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)

So You Want To Take On One Of The Leading Causes of Death in Iraq?

March 9, 2013 by Cody · Leave a Comment 

Congenital heart defects are one of the leading causes of deaths for children in Iraq.

So when you confront it head on, you better be ready for what comes next.

When we put the International Children’s Heart Foundation medical team back on the ground, the press releases go out, the radio and T.V. stations announce their arrival, and hundreds of families in the city rush to make sure that their child is at the top of the list.

The first thing we do is screen each child. But then more come. And then more. And then so many people that you can’t even get through the crowd to see the child being screened.

Siblings take turns standing in line. The dads and moms show up before our team has even woken up. Some even bring their own mats so they can sleep in the waiting room.

And so we keep screening. Because each echo means that child is one step closer to receiving the treatment that need.

Thanks for bringing us back to Najaf. There’s still so much more work to do!

Our Partners:

Basra’s Doctors Are Not Forgotten—Remedy Mission XIV Begins!

December 5, 2012 by matt · Leave a Comment 

“Today our dream is coming true.”

These are the kinds of phrases we’re hearing in the southern port city of Basra right now. The local surgeons told us they’ve been trying to create a children’s heart hospital for nearly 30 years, and today they performed their first operation.

Decades of dreams, now made possible.

Amidst the excitement, hope, and tears, though, you’re not forgotten. You helped make this day possible! In fact, we brag about you guys. Today I told several Iraqi nurses about The Coalition around the world—of which you’re a part—who still care about Iraqis; I assured them they’re not forgotten, either.

And, for me, that’s one of the most beautiful things about this big, messy, collaboration: we haven’t forgotten one another.

Despite all the distance and differences, there are a bunch of doctors in Basra who know that they’re not forgotten, because you’ve remembered and supported them in their lifesaving dream.

The same goes for all the families who are about to receive back a healthy child—I can’t wait to tell them about you! Keep reading. I’ll have fresh faces and stories for you coming soon.

Our Partners:

Zahraa And Her Family Snuck Out Last Night

November 16, 2012 by matt · Leave a Comment 

You can hardly blame them.

They’ve been cooped up in a small hospital room for weeks now, and late last night the doctor gave them clearance to leave. When we arrived in the morning, the family was probably happily asleep in their own beds.

But, despite not getting to see them off, we’re still celebrating. Zahraa is home now, the hole in her heart is finally closed, and she’s set to live a healthy life.

Did you miss Zahraa’s story? See more about her heart defect and her sweet family by following this link.

Remedy Mission XIII is winding down, but we’ll continue sharing more stories with you over the next two weeks.

Keep reading, there’s more to come.

Our Partners:

“We Were About To Sell Our Home”—Getting To Know Zahraa’s Family

November 12, 2012 by matt · Comments Off 

Zahraa isn’t in the best mood right now.

I was making ward rounds visiting families and I stopped in to check on her (catch up on her story here). Immediately after exchanging our ‘salaams’ her parents asked, “Can you tell what’s wrong? She won’t stop crying, she has a fever, and she is upset whenever we touch her.”

Now, I’ve already told you guys that I’m non-medical. I don’t claim to be a doctor. But I’ve picked up a few things about post-operative care from some of the nurses, and so, after a few minutes of discussion, it became apparent Zahraa was in pain because—wait for it—she hadn’t been given her pain meds.

Yes, I figured that out all by myself. Smart, huh?

To be serious, it’s extremely frustrating to think of Zahraa spending an entire night in pain just because a local doctor didn’t take the time to come check on her and give her the necessary medication.

But we aren’t here because the place has competent doctors—it’s actually quite the opposite! We choose to work in Iraq because it’s difficult and because doctors need to learn about things like how and when to distribute medication. Slowly but surely, mission by mission, our partner nurses are writing and enforcing protocols, the surgeons are teaching (and reteaching) surgical techniques, and things are improving.

But last night was a mistake. Zahraa’s parents and grandmother (pictured above cuddling with Zahraa) were worried sick. Being non-medical, they did what they could; they bought her outrageously large stuffed animals (pictured above), tried to hold her, sing for her—nothing worked.For all they knew, their daughter was dying. Thankfully, she wasn’t. I left and brought back one of the nurses to give a more proper inspection. Zahraa took her medicine and began feeling better just a few minutes later, and she’s been fine since then.

With that resolved and the doctor on duty reprimanded (not by me), I sat down to learn more about Zahraa, her parents, and their family’s surgery search. Her father explained that they learned of her heart problem when she was eight months old and that—thank God—she’s the only one in their family with a known heart problem.

When asked about their fears for Zahraa, her father shared,

Zahraa’s parents love her with such intensity that they were prepared to make as many sacrifices as it took to help their little girl. It was obvious, sitting in their hospital room, that they were telling the truth. I’d seen how the mother and grandmother cared for Zahraa, and how the father was constantly taking breaks from work to come check in.

But, thanks to you, Zahraa’s parents didn’t have to sell their home. After years of distress, their daughter is well on her way to recovery now, and she even has a home to go back to—thank you for saving her!

Would you like to be a part of saving more lives and houses? You can bless SO many families just by donating or giving up your birthday for Iraqi children. Donate below to start changing lives now!

Help save more children like Zahraa now!

Our Partners:

Zahraa Is Recovering Beautifully!

November 10, 2012 by matt · Leave a Comment 

You may remember that Zahraa was recently wheeled into the ICU after a successful surgery, but she and her mother won’t be there for long.

As the week progresses and more children are added to the ICU, parents who are willing (and emotionally able) to help care for their children are greatly appreciated.

Our partners, The International Children’s Heart Foundation (ICHF), typically have two nurses and an intensivist on duty per shift. That means there are three fully-trained staff in an ICU that sometimes has as many as six or seven children needing their care.

Of course, there are also local Iraqis who are receiving training and who can lighten the work load, but it’s still quite a load!

Zahraa’s mother helped alleviate some of this, and it’s allowing the nurses to provide better care. The best news, though, is they’re now saying that Zahraa will probably be the first child this mission to head up to the ward.

We’ll follow her up to celebrate with her family and to get to know them a little better soon. Stick with us…

Zahraa Made It Through Surgery!

November 10, 2012 by matt · Leave a Comment 

They wheeled Zahraa out of the operating room and into the ICU. Now she’s got 8 nurses and doctors around her making sure she’s safe and on her way to recovery.

A local International Children’s Heart Foundation nurse will watch over her while teaching the Iraqi nurses how to bring Zahraa back to health. But now, the only thing for little Zahraa to do is sleep! We’ll have more for you tomorrow.

How The Hole In Your Heart Healed, How Zahraa’s Didn’t

November 9, 2012 by matt · Leave a Comment 

Did you know that you once had a hole in your heart?

It’s true. You had the same hole that Zahraa has, actually. You were both born with something called a ductus arteriosus, which is basically an opening between the pulmonary artery and the descending aorta.

But your hole closed, and hers didn’t.

At birth, you took that first gasp of air and—at that instant—this hole in your heart began closing. It wasn’t long before your hole was gone, and your blood flow was perfectly normal. You were fed, you kept your parents up for crazy amounts of time, and you did what babies do—your parents probably didn’t even know the hole was there.

Zahraa’s parents knew early on that something wasn’t right; they learned early on that their child’s hole hadn’t closed and that she would need surgery.

It’s difficult to know why your hole closed and Zahraa’s didn’t. Some research suggests that it’s a hormonal issue, but it’s hard to tell (and honestly way over my head).

Regardless, Zahraa is about to join you and the rest of us by having her PDA closed, and you made that possible! They’re putting her under and operating on her right now, so come back in a few hours for an update.

More to come…

Our Partners:

Update From The O.R.—We’re Saying Goodbye To Zahraa!

October 10, 2012 by matt · Leave a Comment 

Zahraa has passed the test!

Her echo went well, and now she can go home. Watch the above video to get a quick update on Remedy Mission XII and to see shots of little Zahraa heading home with a healed heart!

Stay tuned for more stories from Remedy Mission XII—and we’ve got an update on Hussain coming as well!

Our Partners:

Update From The O.R.—Valve Shmalve, What’s Really Wrong With Zahraa’s Heart?

October 7, 2012 by matt · Leave a Comment 

You’ve read about Zahraa, and we hope you’re following her story.

But wouldn’t you like to know what’s really going on inside her chest? What is it that poses such a lethal threat to her well-being, and what does it take to fix it?

Cardiologists can answer these questions because they spend years studying the heart in medical school, and then they’re constantly learning for the rest of their career. So, since we can’t all be savvy heart doctors, we decided to pull one into the O.R. for a quick interview!

Watch the above video (or click HERE) to get a better understanding of what’s going on inside little Zahraa’s heart!

Our Partners:

Friends, Meet Zahraa!

October 4, 2012 by matt · Leave a Comment 

This little day-dreamer’s name is Zahraa. She’s 6 years old, and—you guessed it!—she really needs a heart surgery.

I only had limited time with Zahraa and her family before she was whisked away for surgery, but the parents seemed terrified for their daughter. A local doctor saw me watching them and shared, “They’re very poor. They don’t know anything at all about the outside world.”

This was a great reminder of the faith these parents have when they give their kids over to us for treatment. I’m sure it takes serious guts to pass your kid off to trained professionals whom you trust and know to be effective (and can communicate with), but to give your kid to strangers from another country? To people who dress, talk, and act in a way that is totally bizarre to you? Maybe even offensive?

I don’t envy them, but I do admire their courage.

Both daughter and her mother, as if on cue, burst into tears as Zahraa was pulled away and taken to the operating room.

Please pray that her surgery goes well, and we’ll have a video update on her progress for you in a few hours.

Our Partners:

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