Fieldset
Noma in Nigeria: Ado and Ifeoma's stories

Three times a year, a team of surgical experts gather in the Nigerian city of Sokoto. They're there to perform life-changing operations for people affected by noma, a gangrenous disease which affects the face and jaw. Dr Muhammad Lawal Abubakar is part of the team...

Abubakar and the team at work in the operating theatre

Our plane circled the airport again, but it didn’t descend. On board were four surgeons, one anaesthetist, and other members of Médecins Sans Frontières / Doctors Without Borders (MSF) staff. Below, beneath the thick Harmattan haze and dust, was the city of Sokoto, where over forty noma survivors, mostly children, were waiting for surgeries.

Eventually the pilot made the announcement: the poor visibility meant there was no way to land. We would have to return to Abuja.

Noma

I am a consultant plastic surgeon from Zaria, Nigeria. In my regular job I work in a public hospital, mainly on reconstructive surgery after trauma or tumours. Whenever I can however, I join surgical specialists from around the world and travel to MSF’s noma project in Sokoto.

How could we best do the reconstruction so that Ado had a chance at a better life?

Noma is associated with poverty: the disease mainly affects people who can’t afford nutritious food or good oral hygiene. The infection starts in the gums and can spread to the face and jaw. It eats away at the tissue, causing facial disfigurements and potentially life-threatening impairments.

While the noma project offers medical care, counselling, and physiotherapy all year round, the surgeries are done in intensive two-week “interventions”, which happen three or four times a year.

plane_wing_1000.jpg

View of the plane wing
The view from the plane

It was another two days before the weather cleared and we were able to make the short flight from the capital. Usually, the first day of an intervention is a rest day, but we had lost too much time already. We dropped our bags at the guest-house and headed straight to the hospital. We had work to do.

Ado

One of the first noma survivors we saw was six-year-old Ado*. She had a large oral fistula – essentially a hole in the side of her face. Saliva leaked through constantly.

Ado was very quiet at our initial meeting. Her parents explained that talking made the leaking of saliva worse, and so the little girl had become very withdrawn. No one wants to play with her. She speaks only in monosyllables. She no longer goes to school.

The team and I immediately started thinking over options. How could we best do the reconstruction so that Ado had a chance at a better life?

The new image

As a plastic surgeon, in any operation you have a three-dimensional image in your mind that you want to recreate. No one else can see it, except your surgeon colleagues of course, who are part of the planning process. Together, your work is to think as you go, molding and shaping the face to that image. As we work, we make adjustments where necessary, amending the image we are working towards. 

planning_meeting_1000.jpg

The surgical team gather to discuss each case
Surgical team planning meeting

For Ado we opted for a simple procedure called a cervico-facial flap. We took some of the soft skin from her neck and moved it up surgically, folding it on itself to create both the cheek and the lining of the mouth. The fistula was covered completely.

Everything went smoothly. Ado won’t be discharged until she’s had her post-operative screening, but already she seems much happier, playing with the other children.

Ifeoma

I’m hopeful that this will be the only surgery Ado needs. But for noma survivors who have multiple or wide defects, we have to do the surgery in stages. That’s what happened to Ifeoma*.

Completing all the surgical stages can take years, as some parts of the face, like the nose, can only be reconstructed once someone is fully grown. That can be really hard on a young person who is facing significant stigma, so the Sokoto team gives counselling to help noma survivors understand that we’re not refusing them surgery, but that we need to wait to ensure a better outcome.

Noma survivors are just like anyone else. They have dreams. They have aspirations.

Ifeoma is a young woman who was badly affected by noma. After several previous surgeries, she went through the final stages of a nasal reconstruction last year. With such intricate surgery there can be complications, so when I saw her at Sokoto Hospital, what was running in my mind immediately was the potential surgical problems and how we might be able to help.

A rare opportunity

When Ifeoma arrived, she looked very different from when I last saw her. Her hair was highlighted, her face was made-up. She looked full of confidence. Still worried, we asked her what the issue was.

“There’s no problem,” she said, smiling. “I just wanted to come and say hi.”

Immediately we burst into excited conversation. It’s rare for us to get to meet noma survivors we've operated on so long after their surgeries, and we were so happy to hear how well she was doing, and how her life had changed since we'd seen her last.

Achieving our goals

Noma survivors are just like anyone else. They have dreams. They have aspirations. As a surgical team we might not be able to completely disguise the fact that yes, this person has had a disease, and yes, they’ve had a reconstruction. Our goal with surgery is to allow survivors to move through life with as little functional impairment as possible, and facing less stigma, so that noma is not a barrier to them achieving the things that they want.

When I think about Ifeoma’s new confidence, or Ado finally playing with the other kids, I feel like we’re achieving that goal.

Looking ahead

This has been an intense trip. Because of the lost days we had to condense our work, working longer hours and taking more cases each day. But the team spirit was high, we were all motivated by the patients eagerly waiting for their surgeries. Now we’re exhausted but happy.

The next intervention will be in June. I hope to be back, alongside other members of the team. I am already looking forward to it.

*Names have been changed

--

Read more: Stories about noma

Nigeria: “I always say noma is a wicked disease”