Janna Coomans. Community, Urban Health and Environment in the Late Medieval Low Countries. Cambridge Studies in Medieval Life and Thought Series. Cambridge: Cambridge University Press, 2021. 350 pp. $99.99 (cloth), ISBN 978-1-108-83177-2.
Reviewed by Lucy C. Barnhouse (Arkansas State University)
Published on H-Sci-Med-Tech (July, 2022)
Commissioned by Penelope K. Hardy (University of Wisconsin-La Crosse)
Janna Coomans’s monograph on public health examines biopolitics and biopower in the premodern city, focusing on notions of moral and political balance informed by medical theory. It is thoughtfully and inventively theorized, with an original interpretation solidly grounded in primary sources. Building on the work of Carole Rawcliffe and Guy Geltner, and moving beyond England and Italy, with their unusually high degrees of centralized urban government, Coomans provides a useful demonstration of how public health initiatives and principles could be implemented in places with different sociopolitical realities. The book is a regional case study rooted in a range of primary source genres but should be valuable to urban historians of other regions and periods as well. Also, while Coomans refers to the Low Countries’ source base as distinctively facilitating this kind of work, I see similar patterns in places with far more fragmentary sources. Coomans explicitly avoids facile comparisons with the failures and successes of contemporary public health strategies. She engages thoughtfully, however, with the conspicuously relevant questions of how multifaceted and decentralized public health strategies can be effective and the implications of conceptualizing public health as a common good.
The first chapter asks: what policies defined a healthy urban society for late medieval people? In answering the question, Coomans builds theory outward from close work with sources. Urban planning and infrastructure were informed by Galenic flow, showing links between theories of individual and collective health. Stone was of both symbolic and practical importance, enabling the flow of water and limiting the spread of fire. Criminals, moreover, might be punished by paying fines in stone for the city walls or other projects seen as contributing to the public good, including hospitals. That cleaners might be "paid" with citizenship also demonstrates the close conceptual link between the physical and moral health of the city. Security infrastructure, too, was conceptualized as part of public health policy. Coomans’s use of original languages is judicious, as in pointing out that pipe masters in the vernacular were known as the committee of sweet or pure water in Latin. Chapter 2 expands the discussion of sanitation measures. These were frequently a tool of establishing civic authority and moved across contested boundaries between public and private rights and property.
Here and elsewhere, Coomans is careful to observe and describe the participation of women in healthscaping; they were involved in a variety of roles related to maintaining public sanitation. Such maintenance was far from ad hoc; it was consistent and preventative rather than reactive. In Ghent, a loose confederation of men and women overseen by the "king of ribalds" formed significant stakeholders in public health maintenance, despite the fact that their activities have left comparatively few written traces. Variation is visible among cities and over time, and a plurality of stakeholders rather than centralization of power remained the norm. Coomans argues against a linear trajectory of centralization or toward government involvement. Instead, politically and spatially decentralized management was habitually and legally negotiated. Chapter 3, “Food, Health, and the Marketplace,” is concerned with the implications of imagining the ideal market as a public space in political, economic, and moral terms. Guilds advocated for the theoretical and practical regulation of these spaces, and there was considerable local regulation governing the transport, processing, display, and sale of goods. Moreover, city governments were in communication with each other about best practices. Infractions of policy could be given explicitly religious penalties, for example, pilgrimage, a point that might bear further investigation. Peaks of policy enforcement, Coomans finds, correlated with plague and famine. Even in the case of grain policy, however, top-down policy was not the norm. Coomans convincingly demonstrates a sophisticated medicalized understanding of meat. This being the case, more understanding of why unhealthy foods could be donated to hospitals, as in Utrecht and Leiden, remains a desideratum.
Chapter 4, “Good Neighbors,” expands on the discussion of public health and private rights, and the ways these were negotiated, with a focus on “informed networks of local inhabitants negotiating various aspects of health and hygiene in their living environments” (p. 176). Here Coomans usefully provides an aggregate chart of types of health-related disputes and also examines their frequency by city. Worth noting is the range of primary sources used to access this information. Coomans also discusses interesting evidence for the dedicated hygiene infrastructure of hospitals, too often invisible in extant sources. The chapter dedicated to plague combats the “bias of crisis” in the historiography and looks at lateral networks of care as integral to managing individual and collective health (p. 217). Coomans argues against plague as a singular and decisive watershed in medieval public health policy. Like Katharina Wolff, Coomans sees similar strategies of disease management used for rabies. More work on late medieval urban public health and hospitals will doubtless help to elucidate how plague did and did not change strategies for managing health and sickness. The porous boundaries between private and public health are here again conspicuously relevant. The question of participation in Mass and religious processions, for example, was particularly fraught, as it required balancing the need to limit contagion with the need to ensure access to spiritual care. Coomans sees evidence for a “distant yet coordinating” relationship between civic governments and hospitals (p. 241). Here and in the discussion of Cellites’ care for the dead and dying, the work could have entered more into conversation with recent scholarship on hospitals.
In chapter 6, Coomans discusses a growing hermeneutic of suspicion applied to groups and activities viewed as potentially perilous to public health and order. In doing so, she brings together strands of historiography that have sometimes been separated, discussing leprosy, poverty, and sexuality alongside each other. Increasingly, late medieval urban communities constructed binary categories of healthy and ill, resident and foreign. The movement and behavior of the poor, particularly of the itinerant poor, was increasingly regulated. Regulation of public space and public behavior was also key to managing sexuality in urban environments. Bathhouses were particularly ambivalent spaces in this regard, as they could both contribute to individual regimens and facilitate disorderly sexual conduct. While the discussion of leprosy and the leprous might be still further enriched by comparing leprosaria with other hospitals, Coomans integrates the scholarship of the last fifteen years to a degree not always achieved.
In situating the work in its historical and historiographical context, the conclusion both warns against facile comparisons between the medieval and the modern and points out ways the multifaceted, locally rooted medieval traditions of managing public health can and should provoke thought about our own attempts to do the same. The case is convincingly made that medieval urban identity was tied up with ideas of salubriousness, as illustrated in the case of St. George driving off a pestilence-causing dragon. Although Coomans opens with this intriguing anecdote, little is said elsewhere of the connections between saintly patronage and the maintenance of health infrastructure, and this might be an area for exploration in further work, building on this and the work of Otto Gecser. In the opening of chapter 1, Coomans observes that “contrary to the popular image of a violent society, the vast majority of people in the later Middle Ages died of a disease” (p. 31). While the Middle Ages as a time of disease is a stereotype in its own right, Coomans convincingly demonstrates that it was also a time of disease prevention and health management.
. Lucy Barnhouse, “From Helpful Gardens to Hateful Words: Moral and Physical Healthscaping in the Late Medieval Rhineland,” in Disease and the Environment in the Medieval and Early Modern Worlds, ed. Lori Jones (London: Routledge, 2022), 52-64.
. Katharina Wolff, Die Theorie der Seuche: Krankheitskonzepte und Pestbewältigung im Mittelalter (Stuttgart: Franz Steiner Verlag, 2021), 169-70.
. See, for example, Adam J. Davis, The Medieval Economy of Salvation: Charity, Commerce, and the Rise of the Hospital (Ithaca, NY: Cornell University Press, 2019); Tiffany A. Ziegler, Medieval Healthcare and the Rise of Charitable Institutions: The History of the Municipal Hospital (London: Palgrave Macmillan, 2018); and Carla Keyvanian, Hospitals and Urbanism in Rome, 1200-1500 (Leiden: Brill, 2015.) On care for the dead and dying, see Letha Böhringer, “Beginen und Schwestern in der Sorge für Kranke, Sterbende und Verstorbene: Eine Problemskizze,” in Organisierte Barmherzigkeit: Armenfürsorge und Hospitalwesen in Mittelalter und früher Neuzeit, ed. Artur Dirmeier (Regensburg: Verlag Friedrich Pustet, 2010), 127-55.
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Lucy C. Barnhouse. Review of Coomans, Janna, Community, Urban Health and Environment in the Late Medieval Low Countries.
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