Episode 46-
Alex Vieira
Thriving in the Chaos: How Dr. Alex Vieira Thrives on the Road Less Travelled
People often take the easy path, but what can you achieve and grow by jumping into thorny problems that don’t have an obvious solution?
Today's guest on Contrary to Ordinary is Dr. Alex Vieira. He’s a pioneer in cleft-palate research, has authored more than 400 scientific papers, and is the most cited expert in the field.
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In this episode, Alex shares his journey from growing up in Rio de Janeiro during the military regime to becoming a leading figure in oral health research. He discusses his decision to pursue dentistry, influenced by an admired uncle, the challenges of starting his research career during the AIDS epidemic, and his fascination with the Human Genome Project.
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In this episode’s commentary, Kim discusses the importance of the entrepreneurial mindset and the roles of genetics and environment in shaping human behavior. He emphasizes the value of collaboration, the importance of local contributions to global impact, and the need to maintain high research standards.
Overall, Alex believes in following one's passion and making meaningful changes in the immediate environment, which he sees as having a trickle-down effect on broader societal improvements.
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Resources
Follow your curiosity, connect, and join our ever-growing community of extraordinary minds.
The Human Genome Project Website
The Power of Habit - Charles Duhigg
Atomic Habits: An Easy & Proven Way to Build Good Habits & Break Bad Ones - James Clear
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Transcript
Dr. Alex Vieira:
It is definitely the interest on generating knowledge that's a big driver. I like to think that we can look at problems and try to make a contribution to society in general. That's what drives me is the possibility of influence the thinking of people. Our generation. That makes me very proud that some of that happened already.
Dr. Kim Kutsch:
On Contrary to Ordinary, we explore the motivations, lives and characters of innovators who see limitless potential around them. Through these conversations, we hope to provide insight into how you can emulate the mindsets of these extraordinary people in your own life and work. My name is Dr. Kim Kutsch and I've spent over 20 years in dentistry before creating CariFree over 20 years ago today. We offer a range of dental products to the industry and the public that promote health and wellness of people affected by dental caries, otherwise known as tooth decay.
Today, I am back after a long break with a special episode. It feels great to return. And I really appreciate everyone who kept listening during our time away. My guest is Dr. Alex Vieira, he's a pioneer in understanding why some people are more likely to develop caries than others. Alex has earned top honors in his field and published more than 400 scientific papers. He's also the most cited scientist in cleft lip and palate research worldwide. He's made a real impact on oral health research and education around the world. But his journey wasn't always easy or straightforward, and I think we can learn a lot from his story. So let's get started with my conversation with Dr. Alex Vieira.
Tell me about your early life, what was it like in Rio de Janeiro growing up?
Dr. Alex Vieira:
It's interesting, I was born during the military dictatorship. And my family, we could classify as a low-mid-income family. And at that point my mom had this plan for me that if I had to be able to succeed, have a good life, I had to join the military because the military was a synonym of having a good stable job. And as I was growing up, the transition happened to democracy, the military dictatorship ended. The first elections happened. I was in my young teenage and actually the first time my mom voted, I went with her. I decided to study dentistry, and so I did a big exam that you do at the end of high school, and I passed to the dental school.
A big influence in my life that geared me away from the military career, which was demanding in the sense that I had to be away from family, studying boarding schools and things along those lines. So because of the influence of an uncle that I had in the family, there was the uncle that made it so that everybody look up at him in my family, he was a oral and maxillofacial surgeon, so I said I'd like to follow that path.
Dr. Kim Kutsch:
And then you ended up in academics and research down the road. And it's interesting to hear you say, looking back, it's easy to see the path that led you to where you are today. But I think when you're in that looking forward, you make decisions that you don't really know the long-term outcome of each of those individual decisions. It's interesting looking back and you see each of those little steps and got you exactly here, which is where you're meant to be, I think.
Dr. Alex Vieira:
Oh yeah, yes. It's nice for you to say it that way. But yes, it's an interesting characteristic of mine, I guess, that I am always looking for maybe the path less traveled, the less obvious path as a way to explore it. And again, when I look back, there are several instances that I actually did that, including going to dental school instead of the military. And then later in my life, becoming a full-time scientist.
Dr. Kim Kutsch:
After graduating, Alex joined the military, and used his earnings to get a master's degree back home in Rio. It was an unusual time for Alex to begin his research career, the AIDS pandemic forced scientists to change how they worked. For example, Alex's class was among the first to use gloves in dental research, which is now standard practice. This marked the start of Alex's journey to help people with complex needs, a path he followed throughout his career.
Dr. Alex Vieira:
During the master's program, I was exposed to a class on genetics, and so this is mid-nineties, so the teacher was talking about the Human Genome Project and the emerging technology and things like that, and I was fascinated by it. End of the classes I went to her and I asked about opportunities to study that at the PhD level maybe. And she said, "Well, I work on epidemiology and birth defects, not really anything to do with AIDS." I told her a little bit about the work I was doing with AIDS and kids and some of the clinical trials. I was involved in some new treatment tentatives for controlling caries at that time. But she said, "Let's talk about it, let I'll think about it and let's talk." And when she came back, she proposed to me I study cleft lip and palate, which was a condition that is craniofacial, but it's prevalent enough on her radar as a dysmorphologist, she's a physician, a neonatologist.
And then she handed me a paper. That paper was a publication that was the first association of a gene variant to cleft lip and palate. It was published in 1989 by someone, the leading author was someone that would become my mentor in the United States. And she said, "I want you to replicate that work with our population." Our population meant that she had, with her colleague and husband at that time, they were managing a birth defect surveillance program in Latin America. That was created in Argentina in 1967 and was running for almost 30 years at that point. And she said, "I want your work to also be the facilitator for us to start collecting biological samples. Because we have all this epidemiological data, I want to tie with biological samples." So I had to get 43 R&B approvals to get my thesis. 43. Some of those are very convoluted, very, very involved protocols. Some of those are simple to do. But there were 43, 43 sites that I had to do.
Dr. Kim Kutsch:
To get internal review board approval at a university to do one study is a lot of work. And you had to do 43 of those to be able to collect all of this data for your thesis?
Dr. Alex Vieira:
Correct. It did take quite a bit of time. But again, there was definitely the scrutiny was rising at that time. And so I was saying, I was in my mentor's home one day, and they are talking and then the conversation went like this. "Well, what do you mean, Alex is going to the United States to do this?" And that was the first time I heard the plan, in their heads that they never communicated to me, was for me to go to complete the work in the United States under the mentorship of the man that was behind that publication that was handed two years before.
So I met Jeff Murray eventually in University of Iowa. And Jeff became my lifetime mentor. I call him my American father because he took me under his wing and he facilitated my transition to United States. So these three people, Ieda and Eduardo, my mentors in Brazil, and then eventually Jeff, those are also very influential in my life.
Dr. Kim Kutsch:
Richard Branson, founder of Virgin, once said you should always surround yourself with people who share your values, the rest will follow. Warren Buffett, Andrew Carnegie and others have given similar advice. Spend time with people you admire and your path will open up. Why share this advice now? With AI and our growing online lives, it's easy to work and grow on your own. But in the end, human connection moves us forward. Many choose the easy path, but Alex was different. He wanted to take on the toughest and most complex problems. At the time, the Human Genome Project was a new and challenging research effort that was changing the field.
Dr. Alex Vieira:
So very early on my training and starting to understand genetics and how that play a role, and again, this is 20 years ago, so that means we are about to get the Human Genome Project completed and announced, all hype is still there. It turned out that the Human Genome Project did not translate to all that knowledge and curing diseases the way the promise was. But that was the hope, to quickly identify complex traits. So at that time, if you think of genetics as the classic way we learn in high school, that is very deterministic, one change will lead to a phenotype. All those conditions, the typical ones, the Mendelian ones, were taken, they were cloning all those genes, they're identifying all those genes, etc. So somebody walking in at that point didn't have those kinds of diseases to study. What was left was everything else, that we call complex or multifactorial.
Dr. Kim Kutsch:
Yeah, yeah, more than one gene maybe played a role.
Dr. Alex Vieira:
Exactly. And then there is a potential influence for the environment. And those are very complex in many ways. And dental caries is a good example of those. So I was immediately interested by this chaotic scenario. So one thing that interested me the most was a conversation I had with my mentor, the one that sent me to the United States, still in Brazil, that she was conceptualizing that for me and then she described it as a chaotic system. And I thought that was fascinating because that meant in very simple terms that an event is unpredictable. We cannot really predict what's going to happen afterwards after that event. So she was making an analogy of a mutation in the genome. A mutation, you cannot really at that point be sure what will be the consequences.
So when you have combination of those variants that might have smaller contributions, that explains a range of disease presentations that you have in populations. So that concept always a caught my eye. And then what was natural then was bringing my expertise, the things that are being exposed, I was a dentist originally, so anything that had to do head and neck, oral, teeth were things that I was more comfortable with. And this concepts of human genetics I was learning. So I was combining those two disciplines.
And then eventually when I was ... the first attempt that I had to get external funding, I wrote this project to be done in families, that my mentor had ascertained back in the Philippines. And essentially the project was to bring a dentist to those families and revisit those families to get the dental development information to analyze all this data that he had on the molecular level. And while I was doing that, the most common reason people would not have teeth is dental caries. So I had to exclude dental caries to make sure what I seen was congenitally missing teeth. So I created this protocol on the field the way we could do that project. That essentially got me very decent data on caries experience of these people. So that was the work that was emerging, that you are familiar, those analyses on dental caries started by looking at that population that was originally ascertained for cleft lip and palate.
Dr. Kim Kutsch:
And so that was really a by-product of that research, it came out of that research, because you had the data on that population.
Dr. Alex Vieira:
Yes.
Dr. Kim Kutsch:
Alex, I'm sitting here listening to your story, I'm fascinated by your story, but you said one thing earlier that you always look to take the road less traveled. Your face lit up when you talked about being in a chaotic system. And that is the road less traveled. I mean, most people would not choose the most challenging, difficult, chaotic pathway.
Dr. Alex Vieira:
True, I think so, I think so.
Dr. Kim Kutsch:
I think most people, human nature is to take the easy path. Do you think that's hard baked in your DNA as a person, is that one of your traits is being comfortable with chaos, liking really big chaotic challenges? It must speak to you.
Dr. Alex Vieira:
It does. And I do believe that those characteristics have to do with the individual background. It's another complex model, if you think of behaviors or risk-taking or personality or however you want to define or measure those traits, there is definitely a genetics background that is defining it as more daring, more cautious and so on, so forth. For a personality one way versus the other way. And of course the environment that you are will be modulating that.
Dr. Kim Kutsch:
Alex, so one of the things when I started doing this podcast looking at extraordinary people, one of the questions I had, is it based on their genetics, are people extraordinary people, is that something that's hard baked? Is it something that they've learned or got influenced to do or is it a choice they made or is it a combination of all three of those?
Dr. Alex Vieira:
I think it's a combination. I think that all those forces are acting. I like one concept that, and I remember to challenge my students describing that, I would ask them, if we swapped parents and if you had my parents instead of yours, you would likely be the same person because your personality, the way you behave, the way you face the world-
Dr. Kim Kutsch:
That's in my DNA.
Dr. Alex Vieira:
That's in your DNA.
Dr. Kim Kutsch:
Alex, that's a really good analogy. I never really stopped to consider that. But is it genetics or environment, a combination of both? But the reality is, yeah, if we swapped parents, you would still be the same person that you are. I don't know that you would end up in the same pathway, but maybe likely that you would've based on how genetics drive behavior.
Dr. Alex Vieira:
And it's not exactly the same pathway, because some of the economic forces might be taking you a different direction, but a similar one.
Dr. Kim Kutsch:
Opportunity.
Dr. Alex Vieira:
And unless there's something very dramatic to take you out of the pathway, some dramatic disease or things along those lines, you probably will be on that pathway.
Dr. Kim Kutsch:
If Alex is right, can we change ourselves by changing our environment even if our genetics say otherwise? Canadian psychologist, Donald Hebb, believes so. He's known for saying neurons that fire together wire together. This simple idea helps explain how habits form in the brain and shape our behavior. The more we repeat a thought or action, the stronger those brain pathways become, making the behavior easier and more automatic. Many books explore this idea like Charles Duhigg's The Power of Habit, and James Clear's bestseller, Atomic Habits. These books show readers the patterns, rewards and long-term benefits of building good habits. Even with this knowledge, shaping our future isn't always easy. Still, adding good habits to our routines is always worthwhile. It helps us change the parts of ourselves we want to improve. In the past, field-side genetics is neat and predictable, but the truth is much more complex.
Dr. Alex Vieira:
And the few things that were done were in the classical way of looking for more deterministic traits. And since they did not make sense, they did not translate immediately, they were dismissed. And I think when you use dental caries as an example, which is a disease that's very peculiar because the environment really plays a major role, it is understandable the whole emphasis on that field on how to intervene on that disease. The importance of fluorides and the amount of work that's been put on working ways fluoride can be delivered. And very little in comparison was to the individual that was receiving those treatments suffering that disease. And the variation was ignored.
There are individuals in the population, if you get a hundred people that never brush their teeth and eat normal diets, etc, there'll be those two, three, four maybe that would never have a cavity. And what's protecting them? The challenge is how we make that understanding of prevention something that is viable at the population level. We're just talking about implementation research the other day, that's the challenge we have now, is how to implement those activities to be able to impact the population so we can see essentially caries disappear.
Dr. Kim Kutsch:
So when we were in London, I asked you this question because I've seen data all over the board, and you told me at that time that the role that genetics plays in tooth decay is about 9%, somewhere around that neighborhood. I mean, as an influence in general you said. I think at the population level it plays about a 9% role. Is that data accurate or is that close or has it changed much?
Dr. Alex Vieira:
I'm not sure exactly what I'm thinking, five years ago now, or seven years ago now to say that 9%, there are a number of outcomes that people have been measuring. So there is a classic statistical approach to determine the burden of genetics or the burden of the environment in a particular condition. And that back in the day would justify a study in genetics for a particular condition. So there was almost a requirement to demonstrate there was a sizeable amount of genetics that's influenced by the variations in the population. That's called irritability.
And irritability is a number from zero to a hundred, and we can talk in terms of percentage as well. And that will give you the burden of the one versus the other. Depending on how you're measuring the outcome that relates to caries, number of cavities or presence of plaque or presence of particular bacteria, et cetera, that number will vary a little bit. And sometimes I've seen the number go as high as 50%, 60%.
Dr. Kim Kutsch:
Wow. But for an individual?
Dr. Alex Vieira:
That's for the population, for the risk of the population.
Dr. Kim Kutsch:
Oh wow.
Dr. Alex Vieira:
The risk of the population. That's not translatable directly to an individual.
Dr. Kim Kutsch:
Right, exactly.
Dr. Alex Vieira:
That's the challenge of how we translate this to then the care site. You don't, they have to talk in terms of susceptibility. If you are my patient, and I see you and I say, "I see that you fit this particular group so there's likely higher risk for dental caries or cardiovascular risk," or whatever that you're talking here, and then you can try to mitigate those risks. So we can implement interventions or propose things to mitigate your risk. For example, coming to the dentist more often maybe because I want to do a professional cleaning more often than the six months that is prescribed by your insurance base because I want to keep your risk lower. The challenge with those numbers is that they do not apply to the individual level and that's why it's so difficult on an individual level.
Dr. Kim Kutsch:
And that's why I've seen them all over the board.
Dr. Alex Vieira:
And they are all over the board because it depends on how you're measuring as well.
Dr. Kim Kutsch:
Yeah, I got that.
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So you've done all this research and work in your career linked to genetics and oral health. And this pairing of these topics led into your academic and research career. What drives you to do that, Alex, I mean, what drives you as a individual to do that kind of research?
Dr. Alex Vieira:
It is definitely the interest on generating knowledge, I think that's a big driver. I like to think that we can look at problems, they are closer to me in the sense of my exposure and training and education, et cetera, and try to make a contribution to society in general. So that's what drives me is the possibility of influence, thinking of people our generation. And in many ways makes me very proud that some of that happened already when people conceptualized, for example, dental care is nowadays like I mentioned.
Dr. Kim Kutsch:
So you're really driven to make discoveries and make a contribution that makes a difference.
Dr. Alex Vieira:
A fair way to put it, yes.
Dr. Kim Kutsch:
There's a great Ted Talk by Erin Jablonski, director of the Center for Entrepreneurship at Bucknell University. She explains that the entrepreneurial mindset isn't just for business people or capitalists. She says people with this mindset are curious, empathetic, and driven. They have big ideas they believe should exist in the world. It's not about money, but about making something meaningful happen. She even quotes Professor Howard Stevenson, Harvard's so-called lion of entrepreneurship, who defined entrepreneurship as the following, the pursuit of opportunity beyond the resources you currently control. In other words, it's about creativity, initiative and resilience. It means finding ways to make an impact no matter where you begin. This mindset shows up everywhere. Entrepreneurs can start nonprofits, invent new solutions or take on challenges in science, research and healthcare.
I believe Alex has this entrepreneurial mindset. His drive to make the world better has led him to make a big difference in his field. Does he see that as extraordinary? Not really. For him it's curiosity, drive and the willingness to act that define success. These are the qualities of an entrepreneurial mindset.
Dr. Alex Vieira:
No, I really appreciate you phrasing that way. Not really. I understand I'm outlier, I cannot demand peers to have the same level of productivity, so I see that.
Dr. Kim Kutsch:
So you'll admit to being an outlier, but maybe not extraordinary?
Dr. Alex Vieira:
True. Let's put it that way. But yes, it's nice to see that that work was quite influential when people look at that and the way I phrased the things. And that was the first time I was describing that there is a connection between being born with cleft lip and palate and your family be susceptible to cancer. Which I think is an important way to look at the problem. And I think that's part of the reason that people like to look for it. The other thing is the connection with the brain and the face. If you look at a face, you're seeing the reflection of the brain or vice versa. Definitely those are tightly connected.
Dr. Kim Kutsch:
So going forward, it's not going to be a surprise to us that we're going to find a lot of cancers that have a genetic component?
Dr. Alex Vieira:
No, it's not. And actually cancer is a genetic disease by definition, if you look at the cellular level. No, it's not surprising. Challenge of cancer continues to be of course the way to control it and prevent it. But we made quite a bit of strides on that. And we're at that point that we are accomplishing discerning individuals that would fare better in particular treatments versus not because of their genetic background.
Dr. Kim Kutsch:
And finding a genetic biomarker that we can appraise their risk going forward throughout their life. I mean, what a huge contribution to an individual. How do you maintain a really high standard when you work?
Dr. Alex Vieira:
I think it's writing. It's asking the challenging questions and trying to be honest in the way you are approaching it. A lot of that work and the publications that you mentioned, they are quite convoluted papers because I don't eliminate piece of data that not necessarily are supporting a direction, et cetera. So I actually include all of them so people can appreciate some of the directions that maybe are less likely to be a good explanation for it.
I think it is a combination of being very comprehensive in the way we're presenting the work, as well as be collegial and be open to the collaborator's input and having a fair share of that, all those contributions being distributed. So I don't see anybody as just my providers of data, providers of samples, et cetera, I truly treat everybody as colleagues in the sense that they want to share that knowledge and gain their knowledge and get their input and go that way.
Dr. Kim Kutsch:
So Alex, what's up next for you?
Dr. Alex Vieira:
So I just moved to North Carolina, so I am at East Carolina University, is a new dental school, relatively new dental school now. We graduated the 10th classes, about to graduate the 11th now in May. The challenge is to create a cohesive research program. It's my first experience as an administrator at that level and I am very excited about it. That part of the country, that part of North Carolina has a very unique aspect of being rural. And so the opportunities lie on looking at the health of individuals that live in the rural areas, disparities that they face, the reasons why. Take advantage of how diverse those groups are.
The footprint of our school also is very interesting because it was created to have rotations of their students in eight clinics outside the headquarters where I am in Greenville, North Carolina. Where those students are trained in those rural areas with the hope that some of the will stay in North Carolina, those areas to serve that population.
Dr. Kim Kutsch:
What's one thing you'd like our audience to look at or consider after our conversation here today?
Dr. Alex Vieira:
I think you follow your passion, you think in terms of making a contribution to your environment. I think if you want, in particular the younger ones that are much more result-oriented than maybe our generation, more immediatist, that you have to be patient to see results. But one thing that data does suggest is that if you want to really change the world the way we all hope, you got to work locally. You got to work where you are. Make life around you better. That has a trickle-down effect of impacting the world eventually. So that's probably my main message.
Dr. Kim Kutsch:
Okay. Be the change that you seek, right?
Dr. Alex Vieira:
Yes.
Dr. Kim Kutsch:
It starts with you, the individual, huh?
Dr. Alex Vieira:
Yes, that's it. I truly believe that.
Dr. Kim Kutsch:
Is there anything else that I didn't ask you that I should have?
Dr. Alex Vieira:
No. It was a pleasure to talk to you. And I'm really glad that you made a point to make sure that we spoke today. No, thank you.
Dr. Kim Kutsch:
Yeah, thanks.
Dr. Alex Vieira:
Thanks for the opportunity. Glad that you're doing this, I think it's important.
Dr. Kim Kutsch:
Thank you so much, Dr. Alex Vieira, for joining me today. And it was great to have you back for another episode of Contrary to Ordinary. Here we aim to inspire and build connections. We couldn't do it without you. If this conversation moved you, made you smile or sparked your curiosity, why not listen to our back catalog of episodes. They're easy to find right here in your podcast app of choice. And if you do one thing today, make it extraordinary. Bye for now.