The embodied poor: health, care, and survival in early modern Dutch institutions

Introduction

The Low Countries, what is today The Netherlands and Belgium, have a long history of various forms of social support, including religious institutions, guild-based welfare, and later physicians and hospitals (Coomans, 2021). These systems were initiated relatively early (prior to 1,000 CE) to provide for those in need (Fierst van Wijnandsbergen, 2013; van Bavel and Rijpma, 2016; Ziegler, 2018). In fact, the Dutch Republic was known for its relatively organized, albeit decentralized, and well-funded local social support compared to other European countries at the time (van Nederveen Meerkerk and Teeuwen, 2014). We have referenced such support in passing in previous bioarchaeological publications, as a potential explanation for our findings (e.g., Casna and Schrader, 2022); however, we have yet to specifically investigate this within the context of the early modern Netherlands. We question: what kind of medical care did people have access to? Was this reserved for the rich? To what extent did the poor also have access to medical care? Did people living in rural communities have access to social support? When would people go to see a specialist or medical care provider? The answers to these questions could greatly impact an individual's disease and nutritional status, as well as chances of survival. The topic of medical care and social support in early modern Western Europe has been well-studied historically (see Coomans, 2018, 2021; Coomans and Marschall, 2024; Grell and Cunningham, 2002; Lindemann, 2010; Ziegler, 2018); however, this has yet to be more thoroughly integrated with bioarchaeological data.

This study reviews the types of social support that were available during the early modern period (defined here as 1600–1850 CE). Even though social support systems began earlier, the focus of this paper is on the early modern period because written documentation of care becomes much more common than in the preceding medieval period. Four sites are examined—Zwolle, Eindhoven, Arnhem, and Middenbeemster (Figure 1)—with particular attention to the availability of social support, insofar as it can be assessed, across axes of urban vs. rural context, socioeconomic status, and sex. Historical data are integrated with bioarchaeological evidence through analyses of age-at-death estimations (transition analysis), pathological conditions that were deemed to be potentially life-threatening (e.g., osteomyelitis, mastoiditis, compound fractures), and direct evidence of medical intervention (e.g., leg brace). It is hypothesized that communities with greater social support experienced longer lifespans and exhibited fewer indicators of potentially fatal conditions than comparable communities with more limited social support. All analyses were conducted using non-destructive methods and followed established ethical guidelines for the respectful study of human remains.

Many variables contribute to survivorship, and skeletal data are inherently biased (as discussed further in the limitations section below); however, examining bioarchaeological data at the population level helps offset some of these risks. By firmly embedding skeletal data within a rich historical context, this analysis bridges the gap between historical accounts of social support and embodied skeletal remains. This approach has the potential to identify discrepancies between intended forms of support and actual access to that support.

Background on social support in the Netherlands

It was during the Dutch early modern period that the first modern economy emerged (de Vries and van der Woude, 1997); this was a time of capitalist pursuits and the expansion of wealthy companies, such as the Dutch East India Company. However, this was also a time of robust social support, poor relief, and care (de Vries and van der Woude, 1997). Through the 17^th-19^th centuries there is a dramatic increase in the amount spent on formal social support (up to 3.3% GDP), which aided up to 9% of the entire population (van Bavel and Rijpma, 2016). This was markedly higher than other contemporary western European countries. However, this societal investment was not equal amongst the entirety of the Low Countries; social spending was highest in the western provinces, namely South Holland and North Holland (van Bavel and Rijpma, 2016). During this period, social support was primarily available through local charity and institutional support, such as church-based charity, guild support, municipal poor relief, workhouses, almshouses, and private philanthropy.

Church-based social support

Religious institutions, both Calvinist (Dutch reformed) and Catholic, offered various forms of poor relief during the early modern period (Voss and van Leeuwen, 2012). As early as 1,000 CE, monasteries, abbeys, and parish churches would offer support to the poor including giving alms (e.g., food, money, clothing, coal). Until the Reformation (mid-1500s), Catholic institutions, including parishes, monasteries, and confraternities (broederschappen), provided social support in the form of alms, food distribution, and caring for the sick and elderly (Fierst van Wijnandsbergen, 2013; Goudriaan, 1996; Janssen, 2009). After the Protestant Reformation, particularly in the northern provinces, the Reformed Church and municipal governments became more predominant.

One such example of Protestant support after the Reformation, was the formation of Deacon's Boards (diaconieën; Spaans, 2002). Deacons, operating at the parish level, were appointed by the church council and were funded through church collections, endowments, and other church income. In addition to other church and communal duties, they provided food, clothing, firewood/coal, medical care, burial costs, and housing in almshouses (diaconienhuisjes).

It is important to note that social support from religious institutions was often conditional. Religious support was frequently limited to their own religion and congregation. Eligibility of social welfare was often restricted to local residents to ensure community improvement, but equally, to bar emigrants and interlopers (Coomans, 2021). There was a moral judgement associated with social welfare. The so-called “deserving poor” including widows, orphans, the sick, and the aged, were viewed with more compassion and support was considered to be justified. However, the “undeserving poor” including, beggars, the drunk, and the criminalized, were considered inferior and rarely received support (Jütte, 1994; van der Heijden, 2011).

Guild and private support

Craft guilds (gilde), which were associations of artisans and tradespeople, often supported members during illness, disability, or death. Guilds became prominent in the medieval period (13^th-16^th century) but continued in the Netherlands until the late 18^th century (Goudriaan, 1996). This would include sick pay (ziekenkas) and medical care when their members were in need. Some larger guilds had arrangements for local doctors or hospitals to reduce or cover medical care expenses for members. Additionally, the guilds would support widows and orphans, provide funeral assistance, and offer other charitable contributions (e.g., communal meals, relief events for the poor). Apart from the latter, most of the social support provided by the guilds were limited to guild members and their families (Palmen, 1996).

As in many areas of Europe at the time, wealthy citizens, families, and merchants funded charitable foundations, orphanages, schools, and almshouses both as a form of civic duty, but also religious piety. These were excellent sources of social support, however, were very situational. Historical data presented by van Nederveen Meerkerk and Teeuwen suggests that, even though there was no uniform legislation during this time, donations by Dutch citizens were stable, even during periods of crisis and declining wages (van Nederveen Meerkerk and Teeuwen, 2014).

Civic poor relief and institutionalization

Beginning in the 17^th century, the municipality became central to the organization of social support, particularly in urban areas. Civic poor relief boards (armenbesturen) were formed and served a similar function to Deacons' Boards; however, they were secular (Dewilde, 2013). Poor boards emerged after the Reformation and essentially filled the social support gap left when Catholic institutions were dissolved. They operated under the supervision of municipal governments in more prominent and larger towns and cities, where population diversity made church-based support insufficient. They were responsible for operating poorhouses, workhouses, and orphanages as well as being involved in crisis relief in times of famine, epidemic, or war. Despite poor boards being secular, they maintained a protestant ethos; they emphasized work discipline and moral reform (Teeuwen, 2015).

Correctional institutions (tuchthuizen) were viewed as disciplinary institutions for people who were deemed idle, criminal, or deviant (Spaans, 2002). Residents were often stigmatized, had few rights, and were thought to be reformable through practices intended to instill a strong work ethic and moral behavior. Workhouses (werkhuizen) provided shelter in exchange for low or unpaid labor (e.g., textile work, woodworking; van Leeuwen, 1996). They were less punitive than correctional institutions, however, there remained a moralizing sentiment. Workhouses were designed to discourage dependency and encourage good work habits. Poorhouses (armhuizen) were available for those who were deemed “deserving” (e.g., elderly, sick, widows, people with no income). They offered basic shelter, food, and sometimes clothing (Buursma, 2009). Lastly, almshouses (hofjes) were specifically built to provide shelter for and generally support single women and the elderly (Spaans, 2002, 2003; van Leeuwen et al., 2014; Dekker and Carlson, 1998; Green, 2024; Ritchey, 2021). There was also a dramatic increase in elderly care institutions, such as hofjes, that opened during this time (Boele and de Moor, 2018).

The earliest hospitals in the Netherlands (gasthuizen), were established to care for the poor, sick, eldery, unwed mothers, and travelers, which differs from our modern concept of hospital (Ziegler, 2018). It wasn't until the 19^th century that more formalized medical institutions became available, and this was often limited to urban areas. The healthcare industry grew between 1650 and 1800; however, there was marked variation across the country and among certain specialists (e.g., apothecaries; Deneweth and Wallis, 2016). Midwifery was also institutionalized at this time, with midwives being formally hired by town and city governments, poor relief boards, and hospitals (Van Lieburg and Marland, 1989; Strocchia, 2014; Teijlingen, 2004).

While there were multiple sources of social support in the Low Countries during the early modern period, the question remains—how accessible and impactful were they? Bioarchaeological data are used to assess whether these forms of care impacted longevity and pathological conditions.

Materials

Early modern Arnhem, Eindhoven, Middenbeemster, and Zwolle were specifically selected because they are contemporary and they vary in urban/rural context, as well as socioeconomic status (Table 1, Figure 1). Furthermore, their social support infrastructure varied (see below), which facilitates a comparison between support strategies and embodied outcomes.

Table 1. Skeletal assemblages examined.

Arnhem

The skeletal assemblage from the courtyard of the Sint-Eusebiuskerk (1650–1829 CE) reflects an urban, low status population (van Laar, 1966; Zielman and Baetsen, 2020). Beginning in the 17^th century, Arnhem experienced massive population growth, as people moved to the city for employment opportunities (e.g., tobacco production, shoemaking, typography; van Laar, 1966). For the most part, these were factory occupations that were low-paying and at risk of occupational accidents (Wintle, 2000). While there were certainly high-status individuals living in Arnhem, our skeletal assemblage likely contains individuals that were of low socioeconomic status given that they were buried on the northern side of the church and in simple wooden coffins with limited to no jewelry or other grave goods (Zielman and Baetsen, 2020).

In terms of social support available for the residents of early modern Arnhem, there were many options including religious and civic institutions. The Diaconie van Arnhem (1583–1791) provided support to those in need (Gelders Archief, 2020); registers of distributions (cedulen van bedeelden) document charity and provide ledgers for money and clothing distributions to the poor (Gelders Archief, 2020). There was also a well-known workhouse (Stadsfabriek Werkhuis, opened in 1782/1783), which specialized in the production of cloth (Arneym, 2022). There was an orphanage located on Bovenbeekstraat (1583–1914), and multiple almshouses, which were funded by private benefactors (Arendsen, 2012; Vredenberg, 1983). Sint Nicolai Broederschap van Arnhem, a local confraternity, which is still in operation today, also provided social support and operated a small guesthouse at the Rijnpoort (Paquay, 2022).

Part of the Sint-Eusebiuskerk's cemetery was excavated in 2017 by RAAP archaeological company. Approximately 350 skeletons were excavated; however, 49 individuals were included due to preservation and chronology constraints (see below for sampling strategy). The cemetery at Sint-Eusebiuskerk was in use from ca. 1200; however, the individuals included here were limited to 1650–1829 to align with the early modern period.

Eindhoven

Located in the southern Netherlands, Eindhoven was a small urban center during the early modern period. Small textile factories and trade drove the economy from the 13^th-18^th centuries, however, this was complicated by repetitive wars (Gemeentearchief Eindhoven, 1975). The church of St. Catharina was founded in 1399 and was one of several churches in Eindhoven (Arts, 2013). Burials associated with St. Catharinakerk likely included middle-high status individuals, including municipal officers, merchants, and business owners.

Eindhoven had several forms of social support available. The Brotherhood of the Holy Spirit (Broederschap van de Heilige Geest) was a confraternity that began in the medieval period and provided care for those in need (Janssen, 2009). St. Catharinakerk itself was a center for relief distribution and maintained support networks for widows, orphans, and the sick. At least one poorhouse was in operation in Eindhoven during this time. De Haspel on the Rechtestraat, was a poor house that was operated by the church's diaconie (1718–1832; Eindhoven Encyclopedie, 2019).

Over 750 skeletons were excavated at St. Catharinakerk between 2005 and 2006 by the municipality. St. Catharinakerk was in use from 1200 to 1850, however, individuals interred between 1650 and 1850 are the focus of this paper. A total of 64 skeletons were analyzed from Eindhoven, based on availability and preservation.

Middenbeemster

Middenbeemster was a small rural, primarily dairy-farming village (Griffioen, 2011). Located in North Holland, Middenbeemster is built upon reclaimed land from the polder expansion of the 17^th century (Aten et al., 2012). The Middenbeemster community was relatively small and daily life was centered upon the one Protestant church in the village, Beemsterkerk. There was likely limited socioeconomic differentiation within this community, given the majority of occupations were dairy-farming based (Palmer et al., 2016). In terms of social support, Middenbeemster had diaconal support via the Beemsterkerk (Waterlands Archief, 2011). Additionally, an orphanage (weeshuis) was built in 1680 located at Rijpwerweg 104 (DiscoverNL, 2025). However, there is no documentation of almshouses, poorhouses, or workhouses. Given the limited scale of the community, relief efforts were likely highly localized and coordinated through the church. The relatively small population and agricultural economy likely fostered a culture of mutual aid and neighborly support.

A portion of the churchyard from the Beemsterkerk was excavated in 2011 by Hollandia Archaeological Company and Leiden University. With the collaboration of the Middenbeemster Historical Society and Leiden University, some burial archival records could be directly associated with specific skeletal remains. These are written documents that recorded basic demographic information (e.g., first name, last name, address, date of birth, date of death, sex). For this publication, sex and age-at-death data are exclusively used. While the burials from the cemetery extend from 1613 to 1866 BC, individuals included here are from 1829 to 1866 CE (Lemmers et al., 2013). Approximately 450 individuals were excavated; however, 132 individuals are included in this study due to the availability of archival data for known sex and age-at-death.

Zwolle

Located in the central Netherlands and connected to the North Sea via the IJssel River, Zwolle has been a strong economic center since the medieval period. Historic sources indicate the Zwolle citizens had the highest income of the Overijssel region and their income was sometimes double that of other contemporary Dutch cities (ten Hove, 2005). The sample included here originates from the Broerenkerk and was excavated between 1987 and 1988 (Aten et al., 1992). Burial records indicate that the individuals buried inside the church walls were of middle to upper socioeconomic status, with occupations such as merchants, municipal officers, and investors. A total of 87 individuals from Zwolle's Broerenkerk were examined here.

The Heilige Geestgasthuis was one of Zwolle's oldest social support institutions founded in 1302 (Zwolle, 2025). It was funded by the city council to provide housing and care for travelers, the sick, and the poor. Het Vrouwenhuis, an almshouse on Melkmarktstraat (founded in 1742), was also accessible (Vrouwenhuis Zwolle, 2025). This almshouse, in particular, was funded by a private donor, Aleida Greve, in her will. However, Zwolle boasted many other almshouses as well (see ten Hove and Zwiers, 2017). Zwolle also had a workhouse, which was completed in 1739/1740 (ten Hove, 1989).

Methods

Sex estimation

Sex was estimated using traditional osteological methods, with the exception of the Middenbeemster sample where archival data was used. Morphological features of the skull (nucal crest, mastoid process, supraorbital margin, glabella prominence, and mental eminence) and os coxae were analyzed (Buikstra and Ubelaker, 1994; Phenice, 1969).

Age-at-death estimation

Only adult individuals (+18 years old) were included in the study. Transition analysis (2.1.044) was used to estimate each of death, except for Middenbeemster individuals where archival data was used. Transition analysis is said to be a more accurate method for estimating adult age at death, particularly for old adults (Boldsen et al., 2002).

Sampling strategy

While the total cemetery size of these samples is oftentimes quite large, this was first limited by chronological scope (early modern period), then by preservation with respect to age and sex-estimation (i.e., individuals whose sex and age could not confidently be estimated were not included), and lastly, at least 50% of the skeleton had to be in excellent to good condition, such that pathological conditions could be examined.

Pathological conditions

The pathological conditions included here were deemed to be serious and potentially life threatening, including infectious diseases, severe osseous infections, dental abscesses, metastatic neoplastic conditions, and severe trauma (Aufderheide and Rodríguez-Martin, 1998; Buikstra, 2019; Ortner, 2003). These were specifically chosen because it is hypothesized that individuals with these conditions were more likely to seek medical attention or care. Equally, these conditions might directly impact survival and the longevity interpretations. Degenerative conditions, for example, were not included as these were likely not life threatening and care was not necessarily required. Traumatic lesions that were relatively minor and would not have required medical expertise or specialized care (e.g., broken rib, toe) were not included. Active vs. healed lesions were differentiated.

Ethical considerations

Throughout this research, ethical considerations for the remains and their archival records were taken very seriously (DeWitte, 2015; Walker, 2008; Zuckerman et al., 2014). All analyses included here are non-destructive. Utmost care was taken while handling human remains. Only necessary archival information was used (age-at-death), and anonymity was respected. All municipalities and local descendants, in as much as is possible, were contacted before conducting this research.

Statistics

A one-way ANOVA was used to examine pathological conditions by archaeological cemetery. The effects of sex (male/female), cemetery (Arnhem, Eindhoven, Middenbeemster, Zwolle), and pathological condition status (present/absent) on survival were assessed using Kaplan-Meier survival analysis (see also Biehler-Gomez et al., 2024; DeWitte, 2014a,b). This non-parametric approach allows for the estimation and comparison of survival probabilities across groups, making it particularly well suited for evaluating differences in longevity within past populations where age-at-death distributions may be incomplete or unevenly represented. Statistical analysis was conducted using SPSS (version 29.0).

Results

Pathological conditions, as defined above, were found in 28% (93/332) of the skeletons analyzed (Table 2). Most of these were active lesions at the time of death (88%, 82/93). Periapical lesions accounted for the largest proportion of pathological conditions, followed by mastoiditis, osteomyelitis, and compound fractures that were not set properly (Table 3). While there are notable similarities in pathological condition prevalence, Middenbeemster males and Arnhem females have particularly high frequencies, while both females and males in Zwolle have low frequencies. A one-way ANOVA suggests there may be meaningful differences in these conditions between sites (F(1, 332) = 3.864, p = 0.050, η² = 0.989).

Table 2. Frequency of severe pathological conditions.

Table 3. Frequencies of pathological conditions examined.

When age-at-death is examined using Kaplan-Meier analysis, there is a significant difference between sites, with the mean survival time of Middenbeemster being markedly higher than Arnhem (Table 4, Figure 2). Males also have a significantly higher chance of living longer than women. Females at Middenbeemster, as well as males at Middenbeemster and Zwolle, have a significantly higher mean survival time than the other sites.

Table 4. Results of Kaplan-Meier survival analysis, showing mean survival times (mean ages-at-death) in years (with 95% confidence intervals).

Interestingly, if the analysis of serious pathological conditions and age-at-death are incorporated, there are no meaningful differences in pathological condition distribution between sex or site (Table 4). According to Figure 3, the presence of pathological conditions provides no advantage during early young adulthood; however, starting at 20 years of age, the presence of a serious pathological condition increases the likelihood of mean survival time. This remains true until 60 years of age, when this association is reversed and the presence of a pathological condition then decreases your chances of survival.

Discussion

These data indicate that there may have been disparities in social support between Arnhem, Eindhoven, Middenbeemster, and Zwolle. There was notable variation between sites, both with the pathological conditions as well as longevity. Additionally, some of this variation appears to be sex specific. These findings underscore the concept of embodiment, whereby social structures, inequalities, and caregiving practices are materially incorporated into the body over the lifecourse (Schrader and Torres-Rouff, 2021). Differential access to social support may have been shaped by rural vs. urban contexts, socioeconomic status, and sex, and appears to have influenced survivorship, the development of pathological conditions, and recovery. Together, these patterns demonstrate how social organization in the early modern Netherlands became biologically embedded, producing unequal health and longevity outcomes observable in the archaeological record.

Middenbeemster stands out as a particularly interesting context, given that these individuals were more likely to have pathological conditions and yet equally likely to live longer. Both Middenbeemster males as well as females had the highest mean survival time of the populations examined here. The prevalence of pathological conditions in males can partially be explained by the inherent risks involved with dairy farming—however, this does not completely explain the differences presented here because trauma frequency is comparable between all sites (Table 2). What was unique about Middenbeemster that could explain these differences?

One of the most notable disparities is the rural context of Middenbeemster. As discussed above, there were marked differences between rural and urban support in the early modern period. It has been documented that many moved from rural areas to urban centers for social support and medical care (van de Pol and Kuijpers, 2005). However, contrary to historic documentation, the data presented here may indicate that the rural support system was more effective than the urban one. Rural care was much more community driven, without support from guilds or institutions, which were present in urban environments. Van Bavel and Rijpma point out that historical analysis of social support during this period typically ignores family and neighbor assistance, as well as direct alms and ad hoc collections, because these are nearly impossible to identify using written records (van Bavel and Rijpma, 2016). It is possible that, given that the Middenbeemster community was relatively small and centered around one church, that the care and support offered was more adept, directed, and tailored to specific needs. It is also interesting that the only instances of direct medical intervention are from Middenbeemster. There is one individual who had the remains of a leg brace and another who had dentures (not included in this sample due to lack of sex and age-at-death data). Comparable archaeological evidence for medical treatments were not found at the other sites examined here.

It has been argued that diarrheal diseases and crowd diseases (e.g., tuberculosis, measles, scarlet fever) would have contributed to high mortality in urban settings (Lewis, 2003). While this is likely true, the bioarchaeological data don't always support this epidemiological perspective. Some bioarchaeological studies have found greater longevity in urban centers (Gamble, 2020), while others have found greater longevity in rural villages (Franklin and Wilson, 2020; Walter and DeWitte, 2017), and some have found no difference between urban/rural counterparts (Betsinger et al., 2020; Redfern et al., 2015). Explanations for these findings appear to extend beyond a basic dualistic rural/urban divide (Betsinger and DeWitte, 2021).

In the results presented here, socioeconomic status may be one possible explanation for variable longevity and pathology in urban environments.

Here we see that Zwolle and Eindhoven have few instances of pathological conditions, yet were moderately long-lived. Zwolle and Eindhoven were both urban communities and the Broerenkerk and St. Catharinakerk cemeteries contain middle-high status individuals. This might suggest that urban care could also be effective. Individuals from Zwolle, had the lowest rates of dental abscesses and trauma. From written records from the Broerenkerk cemetery, it is known that occupations included: second lieutenant, merchant, ship's captain; these are all relatively low risk, which may explain the low trauma rates. Furthermore, it is interesting that Zwolle is the only sample that has no healed pathological conditions—this may indicate that high-status individuals from Zwolle were able to effectively receive care and recover from illnesses, thereby leaving no skeletal traces of previous pathological insults.

Arnhem, a low-status urban population, lies at the other end of the spectrum with, relatively high pathological condition frequency (particularly in women) and a low mean survival time, which, counter to Zwolle and Eindhoven, might suggest that urban social support was not always effective. This may be associated with medical care (i.e., those who could not afford medical or dental care may have died earlier than those who could), but also lack of effectiveness of available social support (e.g., Diaconie van Arnhem, workhouse, almshouses). It is also important to note that the Arnhem sample likely would not have guild benefits; as factory workers, they likely didn't have access to guild membership. Van Steensel has discussed some flaws of urban social support during the early modern period; they suggest that the public, religious, and collective institutions that were providing assistance were doing so with specific target groups in mind—as a result, access to support was frequently discriminatory (Van Steensel, 2013). It's possible that the people buried outside of Sint-Eusebiuskerk fell into this category. The association between socioeconomic status and longevity is also supported by other bioarchaeological research. For example, Amoroso and colleagues found that early life stressors (linear enamel hypoplasia) coupled with low adult socioeconomic status, was strongly associated with early mortality (Amoroso et al., 2014). Using an 18^th-19^th English century sample, Yaussy found increased craniofacial fluctuating assymetery, an indicator of stress during development, as well as increased mortality risk in individuals of low socioeconomic status (Yaussy, 2024a,b).

Amongst all inter-site comparisons, females had a lower mean survival time than their male counterparts. This may be explained by the high birthing mortality rate at the time (Wolleswinkel-van den Bosch et al., 2000). Previous bioarchaeological analysis has found evidence for greater longevity in females than males (Redfern and DeWitte, 2011a,b), while other studies have focused on cultural and social factors over long periods (Biehler-Gomez et al., 2024). Other analysis has found no evidence for sex-based mortality risk (Ham, 2025). These conflicting results likely reflect the multifactorial biosocial context of longevity and biological sex through time.

The pathological data show no relationship with longevity, which may suggest that having a pathological condition does not increase nor decrease frailty, or that the proxies that were used to assess severe medical conditions were flawed. This can be further tested in future studies with additional samples, biomolecular data, as well as a broader range of pathological conditions. We can also interpret the active pathological condition data in light of selected mortality. Active lesions at death may indicate individuals who may have been less able to withstand disease or stress, while healed or healing lesions reflect those who survive and recovered demonstrating a degree of physiological resilience. However, given that the majority of severe pathological conditions were active at the time of death, this may also speak to the truly life-threatening severity of the condition, but also limitations to healthcare during this time period.

The Kaplan-Meier plot (Figure 3) does present interesting context for the interplay between pathological conditions and survivorship. Between the ages of 20–60 individuals with a severe pathological condition were more likely to survive. This is counterintuitive to what would be expected in a pre-antibiotic era. This might suggest that having a pathological condition was a buffer (e.g., physiological resilience, access to care) or, in line with selective mortality, if an individual lived long enough to form an osteological lesion, they were more resilient than their counterparts who immediately died before forming such a lesion (Wood et al., 1992; Marklein and Crews, 2017). At around 60 years old there is an important cross-over where having a pathological condition becomes a distinct disadvantage. Thus, after 60 years of age, you are more likely to die if you have such a pathological condition. This is particularly interesting, given that epidemiologists, geriatricians, and the World Health organization use 60 years of age as a threshold for defining old age due to increased prevalence of chronic diseases and multimorbidity (De Laet and Pols, 2000; Mattiuzzi and Lippi, 2020; Peel, 2011).

The longevity and pathological conditions observed are not intended to be interpreted as solely associated with social support. Numerous factors including, but not limited to, nutrition, stress, environment, occupation, genetics, and climate, also influence age-at-death and disease patterns. However, given the background information on social support discussed above, it is particularly interesting that (1) the only rural site examined here included both men and women that lived the longest and (2) high-status individuals are living longer than low status individuals. Without doubt the pathological and longevity data presented here are intersectional, with multiple factors contributing to an individual's pathological condition status and age-at-death. Within the context of the early modern Dutch period, there was likely a complex multifactorial relationship between socioeconomic status, rural/urban environments, biological sex, and other contributing factors (Mant et al., 2021; DeWitte and Yaussy, 2020; Maass, 2023; Yaussy, 2022).

Limitations

There are limitations to this study, that can be improved upon in future work. The pathological conditions selected here should be viewed as a starting point; it would be interesting to do a broader analysis of pathological conditions, not limiting them to “severe.” After all, severity does not necessarily equate to access or to efficacy of healthcare. The combination of archival and skeletal estimation of age-at-death is potentially problematic. Middenbeemster had the highest mean survival time, yet was the only sample included here that relied upon archival data for age-at-death. This could be coincidence or could suggest inaccuracy in the transition analysis method; a study comparing transition analysis data to the archival data in Middenbeemster is currently underway. Lastly, the effects of demographic non-stationarity, selective mortality, and hidden heterogeneity in risks, could be examined further.

Conclusions

This research has presented new insights into social support, longevity, and health during the Dutch early modern period. Key findings include (1) rural social support may have been more effective than urban support; (2) for urban populations, socioeconomic status played a key role in longevity and likelihood of pathological condition presence, which may be directly related to access to life-saving healthcare systems (3) women did not live as long as men, which is possibly associated with childbirth and/or larger systemic biocultural inequities; and (4) between the ages of 20–60, having a severe pathological condition increased your chances of survival, however, after 60 having a pathological condition decreased your chances of survival. Future research should expand studies of communities in the early modern period; this includes both historical approaches of social support in various communities as well as bioarchaeological investigations of the lived experience. If possible, high, middle, and low status, rural and urban samples should also be integrated into larger studies. Methodological expansion, including biomolecular approaches as well as more pathological conditions may also present nuances to these preliminary findings.

Generative AI statement

The author(s) declared that generative AI was not used in the creation of this manuscript.

Any alternative text (alt text) provided alongside figures in this article has been generated by Frontiers with the support of artificial intelligence and reasonable efforts have been made to ensure accuracy, including review by the authors wherever possible. If you identify any issues, please contact us.

Publisher's note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Footnotes

Edited by: Tracy Betsinger, SUNY Oneonta, United States

Reviewed by: Elena Fiorin, Sapienza University of Rome, Italy

Siân Halcrow, University of Otago, New Zealand