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)

Remember Yahya? His Wait For A New Heart Ends Today!

March 3, 2011 by Cody · 1 Comment 

Remember this boy?

When we first met Yahya he was five years old and we were trying to send him overseas for his lifesaving operation.

The doctors told us that he needed a valved conduit – so we went in search for the piece that could save his life. We found it. The only problem was that the Turkish government was revising their import laws and the local supplier was out of stock.

Because we couldn’t bring Yahya and the device together to Turkey, we were forced to cancel his surgery.

Now Yahya is nearly six years old and he has still been waiting for his heart surgery.

Everything changed when Dr. William Novick told us that he could fix Yahya’s heart without depending on a valved conduit that was half way across the world.

Today he will create the piece that we hope will save Yahya’s life!

The best part (from a macro perspective) is that this is something he’s going to introduce to the local surgeons so that Yahya and all the other children in Iraq waiting in line for $7,000 devices don’t have to go overseas. Furthermore, whereas current devices certainly need replacement, there is a good chance this technique will allow the piece to grow with Yahya’s body. Best case scenario: Yahya may not need a re-operation like he would have from the expensive name brand.

Eventually, they might be able to insert valved conduits by the hands of their local doctors here in Iraq!

We’ve loved our journey with Yahya and today is a milestone for all of us. And all 38 of you who gave to his surgery!

It’s a milestone for Yahya because he’ll be given the surgery his parents have been waiting six years for.

It’s a milestone for the local surgeons because they will begin to learn a groundbreaking, life-changing technique.

It’s a milestone for you because you’re helping us create local long-term solutions to local problems.

Follow Yahya as he get his new heart TODAY!

If you’re on Twitter this week be sure to use the #RemedyMission hashtag to describe all the good news coming out of Iraq this week via @preemptivelove.



With help from our friends:

Sara Rests in Her Room After Surgery; Quickly Discharged from ICU

March 7, 2010 by Jeremy · Leave a Comment 

Sara breezed through ICU in just 24 hours! She’s now back up in her room resting, spending time with her extended family who migrated away from their tumultuous city of Kirkuk years ago currently live in Istanbul.

She wasn’t really feeling like any more photos… I imagine I would not have been either! So we left her alone and let her rest after snapping this shot!

Follow Sara on Twitter: @SaraMuaeed. Subscribe to Sara’s updates via RSS HERE. Follow Sara’s thread of longer stories (with pictures & video) on the PLC blog HERE.

Sara’s Valve Surgery is a Complete Success!

March 5, 2010 by Jeremy · Leave a Comment 

Drs. Sertaç & Ahmet Corrected a Life-threatening Problem w/ Sara’s Valve in a 4 hr. Surgery

Sara’s surgery was a complete success! And for a child living with a congenital heart disease for 14 years, that is no small celebration! Not every condition or child is the same, but generally speaking, congenital heart defects are best addressed at a young age. Years of damage and overcompensation often render a child inoperable or create attendant problems such as pulmonary hypertension.

It’s a joy to see Sara come through surgery with the exact corrective procedure that the doctors had planned on performing prior to surgery.

Yesterday it was virtually out of the question for Sara to marry and have children - her heart condition simply wouldn’t allow that sort of additional stress to her body.

Today, doctors estimate that they have extended her life by up to twenty years before she’s likely to need any additional procedures. At that point, the field of cardiac surgery will be more advanced, and it’s hard to even speculate what options may be available to her at that time. In any case, her heart is healed and her body is healing.

And if she wants to, she can even dream about having kids someday! It’s amazing what you’ve done!

To make a small donation to the next child in Iraq waiting for a surgery similar to Sara’s, please enter the amount of your choice below and press “Donate.”

Follow Sara on Twitter: @SaraMuaeed. Subscribe to Sara’s updates via RSS HERE. Follow Sara’s thread of longer stories (with pictures & video) on the PLC blog HERE.

Can You Imagine Sending Your Child – Like Sara’s Mom Did – Through These Doors for Heart Surgery?

March 5, 2010 by Jeremy · Leave a Comment 

When I spend time with these two year olds, I just see my son, Micah. When I spend time with the four and five years olds, all I see is my daughter, Emma. And I’ll be honest, as often as I tell these parents not to worry and not to fear, it’s very hard for me to imagine sending my own kids down that corridor.

More information on the results of Sara’s surgery as soon as possible…

We have sent six kids down this hallway this week. And we can only do it because of you. And if you’re the parent left standing there, for all the fear and anxiety, you’re still thrilled to see your child going to surgery. All that is required to get the next child down this hallway is: - Enter an amount of your choice below - Press “Donate Now the Amount of Your Choice” - Spend 2 minutes entering your credit card information We’ll get the next child on their way in a few weeks!

Follow Sara on Twitter: @SaraMuaeed. Subscribe to Sara’s updates via RSS HERE. Follow Sara’s thread of longer stories (with pictures & video) on the PLC blog HERE.

Sara Settles in to Her Room at Anadolu Medical Waiting for Morning Surgery

March 4, 2010 by Jeremy · Leave a Comment 

Sara arrived late at night at the Anadolu Medical Center for surgery the next morning after hours of travel with her mom and the Preemptive Love Coalition’s Family Services Director. It was truly amazing to watch Sara caring for baby Deelan during their travel. And despite all the difficulty of traveling to a new place, she was still able to answer all her own questions about her health in a very composed way for the Turkish nurses when they came.

Doctors have given Sara’s family the choice of a mechanical valve or a more organic fix. After weighing the pros and cons, there was consensus all the way around to pursue the organic correction, which is estimated to keep Sara alive without much complication for an additional 20 years, allowing her to marry, have children, and reach her mid-thirties before she will likely need some sort of follow-up procedure.

More information after surgery….

Follow Sara on Twitter: @SaraMuaeed. Subscribe to Sara’s updates via RSS HERE. Follow Sara’s thread of longer stories (with pictures & video) on the PLC blog HERE.

Meet Sara (Twitter: SaraMuaeed)

March 4, 2010 by Jeremy · Leave a Comment 

Meet Sara. Sara hails from the still contested, disputed, and much-disrupted city of Kirkuk, Iraq. So disrupted, in fact, that there were reportedly four bomb explosions in Kirkuk the day before Sara left for Turkey.

Sara’s father works in a local anti-terrorist security unit. Given the backdrop of “Arabization” reaching back decades, conventional Kurdish storytelling now often says that all the terrorists are Arabs and that all the danger lives in the Arab part of city.

Those of us at the Preemptive Love Coalition can speak to that terrible stereotype by referencing our own run-ins with Kurdish terror conspirators. So in hopes of tearing down harmful stereotypes, we’re excited that Sara’s family has drawn so close to baby Deelan’s mother during their surgical sojourn together in Turkey – because Deelan’s mother is an Arab from Kirkuk.

We brought Sara to surgery because of a valve problem she is having that is threatening her life and possibly the life of her future children. At 14 years old, the window of operability for Sara is narrowing. And if she had not experienced your kindness and received surgery, she would likely die during pregnancy or childbirth due to the extreme toll such changes take on the body.

Today, under the skill of Prof. Dr. Sertaç Çiçek, Sara will receive the valve repair she needs and – GOD willing – will be set free to enjoy her adolescent and adult life with much joy and little fear.

Sara is scheduled for surgery on Thursday. More to come…

Special thanks to the college students of FWCM.org for their phenomenal $14,800+ two week fundraising campaign for Sara and one other child. Your passion and effectiveness in fundraising is a testament to the faith, values and lifestyle you profess. We’re looking for 12 other houses of worship, schools, and clubs to partner with us in 2010. For more on our 2010 Fifty Family Focus, click here.

Follow Sara on Twitter: @SaraMuaeed. Subscribe to Sara’s updates via RSS HERE. Follow Sara’s thread of longer stories (with pictures & video) on the PLC blog HERE.

*In accordance with PLC’s desire to lend a hand-up by avoiding strict hand-outs (when possible), Sara’s family contributed $6,500 towards PLC’s highly-discounted surgery prices.