The John E. Fogarty International Center (FIC), part of the National Institutes of Health, for decades has offered a variety of global health fellowships to medical residents, medical fellows, and Ph.D. health scientists. Exceedingly rare has been the dental student who joined them out in the field. But in 2006, the FIC allowed more qualified dental students to participate in its International Clinical Research Scholars and Fellows (FICRS-F) Program. In 2009, Leora Walter, then in her third year at Columbia University College of Dental Medicine, became the fourth dental student to receive the one-year FICRS-F fellowship. She spent the year in Lima, Peru, working with researchers from The Johns Hopkins University Bloomberg School of Public Health, Instituto Nacional de Enfermedades Neoplasticas (the Peruvian national cancer hospital), and A.B. PRISMA, a Peruvian non-governmental organization. Walter has now returned to Columbia University to finish her final year of dental school. NIDCR's Science Spotlight recently spoke to Walter about her work in Lima, her lessons learned, and her take-home messages for other dental students who might be considering a Fogarty International Clinical Research Fellows Program.
Welcome back. What did you study in Peru?
I worked primarily on an epidemiological study that evaluated the prevalence of oral human papillomavirus, or HPV, in a low-income area of Lima.
Why oral HPV?
Head and neck cancers, as a whole, have decreased in the developed world. But oropharyngeal cancer, one of its subsets, has increased. It has been hypothesized that the decrease owes to fewer people smoking than in the past, while the increase is due to oral HPV. In the developing world, little is known about these trends. We already know that HPV is a well-established risk factor for another epithelial cancer -- cervical cancer -- but more research is needed to prove the relationship in the oral cavity.
How many types of HPV are there?
There are over 120 different known types. The one that has the strongest association with oral cancer is HPV-16. When I arrived in Lima, little was known about the effects of HPV on the oral health of Peruvians, especially those from poor and thus more at-risk neighborhoods. Our study is a first attempt to bring the scope of the problem into focus.
Let’s go back, though, to the beginning and why you chose to pursue a Fogarty International Clinical Research Scholarship-Fellowship. Since the Fogarty Center has allowed dental students to apply for a fellowship, few have done so.
No, you’re right. Most dental students are focused – and justifiably so - on completing school. They don’t think that they have the time to pursue anything outside of the standard curriculum. In other words, if you’re training to become a pianist, why spend a year learning to play the violin? A pianist might answer that the experience will help make him or her more musically astute. The same is true here. A background in the basic sciences, global health, epidemiology, you name it, is only a plus for your personal and professional development. So I made the time, and, for me, the Fogarty fellowship provided an absolutely amazing experience that enriched my dental training and will stay with me forever.
But wanting to go and filling out the paperwork are two different things. What made you actually hit the send button?
There’s a short and a long version of the story . . .
Let’s go with the longer version.
Sure. The story starts with a previous opportunity. Between my second and third year of dental school, I spent six weeks overseas through the International Center for AIDS Care and Treatment Programs. It’s called ICAP, for short, and it’s a global initiative of the Mailman School of Public Health at Columbia. What happened was Mailman sent out a mass email and essentially said if you’re interested in doing HIV research, write a research proposal, and we’ll take a look at it. I jumped on the opportunity. I wrote a proposal related to HIV and dentistry. It was accepted, and I was sent to Ethiopia. The program was absolutely wonderful. Everything that happened there inspired me.
I worked in a dental clinic and taught clinicians how to recognize the oral manifestations of HIV. For example, I taught them that if you notice a black-and-blue mark in the mouth, refer the patient immediately to the HIV clinic. It’s likely to be Kaposi’s sarcoma. I also worked with physicians in the HIV clinic. I would illuminate the oral cavity with my penlight and taught them how to perform an oral exam. Up until that point, they had overlooked the oral cavity. One day in the HIV clinic, a doctor joked with me while examining an adult patient, “I’m only going to look in the mouth because you always make me do it.” I said, “Great.” I illuminated the oral cavity for him, and I heard him gasp. The patient appeared clinically to have nodular Kaposi’s sarcoma, which, according to the World Health Organization, is one of the manifestations of stage IV HIV disease. We immediately started a treatment plan for the patient. That experience really stuck with me. It taught me that the traditional divide between medicine and dentistry is artificial. You can’t divorce the two.
I hear that you published a desk reference called Oral Manifestation of HIV, and it’s being used in the ICAP-supported hospitals in Ethiopia. Is that correct?
That’s right. The doctors and dentists need to keep looking, and this was a great way to leave something behind to help them do it.
What happened when you returned to New York?
Well, I should mention that I didn’t want to leave at the end of my six weeks in Ethiopia. But I had to start my third year of dental school. When I got home on September 8, I went through my emails. I noticed one that Dean Davis had sent out that day for the Fogarty Fellowship and an opportunity to get involved in research studies in the developing world. I thought, “Wow,” and my mind started to race. But I must admit, I was really nervous at the thought of applying for the fellowship.
The fellowship lasts for one year. Nobody from the dental school had done it. So, the thought of interrupting school for a year made me nervous. I would be setting myself apart from my classmates. I’d come back, and they would be already graduated and gone. I would also be away from my family and friends for an extended period of time. Things would change, and I would come back expecting everything to be the same. It was a lot to contemplate.
It was a risk?
You bet. It was a complete unknown.
Many dental students worry that a year off will result in a loss of their hard-earned chairside techniques. Was that a concern?
For me personally, no. But when I spoke to the deans and professors, it was their number one concern. They said, “I don’t know whether you should do it. You’ll lose your skills.” But you know what? After three years of dental school, I didn’t think that I was at the top of my game just yet anyway. I still had time to hone my skills. So it really didn’t bother me. Probably my greater concern was my parents.
They weren’t too keen on the idea. My mother has a work colleague whose daughter had gotten into some legal trouble in Peru. It always had been a topic of conversation around the dinner table. So, they had strong reservations about me going there. Throw in the hesitancy of my professors, and both of my parents concluded it was a bad idea. That put me in an awkward position. If I accepted the fellowship, I would do so completely on my own. If I had a bad experience, I would set myself up for an “I-told-you-so.”
But you accepted the fellowship. Why?
Because of my experience in Ethiopia. It was so positive. I felt like I just wasn’t ready to transition out of global health. I needed to dive in a little deeper. So, I worked up my nerve and applied for the fellowship. But I did so with the encouragement of my dean, Dr. Ira Lamster. He said something to me that just clicked. It’s something that I always tell myself.
What was that?
He said, “You never regret something that you do. You regret what you don’t do.” It was almost as though he was reading my mind. I said to him, “You’re right. If I don’t go, I’ll always regret it.” I realized that even if had a bad experience, I’d still leave the wiser. I’ll learn how to do research. I’ll also learn how to get along with other people. It will broaden my horizons.
So you made your final decision and off to Lima you go. In the weeks following your arrival, did you ever second guess your choice?
Oh no, it was such an unbelievably positive experience. I worked with Dr. Bob Gilman from The Johns Hopkins University. He was a wonderful mentor. He and his group had started several studies that involved tuberculosis, Helicobacter pylori, and other non-dental issues. But that wasn’t a problem for me. I knew that I arrived with a unique skill set.
What do you mean?
Before I left, I met with the now former NIDCR director Dr. [Lawrence] Tabak and the now current NIDCR acting director, Dr. Isabel Garcia. They encouraged me quite a bit and said, referring to the fellowship, “You’re the same as any medical student. Your specialty is the oral cavity.” They were absolutely right. They reinforced the lesson I’d already learned firsthand in Ethiopia.
How did you put your specialty to good use on HPV?
Well, it didn’t happen immediately. Initially, I was interested in HIV. But another physician, Dr. Patti Gravitt, came to Lima from Johns Hopkins and opened my eyes to HPV. She was interested in whether intestinal worms had an impact on cervical HPV. She said to me one day, “Why don’t we do some oral rinses?” We talked about it a bit, and I said, “Let’s do it.”
How much did you know about HPV?
Not much. At first, I spent a lot of time at my computer doing literature reviews of HPV and oral cancer. I organized a bibliography, which I had never done before. So that was a worthwhile experience right off the bat. Finally, I met with Bob and Patti, and we decided that I would work on an epidemiological study to determine the prevalence of oral HPV in a specific area of Lima. We then designed the study and decided to obtain oral rinses from roughly 1,500 people. I also wrote a risk-factors questionnaire for study participants, which included questions about demographics, sexual history, dental history, and social history.
What were the demographics of the study participants? And how did you do the oral rinse? Did it require any brainstorming?
Oral rinses can be accomplished with a medium as simple as mouthwash. The patient rinses in the mouth for 30 seconds, spits out, and then the DNA gets analyzed for oral HPV. It’s something that’s been done before. It’s tried and true at this point. As for the demographics, the study was conducted in an area called Pampas de San Juan de Miraflores. It’s extraordinarily poor and has a population of about 40,000. Bob does a lot of field work there, and we obviously try real hard to give back to the community.
Did you speak Spanish?
I spoke some Spanish. But my mother always made fun of my stumbling American pronunciation of Spanish words. But I improved my Spanish when I got there. I adopted myself into a Peruvian family and communicated professionally in Spanish every day. Let me give you an idea. After we received IRB approval to conduct the study, I went out
with my Peruvian fieldworkers and trained them to administer the questionnaire properly and collect the rinse samples. I then went to the lab and made sure the samples were being processed properly. It was an incredible challenge, but it also was an incredible learning opportunity.
Leora Walter, second from left, pictured with the Peruvian fieldworkers
who helped administer the questionnaire and collect rinse samples.
Where does the study stand?
The fieldwork at this point is finished. All 1,500 rinse samples and questionnaires have been obtained and DNA extracted. The questionnaire data are being analyzed, and we are about to begin HPV testing with a grant that we recently received from Merck & Company, Inc.
You presented a poster at NIH several months ago based on this research. What did you present?
Those data are indirectly related to the study. Let me explain. When we launched the HPV study, I asked Bob about the incidence of HPV-associated cancers in Peru. Obviously, it was important to know how common these conditions are at baseline. There were no good answers, so Bob introduced me to one of his colleagues at the Instituto Nacional de Neoplastica, which is the National Cancer Institute of Peru. We discussed the question, and, long story short, I ended up doing a 22-year retrospective study on the incidence of head and neck cancers, specifically, oro-pharyngeal cancer, based on the records at the Instituto Nacional de Neoplastica. I am currently writing an article for publication.
But there’s another interesting thread to this story. Bob now has a post doc from Johns Hopkins who is interested in studying oral HPV. The postdoc, Morgan Marks, is analyzing the 1,500 samples from the HPV study. He’s also looking at the approximately 150 oro-pharyngeal tumor samples that the Instituto Nacional de Neoplastica has stored in paraffin blocks. Morgan will analyze those samples for the presence of oral HPV. So, it will be real interesting to see if there is concordance between the past 22 years and the prevalence rate that we are getting.
When did you return from Peru?
How is it to be back at dental school?
It’s fine. No, actually it’s wonderful. I enjoy working in a patient’s mouth and having a doctor-patient relationship. My plan is to finish dental school this year and, from there, we’ll see what happens.
Did you lose your skills while you were in Peru?
No, I didn’t. At first, I had to think a few times, “Okay, what is the protocol for this procedure?” That was more of an issue for me than how to hold my handpiece. In fact, in anticipation that it might be a problem, I stayed late a couple of evenings and practiced a little bit. But it wasn’t like my first day of third year all over again. I jumped right back into it, and I felt really comfortable.
Thanks for talking, and good luck during your final year at Columbia.