Jeremy Courtney 
The only bad failure is the one from which we fail to learn.
Most organizations put a premium on celebrating successes at the end of every year—we certainly do! But we also believe that we have a great deal to learn from our failures, so we endeavor to share them and the lessons we’ve learned in hopes of avoiding those same mistakes in the future.
When seeking to tackle intractable problems in an environment like Iraq, missed opportunities, missteps, false starts, and failures are par-for-the-course. There will be no improvement in the political situation in Iraq, in the economy, in healthcare, or in the pursuit of peace without a number of flops and failures along the journey. If we already knew what worked, we all would’ve implemented it by now and moved on. The truth is, neither the American government nor the Iraqi—neither international nor local NGOs—truly know what works in Iraq. Most of us are making educated guesses and seeking to rightly adapt programs and principles that have proven successful at other times in Iraq or in other parts of the world.
From this point forward, I want to provide you with an annual (and sometimes real-time) assessment of our failures. In absence of such previous reports, I will use a few minutes to highlight our most meaningful setbacks, failures and lessons learned to date.
Failure #1: Inability to Overcome the High Costs of Buy Shoes. Save Lives.
Since our founding program in 2007, the Preemptive Love Coalition has proven that we are willing to try new methods, forge new ground, and break ranks with low-impact or failed policies and programs. In 2007, we launched our successful Buy Shoes. Save Lives. program—a hybrid micro-economic-meets-social-enterprise model from which we used profits to fund our first lifesaving heart surgeries for Iraqi children. At the time, the U.S. was eager for good news coming out of Iraq and we hit the ground with exciting revenues and no debt. By 2009, however, a lot had changed in America and it was obvious that the BSSL program no longer provided the same return on our investment (read: not worth the work). We endeavored to shake up the product model that had been employed for more than 3,000 years by local artisans. But local resistance proved greater than our savvy or financial incentives. Moreover, the rise of other prominent shoe-based companies (most notably TOMS shoes), ate into the market share and caused both expectations and misconceptions that were difficult to overcome. As a result, we significantly scaled back BSSL production and focused on the creation of different revenue models.
Lessons Learned:
1. Market forces (in every sense) can drastically affect the funding of social programs—especially when tied to a luxury item like $120 hand-made shoes.
2. BSSL served us well and launched us into the space we then occupied in Iraq. But BSSL was never likely to be the financial engine for long-term development in a country like Iraq. We knew that within the first six months and began planning accordingly.
3. Adapt. Keep no sacred cows. Keep innovating.
Failure #2: Delaying and Denying Local Development by Exporting Surgeries
Due to the nature of our network at the time of our founding—and owing to the fragile state of Iraq at the time (including the political hegemony that had been set up at the Ministry of Health)—it was impossible to conduct lifesaving heart surgeries for children inside Iraq. A handful of organizations worked together to send children outside the country to nearby (then far-flung) countries.
From 2007-2009, we exclusively sent children outside Iraq for surgery. We saved more than 50 lives and earned a strong reputation in parts of Iraq for being an organization that would take a chance on children who nearly every other organization would prefer to leave behind. By 2010 it became obvious that the infrastructure and political situation inside Iraq had changed substantially. We began exploring opportunities to bring surgical teams into Iraq in an effort to provide local development and create economies of scale of our export model.
It’s difficult to call the 2003-08 “exporting” model a failure, in part because it seemed so necessary at the time as a stepping stone to something greater. But there definitely came a time in 2009-11 where exporting children to surgery as a primary model of intervention became a failure (in our opinion) for all who kept practicing it primarily.
Lessons Learned:
1. Always prefer long-term, local solutions.
2. Aim to accomplish more for less. We averaged $12,221 per surgery in FY 2009 (a year in which we were solely responsible for all contracts on “exported” surgeries). In FY 2010, the first fiscal year in which we imported solutions through our new Remedy Mission program (and a year in which we still sent five children abroad for surgery), we reduced the per surgery price to a mere $2,222. And that amount did more than buy us a surgery, it bought us hands-on training for local ICU nurses, heart surgeons, and technicians, hastening the day of a fully functioning heart center in two different cities in Iraq.
Failure #3: High Mortality Rates Due to a Underdeveloped Selection Process for Surgeries Done Abroad
Of the 31 children for whom we assumed complete selection, logistical and financial responsibility in FY 2008 and FY 2009 (rather than funding through partnerships elsewhere), six died. No program aims for a 19% mortality rate; especially when operating in world-class hospitals at $12,221 per surgery.
Emotions can cloud vision. Everyone from the organization to the family, the donors and the doctors were looking for a win. We wanted to believe that we were a standard of compassion to be emulated by all—we were the ones who took last chance children. There was some truth in that. We were supported by doctors who believed in a family’s right to decide and who genuinely wanted to give a chance to anyone and everyone. But there was pride as well. We believed that somehow other organizations lacked vision or compassion for rejecting children who were deemed “inoperable” (a word that can mean different things to different parties).
By the time February 2010 arrived, we were very aware of our high mortality trend and began to seek outside counsel on our selection process in an effort to create distance between the actual service providers and the local healthcare referrers inside Iraq. These conversations led us to ease up on the complex cases we were willing to accept and paved the way for a mortality-free stretch from Feb – Dec 2010 in our surgeries done abroad (11 surgeries; 0 mortalities).
Lessons Learned:
1. Pride goes before a fall. There were good reasons that other organizations had implemented selection policies that were more stringent than ours. We had early success accepting a few children who were deemed “inoperable” and we let an unhealthy narrative set in that allowed us to believe that we were more compassionate than others. Of all the failures we’ve experienced to date, I think this failure—and the lesson associated with it—is among the most profound.
2. When the only metric for success is life or death, it is helpful to build a firewall between service providers, funders, beneficiaries, and logistics personnel.
Conclusion: We have had an excellent run leading up to this point, with scores of lives saved and countless stories of peace and reconciliation coming among the various friends we’ve served. But our entire website is mostly dedicated to telling those successes and celebrating the role of our donors and partners in each one. This report is necessary because failure is inevitable. We neither want to hide nor fixate on our failures. But we do want to purposefully take an account of them, learn from them, and report to you how we are moving forward in light of lessons learned.
Moving forward, we will be focusing less on our Buy Shoes. Save Lives. program as a major revenue stream; we have ceased all donor-funded surgeries outside of Iraq; have rescued ourselves from child selection; and have placed all of our focus on bringing in Remedy Mission teams to Iraq in an effort to accelerate long-term, local solutions.
If you have any questions or concerns about this report, the decisions we’ve made, or the direction we are going, please email me at your convenience. I would love to hear from you!
