publication date: Apr. 24, 2020

Conversation with The Cancer Letter

Feist-Weiller mammography vans repurposed to screen for COVID-19 in northwest Louisiana

Andrew D. Yurochko

Andrew D. Yurochko

Professor, Carroll Feist Endowed Chair in Viral Oncology,

Vice chairman, Department of Microbiology and Immunology,

Feist-Weiller Cancer Center;

Director of Research, Center of Excellence for Arthritis and Rheumatology, Louisiana State University Health Sciences Center

This story is part of The Cancer Letter’s ongoing coverage of COVID-19’s impact on oncology. A full list of our coverage, as well as the latest meeting cancellations, is available here.

At least for now, Feist-Weiller Cancer Center at the Louisiana State University Health Sciences Center at Shreveport has repurposed the three vans that were used to provide cancer screening and essential health care to medically underserved communities.

In some areas of northwest Louisiana, the Feist-Weiller program, called Partners in Wellness, while focused on mammography and other cancer screening, also provided the only health care available. Now, the program’s three vans offer testing for COVID-19.

“In many of these underserved communities, this van is their sole source of medical support. It goes out and does normal health care, normal screening, cancer screening, and we have a good rapport within those communities,” Andrew D. Yurochko, director of research at Feist-Weiller Cancer Center, said to The Cancer Letter. “Many of the drivers have been there many years, maybe as the vans have been around. The community knows the drivers. Many of the nurses and the clinicians that go out are also well known. Within the community, it’s a trusted asset.”

Yurochko is also professor and Carroll Feist Endowed Chair in Viral Oncology, vice chairman in the Department of Microbiology and Immunology at Feist-Weiller Cancer Center, and director of Research at the Center of Excellence for Arthritis and Rheumatology at Louisiana State University Health Sciences Center.

COVID-19 provides a lens into the deep health disparities between rural and urban populations in northwest Louisiana, parts of Arkansas, and Texas—all regions that Feist-Weiller Cancer Center serves.

“Many in the underserved communities, again whether suburban or rural, don’t have a primary care physician and don’t really have a strong access to health care. So, they can’t reach out to find out whether this is a common cold, or flu, or really COVID-19,” Yurochko said.

“That same idea, whether it’s a virus or a cancer, heart disease, or any element—it’s been emphasized and exacerbated with the virus. You get the virus, and you get symptoms five to 10 days later. If it gets severe, it’s a very rapid onset—and with a cancer it can be months, years or decades. That same thing that we’re seeing with the virus is just extended in cancer,” Yurochko said.

What does COVID-19 teach us about these disparities?

“If we don’t address the issues from a standpoint of dollars and cents, we won’t be able to have expanded health care availability,” Yurochko said. “I hope this issue with negative acute outcomes in the underserved community really highlights that we need to do something.”

“If it does highlight that point, and if money were to be available, I think we could have, via this very sad current outcome, a better positive outcome long-term in the context of cancer or any other type of chronic disease,” Yurochko said. “If I had a crystal ball, I’d probably be a rich man, but I wish that that crystal ball would tell us that we will see expanded health care. I just don’t know if that’s the case.”


Yurochko spoke with Alexandria Carolan, a reporter with The Cancer Letter.


Alex Carolan:

How is Feist-Weiller Cancer Center addressing disparities of COVID-19 in Louisiana? Can you tell me about the vans you send out for rural areas for COVID-19 testing?

Andrew D. Yurochko:

We serve both urban and rural communities. It was originally set up for women’s health and mammography, but it’s been expanded to cancer across many spectrums, as well as normal health care—in the context, that if you’re going to do a cancer screening, you need to have normal background for blood work and body weight, etc.

And the vans, through our Partners in Wellness, have a series of steps we use to promote health care in our parish communities. The vans were purchased for the Louisiana State University Health Sciences Center via private money in a public-private partnership. These vans are designed to go out to the underserved in the context of cancer screening. In addition to the cancer screening and health care, there’s also education. We have an education component as part of Partners in Wellness, that does talk about health care. It talks about obesity and cancer, smoking and cancer, diet and cancer, etc.

All of this goes hand-in-hand. What we’ve done in the context of COVID-19, the pandemic disease caused by infection with SARS-CoV-2, we’ve utilized the setup that this van has—both in the actual physical aspect of having a van that’s set up for medical health care—and the partnership that the cancer center has set up with the community.

In many of these underserved communities, this van is their sole source of medical support. It goes out and does normal health care, normal screening, cancer screening, and we have a good rapport within those communities. Many of the drivers have been there many years, maybe as the vans have been around. The community knows the drivers. Many of the nurses and the clinicians that go out are also well known. Within the community, it’s a trusted asset.

What we are trying to do in the context of community health with the pandemic is utilize these vans and the community outreach that’s set up to sort of repurpose these vans, if you want to call it, to go out collect samples for our new viral diagnostic labs. The vans are already in play or already available. There are three different ones.

We have the appropriate nursing staff through our new diagnostic lab, the Emerging Viral Threat lab. These trained personnel who know how to do the appropriate swabs to get testing for the virus. We can send in our vans using the existing infrastructure, the vans, the communities that these vans already work within.

Whether it’s a rural or urban community that has maybe a single health care system, or a clinic that we know the physician or they know the physician, we can coordinate with them to have meetings spots—and basically utilize a format and a structure in place and a community trust can go out and do this community service, which would be to get nasopharyngeal swabs and test for the presence of the virus.

We obviously follow all CDC, federal and state guidelines on testing right now. For the current situation, we are testing with the knowledge of a physician saying we need someone to be tested via a series of guidelines that they have. Eventually, we’d like to move from the now of targeted screening, to a more broad screening plan as we open up the state. We’ll be able to use the same van, following expanded guidelines to do greater testing—say in nursing home,s or underserved communities, to get local businesses back online to be able to test the workers, the owners, and other community members in this underserved population.

The vans don’t just go to the Shreveport and rural and urban aspects of our local parish—it really handles the entirety of northern and central Louisiana. We’re right smack in the middle between Jackson, the capital of Mississippi, Little Rock, the capital of Arkansas, and Dallas, Houston, and Baton Rouge. We are the one city in the middle—and can reach all the underserved within, really, three states. A lot of these areas in Louisiana, southern Arkansas, eastern Texas, and even as we go towards eastern Louisiana along the Mississippi River Delta, these are very poor areas. There are a lot of people who are in the classic sense underserved. The van really is their only source of medical assistance, medical health, diagnoses.

By utilizing the van for the context of the SARS coronavirus diagnosis and/or helping those citizens out, we can of course make a difference in their health, but also give them a diagnosis in an area where there’s very little testing. We can go forward as we try to open up the state, to provide these rural parishes, or smaller cities, and the underserved in both urban and rural environments—provide them with a chance to receive a diagnosis for the virus and/or serology testing for the presence of a past infection with the virus.



Your cancer center is really in this unique position and has the unique resources to get testing to areas that may not otherwise have access.





What does COVID-19 teach us about addressing these disparities?


In regard to health disparities, it has been reported in various newspaers and by the Louisiana Department of Health that in the context of racial disparities, the African American community in Louisiana has a higher incidence of infection and a higher case fatality rate.

And the numbers are very striking, based on the ones that I have seen. It tells us really when you look at the root causes, that the inability to access health care has a major impact on health outcome. This is an issue I think our cancer center and our medical school, which was really set up as a charity hospital to cover the indigent for the underserved in this part of the state—have always recognized.

It’s obviously a very sad situation and very unfortunate situation, but I think it highlights the need for additional care and real need to reach out to our underserved community members.

It would be great if we’d go back in time and address this 20 to 30 years ago and be in a better situation now, but I think what it’s telling us is emphasizing what we know to be true and what we need to address. It’s putting it front and center in the news, that the African American community is seeing a much greater rate of infection than the caucasian community, and we’re seeing a higher rates of fatalities too.

As a human and as a faculty member at a medical school, I hope that the state, the federal government and all of us can do more to help solve this problem. In fact, our governor just set up a task force to address this issue. Members of our cancer center outreach programs are on that task force. That’s really what our mission of the cancer center has always been. It is also what our new lab that’s partnering with the van and aspects of the cancer center is hoping to do via some of our community money that we received to specifically meet the needs this underserved members of our community in the context of viral diagnosis and appropriate care.

It certainly doesn’t address all the health care issues, but I think at least gets us a little closer to addressing community health care and community outreach. It provides chance of fgetting people in all communities back to work. Obviously, if they’re sick, we hope to get them identified as testing positive for the virus and provide them with appropriate health care.

If you don’t get treated early enough, that is a problem. Things can go from difficulty breathing to much, much worse, and it can happen very quickly—and really, in a matter of hours. And in the community that doesn’t have access to health care or for people who don’t have cars, this can result in a fatal outcome very quickly.



Essentially, these vans are able to be proactive for treatment. They can be screened for COVID-19, find out whether they have it, and maybe seek treatment earlier.


Correct. That’s our goal. Now, initially, we have to follow CDC and state guidelines on testing, which being a physician or somebody in that sort of role has to identify the patient with symptoms.

Now, as we open up and they relax the guidelines so that we can start screening more in the community, then we will absolutely be able to expand that ability to be proactive in the underserved community. All the first responders are always going to get tested, physicians on the frontline, health care workers, faculty at the medical school to be able to go back to work—are going to have a much easier chance because we’re required to be tested to actually be in a medical school and/or hospital setting.

But this opens up, as you mentioned, proactively, the ability to screen community members that work in many aspects of the jobs that we want to be opened up—from trash collection to restaurant workers, to workers that work in grocery stores, or other appropriate businesses. It really has an effect or will have an effect on the entire city, and the entire parish and the region.



To broaden this a bit, how have protocols changed at your cancer center since the start of the COVID-19 outbreak?


In the context of cancer treatment, anything that’s required for life, to maintain life, so anyone with a severe cancer who’s undergoing chemotherapy, all those things that are important to keep a patient alive will certainly continue.

What has certainly stopped in the context of cancer center is anything that could be put off. For instance, some sort of skin cancer that obviously was not metastatic, hadn’t broken the layers and wasn’t going to be a significant issue. Those sort of things that they say we can deal with this next month, or so. None of that will be handled now.

Before, many people, they saw a little lesion and said “Can I take it off next week?” Assuming you could see a physician, they would do that. All that sort of stuff’s being postponed. My guess is, if you had some significant issues and you had an emergency, and needed to see an oncologist, they would definitely make time for you.

If someone had serious leukemia or something that needed to be treated now, they’re not going to prevent that from taking place. I hate to say anything cancer-related is not essential, but in that context, anything that can be postponed at least safely, will not be handled right now.



And that seems to be the case across the country. As a result of COVID-19, how might these disparities in cancer patients be exacerbated down the line?


That is a difficult question to answer, and it’s obviously very relevant. I think the issues that we’ve seen—COVID-19 as a disease, and the health disparities in the context of infection and fatalities—have highlighted how lack of health care access is a significant problem. If we don’t address the issues from a standpoint of dollars and cents, we won’t be able to have expanded health care availability.

Like I said, our cancer center does that, but we have to work within the confines of the money that we have—private donations, public donations, health care dollars from the state and the federal government. To do this, there is a limit.

I think emphasizing the issues with the viral infection says that if we don’t do a better job in the context of reaching out with community health, identifying stigmas, identifying issues that require attention—what is something that you need to go see a physician for, what is not?

Again, remember many people in our communities don’t even have a primary care physician to talk to. This is something that was emphasized with COVID-19, that when someone has a fever and/or symptoms, potentially, of COVID-19, everyone says, “Oh, call your doctor and ask if it’s a problem and what should you do.”

Many in the underserved communities, again whether suburban or rural, don’t have a primary care physician and don’t really have a strong access to health care. So, they can’t reach out to find out whether this is a common cold, or flu, or really COVID-19.

That same idea, whether it’s a virus or a cancer, heart disease, or any element—it’s been emphasized and exacerbated with the virus. You get the virus, and you get symptoms five to 10 days later. If it gets severe, it’s a very rapid onset—and with a cancer it can be months, years or decades. That same thing that we’re seeing with the virus is just extended in cancer.

Now I hope, again, as a person who’s interested in community health and working in the public health care setting, I hope this issue with negative acute outcomes in the underserved community really highlights that we need to do something.

If it does highlight that point, and if money were to be available, I think we could have, via this very sad current outcome, a better positive outcome long-term in the context of cancer or any other type of chronic disease.

Again, that’s going to require community health outreach and funds to support that mission. I hope that that will happen. It’s going to be a very difficult, as we all know, economic time in the next year or two. If I had a crystal ball, I’d probably be a rich man, but I wish that that crystal ball would tell us that we will see expanded health care. I just don’t know if that’s the case.

I know our mission in our Emerging Viral Threat lab, will be to help these diagnoses, both PCR for detection of the virus and serology to detect possible evidence of infection will continue. We will also continue to meet our mission to care for the underserved and do education and outreach within that community.



How could COVID-19 change how treatment works in a post-pandemic setting? Whether this means expanding your Partners in Wellness program, among other things.


I think many things will change, as we see things that worked and things that didn’t work, by staying home we saw benefits of telemedicine, and of online learning at college and high school settings. In the context of education, I think we’ll see a lot more online education. I bring that up not just for elementary or high schools, colleges, but that also means community outreach could be done via that online mechanism.

On the other hand, I think we have to be careful not to overreach with that, because in communities that don’t have strong access to the internet and computers, that sort of element will be delayed. We’ll have to find a way to reach out whether that be through a local community clinic and churches in underserved communities, maybe we could have teleconferences with multiple people on the context of education.

Again, these are just some ideas and people have to think about them going forward.

But in a broader sense, I think telemedicine is going to be a way to move forward as we continue to maintain social distancing, which seems like it’s going to be an issue for the next few years at the very minimum.

I think it also provides more rapid and easy access to health care. A rural physician will be able to have access to all of the modern tools as a large health care setting, such as a medical school, where you could call in and say, here’s my patient, what do I need to do? What do I need to check on? Here’s their number—rather than send a patient to the city or to our med school, we could almost do that from a distance.

As I said, in communities that don’t have access to a computer, we still need to have boots on the ground and thus we will have to be able to consider all elements. So whether they’re boots on the ground needed with the face-to-face, as much as you can deal with that in a pandemic or post-pandemic environment, as well as an electronic mechanism. I think those are things we will have to consider.



I’d like to switch gears a bit to discuss research-related endeavors at Feist-Weiller Cancer Center. You mentioned the Emerging Viral Threat lab. What is it, exactly? How does it work?


We, being many folks at LSU Health Sciences Center, created it from scratch. We had some open labs that we used to build this lab, using the expertise of researchers in virology, microbiology, and immunology. It was a multi-talented series of folks that put this together. It’s not one single person that was involved in this. Many people came together to make this work.

What we did, we set up a lab where we can get samples from the hospital, from clinics, from van swab patients, and other sources. We could then process those samples into our electronic records. We then take those samples into what we call the hot room, which is where the vials from patients with potentially live virus are processed via a robot. These samples go from virus in the swab to RNA, which can then be taken to the next room for the next step of the processing.

Obviously, everyone’s using proper protective equipment in the lab, and especially in the hot room. We can then take those samples and do what we’re asked to do, whether it be detecting the virus through some mechanism like PCR—and we have done this in a validated clinical setting. Our lab is validated to do these tests, and we try to get answers out in 36 to 48 hours. But we’ve been really pretty close to 24 hours from the onset of the sample testing to the outcome, which is a bonafide report that’s been medically verified, and is then sent to the physician in charge.

This Emerging Viral Threat lab, or the EVT that we set up, has short-term goals—being to diagnose the virus via PCR as well as serology to test for antibodies to the virus. That’s our short-term goal. For the mid-term, our goal is to get people back to work, to do more community screening as you see and hear in the news. This ability to go out in the community and do wider spread testing will help with this goal.

Then long-term, we like to set a tone of being a laboratory that continues surveillance—whether a year or five years from now—and opens us up not just to test for the current virus, but other things from the flu, to new pandemic-type viruses that might arise—as well as modulating research within the community that could be of fundamental importance through its ability to direct, and new treatment options for this virus or others as well.



What other forms of research are being done at Feist-Weiller Cancer Center and Louisiana State University Health Sciences Center?


We are doing clinical trials, and this is really the interwoven nature of all this stuff we’ve been talking about. By having our lab diagnose patients quickly, we’re able to know who was positive, and therefore who had COVID-19, and to then open those patients up to clinical trials.

As you mentioned, these trials are not directly through the cancer center in the context of ongoing oncology type trials, but they are set up through the lab and the school—and since the lab was piggybacking off the genomics, the cancer genomics lab, it’s all interwoven.

One such trial is inhaled nitric oxide, this is a gas that had been used in children, and it’s an element that is important in preventing lung damage. The idea is, in a very colloquial sense, that the difficulty people have breathing is caused by lung damage due to a viral infection.

If there are products, in the case of this inhaled gas, it’s very rapid. It gets in and it is hoped that it can mitigate some of the damage caused by the virus and improve lung function. It’s also not a gas that gets rapidly taken up into the blood system in this case, but rather it can directly influence lung function.

So, by having this lab, and having a medical school willing to do this, we’re one of only a few medical centers testing this inhaled gas for outcome in COVID-19 patients. There’s no data yet on whether it has worked in the context of improving outcome. All other studies have shown that it should be efficacious.

In the context of convalescent plasma, that’s the idea that someone who’s had the virus has antibodies in their plasma. If you put those antibodies into a sick patient, those antibodies will run around the patient so to speak, and block viral infection and replication, mitigating disease and hopefully showing a positive outcome and a quicker recocvery.

Again, through the lab we have set up serology, and this is a collaboration with our life share blood group here in Shreveport. We look for people who have recovered from the virus. We take some of their blood, we test it out in our serology assay, make sure they have antibodies to the virus and what that antibody titer really is, and then we can use that plasma as a treatment for others in our ICU who might be very, very sick.



I’d like to talk about how Louisiana got to the point where it is now in terms of the prevalence of COVID-19. What happened?


Sure. As you know, everyone knows that Louisiana is a very festive state.

Mardi Gras is the same as Fasching, or Carnivale, which occurs in many countries around the world. It’s a huge tourist draw. New Orlean’s Mardi Gras is a big deal. People come from all over the world, all over the country. In Shreveport, the other end of the state, there are also multiple Mardi Gras parades and festivals and so forth.

From a virus standpoint, these are large groups of people where there can be tens of thousands to hundreds of thousands, really over a period of several weeks. All of these people coming together in close proximity, and it’s very likely there were a few people probably asymptomatic shedders in those large groups—with people shoulder-to-shoulder, involved in all the fun stuff that’s Mardi Gras. It’s very likely this allowed the virus to unfortunately just blow up from an infection standpoint, and thus get access to huge numbers of people that then dispersed going to multiple parishes in Louisiana, and multiple states around the country, and probably even multiple countries around the world.

The same thing holds true for Shreveport where I’m at. There are Mardi Gras parades here, and a lot of the local people from five or six different states—from Texas, Arkansas, Mississippi, Oklahoma—and probably as far away as Tennessee, and I’m sure other states as well come and have fun at these festivals. It’s just a large group of people. Again it’s what a festival is, to get together and have a good time.

From a virus standpoint, it’s a giant incubator to rapidly spread virus. I think this is what happened, and we saw the first cases in New Orleans really about two weeks later, coming into emergency rooms with atypical pneumonias—and the same thing roughly happened here in Shreveport. It’s just an unfortunate circumstance, and very sad.

Right now, I think Louisiana is in the top five or so when thinking of our population and numbers of tested positive patients as well as deaths—it’s a very high level and we’ve been very heavily affected.

We’ve mentioned some of it in the context of overall numbers, but also the disproportionate effect on underserved communities. So it’s really a very sad situation and very unfortunate the way it is and at least elements of Mardi Gras contributed to this infection rate. I don’t want to put all the onus on that, because, obviously, the virus was already here much earlier than we realized, which is based on new data, so there were kids in school, people shopping, etc that also contributed to viral spread.

I think when we go back and take a look, what we’re going to see is it was probably more widespread in the community a lot earlier than we realized in what we are calling asymptomatic shedders.

It was really in those healthy individuals spreading below our limit of detection that helped spread the virus. It was only when it got in nursing homes and in people with some of these other illnesses that it really blossomed in a negative way as a virus.

And so at Mardi Gras, the virus just did what a virus does, which is spread and spread. I really think that Mardi Gras—and it’s been in the newspaper here locally and throughout the state—was a breeding ground for dissemination of the virus.

It was just a perfect storm for the virus that people are wall-to-wall, bumper-to-bumper there. They’re at parties, they’re having a good time, all the frivolities that go with that. Then again, obviously, they came back home from Mardi Gras in February and spread it to kids, who went to school, who then spread it to other kids, who in turn brought it home to parents, and churches and work, etc.

You had a larger underlying viral load, so to speak, that that then allowed it to more quickly explode. That’s at least, I think, a pretty viable explanation for what happened.



And you saw similar things in New York. They had the St. Patrick’s Day celebrations. Nothing was shut down then yet. In Florida, you had spring break along the beaches. Many states weren’t proactive enough in this whole scenario. So, where do we go from here? How do we get past this?


So, I think that’s truly a billion-dollar question.

How do we get by? There are a number of different models that are out there, and none of them at present, say, we’re going to get rid of the virus. It’s within our population, whether it’s long-term, like some of the benign coronaviruses. Put in perspective, this particular coronavirus is in the beta coronaviruses.

The first SARS coronavirus, the MERS coronavirus and two of the four benign coronaviruses that cause some of the commons cold are all grouped closely together. All of these viruses, jumped from animals, some from as early as the 13th century, and some up as you know just last year.

There are four benign coronaviruses.

Two of those, OC-43 and HKU-1 are the two mostly closely related to the SARS-COV-2, and they are in the normal community. They seasonally come in, cause the common cold, they disappear and come back year in, year out. And the questions then, are what’s going to happen with this new virus? Is it going to be a seasonal player and show that type of a feature, a seasonality of every winter?

We do know that from studies in Brazil, Australia and other countries with warmer climates are seeing outbreaks right now, suggesting that the virus does fine in warmer climates. How does this country deal with it? A lot of it depends on unknown areas. Is this a virus that’s going to slowly mutate like the benign coronaviruses and become less dangerous, to be a seasonal common cold, or would it become more dangerous? Is this virus going to be maintained in its somewhat nasty form and level of fatality?

There are a number of different variables. We just don’t have the data, it seems like it might be five times worse than the flu, to maybe 20 or 100 times worse depending on what study you look at. We won’t know until we have more data, but I think short-term, it’s very likely to be around in the summer in some form and then to return in the fall. Kids are going to go back to school and we’re going to have to continue social distancing or there will certainly be a flare up of viral infection.

We’re going to have to continue screening. We’ve talked about the van. Part of our mission is going to be to continue going into the community, screening for the virus and for antibodies via serology, to keep our community safe. If there’re outbreaks or hotspots, we’re going to want to trace those infections to keep it from getting out of control.

Obviously in schools, we don’t want it to be prevalent in schools. We don’t know when a vaccine will be made. They’re talking 12 to 18 months, but that would be the fastest vaccine ever made, and obviously every person probably on the planet is hoping that the vaccine actually meets that deadline. But most vaccines take five years, 10 years or longer—and so, it is a lot of unknowns. There’s a lot of very interesting models out there with information saying it will be a seasonal virus to saying it will be a biannual virus, obviously coming back every other year.

The new normal may just be that this virus is around us for the long haul. I hope, ultimately, from the virus standpoint, that it acts like the benign coronaviruses that did jump from animals and became one of the harmless causes of the common cold. The thing is, these other four coronaviruses did jump from farm animals and other animals. They know that from sequence and fingerprinting of the viral genomic sequence.  So we hope this new virus will also become less a problem with time.

These coronaviruses jump species on a normal basis, and over time, when they do jump, they in the end usually become more benign. That’s really the hope, that long-term they become more benign and just cause a common cold-like illness and normal upper respiratory infections, and not one that has the high rate of fatalities that the current one has. That would certainly be a hope, as is getting an effective vaccine that can mitigate infection. But yeah, right now we’re going to have the new normal—this virus and dealing with elements of it for quite some time.



Absolutely. And is there anything else you’d like to add?


It’s important that we talk about the lab, in the context that it was set up as a real group effort by many people, from administrators to scientists, to clinicians, to nurses, to computer programmers, to try to help our community in this pandemic.

It started from a grass roots lab working with aspects of our cancer center, and expanded to an important element in community service, committee outreach, and community health. It’s one of the things that we had talked about earlier, that since it’s part of the LSU Health Sciences Center, the medical school, which is a state school and not part of the hospital, we can more easily perform community outreach and care for underserved—where the hospital’s lab that does the same function is set up to care for patients that come only into the hospital.

I think that’s an important distinction, and one that I think we can have really a strong effect on the community. It’s a little bit of a model for at least the state, and maybe others, of how a collaborative endeavor between many different players can have a positive outcome and a positive effect on our community.

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