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    Statement by
    Lois Cohen, Ph.D.
    Associate Director for International Health, National Institute of Dental and Craniofacial Research, NIH
    NIH's activities to treat NOMA
    before the
    Congressional Human Rights Caucus (CHRC)

    May 2, 2002

    Members of the Caucus:

    I am pleased to present the perspective and experiences of the National Institute of Dental and Craniofacial Research (NIDCR) concerning our support of research on the disease of Noma.


    Over the past 53 years of this Institute's existence, our nation's investment in dental, oral and craniofacial health has consistently included attention to global public health issues and concerns. The major rationale for this international perspective beginning in 1948, when the Institute was established, continues today as we recognize that health issues know no geographic boundaries and that to protect the health of our own people, we need to collaborate with others around the world to advance science. (1)

    To accelerate international collaboration in key areas where the global research needs are critical and where it is impossible to conduct such research solely within the U.S., the NIDCR created an Office of International Health (OIH) in March 1998 to target strategies to advance dental, oral and craniofacial science globally. This office also serves as a PAHO/WHO Collaborating Center for Dental and Craniofacial Research, as it functions as an essential liaison with international agencies and organizations involved in global oral health research within the U.S. Government and externally in this country and abroad.


    Oral health is an integral part of general health; one cannot be considered without the other. With that perspective, in the late 1980's, our Institute led an initiative with the Fogarty International Center (FIC) and the World Health Organization (WHO) to develop a global oral health research agenda. We supported an international workshop to identify priorities, obtaining the perspectives of over one hundred scientists from different countries.

    A report issued in April 1989, listed Noma, or cancrum oris, as one of the priority global research topics, and recommended investigations regarding its prevalence, etiology and management. (2) Interestingly at that time, it was thought that Noma was a later stage of untreated acute necrotizing ulcerative gingivitis in children. Subsequently, that view has evolved to reflect evidence that Noma is related to immune suppression, perhaps associated with malnutrition and/or prior infections, such as measles, HIV/AIDS or herpetic lesions.

    Subsequently, a Joint Working Group of the WHO and the Federation Dentaire Internationale (FDI) in 1992 prepared a five item priority agenda for international collaborative oral health research. Noma was one of those original items. The WHO, through its Advisory Committee on Health Research, took up the issue and the Institute, which had participated in the Joint Working Group, began to explore how to stimulate this scientific opportunity.

    Working with the Fogarty International Center and its infectious diseases research and training program, we were able to supplement its investment at the University of Maryland, where there was a researcher, Professor Cyril Enwonwu, already engaged in the study of Noma. During FY1997 and FY1998 work was begun with support of a supplement to an FIC grant T37TW0025. An editorial published in Tropical Medicine and International Health, December 1997, "The Need for Action Against Oro-facial Gangrene (Noma)" was co-authored by the late Dr. David E. Barmes, who had served on our OIH staff as Special Expert for International Health, along with Professor Enwonwu, M.H. Leclercq of the WHO staff in Geneva, Dr. D. Bourgeois of the University of Lyon in France and Prof. W.A. Falkler of the University of Maryland. (3)

    During FY 1999 and FY2000 the Institute continued to support this research through a competitive grant supplement D43TW00907A, and that grant extends to June 2002.

    In April 2000, in an effort to stimulate additional scientific interest in this area, NIDCR staff organized a workshop, Noma: Building a Research Infrastructure for Developing Countries. The University of Maryland team presented its work, and participants included key researchers and policymakers from the WHO programme in Geneva, the Nigerian Institute of Medical Research, Institut d'Odontologic et Stomatologic in Senegal, the Dutch Noma Foundation, and the Fogarty International Center, as well as interested scientists from the University of Pennsylvania, University of Washington and The Forsyth Institute in Boston, MA. It is hoped that as a result of this workshop, additional research grant submissions will be generated for eventual support from this Institute and any potential collaborating funding partners in this country and abroad.

    In April, 2001, WHO-AFRO sponsored a Consultative Meeting on the Management of the Noma Programme in the African Region. That meeting was held in Harare, Zimbabwe, and generated recommendations related to research, along with others regarding information, education and communication, epidemiological surveillance, training and health care. The research recommendations focused on studies of viral infection, stress and the role of biological factors in the etiopathogensis of Noma and called for the involvement of centers from other regions of Africa. (4)


    An overriding issue as the NIDCR and other research sponsors attempt to meet the challenge of Noma research, is the lack of research infrastructure in the very places where the disease is prevalent. In order for the needed multidisciplinary teams of scientists, drawn from a variety of countries, to meet and to engage in collaborative research with personnel in the countries where the disease occurs, it becomes apparent that there is a deficit in infrastructure to support the training of research personnel, trained research mentors, and treatment providers able to manage the disease which exists. These same barriers face all research sponsors here and abroad and prevent the science teams from pursuing this compelling research priority. A collaborative approach will be necessary to plan and implement research training and support for promising young scientists in the biomedical, epidemiological, socio-cultural and health services sciences. Seed support for their initial research will be required to sustain research upon re-entry at their home institutions. These ideas were surfaced once again last week during a WHO-AFRO consultative meeting on new approaches to oral health training and education in Africa, held in Cape Town, South Africa. (5)

    With its longstanding commitment to advance the science which pertains to such devastating diseases and to prevent their occurrence where those diseases occur presently and where they have yet to spread, the NIDCR continues to play a role to improve health and the quality of life for generations to come through international collaborative oral health research. (6)

    Thank you for the opportunity to share our views with this Committee.


    1. Harris, R. Dental Science in a New Age. Rockville, MD: Montrose Press, 1989.
    2. National Institute of Dental Research and Fogarty International Center. International Collaboration for Oral Health Research: Report of an Inquiry into the Biomedical and Behavioral Research: Priorities, Facilitation and Support. April 1989.
    3. Barmes, D.E., Enwonwu, C.O., Leclercq, M-H, Bourgeois, D. and Falkler, W.A. Editorial: "The Need for Action Against Oro-facial Gangrene (Noma)", Tropical Medicine and International Health, Vol. 2, No.12, Dec. 1997, pp 1111-1114.
    4. World Health Organization, Regional Office for Africa, Consultative Meeting on Management of the Noma Programme in the African Region - Final Report. Harare, Zimbabwe, June 2001.
    5. World Health Organization, Regional Office for Africa and WHO Collaborating Centre for Oral Health, University of the Western Cape, Summary Report of WHO Consultative Meeting: New Approach to Oral Health Training and Education in Africa, Cape Town, South Africa, April 23-26, 2002.
    6. Science Knows No Country, documentary video (12:10), available from the Office of International Health, NIDC

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Last revised: May 31, 2002