Background The Pathology of Anemia Anemia can be present in the body as a result of a genetic inheritance, as in the case of sickle cell anemia, or by acquiring it, for example, by having an iron-deficient diet. In the past it was always assumed that acquired anemia could only be evident during life, but in the last thirty-five years it has become known that, in moderate to severe cases, it can still be seen post mortem in bone changes which most often manifest in the skull (Stuart-Macadam 1992: Anemia Among Past Maya 154). In young children acquired anemia is Populations: When Will We Have the usually apparent with varying degrees of severity. As such, the bony changes that are Answer? evident in skeletons are most often (unless they are children) evidence of survival of anemia and therefore, shed light on the overall health during growth and development. Welcker (1885, 1888) Today it has been estimated that as quoted in Stuart-Macadam, was the first to approximately 2.15 billion people worldwide are notice cribra orbitalia, a form of porous lesions iron deficient, and almost 1.20 billion people within the inner orbits of the eye (Figure I) suffer from various severities of iron-deficiency although it was not until 1961, that it was anemia (Wright & Chew 1999: 925). Anemia actually linked to diet deficiencies, specifically has also been a serious problem for several anemia (Stuart-Macadam 1992: 153). In the populations in the past, including those of the skeletons of young children, the initial reaction ancient . Although we cannot to severe anemia was the pitting around the know for sure the actual prevalence of the orbits, although evidence of this in older disease among the ancient populations, with the individuals by itself suggests a more moderate available skeletal analysis from the form of anemia (Wright & White 1996: 157). osteoarchaeological record we can at least infer Williams (1929), as quoted in Stuart-Mnacadam, that it was a health problem for the Maya, as it is was the first to connect iron deficiency anemia for the world's populations of today. The Maya with porotic hyperostosis, the bony evidence civilization flourished from approximately 900 found in the cranium. In older children who are BC to AD 900 with populations occupying areas still dealing with anemia, the external table of the including , , and cranial vault becomes pitted in appearance, and . There have been many studies devoted often thicker, which heals and remodels during to the rise and fall of the Maya, and almost every maturation and adulthood. The bones of the other aspect of their daily lives. However, skull, including the parietals and the occipital studies on the prevalence of various diseases bone take on a spongy, porous look, as evident in among the Maya have not been researched as Figure 2. Both forms of iron-deficiency anemia much as their importance would warrant and, are generally described first as lesions at various beyond this, the various causes or reasons for the points of development of the infection, from prevalence of so many health related ailments active, to healed and remodeled, depending on have not been adequately researched. With the the condition of the individual. Among the exception of diseases that the Spanish mayor ancient Maya there is also a wide range of may not have inadvertently transmitted, such as skeletal evidence of both types of lesions as well small pox and syphilis, discussion of ailments as various stages of bone remodeling. These will that were not immediately life threatening, or be described in more detail in the proceeding infectious were generally ignored. This paper sections of this paper. will examine the various models that attempt to The Osteological Paradox explain the high prevalence of iron deficiency At this point it is necessary to briefly anemia among the ancient Maya civilization, as review the Osteological Paradox. Suggested by well as possible faults inherent in each. Wood et. al. (1992), the paradox brought to light the inherent problems in inferring past health from skeletal samples of the archaeological

TtJ n;\l ',-pl1 j 2!JfN-·.?tj(J~ c;)p...·l~.!:hr~': 2iiOST()'lL\1: Tht. 1"\V() }mnu! nf .\nrhrGpf;!'),:';Y record. For instance, it has in the past, and to a infection and stress (Wright & White 1996). certain extent today, been believed that there Hammond (1982), also suggested that during should be a common correlation between the Post-Classic times there was a decrease in disease we see in burials and the actual nutritional standards, and according to burials an prevalence of that disease in past populations. "increased susceptibility to endemic diseases Unfortunately this conclusion does not take into which may have become epidemic"(Wright & account selective mortality and hidden White 1996: 154). By these accounts the Maya heterogeneity. Selective i!lortality, as described appeared to be unhealthy, whether due to by Wood et. al. (1992), means that the samples anemia, environmental factors, or infectious of the population that have been unearthed are disease. Anemia however comes up over and just that, a sample, and as such would not over as a serious problem for the ancient Maya. indicate all of the people that were at risk for the In several sites, including Cuello, , disease, or even all of those who suffered from it, and Tancah the majority of the burials but rather just those who died, and only at their containing evidence of anemia were seen in individual age. This means that when children. This suggests that children were dying researching burials one can only infer health as a result of very severe anemia, as evidenced in from those that are present Thus we cannot, to many of their burials (Figure 4). The numbers any great degree, deduce what the health of the for these sites, and others discussed below, are rest of the population would have been. Hidden summarized in Figure 5. Below are two models heterogeneity, another aspect of the osteological that attempt to account for the prevalence of paradox, insists that the populations of the past anemia among the ancient to historical period were made up of "an unknown mixture of people Maya. with varying amounts" of susceptibility to disease, and as such the skeletal remains that we Maize-Dependent Model see are simply those with a vulnerability to This model, as suggested by its title anemia (Wood et. al 1992: 334). This revolves around the hypothesis that the Maya vulnerability could be due to genetics, socio- were so dependent on maize, and it composed so economic factors or even the time period in much of their diet, that it led to health problems, which they lived. Overall the paradox should be specifically anemia. Williams quoted in EI- taken as a cautionary note for all those Najjar, first proposed this in 1929 as the Dietary attempting to infer population health from the Model, but it was not until 1976 when EI-Najjar archaeological record. This study by Wood et. reevaluated the idea that it came to specifically al. has been cited frequently since its publication, deal with maize. They both found that there was and as such it is a truly groundbreaking theory a link between anemia and a diet comprised of that all archaeologists must take into staples low in iron or substances that interfered consideration. It is therefore worth noting that with iron absorption, such as millet (Holland & any population generalizations contained within O'Brien 1997: 184). Maize, a well-known staple this paper are solely due to the original author, of the ancient Maya, as well as the Maya of although every attempt has been made to exclude today, was found to be low in iron, with the these conclusions unless used for the purpose of added detriment of having the chelating effect of analogy. the phytic acid (ibid.). This meant that a lot of The two models discussed below for the the iron that was present in the maize was potential causes of anemia among the ancient nutritionally unusable. In fact, less then seven and historic Maya are both accepted hypotheses percent of the iron in maize is readily available within the archaeological community. Several to be absorbed. Several areas throughout the ancient and historic sites are discussed below, Maya realm have been characterized as having and Figure 3 illustrates their locations throughout medium to high instances of anemia, caused by a the Maya realm. maize dependent diet. Hooton (1940) as described in Wright and Chew, was the first to The Ancient and Colonial Period Maya describe these high instances of anemia at the There appears to be a general consensus Cenote of Sacrifice at Chichen Itza, a Post among many Maya specialists that the Classic site. He speculated that since the population, for its duration, were in less then majority of the infected burials were children ideal health. For example Freidel and Schele (78% of child burials), there was a connection (1990) suggested Late Classic Copan was the site with diets that depended mainly on maize of Maya that dealt with malnutrition, sickness, (Wright & Chew, 1999). At the Altar de

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t (lP~Lght 2(1115 i( l·fl·:\.!: '1he L\\( J .!(.urn'lI ()i:-/\r:thn;pol<'g~ Sacrificios during the Classic period, Saul (1973) Stuart-Macadam (1992), the parasItIc model found an extremely high instance of porotic suggests that contrary to the generally held hyperostosis (up to 89% of the adults found) belief, anemia is actually a positive adaptive (Saul 1973: 316). He felt it was so significant response to environmental stress (Holland & that it became the basis for a nutritionally centred O'Brien 1997: 184). In fact, proponents of this argument for an ecological collapse of the Maya model contend that diet actually plays a minor (Wright & White 1996: 158). In Cuello, a Pre role, if any at all, in the disease, and they believe Classic site, there appears to be less incidence of anemia should be seen as a body's defense porotic hyperostosis as compared to other Maya against disease. The parasite (which will be sites including Copan (Saul & Saul 1991: 146). discussed below) would have been more According to Wright and Chew (1999), this common in sedentary populations as opposed to indicates less maize consumption, which is migrants, in which unsanitary conditions would confirmed also by stable carbon isotopic have been prevalent. The shift to agriculture analysis. At , which was also would have contributed to the increase in established by isotopic analysis, there is a greater parasite "quantity" and the chances of a person incidence of anemia among the Post-Classic contracting an ailment (Armelagos et. al. 1991: population then earlier periods, which 16). corresponds to an increase in maize Theoretically, a parasite, such as the consumption. Unfortunately, there is also an tapeworm enters the body and causes massive increase found during the Historic period, for blood loss, and therefore anemia. The which White (1988: 14) has no explanation. hookworm, Ancylostoma duodenale, is known to Wright and Chew also speculated that since the have been present pre-Hispanically in both North majority of porotic hyperostosis incidences were and South America, so it would have been safe to generally less common in the late Prehispanic assume it was present in Mesoamerica (White and Historic period, when maize consumption 1994). Many authors also cite that in Guatemala was lower, higher instances of porotic today parasitic infection has reached 100% in hyperostosis from the Classic period could be some areas (White 1988: 14). In fact White caused by the higher intake of maize. (1994) also believes that Lamanai, being in a Although abundant, these sites do not tropical lagoon environment, was susceptible to tell the whole story. Regrettably there has been a parasites especially those that were insect-borne. lot of debate about the validity of this model. Beyond this, as a result of the variety of One problem, according to Wright and White environmental conditions in which porotic (1996) being that if indeed nutrition was the hyperostosis has been seen, it appears to be more direct cause, there should be a change in the likely that other causes besides diet, such as the abundance of lesions over time. When the parasite may account for the frequency of samples from Altar and were reanalyzed anemia. This hypothesis coincides with the there was no noticeable decrease in the amount variability in the amount of maize prevalent in of lesions, suggesting that diet may not have various diets (Wright & White 1996: 157). The played as large a role as Saul (1973) originally climatic inconsistency may control the thought. Beyond this, at Ixirnche, a Post-Classici distribution of the parasite, considering the Historic site, in which maize consumption was larvae can only survive in temperatures between very high, when measured by isotopic analysis, 70-85°F. Wright and White contend that this porotic hyperostosis had one of the lowest would explain the abundance of evidence of frequencies compared to other sites throughout anemia at lowland sites, and the limitedness in the Maya region (Wright & White 1996: 160). highland sites, such as Ixirnche (1996: 161). Although, as Armelagos et. al. (199 I) pointed Overall it appears few academics are willing to out, porotic hyperostosis does occur more often attribute evidence of porotic hyperostosis with among agriculturalists than among foragers, parasites, and yet the theory is still circulating suggesting that diet does play a key role. within academic circles. Overall it seems clear that there is no consensus There have been several major on how much importance should be placed on criticisms against the parasite model, many of diet. which come from the work of Holland and O'Brien (1997). They state "we believe that Parasitic Model anemia, whether it is caused by maize or First suggested by Hengen in 1971 nematodes, is a sign that something is seriously (Stuart-Macadam 1992), and specialized by wrong" (Holland & O'Brien 1997: 185).

'II JTF \ r "(,1 1., 2!JfI+ ,'.1)' IS C')l"'n~hr <' YOS TOTF\!: Th, 1.'\\;0 .!'lUm:ll d' .\""hropd,;.;'· Therefore, it is difficult to understand how the The Maya of Today presence of anemia could actually be a "good" Today's populations of Maya have been thing. Anemia can take the form of a very studied on several occasions in an attempt to debilitating illness, especially in terms of construct an analogy whereby to compare the weakness and susceptibility to fainting. It is ancient and historic presence of anemia. Wright difficult to understand, with the ideas of natural and Chew have attempted to use this analogy to selection, that this would be "selected for" (as not only explain the presence of anemia, but they nothing actually is), when it would obviously be have also, whether purposefully or not, cast more a drawback for populations that generally based doubt on both the maize-dependent model and their days around some form of physical labour. the parasite model. When looking at the diet of If in some sites prevalence of anemia among the present Maya populations, Roys (1972), noted in burials was 80%, how could daily activities Wright and Chew, that the diets of past and possibly take place? Although just a sample, at present Maya had very little difference (Wright the very least these people were probably unable & Chew 1999: 927). In fact, if any important to work. Also, to almost completely rule out diet difference exists, it is that the Maya of the past as a causing factor appears to be lack of common were actually healthier, having more access to sense, especially when in our modem times it has meat and fish than the present poor peasants of become common knowledge that diet plays such modem Mesoamerica (Robin 2001: 19). This is a major role. Although it is safe to say that diet puzzling for proponents of the dietary model, may not be the sole cause, it is a stretch to say especially considering present incidents of that parasites would be the major foundation. anemia are equal to or less than that of past One problem with naming one attribute with the populations (Wright & Chew 1999: 928). If diet blame is the variety of populations and had indeed decreased in nutritional quality, one environments in which anemia has been would expect to fmd an increase in anemia, and anciently and historically present. For example, yet the results we see today are subjective as a Wright and White stated that the Maya series result of the osteological paradox. Perhaps in have shown pervasiveness of porotic reality, anemia was far more prevalent in past hyperostosis among populations amounting to populations than we are willing to admit, and yet 77% in sub-adults and 65% in adults (1996: 159). we cannot infer beyond the evidence we have. This has been found to correlate with Coastal Evidence has also been suggested that children Californians in which the cause has been were weaned for longer periods of time during attributed to parasitism, and yet also among ancient and historical times: four years compared populations of the Southwestern Pueblo at to only twenty-two months today (ibid.). It is not Canyon de Chelley and Chaco Canyon (where it clear how this correlates with "healthier" is more prevalent) in which the cause has been children. Of course breast milk is today seen as found to be linked directly to maize agriculture better than bottled formula, and yet in terms of (ibid). There appear to be too many questionable iron content, breast milk is actually lower then results to actually solidify the parasite as a the new "iron fortified" brands. Had ancient and predisposition to anemia. If the presence of historic mothers been anemic themselves, their anemia among present populations were to be breast milk would likely have been even more taken into account, it is difficult to see how a deficient. What appears to be evident throughout parasite could cause so many illnesses. the literature is that no single cause has been Specifically, if parasites, most likely due to poor accepted wholeheartedly. More prevalent today sanitary conditions are the cause, how can they is a third model in which a variety of causes have be attributed to so many sufferers living in North been attributed to the prevalence of anemia. America and Europe in which, in general, These include diet, parasites, environment, and conditions are at the very least better than they the presence of "outsiders", whether traders or were during ancient and historic Maya times. later colonists, such as the Spanish. I think, Anemia, although a very common ailment, however, that this is just an easy way out, but appears to have a multitude of causes, but with a does not rule out the probability that there is an general understanding, especially among the alliance of causes. Until more research is done, medical community, that diet can and does playa and perhaps when the medical community and key role. the archaeological community can collaborate, this is what we are left with. I agree that this third model can explain every incidence of anemia among the ancient and historical Maya,

[-()TI.\I \,,1 I'" cll(l-l-?'"') { -! !pynght :L :(1I J:) 'I (I IT:\L The [, \V{) .!(>ufnal or:-;\nrhnipolc 'flY but until it can be solidified as a group cause it Environment: A Journal of Interdisciplinary appears to just be a "band aid" solution, that Studies. 13 (1):9-22. needs to be studied in greater detail. EI-Najjar, M.Y., DJ. Ryan, C.G. Turner II, B. Conclusions Lozzoff 1976. The Etiology of Porotic Anemia has reached pandemic Hyperostosis among the Prehistoric and Historic proportions in our world population, so it would Anasazi Indians of Southwestern United States. seem natural to assume that it has regularly been American Journal of Physical Anthropology. present in past populations. Unfortunately we 44(3):477-487. only have a limited number of skeletons from which to learn, and inferring beyond that sample Holland, Thomas D., Michael 1. O'Brien 1997. has its own inherent problems. From the Parasites, Porotic Hyperostosis, and the available sample however, anemia was an Implications of Changing Perspectives. important ailment and as such it is important to American Antiquity. 62 (2): 183-193. understand the causes. The maize-dependent model and the parasitic model have both been Robin, Cynthia 2001. Peopling the Past: New presented in the literature over the past quarter Perspectives on the Ancient Maya. Proceedings century and yet there is still no clear consensus. of the National Academy of Sciences of the The new "third model" has tried to solidify the United States of America. 98 (1): 18-21. previous ideas by simply incorporating them in order to explain the vast majority of incidences, Saul, Frank P. 1973. "Disease in the Maya area: and yet maybe that should not be the goal. Just The Pre-Columbian Evidence." In The Classic as every other pathology does not always Maya Collapse. pp.30 1-324. Albuquerque: manifest itself in the same manner, perhaps University of New Mexico Press. anemia simply has different causes related to genetics, socio-economic standing and the Saul, Frank P., Julie Mather Saul 1991 "The environment. Therefore, perhaps we should not PreClassic Population of Cuello." In Cuello: An try to create one causation but rather population Early Maya Community in Belize. pp. 134- or environmentally specific theories (as opposed I58.Cambridge: Cambridge University Press. to one all encompassing hypothesis) that would explain the varying degrees of the illness. Just as Stuart-Macadam, Patricia 1992. "Anemia in Past stature and age need to be looked at with Human Populations" In Diet, demography, and population specific models, specific Disease: Changing Perspectives on Anemia. pp. manifestations of anemia should also become 151-170. New York: Aldine De Gruyter. specific to populations throughout the world. Until more research is done, and perhaps more White, Christine D. 1988. The Ancient Maya work is conducted on analogy, we will have to from Lamanai, Belize: Diet and Health over rely on the questionable models that exist today. 2,000 years. Canadian Review of Physical In my opinion it would appear that diet should Anthropology. 6 (2): 1-21. still form the basis of any model, especially considering that the addition of iron, either as White, Christine D., Lori E. Wright, David M. supplements or extra foods, can have such a Pendergast 1994. "Biological Disruption in the reversal effect on the disease. Early Colonial Period at Lamanai." In In the Wake of Contact: Biological Responses to Conquest. pp. 135-145. New York, Wiley-Liss, Inc.

Wood, James W., George R. Milner, Henry C. Harpending, Kenneth M. Weiss 1992. The Osteological Paradox: Problems of Inferring Prehistoric Health from Skeletal Samples. Armelagos, George J., Alan H. Goodman, Current Anthropology. 33 (4):343-370. Kenneth H. Jacobs 1991. The Origins of Agriculture: Population Growth During a Period Wright, Lori E., Francisco Chew 1999. Porotic of Declining Health. Population and Hyperostosis and Paleoepidemiology: A Forensic Perspective on anemia among the

'1'1 JTF,\f ",,11 J 2l)(H-.'\iil~ C:''f'''r;f.:hi: :<,' .>'OOS'rern: \1: I.li<.('\'CO .I·lUlTul of \mhropui· 'g" Ancient Maya. American Anthropologist. 100 (4):924-939.

Wright, Lori E., Christine D. White 1996. Human Biology in the Classic Maya Collapse: Evidence from Paleopathology and Paleodiet. Journal of World Prehistory. 10 (2):147-198.