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)

“Thank You For Save Her, Sir!” Proud Parents Bring Back A Healthy, Adorable Sema

September 13, 2012 by matt · Leave a Comment 

Every mission I could swear I’d met the cutest child on the planet, they’re always one-upping each other. But today this little jewel was carried into the hospital break room, and I’m quite sure she takes the cake. And the crazy thing is, I’d already met her and didn’t realize it!

Her name is Sema (pronounced seh-mah), and she was the first arterial switch operation to be performed in Najaf last February. She was actually one of the first operations from Remedy Mission IX, and now she’s back for a post-op screening (just to make sure everything’s working alright).

Since our last encounter, Sema has learned how to smile, clap, eat on her own, and her skin is now a nice, life-like hue—as opposed to the blueberry tone she had before. Her parents were ecstatic and insisted that I take photos—a dream come true for any photographer!

After Sema had thoroughly won all of us over, her father grabbed Dr. Novick’s hand and, with a cracking voice and moist eyes, said, “Thank you for save her, sir!” His joy was a great reminder of why we do what we do, and it was a great reminder of how desperate these parents are. As you can imagine, the entire team was encouraged by their visit.

But Sema and her sweet smile wouldn’t be with us today if it weren’t for you—you gave money to make sure these Remedy Missions happen, and Sema is a testament to that. Would you consider giving again? Click here to donate and to help us save more children like Sema—we can’t do this without you!

“His Surgery Would Be Five Years Away”—A Father Shares His Story!

February 15, 2012 by matt · Comments Off 

Doctors assigned little Nassir a number—119—and then told him to get in line.

“Should I get a hotel near the hospital for a few days?” his father asked. “No, come back in 5 or 6 years.” So Nassir’s father went home dejected with nothing to do but wait. But waiting could render Nassir inoperable, and then it would be too late.

But, thanks to you, Nassir and his family are getting another chance. Click here to listen to a father tell of his search for a surgery.

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Hamma Is In Surgery!

February 11, 2012 by matt · Comments Off 

Remember super-sad-faced Hamma?! He’s getting surgery now!

I spent much of the day running in and out of the operating room to check on him. His father kept poking his head in from the hallway and whispering, “Psst! Mister! Photo Hamma?”

I felt like an image delivery boy with all the running back-and-forth, but letting Hamma’s dad ‘watch’ his son’s progress through surgery was extremely rewarding—at one point he even side-hugged me!

Here are a few of the photos I showed dad throughout the day:

(The boy isn’t alone here, the nurse just stepped away from the window)

As you can imagine, each picture I showed them brought on strong emotions, and by the end of the day his parent’s eyes were bloodshot from lack of sleep and crying. But the doctors report that the surgery is going well.

More to come…

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Iraq Sees Its Second Arterial Switch—Ever!

January 14, 2012 by Cody · Comments Off 

Baby Ridha was born just 19 days ago. She may not be old enough to keep up with The Fantastic Five, but she was born at the perfect time for the surgeons to save her life. By the time Remedy arrived, Ridha’s heart was at the perfect developmental stage to be fixed, making her the 2nd (and the youngest!) baby to ever receive an arterial switch in Iraq!

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In a Word: “Call”

December 21, 2011 by matt · Comments Off 

A view from the minaret of a local mosque as the call to prayer sounds.

Understanding Ramadan, or Why My Fingers Are Crossed For A Sheep

August 12, 2011 by Lydia · 368 Comments 

The streets were absolutely silent. No kids running around, no mothers yelling after them. It was a little after one on the first day of Ramadan and the whole neighborhood seemed to be telling me, “For goodness’s sake, get out of this heat, go back inside and preserve what few bodily fluids you have.”

But I had a specific mission this day. Having been raised a Christian in the Midwest of the United States, I have very little first-hand experience with Islam. So on this day I was headed to a friend’s home to learn more about this Ramadan business.

Medya and her family welcomed me into their quieted home. The soporific atmosphere had already gotten to her older brother, who lay sleeping on the couch, while other family members wandered around in their house clothes alternating between reading the Koran and staring into space. So this is it? I wondered.

Thirty days devoted to inactivity and religious texts? If there’s one thing I’ve picked up on about my Muslim friends its their whole-hearted love and respect for God’s will. They are intensely devoted to knowing it, following it and furthering it. I soon discovered that the scene in this room demonstrated no less than this.

For the next hour and a half Medya and her siblings (and Google Translate) walked me through the ins and outs of Ramadan. I learned that any good deed done during these 30 days will count for many times over during the rest of the year. They explained people will be more generous, more kind and more caring during this time than any other.

Ramadan is “the month of forgiveness”—a time of fasting and petition before the Most High. A sin forgiven during Ramadan is a sin forgiven 100 times over for the next year. And as Medya reminded me, “God is at all times merciful.” Similarly, if you read the Koran during these 30 days it will be to God as if you’ve read it 30 times. (Medya and her sisters will each read the Koran twice this year—to build a credit of 60 times).

As the afternoon wound down (if that’s possible) they began explaining the concept of “Zikat”. It’s a percentage of all your “saved” assets that must be given to the poor. Any money you’re not using, gold you’re not wearing, or livestock you shepherd must be accounted for. 1 oz of silver for every 140 oz you have, 2.5% of your gold, 1 sheep for every 40. This rule instated by the prophet Muhammed himself has changed some over time.

In most Muslim countries, there is no longer a “Ministry of Zikat” to monitor and distribute these offerings. Instead each family brings their personal percentage of wealth directly to a family in need. “In need” ranges anywhere from abject poverty to refugees to those people displaced because of volunteer work or schooling.

As we covered this last category, Medya’s brother looked at me and laughed, “Lydia—that’s you! Maybe you will get a sheep.”

In the News: “10 Things You Didn’t Know About Ramadan”

August 2, 2011 by matt · 2 Comments 

Ramadan Kareem, everyone!

The Muslim holy month of Ramadan began yesterday, and TIME Magazine published an article on their website with a few interesting facts that you may not have known.

For example, do you know why Ramadan is such an important month for Muslims? Do you know the traditional fast-breaking foods? Some Muslims don’t even swallow their spit during fasting hours! To learn more, check out the TIME article.

And to all of our Muslim friends: what did the TIME article leave out? Use the comments section below to share more interesting tidbits about Ramadan with us!

3 Things I Could Have Only Learned From The Kurds

July 24, 2011 by Ryan · Comments Off 

1: Dressing up isn’t only about looking good

For the most part, in America, men don’t dress up to impress their platonic male friends in social settings. When going out somewhere, whether it’s a sporting event, coffee shop, fast food joint or just hanging out somewhere, men typically don’t dress to impress their male friends. We just don’t. If I showed up to have lunch with a friend wearing slacks, dress shoes and a button down shirt, he’d almost be sure to ask where I was coming from or where I was going, that required such attire.

Would you press your shirt and throw on a tie for an all-guys backyard barbecue? Would you shine your shoes and put on slacks to go watch a ball game at a friends house?

Let’s be honest. The answer is no, you wouldn’t.

But the Kurds do. Every weekend in the bazaar, at tea shops or just walking in the street I see Kurdish men wearing slacks, button-down shirts and the shiniest shoes I’ve ever seen in the dustiest place I’ve ever been. Here in Sulaymaniyah, dressing up is not all about looking good. It’s an expression of respect to the people around you as well as to the friend you are meeting for tea. Dressing up isn’t about demonstrating how dapper you can look. It’s about wordlessly saying, “The time I spend with you is a special occasion, and that is worth dressing up for.”

2: Hospitality isn’t just refilling the bowl of potato chips

I always try to be a good host when people come over. I’ve got the basics down – offer them food, offer them drinks, “is there anything I can get you?” – you know, the usual. But since coming to Kurdistan, I’m realizing that hospitality isn’t just refilling the bowl of potato chips; my hospitality should not be confined to guests at my house.

While being here, so many Kurds have gone to great lengths to show me hospitality: from physically leading me to my destination when I’m lost (despite it being in the opposite direction of their destination) to spending entire afternoons with me drinking tea, playing backgammon, teaching me Kurdish and talking about life. When was the last time you spent an afternoon with a stranger, let alone an acquaintence, just to show them a good time?

3: We all yearn for reconciliation

I entered Kurdistan harboring misunderstandings. Besides some brief reading of Kurdish’s history, most of my opinions of Kurdistan were shaped by mainstream media and ignorance. Let me tell you, that was a mistake. My Kurdish friends laughed as I explained the common perceptions of Iraq and Muslims in general, and grimaced soberly as they explained that Osama Bin Laden wasn’t a real Muslim because of the way he perverted, corrupted and twisted the teachings of Islam for violence and hatred.

My Kurdish friends laughed as I told them that not all Americans are like the people on Jersey Shore and that our nation isn’t entirely filled with debaucherous hedonists. They nodded disapprovingly as I spoke about the Westboro Baptist Church and their hateful and irreverent propaganda, and nodded in agreement as I said that we reject them as true representations of Christian theology and culture.

Many things became clear through these conversations, but the most profound epiphany I experienced was that we all yearn for reconciliation. We spoke about TV and culture, but what we were doing was reaching for common ground, understanding, and reconciliation. In discussing our differences and our misunderstandings, we found a common desire for peace between our cultures.

See One. Do One. Teach One. Remedy Mission Trains Iraqi Heart Doctors and Nurses for the Future of the Children and their Country

February 23, 2011 by Jeremy · Comments Off 

Push play above for a peek into what it means for our volunteers to be here training local Iraqi heart doctors and nurses. After you’ve viewed it, please “SHARE” below with Facebook, Twitter, StumbleUpon, Digg, etc.

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

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Alawi Receives His Much Needed Heart Surgery!

February 21, 2011 by Cody · Comments Off 

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

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

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

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

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

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

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