A/HRC/19/73 that region and a global incidence per year of 30,000–40,000.80 Experts consider this data to be rather conservative, given that less than 10 per cent of the individuals suffering from noma seek medical care.81 In the evocative words of Dr. Enwonwu, a leading expert on noma, these cases represent merely “the tip of the iceberg”. 82 37. This need for recent data is more pressing in the context of the recent food and economic crises. The effect of the latter on the incidence of noma is believed to be important given that, as a consequence of the crises, the number of individuals, including children, suffering of hunger and malnutrition has skyrocketed.83 Previous medical studies have pointed to the link between economic crisis, shortages in food and the incidence of noma. Some specifically identify the declining food supplies in the 1980s in sub-Saharan Africa and the subsequent severe chronic malnutrition as one of the explaining factors of the reported increase of noma.84 The effects of the food crisis in Niger in 2005 were registered by the NGO Sentinelles three years later when the number of small children with noma doubled. This increase in noma cases is probably explainable by the fact that malnourished babies were born to malnourished mothers, the latter victims of the 2005 food crisis.85 The importance of accurate and up-to-date information on noma cannot be understated. 38. On an institutional level, attempts to focus on noma have been discouraged by the lack of recent data.86 In turn, the lack of focus on noma is precisely what determines the low interest in gathering information on the incidence and distribution of acute noma worldwide. This vicious circle leads to the situation that the majority of children and other individuals with noma are not receiving treatment and are thus neglected. B. Causes, predisposing factors and treatment of noma 39. Researchers have not identified a specific micro-organism responsible for causing noma.87 Despite the lack of certainty in respect to the microbiology and pathophysiology, there is a wide consensus among experts that noma results from the interaction between several main elements: malnutrition, poor oral hygiene – itself a consequence of extreme poverty, compromised immunity and intraoral infections. 88 80 81 82 83 84 85 86 87 88 14 Ibid., p. 402. Enwonwu, “Noma – The Ulcer”, pp. 221–224; Baratti-Mayer, “Noma: an „infectious‟ disease”, p. 421; M.L. Srour, “Noma in Laos”, p. 539. Enwonwu, “Noma – The Ulcer”, pp. 221–224; see also Winds of Hope, WHO/AFRO, Rapport de la 5ème Table Ronde sur le Noma, Geneva, 9 September 2006. Available from www.nonoma.org/doc_pdf/rapport_table_rond.pdf. A/HRC/AC/3/CRP.3, pp. 11–12; WHO, “The Global Food Crisis: Implications for the Health of People in the African Region”, 2008. Barmes, “The need for action”, p. 1112. P. Joly, Sentinelles, Communication with Jean Ziegler, 27 July 2009. The Regional Office for Africa is said to be finalizing the report of a noma survey realized in 20072008 in Africa. Phillips, “Pro- versus anti-inflammatory cytokine profile”, p. 70; Baratti-Mayer, “Noma: an „infectious‟ disease”; B.J. Paster et al., “Prevalent Bacterial Species and Novel Phylotypes in Advanced Noma Lesions”, Journal of Clinical Microbiology, vol. 40, No. 6, June 2002, pp. 2187– 2191. Fieger, “An estimation”, p. 402; Enwonwu, “Noma (cancrum oris)”, p. 151; Enwonwu, “Noma – The Ulcer”; interview by Bertrand Piccard, «Notre nouveau but: mettre sur pied une Journée mondiale contre le noma», Tribune Medicale, 29 September 2006.