Neglected tropical diseases are a group of diseases associated with people who are extremely poor, lack access to healthcare, have no access to clean water, practising poor sanitation and hygiene. These diseases cause significant economic loss as the bodily defects—in the leg, eye, brain viz general development—prevent the patients from engaging in productive activities. For example, there are documented cases of villages with fertile agricultural land that were deserted as a result of river blindness.
This group of diseases, which include schistosomiasis, soil-transmitted helminths, rabies, yaws, etc affect about 1.7 billion globally and 35% of this figure are in Africa. With the rising level of poverty, the possibility of an increased number of cases is a safe assumption. In view of this, various health organisations have been directing their attention to these diseases, addressing risk factors, providing free treatment, funding research all with the aim of halting the poverty-health-poverty cycle associated with this group of diseases.
While the slogan, ‘leave no one behind,’ has taken a centre stage in the pursuit of universal health coverage, it is safe to assert that we should also ‘leave no disease behind.’ The WHO has declared January 30 as World NTD Day and there is a rising global army dedicated to this once forgotten disease with the slogan #beatNTDs. Governments of nations have swung into action to change the narrative, international organisations of repute have deliberately beamed their searchlight on these diseases and are working with the relevant guidelines to eradicate them. Even media houses and platforms are not lagging behind in ensuring that the goal is reached.
This momentum thus presents the opportunity to talk about other disease entities that match the NTD criteria but are yet to be officially recognised and added to the list. Of interest to this author is noma. It is an oral health disease of poor and malnourished children between two and five years, which has been described as the ‘face of poverty.’ It starts from the gum and can end anywhere on the face, destroying both bones and soft tissues. If it is the cheek and lip, there is a facial defect that causes stigma and also prevents the child from feeding adequately because the food in the mouth will be dropping off.
Sometimes the pattern of defect is a big challenge for surgical repair. Of note, there is a documented case of a facial defect due to noma that was enormous as to cover the area of the face corresponding to the location of a properly worn facemask. In many instances, there is the occurrence of trismus—also referred to as lockjaw—which restricts the range of motion of the jaws, limiting the opening of the mouth.
Noma shares the basic characteristics of NTDS whence it is closely related to poverty, poor water, sanitary and hygiene issues, significant morbidity and bodily defect, but in what other ways does NOMA relate to other NTDs already recognised?
First, it is bacterial-related like buruli ulcer, leprosy, trachoma and yaws. From the experience of managing noma cases, patients usually present cases at the hospital when infection is in the acute stage, where mortality—which had been attributed to bacterial sepsis and dehydration—is exceptionally high (70-90%). When immediate administration of fluids, antibiotics and other management protocols are instituted, there is a significant reduction in mortality from 70% to near zero. Like every other disease, noma runs a very long course: starting from gingivitis (gum inflammation), but no medical solution is sought until there is a threat to life at the acute phase. When noma is recognised, and put in its rightful place, there will be adequate support, not only by assisting centres with curative management of cases but by preventive measures from the moment the gum is infected and at a commensurate scale on which the disease is seen.
Secondly, noma is a skin-related NTD. The protective functions of skin such as thermoregulation, Vitamin D metabolism and physical barrier to diseases are widely recognised. Considering the surface area of the facial skin, one can downplay their contribution to these functions stated above. However, the destruction of facial tissues greatly imparts recognition, esteem, aesthetics in addition to the functional deficit. Because these tissues are located in regions that cannot be masked by clothes, there is a high level of stigma associated with their destruction as seen in noma, bearing in mind that surgical reconstruction does not bring survivors to a perfect premorbid state. As such, the umbrella body of ‘skin-related NTDs’ is yet a platform to accommodate noma to ensure that no disease is left behind.
Thirdly, noma can also be considered under the term ‘head and neck NTDs.’ While the term head and neck cancer is prominent in cancer programs, it has not been given a thought in the effort to #beatNTDs. Evidently, the contiguous spread of diseases is a recognised phenomenon in medicine. Also, compartmentalisation is done seeing the anatomic and embryologic connection of various tissues explains the progression of symptoms. For example, the progression of the tissue necrosis from the gum to cheek sometimes leads to the destruction of the lower eyelid( and I have seen cases of blindness from noma). This is yet another umbrella action that can be used to bring noma into recognition as NTDs and leave no disease behind.
There is no doubt that noma fits perfectly in the description of NTDs from many perspectives and also has some peculiar characteristics. The ongoing process of adding new diseases to the WHO NTD list may take a while. Therefore, it will not be out of place to see strategic partnerships under the themes suggested above wherein the noma disease can be fully integrated. This becomes necessary to #beatNTDs.
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