The Shifting Interface of Public Health and Urban Policy in South Africa

Abstract

The paper traces the evolution and periodization of shifting ideas about the critical issues shaping city planning in South Africa, looking both at the relative and variable importance ascribed to health and other factors such as labour, economic reconstruction and housing. While the evolution of the South African city cannot be read without an understanding of the role of public health, changing ideas about cities and public health necessitate careful historical unravelling before any causal relationships can be identified. Any urban reconstruction, including post-COVID-19 reform, will demand deep knowledge of how the health/planning nexus has evolved, alongside expert advice on how to maximize urban health.

Introduction

South Africa, like many other places colonized by European powers, is a nation where issues of public health were closely associated with the early enforcement of urban racial and territorial segregation. ¹ Paradoxically, improving public health has also been the basis for urban reform, reconstruction and development. Yet health, while a foundational imperative of the structuring of colonial African cities, was not the sole or even dominant imperative in the shaping of the South African city; the once influential voice of medical professionals appears to have waned over the twentieth century even while essential traces of the segregationist logic of the ‘sanitation syndrome’ remained following the end of formal race-based discrimination. ² Faced with the evidence that COVID-19 has had a dramatically differential impact on the urban populations of South Africa, ³ reinforcing old divisions of race and class, there is once more an imperative to reflect on the relationship between health outcomes, urban form and the management of cities and towns.

The patchy attention paid to cities by health professionals and the dismissive attitudes of planners toward health are better understood when put into longitudinal view. Most recently, South African cities have found that, despite over a century of sustained attention to urban public health, the country was inadequately prepared to deal with the massive urban rupture of COVID-19. The residue of past policy regimes that sought to mitigate the impact of disease were corrupted by political imperatives of control and – while public health ambitions remain etched in laws about planning permissions, water quality, building codes, the size and shape of the administrative mechanisms of government and in the financial flows that drive the city – this has not always been in ways that serve the needs of the majority or the most vulnerable. ⁴

The complex division of South Africa’s powers and functions, that regulate both the urban and health systems of the country and their interactions, bear witness to vacillating official concerns with the relationship between urban form and human well-being. ⁵ We explore how, over time, national government has shaped local or urban policy and health policy in varied institutional ways. Taking a long view of policy change, we highlight clear shifts in biomedical and city planning practices that help explain the uneven priority ascribed to urban public health. We also demonstrate that the way in which policy transformation and the shifting role of the state in cities is conceived and implemented lends itself, more or less readily, to the demands of urban health reformers. Lessons from South Africa for a post-pandemic future illuminate how health can be, and has been, a force for both good and evil. A more nuanced lesson is that there can be no assumption that health policy and urban planning reforms are complementary. The case to link health and city reform is neither automatic nor formulaic. To make the changes needed to address the post-COVID-19 ambitions of cities, the precise interface between health policy and city planning must be updated and reformed. Our retrospect of the South African case suggests that this can only be successfully done through engagement with embedded legacies of health and place and a detailed understanding of the changing ideas underpinning medicine, city politics and urban management.

As South Africa, like almost every other nation, faces up to the post-COVID-19 opportunities and imperatives for urban change, it is imperative that both backcasting as well as forecasting inform what is seen as feasible and desirable for improving urban health. Fundamentally, we suggest that the realities of how government came to work as the complex regulatory system that it is today must inform the expectations of future planning in reducing health risks and maximizing urban wellbeing – especially where this involves understanding the declining influence of health professionals in planning. This piece thus presents a broad historical overview of the ‘urban question’ in South Africa and describes the various kinds of urban reform initiatives (including but not limited to health) that have emerged since the start of the twentieth century. It seeks to locate the current moment of renewed interest in inclusive, resilient and healthy urban reforms within a longer history of political and economic debates, processes and contestations.

A key starting point for our discussion is that states, and for that matter individual government departments and programmes (health or any other), are neither unitary nor static. ⁶ They are composed of a diversity of different actors and interests; they learn and change. Their roles and interventions can shift in relation to high-level political and social objectives, and in response to public disagreements and conflicts. The dominance (or not) of a health or planning agenda varies in response to the composition of government in all of these ways. The aims, structure and character of a state may also change in accordance with emerging material and spatial trends manifesting at various scales. Notably, the institutional architecture for urban governance is formative of and shaped by the dynamics of cities and urbanization as well as imperatives such as technological change, economic collapse or pandemics that tend to emanate from or be concentrated in cities. Indeed, we shall argue that problems specific to cities and urban areas, like the outbreak of disease, have historically played a significant role in shaping wider national questions, institutional arrangements and governmental responses in South Africa. We explore some of these dynamics in South African planning history with particular reference to the mechanisms and instruments of urban governance reform – including the support that central administrations provided to local governments to address deep urban health crises like the outbreak of influenza and the decades of urban policy that virtually ignored health concerns.

To track the imprint of various large-scale planning interventions in cities (only some of which were prompted by health imperatives), we identify four critical moments of urban governance reform in South African history, focusing on the processes by which reforms were established, and the instruments or ‘levers’ used for their implementation. These ‘moments’ include the creation of a unified South African state in the first decade of the twentieth century, the shift to formal apartheid policy in the period immediately following the Second World War, the growing ‘crisis of apartheid’ of the 1970s and 1980s, as well as post-apartheid democratization. In this periodization, only in the first period was health the dominant informant of urban planning, although epidemiological risks and problems have persisted even with antibiotics and other major healthcare improvements. Understanding the relationship between the city and health in South Africa in this way is important in two distinct ways. Firstly, the longer view of planning history reveals that health, while having an enduring mark on the city, was by no means the major urban policy imperative for much of the twentieth century. Secondly, these are the foundations on which a post-COVID-19 urban health agenda will be constructed for the twenty-first century.

Unification

The conclusion of the South African or Boer War in 1902 paved the way for British authorities to forge a new South African colonial state. Geographically, this was to comprise a series of separate territories, including the British colonies of the Cape and Natal, and the independent Boer republics (the Orange Free State and South African Republic, later known as the Transvaal). In the post-war era, colonial authorities faced the basic political challenge of stamping British authority over the region, while gradually laying the foundation for South African unification and responsible self-government. This, however, raised critical problems of administrative and legal integration. The creation of the Union of South Africa in 1910 meant the very different institutional and juridical systems active within each of the former colonies and republics would have to be aligned and consolidated. Moreover, officials had to ensure uniformity on key political and strategic issues such as industrial-economic development, ‘native policy’ and, increasingly, urban policy. Their efforts to do so were strongly fashioned by major health events.

British plans for reconstruction and unification coincided with sharp post-war economic and spatial transitions in addition to outbreaks of disease. Strong economic growth on the ore-rich Witwatersrand encouraged migration into towns and cities; Johannesburg in particular grew rapidly. Urban growth raised a series of policy problems. For one matter, urban populations needed to be fed, preferably without relying on costly imports, which brought the question of agricultural modernization into focus. ⁷ Moreover, as overcrowded slums swelled to accommodate new residents and jobseekers, threats of ill-health and epidemic disease in urban areas became key topics of political debate and action in the years before and following unification. ⁸ In Cape Town, outbreaks of bubonic plague in 1901 fostered the emergence of a ‘sanitation syndrome’ that linked the urban presence of Africans to disease and anti-social behaviour. ⁹ Public pressure led to the construction of Ndabeni township, to which Africans were forcibly removed. ¹⁰ Similar anxieties and responses would soon play out elsewhere, and the problem appeared to demand a coordinated central response.

In this period, a central urban problem directing governmental thought and intervention concerned the ‘urban native question’. The basic issue was how authorities should deal with African migration, residency and employment (and the risks perceived to result from those trends) in South Africa’s growing towns and cities through state control. For leaders and officials, key questions included should these trends be officially tolerated, accepted or rejected? What role should different levels of government fulfil in holding back disease and enforcing control? And how should all of this be financed?

The post-war colonial state quickly assumed a controlling and coercive role in the design of the systems that regulated the production of urban space. In the former republics, officials acted to secure the interests of a new, assertive urban bourgeoisie and to create the conditions for mining capital to flourish. In part, this meant serving the aims of an emerging ‘gold and maize alliance’: an informal coalition of mine owners and ‘progressive’ large-scale farmers who supplied food to the burgeoning Witwatersrand market. ¹¹ The alliance was built around a shared set of economic interests: ensuring low wages for workers, producing cheap food to feed them and generally promoting and preserving ‘a highly exploitable and disciplined black wage labour force’. ¹²

The way these alliances and interests played out within the urban environment was critical to shaping the objectives and forms of later urban policies. Officials wanted to regulate the establishment of townships, urban density and land-use to provide the conditions for reproducing a low-paid workforce that was sufficiently distanced as to minimize any threat to the elite. In Johannesburg, such conditions of reproduction included an urban environment free from the ravages of epidemic disease. Another was preventing the formation of a ‘sharply demarcated central working-class area’ wherein rentals were costly and an ‘aggressive class consciousness’ might all too easily foment. ¹³ Authorities aimed to regulate and prevent the migration into cities of ‘undesirable’ white people and Africans. They also sought a legal basis for the eviction and forced removal of Africans from urban areas, justified on public health and sanitary grounds, and of poor white people from the city’s growing slums. Africans were to reside in new, peripheral and municipally established townships like Klipspruit. Working-class whites, by contrast, were to be ‘stabilized’ in relatively well-serviced suburbs that conformed to the latest international ideas surrounding healthy buildings and building codes. ¹⁴

In the post-war reconstruction and unification period, the primary mode of policymaking – and the principal mechanism through which a national urban agenda took shape – was a particular kind of governmental institution and process: the expert commission. In the years following 1902, colonial officials appointed a raft of commissions to deliberate on issues such as land demarcation and ownership, tariff policy and ‘native affairs’. Most importantly, at least for questions of urban governance, was the Transvaal Local Government Commission, known as the Stallard Commission – notorious for proclaiming in 1922 the doctrine ‘that the towns were essentially the creation of the white man, and that the black man’s presence there could be justified only insofar as he served the white man’s needs’. ¹⁵ Under its recommendations, proper security of tenure in urban areas was to be denied to all Africans.

The ‘Stallard doctrine’ directly informed the content and aims of the 1923 Natives (Urban Areas) Act, which sought to control urban race relations over a variety of domains including those relating to public health. ¹⁶ The Urban Areas Act empowered local authorities to set aside areas for African occupation (but not ownership) in separate ‘locations’, to provide (or require employers to provide) residences for Africans working in urban areas and to implement a basic system of influx control. ¹⁷ It thereby entrenched the racialized ‘separation between planning for “locations” and planning for the rest of urban South Africa’. ¹⁸ Essentially, the Act defined a system of local government for South Africa, introducing ideas around the practicalities of governance at the city level which then extended to the delivery of transport and housing. It was an innovative piece of legislation, among other things codifying a twin-track, segregated system of municipal financial management that uncoupled public good investments in African and white parts of the city. The Act also required each municipality to establish a separate native revenue account for all moneys contributed by location residents from fines, fees, rents and beer hall takings. This money had to be ‘spent on improvements to the location’; it was not to be ‘swallowed up in the general rate fund’ and spent elsewhere. ¹⁹

As a mechanism of governance reform, an expert commission like that chaired by Colonel Stallard was distinctive in several ways. It addressed a particular problem, sat for a limited period, and reported under the ultimate authority of a figurehead chairperson. The commission – occupying a ‘quasi-autonomous’ position in relation to the state – played a particularly important role in helping to arrive at, and in bringing legitimacy to, difficult policy decisions in the context of political division or debate over a central moral dilemma. Stallard, in fact, faced a choice between two highly contested positions: divisions within a debate that would shape South African urban policy and the wellbeing of residents in the country’s cities for years to come. On the one hand, there was the option of accepting, accommodating and ‘stabilizing’ an African working class in towns and cities. On the other, African workers could be excluded through their designation as temporary migrants from rural areas. Embracing the latter option, the top-down Stallard Commission ushered in an unstable regime of city governance that, possibly inadvertently, saw disease concentrated among African city dwellers who were not the main beneficiaries of investments in water, sanitation, parks, schools and clinics that were reserved for use by white people. ²⁰

A second important mechanism of governance reform was the consultative conference. The key example here is the 1918 Public Health Conference, attended by a variety of medical professionals, officials from all levels of government, representatives of professional associations, plus a range of other interested and affected parties. During the Conference, and through the consultative processes followed in the subsequent drafting of the Public Health Bill, municipal officials emerged ‘at the forefront of the demand for urban reform’, notably ‘requesting powers to monitor disease and control slums’. ²¹ The end result was the 1919 Public Health Act. In line with their requests, local authorities were indeed granted more powers to finance and carry out slum clearances and public health programmes. Although the Act did not address wider principles of town planning, it did include measures to enable the control of building coverage, and to zone urban areas for particular kinds of land use. ²²

The practical significance of the 1918 Conference was that it enabled a wide range of actors, including technical experts, to be consulted in relation to a discrete problem. It collected different viewpoints and kinds of evidence, in the form of both written and oral testimony, to help arrive at a consensus on appropriate policy processes and technical solutions. However, as with the expert commission, there was also an important political and symbolic function. By providing a common platform for different kinds of professionals, levels of government and public interest groups to engage with a national process of policy reform, the Conference offered a way to overcome a political impasse, and thereby to legitimate the state’s subsequent actions. In this sense, it can be seen as an early precedent for another mechanism of reform: the post-apartheid consultative policy forum, which we discuss later.

Urban reform in a unified colonial South Africa emerged with and through a strong coupling of planning and health concerns. Health was a key axis along which the colonial state could begin to promote consistent urban policy and management across the territory. While the health agenda was given impetus by conditions of crisis – notably in the form of the influenza pandemic – it also predated a politics of crisis, emerging from a longer-run set of processes and concerns. Here the prevention of disease and promotion of health by securing control over the production of the built environment was deeply implicated with perceived problems of migration, labour and poverty, as well as an emerging politics of racial segregation. However, that close coupling of planning and health would gradually unravel as new national political imperatives and local urban priorities came to the fore.

Post-War Reconstruction and Apartheid

The conclusion of the Second World War was another historical moment that offered South African leaders an opportunity for urban major governance reform and institutional restructuring at multiple scales. By now, South African cities saw a large proportion of the urban poor living in the desperate and unhygienic conditions of informal shantytowns. ²³ While the War was a global conflict, in South Africa, it nonetheless consolidated and highlighted a range of significant national and urban political and socio-economic transitions. These dynamics, in turn, encouraged massive state investments in wartime and post-conflict reconstruction and reform. Indeed, Freund has characterized the period 1939–1945 as one when a ‘developmental state’ form, intimately tied to the process of industrialization, was very nearly realized in South Africa. ²⁴ It was a modernizing ambition, however, that would be foreclosed by the election of a National Party government by an all-white electorate in 1948.

The central urban problematic defining the wartime and post-war period remained that of how to manage the familiar issue of African migration and residency, even if this was overlaid with new kinds of realities and demands linked to the country’s rapid industrial expansion. The shifting dynamics of economic production and labour demand appeared to call for strong state control over the economy and its spatial distributions. The state increasingly sought to manage these dynamics through highly top-down modes of regional and urban spatial planning. In the process, the discourse of health became more muted. While there was consensus and continuity before and after 1945 in emphasizing centralized government planning and control, and around a broad policy of urban racial segregation, major political debates and points of contention remained. These included the familiar dilemma of whether the African urban workforce should be settled and ‘stabilized’, or whether the state should remain committed to a system of migrant labour and segregation at a larger territorial scale. The sanitation syndrome no longer provided the major ideological justification to partition the towns. Faced with challenges of economic reconstruction, the question of urban policy was framed around how the state should go about forging an appropriate ‘racial order in industrial urban life’. ²⁵

The disruptions of global war unleashed a modernist planning fervour in South Africa, a drive to reconstruct towns and cities in order to address ‘the dislocations of the age’. ²⁶ Urbanization and industrialization had already gained momentum through the 1930s, driven by the rise of a ‘minerals-energy complex’ underwritten by the establishment of giant parastatals like Eskom and the Iron and Steel Corporation (ISCOR) in the 1920s. ²⁷ The star of the metal-working industry rose quickly, becoming the largest sector by value of total output by the time war was declared. Moreover, the swelling urban workforce and middle-class were opening up markets that encouraged the growth of consumer-oriented industries operating in sectors like food, beverages and tobacco. ²⁸

The expansion of manufacturing and mechanization set in train by these developments saw the growth of semi-skilled jobs, many of which were taken by Africans, Indians and Coloureds. ²⁹ Yet, such opportunities were unevenly distributed. By the late 1930s, two facets of the ‘urban native question’ had come to dominate South African politics. The first was the large scale of poverty experienced by urban Africans. The second was the perceived instability of African family life in the townships, supposedly encouraging social dislocation, unrest and low worker productivity. ³⁰ Inter- and intra-urban health inequalities, evidenced, for example, in the burden of tuberculosis, mirrored those of the increasingly polarized urban population. Expanded production arising from the needs of the war economy – notably in the metal and engineering sector – acted to accelerate the emergence of both industrially employed and unemployed urban populations. ³¹ Pressure on the housing supply increased. ³² Potentially lucrative urban land was occupied and settled irregularly. A sense of urgency arose; calls for state intervention intensified. ³³ In this context, meeting the basic service needs and primary healthcare requirements of African urban residents was an idea that never completely receded.

For a loose alliance of social reformers comprising liberals, academics, urban African leaders, missionaries and urban administrators, the War appeared to present a window of opportunity to realize the ideal of a ‘racialized welfare state’ serving the needs of a bounded urban population through a more modern, centralized and interventionist mode of government – an ideal that took root amid the socio-economic hardships of the 1930s. ³⁴ Their reformist ideas merged with a broader global enthusiasm for the benefits of ‘scientific’ state-led planning of both economy and space to build modern and healthy societies. ³⁵ In South Africa, these ideas found their spatial correlate in new and ambitious projects of urban development. Indeed, the industry-oriented interventionism and paternalism of the Smuts wartime government could be seen in the planning and development of ‘company towns’ like Vanderbijlpark, laid out in 1941 on land purchased by ISCOR. ³⁶ Plans for new towns like these set aside areas for whites, designed according to the latest principles of modernist town planning, as well as separate accommodation and service standards deemed appropriate for low-waged African workers. Yet they also incorporated obvious class-based inequalities within race groups, reflected in the spatial layout and service levels allocated to different areas and categories of employee. ³⁷

Wartime developments had the effect of reemphasizing a range of divisive political debates. Such debates focused on the desirability of different forms of segregation, whether urban Africans should indeed be regarded and accommodated as permanent settled residents, as well as the broader issue of how to respond to the massive restructuring of the industrial workforce. The response from the Smuts government to these questions and debates was familiar: the appointment of a commission, specifically the Native Laws (Fagan) Commission, in 1946. Reporting two years later, it concluded that state policy should look to facilitate and encourage the stabilization of the African labour force. Accordingly, influx controls should be relaxed, and appropriate facilities (including housing and segregated hospitals and clinics) provided to enable African workers to lead a permanent and settled life in urban areas. To increase regulatory efficiency, moreover, urban administrative structures should be rationalized, notably through the establishment of a centralized system of labour control. Overly ‘directive’ forms of state intervention were explicitly rejected. ³⁸

Despite its acceptance of permanent African urban settlement, the Fagan report nonetheless recognized that ‘migratory labour cannot be prohibited by law or terminated by administrative action’. ³⁹ This pragmatic position reflected not only the dynamics of urban change unfolding at the time, but also the particular labour needs of different economic sectors: secondary industries required skilled and therefore healthy and more stabilized labour, while the mines continued to depend on the migrant system. It was, however, a notable shift away from the Stallardism of the 1923 Urban Areas Act and subsequent legislation like the 1937 Native Lands Act. ⁴⁰ Yet this dualist model of urban management, which became common elsewhere on the continent and from which rudimentary urban public health systems emerged, was a shift that would never materialize in practice for South African cities.

The 1948 election of the National Party was not necessarily a defining or ‘watershed moment’ in South African history. There were certainly continuities between the new apartheid regime and previous state logics and practices, including that of urban racial segregation. Like its wartime predecessor, the post-1948 government remained committed to the ideal of a more interventionist and centralized state linked to the need for various forms of social ‘upliftment’, albeit for different political and ideological ends versus those propounded by social-welfarist reformers in the late 1930s and early 1940s. ⁴¹ There was, however, one critical policy shift: an enthusiastic re-embracement of the Stallardist notion that Africans should be regarded as ‘temporary sojourners in urban areas’. ⁴² This hard line on segregation would impact directly on every aspect of African urban life, from transport to health. The Sauer Commission, which set out the National Party’s position on the ‘colour question’ in a 1947 report, signalled the revival of this brand of segregationism. Yet, it would be insufficient to depict the Sauer report’s recommendations as simply a return to a predefined Stallardism. In fact, they were the outcome of an ‘unresolved conflict’ between competing conceptions of apartheid within the nationalist alliance: one seeking the ‘purist’ ideal of ‘total segregation’; the other, a more ‘practical’ position, looking to retain ‘uninterrupted access to an abundant supply of cheap African labour’. ⁴³ The Sauer report thus espoused, and attempted to resolve, an ‘internally contradictory and ambiguous’ combination of different ideals and modalities underpinning apartheid. ⁴⁴

The shift in emphasis endorsed by the Sauer Commission was accompanied by a concerted push to centralize government power. The national state increasingly took upon itself the responsibility to regulate the presence and life of Africans in urban areas. ⁴⁵ Centralized control was promoted through an aggressive process of public sector reform and transformation involving the installation of Afrikaner apparatchiks in key public and parastatal agencies, such as the railways ⁴⁶ and, perhaps, hospitals – although that history has yet to be written. As local authorities found their powers and autonomy increasingly eroded by the direct interventions of central departments, divisions and conflicts between local and central officials over everyday aspects of urban management became more commonplace. ⁴⁷ In the decades through which South African cities stayed free of major outbreaks of infectious disease, health slipped further from its place as a dominant policy imperative in the early twentieth century.

Strict influx controls, further restrictions on African rights to permanent urban residency, and state-led removal and resettlement programmes emerged as the key instruments to give life to the Sauer Commission’s recommendations. ⁴⁸ The strict implementation of pass and influx controls, however, were arguably not intended to perpetuate temporary migration so much as to reproduce differentiated forms of labour power – to stabilize a certain (urban) section of the African workforce against that comprising temporary migrant labourers. ⁴⁹ As in previous decades, housing remained a key instrument of enforcing racial segregation (legally enforced and entrenched via the 1950 Group Areas Act) and to control how Africans might reside in and move about urban areas. Popular resistance to this regime of control – and the extent to which the state was willing to enforce its workings through violence – was visibly expressed in the Sharpeville Massacre of 1960. ⁵⁰

Apartheid policy of the late 1950s and 1960s sought to contain the process of African urbanization as one element of a larger, ‘purist’ vision of territorial and economic racial separation. ⁵¹ At the regional level, this was to be secured through the creation of ethnically defined and ‘self-governing’ African homelands’, pursued alongside a policy of industrial decentralization that aimed to distribute economic activity and employment and thus prevent African movement into towns and cities. ⁵² At the urban scale, the objective was to ‘compress’ classes along racial lines, locking distinct class groups into singular geographical and social spaces. Urban service provision of shops, clinics and schools all were subjugated to this racist rationality. A principal means of class compression and race partition was an ambitious government programme for the construction of large concentrated African townships, removed from white residential areas but close to industrial centres of employment. ⁵³ This was a notable change from previous policies that favoured the development of small, dispersed locations. In this period, the central state’s preference was for the African labour force to be accommodated in migrant hostels, where doctors were on site, rather than in settled family units. ⁵⁴ Significant investments in transport infrastructures and services were critical to enabling this broader ‘purist’ vision, allowing people to access places of work, residence and recreation while minimizing interactions between races. ⁵⁵

The post-war era of reconstruction and apartheid gave rise to a distinct mechanism of policy reform: the permanent advisory commission. Here, the key example is the Natal Town and Regional Planning Commission (NTRPC). Established in 1951, through the energies of several key provincial administrators and planning officials, the NTRPC was influenced by wider post-war reconstructionist thinking and British enthusiasm for ‘the idea of a commission as an instrument of public reconstruction’. ⁵⁶ While primarily an advisory body to the provincial government, the NTRPC also played a limited role in approving developments and in funding and producing new research. One of its significant contributions was to link local thought and practice around planning with more international trends. ⁵⁷ It addressed itself to a wide range of spatial planning and development issues, in the process pioneering a more rational and scientific approach to regional planning in the province of Natal – something unrivalled in the national context.

Comprising ‘persons from outside government’ who advised and decided on a range of planning (but not health) matters, the NTRPC was effective partly because of the strength of its leadership, in the form of several successive chairpersons, who shaped its research agenda and were able to both defend and provide continuity to the institution’s particular ‘ethos’ and approach. ⁵⁸ However, its real contribution lay beyond the individual personalities and expertise of its leaders. Its value lay more with the philosophy of planning, and of its own role and approach, that the Commission was able to articulate, which enabled officials to make consistent policy statements and decisions. It was the intellectual and technical support that the NTRPC, as an institution, could provide to planning officials that was unique and significant. As Harrison and Mabin argue:

It was the presence of the Commission as a quasi-autonomous body and the support of the Commissioners that provided planning officials with a level of autonomy within the bureaucracy that enabled them to undertake planning that was arguably more innovative and successful than in the other provinces. ⁵⁹

We can see that the NTRPC’s role as a permanent, quasi-independent, and collective advisory body and thought leader differed from that of the short-lived and expert-led commission more commonly found in the earlier history of South African urban reform. Not only was the NTRPC almost completely unconcerned by matters of health and well-being, it also held a particular philosophy and normative position, from which it was able to exercise consistent influence over policy and planning decisions over an extended period. The expert commission, by contrast, sought to arrive at a normative position in the circumstances of a policy dilemma or impasse, and to assess the implications of that decision for future policy across a wide range of government sectors and functions.

The onset and apex of apartheid policy saw an obsessional concern with the control of labour, and much historical writing on the apartheid city has focused on the dynamics of race and class associated with industrialization, housing and movement control. Fewer scholars, including planning historians, have considered the place of health within an apartheid spatial agenda. For, while urban planners increasingly focused on realizing modernist ambitions of spatial planning and mobility through a lens of racial segregation, health problems were increasingly subsumed within a state apparatus of biomedicalized curative healthcare vested at the level of provincial government. ⁶⁰ Local authorities in principle retained responsibility for preventive and promotive healthcare, but increasingly the emphasis of the state was on building hospitals and care centres in urban and rural regions rather than close regulation of the production of the built environment. The health and planning agendas were thus decoupled horizontally (through the emergence of government silos addressing various modes of key service provision) and vertically (as health care was increasingly vested at the provincial rather than local level). This decoupling would be reproduced as systems of segregationist control began to falter, and the focus of anti-apartheid opposition coalesced around broader territorial issues of healthcare equity.

The Crisis of Apartheid

The 1970s was a period of transformation in South Africa, marked by growing economic and social crises. The racialized burden of disease drew surprisingly little attention, a major shift from earlier times when health was the vanguard of public policy. It was an era of soaring unemployment among African workers, an upsurge in labour militancy, and an intensification of popular urban protest against apartheid policies, the most obvious manifestation being the Soweto Riots of June 1976. ⁶¹ In this context, the state’s urban agenda increasingly focused on the imperative of maintaining control in the face of mounting opposition and economic downturn.

From the late 1960s, the government’s policy of industrial decentralization began to shift from the Verwoerdian focus on developing areas bordering the ‘homelands’ (specifically those located nearer metropolitan areas) to one of controlling metropolitan growth, and in particular the growth of the urban African workforce. Industrial decentralization would now be pursued in support of homeland development. In response to protestations from business interests, in 1971 a commission recommended that the government reduce metropolitan growth controls and boost incentives for industrial decentralization. ⁶² Meanwhile, money and concrete were poured into the country’s system of motor highways, seemingly encouraging decentralization by making remote homelands more accessible. ⁶³ As engineers and transportation experts gained influence in cities and among spatial planners, medical offers of health had little presence in urban reform debates and initiatives.

As the 1970s wore on, these measures did little to prevent South Africa from sliding into long-term economic decline and social unrest, or indeed to stem the growth of African urban populations. By the end of the decade the apartheid state was forced to accept the inevitability of African urbanization. ‘Reform’, initiated under the state leadership of P. W. Botha, entailed attempting to channel the urban process in an ‘orderly’ manner, while clinging to a faltering system of influx control. ⁶⁴

Such changes were endorsed by the 1979 report of the Riekert Commission, for example, which sat to assess various legislative issues affecting manpower utilization. While the Riekert report evinced an acceptance of the fact of African urbanization, it also sought a continuation and strengthening of controls over African movement and residence. ⁶⁵ It advocated distinguishing the needs of African ‘insiders’, enjoying freedom of movement and the right to live in urban areas, and those of rural ‘outsiders’, who would be prevented from moving to urban areas through strict controls over employment and accommodation. ⁶⁶ In this sense, the Riekert Report echoed the debates and options considered by the Fagan and Sauer Commissions three decades earlier.

With respect to spatial-economic policy, from 1982 the state’s industrial decentralization programme was revised and expanded, again in support of homeland development, albeit now framed within the objectives of ‘regional development’ targeting both homeland and adjacent white areas. Indeed, the basic policy of industrial decentralization as a means to channel growth outside of core metropolitan areas would remain an agenda of the post-apartheid state. Although removed as official policy in 1996, arguably this logic of decentralization – of ‘spreading’ economic development and job creation across territorial space to reduce regional inequalities – continues to retain some influence over South African developmental thought, strategy and practice. ⁶⁷

At the urban scale, a key objective of late apartheid ‘reform’ involved fostering a ‘black elite’ in the townships to act as the state’s ‘junior partners’. ⁶⁸ Moreover, state interventions increasingly facilitated class differentiation and the emergence of ‘socially demarcated residential areas with differential access to urban services’. ⁶⁹ Reform also involved developing a segregated system of local government, with urban areas divided between local authorities administering separate ‘white’ and ‘black’ areas. ⁷⁰ But many residents refused to cooperate with the underfunded ‘puppet’ local authorities serving ‘black’ areas. Resistance increased through the 1980s, becoming more violent towards the end of the decade as the apartheid system disintegrated. The implications of these trends for urban policymaking and health governance reform in post-apartheid South Africa are not clear as the apparent uncoupling of health policy, as a national competency, and urban planning, as a multi-scale domain of state action, became entrenched.

In this period of protracted crisis, the apartheid government’s approach to addressing the imperatives and dilemmas of urban reform largely relied on the familiar model of the expert commission. Aside from that chaired by Riekert, another major commission produced the Wiehahn report in 1979, recommending various reforms to labour relations, in part as a response to the rise of (then illegal) African trade unionism. ⁷¹ Yet the political and material conditions of the late 1970s and 1980s also saw another and quite different kind of reform initiative rise in significance: the independent or non-governmental development organization. Here the key example was the Urban Foundation, established by South African ‘big business’ interests in the wake of the Soweto Riots. A think-tank and lobby group, with close informal ties to the liberal opposition Progressive Party, the Urban Foundation ‘piloted new approaches to low-cost housing’, attempting to ‘steer the state towards more laissez-faire approaches to housing and urban development’. ⁷²

The Urban Foundation played a particular role in the context of a governmental system that was increasingly incapable of controlling urban processes or, indeed, of formulating a credible and popular response. This role was often that of a think-tank: researching and providing evidence for alternatives to the apartheid vision and modus opperandi. Yet it could also play a more direct advisory role. As Harrison and colleagues note, as systems of influx control began to break down in the early 1980s, the Foundation was ‘instrumental in assisting the state to develop new legislation for rapid land release for urban development’. ⁷³

As an example of an independent development organization, the Urban Foundation represents another kind of mechanism for driving governance reform. It is a mechanism characterized by the status of the ‘critical outsider’: an institution providing constructive critique of government policy and practice, as well as credible alternative solutions to public problems. This differs from the advisory role performed by quasi-autonomous institutions like the government commission, the latter being more constrained by the underlying structure and ideology of the state. Moreover, the legitimacy of something like the Urban Foundation did not emerge from the strength or recognition of its individual leadership, from its institutional location, nor from any underlying normative philosophy, but rather from the quality of its technical expertise and recommendations.

Efforts to articulate an alternative to apartheid urban policy had very little overlap with reforms concerned with health. For the latter, the imperative was to oppose systems of unequal healthcare provision in the form of curative services – redressing the unequal territorial distribution of doctors, hospitals and clinics among the Bantustans and nominally ‘white’ areas through the creation of a national healthcare system. While health-based opposition to apartheid thus focused on problems such as service equity, closing urban–rural inequalities in service funding and quality, increasing primary care and promoting access to care, ⁷⁴ the emerging urban agenda for a post-apartheid South Africa addressed itself to issues of fiscal reform, housing, transport and the delivery of basic services like water and sanitation. ⁷⁵ The bifurcated push for health and urban reform acted to reproduce the decoupling of planning and health seen in previous decades. It would remain so in the transition to democracy and through the articulation of a post-apartheid vision for socio-spatial transformation.

Democratization

A third key period of urban governance reform arose from the fall of apartheid, and the shift from white minority rule to a representative South African democracy. The context for this transition was one of rapid and uncontrolled urbanization. The removal of influx controls during the 1980s led to increased African migration into South African cities, aggravating problems of overcrowding and the growth of informal settlements. Protest action had rendered many urban spaces practically ‘ungovernable’ by the end of the decade. Moreover, the state now had to serve the entire population, rather than particular interest and race groups. And it had to rapidly elevate the lot of vast numbers of people who had been structurally disadvantaged by apartheid policies. Its urban reform interventions can be roughly grouped into two phases: an initial post-1994 drive to universalize access to housing and basic urban services, and a subsequent period of reflection on the developmental impact of government policy, particularly with respect to spatial form. Health sector reforms were undertaken in parallel to the reworking of built environment functions and a system of local government, but they were never integrated. ⁷⁶

The conditions and imperatives of a newly democratic nation had at least three major implications for the work of government. Firstly, the state assumed a commitment to high-level social and political objectives of creating a universal franchise, progressively realizing broad-based socio-economic rights, promoting racial and economic integration, encouraging sustainable development, and reducing poverty and inequality. ⁷⁷ Secondly, it meant implementing an ambitious programme of public sector reform in order to overcome the country’s inheritance of racialized and fragmented governmental structures. This ‘old regime’ was characterized by top-down administrative and managerial practices, unequal allocation of financial and human resources, and widespread disregard for principles of public accountability. ⁷⁸ And thirdly, it entailed a commitment to decentralization as a response to the controlling and coercive nature of the apartheid state, and as a way to reorient the public sector towards improved service delivery and promoting rapid socio-economic development.

Forging a new system of local government and administration faced the challenge of integrating and aligning the policy and legal systems of the reasonably functional and effective municipalities serving ‘white’ areas, and the under-capacitated and discredited authorities in ‘black’ areas. The system that ultimately emerged ‘was both informed by the past and was intentionally designed to break with the unequal legacies of inherited municipal practices’. ⁷⁹

What were the key mechanisms of governance reform in this context of heated post-apartheid contestation? Health was not one; housing was a far more prominent concern in post-apartheid urban debates. Indeed, the opening of multiparty negotiations after 1990 fostered a new kind of mechanism, namely, the consultative forum. An important example was the National Housing Forum (NHF), established in 1992. Described retrospectively as a ‘totally new concept in the South African development environment’, the NHF ‘provided the space for a legitimate and consensual process of negotiating a new housing policy, involving all the necessary stakeholders and not merely organs of government’. With the existing housing scheme (associated with the apartheid government) thoroughly discredited, the country faced a ‘housing policy vacuum’. The NHF was seen as one means to ‘gather the resources and housing expertise’ required to develop a policy that was held as legitimate and suited to the context of a new democratic nation. ⁸⁰

By 1995, discussions within the NHF had produced democratically agreed policy guidelines in the form of the Department of Housing’s White Paper. The new government’s capital subsidy scheme, the Provincial Housing Boards that allocate the subsidy, the policy-oriented National Housing Board, the 1995 Development Facilitation Act, plus a range of end-user financing initiatives, were all developed from the efforts of the NHF. ⁸¹ However, the process was not straightforward. The policy guidelines were the outcome of intense debate within different sectors of the NHF. Vanessa Watson, an urban planner and member of the Forum’s Working Group 5, recalls a debate over the proposed capital subsidy scheme:

There was a “breadth versus depth” debate around the use of housing subsidies. The “breadth” position said the policy should spread the subsidies as evenly as possible across as many people and households as possible, which meant providing a small plot of land and a basic house to each. The “depth” position argued for an integrated human settlements approach, recognizing that some types of housing would cost more than others. Well-located affordable housing would need a much bigger subsidy, meaning you could only give out a limited number of subsidies. The World Bank was heavily involved through the Urban Foundation, and they liked the “breadth” approach, because if you gave each person their tiny plot of land, they could have freehold tenure. Whereas if you went for “depth,” and were building three-story walk-up apartments, it would be much more difficult to give freehold tenure – you might have to go for rental. ⁸²

Ultimately, the ‘breadth’ position on subsidies won out, forming the basis of the NHF’s final recommendations. This resolution has fundamentally shaped housing policy and delivery in post-apartheid South Africa. Yet this debate, played out around the specific issue of subsidies, had much wider resonance to the post-apartheid urban question – it signalled a disagreement between those arguing that the future of South African cities should be oriented around the objectives of infill, higher density and better urban quality, and those in favour of a maximized redistribution of resources. Indeed, echoes of this ‘depth versus breadth’ debate remain. A contemporary version divides those arguing for the spatial targeting of state investments in central urban areas, and those who see the universal provision of basic services like housing or indeed health care (to people wherever they reside) as the fundamental priority of developmental government.

The NHF represents a particular mechanism of policy reform, perhaps unique at the time, albeit with predecessors – the Public Health Conference of 1918, it could be argued, entailed a similar logic of multiparty negotiation to produce a framework response to a discrete policy problem. As a mechanism of reform, the consultative forum is characterized by the assembling of a wide range of competing interests and technical expertise, in a non-hierarchical manner, in order to reach consensus on the policy options available to address a particular problem (in this case, the ‘housing crisis’ and ‘policy vacuum’). Even if consensus could not be reached on every issue (such as the proposed system of capital subsidies), the legitimacy and value of the NHF lay in the very means by which it strove for that end. Indeed, as the Chairperson later reflected, ‘the collaborative impetus that the establishment of a national housing forum provided may have been the most important factor in addressing the conflict of those times’. ⁸³

The elaboration of the policy and institutional apparatus to give effect to a vision for democratic, integrated and sustainable South African cities tended not to focus on health but on the reforms necessary to extend traditional urban services such as water, sanitation, transport and housing. In some ways, an opportunity was missed to promote a closer coupling between planning and health concerns. Health activists and policymakers, for their part, were preoccupied with the tasks of forging a new national health system while extending the supply of and access to primary health care services according to a rights-based approach. ⁸⁴ The emphasis of the health agenda remained one of curative care vested at the institutional level of provincial and national government. The pressures and objectives of the post-apartheid transition thus acted to sustain a decoupling of planning and health concerns, reproducing divergent logics around promoting health and the production of the urban built environment. The COVID-19 pandemic has emerged in and through that bifurcated policy and institutional context, generating renewed calls for closer attention to the interlinkages between space, the environment and health outcomes. In responding to those calls, let us remain attuned to the lessons of history.