Author: Amelia Crabtree
Conflict Origins
Mozambique, a predominantly Christian country in southeast Africa, won independence from Portugal in 1975. After a bloody civil war which lasted from shortly after independence into the early 1990s, guerilla fighters continued to clash with Mozambican military groups until 2019. However, beginning in 2017, a separate Islamist extremist group called Al Sunnah wa-Jama’ah, or ASWJ, began an insurgency in the northernmost province of Cabo Delgado, one of two Muslim-majority provinces in the country. Since then, more than 2,000 people have been killed and 700,000 have become internally displaced.
ASWJ, also known as al-Shabaab but of no relation to the Somali al-Shabaab, calls itself the ISIS of Mozambique. The organization consists of considerable numbers of foreign fighters, particularly from the Great Lakes region in south central Africa, as well as disenfranchised young men from northern Mozambique. However, the ultimate goal of the insurgency has not been stated by ASWJ, and there does not appear to be consensus regarding its motives. The first attacks in 2017 targeted police posts and government facilities, though more recently ASWJ attacks have burned food supplies, killed and kidnapped women and children, and beheaded those perceived to not support the group, a method first employed by the Islamic State in 2014. A specific inflection point that spurred the conflict does not appear to have occurred and, instead, the group began using violence indiscriminately rather than coercing material support through bribery of provincial leaders once they had enough adherents to successfully launch an insurgency.
Conflict Drivers
While Cabo Delgado has been unstable since the civil war, the current insurgency appears to be driven by two factors. The first is the perception that the central Mozambican government mistreats the northern provinces. The region has an abundance of natural resources, including natural gas, gold, and rubies, which are being harvested largely by international corporations. The largest foreign investment in Africa is a gas liquification plant off the coast of Palma in the northernmost part of Cabo Delgado. The plant, owned by the French company Total Energies, is one of two in the province; the other is owned by ExxonMobil, an American corporation. Together, the two plants were estimated to bring in approximately $100 billion over the next 25 years. Despite this, Cabo Delgado has long had one of the highest poverty rates in the country, and the gas projects brought few jobs to locals, directly or indirectly. With none of the benefits of the gas projects being reaped by the local populations, the disruption to daily life and transfer of traditional lands to the oil sector magnified the preexisting dissatisfaction towards the central government. The government in Maputo, nearly 2,000 miles south, is consequently viewed as controlling the local natural resources and influencing decisions that have deleterious impacts on the region. ASWJ has harnessed this into support for their group, particularly among younger men who are most impacted by the lack of economic opportunity.
Secondly, cultural disparities are also driving the conflict. Mozambique as a whole is less than 20% Muslim, though Cabo Delgado is over 50% Muslim. As a result, extremists are taking advantage of the poor economic conditions in the region and perceived lack of support from the central government to promote the creation of an Islamic state in which the priorities, both economic and cultural, would reflect those of the local population. Historically, Cabo Delgado and Niassa, the other northern Muslim-majority province in Mozambique, have shared more characteristics with the southernmost regions of Tanzania, including the Lindi, Mtwara, and Ruvuma Regions. Sharing Sunni Islam and historical ties, the northern provinces are more influenced by their Tanzanian counterparts than the Christian-dominated south, home to the country’s capital.
Government Reaction
The Mozambican government has been working to quell the insurgency by sending national security forces and private security contractors from Russia and South Africa to combat ASWJ fighters, restore order, and protect investments in the region. However, the national security forces have been accused of abuses against internally displaced persons including arbitrary arrests, use of excessive force, abduction, and torture of detainees. Additionally, several counterterrorism-focused activities by the Mozambican security forces have been condemned as Islamophobic. Regional neighbors, through the Southern African Development Community (SADC), have also deployed troops in conjunction with Mozambican forces to the area, but concerns remain that too much of a military campaign will only drive the conflict elsewhere in southeast Africa. The Portuguese government has been successful in offering troop support to train Mozambican soldiers; the cooperative agreement currently runs until 2026 and will bring a total of 140 Portuguese troops to Cabo Delgado. The United States has also deployed one Army special forces unit to help train the Mozambican security forces. Most of these deployments occurred in late 2020 and are believed to have had a positive impact on the conflict by decreasing the land area held by ASWJ. However, it is still too soon to say if this progress will hold.
As northern Mozambique has become increasingly unstable, both natural gas fields in Cabo Delgado have paused operations indefinitely. Consequently, the future ability of foreign governments to tap gas fields offshore from Cabo Delgado remains in limbo. Additional investments in the country could also slow, considering the heightened risk foreign companies would have to take on by working in a country with ongoing, violent conflict. As a result, social services to not only Cabo Delgado but the whole country could decrease, resulting in further economic collapse, lack of educational and employment opportunities, and thrust the country back into a wider civil conflict.
Leprosy
Leprosy is an infection caused by Mycobacterium leprae, a rod-shaped bacterium that is Gram-positive. The Mycobacterium family also includes the causative agent for tuberculosis in humans. Leprosy first began infecting humans thousands of years ago, traveling along human migration routes from Africa to Europe and Asia. European colonization spread the disease to the Americas and later, island nations in the Pacific Ocean. Individuals of all ages can be affected by leprosy, but the incubation period of the bacteria can range from nine months to up to 20 years after infection. However, the average incubation period is five years. Leprosy causes nerve damage, which can result in an inability to feel pain; the primary physical symptom, though, are skin lesions with sensory loss which vary greatly in presentation. Diagnosis of leprosy is through a skin or nerve biopsy of the affected area. Because of the barriers requiring pathology services for diagnosis present in the developing world, field programs use clinical presentation of skin lesions to determine a leprosy diagnosis. Beyond humans, the only known natural host of M. leprae is the armadillo.
The method of transmission for leprosy is still not known. It is suspected that the bacteria can transmit from person to person through prolonged, close contact with an individual with untreated leprosy, potentially through coughs, sneezes, and other droplets. However, nearly 95% of those who are infected with M. leprae do not develop leprosy as their immune systems are able to fight the bacteria. Fortunately, leprosy is easily treatable through a multidrug therapy (MDT) regimen consisting of dapsone, rifampicin, and clofazimine. The combination of these three drugs should be taken for anywhere from six to twelve months depending on the number of lesions individuals have, with patients who have more lesions requiring longer antibiotic treatment. The World Health Organization has provided free MDT for the treatment of leprosy since 1995. While the Bacillus Calmette-Guérin (BCG) vaccine that is primarily used against tuberculosis can be effective against leprosy, it was not designed for that purpose. Studies measuring its efficacy for preventing leprosy have varied from 26-61% effective, and the BCG vaccine is not generally used to prevent leprosy as a result of the WHO-sponsored MDT campaigns globally.
Leprosy in Cabo Delgado
Cabo Delgado, Mozambique’s northernmost province, has been embroiled in civil conflict since 2017. More than 700,000 people are designated as internally displaced, and those who have stayed have lost access to healthcare, education, and other social services. In 2020, Mozambique had the second highest prevalence of leprosy on the African continent with 66 new cases per 1,000,000 population; it was only surpassed by Somalia, another conflict-ravaged country, though data for Somalia is inconsistent and relatively unreliable. Cabo Delgado has generally had one of the highest prevalences of leprosy in the country along with the other northeastern provinces, Niassa and Nampula, likely as a result of lack of access to healthcare. However, the near-doubling of leprosy cases in Mozambique between 2016 and 2018 was as a result of case increases in Cabo Delgado alone. The WHO estimates that the drop in reported leprosy cases in 2019 and 2020 were the result of lack of testing due, first to Cyclone Kenneth and later, due to the COVID-19 pandemic, not because of an actual decrease in leprosy cases in the country.
As a result of the civil conflict, nearly one third of the province’s 132 health care facilities have closed. Further healthcare facilities were destroyed in 2019’s Cyclone Kenneth. As a result, many individuals who have been displaced internally in northern Mozambique or still in their homes are unable to access basic health services or treatment for chronic conditions that require regular treatment like HIV, malaria, and tuberculosis. This situation has proven to be a prime breeding ground for a leprosy outbreak as immunocompromised individuals are more likely to develop leprosy from M. leprae infection.
Historically, leprosy has been associated with poverty, and individuals with leprosy were often stigmatized by their communities. In multiple regions of the world, there have been positive associations between food insecurity and leprosy incidence. Considering that approximately 197,000 individuals in Cabo Delgado, of which 75,000 are children under the age of 5, are projected to be in high acute food insecurity by February 2022, there will likely be more cases of leprosy in the region in the next years. Furthermore, anemia has been shown to be a risk factor for M. leprae infection to develop into leprosy. Malaria, the main cause of anemia in children, has increased sharply in incidence in Cabo Delgado, spiking from 29% in 2018 to 57% in early 2020, likely due to both increased rainfall and favorable reproductive areas for the Anopheles mosquito in IDP camps scattered throughout the province.
The current leprosy outbreak in Cabo Delgado is likely due to the poor living conditions endured by IDPs in the province. Many of those displaced have settled in Pemba, the province’s capital, in informal camps while looking for work. However, lack of adequate nutrition, lack of sanitation, and lack of access to regular healthcare services make it more difficult to contain an outbreak. Because those infected with M. leprae may have weakened immune systems, it causes them to be more likely to develop leprosy. Those who develop leprosy are then able to pass along the bacteria to others while living in close quarters like IDPs, making transmission is more likely.
Until the conflict in Cabo Delgado ceases or those fleeing the violence are able to be fully integrated into host communities, the outbreak will continue. International organizations, including UNHCR, the WHO, and OCHA are working to improve local health services that could help quell the outbreak through diagnosis and treatment of individuals impacted. However, individuals with leprosy are more reticent to seek care as a result of the lack of understanding of the disease and the physical deformities that often accompany it. Improving communications with IDP communities about the importance of seeking medical attention early in the progression of the disease and the curability of the disease could mitigate against the stigma of leprosy. However, health care facilities need to be operational and accessible to the population before this can occur.
Next Steps
Fortunately, there are a number of independent organizations that are working in tandem with global multilateral groups to address leprosy in Cabo Delgado. The Leprosy Mission, a religious organization based in the United Kingdom, is actively raising money to combat leprosy in northern Mozambique through leprosy-specific health centers that also serve as community centers; they recently received a £2 million grant from the UK government to support their efforts. Caritas, the Global Leprosy Programme, and Netherlands Leprosy Relief have been present in the region since the conflict began and are working to reinstitute regular access to healthcare facilities to enable earlier diagnosis of leprosy among IDPs. That said, leprosy has not risen to the top of the list of health crises in the area, falling behind primary care, COVID-19, malaria, and HIV. Additionally, health facilities need to be rebuilt in the wake of ISIS-Mozambique attacks and cyclones. Consequently, it is unlikely that these investments in both leprosy diagnosis and treatment will have an immediate impact on the outbreak.
The major causes of the leprosy outbreak need to be addressed not only to decrease case rates but also help promote stability in the region. While the conflict in Cabo Delgado continues with no end in sight, hundreds of thousands of individuals are displaced and extremely vulnerable to infectious diseases, including leprosy. Furthermore, as a result of climate change, the region is at more risk for cyclones of increasing severity. As cyclone season in Mozambique begins in December, we are likely to see increases in both leprosy and other diseases common in conflict settings.
Lessons Learned and Outcomes
Despite the atrocities ongoing in northern Mozambique, this conflict likely could not have been prevented. Thanks to the successes experienced by other Islamist militants in East Africa, extremist groups feel empowered to cause civil unrest, attempt to build separatist coalitions through violence, and exploit the people in these regions. The underlying causes of the Cabo Delgado conflict are complicated and reflect the causes of similar conflicts in the region, particularly the ongoing crisis in Somalia. The central government, located in Maputo, is run by officials who are not from the northern provinces, are of a different religion, and are perceived to exploit the natural resources without the consent of the local populations. This economic exploitation, coupled with disparate social and cultural values, provides justification for radical groups to use force to defend their way of life. Furthermore, continuing environmental disasters will exacerbate the ongoing poverty, poor health conditions, and stagnation of economic growth. As climate change worsens, the frequency of cyclones and subsequent flooding impacting Cabo Delgado is likely to increase and result in more barriers preventing the long-term improvement of living conditions.
For other countries in similar situations, many of which are also in sub-Saharan Africa, efforts should be made to engage the local communities where natural resource harvesting is occurring. Although this is a challenge, it can allow communities to feel more involved in the investments of these outside, often foreign, companies. Economic investment is not an assured path through which an area is able to develop, particularly when locals are not involved. Requiring proffers by foreign companies coming into regions to take natural resources to support local education, provide a quota of jobs for locals, and ensure a return-to-normal for the environment, could facilitate this.
Ultimately, however, it is likely that the Cabo Delgado conflict will continue for the foreseeable future. The goals of ASWJ are still not apparent, precluding the possibility of the government being able to negotiate with the group. Moreover, as the causes of the conflict are disparate and cannot be tied to one event, the prospect of finding a way to address the root cause is bleak, and the atrocities and ensuing humanitarian crisis is expected to continue to worsen.
This article was prepared by the author in their personal capacity. The opinions expressed in this article are the author's own and do not reflect the view of their place of employment.
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