Health interventions do not cause Malthusian conflict dynamics: Evidence from the expansion of HIV treatment in Africa

Recent research concludes that health improvements in the 20th century caused a surge in social conflict by accelerating population growth. Rationalized by Malthusian population dynamics, this indicates a potential trade-off for world-wide health initiatives, especially in conflict-prone regions. Here, we re-investigate this question with fine-grained contemporary data. After conceptualizing the chain of mechanisms that links health-driven population growth to conflicts, we address the question whether health improvements cause Malthusian conflict dynamics in 50 countries in Africa over the period 1990–2017. The analysis combines the massive worldwide roll-out of antiretroviral therapy (ART) for HIV-positive individuals during the early 2000s with local variation in treatment potential before the onset of this expansion. We find that the deployment of ART has indeed led to a demographic expansion. In sharp contrast to the literature on Malthusian dynamics, we find that this health-induced population growth has not resulted in a surge of conflict measured in terms of (small or medium scale) social violence or large scale armed conflict. For armed conflict, we find no effects, whereas for social violence we detect a reduction. The findings substantially qualify existing evidence by documenting that public health provision and medical innovation, while entailing accelerated population growth, do not necessarily induce Malthusian conflict dynamics, but rather may entail a “double dividend” in terms of health improvements and a reduction in conflicts.Author summary: In recent years, warnings of Malthusian conflict dynamics have become increasingly popular. The argument brought forward is that health improvements in poor countries may lead to population growth that could fuel social violence and armed conflicts through higher resource pressure. The current article draws on very fine-grained data for the expansion of antiretroviral therapy (ART) for HIV-positive individuals during the early 2000s to study the impact of better health treatment on population growth and, in turn, the effect of population growth on conflict in 50 African countries over the period 1990–2017. We find that better health care positively affects population growth, as expected. Yet, the link between population growth and conflict is conceptually more subtle. On the one hand, accelerated population growth may exacerbate resource scarcity and conflict, yet on the other hand, better health may reduce grievances by inducing economic development through scale effects, higher labor productivity and market expansion, which in turn could attenuate conflict risks. Empirically, the article finds that the expansion of ART treatment has —if anything—led to an overall reduction in social violence in Africa. These findings qualify existing arguments on Malthusian conflict dynamics and imply that rather than a trade-off, global health care investments may improve health and reduce conflict, thereby entailing a “double dividend”.