Facing Africa: Describing Noma in Ethiopia

Abstract

Noma affects the most marginalized communities in the world, beginning as oral ulceration and rapidly progressing to orofacial gangrene. With a mortality rate estimated to be as high as 90% and with very few able to access treatment in its active phase, very little is understood about the disease. This retrospective review of patients treated by Facing Africa for deformity and functional impairment secondary to noma between May 2015 and 2019 highlights some of the difficulties encountered by those afflicted. Eighty new patients with historical noma defects were identified and were seen over the course of nine surgical missions, with notes providing valuable geographical, socioeconomic, and psychosocial information. The mean self-reported age of onset was 5 years and 8 months, with a median time of 18 years from onset to accessing treatment. Before intervention, 65% covered their face in public, 59% reported difficulty eating, 81% were unhappy with their appearance, and 71% experienced bullying. We aimed at emphasizing the significant burden, both psychologically and physically of noma, demonstrating the disparity between recent decades of progress in the well-being of Ethiopians in general and the access to health care and mental health support for some of those most in need.

Figure 1.

A 3-year-old girl with acute noma; this image encapsulates why the term “the face of poverty” is so fitting. The destructive and aggressive nature of the disease is clearly seen alongside the hallmarks of protein energy malnutrition. This figure appears in color at www.ajtmh.org.

Figure 2.

Geographical distribution across Ethiopia, by region, of noma cases seen by Facing Africa between May 2015 and May 2019. This figure appears in color at www.ajtmh.org.

Figure 3.

Pattern of disease distribution, as classified by Montandon, of cases seen by Facing Africa between May 2015 and May 2019. This figure appears in color at www.ajtmh.org.

Figure 4.

A 59-year-old woman who previously had noma underwent reconstruction of the defect with a radial forearm free flap. This figure appears in color at www.ajtmh.org.