continued joy in serving the people of Iraq as we seek to undo the effects of Saddam’s reign.

Rezhin Doing Great Post Surgery & Growing Up Fast After So Much Childhood Lost

July 8, 2009 by Jessica · 1 Comment 

Last Thursday PLC Family Advocates and a few summer interns went to visit Rezhin, a tiny and precious 12-year-old girl who received heart surgery in early 2009. As we watched a slideshow of her stay at the hospital, we were able to see the bond she formed with the PLC staff and the other kids who were there during that time. Now that school is out for the summer, she doesn’t have anything planned besides enjoying the break from school!

She is doing so well physically now (which is exciting!), but we can’t help but grieve the years of childhood that she missed out on while waiting for surgery…especially since she is now caught in the awkward age between being a kid and wanting to “grow up”. At one time during our visit, she pointed out a bracelet on her wrist that she got during her time away with a smile. This reminds us not to dwell on the past but to be thankful for the ways she has been healed and hope for the new way that she can live. We greatly enjoyed being in their home and the summer interns are particularly excited to see her again this summer before heading back home.

Rezhin represents another of the many Iraqi children who are not getting their surgeries in a timely manner. Granted, her condition had not deteriorated to the point of inoperability when she received her surgery, but she had already missed out on all of her childhood years, sick and playing it safe by the rules established for her by an easily corrected heart defect.

To help future kids like Rezhin get well and keep their childhood, please consider donating to the Shad Faraydoon Memorial Fund for Infant Surgeries by clicking here.

Ranu Giving Others Rides on Her Bike After Her Successful February Surgery

June 29, 2009 by Jessica · 1 Comment 

Yesterday, PLC Family Advocates and Summer Interns visited Ranu, one of our heart surgery kids from February.

She looks so different, we almost didn’t recognize her! Not only does she have a new hair cut, but she looks much healthier. While we were there, she was running and playing, which she was unable to do before her surgery. Prior to her surgery, whenever she was tired, she just laid down wherever she was. Now, she is able to run and play like any other 5 year-old. In fact, she was so active, while we were there, she gave kids rides on her two-seater bike.

Bruska Ready for School in the Fall After Successful Heart Surgery Last January

June 27, 2009 by Ruth · 173 Comments 

Yesterday, PLC Family Advocates and Summer Interns went to visit Bruska. Bruska was all smiles while we were there. She really wants to go to school next year with her older sister. You can tell she really loves her family and that she enjoys being around people. As our physical therapist, Ruth, worked a little with her, her face lit up – especially while playing with her doll.

She is doing well since her heart surgery in January.

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