Noma in Nigeria: The Face of Poverty Behind a Preventable Disease

By Eyitayo Lawal

What if poverty could be seen on a child’s face?

Poverty is often described using numbers: household income, food security, employment and access to basic services. These measures are essential; however, they do not always capture what deprivation really looks like in the life of a child. Sometimes, poverty becomes visible through the diseases that thrive where several forms of deprivation intersect. One of the most devastating examples is Noma.

Noma is a severe, rapidly progressing disease of the mouth and face that mainly affects young children, especially those between the ages of 2 to 6 years, who live in conditions of extreme poverty, malnutrition, poor oral health and weakened immunity [1,2]. The disease often begins with inflammation of the gums and most times rapidly progresses to destroy the soft tissues, bones and skin of the face if it is not detected and treated early [1].

The consequences can be devastating, as children who survive advanced Noma may experience severe facial disfigurement, difficulty eating, speaking, swallowing, and breathing, as well as stigma, discrimination and social isolation [1,3]. However, it is important to note that Noma is preventable and, when identified early, its progression can be stopped using relatively simple interventions like appropriate antibiotics, improved nutrition and oral hygiene [1,2].

Noma is, however, more than a disease, as it is a window into the face of poverty.

When Poverty becomes visible

Noma does not emerge from poverty using a single pathway. Rather, it develops across a complex web of vulnerabilities. Malnutrition can weaken a child’s immune defences; poor oral health can increase susceptibility; infectious diseases and other forms of immunosuppression can further compromise the child, while limited access to healthcare can delay recognition and treatment [1,2].

These vulnerabilities can reinforce one another, and this is why WHO describes the disease as a marker of absolute poverty [1]. The disease is strongly linked with extreme poverty, malnutrition, poor oral health and other social and environmental conditions that disproportionately affect marginalised communities [1,2].

The disease can therefore reveal what income statistics may not. Behind the visible destruction of a child’s face could be a history of inadequate nutrition, limited access to healthcare, poor living conditions and social exclusion. The facial damage is visible, but the deprivation that created the conditions for it may remain largely unseen.

Noma in Nigeria

Nigeria is a special country in the history of Noma. The disease has been reported in northern Nigeria for a long time, with Sokoto being one of the important centres for treatment and care for Noma. An analysis of 1,383 patients managed at the Noma Children’s Hospital between 1999 and 2024 estimated an incidence of 87.8 cases per 100,000 population across northern Nigeria, with the highest estimated incidence recorded in Sokoto at 691.4 cases per 100,000. Children under 10 years had the highest incidence among the age groups studied [4].

These data show the significant incidence of Noma in northern Nigeria. However, they do not prove that Noma is found only in the northern part of the country.

A case-based study conducted from 2011 to 2020 in 34 states and the Federal Capital Territory (FCT) found 7,195 persons with Noma-related conditions [5]. The highest number was found in the Northeast region, and cases were also documented in other regions not traditionally associated with Noma, such as Ondo State in the Southwest [5].

The study was not designed to estimate national prevalence, so the findings cannot be concluded to show that Noma is equally prevalent in Nigeria [5]. It does show that cases may occur over a much wider geographical range than is normally considered the disease’s range. This matters because the reported map of Noma isn’t necessarily the same as the vulnerability map of Noma.

A Disease that can Hide in Plain Sight

The most disturbing part of Noma is that it can easily go undetected. The disease is a rapid-onset disease, and accurate burden estimates are challenging, as cases can be undiagnosed, untreated or unreported. WHO identifies lack of awareness, stigma, underdiagnosis and the high mortality associated with Noma among the factors that make its true burden difficult to estimate [1].

This gives rise to an interesting paradox. A community with few cases could have a low prevalence of Noma. It could also be a community with a low rate of case recognition and recording.

The challenge begins with awareness.

In Sokoto and Kebbi, a cross-sectional study in 2026 revealed that while many health care workers had heard of Noma, there were significant gaps in their knowledge and experience. Although 66% of healthcare workers had heard of Noma, only 19% reported ever treating a patient with the disease [6]..

If knowledge gaps persist in areas where Noma is already recognised, identifying the disease may be even harder in communities where it is rarely considered.

A child living far from specialised services may therefore remain invisible to the health system until the disease has progressed significantly.

The Human Cost of Survival

Surviving Noma does not necessarily mean returning to a normal life. Severe Noma may cause permanent deformities and disability in the face of the survivor. Survivors might have trouble eating, speaking, swallowing, breathing or seeing, depending on how much tissue damage has occurred [1]. These physical consequences can be accompanied by stigma, discrimination and social isolation [1,3].

These impacts can affect children’s education, relationships, and future opportunities. Families can also face substantial financial pressures from treatment, reconstructive surgery, rehabilitation and ongoing care. Some survivors will have serious residual effects and may need reconstructive surgery, rehabilitation and ongoing support [1,3]. Families facing poverty and limited access to health services are particularly at risk of not being able to access such services.

The disease can thus reinforce the very disadvantage that created the conditions for it. Poverty increases vulnerability to Noma; surviving Noma can then create further physical, social and economic vulnerability.

Why Noma became a Neglected Tropical Disease

For decades, Noma received relatively little attention despite its devastating consequences. That changed in December 2023, when the WHO officially recognised Noma as a neglected tropical disease [3]. The decision was significant because it brought greater international attention to a disease that disproportionately affects vulnerable and marginalised populations.

Nigeria played a leading role in this process. In January 2023, the Government of Nigeria submitted the official request to include Noma on the WHO NTD list on behalf of 32 Member States [3].

The recognition was therefore not simply a classification exercise. It represented an opportunity to bring Noma into broader efforts to address neglected diseases, strengthen surveillance and detection, mobilise resources and improve prevention and treatment for affected communities [2,3]. But recognition alone will not eliminate the disease.

Unmasking what lies behind Noma

If Noma is a visible manifestation of extreme poverty, then preventing it requires us to address the conditions behind the disease.

Early detection is critical. WHO notes that when Noma is identified at an early stage, its progression can be rapidly halted with appropriate treatment, including antibiotics, improved nutrition and basic oral hygiene [1]. The challenge is therefore not only having treatment available but ensuring that children reach appropriate care before irreversible damage occurs.

This makes primary healthcare and community-level awareness particularly important. Healthcare workers need to recognise early signs of Noma and understand when urgent referral is required. Communities and caregivers need information that can help them identify concerning oral changes and seek care promptly. Surveillance systems also need to capture cases beyond specialist centres and established areas of high reporting [1,2].

But prevention cannot stop at case detection. The conditions associated with Noma demand a broader response. Nutrition, oral health, water, sanitation and hygiene, community awareness and access to healthcare all have a role to play [2].

WHO’s 2026 Noma Control Technical Brief therefore recommends an integrated approach that includes early detection, case management, nutritional support, oral healthcare, WASH interventions, community awareness and integration of Noma control into national health systems [2]. In other words, we cannot treat our way out of a disease that is rooted in deprivation.

Looking beyond the face

Noma forces us to look beyond what is immediately visible. We see the destroyed tissue, the scars and the facial disfigurement. But behind those visible consequences may be a much longer story: a child who was malnourished, a family with limited resources, inadequate access to healthcare, poor oral health, unsafe living conditions or a community where the disease was not recognised early enough.

The face tells us where the damage ended up. It does not necessarily tell us where the problem began.

This is why we should understand Noma within the broader context of poverty and inequality. The disease reflects the interaction between biological vulnerability and social conditions, particularly in communities with limited access to basic health and social services [1,2].

This is also why the response must extend beyond specialist Noma hospitals. The recently released WHO Noma Control Technical Brief places early detection, community awareness, surveillance, oral health, nutritional support, water, sanitation and hygiene, and integration into national health systems at the centre of Noma control [2]. For Nigeria, this creates an opportunity to strengthen Noma detection and prevention beyond specialist facilities and established areas of high reporting. Three priorities could help:

• Strengthen early detection at primary healthcare and community levels. Primary healthcare workers, community health workers and other frontline providers should be equipped to recognise the early signs of Noma and understand when urgent referral is required. Earlier recognition could help ensure that children receive treatment before irreversible damage occurs.
• Use existing health platforms to identify populations at risk. Nutrition, maternal and child health, oral health, WASH and community health platforms can provide opportunities to identify communities where several of the conditions associated with Noma converge. Using these platforms to strengthen awareness and identify vulnerability could help shift the response from waiting for advanced cases to recognising and addressing risk earlier.
• Strengthen surveillance beyond known Noma hotspots. Surveillance efforts should extend beyond locations where Noma has already been reported. Integrating Noma awareness and case detection into routine health services could help identify cases in communities where the disease may be present but remains under-recognised or unreported. This matters because the absence of reported cases does not necessarily mean the absence of vulnerability.

The face of poverty should not become a life sentence

Noma is a devastating disease, but it is not an inevitable consequence of poverty.

It is preventable. A child should not have to lose part of their face before their vulnerability becomes visible to the health system. A disease that can be halted in its early stages should not progress to irreversible facial destruction simply because a child lives in a community where poverty, malnutrition and limited healthcare intersect [1,3].

Nigeria has already helped bring Noma out of the shadows by leading the effort that resulted in its recognition as a neglected tropical disease [3]. The next challenge is to ensure that this recognition reaches the communities where Noma is most likely to emerge.

That means seeing Noma not only as a disease of the mouth and face, but as a warning about the conditions in which children live. Because Noma may destroy a child’s face, but poverty creates the conditions that allow the destruction to begin. To eliminate Noma, we must therefore look beyond the wound; we must unmask the poverty behind the face.

References

1. Noma. www.who.int. 2023. Accessed 9 September 2026. https://www.who.int/news-room/fact-sheets/detail/noma
2. Ending the Neglect to Attain the Sustainable Development Goals: Noma Control: Technical Brief. Who.int. 8 July 2026. Accessed 7 September 2026. https://www.who.int/publications/i/item/B09724
3. WHO Officially Recognises Noma as a Neglected Tropical Disease. www.who.int. 2023. Accessed 7 September 2026. https://www.who.int/news/item/15-12-2023-who-officially-recognizes-noma-as-a-neglected-tropical-disease
4. Braimah RO, Adeoye J, Taiwo AO, et al. Estimated Incidence and Clinical Presentation of Noma in Northern Nigeria (1999–2024). PLOS Neglected Tropical Diseases. 2025;19(5):e0012818. doi:10.1371/journal.pntd.0012818
5. Ver-or N, Iregbu CK, Taiwo OO, et al. Retrospective Characterisation of Noma Cases Found Incidentally across Nigeria during Outreach Programs for Cleft Lip from 2011–2020. The American Journal of Tropical Medicine and Hygiene. 2022;107(5):1132-1136. doi:10.4269/ajtmh.22-0388
6. Olaleye M, Amirtharajah M, Farley E, et al. Healthcare Workers’ Knowledge, Attitudes, Perceptions and Practices of Noma in Northwest Nigeria: A Cross-sectional Study. BMJ Public Health. 2026;4(1):e003968. doi:10.1136/bmjph-2025-003968