Medication against misery: How health interventions can address ill health and also prevent conflict

Editor's note: This article originally appeared on VoxEU.

Misery is rarely limited to a single dimension of life, as illustrated by the tragedies unfolding simultaneously in wars and conflicts. Fatalities and injuries are accompanied by economic crises and mounting grievances, deteriorating health, and a depletion of both human and social capital (e.g. Shemyakina 2011, Besley et al. 2013, Mueller 2014, Cottenier et al. 2016). Negative health shocks, in turn, are a potent determinant of unrest, fuelling the risk of conflict. Malaria outbreaks, for instance, have been found to have a robust and significant conflict-inducing effect in Africa and elsewhere (Cervellati et al. 2017, 2021).

In our research (Berlanda et al. 2022), we show that there is ‘medication’ against both ill health and conflict. We empirically study the effects of a large-scale health intervention – the expansion of antiretroviral therapy (ART) for HIV/AIDS – on violent events throughout Africa. We exploit exogenous variation in the exposure to ART expansion in a country or sub-national region by combining differences between countries and regions in the potential for ART treatment (based on HIV prevalence before ART became available) with time variation in access to ART worldwide (based on the global variation in prices and production costs of ART, which substantially account for the evolution of ART access in countries).

We find a statistically significant and quantitatively substantial drop in incidents of social violence, at the country level as well as the sub-national level. This reduction is largely due to a drop in riots and demonstrations related to economic and human rights. No impact on large-scale armed conflict is found. This echoes earlier findings that social unrest can be driven by grievances and frustration with the provision of local public services, whereas large-scale military rebellions are shaped by other factors as well. As noted by Collier et al. (2009), factors such as state capacity and rebel financing through natural resource rents play a major role in determining whether armed rebellion is feasible and for grievances to escalate into full-blown armed civil war.

Regarding the mechanisms through which ART treatment helps drive down social violence, one channel is a reduction in economic grievances. While our results confirm previous results on the economic benefits of health interventions against HIV/AIDS (e.g. Tompsett 2020), we find that this ‘economic’ channel does not account for the entire reduction in social violence.

We uncover the key role of an increase in individual approval of government policies related to HIV management, basic health provision, and economics in general. Unsurprisingly, this heightened approval is limited to health policies, and we detected no change in public approval for other unrelated policies (such as education). The successful public health intervention also leads to an increase in individual trust in institutions like the parliament and the local government.

Overall, these results suggest that ill health may be a powerful driver of social unrest and violence, and that beyond improving health and economic conditions, public health interventions can tackle social violence. A counterfactual simulation analysis shows that the ‘peace’ gains of stepping up HIV treatment are largest in countries with intermediate HIV prevalence and where ART has relatively low priority.

What are the implications of our findings for ongoing social violence and conflict around the world? We argue that stepping up the quality of public goods provision in situations of soaring social violence should be a priority for government policy. Beyond alleviating human suffering and addressing basic needs, successful public health interventions are crucial pillars of a healthy economy (Bloom et al. 2021). Getting health policies right yields legitimacy to the state and helps build trust.

Especially for destroyed economies in post-conflict settings, a focus on rebuilding an effective public health system may yield great long-run economic and social benefits. Outside donors can help governments build state capacity and fund well-functioning public-goods provision.

As argued by Rohner and Thoenig (2021), key policies are those that yield productivity gains and hence increase the opportunity cost of conflict, as opposed to policies that entail transfers of appropriable cash. Our study is one of the largest-scale empirical studies that illustrate the force of this argument, drawing on data covering a whole continent and zooming in on the neglected nexus between health policies and peace.

References

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