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)

Tarza Leaves Jordan

December 3, 2008 by Jeremy · Leave a Comment 

This was Rezhin and Tarza‘s last week in Jordan. These two girls are just precious and full of life. Every day they’ve talked about when they would get to go home to see their families. You could see the anticipation growing in them each day and never would have imagined that these two girls running around playing, recently had had heart surgery. It’s exciting to think who they will become as they return home with new hearts.

They are deeply appreciative for the nurturing care they’ve received from the staff here and truly love the women here. They made thank you notes in their  Sorani dialect for some of the staff thanking them and making sure they knew they would be missed. Last night they even invited Donna to share one last meal with them before preparing to leave.

Everyone woke up this morning freshly cleaned and with their best clothes on. Packing must have begun last night, leaving things only to be tidied up today. After waiting several hours, we all loaded up in the van mid-afternoon to start the journey home. It was a beautiful day, providing for a nice drive and great views of the country. Once at passport control things went fairly smoothly and they were able to make a couple of quick purchases from the Duty Free Shop before going outside to wait for the bus.

Sadly they faced a long wait on the other side of the border crossing, making what was already a long day that much longer. After a quick nap, they’ll awake early in the morning to head to the airport to return home.

What a privilege it has been to meet these two beautiful girls. How grateful we are that they have many more years of health and life ahead of them!

Excellent Echo Report, Fun With Beads

November 24, 2008 by Jeremy · 603 Comments 

Tarza got an excellent report after her echo, and although her mother was hoping to be able to leave after today, Dr. Tamir said Tarza should come back in one week for the final echocardiogram. We are thankful for this good report, and expect Tarza will be on schedule to go home early next week.

A Very Good Report

November 17, 2008 by Jeremy · 464 Comments 

We made our way to the hospital this morning for Tarza and Rezhin‘s follow-up echos. After waiting nearly an hour, each girl was taken in for her echo.  Afterwards, the report was that they are doing really well.  Neither of the girls has any sign of water in her lungs, nor are they on any medications, only vitamins.

After they left the echo they met up with Ali and his father as they were walking outside.  Both mothers and daughters sat outside with Ali and rejoiced with Ali’s father. Both Tarza and Rezhin will have another echo next Monday.

Echo Shows No Water In Lungs

November 17, 2008 by Jeremy · 875 Comments 

We made our way to the hospital this morning for Tarza and Rezhin’s follow-up echos. After waiting nearly an hour, each girl was taken in for her echo.  Afterwards, the report was that they are doing really well.  Neither of the girls has any sign of water in her lungs, nor are they on any medications, only vitamins.

After they left the echo they met up with Ali and his father as they were walking outside.  Both mothers and daughters sat outside with Ali and rejoiced with Ali’s father. Both Tarza and Rezhin will have another echo next Monday.

Tarza Recovering

November 16, 2008 by Jeremy · 399 Comments 

I went to the hospital yesterday to bring Tarza and Rezhin back to the  house.

They were ready to leave when I got there.  The trip went well, the taxi driver was very pleasant, he couldn’t speak english and he called another taxi driver over to translate to him what I was saying, they also told us to have a good journey. The girls are doing great and were glad to get back to the house.  Lawk and his mom were also glad to see them. The hospital will let us know when they go for their echocardiogram.

Rezhin Released from the Hospital

November 16, 2008 by Jeremy · 14 Comments 

I went to the hospital yesterday to bring Tarza and Rezhin back to the  house. They were ready to leave when I got there.  The trip went well, the taxi driver was very pleasant, he couldn’t speak english and he called another taxi driver over to translate to him what I was saying, they also told us to have a good journey. The girls are doing great and were glad to get back to the house.  Lawk and his mom were also glad to see them. The hospital will let us know when they go for their echocardiogram.

2 surgeries already done!

November 13, 2008 by Jeremy · 29 Comments 

Rezhin and Tarza just barely arrived with our partner organization before they received the news that they could head right in for surgery! If you’ve read some of the other posts here you may have seen that some kids can have a lengthy waiting process until they can have their surgery. Rezhin and Tarza waited just one week before they underwent successful heart surgeries on November 10th. Both Rezhin and Tarza’s surgeries were relatively simple ones, according to the surgeons. They had the same heart defect called Atrial Septal Defect, which is a hole in the wall between the atriums of their hearts. The girls had no complications and were alert and awake following their surgeries.

Both girls are already out of the ICU and healing well. After their move out of the ICU yesterday both girls spent time together eating Doritos and M&Ms- which must mean they’re definitely feeling better! This is, of course, a big relief to their worried parents who have endured many years of worry over their child’s health and future. What a gift to these parents to have children who are now healing! How amazing that we get to be part of that too!

Recovering In Children’s Ward

November 12, 2008 by Jeremy · Leave a Comment 

Today, I found both Tarza and Rezhin out of the ICU and in the ward. While I was visiting this afternoon the girls were munching on Doritos and peanut M&M’s.  It seems as if they are on their way to a full recovery.

Out Of ICU, Munching Doritos

November 11, 2008 by Jeremy · Leave a Comment 

Today, I found both Tarza and Rezhin out of the ICU and in the ward. While I was visiting this afternoon the girls were munching on Doritos and peanut M&M’s.  It seems as if they are on their way to a full recovery.

Surgery Went Well, Without Complications

November 10, 2008 by Jeremy · Leave a Comment 

Tarza had her surgery this morning. Tarza’s mother was nervous and was crying. Ali’s father and Rezhin‘s mother were with her. While we were waiting to see Tarza after her surgery, they wanted to go to lunch, so we went to the cafeteria and ate. Later went to drink tea. They had not let Tarza’s mother see her yet. It was a good while.

Ali’s father had gone in to see Ali in the ICU, and stayed for awhile. When he came out, he told Tarza’s mother to go in, so she did. When she came out she was crying. Even though we can’t understand each other’s language, I still have that compassion of a mom.

When I went in to see Tarza, I asked the doctor how Tarza’s surgery turned out. He said very well, with no complications. By the time I left, Tarza was awake and alert.

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