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)

PHOTOS: Lining Up And Weighing In—Let The Operations Begin!

July 13, 2012 by Kendelyn · Leave a Comment 

Before a child hops up on the operating table, they must take their turn on the scale so the anesthesiologist can know the correct dosage to administer so they can sleep safely during their operation. Below are a few of the children who are lining up for their shot at a healed heart.

Come back over the next few days to meet these children and to hear their stories!

Our 85 suture kits are FULLY funded — Thank you for helping fund $765 worth of medical supplies!

Our Partners:

Baby Blue to Rosy Red—Two Years Later and Iman is Doing Great Thanks To You!

May 31, 2012 by Craig · Leave a Comment 

Nearly two years ago, we began our first Remedy Mission with the International Children’s Heart Foundation and Living Light International. For us it was a great risk to take. We had only sent children out of the country and, all-in-all, that model was proven. It was safe.

But thanks to your support, we were able to begin training doctors and treating children inside Iraq. And we were able to serve a little girl named Iman (along with 23 other children). Now, just under two years later, here she is:

Iman is from Dohuk where our partner doctor, Dr. Kirk Milhoan, and his team screened newborns for heart defects. Now Iman is happy and healthy, able to enjoy playing games with her friends, learning in school, and spending time with her family.

Safe at last from her childhood disease, Iman’s life is full of potential. Thank you for giving these children a future!

Watch Our Animated Manifesto!

April 24, 2012 by matt · Comments Off 

Over the last few months we’ve seen an incredible influx of new readers and supporters, so it seemed good to put our most informative and successful video to-date back on the blog.

Whether you’re brand new or if you’ve been here a hundred times, watch it and let me know your reaction. Is it naive? Spot-on? Over-the-top? Email me!

No More Crying—Hamma Is Going Home!

February 12, 2012 by matt · Comments Off 

I was a little worried when Hamma had to be carried from the ICU into the children’s ward. But the doctors said he is doing well and should be able to go home in a few hours. Then, sure enough, he perked up and now he’s walking all over the place!

After a sick heart, a smashed nose, and a surgery, I finally got what seems to be a smile out of this little boy. Isn’t he cute?

And he has reason to smile! His surgery was a complete success, and he is going home. Thank you for making Hamma’s surgery possible, and thank you for putting his best days ahead of him!

Our Partners:

In the News: “Rebuilt Iraq hospital plans surgery on infants”

September 1, 2011 by Craig · Leave a Comment 

Photo credit: AFP

A hospital in Iraq is back up on its feet after years of getting knocked down and now it’s better and bigger than ever!

Rebuilt after many years of violence in Iraq, the Ibn al-Bitar Hospital for Cardiac Surgery in Baghdad is beginning a new program to teach its doctors how to better operate on children who need heart surgery.

“”Until now, we have not been able to conduct heart surgery on infants,’ said Doctor Hussein Ali al-Hilli, director of the Ibn Bitar Hospital for Cardiac Surgery in Baghdad.

‘We receive 80 children a day with various heart-related birth defects that we cannot treat. We need three years to learn because such procedures are complicated,’ he added.”

Want to know more about this amazing project? Check out the full story here and tell us what you think in the comments section below!

Our Animated Manifesto

August 5, 2011 by Ted · 1 Comment 

Allow me to introduce PLC’s newest video!

If you’re unfamiliar with our work, we consider this our manifesto. Everything we do boils down to this belief: reconciliation happens through healing.

With your help, that which has been destroyed and ‘unmade’ can be rebuilt. It can be healed.

—

For all you video connoisseurs, what did you think? Give us some feedback in the comments section below, or connect with us on Vimeo.

3 Reasons You Can Give Someone To Show Them Iraq Is Changing For The Better

June 26, 2011 by Cody · 1 Comment 

Yesterday on the drive to southern Iraq we ran over a pothole. Actually, we ran over several potholes.

The biggest pothole of the day – and the same one that made the loudest noise as our van clung to its parts – was the same one that caused my Iraqi friend next to me to groan and say, “I just want to see change. I want to see something different now that the war’s over. Where are the new roads? Where are the signs that Iraq is changing?”

The next pothole we hit launched us both into a conversation attempting to answer that question. It kept us busy for most of the drive, but we kept coming back to the same 3 immediate signs that Iraq is changing for the better.

Sign #1: Right now, families are traveling from all over southern Iraq to come to this Remedy Mission. Before, families were lining up to leave the country trying to find the doctors that could save their children from their heart defects. Today, families are lining up outside a hospital in southern Iraq, waiting for their child’s chance at a lifesaving heart surgery. For the first time, families don’t need to leave the country to find the cure.

Sign #2: This week, a Sunni family will hand their child over to a Shiite doctor to be saved. In 2007, at the height of the violence in Iraq between Sunni and Shiites, this would have been unheard of. Now, the disease that’s threatening their children is bringing them together!

Sign #3: The notorious “brain drain” that happened when 20,000 of the 34,000 registered doctors in Iraq fled during the war is being reversed. During our last Remedy Mission in northern Iraq we met one of the doctors who had returned. Today we’re not only seeing doctors return, but – thanks to Remedy Missions – the doctors who never left are being equipped and trained, too. Their training is changing the tide of healthcare in Iraq.

So, the next time you hear someone looking for a reason to believe Iraq is changing for the better, start by giving them these 3.

Or better yet, show them the above photo of Rayed smiling before he received his lifesaving heart surgery during Remedy Mission V. Then tell them to stay tuned because Remedy Mission VI is already underway here in southern Iraq!

Our Partners:

Why Father's Day Means So Much to Hafez And His Son

June 15, 2011 by Jeremy · Comments Off 

At exactly this time last year, Hafez (pictured above) was facing down the worst Father’s Day of his life as he desperately worked against the clock to save his son’s life.

At exactly this time last year, we asked for your help… and you came through in a huge way, raising more than $30,000 in just a few weeks so we could launch our first-of-its-kind Remedy Mission inside Iraq.

At exactly this time last year, you made this father’s day and helped secure for him a happier life than the one he was facing without you.

Meet Abdul Kareem – the son of my friend, Hafez. When I met them, they did not have the money to pursue surgery outside of Iraq like all the rich people, people with political clout, or the lottery winners.

I’ll never forget Hafez’s plea to me – certainly the same plea I would make on behalf of my son – “Just do something for him. He’s just a little boy.” He got so emotional that he excused himself from my office. This father, having done all he could for his son, walked away from the office crying. Abdul Kareem needed heart surgery before his first birthday or he was likely to become entirely inoperable – “a lost cause.”

But you weren’t about to let that happen!

The day our surgical team arrived from all over the world for Remedy Mission I, Hafez must have seen us on the news because he called me ten times: “Is my boy going to surgery? Mr. Jeremy, just do something to help my little boy!”

His boy was going to surgery, thanks to those of you who gave in response to our request last year’s for Father’s Day and our Remedy Mission launch!

There is another moment with my friend Hafez that I won’t forget – the day his son Abdul Kareem had surgery. I remember it so distinctly because after the surgery Hafez grabbed me, kissed me, and gave me an

tearful “thank you” for keeping our word; for saving his son’s life.

Once Abdul Kareem was discharged to return home, Hafez sent me a message from the road. The message said something like, “Thank you so much for your organization and for helping my little boy. We will not forget you.“ With tears running down his face, he wanted to thank you each by name. You made a father’s dream come true. And you prevented his big brother, Abbas, from growing up without a soccer-buddy.

Dad, I love all the great memories we’ve made together. This year, I wanted to add, “saving a child’s life in Iraq” to the list, so that another child and his father can make great memories together too.

We want to make it easy for you to honor your dad this Father's Day and help save the life of baby Ghazel. A simple $10 donation will help us save her life and cover the cost of two hours of hands-on training with local Iraqi surgeons! A $25 donation will accomplish that and add hours of training in Iraq for an additional three Iraqi doctors and nurses! If you like, we'll even provide you with a free downloadable card that you can print and give to your dad this Father's Day!

Meet the Interns: Our First Impressions of Iraq

June 7, 2011 by Ted · Comments Off 

Surgery, the “Neglected Stepchild” of Global Health

April 3, 2011 by Alex · 1 Comment 

In preparing for my 2nd internship with PLC this summer I came across an article written by two well-known global health advocates and physicians (a prof at Harvard and the current president of Dartmouth, if you’re into credentials) on the topic of surgery in the global health movement. [Paul E. Farmer and Jim Y. Kim. 2008. "Surgery and Global Health: a View from Beyond the OR." World Journal of Surgery 32:533-536].

After discussing this article with one of the directors at PLC and thinking about our current model for surgical aid in Iraq, a few points stood out:

The authors’ first argument is that surgery is the “neglected stepchild of global healthcare.” The fact is, although surgical diseases (CHD being one of the most prevalent) are a major cause of death and disability in much of the world, the vast majority of healthcare programs don’t address surgical needs.

Why? Because surgical interventions are usually complicated and require a larger investment than other kinds of health interventions, and treating surgical diseases requires a more advanced infrastructure and the involvement of more professionals than treating, for instance, malnutrition or malaria.

There is also the fact that surgical diseases have lacked the same kind of advocacy and exposure that have led to funding and programs for “high-profile” diseases like tuberculosis or AIDS.

The other major issue addressed by Farmer and Kim is that countries that actually have the surgical services often only have them in just a few locales, and the treatment is usually too expensive to be accessible by most of the population.

The question then arises: how do we make this treatment available in settings where infrastructure is poor, trained professionals are scarce, equipment is needed, and “the only thing not needed is disease, which exists abundantly.”

Remedy Missions are our answer to that question.

As you know, we recently moved from sending children abroad for surgery to a model that provides more surgeries at less cost while simultaneously training local professionals.

These Remedy Missions specifically address the impediments to surgery in global health described by Farmer and Kim.

They provide treatment of CHD for families that would never be able to afford traveling abroad for surgery. Our work also means we’re freeing surgeons up to focus on surgery, because, as Farmer and Kim write, “clearly we don’t want surgeons to be dragged out of the operating room to manage logistics, supply chains…and financing.”

Remedy Missions provide crucial training for all the different health professionals that are required for a surgery to be successful (surgeons, cardiologists, nurses, etc.).

This process of providing surgery and training is also an exercise in infrastructure building as we work toward the development of heart centers in northern and southern Iraq. The fact that we can count both regional and national governments as partners addresses the need for surgical care in the public sector in Iraq, and it bodes especially well for poor families who will need to receive treatment in the future.

Lastly, the partnership and advocacy of our supporters (that’s YOU) is helping to raise awareness of the burden of CHD and other surgical diseases in places like Iraq.

With well-planned, structured interventions that take into account the needs and problems associated with surgical disease globally, and the support and advocacy of a Coalition of concerned individuals and communities (that’d be you again), problems like CHD can cease to be a “neglected stepchild” of global health and instead serve as a model for building health systems and effecting powerful change in global contexts.

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