Reframing Noma – From Neglect to Action
Introduction
When looking at the limited literature available on Noma, a disease that viciously destroys the facial tissues and bones, it is often referred to as the “face of poverty and malnutrition.”
This has always been a powerful and poignant way to frame Noma, highlighting the disease’s disproportionate impact on children in impoverished communities where malnutrition is widespread. It draws important attention to the concept of Noma’s existence being the result of a deeper neglect of the social determinants of health.
In public policy, the framing of a problem is a strategic endeavour, purposefully used to influence public perception, who is seen as a stakeholder, and the action towards solving the problem.
Scholars studying why some global health problems become political priorities point to one key factor: how the issue is framed. The framing must resonate both within the advocacy network and with external audiences.
Given the years of neglect and policy inaction Noma has endured, it is worth questioning whether “the face of poverty and malnutrition” is the most strategic way of positioning this disease, and if elements are missing from the current frame.
SDGs and Issue Framing
The persistence of Noma is the result of, among other factors, poverty and malnutrition. These are undeniably root causes of such a devastating disease, and like any health concern, addressing the root causes is crucial for sustained change.
Poverty and malnutrition are central to global health agendas as ending them are Goals 1 and 2 of the Sustainable Development Goals (SDGs). Achieving these goals would have significant intersectional impacts on all facets of life, including the eradication of Noma. However, framing it as the “face of poverty and malnutrition” might not be the most effective for the immediate policy action needed.
The current frame may risk instilling the belief that Noma is inevitable in the existence of poverty and malnutrition. It is possible that framing Noma as such inadvertently draws attention away from other factors that, when addressed, can be the earliest and most manageable ways of preventing Noma.
Case Example from Cameroon
There is one factor in particular that we want to emphasize is missing from the current frame, but before we go any further, let’s look at a Noma case from Cameroon (Ngokwe et al., 2024).
The Yaoundé University Teaching Hospital received a referral from the pediatric department for a young girl, 9 years old, presenting with facial ulceration.
This was a typical Noma case. As the “face of poverty and malnutrition” suggests, this young girl was malnourished, underweight, and living in impoverished conditions. Not only did Noma have detrimental physical implications, but the patient also suffered social hardships. She stopped going to school due to the stigma associated with Noma and was isolated in her village.
Being from a rural village in Cameroon, her access to healthcare facilities was extremely limited. She was only taken to the hospital as a last resort when her facial ulceration got much worse. At this point, the patient had been suffering from Noma-related symptoms for 3 years, highlighting the missed chances for early prevention of Noma.
This young girl’s battle with Noma was not the result of a single cause, but several interconnected factors, from poverty to malnutrition to poor oral hygiene, limited access to healthcare, and a widespread lack of awareness about the disease itself. The social stigma she experienced was also a factor that contributed to the rapid, untreated progression of the disease.
But there is another very important element to this case.
Noma in the Immunocompromised
The patient was immunocompromised. There was a suspected mother-to-child transmission of HIV. When this patient was brought to the hospital, she had never received any anti-retroviral therapy (ART). Her viral load was very high due to the lack of ART, leading to her extreme immunocompromised status.
Many of the same articles that refer to noma as the “face of poverty and malnutrition” also describe it as an opportunistic disease preying on the immunocompromised. Individuals with weakened immune responses resulting from illnesses and infections such as HIV/AIDS, malaria, and measles have a higher risk of developing noma (Srour et al., 2017).
This predisposing factor may not receive adequate attention within the current approach to noma. The connection between noma and immunocompromising conditions is often overlooked due to the stigma associated with the conditions, resource constraints, healthcare capacities and fragmentation, and limited surveillance within noma-endemic areas. However, giving it greater emphasis through framing could lead to earlier and more integrated prevention efforts.
Noma is a preventable disease. The case of this young girl in Cameroon should not have happened. There are many stages in which intervention would have prevented the severe damage that Noma went on to cause.
What we and many healthcare professionals and Noma advocates are emphasizing is the importance of early intervention through integrated efforts. The way Noma is framed can help push this message.
In the case of the young girl in Cameroon, Noma eradication efforts could have been integrated within treatment campaigns for HIV/AIDS. In other cases, efforts could be integrated into oral health campaigns to promote good oral hygiene practices, as well as vaccination campaigns to prevent and treat other diseases that leave individuals immunocompromised.
These are just a few of the many ways Noma prevention can be integrated into other health efforts to stop the disease before its development, or within the early stages.
Concluding Call to Action
Going back to the question of reframing Noma, by framing it instead as a “preventable and treatable disease” through health system integration could be more effective in mobilizing policy action, as there are interventions that can significantly reduce the burden of Noma. This reframing should be adopted by policymakers, global health agencies such as the WHO, NGOs, advocacy coalitions, donors, and research institutions to push efforts towards prevention and integration.
In 2023, Noma was added to the list of neglected tropical diseases (NTDs) by the WHO. This designation is a major development in the framing of Noma. The classification as an NTD and continuing to frame Noma as a condition that is both preventable and treatable through early intervention and health system integration can help drive a shift in policy action and begin to break the cycle of neglect.
Authored: Lauren Davies and Brian Zilefac
Lauren is a MSc Global Health candidate at McMaster University with a focus on NTDs, health inequities in LMICs, and policy advocacy. She is currently working on a project exploring noma efforts since its introduction on the global health agenda.
Brian is a current PhD student at the University of Melbourne, focusing on oral cancer prevention. Brian also has a keen interest in tropical diseases especially those affecting the head and neck region.