The following article is based on a report �The tragedy
of Noma ,� prepared by Mr.
Jean Ziegler, Vice-President of the Human Rights Council Advisory Committee.
Unless otherwise noted, the quotes in this article are excerpted from this
report by Mr. Ziegler.
Malnutrition and hunger are not only direct killers of
children and adults all over the developing world. A lesser-known but horrible
result of the negligence and callousness of the rich Western world is a cruelly
disfiguring disease called noma (from Ancient Greek nomē �spreading of sores�),
a scourge which is destroying lives in large parts of the developing nations.
Until very recently, little has been done in the world in
order to deal with this awful disease, partly because it was mostly hidden
away, due to the cruelly disfiguring facial sores that it causes.  Impoverished
parents, having children who were infected by noma, tended to hide their
children away with their animals out of shame that they might bring dishonor on
their families. It should be noted that noma is not even mentioned in a fact
sheet on the top killer diseases in the developing world.
Nevertheless, for quite a few years now, private individuals
as well as organizations have begun to deal with the victims of this horror.
Treatment is possible at an early stage and surgery to restore destroyed faces
is quite possible even at later stages. But the steps that have been taken so
far are so few and far between that attention has to be drawn to the need for
the World Health organization (WHO) to deal with it on a far larger scale.
The characteristics of noma
But let us first take a look at how and why this disease is
spreading in poor parts of the world and then what can be done to make serious
efforts to eradicate it, as has been done with other scourges such as leprosy,
malaria, tuberculosis, measles and a multitude of other diseases that are now
increasingly under control.
Noma (cancrum oris), which borrows its
name from the Greek term �to devour,� is a devastating infectious disease that
destroys the soft and hard tissue of the face. The lesion begins as a localized
ulceration in the gingiva or the mucosa of the cheek or lip and spreads rapidly
through the orofacial tissues. Untreated, the skin of the cheek or lip is
typically perforated within a week of the start of the swelling. The gangrene of
the facial tissue quickly spreads to other parts of the face such as the nose
or an eye, leaving a terrible hole in the face. Noma leads to gangrene, sepsis
and in 70-90% of cases, death. Most deaths are attributed to complications such
as pneumonia, diarrhoea and septicaemia associated with severe malnutrition.
Survivors suffer threefold: disfigurement, functional impairment and social
This terrible, disfiguring and lethal disease mainly affects
children aged 1 to 6, but late stages have also been observed in adolescents
and adults. From studies in Nigeria it can clearly be seen that it affects
children suffering from malnutrition and that affluent sectors of the
population are spared. It is clear that it has to be seen as �a socioeconomic
disease afflicting preferentially the deprived malnourished children in poor
and mostly rural communities� (Reshma S Phillips et al. 2005)
Incidence of noma
The disease has virtually been eradicated from Europe and
other countries with a high standard of living. It reappeared however in Nazi
concentration camps (Bergen-Belsen and Auschwitz) during World War II, where
food shortages were particularly prevalent. The disease has also been
documented in HIV/AIDS infected patients from developed nations. A retired
68-year-old man from Great Britain was reported in a study from 2006 as
suffering from noma.
However, the majority of people suffering from noma live in
sub-Saharan countries. Cases are also reported from other countries in Africa,
Asia and also in Latin America.
It is estimated (according to WHO in 1998) that 140,000
individuals yearly are infected by noma and that 100,000 of these are children between
1 and 7 living in sub-Saharan Africa.
Several factors make exact numbers difficult to obtain, one
problem being that children with noma are often hidden by their parents, since
noma is considered a social stigma, the same way that leprosy victims are
generally seen as a shame to their families.
Because of a lack of appropriate
information for the population in general and mothers in particular, noma tends
to be perceived as a curse or as shame on the family whose child contracts it.
It is certainly a powerful taboo that causes families to sometimes hide or
isolate their children whose faces are disfigured by this disease with [their]
animals. Furthermore, experts in the field have reported that noma is ignored
and neglected by political authorities.
Causes and predisposing factors
Despite the lack of certainty in
respect to the microbiology and pathophysiology, there is a wide consensus
among experts that noma results from the interaction between three main
elements: malnutrition, intraoral infections and compromised immunity.
Protein-energy malnutrition in combination with deficiencies
in vitamins (A and B) and minerals are putting children at a high risk for
attracting noma. A weakening of the immune system, often due to diseases (such
as measles, malaria, tuberculosis, typhus, HIV) and poor oral hygiene also
contribute to the development of the disease. Other risk factors are lack of
safe drinking water and generally poor sanitation.
The treatment of noma
The WHO identifies four stages of the
disease; noma can reach its terminal phase in the extremely short time span of
three weeks. In the early stage, when the gingiva is bleeding and has lesions,
impending noma can be treated in a manner which is �simple, effective,
low-cost� with disinfecting mouth-rinses and daily food with vitamins. During
the next phase, involving swelling of the face and fever, mouth-rinses,
administration of antibiotics and nutrients supplementation is essential. These
have been shown to prevent the progression from the initial ulceration to the
acute phases of the disease, which presuppose emergency care and reconstructive
The death rate associated with noma is spectacularly high.
However, with early treatment -- oral hygiene, antibiotics and nutritious feeding,
the rate can be lowered from 70 -- 90% to approximately 20%. Thus, early
recognition of the clinical signs of the disorder is vitally important,
followed by proper treatment. Also, vaccination against infectious diseases
such as measles would considerably cut the incidence of noma.
Improving the diet of malnourished
children in risk areas could considerably lower the death rate and occurrence
of this disorder. Bertrand Piccard , the founder of the organization Winds
of Hope and president of the �No Noma - International Noma Federation,�
considers that �the vaccine against noma, would be to feed all of Africa.� In
more realistic terms, and in accordance with the Millennium Development Goals,
�M�decins sans fronti�res� (Doctors Without Borders) calculates that 2.76
billion Euro are needed to eliminate acute severe malnutrition of children. Put
in perspective, 2.76 billion Euro represents a truly insignificant fraction of
the economic recovery plans which have been approved in the last months by governments
throughout the globe.
Quote from �NOMA:
THE FACE OF POVERTY�
�Because Noma isn�t contagious, it�s
nobody�s priority. Because it�s directly linked to malnutrition and poor
hygiene, it�s seen as a problem without a solution. And yet it is a symbol. It
is the symbol of the state of disparity in which our world is evolving,
fractured into extravagant societies and starving populations, ultra
sophisticated technologies and total destitution. It is also the symbol of our
short-sightedness when we forget that humanity won�t be able to advance very
far by leaving three-quarters of its population behind. Sounding the alarm is
not a simple gesture of na�ve solidarity, but truly of addressing the problem
of safety for the future of our planet.� (Dr. Bertrand Piccard, President of
the International NONoma Federation and President of the Winds of Hope
The impact of the food and economic crisis
The effect of the aggravated food crisis due to the economic
downturn must be addressed.
According to the Food and Agriculture
Organization (FAO), as a result of the recent food crisis the number of
chronically hungry people rose by 75 million in 2007, to reach a total of 923
million undernourished people. Today�s reality appears to be even bleaker than
the one in 2007. A recent statement of the World Bank considers the number of
undernourished to now exceed 1 billion. Looking at this data in a disaggregated
manner shows that 89% of the 923 million chronically hungry people live in Asia
and the Pacific and Sub-Saharan Africa.
The prevalence of malnutrition in both urban and rural
households has dramatically risen due to the increased cost of staple foods,
such as grains and vegetable oils. The situation in South Asia is particularly
Specifically in South Asia, the United
Nations Children�s Fund (UNICEF) puts the number of hungry people in 2009 at
400 million, up by 100 million from the already unacceptable figure of pre-crises
days. Moreover, of the 175 million children under 5 years of age living in the
region, 45% are malnourished. By any measure this is the highest rate of
malnutrition in the world, �eclipsing even Sub-Saharan Africa.� This picture is
even more worrisome as it is generally acknowledged that the GDP growth rates
of South Asia are twice as high as those in Africa, which means that surpluses
during pre-crises years have not been used properly to tackle malnutrition of
the rate of malnutrition and hunger, intensified by the continued effect of the
food, fuel and financial crises, �violate the rights of every child to food,
education, good health and protection.� (UNICEF report, June 2009 -- A Matter
of Magnitude -- The Impact of the Economic Crisis on Women and Children in
In Jean Ziegler�s report, it is stated that medical studies
have pointed to the link between the economic crisis, shortages in food and the
incidence of noma.
Initiatives to Combat the Disease -- WHO, national
governments and non-governmental cooperation
In the African region, some progress
has been achieved. It is essential to note the involvement of NGOs, charities
and private individuals. These have been the driving force of the fight against
noma, offering financial, logistical and medical support and assistance. To
exemplify, the Noma Hospital in Sokoto, Nigeria (the only facility in Africa
dedicated to the treatment of noma) has been established at the initiative and
with the funding of �AWD-Stiftung Kinderhilfe� from Germany, the �Dutch Noma
Foundation� and �Facing Africa� from England with the cooperation of Nigerian
authorities. To date, activities in the fight against noma have been
implemented mainly in Africa, . . . It appears that the lack of funds made it
impossible to expand the programs on noma to the Asian and Latin American
continents, despite the fact that both regions have documented cases of noma.
Some steps forward have been made in terms of information and raising awareness
on noma issues. With the help and financial support of a coalition of NGOs, the
International Noma Day took place in Geneva on the 22 May 2008.
Raising awareness through any means available about this
deadly disease is critical in this crisis period when malnutrition as the key
risk factor has considerably increased.
While the goodwill and the competence
of the WHO Africa Regional Office remains unquestionable, more must be done in
the fight against this disease. . . .
Noma remains insufficiently prioritized at global and regional level. Despite
having an associate mortality rate comparable with diseases such as acute upper
respiratory infections, multiple sclerosis and appendicitis, noma does not
appear in annual WHO reports. Moreover, noma is not listed among the major
killers like malaria, diarrheal diseases, HIV/AIDS infection, measles,
tuberculosis, and severe chronic malnutrition. However it is a complication of
these diseases. As such and following plain logic, it should receive more
It is simply logical that noma should receive more
attention. It is not a contagious disease, but solely due to environmental
causes and it would consequently be totally within our power to combat and
cure. It is the clearest indicator of extreme poverty, but even though the
mission of the World Bank is to reduce global poverty, this deadly disease does
not sufficiently attract its attention. Noma was not even mentioned in the 1996
World Bank/WHO publication �The Global Burden of Disease.�
It is true that in 1998, the WHO Regional Committee declared
the disease a priority on the African continent, but there is still not
sufficient attention being paid to this cruel and stigmatizing disease. More
real action is needed from international organizations.
The lack of public attention given to noma, the way this
remains an anonymous disease can be seen as a result of the lack of data and
WHO reports on the disease. The tragic effect is that fundraising and thus a
capacity to combat the disease are being compromised by this lack of knowledge
concerning this scourge that destroys human lives which could so easily be
saved. Money and information are missing in a world where billions of dollars
are given in the wink of an eye to huge banks where CEOs are drowning in money.
Let me remind you that over 100 000 people, the vast
majority of which are children, die every year because of noma.  And all it
would take to combat this killer disease is eliminating hunger and malnutrition
at a cost that would be a pittance compared to the trillions that are poured
into the banks world-wide in the kind of welfare that is showered upon our
financial institutions, instead of giving priority to the crying need for
action to eliminate hunger, malnutrition and faulty sanitary conditions which
are the causes of several perfectly avoidable diseases.
As a gripping demonstration of the priority given to banks before
human beings, I repeat a passage from a recent interview with Jean Ziegler on
the French information site BASTA!
�On October 12, 2008, the Heads of
State of 15 countries that share the Euro, the 27 countries that make up the
European Union, got together under the chairmanship of Ms Merkel and Mr Sarkozy
at the Elys�e Palace in Paris. In 3 hours and 30 minutes, they released 1.7
trillion dollars to improve the European banks� lending capacity and to raise
the level of auto-financing for those banks from 3 to 5%. The fact is that the
UN has said that eradicating world hunger, eliminating the massacre of hunger,
would cost 21 billion dollars over five years, less than one percent of the
amount given to the banks.� (emphasis by SON)
Back to Mr. Ziegler�s report from the UN Human Rights
Council Advisory Committee.
Noma is not addressed from a human
rights perspective, despite being a human rights issue. This report insists on
the links between noma and the right to food of the most vulnerable members of society,
children living in poverty. Furthermore, the right to water, the right to
adequate health care and not least the right to life are at stake. Addressing
noma from a right to food perspective has implications for States and their
obligations under international human rights law, as well as for international
organizations in their response to noma and malnutrition.
Research into the causes and effective prevention and
treatment of noma should be seen as a priority in solving the problems of
injustice and inequality in today�s world. We already know that supplying
nutritious food, vitamins plus minerals and vaccinations against the diseases
that bring noma in their wake, measles, etc. can cure this disease at an early
stage. Also, surgery can achieve miracles in cases where disfigurement has
already gone too far to reverse the effects of the disease. It is of course
essential to detect the disease at as early a stage as possible. This requires
money and information among the populations at high risk.
RECOMMENDATIONS for what can be done to alleviate the
curse of noma
Noma is killing, disfiguring, and
destroying the lives of children. The persistence of noma in today�s world
raises doubts not only about our morality, but it also comes to prove that the right
to food of the children, the most vulnerable members of the international
community is being severely violated. Malnutrition is the main predisposing
factor of noma; malnutrition is easily treatable. To respect, protect and
fulfill the right to food concerning the most vulnerable groups affected or at
risk of being affected by the noma disease, the following steps should be
fight against noma must be made a priority at international level. . . . In
the view of the rise in malnutrition, all regions at risk must be included
in the monitoring system.
cooperation on the issue of noma must take place. . . . Noma should become
integral part of the international response given by organizations such as
FAO, WHO, UNICEF, the World Bank, etc. to the challenges posed by the food
and economic crises.
must put in place national programs against noma or strengthen existing
frameworks. States should allocate sufficient funds for prevention and
information activities, as well as for nutritious food aid to individuals
facing malnutrition. In case of lack of funds and faced with emergency
situations, States have a legal obligation to appeal for international
humanitarian aid. Not making such an appeal would be an encroachment on
the right to food. Other States have a responsibility to cooperate as it
is clear from Articles 2 and 11 of the International Covenant on Economic,
Social and Cultural Rights and from customary international law.
The fact that this horrible disease is still continuing to
wreak havoc in the developing world should be to the eternal shame of the
wealthy countries -- the other side of the coin where waste and luxury are the
law of the land and overfeeding is the prevalent health problem.
A few organizations such as the World Bank and the
International Monetary Fund (IMF) are supposedly responsible for solving the
ever-increasing and global problem of hunger. However, all they have done so
far is to ever more enrich the rich countries and further strangle the poor
countries that have been forced to humbly ask for loans to get out of their
unacceptable living conditions. Instead of being enabled to give their people
decent living conditions, these countries have been forced by the IMF to accept
austerity measures, i.e. cutbacks in social spending and devaluation of their
currencies, making the paying back of their loans even more hurtful and causing
the living conditions of their citizens to deteriorate even further.
So, as the poverty-stricken nations are gasping for breath,
lacking food and clean drinking water and being robbed by the Big Transnational
Corporations, while the rich 2% of the world population are gathering up
further obscene wealth, the drive to the destruction of a decent and ethical
cohabitation in this world is speeding up by the day.
O�Neall is an Axis of Logic columnist, where this essay first appeared, and is
based in France. Her insightful essays are republished and read worldwide. She
can be reached at email@example.com.
- HUMAN RIGHTS COUNCIL, Advisory Committee, Third
session, 3-7 August 2009, Item 3 (b) of the provisional agenda.
- For graphic illustration
of disfigurement by noma go to �Facing Africa� and �Project Harar
- Bertrand Piccard and Brian Jones promised each other
to dedicate their achievement (completing a non-stop balloon flight around
the globe in 1999) to the children of the world and to use the media
exposure and fund-raising potential of their fame to combat forgotten or
- The World Health Organisation
(WHO) estimates that 140,000 new cases of Noma occur each year and of
these, a mere 10% survive. That means that 126,000 die each year, mainly
in sub-Saharan countries from Senegal to Ethiopia, a region known as �the
Noma belt.� (Facing Africa -- NOMA)