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)

From My Heart to Yours—An Intern’s Personal Encounter With Congenital Heart Defects

June 26, 2012 by Tyler · Leave a Comment 

Hey guys! I want to tell you a story…
My cousin’s daughter, Madi, was born with a congenital heart defect (CHD). Seeing my cousin suffer wasn’t the only reason I chose to work with PLC this summer, but it was a major one.

Madi’s fight for her life began the day she was born, and it serves as a constant reminder of how important my work is here in Iraq.

Madi (short for ‘Madison’) spent the past 9 months in the world-renowned Texas Children’s Hospital receiving constant care and, for the past 4 months, she has been kept alive by a “Berlin heart,” an artificial device that pumps blood for her heart until she can get a transplant, technology that does not even exist in Iraq. Since Madi began treatment with the Berlin Heart, her name has been at the top of the heart transplant list in Houston. Through all that has happened, I have seen the complexity of CHD and the importance of having a well-trained medical staff.

I’m happy to report that, on May 29^th, Madi received a NEW HEART! And this past week, after over 220 days in the hospital, Madi is now at home and ready to start the life she is supposed to live.

Our family spent months in prayer for Madi, and now we’re rejoicing, grieving, and praying through all that has happened. Although God has brought Madi and her family far, their journey is by no means over.

I hope you can join me in the celebration of a saved life, realizing that this is how families all across Iraq are affected when their child is saved. To date, PLC has saved hundreds of lives and will continue to save more. But each child has their own story and their own friends and family who are deeply involved in their battle with CHD.

So, wherever you are, try to enter into their story; see, feel, and think as they do, and then thank God if you have healthy children and great healthcare! You can also join us in our battle to fund surgeries, build infrastructure, and raise awareness for Iraqi families who aren’t as fortunate as my own by giving toward our brand new Remedy Fellowship campaign—help us save 300 little lives!

Want to hear more of Madi’s story? Check out stories by ABC or Fox News to learn more about this amazing little girl.

“No longer will she have to struggle to catch her breath every hour of the day or feel like she can’t stand and play with her toys because she’s too tired. Our baby girl will get to experience what life is meant to be, not what it has had to be for the past 22 months.”
—Tabitha Fleak, Madi’s mom

Breaking News: Ali Made It Through Surgery!

January 19, 2012 by Cody · Comments Off 

Ali was just brought out of the operating theater and into the ICU—with a mended heart!

The next 24 hours will be absolutely crucial for Ali, though. The operation was a complete success, but now we have to wait to see how his heart and the rest of his body will respond.

I ran into the ICU so I could take the above photo of Ali and show it to his mother. She was ecstatic to see her little boy!

Who knows what will happen next—Ali could be up walking around as soon as tomorrow!

Our Partners:

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.”

 

Baveel

April 16, 2008 by Ruth · 482 Comments 

 Two weeks ago Baveel came to visit us at the office. We lost electricity just before he arrived so understandably he wasn’t’ able to make the climb to our office on the 6th floor so we just met outside in the car. He’s recovering reasonably well from his surgery and looks super cool with his new hair style which he had done in Jordan! On the down side, he isn’t eating well and is quite underweight which is hindering him from reaching his full potential. He also needs to start building up his exercise tolerance; he had been spending the majority of his time indoors playing computer games. I explained the importance of eating well and being more active and gave him some ideas as to how to work on these things. I’m hoping that when we see him again next week that he will have his appetite back and that he’ll be playing less computer games and instead be playing much more outdoors with his friends. If you’re inclined towards prayer, lift up one for Baveel as he continues to recover.

The Wait is Over

February 20, 2008 by Jeremy · 633 Comments 

The wait is over! Being the last of the Iraqi children who came over the border on December 31, 2007, Arya has now been admitted to Wolfson Medical Center for surgery scheduled for tomorrow morning, February 21st. The complexity of his heart condition and the severity of the operation necessitated the delay.

For Arya’s mother, the months of heartache while watching other children go into the hospital and subsequently return and leave for home was quickly becoming unbearable for her to behold. We are pleased to tell you that today, we saw Mom jumping for joy and speaking as clearly as she could in English, “I love you, I love you” as she stood in the pediatric ward smiling from ear to ear as she told us how God answered our prayers.

Aras comes through surgery today

January 3, 2008 by Jeremy · Comments Off 

 

Today it was finally time for Aras’ surgery. Accompanying an older child for their surgery is very different than going with one of the toddlers or pre-school aged children. Patients here are not given any sedation before they go to the operating room, so Aras was fully alert, and knew exactly what was about to happen, and couldn’t hide his fear in those final moments. Seeing him cry made his mother cry too. Seeing Diyka Aras’ distress as we walked out into the hallway, one of the medical personnel asked us to wait while she went to check on how long it would be before he would come upstairs. The answer we were given was that it would be a long surgery of about five hours.

 

 Five hours later. Dr. Sasson, the surgeon who performed the operation, came by and told us that everything went very well. Diyka Aras was very relieved, yet as is always the case, she wasn’t able to be sure all was well until she saw her son for herself. When we saw two men wheeling his bed down the hall to the ICU, she cried and thanked God as we walked with them until they were inside. 

Hussein’s Sister Died of Heart Complications

November 8, 2007 by Jeremy · Comments Off 

This is cross-posted from our partner Brothers Together’s site. We wanted you to hear this story so you could feel the gravity of the problem these famillies face.

Tuesday, November 6, 2007
Sister Died of Heart Disease
Filed by Donna Petrel

A sleepy Hussein arrived with his mother from the Save A Child’s Heart house this morning, along with Mustafa and his mother, for his echo and further tests. Yesterday Dr. Katz attempted to do an initial echo on Hussein, but none of us could settle him down enough for the echo to be done. Because it was late in a very long day, the doctor decided that waiting until today would be best for all of us, and dismissed Hussein to the SACH house. This morning Hussein was given a syrup to make him sleepy so he would not be distressed over the echo, and even though he arrived at the hospital already sleepy, this did not stop his fearful fretting for quite awhile. Yet when he finally fell asleep, he was peaceful during an hour-plus long echo by several doctors who were discussing his complicated case as they went through the examination. Hussein awoke before the end of the exam, and Dr. Tamir spoke to him gently about helping him grow up to be a big boy, which seemed to settle him back down so the exam could be finished to the doctor’s satisfaction.

During today’s exam when Dr. Tamir took some family information about Hussein, his mother told of the death of an older daughter who also apparently had heart problems. She told of how the doctors in Iraq could not help her after she was admitted to the hospital at the age of nineteen, and so after four months, the daughter died. She had shared with me in Amman that one of her children died, but she did not tell me the details. After hearing this today, it helped me realize why she is so anxious to know whether Hussein will be able to have surgery or not.

Later in the day as Hussein still waited at the hospital, this usually shy boy was content to go to the children’s playroom where they were making balloon animals. He also enjoyed playing with his friend Mustafa and visiting with Hedi in his room there. It was determined that both Hussein and Mustafa could return to the SACH house for the night, and come back for more testing later in the week. Tomorrow we hope to visit them there. Please keep praying for Hussein and his mother as they wait for the surgery which will give him a new heart, and give joy to the heart of his dear mother.

One Degree of Separation from the President’s Wife

July 15, 2007 by Jeremy · 272 Comments 

Today Buy Shoes. Save Lives. was just one degree of separation away from the First Lady of Iraq. This is one very good thing about media here: if you know someone high up at a media office, they are inherently close to the most important people in the country.

So today we pitched Buy Shoes. Save Lives. to two different people who “know” the First Lady. I leave it up to you to guess what that actually means for us. I currently have no idea.

The First Lady is well-known for her organization, Save the Children. It was all but guaranteed that she could at least expedite the visa process for children we send abroad. That is no small thing, as we currently know of two children who need medical care but are held up in process for a visa.

But there’s also potentially funding available – and I’m hopeful she would like the idea of us creating one of the first non-oil Iraqi exports.

So, if you are one who prays, please do so tonight, asking God to make this a networking opportunity that does not fall flat in the Iraqi dust. We admit that we are nobodies, know no one, and need as much help as we can get. Therefore, we hope to close the last degree of separation and get some sort of underwriting for our attempts to help Iraqi children.

Thanks.

Jeremy and Cody