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)

How Caring for Iraqi Children Made Me A Better Father

June 16, 2011 by Jeremy · 1 Comment 

Hope for Baby Bakir and His Ruined Hometown

November 15, 2010 by matt · 2 Comments 

Meet Baby Bakir (pronounced bah-ker). Thanks to the combined efforts of Nahoko Takato, the talented doctors and nurses at Anadolu Medical Center, and the Preemptive Love Coalition, this beautiful little boy is now recovering after receiving a lifesaving heart surgery in Istanbul, Turkey.

This is actually an exciting week for Bakir’s hometown of Fallujah as it’s the first annual Remember Fallujah Week. US veteran Ross Caputi launched the Justice for Fallujah Project to decry the atrocities committed against the citizens of Fallujah during the Iraq War.

US officials report that more than half of the city’s 39,000 homes were either damaged or destroyed in Operation Phantom Fury in 2004, and, like Bakir, many of the city’s children have continued to experience the lingering effects of chemical weapons in the form deadly heart defects.

Yet in the midst of so much destruction, we’re eager to offer you stories like Bakir’s. In a city of rubble, his is a bright story of hope and future.

You Just Helped More Kids in 12 Days Than Any 12 Month Period in Our History… for Less!

September 13, 2010 by Jeremy · Leave a Comment 

Deeya is alive and doing well at home today because of the surgery you provided for her in Iraq!

Wow! What a phenomenal trip it has been these last few weeks as you have brought a new remedy to the children of Iraq through the surgical and nursing team of Dr. William Novick. It’s high time we update your impact to help Iraqis make a better future for themselves and their children.

The total expense for our first Remedy Mission was approximately $90,000. This amount was further subsidized by the Director of Health in our city and the Kurdish Regional Government in Washington D.C., and the International Children’s Heart Foundation. The balance was underwritten by you!

This family was not yet chosen for surgery… they are still waiting for our next Remedy Mission.

Locally, Remedy Mission was a great success. We ended the week at dinner with the governor and the health director where they invited us to start our next Remedy Mission as quickly as possible. When we suggested May 2010 as a next date, all the surgeons and the health director rallied together to urge us to begin again in February instead.

Our current proposal is a five year plan comprising four trips per year to make the Sulaymaniyah Cardiac Center a premier facility in the region that is able to perform 12-14 surgeries per week without foreign assistance. We estimate that this will cost $1.5m and we are currently talking with the local authorities in hopes that they will choose to shoulder the majority of that expense.

During Remedy Mission ICHF and local surgeons performed 25 corrective cardiac procedures. Put differently, we helped more kids in 12 days than we have in any 12 month period to date… at a massive savings compared to our work in Iraq… with hands-on training for Iraqi doctors and nurses! A typical all-inclusive surgery in Istanbul costs us $10,000 (after subsidies). That expense is usually shared among the family of the child, local and international donors. The typical PLC international donor portion of a surgery in Turkey is $3-5k.

Cody Fisher reviews the list of kids who received surgery and kids still in line for February 2011.

The numbers for Remedy Mission look much different. Not only are we able to work in partnership with others more during Remedy Missions, but every surgery represents a local development and training opportunity. The all-inclusive price for all partners was approximately $3,600 per child (compared to $10k in Istanbul and much more in the States or Europe).

Remedy Mission has taught us a lot about being fiscally and developmentally responsible. Therefore, in an effort to redouble our commitment to long-term local solutions, we will be increasing our Remedy Mission funding in hopes of facilitating four Remedy Missions in our current city in 2011.

The following families are still waiting in line for our help…. Will you be the remedy? Donate the amount of your choice below to get our next Remedy Mission off to a strong start!

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.

VIDEO: Four Iraqi Children Arrive in Istanbul for Lifesaving Heart Surgery

July 20, 2010 by Jeremy · Leave a Comment 

On July 18th four Iraqi kids arriving in Istanbul, Turkey in need of lifesaving heart surgery. They have entered a country about which they have mostly heard negative stories.

This week will change their perspectives and change their lives forever…

Follow Chro on Twitter: @ChroArkan. Subscribe to Chro’s updates via RSS HERE. Follow Chro’s thread of longer stories (with pictures & video) on the PLC blog HERE.

Follow Leah on Twitter: @Leahibrahim. Subscribe to Leah’s updates via RSS HERE. Follow Leah’s thread of longer stories (with pictures & video) on the PLC blog HERE.

Follow Nivar on Twitter: @NivarMohammed. Subscribe to Nivar’s updates via RSS HERE. Follow Nivar’s thread of longer stories (with pictures & video) on the PLC blog HERE.

Follow Jeen on Twitter: @JeenMustafa. Subscribe to Jeen’s updates via RSS HERE.

Purple Dress & Purple Skin – Nivar Arrives in Istanbul in Time for Much Needed Heart Surgery

July 18, 2010 by Jeremy · Leave a Comment 

Her purple dress could not have matched her skin tone any better. As Nivar disembarked the airplane after arriving safely in Istanbul, I was more than a little scared that all our efforts were going to amount to a movement from the frying pan to the fire.

The oxygen in a crowded airplane cabin at cruising altitude is not the ideal environment for a child with a heart defect that inhibits the flow of oxygen throughout her body. And when I saw Nivar crouching down in the airport after going through the first round of security, I was really afraid that we might lose her right then and there.

In GOD’s kindness she worked through her breathing difficulty with the determination of someone who has never known any better. While I was worried about her, she seemed to hardly know anything was wrong. This shortness of breath, clubbed hands and toes, and deep blue skin is all she’s ever known.

Upon arriving at the hospital it was more of the same. She preferred to crouch on the floor to sit in her beautiful private bed. In fact, she preferred to crouch on the floor to pretty much any thing else at all.

But she’s here. She survived the flight and the travel across town – two things that we are constantly concerned about with children who are as sick as Nivar. Now she is in the capable hands of the medical staff at the Anadolu Medical Center. In a few days’ time, she will have had her heart surgery and, with great likelihood, will be on her way to a totally new life of long walks and intense soccer matches with her brother.

Stay tuned for more…

Follow Nivar on Twitter: @NivarMohammed. Subscribe to Nivar’s updates via RSS HERE. Follow Nivar’s thread of longer stories (with pictures & video) on the PLC blog HERE.

Photo of the Day

July 6, 2010 by Lydia · Leave a Comment 

Two weeks from now we will be taking five kids to Istanbul for surgery! Keep watching the blog for updates on their progress.

Bawar Plays Football While We Visit Inside About His Much Needed Heart Surgery

May 13, 2010 by Joshua · Leave a Comment 

It looks like we found Bawar in time… still playing football! But before his window of time runs out, we plan on taking him to a much needed heart surgery in Istanbul, Turkey.

Baby Leena Leaves Iraq for Urgent Surgery in Turkey

April 14, 2010 by Jeremy · Leave a Comment 

It was about mid-morning on Sunday when Leena’s dad came into our office, frantically looking for help for his daughter who was dying before his eyes from her congenital heart defect.

We contacted our partners in Istanbul at the Anadolu Medical Center and they concurred: it might be too late for Leena, now 50 days old, but if there was any remaining chance she should come immediately.

With unprecedented speed we worked with Leena’s father and their extended family to get Leena to surgery. The family and friend network rallied quickly sold their car and rallied with a total of $10,000. Within just a few hours we were able to get our local staff, Leena, and her mother on the very last seats out of Iraq on Tuesday’s flight to Istanbul.

The picture above is Leena’s last moments with her father before leaving him to go back to the village where he is 8 year old Mohammed Star’s elementary school teacher, whom we sent to surgery in November 2009.

Are you looking for a way to get involved? Let us suggest the following three actions: - Sign up for our newsletter to stay apprized of news and deals on stuff you can buy to save lives in Iraq. Name: Email: - Send out a “tweet” or a message about us on Facebook, suggesting your friends check out these dear Iraqi kids. - Give your time or money. Both save lives! For volunteering, send an email to cody@preemptivelove.org. For life-saving tee shirt, shoes, and scarf purchases, head over to our Buy Shoes. Save Lives. store for our 25% OFF SPRING SALE. For donating money, please use the fast and simple form below.

Meet Deelan (Twitter: @DeelanKameran)

March 2, 2010 by Jeremy · Leave a Comment 

Deelan arrived in Istanbul, Turkey last night on a plane from Iraq thanks to Atlasjet Airlines and the generous support they’ve offered to help us get this February group to surgery. If you are one of our summer interns, we highly recommend that you choose Atlasjet to fly into Iraq.

Our Family Services Director, Jessica Courtney, (who, if you’re keeping score at home, is also my wife) accompanied Deelan, his mother, and one other family to Istanbul last night to round out our February/March group of surgeries.

Special thanks to the Alice Abdi at the Anadolu Medical Center for the continual support, for staying late at the hospital to receive these dear kids, and for sending – as always – a special private van to pick up these fearful families. This keeps our costs low, speeds up our travel, and most importantly, shows the kind hearted desires of so many here in Turkey as they reach out to Kurds and the rest of the people of Iraq in providing these deeply discounted, life-saving heart surgeries.

Deelan is not doing well at all – crying nearly constantly and facing down dangerously high pulmonary pressure in addition to the huge hole between the lower two chambers of his heart .

Deelan is scheduled for surgery on Wednesday.

Follow Deelan on Twitter: @DeelanKameran. Subscribe to Deelan’s updates via RSS HERE. Follow Deelan’s thread of longer stories (with pictures & video) on the PLC blog HERE.

*In accordance with PLC’s desire to lend a hand-up by avoiding strict hand-outs (when possible), Deelan’s family contributed $5,000 towards PLC’s highly-discounted surgery prices.

50 Family Focus + Two Teams of Turks = 90 Kids in 2010

December 30, 2009 by Jeremy · 527 Comments 

To date, we’ve served 45 children by offering families a hand-up in their efforts to save their own children’s lives. We’ve seen poor families work harder and smarter to take part in our family participation program to fund a portion of their child’s surgery.

As we enter 2010 we plan to up the ante and send 50 children out to surgery in Istanbul, Turkey at the Anadolu Medical Center. We hope to do this by sending four children every month. (January’s group is already set and February and March are filling up quickly!). The price tag for these surgeries will be roughly $500,00 – with at least 50% of that amount coming from local Iraqi sources!

Additionally, we hope to make 2010 a year of investing in local infrastructure by creating forums for the exchange of knowledge, skills, and experience by bringing in foreign experts to operate and train local cardiologists, surgeons, and nurses to hasten the day of more local solutions to local problems in Iraq.

We aim to bring 2 surgical missions into Iraq this year to serve 40 additional children in local hospitals by training local surgeons, cardiologists, and nurses. We have already begun screening candidate hospitals, cardiologists, and surgeons to ensure our investments go to the most disciplined and visionary practitioners.

Kids like Honya, Vary, or Mohammad have made 2009 an amazing year. Does 90 kids mean that 2010 will be twice as joyous?

Click here to join in on the Fifty Family Focus for 2010.

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