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)

Introducing the Shad Faraydoon Memorial Fund: $50k to Fund 10 Infant Surgeries

June 29, 2009 by Jeremy · 56 Comments 

Shad Faraydoon always stood a chance of being healed. Unfortunately, every day that went by throughout his ten year life was a day that further diminished his heart’s capacity to function on its own and oxygenate his blood.

By the time the Preemptive Love Coalition met Shad he was ten years old. We marshaled all the resources we needed to help Shad and in less than a month he was admitted to surgery in May 2009. Unfortunately, Shad did not respond to the corrective measures of the surgeries as we had all hoped he would. Too many years of living with his heart defects had hindered his body’s ability to operate as it was intended. A series of blood clots finally contributed to Shad’s death a week after his surgery.

We established this memorial fund with Shad’s family in order to fund ten surgeries for infants who will benefit most from early intervention. Shad waited ten years for his chance and every day made him a less likely candidate for life-saving heart surgery. In honor of Shad’s struggle and in hopes of using his beautiful life to help others we have established this memorial fund so that infants – unlike Shad – do not have to wait for life-saving resources to become available to them.

Our 2009 goal for the Memorial Fund is
$50,000 to fund surgeries for 10 infants.

A Glimpse of Things to Come

In May 2009 PLC set out to film the journey of three children to life-saving heart surgery with filmmaker Michael Dalton and photographer Foster (Matt) Addington. Shad Faraydoon was one of those children.

To our great sadness and surprise, Shad’s ending was much different than we had expected. Nonetheless, Shad and his father, Faraydoon, will feature prominently in the forthcoming full-length documentary. It is our hope that the anxiety and anticipation, the hope and hopelessness in Shad’s personal journey will be a compelling call to action so that children don’t have to wait in line ten years for surgeries that could otherwise save their lives.

Shad Faraydoon’s Funeral

June 14, 2009 by Jeremy · Leave a Comment 

We attended the second day of Shad’s funeral on Thursday in two groups: men and women.

The men gathered in the mosque for about 5 hours straight as other men who knew the family gathered to pay their respects. Inside the mosque the male family members stood around the perimeter and greeted the male guests each time they entered the room. Meanwhile the cleric sang prayers for the child.

The women gathered under a large tent outside the family’s house and loudly mourned the loss of little Shad. Hundreds of women turned out over the course of the last few days. It was an understandably intense emotional experience – especially for those of us who are largely unaccustomed to Middle Eastern modes of mourning.

Shad’s family has remained very kind and open to us even in the midst of their great loss. We hope to continue on with them insofar as they will allow us in the coming months and years.

Airport…still

June 9, 2009 by Jeremy · Leave a Comment 

We were on the bus headed to the airplane when a Turkish flight attended came inside the bus and called for Faraydoon Hama – Shad’s father.

We both disembarked and began one of the most painful, maddening, frustrating discussions of our lives with the Turkish airline, the Turkish customs agents, the hired logistics company, and the hospital staff. We had all of 5 minutes to sort out the situation or be left behind.

The situation: Customs was requiring an obscure document from the Iraqi Consulate even though the Iraqi Consulate had assured us that everything we procured yesterday would suffice.

In the end, we were pulled off the plane and Shad’s body was held up in Customs another 5 hours. We’ve been rerouted to a different city in Iraq and are currently set to arrive at 1 a.m. this evening.

After all of that, we were informed that Shad’s body would not be on the flight with us. The logistics company ended up contracting a cargo company to transport the body.

All of this to say, Shad’s father and his family have seen insult upon insult added to great injury. I’m not sure there is much “fault” or “blame” to be cast here, but for a grieving father everything is seen in terms of fault and blame.

If all goes well they will meet their family outside the “gates” of their city at about 4 a.m. to begin the grieving process in earnest.

Shad & The Rest of Us Heading Home to Iraq

June 8, 2009 by Jeremy · Leave a Comment 

After immeasurable sadness and disappointment Shad’s father, Faraydoon; Faraydoon’s brother-in-law who made a special trip from Sweden to be with him in his loss; and I are boarding a plane Tuesday morning at 11 a.m. in hopes that the logistics firm we hired will be able to complete all of the necessary procedures with Turkish Customs and our partners at Atlasjet airline so that Shad’s body will be able to travel home on the same flight.

We expect scores of people at the airport in Iraq tomorrow afternoon to receive Faraydoon and Shad’s body back and to formally begin the mourning process.

Shad’s life and Shad’s death have affected us each deeply… and it has clearly affected many of you as well. We are so grateful for the depth of your emails and condolences and encouragement that we not grow weary as a result of this horrendous set back but that we push forward for the sake of the thousands of other children in Iraq who – barring a lot of financial generosity and a miracle – could very easily meet a similar end.

Day of Prayer and Preparation for Shad Faraydoon Hama

June 8, 2009 by Jeremy · Leave a Comment 

Today is a day of prayer and preparation for Shad Faraydoon Hama and the repatriation of his body into Iraq. Today, in accordance with Islamic rites and rituals, a Muslim cleric will be called upon to facilitate the washing of Shad’s body and it’s preparations for burial (which will likely occur sometime tomorrow afternoon, immediately upon arrival in Iraq).

Meanwhile in Iraq the men of Shad’s family have been praying for Shad and his father in their neighborhood mosque.

These are difficult days and many more are still ahead.

One of the preparations under consideration stems from the desire on the part of some to begin a memorial fund in Shad’s name as a way of funding heart surgeries for kids so that they do not have to wait ten years before they receive their chance at life. Above all, our concern right now is to honor Shad’s family and to not make a show out of his death. He was valuable and loved in his own right – regardless of whether his death leads to the benefit of others.

If we choose to act upon the calls and encouragements for a memorial fund, please know that we will have done so very carefully and in full consultation with his family.

Shad Faraydoon Hama (b. Nov. 18, 1999 – d. June 6, 2009)

June 6, 2009 by Jeremy · 5 Comments 

Shad Faraydoon Hama passed away this morning after ten years of fighting the heart disease, blood problems, and the resulting pulmonary embolism that finally took his life.

Dr. Sertaç Çiçek and his team tried everything known in the realm of pediatric cardiology to save Shad’s life… but in the end ten years of suffering had taken too much of a toll on his increasingly fragile body.

On June 3rd – when Shad was still surprising everyone by how well he was doing – he and his father talked extensively about when he would be going home. His father insisted that they would leave on Saturday. But Shad – as though he knew something that no one else knew – maintained that he would not be ready to leave by Saturday… that they would return together on the Tuesday morning flight.

In the end, they were both right. Shad did leave this place today, Saturday, June 6th. And his father is scheduled to return to his home city with his son’s body on Tuesday, June 9th.

As we stood with his father by Shad’s bedside this morning just minutes after his death, the most joyous and saddest words I’ve ever heard with my own ears were spoken by Shad’s father to his little boy. He said:

My dearest little Shad, your life on this earth was so difficult and full of sadness. But it was such a joy for me to have you here. But now your life here is over; you are in Joy and Happiness forever. But now I am the one left in difficulty and sadness without you.

You were like seven sons to me. You were like seven brothers, too. My son! My friend! What will I tell your mother? What will I tell your grandmother? My eldest boy… how can I live without you?

Xwa hafiz, Shada gyan. Xwa hafiz.

Shad in Critical Condition after Two Emergency Surgeries

June 4, 2009 by Jeremy · 4 Comments 

Ten year old Shad is back in ICU after a surprisingly wonderful night last night with his father up in their personal hospital room. Shad spoke with his dad a great deal last night about his excitement to return to Iraq, his eagerness to sit with his mom and play with his little brother and little sister, and his excitement over how many people were going to come visit him upon his return.

But if things do not turn around significantly – and fast – it looks as though many people will come to visit Shad in Iraq, but not in the way we’d all hoped and planned.

Shad’s blood does not respond well to anti-coagulants, being very viscous and subject to so many years of oxygen deficiency. Last night after a sudden bout of diarrhea it seems that Shad became dehydrated very quickly giving rise to blood clots which eventually blocked the flow of blood in his pulmonary artery. His oxygen level quickly decreased as he was rushed to the ICU.

He was quickly admitted to his third surgery in a week where doctors put him back on the “heart and lung” machine and began their third attempt at correcting years of damage.

But three hours after the surgery finished, while resting under heavy sedation in ICU, Shad went into cardiac arrest again and the doctors had to open him up in ICU and perform the fourth surgery on Shad.

As we write this (10pm, Istanbul, 06/04/09) Shad is still in critical condition but his father has lost all hope that he will pull through. Doctors are saying there is a chance, but it is clear that after ten years and four surgeries in one week the odds are severely stacked against him.

In the midst of great grief (real and anticipated) Shad’s father has been very grateful today to Dr. Çiçek, his team, the nursing staff, PLC, and ultimately to God – in whose hands are all things. He has also spent a lot of time telling us how much he has learned from his son about patience, kindness, and caring for others.

In any case, Shad was made to wait ten years too long for these surgeries. But it doesn’t have to be too late for other children in Iraq.

Shad is still alive. And so is our hope.

Better Late Than Never: Shad Comes Out of ICU!

June 2, 2009 by Jeremy · Leave a Comment 

It took him longer than the rest of the kids – a direct result of so many emaciating years of lack of oxygen that has made his body too weak to cough (to clear his lungs) and move on his own. Nonetheless, Shad emerged from ICU today and is on the road to being a much healthier young man! A weight has clearly been lifted off his father’s remarkably strong shoulders…

Thanks for all you’ve done to make this new future a reality for Shad, his parents, and his little brother and sister.

Shad Makes it Through Surgery!

May 27, 2009 by Jeremy · 1 Comment 

This is what a fighting chance at life looks like!

But Shad’s dad couldn’t stand it… he said he didn’t want to see his son like this. He’ll return to ICU once they take out the tubes and have him more stable.

Nonetheless, Shad’s father understands the ramifications of this life-saving surgery and is full of joy and hope today.

From Shad’s family, Roman’s family, and all of us at the Preemptive Love Coalition “thanks!”

PHOTO CREDIT: Matt Addington (ToOpenYourEyes.com)

Shad & Heran Accepted to Surgery

May 25, 2009 by Jeremy · Leave a Comment 

We just left the cardio catheterization lab at ASM Hospital in Istanbul where Dr. Cicek has accepted Shad (10 yr. boy) and Heran (7 yr. girl) to surgery. It was a phenomenal moment!

Upon going upstairs and telling Shad’s father and Heran’s mother we all erupted in hugs and celebration… praises to God and thanks to each other after a long day of waiting, playing, and patience. It was a moment we will never forget!

Roman goes to surgery at 10 a.m. Istanbul time, Tuesday morning.

PHOTO CREDIT: Matt Addington

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