International Journal of Paleopathology 1 (2011) 3542

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International Journal of Paleopathology

journal homepage: www.elsevier.com/locate/ijpp

Research Article

Survival against the odds: Modeling the social implications of care provision to
seriously disabled individuals
Lorna Tilley , Marc F. Oxenham
School of Archaeology & Anthropology, College of Arts and Social Sciences, Australian National University, Canberra, ACT 0200, Australia

a r t i c l e

i n f o

Article history:
Received 9 October 2010
Received in revised form 15 February 2011
Accepted 16 February 2011
Keywords:
Palaeopathology
Vietnam
Healthcare
Paralysis
Klippel-Feil Syndrome
Neolithic

a b s t r a c t
Survival of an adult male (M9) with juvenile-onset quadriplegia in Neolithic Vietnam indicates provision of continuous care from his community, and adds to the growing literature documenting survival of
disabled individuals in prehistory. Although the role of care-giving in achieving survival is occasionally
acknowledged it is rarely elaborated, and a bioarchaeological model of care is missing. Contextualized
analysis of specic instances of care can offer unique insights into contemporary culture, as the case of
M9 illustrates. The bioarchaeology of care identies likely functional impacts of the pathology; possible
and probable health challenges encountered; and nature of the support required to sustain life. Consideration of these factors in relation to lifeways practices and behaviours extends and enriches archaeological
observations of M9s community. Additionally, M9s survival of extreme disability suggests certain personality traits touching on aspects of identity. Still under development, this new methodology promises
to be a valuable heuristic tool.
2011 Elsevier Inc. All rights reserved.

1. Introduction
Between 37004000 years ago in northern Vietnam a young
man survived for approximately 10 years with disabilities so severe
he would have been dependent on assistance from others for every
aspect of daily life. Paralysed from the waist down and with at
best very limited upper body mobility (Oxenham et al., 2009), the
skeletal remains of Man Bac Burial 9 (M9) provide evidence of a
pathological condition difcult to manage successfully in a modern medical environment. In a subsistence Neolithic economy the
challenges to health maintenance and quality of life would have
been enormous, yet M9 lived with minimally paraplegia and maximally quadriplegia from childhood into his third decade. M9s
survival reects high quality, continuous and time-consuming care
within a technologically unsophisticated prehistoric community.
M9s pathology and its diagnosis are detailed in Oxenham et al.
(2009). The current paper builds on this previous work to explore
the wider implications of M9s survival.
A communitys response to the health care requirements of
its members is shaped by a combination of cultural beliefs and
values; collective knowledge, skills and experience; social and
economic organisation; and access to resources (e.g. Bates and
Linder-Pelz, 1990; Hardey, 1998; Hofrichter, 2003; Mishler, 1981;
Pol and Thomas, 2001). In turn, and within physiological param-

Corresponding author. Tel.: +61 02 6125 3498/6247 2174; fax: +61 02 6125 2711.
E-mail address: lorna.tilley@anu.edu.au (L. Tilley).
1879-9817/$ see front matter 2011 Elsevier Inc. All rights reserved.
doi:10.1016/j.ijpp.2011.02.003

eters, the way a person responds to the experience of a serious

disease or injury reects not only the treatment received, but
individual characteristics, beliefs and behaviours formed within a
specic socio-cultural environment (Bowling, 2002; Fbrega, 1997;
Garro, 2006; Lieban, 1977). It follows from these observations that
analysis of the functional impact of a signicant pathology and the
manner in which both the person affected and their community
respond to the demands of this condition potentially offers insights
into aspects of the contemporary society, and even a sense of the
personality of the individual receiving care.
The provision and receipt of health care may therefore reect
some of the most fundamental aspects of a culture. There exists
a rich palaeoanthropological and bioarchaeological literature documenting individual cases of palaeopathology, including those in
which the likelihood of care is explicitly acknowledged if not elaborated (see for example Dickel and Doran, 1989; Hawkey, 1998; Luna
et al., 2008; Trinkaus and Zimmerman, 1982), and exploring interactions between lifeways, environment and evolution of disease
and impact of these on population health status (e.g. Larsen, 2000;
Ortner, 2003; Roberts and Manchester, 2005; Steckel and Rose,
2002). However, archaeology has overlooked prehistoric health
care provision as a specic focus for analysis, and a valuable source
of information on past behaviours is being ignored. A bioarchaeology of care analytical framework, outlined below and illustrated
through application to the case of M9, is being developed to address
this decit.
In the prehistoric setting, provision of health care is inferred
from physical evidence in human remains which suggests that, at

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L. Tilley, M.F. Oxenham / International Journal of Paleopathology 1 (2011) 3542

some stage, an individual experienced a pathology that required

and received assistance to enable or facilitate continued survival.
Indicators of receipt of care comprise skeletal or preserved soft
tissue evidence that (i) suggests survival over time with a continuing disability rendering functional independence impossible, or (ii)
represents healed or healing lesions associated with an illness or
injury necessitating care for recovery. Health care is operationally
dened as the provision of assistance to an individual incapacitated
as a result of a pathological condition who, without this assistance,
may have been unlikely to survive to age at death. Care provided
may have lasted weeks, months or years, and could have consisted
of anything from basic supply of provisions, through dedicated
nursing or direct medical intervention, to longer term modication
of group activity to enable community participation. In this paper
disability, a contentious term in bioarchaeology (Dettwyler, 1991;
Cross, 1999; Molleson, 1999; Roberts, 1999, 2000), is employed
in accordance with the World Health Organisation (2008) usage
to refer to a state arising from impairment in body function or
structure, associated with activity limitations and/or participation
restrictions, and given specic meaning in relation to the lifeways
context in which the pathology is experienced.
The bioarchaeology of care approach is designed for application
at a case-study level. Initial analysis focuses on the probable impact
of a serious pathology upon an individuals ability to operate within
their immediate physical and social environments. Where diagnosis is relatively straightforward (pace Waldron, 1994), modern
clinical literature can provide information on the range of associated disease symptoms and likely outcomes. Even in cases where
the exact diagnosis is uncertain, the physical evidence of pathology may allow conclusions about minimum level and duration of
functional impairment. It is taken as given that every individuals
experience of a pathology is unique (Bowling, 2002; Martin Ginis
et al., 2005 in relation to spinal cord injury specically) and that
complete condence in relation to the nature and extent of the
impact of a pathology is not possible. However, a model of what
care-giving likely comprised may be derived from considering (i)
the minimum range of disability/ies associated with the evidence of
pathology in relation to (ii) the possible opportunities for, and constraints on, the provision of support in the corresponding lifeways
context.
The above principles are employed to explore what M9s
extended period of survival, against all odds, may contribute to
understanding the social and economic practices of the prehistoric
community of Man Bac, and what it may suggest about this young
man as an individual. This study provides a demonstration of the
amount and quality of information obtainable through a bioarchaeology of care analysis. In doing so it contributes to the growing
discussion in the bioarchaeological literature on social dimensions
of the past and, more broadly, helps to illustrate how case studies
of individual remains can contribute to achieving a fuller picture of
prehistoric society.
1.1. The context for care
Identifying the range of care likely required for M9s survival,
and how, and at what cost, this care might have been provided,
requires an understanding of the Man Bac physical environment,
socio-cultural context and general level of health.
In summary, the Man Bac cemetery is located in Ninh Binh
province of northern Vietnam, 100 km south of Hanoi. Excavations
carried out between 1999 and 2007 produced the remains of 95
individuals, extending through three separate layers, all primary
burials, and comprising the rst signs of human presence at the
site. During occupation Man Bac was located at the mouth of an
estuary of one of many rivers making up the Red River Delta, with
a landscape of at loess interspersed with sharply rising, rugged,

Fig. 1. Photograph of the modern day Man Bac landscape, looking southwest, with
the cemetery excavation site on the middle right (modern cemetery left foreground).
In the Neolithic the lower ground would have been underwater, and the cemetery,
which is slightly elevated, would have been on the bank of a tidal river.

limestone karsts (Fig. 1). The climate would have been similar to
that of the present, with cool, humid winters (minimum average
temperature during January is 12 C, frequently descending to 6 C)
and hot, wet summers (Sterling et al., 2006).
Archaeological evidence suggests a predominantly huntergatherer economy. Faunal remains indicate a focus on terrestrial
and aquatic vertebrate resources (Sawada and Vu, 2005), with
preliminary stable isotopic data indicating over 50% of protein
intake derived from sh (Yoneda, 2008). While long grain rice
has been recovered from contemporaneous Red River Delta sites
(Nguyen et al., 2004), conrmatory evidence for rice cultivation/consumption has proved elusive at Man Bac. A preliminary
analysis of the Man Bac pottery suggests extensive regional links
among the Red River Delta communities (Nguyen, 2008), while
lithic evidence indicates trade routes extended as far as Shang
Dynasty China during this period (Higham, 1996).
A detailed description of M9s pathologies, a brief review of
some common health implications of immobility, and more information on the bio-cultural context for the discussion of care are
presented in the supplementary information section. Readers are
strongly encouraged to view this before continuing.
2. Caring for M9
M9, a male of between 20 and 30 years, was buried exed,
on his right side, and oriented northsouth. This contrasts with
standard Man Bac mortuary practice (extended, supine, eastwest
orientation). Skeletal abnormalities suggestive of serious pathology
were immediately apparent on excavation, and are clearly visible
in Fig. 2.
M9s remains manifest extreme disuse atrophy of lower and
upper limbs, full ankylosis of all cervical and the rst three thoracic
vertebrae, a permanent torticollis, and bilateral temporomandibular joint degeneration. A diagnosis of Klippel Feil Syndrome (KFS)
Type III has been proposed (Oxenham et al., 2009). The severity
of pathology leaves no doubt that M9 was dependent on others
for survival from onset of paralysis in adolescence onwards. The
precise nature of the support he required cannot be known, but
the constraints inherent in osteological analysis make it likely that
the nature, duration and complications of his pathology will be
underestimated. Nevertheless, analysing the likely impact of M9s
disabilities within the contemporary physical and cultural environment of Man Bac is one way of identifying what at a minimum
his care comprised.

L. Tilley, M.F. Oxenham / International Journal of Paleopathology 1 (2011) 3542

Fig. 2. Photograph of MB07H1M09 in situ immediately prior to removal; note

extreme gracility of limbs. The single preserved grave good (a terracotta pot) was
removed at an early stage of the excavation.

There are obvious caveats to this approach. Individual variability

in response to disease has already been acknowledged. Similarly,
palaeopathology relies on clinical experience to understand the
effects of disease on physical and psychological function, and this
modern, usually Western, frame of reference refers to a very different medico-cultural environment to that of the Vietnamese
Neolithic. More particularly, the manner in which M9s condition emerged may have helped to shape the support he received.
Although making no difference to the practical aspects of longterm support required, the timing and nature of disability onset
may have had implications for the decision to provide care and for
mode of care-delivery. This information is not retrievable from the
archaeological record, and the following analysis of M9s care is
based on evidence of disease present at time of death.
By referring to modern clinical literature (e.g. Bergman et al.,
1997; Martin Ginis et al., 2005) a minimum level of practical support required for M9s survival can be identied under the headings
of:
Basic care: assistance with the daily necessities of life, such as
provision of food, water, shelter, transport, and help with dressing
and other everyday activities; and
Advanced care: maintenance of personal hygiene, managing
environmental and physical safety concerns, general health
maintenance, monitoring to ensure continued well-being, and
dedicated nursing and other medical interventions as needed.
This division does not imply that various tasks were necessarily carried out by different people or at different times. Caring for
a person with severe handicaps is an integrated activity; the distinction between basic and advanced care is arbitrary, because all
aspects of care are critical to preserving life, and all interact to make
up the standard of care provided. Arguably, however, the forms of
care listed as advanced are more intimate, more labour intensive
and demand a higher level of skill and/or commitment than those
described as basic, and this is what these categories reect.
2.1. Basic care
2.1.1. Food and water provision
M9 was incapable of obtaining food and water independently,
so these essentials must have been supplied by others. Upper limb
handicap, combined with cervical ankylosis and a permanent torticollis, would have affected coordination, possibly posing problems
for M9 in feeding himself. Restrictions on head and neck movement, combined with those associated with temporomandibular
joint osteoarthritis, may have been an obstacle to efcient mastication, although level of tooth wear observed in M9 appears normal

37

for age. It would have been more difcult for M9 to hold a drinking vessel at the correct angle for imbibing. It is probable that M9
received assistance with both eating and drinking, but he would
almost certainly have required help in relation to the latter.
M9 may have been provided with a special diet, possibly involving additional processing to encourage appetite and facilitate
digestion and absorption. Immobility is associated with adverse
gastrointestinal outcomes ranging from anorexia to constipation
(McKinley et al., 2002; Olsen and Schroeder, 1967; Schnelle and
Leung, 2004). Constipation and/or mechanical bowel obstruction
are an almost inevitable corollary to prolonged immobility in the
absence of an appropriate diet, and the consequences can be severe
(McKinley et al., 2002; Olsen and McCarthy, 1967; Teasell and
Dittmer, 1993); M9 may have received food(s) with known laxative
properties to facilitate bowel movement. Immobility-associated
changes in metabolic function also affect dietary requirements;
high levels of dietary protein are needed to compensate for poor
nutritional absorption resulting from reduction in cell metabolism
rates, and foods with an acid residue, such as sh, meat, poultry
and cereals, may be benecial in countering increases in system
alkalinity which affect urinary and other functions (Agarwal, 2002;
Olsen and McCarthy, 1967; Olsen and Schroeder, 1967). M9s carers may not consciously have been aware of developing an optimal
dietary regime, but they probably arrived at one through trial and
error aided by the fact that their normal diet was based on high
protein, low fat, marine foods.
It is critical for immobilised individuals to be kept well hydrated.
Dehydration can be both an outcome of, and a contributor to, body
organ dysfunction (Bergman et al., 1997; Massagli and Reyes, 2008;
Olsen and McCarthy, 1967). Attention must have been given to
ensuring not only that M9 had water within easy reach (particularly important in the hot months when sweating increases loss of
body uid), but that he was assisted in drinking if this was required.
Maintaining M9s health must have involved establishing a
balance between his digestive capabilities and his nutritional
requirements; his continued survival suggests this was achieved.
2.1.2. Transport
Following onset of paralysis it would have been impossible for
M9 to undertake signicant independent movement. There is no
evidence of contemporary draught animal domestication in this
region, so if travel was undertaken M9 must have been transported
by others, possibly on a litter or even by water. Consideration of
transportation issues may offer an insight into the Man Bac economy. It would not be impossible for a community undertaking
seasonal movement to support a seriously handicapped individual (e.g. Dickel and Doran, 1989), but it would be very unusual. The
extreme fragility of M9s limbs would have rendered them vulnerable to fracture from even minor trauma. Given the lack of evidence
of antemortem injury it seems unlikely that M9 was involved in
travel over long distances, supporting the independently derived
hypothesis that Man Bac was predominantly a sedentary community. Despite this, M9 must frequently have been moved over short
distances, if only for the purposes of maintaining the standard of
hygiene necessary to avoid infection. He would have been dependent on the physical strength of others for his conveyance, and on
their caution in carrying him for his safety.
2.1.3. Shelter
There is no direct evidence of dwellings from this period, but
it would have been impossible for M9 to have survived constant
exposure to the elements for any period of time. A water, wind and
sun-resistant shelter must be assumed. M9s continued survival
would also have been dependent on both (i) a structure elevating him off cold or wet ground, and possibly providing him with
support for resting in a sitting position, and (ii) provision of a soft

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L. Tilley, M.F. Oxenham / International Journal of Paleopathology 1 (2011) 3542

surface upon which to lie. Failure in either of these areas would

have resulted, at a minimum, in continuous challenges to M9s
health from acquired pressure sores and respiratory tract infections
(AHCPR, 1992; McKinley et al., 2002; Olsen and McCarthy, 1967).
2.1.4. Dressing
Limitations on upper body function would have been a serious
impediment to self-dressing. In a modern clinical context the ability
of an individual with spinal cord injury to clothe and clean themselves is given prominence because independence in these areas
is associated with psychological well being (Krause et al., 1997).
Although nothing has been recovered from the cemetery excavations that sheds light on the specic dress customs of the Man Bac
community, there is clear evidence for textile manufacture in the
contemporary Phung Nguyen period (Cameron, 2002), and winter
temperatures (Sterling et al., 2006) would have necessitated some
form of covering during this season at least.
2.2. Advanced care
2.2.1. Personal hygiene
M9 would have been completely reliant on others for the maintenance of personal hygiene, and this must have involved a regular
regime of bathing and toileting. Although possibly bathed in situ,
M9 may have been moved elsewhere for, and/or assisted in, the
voiding of bowel and bladder.
This care was fundamental to his survival. Had M9 been left
for any extended period lying in his own waste this would have
increased vulnerability to breaches of skin integrity and to bacterial and parasitic infection (AHCPR, 1992; Stillman, 2008). Similarly,
changes in metabolic function associated with immobility may
lead to increased sweating (Campagnolo, 2006; McKinley et al.,
2002), and this physiological response would have intensied during the humid summer season. Sweat-moistened skin would also
have increased M9s susceptibility to pressure sore development
and have required particular attention. All the above complications
can have potentially fatal consequences for an immobile individual
(Stillman, 2008; Thompson Rowling, 1967; Yeo et al., 1998). Assistance would have included removal and disposal of body wastes;
continual observation and action to ensure M9 was clean and dry
(wiping, bathing, towelling); and frequent replacement of soiled
bedding.
2.2.2. General supervision
Individuals who suffer loss of sensation as a result of spinal cord
damage are vulnerable to acquired injury in affected areas of their
body because they are unable to tell when damage is occurring;
even immobile individuals who do not suffer sensory decit will
lose an amount of sensation over time (Bergman et al., 1997). For
M9, hazards probably included open res; surfaces capable of penetrating or tearing the skin; disease-carrying or poisonous insects
or reptiles; lengthy exposure to damp or cold; and the range of
domestic accidents that happen when people live in close proximity. Support in this context would not only have entailed being
aware of the location of M9 in relation to potential threats and
acting to reduce risk, either by environmental management or by
removing M9 from danger, but also undertaking regular physical
examinations to ensure absence of injury.
2.2.3. Health maintenance, health monitoring, and dedicated
nursing
Modern clinical experience suggests that care interventions
must have occurred at various stages throughout the latter half
of M9s life. Characteristics of symptom onset would have shaped
treatment approach. If M9 experienced a gradual decline in
mobility and sensation, then the initial need for direct medical

intervention may have been minimal and support efforts concentrated on compensation for functional restrictions. If paralysis was
of sudden onset, then intensive care would have been necessary
over the initial period of stabilisation (Lee and Green, 2002), followed by development and implementation of an ongoing support
regime. At a minimum, M9 probably experienced severe restrictions on head and neck movement from birth, and he may also have
manifested other signature characteristics of KFS (Hensinger et al.,
1974; Thomsen et al., 1997). Indeed, M9 may have been marked
out as different and possibly in need of assistance before paralysis
occurred.
Individuals with long term mobility constraints face an extensive range of possible secondary complications. Some, such as
osteoporosis, are unavoidable, and many are potentially lifethreatening (e.g. Anderson and Spencer, 2003; Dittmer and Teasell,
1993; Marik and Fink, 2002; Teasell and Dittmer, 1993). M9 displays
extreme atrophy and bone demineralisation of both upper and
lower limbs (Oxenham et al., 2009), but most other complications
have no effect on bone. It is therefore impossible to say what other
health challenges M9 experienced, but it is hardly credible that he
experienced none at all (Corcoran, 1991; Lee and Ostrander, 2002;
McKinley et al., 2002). Close monitoring of an immobile individual
is required to ensure that symptoms associated with complications
are addressed quickly. Consideration of what this monitoring may
have comprised in relation to M9, and what sort of care may have
been provided in direct response to an acute challenge, provides
insight into carers awareness of what constituted a health threat
and their ability to respond effectively.
Looking out for M9 must have included recognition of early
symptoms of distress, even if these could not be attributed to a
specic cause. Cardiovascular dysfunction may manifest in dizziness, rapid heart rate, excessive sweating and headaches (Claydon
et al., 2006; Olsen and Thompson, 1967; Winslow, 1985) and respiratory system dysfunction in difculties in breathing and coughing,
or raised temperature (McKinley et al., 2002; Olsen and Johnson,
1967). Urinary and renal dysfunction may manifest in raised temperature, pain, blood in the urine or nausea (Bergman et al., 1997;
Olsen and Schroeder, 1967). Constipation or bowel obstruction
may manifest in loss of appetite, general discomfort, abdominal
swelling, tangible mass in the colon, or abdominal pain (McKinley
et al., 2002; Olsen and McCarthy, 1967).
The communitys ability to treat these conditions aggressively
was probably limited, but effective therapies may have existed
nonetheless. Modern clinical experience shows that physical therapy interventions can be very successful if applied in the early
stages of complications. Mobilisation, turning, repositioning, elevation, massage, percussion and postural drainage can improve
respiratory and circulatory function, and repositioning, elevation,
manual pressure, massage and manipulation can assist urinary ow
and faecal elimination (McKinley et al., 2002; Olsen and Johnson,
1967; Olsen and McCarthy, 1967; Olsen and Schroeder, 1967;
Olsen and Thompson, 1967). Preventing dehydration and providing
appropriate nutrition, previously discussed, is critical to maintaining the tness levels necessary for overcoming health challenges.
Historic and ethnographic research suggests that use of herbal
remedies for treatment of fevers, pain and gastrointestinal complaints may have been common (e.g. Ferrence and Bendersky, 2004;
Halberstein, 2005; Lieban, 1977). Direct evidence for the use of
betel nut (Areca catechu) in Metal Age northern Vietnam is clear
(Oxenham et al., 2002) and its use as medicament for children at
Man Bac has been inferred (Oxenham et al., 2008a), but a general
lack of palaeobotanical evidence from Man Bac precludes further
comment.
When M9 experienced acute health complications, intensive
care over days or even weeks would have been necessary. The physical therapies outlined above must have been applied at frequent

L. Tilley, M.F. Oxenham / International Journal of Paleopathology 1 (2011) 3542

intervals, suggesting at least one, but probably more, dedicated

carers with the strength to lift, move and manipulate M9 without
compromising his safety.
Even without an acute health condition as stimulus, M9 must
have received daily physical manipulation because this was the
main risk mitigation strategy available to his carers. Protecting
M9 against the hazards of immobility must have involved regular repositioning and massage. At a theoretical level, there can be
little doubt that M9 received such prophylactic care and that this
was integral to his extended survival. At an empirical level, and
in relation to two of the most common complications of prolonged
immobility (pressure sores and bone fracture), absence of evidence
in the skeleton becomes possible evidence for receipt of care in its
own right.
2.2.3.1. Absence of evidence: pressure sores and bone fracture.
Changes in skin elasticity, vascular function and muscle tone resulting from prolonged immobility render the skin vulnerable to both
pressure and shearing forces, and facilitate pressure sore (ulcer)
formation. When the skins surface is ruptured the risk of wound
infection is high; once established infection is difcult to control,
and unless contained will cause extensive deep tissue damage, may
become systemic, may spread to bone, and may prove fatal. Pressure sores need early attention to achieve uncomplicated healing
(AHCPR, 1992; Margolis et al., 2003; Olsen and Edmonds, 1967;
Stillman, 2008).
To avoid sores the resting surface of an immobile individual
must be soft but supportive, and the person must be regularly
repositioned to relieve areas of pressure (AHCPR, 1992; Olsen
and Edmonds, 1967; Stillman, 2008). Monitoring skin condition
is essential; damp conditions increase vulnerability to lesions, but
cracked, dry skin creates entry points for infection, and requires
lubrication (AHCPR, 1992; Olsen and Edmonds, 1967; Stillman,
2008). In modern, sophisticated, clinical contexts the lifetime risk of
immobile individuals experiencing pressure sores is approximately
85% (Stillman, 2008, p. 1), and pressure sores are acknowledged
as an ever-present problem for this population (AHCPR, 1992;
Margolis et al., 2003; Olsen and Edmonds, 1967; Stillman, 2008).
Had M9 suffered untreated pressure sores these lesions would
almost certainly have led to long-term systemic infection, which,
had M9 survived, would likely have been expressed in bone. The
absence of evidence for infection from pressure sores (or from any
other cause) in the recovered skeletal elements, combined with
length of M9s survival with paralysis, suggests a minimum level of
care comprising regular inspection and cleansing of skin surfaces,
provision of cushioning materials, and routine physical manipulation.
It is unlikely that M9 was able to avoid the initial stages
of pressure sore development, given their ubiquity in situations
of prolonged immobility (AHCPR, 1992; Stillman, 2008). Treatment would have required keeping the lesion clean, with possible
debridement of necrotic tissue to promote healing. This management of early stage pressure sores would have been within
the technological capability of the Man Bac community, and it is
possible that the sites marine proximity encouraged the use of seaweed dressings or saline washes, effective antiseptics used in some
therapies today (Stillman, 2008). Treatment would have required
sophisticated and dedicated effort, however, and again reects the
high level of commitment to M9s survival.
Absence of evidence of antemortem bone fracture in M9s
remains, despite their gracility, also reects the quality of care provided. Immobility over a lengthy period results in osteoporosis; lack
of weight-bearing exercise leads to depletion of bone calcium and
demineralisation and bones lose density, becoming brittle and subject to fracture under minor stress (Bergman et al., 1997; McKinley
et al., 2002; Olsen and Edmonds, 1967), with such fractures occur-

39

ring most commonly in the femur, spine and wrist (Dittmer and
Teasell, 1993). M9s preserved lower and upper limbs display no
sign of antemortem damage, despite extreme atrophy rendering
them potentially vulnerable.

3. Discussion
The case of M9 is perhaps the earliest and the most extreme
prehistoric experience of long-term survival with total disability.
Only one other instance of survival with such extensive paralysis
is known; that of an individual from Hokkaido, dating to around,
3500 years BP (Suzuki et al., 1984). The predicted outcome of a
condition with such a severe functional impact and such a wide
range of potential health complications would have been rapid
death, long before the pathology had a chance to register in the
skeleton. There can be no question that M9s survival was due
to the care he received, and this enables certain observations to
be made about Man Bac as a community and about M9 as a person.
Because the size and composition of the Man Bac community
is not known, it is impossible to tell whether carers came exclusively from M9s family; whether carers were drawn from non-kin
community members; or whether there existed dedicated healers for particular aspects of treatment. It is possible to extrapolate,
however, that the act of caring for M9 received general community
endorsement. At some stage following paralysis onset the extent of
functional impact, combined with failure to improve, would have
made it clear that M9 was not going to recover independence;
that his health would probably deteriorate further; that he would
never be capable of making a substantive material contribution to
the community (whatever other contribution he was capable of);
and that he would require continuing and labour intensive support for the rest of his life. In practical terms, the costs to a small
community of supporting M9 involved not only the provision of
resources necessary for his survival, but also compensation for the
labour foregone of those involved in meeting care requirements.
The Man Bac environment was relatively resource rich a situation facilitating the full time support of a dependent individual and
compensating for community members taken out of mainstream
activity to provide dedicated care. Nevertheless, in a small subsistence community it is usual for all members to participate in the
economy as soon as they are old enough to do so (Oxenham et al.,
2008a). In the case of M9, it is fair to assume that the adoption and
maintenance of support behaviours, resulting in reduced productive capacity for the community over a period of years, would have
required consent and cooperation from the group as a whole.
Consideration of the support likely received by M9 provides
clues about behaviours in Man Bac for which there is no material evidence as yet. For example, essential tasks of bathing and
drying M9, as well as the need for covering in colder months, suggest textile production. Lack of antemortem injury to M9 suggests a
sedentary community lifestyle. Meeting M9s dietary requirements
suggests a broad knowledge and range of food resources, food
processing skills capable of overcoming constraints on appetite
and digestion, and the ability to take the time needed for special
food preparation. Furthermore, while prior experience of such an
extreme condition as M9s is unlikely, the effectiveness of the care
enabling his long term survival suggests a community experienced
in looking after people incapacitated by disease or injury. The elevated level of general health stressors in Man Bac (Oxenham et al.,
2008b), as well as ethnographic research into disease frequencies
and healthcare practices among hunter-gatherer and horticulturalist societies in South America, Africa and Papua New Guinea (e.g.
Frankel, 1986; Kaplan et al., 2000; Lewis, 1975; Sugiyama, 2004),
indirectly support this observation.

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In summary, the effective and long-term response to M9s

condition argues for a socially stable and cohesive community
experienced in nursing the sick; capable of assessing the likely
demands and costs of care-giving in relation to a serious and permanent pathology; able to develop a set of procedures for responding
to this situation successfully; and willing and able to maintain these
procedures over years. The Man Bac community made an informed
commitment to the extended care of one of its members, probably
one reviewed and re-committed to in response to changes in and
the inevitable decline of M9s health status.
3.1. Caring for M9: cultural values in practice
Motivations for any substantive human behaviour are multifaceted, ambiguous, often contradictory and, at a distance of around
4000 years, impossible to unravel completely. We can never know
exactly how the Man Bac society understood illness and how this
may have affected the decision to care for M9, but while acknowledging the warnings of authors such as Dettwyler (1991) on the
dangers of retrospective attribution of motive (particularly that of
compassion) in the bioarchaeological context, it may still be possible to gain partial insight into the value placed by this community
on caring for others in need. For example, the considerable effort
put into keeping M9 alive suggests that the people of Man Bac were
not fatalist in their views of disease and its origins.
Man Bac mortuary practice indicates that, in death at least, the
community made little distinction between individuals on the basis
of age, sex or other visible characteristics (Oxenham et al., 2008a).
However, individuals who are perceived as different by their community in life are frequently distinguished by different treatment
in death (Fay, 2009; Shay, 1985). Although M9 was buried with
his contemporaries in the Man Bac cemetery, there were dispositional anomalies in his burial. His atypical position and orientation
may have been an outcome of limitations imposed by his physical
condition; specically, difculty in breaking ankylosis and exure.
Conversely, it is possible that this mortuary positioning was a mark
of M9s difference, and had meaning in relation to either his position in the community or his passage into the afterlife. Whatever
the reason for differences in mortuary treatment, there is no indication of careless handling and every sign of respect for someone
who was unique in his physical disability.
M9s survival may reect a high value placed on individual life
within the Man Bac community. While the culturally-mediated
nature of psychological health is acknowledged (Lillard, 1998;
Scheper-Hughes and Lock, 2006), it is worth speculating on M9s
experience in the context of modern clinical observations. Psychological depression, associated with loss of self esteem, social
isolation and social rejection, is a signicant comorbidity of paralysis resulting from spinal cord injury (Bockian et al., 2002; Boekamp
et al., 1996; Kennedy and Rogers, 2000; Krause et al., 1997;
Olsen, 1967). Direct (suicide) and indirect (e.g. failure to cooperate
with treatment) self-destructive behaviours are a leading cause of
mortality among this population, with perceived quality of life positively correlated with length of survival following disability onset
(Krause et al., 1997). Additionally, psychological depression, mediated via physiological stress systems, is associated with a variety
of adverse impacts on physical health status, including reduction
in general immune system function (OLeary, 1990; Weisse, 1992;
Zorrilla et al., 2001); increased risk of cardiovascular disease and
congestive heart failure (Jagoda et al., 2003; Sherwood et al., 2007);
and increased incidence of respiratory tract pathologies (OLeary,
1990).
It is impossible to make a direct comparison between modern
and prehistoric experience at a behavioural level, but it is reasonable to assume that physiological responses to stress were the same
then as now. In a situation in which amenities were basic, had M9

suffered from clinical depression there is little doubt that he would

have quickly succumbed to health challenges in his environment.
It seems reasonable to conclude, therefore, that to have survived
with his disabilities for more than 10 years M9 must have received
extensive psychosocial as well as physical support. Modern experience (Bockian et al., 2002; Krause et al., 1997) suggests that at a
non-culturally specic level this must have included the creation of
a secure, emotionally-supportive, inclusive environment in which
care was provided ungrudgingly, enabling M9 to grow to adulthood,
to develop a role for himself within the group, to retain a sense of
self respect, and to interact with others in his community at whatever level was possible. In view of the prolonged and particularly
demanding nature of the care provided, it seems justiable to speculate that the carers motivations included compassion, respect and
affection.
3.2. M9 the individual
The past 15 years has seen growing interest in attempts to infer
the individual from archaeological evidence of material culture
(Meskell, 2000; Thomas, 2002). In most cases this focus has resulted
in the production of a stereotype or cipher identied as the actor.
It has rarely revealed any hint of a once-living human being.
Osteological evidence can enrich approaches to understanding
the individual within their archaeological context, although this
potential is rarely exploited in practice (Sofaer, 2006). Considerable
information can be extracted from skeletal remains, including sex
(implications for gendered behaviour); age at death (implications
for rites of passage); general physical demands of corresponding
lifeways; and place of origin, travel undertaken, and diet (Oxenham
and Tayles, 2006; Robb, 2002; Sofaer, 2006).
Palaeopathological analysis contributes an intensely personal
perspective there is little that has more immediacy than experiencing a pathology severe enough to leave markers on bone. Where
aspects of individual response to pathology can be inferred, this
may provide clues to personality.
For a minimum of the last 10 years of his life M9 would have been
unable to take on the normal role of those in his cohort. He could
only watch on as his peers participated in the activities of late childhood/early adolescence in Man Bac. He experienced the hormonal
changes of adolescence as a severely disabled individual (although
the impact of these may have been mitigated by immobility-related
changes in metabolic function [Olsen and Wade, 1967]). M9s peers
moved through adolescence to adulthood, being admitted into
the roles and responsibilities associated with achieving different
age-related stages in life (Robb, 2002), while he remained without prospect of attaining normal development. Although M9 may
have contributed to his group in many ways for example, the
very success of M9s continued survival may have been a source of
strengthened community identity and cohesion none of these is
archaeologically accessible. All that can be concluded with certainty
is that M9 was reliant on others for every aspect of his physical and
social existence.
M9s prolonged survival with disability suggests an extraordinarily strong will to live; a robust psychological adaptation; a self
esteem capable of overcoming the complete loss of independence;
and a personality capable of inspiring others to maintain high quality and costly care over time.
4. Conclusion
The bioarchaeology of care approach uses evidence of caregiving to explore details of past behaviour that may be impossible
to retrieve through other means. It does this by providing a focus
and a framework for synthesising information from archaeological,

L. Tilley, M.F. Oxenham / International Journal of Paleopathology 1 (2011) 3542

anthropological, palaeopathological and modern clinical sources.

The methodology is based on individual case studies. As the number
of case studies increase these will undoubtedly contribute signicantly to the broader theoretical debate on the origins of care, but
at present generalisation from one situation of caring for a disabled individual to another such situation should be undertaken
with extreme caution. Although there may be points of similarity,
each case of care-giving is unique. The example of M9 illustrates
the methodologys potential for achieving a more detailed and more
nuanced understanding of aspects of contemporary prehistoric cultural practice and social relations in a specic small community, and
in this instance consideration of M9s experience of pathology over
time also allows speculation on aspects of personality, allowing a
glimpse, if only partial, of a real person.
By denition, the bioarchaeology of care approach is restricted
to instances in which care-giving can be inferred. Although in the
example of M9 the level of disability involved was extreme, the
methodology employed in this study can be used in less dramatic
cases of pathology where the evidence suggests that the individual affected required assistance from others over a period of time.
Even when it is only possible to use this approach in a limited
way, the perspective it offers should enrich more general analyses. The analytical framework is still undergoing development, but
as demonstrated in this paper it promises to be a valuable heuristic
tool.
Acknowledgements
We thank the Institute of Archaeology, Hanoi, Vietnam, and
Hirofumi Matsumura of the Sapporo Medical School, Hokkaido,
Japan, for their cooperation in the excavation of MB07H1M09. Part
of this research was funded under an Australian Research Council
Discovery Grant.
Appendix A. Supplementary data
Supplementary data associated with this article can be found, in
the online version, at doi:10.1016/j.ijpp.2011.02.003.
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