Efforts continue to suppress antibiotic-resistant salmonella in Ethiopia

Children play outside near Awash, Ethiopia. Courtesy of Dr. Wondwossen Gebreyes.

In the diverse sub-Saharan ecosystems of Ethiopia, interaction between humans and animals is part of daily life.

This reality is likely a key player in the spread of infectious bacteria like salmonella, which is capable of interspecies transmission. And when frequent human-animal interaction is combined with mal/under-nutrition, subpar sanitation, an HIV/AIDS epidemic and the misuse of antibiotic drugs, the progression of salmonellosis (salmonella infection) in Ethiopia becomes an issue of global significance.

Dr. Wondwossen Gebreyes, professor and director of Global Health Programs at The Ohio State University College of Veterinary Medicine, has led a research initiative addressing infectious disease in Ethiopia since 2011. One of the initiative’s goals is to discover the various strains, sources and avenues of salmonella in the region.

Of primary concern is multi-drug resistant (MDR) salmonella, which has found refuge in Ethiopia and other developing regions due to the overuse and misuse of antibiotics. When antimicrobial drugs are misused, more paths are cleared for bacteria to develop new, multi-drug resistant strains. When an infection is immune to available treatments, morbidity and mortality rates rise.

Balbine Jourdan

Balbine Jourdan, student at The Ohio State University College of Veterinary Medicine

A study conducted in 2013-14 tested stool samples from 765 humans with gastrointestinal complaints at 10 primary health care centers in Addis Ababa, Ethiopia. 59 samples tested positive for salmonella; 27 of these were resistant to three or more antimicrobials; 17
were resistant to five or more antimicrobials; and two were resistant to more than 10 drugs.

This summer, Ohio State veterinary student Balbine Jourdan is working with the Gebreyes team in Ethiopia to study the role of wildlife in circulating MDR salmonella across space and species, which is currently unknown.

Previous work has focused on the prevalence of MDR salmonella in livestock, since the bacteria is known to spread via consumption of animal-derived food products or contaminated water. The next step is for researchers like Jourdan to examine other nearby channels, so that risk factors can be determined.

“The study Balbine is doing this summer will be invaluable in identifying reservoirs of MDR salmonella,” Dr. Gebreyes said. “The data could potentially identify highly MDR strains of wildlife origin, as well as unique genes and resistance factors.”
Canis_simensis_-Simien_Mountains,_Ethiopia-8_0While in Ethiopia, Jourdan will collect samples from carnivorous wildlife carcasses (including hyenas, jackals, foxes and servals) to test for the presence of salmonella. She will also test domestic dog and livestock feces found near sampled carcasses to help indicate direct or indirect transmission from domestic sources.

After seven weeks, Jourdan will return to the U.S. to conduct antimicrobial susceptibility tests, in which salmonella isolates are tested against 12 antimicrobial drugs to detect resistance. This will yield a better understanding of the scope of MDR salmonella in Ethiopian wildlife.

“The findings can be used to evaluate the magnitude of antimicrobial resistance and advise proper antibiotic use not only in Ethiopia, but in other developing countries,” she said. “Such information will be vital for the interruption of transmission cycles and the development of management strategies.”

The results will be compared to prior research on MDR salmonella found in livestock and domestic dogs, in order to map any geographic or pathogenic patterns of resistance.

When asked about the challenges she’ll face during the course of this research, Jourdan noted communication struggles between researchers and Ethiopian locals.

“It has been a challenge already to educate the locals on the importance of research and disease surveillance not only in terms of finding treatments, but in terms of disease prevention.”

That being said, she has thoroughly enjoyed becoming acquainted with a different way of life.

“This project encompasses two of my biggest passions: research and travel,” she said. “I cannot put into words how important I think it is to experience different cultures and traditions. We have so much to give, but we cannot forget that others have so much to give back.”

Jourdan is working toward a dual DVM/MPH-VPH (Master of Public Health in Veterinary Public Health) degree, which she will complete in 2020.

“I have always had a passion for Global Health work, particularly in zoonotic diseases and conservation,” she said. “I want to use my degree to help improve the lives of both humans and animals.”

She plans to collect further data in Ethiopia next year.

Jourdan’s research team includes Dr. Gebreyes, Dr. Jeanette O’Quin, assistant professor-clinical in the Department of Veterinary Preventive Medicine and Laura Binkley, a doctorate student at the college working on disease surveillance in Ethiopian wildlife with a focus on rabies and pathogen discovery.

This study is part of the Ohio State-Ethiopia One Health Initiative, a partnership between the university and various U.S. and Ethiopian institutions that aims to prevent the spread of infectious and chronic diseases, build capacity for the healthcare workforce in Ethiopia, address environmental concerns and more.

Nearing vaccine for virus behind most foodborne-illness outbreaks in U.S.

X-ray crystallographic structure of the norovirus capsid

Human norovirus is contracted by 21 million people per year in the U.S., and is responsible for more than 60 percent of annual foodborne-illness cases, according to the Centers for Disease Control and Prevention.

Symptoms of norovirus infection include vomiting, abdominal pain, diarrhea, fever and dehydration that can last up to several weeks. The virus is resistant to commonly used disinfectants and easily transmitted through food, water or close contact. Since its discovery in 1968, regular outbreaks have occurred in crowded spaces such as schools, restaurants and cruise ships.

There is currently no vaccine or treatment for norovirus, and several factors prevent it from being extensively studied. Since the virus doesn’t replicate outside of bodily tissue, it cannot be analyzed in cell culture, and traditional animal models cannot be used because the virus doesn’t infect mice and other small mammals.

“So we basically don’t have any tools to study this virus, which is quite frustrating in the field,” said Dr. Jianrong Li, associate professor at The Ohio State University College of Veterinary Medicine. “For these reasons, we don’t have a vaccine or antiviral drugs for the virus. It’s been a big puzzle for about 50 years.”

Despite these issues, progress has been made by Li and his research team, who were able to identify an animal model to study norovirus. They found that gnotobiotic, or germ-free, pigs are able to contract an infection from the virus, and can therefore be used in their research.

Li’s team recently received a five-year, $3.1 million R01 grant from the National Institute of Allergy and Infectious Disease to continue their work on developing a human norovirus vaccine. Li’s collaborators include Drs. Prosper Boyaka, Xiaoming He and Steven Krakowka, all investigators at The Ohio State University, and Dr. Xi Jiang of Cincinnati Children’s Hospital Medical Center.

The vaccine’s molecular composition is basically complete, Li said, and has proved effective in germ-free pig models. The researchers’ next steps are to enhance the vaccine’s effectiveness and to identify a suitable delivery method.

“The vaccine is actually quite simple. It contains Virus-Like Particles (VLPs) or P particles, which look like norovirus but they’re not infectious,” Li said. “So you can use VLPs to generate a strong immune response in which antibodies neutralize the virus. The body will remember this and become resistant to norovirus.”

One issue with the vaccine concerns with how it can be safely delivered orally without first being destroyed by the gastrointestinal tract.

Li and his colleagues will solve this problem by inserting the vaccine inside several layers. The outermost is a micro-particle that is resistant to stomach acid, and the second is made of lactic acid bacteria (LAB), which is a probiotic found in foods such as yogurt.

The idea is to enclose the vaccine inside a LAB-based capsule to be taken orally. The capsule only allows the VLPs to be released once they reach the intestines, so that the body can generate a proper immune response.

Li’s team is now working on improving the strength of the vaccine, which will be done by adding a molecule that targets specific cells to enhance the immune response.

“The goal after these five years -if the improved vaccine is effective in pigs- will be to test it on non-human primates,” he said.

The ability to create and test a human norovirus vaccine is a notable scientific breakthrough, and this model may lead to the invention of vaccines for other viruses.

In addition to the NIH R01 award, Dr. Li has been awarded four grants from the U.S. Department of Agriculture totaling to $36 million (one $25 million, two $5 million and one $1 million) since 2010 for research on norovirus. He was Principal Investigator or co-PI for each study.

“Our ultimate goal is to develop effective mitigation strategies and vaccines for human norovirus,” Li said.

From left: Dr. Prosper Boyaka, professor of veterinary biosciences at The Ohio State University, Dr. Jianrong Li, associate professor of veterinary biosciences at The Ohio State University, and Dr. Xiaoming He, associate professor at Ohio State's College of Engineering.

From left: Dr. Prosper Boyaka, professor of veterinary biosciences at The Ohio State University, Dr. Jianrong Li, associate professor of veterinary biosciences at The Ohio State University, and Dr. Xiaoming He, associate professor at Ohio State’s College of Engineering.

Research reported in this article was supported by the National Institute of Allergy and Infectious Disease of the National Institutes of Health under Award Number R01AI123661.

Original Story

Working toward a cure for HIV

From left: Dr. Sanggu Kim, assistant professor at The Ohio State University College of Veterinary Medicine and Dr. Hannah Yu, postdoctoral fellow, stand in their lab in the College of Veterinary Medicine's Center for Retrovirus Research on May 10, 2016. Columbus, Ohio.

From left: Dr. Sanggu Kim, assistant professor at The Ohio State University College of Veterinary Medicine and Dr. Hannah Yu, postdoctoral fellow, stand in their lab in the College of Veterinary Medicine’s Center for Retrovirus Research on May 10, 2016. Columbus, Ohio.

There are 36.9 million people worldwide living with Human Immunodeficiency Virus, according to the Centers for Disease Control and Prevention.

Now, more than ever, a cure for HIV is in sight, thanks to researchers like Dr. Sanggu Kim, assistant professor of veterinary biosciences at The Ohio State University College of Veterinary Medicine.

Kim obtained a PhD in biomedical engineering in 2007, and became an Ohio State faculty member in January. He has been studying HIV infection for 14 years, and was recently awarded a three-year, $747,000 grant from the National Heart, Lung and Blood Institution to continue his research on the virus.

Today, the standard treatment for HIV is antiretroviral therapy, which entails a cocktail of drugs that suppress HIV-1 replication in hopes of preventing AIDS. These treatments are a great stride and have saved many lives across the globe, but they neither cure HIV, nor eliminate the possibility for the virus to build up a resistance.

Kim’s current work focuses on perfecting a novel gene therapy method in which stem cells called hematopoietic stem/progenitor cells (HSPCs) are extracted from bone marrow, engineered to be HIV-1 resistant and then placed back into the body. The goal is for the engineered cells to replace the damaged immune system by repopulating the blood system over time with HIV-protected cells.

“This treatment could ultimately eradicate HIV-1 from its reservoirs,” Kim said.

Although HSPC-based therapy sounds promising, replacing an entire human immune system is a complicated feat. Until several issues have been resolved, clinical success cannot be ensured.

“Recent trials have shown that even after HSPC transplant, less than one percent of cells were protected from HIV, which doesn’t really help the patient,” Kim said. “We don’t really know what level of protected cells is required for clinical success, so my main focus in this project is to determine a threshold.”

One major problem concerns the replenishment of T-cells, which are highly damaged in HIV patients but key to a functioning immune system. Like all blood cells, T-cells arise from HSPCs, but only a tiny fraction survive long enough to become capable of destructive action. This is due to a sophisticated selection process in the thymus that researchers are just beginning to understand.

“We need to find a completely new approach to have better T-cell recovery,” Kim said.

Progress is currently underway thanks to a new technology called vector tagging, which allows individual stem cells to be followed in the body. After using vector tagging to study the nature of HSPCs, Kim and his colleagues began to see holes in the prior assumption that all stem cells are the same.

“We found that stem cells are not equally functional; they behave in a particular pattern,” Kim said. “Certain pools are biased toward producing T-cells, others are biased in producing granulocytes, etc.”

Using a unique mouse model that mimics human T-cell death by HIV, Kim and his research team will further analyze the nature of T-cell selection, as well as identify how many healthy T-cells are needed for full immune system recovery.

“This system is much more complex than we originally thought,” he said, “And as we better understand it, we can improve therapeutic options for the patient.”

Over the next three years, Kim hopes to create a mathematical model to guide the development of new HIV gene therapies. If the specifics of this complex technique can be determined, a cure for HIV may be within reach.

Original Story

Hearts of infant mice have self-healing abilities, researchers look closer

Did you know that some amphibians and fish have hearts that regenerate muscular tissue cells following injury? This healing mechanism, called cardiac regeneration, is sustained throughout the creatures’ lives.

But for humans and other mammals, the heart’s reparative ability is confined to a small window of time during infancy. For mice, studies have shown that this window of time is about seven days. The heart of an infant mouse will self-repair in response to damage during this period, after which the capacity for cardiac regeneration is lost.

Sylvie Cohen (Far Left) with the other vet students that participated in the NIH internship program and the two directors of the program (Dr. Mark Simpson, DVM, PhD and Dr. Chuck Halsey, DVM, PhD).

Sylvie Cohen (Far Left) with the other vet students that participated in the NIH internship program and the two directors of the program (Dr. Mark Simpson, DVM, PhD and Dr. Chuck Halsey, DVM, PhD).

Sylvie Cohen, second-year student at Ohio State’s College of Veterinary Medicine closely examined cardiac regeneration processes in one-day-old mice this summer at the National Heart, Lung and Blood Institute’s Laboratory of Molecular Biology. Cohen’s focus was on studying the molecular and cellular channels underlying heart-regeneration in mice.

Cohen and her team worked in the lab of Dr. Toren Finkel, senior investigator at the NIH’s Laboratory of Molecular Biology. First, the team wanted to test whether the infant mice’s hearts would actually repair themselves following injury. To do this, a microsurgery was performed on the experimental group that involved cutting off blood supply to the left anterior descending coronary artery, inducing a heart attack (modeled in figure below).

To establish how the neonatal mouse heart responds to ischemic injury, Cohen and her team permanently ligated the left anterior descending coronary artery of 1-day-old mice.

To establish how the neonatal mouse heart responds to ischemic injury, Cohen and her team permanently ligated the left anterior descending coronary artery of 1-day-old mice.

After 21 days, the mice that had heart attacks had fully recovered as their hearts had gradually generated new muscular tissue. Cohen and her team were able to see the cardiac regeneration process in action through histologic analyses of the mice’s heart tissue. As seen in the figure to the left the heart increasingly repaired itself over time, getting back to normal around day 21.

In addition to testing the mammalian heart’s capacity to regenerate for a brief period after birth, Cohen and her team also looked at what they consider a key-regulator in the cardiac regeneration process: a gene called BMI1. BMI1 has been shown to play an important role in cardiac muscle development, so researchers have hypothesized that it’s vital during cardiac regeneration.

To measure BMI1’s effect on heart regeneration, Cohen’s team compared the rate of cardiac healing in normal infant mice against BMI1-knockout infant mice. They found that the mice without the BMI1 gene had a reduced ability to renew cardiac muscle tissue, suggesting that BMI1 “is an important regulator of cardiac regeneration,” Cohen said.

Heart disease is the leading cause of death in the U.S., claiming the lives of more than 600,000 people per year, according to the Centers for Disease Control and Prevention. “Identifying key regulators of the cardiac regeneration process is an important step toward potential regenerative therapies such as gene therapy or pharmaceuticals” Cohen said.

Working with doctors and students from both veterinary and human medicine really enhanced the team’s collaboration and Cohen’s understanding of the research, she said. “It helped us maintain a holistic view.”

To assess the regenerative capacity of the neonatal mouse heart after ischemic injury, histological analyses were performed after coronary artery ligation. By 21 days after myocardial infarction, there was little evidence of fibrosis when using Masson's trichrome staining.

To assess the regenerative capacity of the neonatal mouse heart after ischemic injury, histological analyses were performed after coronary artery ligation. By 21 days after myocardial infarction, there was little evidence of fibrosis when using Masson’s trichrome staining.

This study was a part of the NIH’s Summer Internship Program in Biomedical Research for Veterinary Medical Students.

Studying effects of Toxoplasma gondii on mice

An estimated 30 percent of the world is infected with the parasite Toxoplasma gondii, including 60 million people in the U.S., according to the Centers for Disease Control and Prevention.

Mary Carter, second-year student at Ohio State’s College of Veterinary Medicine, spent her summer at Stanford University studying the molecular underpinning of the parasite and its infectious processes in mice.

T. gondii is a very complex and successful parasite,” Carter said. “We’re still trying to figure out how it infects such a broad range of hosts while simultaneously altering the host’s immune response to avoid detection.”

Mary Carter, second-year veterinary student (bottom right), poses with her research team, including Drs. John Boothroyd and Sarah Ewald, at Stanford University in August 2015.

Mary Carter, second-year veterinary student (bottom right), poses with her research team, including Drs. John Boothroyd and Sarah Ewald, at Stanford University in August 2015.

The parasite causes a condition called Toxoplasmosis, which can cause a range of issues in people who don’t have a fully functioning immune system, including fever, pneumonia, chronic inflammation, central nervous system disorders and fatality. Most healthy adults are asymptomatic and completely unaware they are infected.

T. gondii lives and reproduces in cats without affecting them. Most humans and other intermediate hosts (such as mice) are presumed to acquire it through exposure to infected cat feces or poorly cooked food. It can also be transmitted from mother to child during pregnancy, which is why pregnant women are strongly advised to avoid scooping cat litter. There are two stages of T. gondii infection: acute and chronic. If caught in the acute stage, the disease can be treated, but since it’s hard to detect and requires a specific blood test it often moves to the chronic stage, creating cysts in muscle and brain tissue. Recent studies have linked T. gondii with an increased incidence of mental disorders like schizophrenia and bipolar disorder, which is plausible since it affects the brain.

When mice are infected with T. gondii, they show lethargy, severe weight loss and intestinal inflammation during the acute stage, Carter said. After about 14 days they start to recover, but the weight loss and stunted growth (called wasting) remains for the rest of their lives.

Carter and her research team at Stanford (shown on right) want to understand how T. gondii causes weight loss in mice by examining its molecular processes throughout infection. They also measured differences in food intake, body weight, muscle and fat mass. Results are currently pending, and will be useful in understanding the wasting processes that occur in diseases like MS, cancer cachexia or chronic kidney disease.

Microscopic view of Toxoplasma gondii

Microscopic view of Toxoplasma gondii

Carter said she was interested in infectious disease research because her cat died of Feline Infectious Peritonitis when she was young, and there was very little information about why FIP occurred in cats or how it was treated.

“There are still so many diseases, including emerging diseases, that we don’t understand,” she said. “We have a lot of great information on T. gondii, but there is still a lot to learn.”

Toxoplasmosis is considered a “Neglected Parasitic Infection,” one of five parasitic diseases that the CDC has identified for public health action.

Health & Habitat analysis of endangered Ohio rattlesnakes

Katie Backus, second-year veterinary student at Ohio State (left), acquires a blood sample from a massauga rattlesnake in northeastern Ohio in the summer of 2015.

Katie Backus, second-year veterinary student at Ohio State (left), acquires a blood sample from a massauga rattlesnake in northeastern Ohio in the summer of 2015.

This summer, second-year student at The Ohio State University College of Veterinary Medicine Katie Backus completed a comprehensive health analysis of massasauga rattlesnakes in partnership with the Ohio Department of Natural Resources. The data will be studied along with land use and habitat condition.

Eastern massasauga rattlesnakes dwell in northeastern regions of the U.S., including Ohio. The species has been a candidate for the Federal Endangered Species Act since 1999, according to the U.S. Fish and Wildlife Service.

The decline of massasauga rattlesnake populations is mostly due to human and agricultural activity as well as habitat loss or destruction. The snakes typically inhabit wetland areas.

The research team tracked and captured massasaugas to acquire blood samples, swab tests for fungal disease and height and weight measurements. They’re also reviewing data on water quality, vegetation density and land use in surrounding areas. Water that flows downstream from farms may contain chemicals associated with agricultural runoff, which has been observed to cause adverse effects in other species.

“Agricultural runoff could be weakening massasaugas’ immune systems,” Backus said, “Possibly predisposing them to fungal diseases and other health issues.”

Backus and her team, led by Greg Lipps, amphibian and reptile conservation coordinator and conservation biologist, were able to capture approximately 55 massasaugas in northeast Ohio. Around 20 were recaptures. The results from fungal disease tests are still processing.

To capture the massasaugas, Backus and her team would walk around in protective gear with snake tongs and bags. Once captured, they would guide the snakes head-first into a plastic tube to prevent biting (as they are venomous), to perform diagnostics. A stress measure – a hormone called leptin – was taken into account during the health assessment.

A massassauga rattlesnake in a wetland area in northeastern Ohio. The species is now endangered.

A massassauga rattlesnake in a wetland area in northeastern Ohio. The species is now endangered.

The results of the study will help the ODNR with conservation efforts, as not much is currently known about the relation between massasauga health and habitat. The ODNR will likely try different techniques on different plots of lands to see what works for the snakes, Backus said.

“I learned so much throughout this process,” she said. “Not only handling snakes, but about government wildlife departments, the history of Ohio’s environment and ecology in general.”

Veterinary medicine plays many roles, and conservation medicine is an important one. This study is an example of how veterinary research can intertwine factors of human, animal and environmental health.

Acute Lung Injury in influenza patients

Patients with severe cases of influenza sometimes develop Acute Lung Injury (ALI), a highly damaging condition that can be fatal. Treatment options are limited.

MicroRNA (miR) are non-coding RNA molecules that take part in the regulation of gene expression, and they’ve been observed to act abnormally in inflammatory diseases, some forms of cancer and more.

Third-year veterinary student at Ohio State, Leon Schermerhorn. August 6, 2015; Columbus, Ohio.

Third-year veterinary student at Ohio State, Leon Schermerhorn. August 6, 2015; Columbus, Ohio.

Last summer, third-year veterinary student at The Ohio State University Leon Schermerhorn studied the molecular structure of influenza-induced ALI lung cells and, with his team, was able to conclude that a single miR, miR-155, may play a direct role in the progression of the disease. The team, led by associate professor in Ohio State’s Department of Veterinary Biosciences Dr. Ian Davis, discovered this by determining all miR expression levels in ALI lung cells. The results showed that miR-155 was highly over-expressed by alveolar type II (ATII) cells , which are the primary site of influenza virus replication. As influenza increases in severity, miR-155 expression becomes greater. This is harmful because an upregulation of miR-155 seems to provoke a raise in several types of white blood cells and signaling proteins, causing lung inflammation.

Since miR-155 expression by ATII cells could be responsible for the progression of influenza-triggered ALI, Schermerhorn and Davis hypothesize that miR-155 may be a target for therapeutic intervention. Influenza-induced ALI becomes less severe in mice that ATII cell miR-155 expression has been blockaded, called miR-155-knockout mice.

This summer, Schermerhorn is testing a gene therapy method’s ability to delay onset or reduce severity of influenza-induced ALI in mice. The method involves inserting pieces of specially engineered DNA – in this case lipoplexes carrying antagomiRs – into mice that will target ATII cells and inhibit miR-155 expression. His results will give further data on the role of miR-155 in influenza development in general, as well as the efficacy of inhibiting ATII cell miR-155 expression with antagomiRs.

“Research in public health and infectious diseases has always interested me; I like to solve problems,” Schermerhorn said. “Since influenza is a high-consequence pathogen, this study was a good fit from the start.”

Understanding how influenza affects cystic fibrosis patients

An estimated 30,000 people in the U.S. are living with Cystic Fibrosis (CF), a fatal genetic disease, according to the Cystic Fibrosis Foundation patient registry.

CF can affect many parts of the body, but it primarily impairs lung function. The lungs in a person with CF are colonized and infected by bacteria from a young age due to poor mucus clearance, which results in chronic inflammation. This makes them susceptible to various infections, and seasonal influenza viruses in particular present a huge risk. When CF patients contract influenza, it can cause severe, sometimes life-threatening symptom exacerbations, making their lungs vulnerable to additional bacteria. Currently, winter CF exacerbations are difficult to treat.

Part of the problem may be an abnormal increase in activity of proteins called pattern-recognition receptors (PRRs) following infection. PRR signaling usually helps the immune system detect viral infection to begin fighting it off, but an excessive response to viruses can cause severe inflammation.

Young5Second-year student Sarah Young is working with Dr. Ian Davis, associate professor in the Department of Veterinary Biosciences, to examine the molecular processes behind influenza infection in CF patients, specifically abnormal PRR signaling in infected lung cells. Young and Davis hypothesize that irregular PRR signaling causes the excessive inflammatory response in CF patients with influenza. To determine if their hypothesis is correct, Young is infecting both regular and CF human airway cells with influenza A virus to examine how PRR signaling differs between groups. The cell cultures that she’s working with use cells from donor lungs, gathered by Dr. Mark Peeples of Nationwide Children’s Hospital.

Once complete the study will provide new information on the natural immune response of CF patients to influenza infection, said Young, who was born with the disease.

“It’s rare to get the chance to research the disease you actually have,” she said. “It has given me more interest and motivation.”

CF is only known to occur in humans, but the study utilizes Young’s knowledge in veterinary medicine nonetheless, Davis said.

“Veterinarians have a great role to play in human medical research,” Davis said. “We have a different perspective, and there are not enough of us involved in it.”