A/HRC/19/73 32. The clinical data available is unanimous: children are the main victims of this debilitating disease. Acute noma occurs predominantly in malnourished children up to 6 years,59 while sequelae have been observed in adolescents and adults. 60 Having studied patients with noma in Nigeria, scholars concluded that noma is not observable in children of “elite Nigerians residing in affluent sections of the urban areas” and that “it is rather a socioeconomic disease afflicting preferentially the deprived, malnourished children in the poor, rural communities”.61 Medical studies concur on the specific population group that is predominantly affected by noma: deprived and severely malnourished young children from communities living in extreme poverty. 62 A. History of noma, incidence and distribution of the disease 33. Known in classical and medieval Europe, noma remained common in Europe and North America until the beginning of the twentieth century.63 As early as in the eighteenth century, awareness had increased that noma was related to poverty, malnutrition and diseases from which the child suffered previously, such as measles.64 The economic progress witnessed by European and North American societies is credited with having allowed them to feed their children sufficiently and hence to practically eradicate noma.65 Cases of noma reappeared in the Nazi concentration camps of Bergen-Belsen and Auschwitz66 and in some other European countries subjected to extreme food shortages during the Second World War.67 More recently, the disease has been documented in patients with HIV or AIDS from developed States, suffering of malnutrition, bad oral hygiene and immunosuppression.68 34. Low- and middle-income countries, particularly in Africa and Asia, are considered to be the most affected by noma.69 Experts, including from non-governmental organizations (NGOs), working in the field describe the area that stretches across parts of West Africa and Central Africa towards Sudan as the “noma belt”. 70 It is assumed that a large number of 59 60 61 62 63 64 65 66 67 68 69 70 12 International Health, vol. 2, No. 12, 1997, p. 1113. Ibid; Tsechkovski, “A disease such as Noma should not exist”, p. 1; P.A. Van Damme, “Essay: noma” The Lancet, vol. 368, December 2006, pp. S61–62. Facing Africa, “What is noma?”. Available from www.facingafrica.org/FA08/content/site/en/pages/whatisnoma/default.asp. R. S. Phillips, C. O. Enwonwu, W. A. Falkler, “Pro- versus anti-inflammatory cytokine profile in African children with acute oro-facial noma (cancrum oris, noma)”, European Cytokine Network, vol. 16, No. 1, March 2005, p. 70. C.O. Enwonwu, “Noma – The Ulcer of Extreme Poverty”, The New England Journal of Medicine, vol. 354, No. 3, January 2006, pp. 221–224; M.L. Srour et al., “Noma in Laos: Stigma of Severe Poverty in Rural Asia”, American Journal of Tropical Medicine and Hygiene, vol. 78, No. 4, April 2008 p. 539. K. Marck, “A History of Noma, the “Face of Poverty”, Plastic and Reconstructive Surgery, vol. 111, No. 5, April 2003, pp. 1702–1707. Ibid. R.Voorhoeve, “Review”, Bulletin of the Netherlands Society of Tropical Medicine and International Health, vol. 49, No. 1, February 2008, p. 13; Enwonwu, “Noma – The Ulcer”, p. 222. Enwonwu, “Noma (cancrum oris)”, p. 148. Bos, Surgical Treatment, p. 11. Enwonwu, “Noma (cancrum oris)”, p. 148; A. G. Buchanan et al., “Necrotizing stomatitis in the developed world”, Clinical and Experimental Dermatology, vol. 31, 2006, p. 372. P.E. Petersen, “World Health Organization Global Policy for Improvement of Oral Health – World Health Assembly 2007”, International Dental Journal, vol. 58, 2008, p. 117. Consultative Meeting on Management of the Noma Programme in the African region, Harare, 19-21 April 2001, Final Report; Facing Africa, “What is noma?”.