When she was eight, Hawa tripped on her way to school. A few weeks later, part of her face fell off.
No scraped knee should ever turn into a hole in a little girl’s face.
But Hawa lives in Sierra Leone, where her stumble set off a cascade. First, the scratch evolved into a deep-space infection in her leg. However, because she lived with nine siblings, and because her family survived on an intermittent income, a doctor’s visit would have been a luxury.
Then the flesh around her upper lip turned red. Then purple. Then black. Then her mother took her to the hospital, where she was given oral antibiotics. They didn’t work.
Hawa stayed in the hospital for months, only leaving after her family’s money ran out. During that time, the normal commensal bacteria in her mouth and nose destroyed her nose, her upper lip, her hard palate, and the sight in her right eye. She would spend the next fourteen years covering the hole where her nose used to be with a scarf.
Hawa’s disease—called noma or cancrum oris—does not exist in high-income countries. The last time it was seen with any regularity was in the Nazi concentration camps of World War II. That’s because, fundamentally, it is a disease of malnutrition, of poor oral hygiene, of poverty—and of inequity.
But commensal bacteria don’t have to destroy a little girl’s face. There’s nothing special about the bugs in Hawa’s mouth. We’ve all got them. Even with her chronic malnutrition, if Hawa had been placed on intravenous antibiotics and given good oral hygiene within the first 48 hours of the onset of her facial infection, the whole cascade could have been arrested.
In her case, economics, distance, transportation, and family pressures delayed her presentation long enough that, by the time she got to the hospital, the antibiotics could do nothing to halt the advancing necrosis. All they could do was impoverish her family.
In his book, In the Company of the Poor, Paul Farmer writes, “Poverty is not some accident of nature but the result of historically given and economically driven forces.” In Hawa’s case, those forces look like being born a girl into a rural village in a previously colonised country not two years after the end of a decade-long civil war that claimed 50,000 lives.
And Hawa isn’t unique. Thirty percent of the world’s disease requires surgery, but 5 billion people can’t access surgery when they need it. And a quarter of people who get surgical care every year are driven into financial catastrophe by its costs.
The historically given and economically driven forces behind Hawa’s face—they’re everywhere. And they are the challenge—and the opportunity—of surgery.
In the end, repairing Hawa’s face isn’t complex. It simply entails moving the right types of normal tissue from the right places to re-create a nose and a lip and a hard palate. The techniques to do this have been around since before the destruction of Babylon.
The hardest part of Hawa’s story isn’t what happens within operating theatre walls. The hardest part is getting her there.
Hawa’s face tells more than just the story of an infectious disease run riot. It tells the story of forces she never bargained for. Of systemic inequities—a lack of knowledge that treatment exists, distance to the nearest hospital, economic stressors on her family, a lack of surgical providers, and a dearth of surgical infrastructure—she had no part in creating. It tells the story of a girl who lost the birth lottery.
For far too long, the global health community has treated surgery as a luxury, a problem to be addressed once more “important” global health issues are resolved. Absent from national health plans or international resolutions, surgical disease has been relegated to the purview of two-week mission trips and surgical safaris.
In other words, it’s been relegated to the perpetuation of colonial structures, doomed to suffer under historically given dynamics. “We” send “our” surgeons to “their” countries to fix noses and lips, while leaving deeper, systemic inequities that underpin them unchanged.
It’ll never work. Surgical disease like Hawa’s is enmeshed. It’s entangled in complex historical and structural forces.
To address it well, we must take off our colonial glasses. We must look beyond the operating theatre’s walls. We must see surgical disease not as an accident of nature—and we must see surgery as the starting point for reversing Farmer’s forces.
We’ve known how to make Hawa’s face better for a thousand years. We must make her life better too.