Noma, a disfiguring mouth disease, can be found in many extremely poor countries, but the condition is especially common in sub-Saharan Africa.
Noma comes from the Greek word nemo, which means to "graze" or to "devour," and its ravages can be seen on the faces of children who have it. The disease is characterized by massive mouth ulcers that erode the gums and then the face.
It was common in Europe and North America until the early 20th century when it disappeared. But it surfaced again during World War II in the German concentration camps Auschwitz and Bergen-Belsen.
In 1998, the World Health Organization estimated 140,000 children around the world are afflicted each year with noma. But Cyril Enwonwu, a professor of biomedical sciences at the School of Dentistry at the University of Maryland in Baltimore, says the WHO figure greatly underestimates the actual number of victims. He believes WHO counted only those youngsters who are treated in hospitals, which he says represents only 10 percent of the cases of noma.
"Many children with noma are hidden, or they die before reaching the hospitals," he said.
Dr. Enwonwu saw his first case of noma while visiting a farming community in northwestern Nigeria to give routine dental examinations to sick children.
According to Dr. Enwonwu, although noma is found in extremely poor areas of South Asia and South America, most cases occur in poor regions of sub-Saharan Africa.
Experts are not sure what causes the disease, but they have discovered a pattern: Noma usually strikes children between the ages of one and four after an illness such as measles or malaria. The children are not vaccinated against routine illnesses, their families sleep with their animals, and they drink filthy water. Also, children with noma are extremely malnourished. Death occurs in 70 to 80 percent of the cases from massive infection.
There's also stigma attached to the disfiguring disease, and Dr. Enwonwu believes children with noma are sometimes the victim of infanticide.
"It's not something one can speak of with any degree of certainty because people are reluctant to talk about it," he noted. "But I believe in some areas, where noma occurs, some infants are literally neglected and literally left to die."
Dr. Enwonwu is urging international health officials to focus resources toward ensuring the immunization, nutritional and dental needs of families at risk for noma, including treating any suspicious mouth lesions.
Professor Enwonwu acknowledges he is fighting an uphill battle.
"I get very emotional when I talk about this disease," he said. "Each time I go into the villages, I keep asking myself, 'Why should this occur in this time in human history? Why should it occur to children?' We don't have an answer yet."
Professor Cyril Enwonwu described noma in an essay entitled "The Ulcer of Poverty," in the January 19 issue of the New England Journal of Medicine.