Skeletal Health in Early Egypt MPhil Thesis Sarah Musselwhite

SKELETAL HEALTH IN EARLY EGYPT
The Effects of Cultural Change and Social Status
Sarah Musselwhite
Christs College
This dissertation is submitted for the Degree of Master of
Philosophy
August 2011
University of Cambridge
PREFACE
This dissertation is the result of my own work and includes nothing which is the
outcome of work done in collaboration, except where specifically indicated in the
text.
The dissertation does not exceed the 15,000 word limit stipulated by the Degree
Committee for the Faculty of Archaeology and Anthropology.
Word count: 14,965
ABSTRACT
This study investigates variation in skeletal health among Predynastic and Early
Dynastic Egyptian populations in relation to state formation and social status. Health
has been shown to correlate with political, economic and social change in past
societies, but many studies utilising skeletal data fail to examine its archaeological
context in detail. Here, variation in the frequency and severity of three skeletal stress
markers that reflect population healthcribra orbitalia, porotic hyperostosis and
linear enamel hypoplasiawas measured. 179 individuals were sampled across 6
distinct Predynastic and Early Dynastic populations. The social context of each
population was investigated through examination of original excavation reports. The
results suggest that overall health improved after the initial transition to agriculture
due to dietary diversification, but then declined with increasing urbanisation
because of the negative effects of increasing population density. Investigation of
elites buried in Cemetery T at Nagada and individuals buried around the First
Dynasty royal funerary enclosures at Abydos revealed that high social status did not
always confer good health in early Egypt. The adoption of methods from both
Egyptology and Biological Anthropology has shown great promise in reconstructing
the health of the early Egyptians and relating it to their social context.
TABLE OF CONTENTS
1. INTRODUCTION
1.1.
Research context and questions
1.2.
What determines health?
1.3.
Health and cultural change
1.4.
Health and social status
1.5.
How do you measure skeletal health?
1.5.1. Skeletal stress markers
1.5.2. Linear enamel hypoplasias
1.5.3. Porotic hyperostosis and cribra orbitalia
1.5.4. Childhood health
1.5.5
The osteological paradox
1.6.
Previous studies of skeletal health in Egypt
1.7.
Research aims and contribution
1
1
2
3
3
4
5
6
7
9
10
11
13
2. DATA AND METHODS

2.1.
The skeletal material used
2.1.1. El-Badari
2.1.2. Hierakonpolis
2.1.3. Nagada B
2.1.4. Nagada T
2.1.5. Tarkhan
2.1.6. Abydos
2.2.
Sampling procedure
2.3.
Assigning age and sex
2.3.1. Age
3.1.2. Sex
2.4.
Measuring the skeletal stress markers
2.5.
Data analysis
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15
18
19
21
22
23
24
25
25
25
28
29
29
30
32
3. RESULTS
3.1.
Inter-population differences in stress markers
3.1.1. Cribra orbitalia
3.1.2. Porotic hyperostosis
3.2.
Intra-population variation in stress markers
3.2.1
Sex
3.2.2. Age
3.3.
Association between different stress markers
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33
33
39
44
58
58
59
60
4. DISCUSSION
4.1.
Health and cultural changetemporal trends in the stress markers
4.1.1. The Badarian period
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61
61
4.1.2.
4.1.3.
4.2.
4.2.1.
4.2.2.
4.2.3.
The Nagada I period onwards

The Protodynastic (Nagada III) and Early Dynastic periods
Health and social statusis there a link?
Servants to the First Dynasty kingssubsidiary burials around the
royal funerary enclosures
High status elites and leaders of NagadaCemetery T
Health and gender
62
65
68
68
73
75
5. SUMMARY AND CONCLUSION
76
BIBLIOGRAPHY
APPENDICES (CD)
78
83
ACKNOWLEDGEMENTS
I would like to thank my supervisors Dr Kate Spence and Dr Jay Stock for their advice
throughout the year and for reading drafts of this dissertation. Thanks also goes to
the Directors of the Duckworth Laboratory and Ms. Maggie Bellatti for allowing me
access to the skeletal material.
I would also like to acknowledge Daniel Strange and Lucy Musselwhite for
proofreading and technical assistance.
LIST OF TABLES
Table 1 - Origins of the skeletal material used in this study ....................................... 16
Table 2 - The skeletal sample taken in this study ........................................................ 25
Table 3 - The age distribution of the individuals sampled .......................................... 27
Table 4 - The scoring system used for measuring cribra orbitalia and porotic
hyperostosis ................................................................................................................ 31
Table 5 - Percentages of the highest frequency molar, premolar, canine and incisor
with LEH, by population ............................................................................................... 55
Table 6 - Percentages of the two highest frequency molars with LEH, by
population .................................................................................................................... 56
Table 7 - Average age (years) of LEH formation per individual (averaged across all
LEH bands), by population ........................................................................................... 56
Table 8 - Average age (years) of LEH formation in left maxillary second molar, by
population .................................................................................................................... 57
Table 9 - Average age (years) of LEH formation in right maxillary second premolar,
by population ............................................................................................................... 57
Table 10 - Average age (years) of LEH formation in right maxillary canine, by
population .................................................................................................................... 58
Table 11 - Average age (years) of LEH formation in right maxillary second incisor,
by population ............................................................................................................... 58
LIST OF FIGURES
Figure 1 - Linear enamel hypoplasia bands .................................................................. 7
Figure 2 - Porotic hyperostosis ..................................................................................... 9
Figure 3 - Cribra orbitalia ............................................................................................... 9
Figure 4 - Map showing the locations of the populations sampled ........................... 17
Figure 5 - Timeline of the periods studied .................................................................. 17
Figure 6 - Sexually dimorphic cranial features ........................................................... 29
Figure 7 - Location of the cemento-enamel junction ................................................. 30
Figure 8 - Percentage of individuals with cribra orbitalia severity score 1 or above,
by population ............................................................................................................... 34
Figure 9 - Percentage of individuals with cribra orbitalia severity score 2 or above, by
population .................................................................................................................... 35
Figure 10 - Percentage of individuals with each severity score of cribra orbitalia, by
population .................................................................................................................... 36
Figure 11 - Average severity of cribra orbitalia in each population ............................ 37
Figure 12 - Percentage of individuals with severe cribra orbitalia (scores 3 & 4), by
population .................................................................................................................... 37
by time period .............................................................................................................. 38
Figure 14 - Percentage of individuals with porotic hyperostosis severity score 1 or
above, by population ................................................................................................... 40
above, by population ................................................................................................... 40
Figure 16 - Percentage of individuals with each severity score of porotic
hyperostosis, by population......................................................................................... 41
Figure 17 - Average severity of porotic hyperostosis in each population ................... 42
Figure 18 - Percentage of individuals with severe porotic hyperostosis
(scores 3 & 4) by population ........................................................................................ 42

above, by time period .................................................................................................. 43
Figure 20 - Percentage of individuals with LEH in each population ............................ 45
Figure 21 - Average percentage of scorable teeth with LEH per individual, by
population .................................................................................................................... 45
Figure 22 - Percentage of individuals with LEH, by time period.................................. 46
Figure 23 - Average number of scorable teeth per individual in each population ..... 47
Figure 24 - Average number of scorable teeth in individuals with LEH and without
LEH, by population ....................................................................................................... 48
Figure 25 - Association between number of scorable teeth per individual and
number of teeth with LEH, whole sample ................................................................... 49
Figure 26 - Diagram of tooth types ............................................................................. 50
Figure 27 - Average number of posterior and anterior teeth per individual in each
population .................................................................................................................... 51
Figure 28 - Percentage of each tooth type with LEH, whole sample .......................... 51
Figure 29 - Percentage of individuals with LEH in posterior dentition in each
population .................................................................................................................... 53
Figure 30 - Percentage of individuals with LEH in posterior dentition, by time
period ........................................................................................................................... 53
CHAPTER 1 INTRODUCTION
1.1. Research context and questions
This study uses skeletal data to investigate how health varied among Predynastic
and Early Dynastic Egyptian populations, as the Egyptian state formed and new social
classes emerged. These periods were characterised by profound economic, political
and social changes: agriculture was introduced into the Nile Valley from the Fertile
Crescent and allowed the production of surplus food to support craft specialisation;
foreign trade flourished and allowed exotic raw materials to be imported into Egypt
for the manufacture of elite prestige items; urban centres developed and acted as
important arenas of elite activity and social stratification became more pronounced.
These changes cumulated in the rise of several different proto-states, of which the
most significant were centred on the Upper Egyptian sites of Nagada, Hierakonpolis
and This (Kemp 2006), and ultimately provided the ideological foundations for later
Egyptian kingship. Cultural unification of Egypt was complete by the Nagada II
period, followed soon after by political unification in the Nagada III period (Wilkinson
2000) and the establishment of a new political capital at Memphis. However, little is
known about how all of these processes affected the physical wellbeing of people
and how their relationship with the physical environment changed over time.
Skeletal remains are a particularly important source of information in these early
periods because archaeological evidence is generally poor compared to later
periods. Much of our evidence so far has come from studies of material culture
associated with burials or changing cemetery patterns, but these are limited in what
they can tell us about societal change and are biased towards representation of the
1
deceased in the afterlife. Skeletal health can tell us about the key political, economic
and social factors that shaped peoples lives whilst they were living. Furthermore,
skeletal health can provide insight into whether the changes brought to society by
state formation had the same effects on everyone, regardless of the social group to
which they belonged.
This study will address two key questions. Firstly, did health change over time
from the beginning of the Predynastic Period to the Early Dynastic Period, and if so,
why? What factors were underlying such changes? Secondly, were social status and
health correlated in these early periods? Ultimately, this study will examine the link
between political, economic and social change, and the health of populations.
1.2. What determines health?

Health can reveal many things about a groups physical and social environment:
the diet and level of nutrition obtained from it, disease prevalence, population size
and density, quality of living conditions, sanitation level, access to healthcare
facilities, occupational status and the level of technological development. These
factors rarely influence health singularly, but rather are all interlinked: for example,
infectious diseases will spread more easily and quickly in a high-density settlement
with cramped living conditions and poor sanitation. All of these factors affecting
health can be influenced by changes within the biological environment, such as the
introduction of a new disease or a change in climate. But, changing social, political
and economic factors have the potential to have a bigger impact on health,
especially if the biological environment remains fairly constant (Goodman et al.
1984).
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1.3. Health and cultural change

The cultural changes brought about by the emergence of the Egyptian state
would have provided great potential for health change over time, bringing new
health risks and benefits. The introduction of agriculture brought with it a change in
diet and its nutritional value. It also increased the potential for disease spread
through greater animal-human contact and exposure to Nile floods. A new type of
economy emerged, based on agricultural surplus and foreign trade. The latter might
have allowed the exchange of ideas that may have benefited health, but would also
have increased the likelihood of new diseases being introduced into Egypt to which
no immunity existed. As communities became increasingly sedentary and focused on
key political centres, increases in population density would have increased the
potential for disease spread and unsanitary living conditions. The rise of social
inequality and the uneven distribution of power may have resulted in some groups
of people being deprived of essential resources needed to maintain good health.
One would expect to see temporal change in the general level and type of health
problems people were experiencing.
1.4. Health and social status

The emergence of the state in Egypt was characterised by increasing social
stratification and the growing power of a social elite. In a society which has
substantial status differences between different groups of people, it is proposed that
high status individuals should theoretically have a better level of health than lower
status individuals. This theory is based on the concept of differential access to
resources, in which your social status determines your level of access to food,
3
particularly that with high nutritional content, and other resources which can affect
health such as general environmental quality and healthcare (Keita & Boyce 2006).
The promotion of easy access to such resources among higher status individuals
results in a better biological response to the environment (Cucina & Ican 1997) and
the stresses it causes.
Some studies have revealed a link between high status and good health (Cook
1981). However, there are also studies which have shown no such health distinctions
between high and lower status individuals groups from the same society. Robb et al.
(2001) found no significant association between various skeletal indicators of health
and social status as defined by grave goods from the Italian Iron Age site of
Pontecagnano; Cucina and Iscan (1997) found that disruption in childhood growth
was common among a high status group from the Fort Center site in Florida, US,
dated to A.D.200-800. This variation indicates that the relationship between social
status and health depends very much on the particular social context from which the
studied groups originate and the mechanisms in place within that particular society
to control resource distribution. The present study ensures that the social context of
each skeletal population sampled is investigated in detail so that the relationship
between social status and health can be examined further.
1.5. How do you measure skeletal health?

The health of past populations can be assessed in a variety of different ways. In
Egypt, information about common health problems and medicine can be gained
from medical papyri, items found in burials and artistic representations in tomb
scenes. However, these do not allow us to make detailed comparisons between
4
different groups and are also biased towards the elite view of the world. The analysis
of stable isotope ratios from bone and teeth is very informative of past diet, which
has a strong influence on health, but is not a direct measure of an individuals health.
The analysis of skeletal health provides the most direct way of quantifying health
differences between populations and hence will be used in this study.
1.5.1. Skeletal stress markers

A skeletal stress marker is simply a skeletal response, often visible by eye, to a
physiological stressor, whether that stressor is a strain, trauma, disease or nutritional
disorder. In this study, three skeletal stress markers will be used to quantify the
health of each individual, and subsequently populations: linear enamel hypoplasias
of the teeth, porotic hyperostosis of the cranial vault and cribra orbitalia of the roofs
of the orbits. Specific stress markers were chosen, rather than simply recording all
signs of poor health, so that health was directly comparable between populations.
Although only a handful of diseases or conditions manifest themselves on the
skeleton, the stress markers chosen are three of the most frequently documented
among ancient societies, and are thus the most commonly used markers in the
investigation of skeletal health. These markers were also chosen because they
manifest themselves on the skull; this was very important because only cranial
skeletal material was present for the populations being investigated. Furthermore,
by measuring three skeletal stress markers, and looking for any association between
them, a more complete picture of an individuals health will be gained than if just
one was used in isolation.

Linear enamel hypoplasias (LEH) are a type of defect in the thickness of the tooth
enamel, which appear as horizontal grooves on the enamel surface and are usually
visible with the naked eye (Goodman & Rose 1990) (Figure 1). They form in
childhood as the result of severe physiological disturbance to growth, which in turn
can be the consequence of malnutrition or disease, or most probably an interaction
between the two (Lovell & Whyte 1999; Keita & Boyce 2001); if a child is
malnourished, they are more susceptible to disease, and vice versa. As tooth enamel
does not remodel after its initial formation, any defects due to growth disruptions
will be preserved in adults, and thus linear enamel hypoplasias provide a reliable
index of childhood health (Goodman & Rose 1990). Studies of modern populations
have frequently linked high enamel hypoplasia prevalences to poor living conditions
and low socio-economic status because they promote poor diet and/or high disease
prevalence (Larsen 1997); higher prevalences have in general been found among
individuals from developing countries than those from developed countries
(Goodman & Rose 1991). As linear enamel hypoplasias are not caused by a specific
condition, they are therefore viewed as general indicators of childhood health
(Larsen 1997).
Figure 1 - Linear enamel hypoplasia bands (Adapted from: (Larsen 1998))

Porotic hyperostosis is characterised by the porous appearance of regions of the
surface of the cranial vault (i.e. the bones surrounding the brain), often with notable
bilateral symmetry in its distribution (White & Folkens 2005) (Figure 2). Cribra
orbitalia is the appearance of similar lesions, but confined to the roofs of the orbits
and is also often bilaterally distributed (Stuart-Macadam 1989) (Figure 3). The most
commonly cited view is that both porotic hyperostosis and cribra orbitalia are
caused by iron-deficiency anaemia, a condition which can be caused by dietary
deficiency in iron and/or diseases which lead to the loss of iron, such as some
intestinal parasites (Larsen 1997; Keita & Boyce 2006). Under this theory, the porous
lesions result from the expansion of the tissue between the inner and outer bone
layers of the skull, caused by the bone marrows attempt to increase production of
red blood cells (White & Folkens 2005). Like LEH, they are also thought to develop in
childhood, with the cases present on adult skeletal remains being those which have
not remodelled. Thus they are indicative of childhood health (Stuart-Macadam

1985).
However, it is important to note that some recent studies have challenged these
assumptions. Some have suggested that porotic hyperostosis and cribra orbitalia
may not always have the same underlying cause (Stuart-Macadam 1989). It has also
been suggested that a wider range of metabolic disorders may also be responsible
for the conditions. A recent study by Walker et al. (2009) has suggested that porotic
hyperostosis may be caused by inherited haemolytic anaemia or acquired
megaloblastic anaemia resulting from vitamin B12 and/or folate deficiency, and that
cribra orbitalia may be caused by infectious disease, scurvy or vitamin B12 deficiency
megaloblastic anaemia. A subsequent paper though argued that iron-deficiency
anaemia should not be ruled out as a potential cause of either porotic hyperostosis
or cribra orbitalia (Oxenham & Cavill 2010). Furthermore, like LEH, the synergetic
link between malnutrition and disease in causing the conditions is emphasised
(Facchini et al. 2004). In view of this debate, these two markers, as with LEH, will be
treated as general indicators of childhood health in the present study. The irondeficiency anaemia hypothesis will be considered within the specific environmental
context of early Egypt in the discussion.
Figure 2 - Porotic hyperostosis (Source: (Gregg & Gregg 1997))
Figure 3 - Cribra orbitalia (Adapted from: (Aberdeen Art Gallery and Museums
Collections n.d.))
1.5.4. Childhood health

It should be emphasised that these stress markers together provide a measure of
childhood health, but from this we can gain an idea of the general level of disease
and/or malnutrition present within the general population (Keita & Boyce 2001). The
relationship between environmental stress and poor health is complex, especially
among children. Children, particularly those under five years of age, are highly
susceptible to bacterial, viral and parasitic infections. After weaning, these can often
occur from contact with contaminated food and water, the risk of which is increased
when general sanitation is poor (Kent 1986). Many infections can lead to chronic
diarrhoea which can cause severe dehydration and malnutrition by inhibiting the
absorption of nutrients from ingested food (Carlson et al. 1974; Facchini et al. 2004).
If the diet is already nutritionally inadequate, then the effects of this will be
enhanced.
1.5.5. The osteological paradox

There has been debate, termed the osteological paradox (Wood et al. 1992), as
to whether poor skeletal health is always representative of poor health during an
individuals life, with the argument that it may sometimes indicate that an individual
survived for long enough with a disease for it to manifest itself on the skeleton, and
thus could be considered as a sign of good health. Moreover, a high frequency of
childhood stress markers observed in adults may also suggest that that individual
was actually strong enough to overcome those stresses and survive into adulthood.
However, this argument can be criticised as many diseases only become manifest on
the skeleton when they have reached a severe enough state and a high frequency of
stress markers still indicates that individuals were not sufficiently protected from
disease or malnutrition in the first place. Skeletal health can still be used to reliably
compare the level of disease and/or nutritional stress present within the
10
environment in which a group lived and the likelihood of a member of that group
suffering from poor health.
1.6. Previous studies of skeletal health in Egypt

Existing studies of skeletal health in ancient Egypt are limited in that often data is
used to make very broad temporal comparisons between populations. For example,
Zakrzewski (2003) investigated changes in stature (a general indicator of health)
from the Badarian period to the Middle Kingdom. Another study by Duhig (2000)
measured changes in several skeletal stress indicators from the Predynastic Period to
the Middle Kingdom, although did choose to focus on the First Intermediate Period.
Although such broad comparisons are useful for pinpointing time periods for more
detailed study, failure to fully take into account the variation in the physical and
social environment of the populations sampled severely reduces the accuracy with
which changes in health can be interpreted. This limits what can be said about the
relationship between health and cultural change.
In the context of early Egypt, few studies have been carried out with the level of
detail needed to make reliable interpretations of health change over time. Keita and
Boyce (2001) investigated changes in the prevalence of porotic hyperostosis and LEH
over the Nagada I, II and III periods, with their results indicating an improvement in
health over time, despite increasing population density and increasing social
inequality. A further study by Keita (2003), which looked at just porotic hyperostosis
prevalence, complements this with an observed decline in health from the Badarian
to Nagada I periods, followed by an improvement to the First Dynasty. Another by
Starling and Stock (2007), investigating LEH prevalence, also points towards an
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improvement in health after the Badarian period, although this study was not
focused solely on Egypt. Studies using just one or two populations have also been
carried out, with the advantage that they often employ a multitude of different
skeletal stress markers to quantify health. One such study by Greene (2006)
compared both diet and dental health between two populations from Hierakonpolis
and Nagada, mostly dating to the Nagada II period, and found that children from
Hierakonpolis were healthier than those from Nagada. Another study by Kumar
(2009) used multiple stress markers to compare the health of individuals from a
Nagada II cemetery at Hierakonpolis with data from other populations dating from
the Upper Palaeolithic to the Old Kingdom, and concluded that there was an overall
decline in health with the introduction of agriculture and increasing socio-economic
disparities.
These existing studies of health in early Egypt are limited in their scope and the
approaches they employ. Firstly, the relationship between health and cultural
change only becomes apparent when populations from different contexts are
compared with one another, so studies involving just one or two populations are
limited in what they can reveal. Secondly, the most useful studies which have
compared several populations over the Predynastic and Early Dynastic periods have
not always used multiple stress markers to quantify health change; the study by
Keita (2003) above only looked at the change in porotic hyperostosis prevalence. The
use of multiple indicators is essential if reliable conclusions of overall health change
are to be made as each skeletal stress marker only tells us about one aspect of an
individuals or populations health. Furthermore, the use of more than one stress
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marker reduces the number of potential interpretations that can be made from the
data.
Thirdly, many studies have failed to trace the skeletal material used back to their
original archaeological contexts; often original excavation reports are not even
referenced in studies, implying that they were not consulted. This has resulted in
interpretations of health changes and differences being made without fully
considering how a groups social context could have affected their observed health.
Finally, the relationship between social status and health has only been touched
upon, not just in the context of early Egypt, but for most periods of Egyptian history.
This is surprising considering that social status is such an important issue within
Egyptology.
1.7. Research aims and contribution

The present study will carry out an in depth investigation of the temporal and
social variations in health. It will compare the health of six early Egyptian populations
using three different skeletal stress markers to quantify change. Importantly, the
social context of each population will be investigated in detail so that the observed
changes can be more reliably interpreted.
This study adopts a multi-disciplinary approach using the methods of both
Egyptology and Biological Anthropology to quantify health differences between
different early Egyptian populations. This allows a much fuller picture to be gained of
health and the fundamental social differences between the studied groups than
would otherwise be gained if each discipline was used in isolation. The results
contribute to our knowledge of social change and social status in early Egypt, a
13
period of Egyptian history for which we know comparatively less than later periods.
Beyond Egyptology, it has wider implications for investigating the effects that major
cultural changes such as agriculture, urbanisation and social stratification have on
the ability of a human group to adapt to its environment, as well as providing more
accurate models for state formation in other areas of the world.
14
CHAPTER 2 DATA AND METHODS

2.1. The skeletal material used
Six populations were sampled, from a range of archaeological sites of significant
socio-political importance in the emergence of the Egyptian state and dating to
various cultural phases spanning the early Predynastic to Early Dynastic periods. A
summary of the populations is presented below (Table 1), along with a map of their
locations (Figure 4) and a timeline (Figure 5). All of the skeletal material used in this
study is from the Duckworth Collection, held in the Leverhulme Centre for Human
Evolutionary Studies, at the University of Cambridge.
15
Table 1 - Origins of the skeletal material used in this study

Origin of
Approximate date of
skeletal material skeletal material
Excavator(s) of skeletal material &

publication date of excavation
report
El-Badari Badarian graves
Badarian period
Brunton & Caton-Thompson (1928)
Hierakonpolis Prehistoric &

possibly the
Fort cemeteries
Mainly Nagada II period,

with possibly some
Nagada I & III
Quibell & Green (1902)
Nagada cemetery B
Mainly Nagada II period
Petrie & Quibell (1896)
Nagada cemetery T
Nagada II & III period
Petrie & Quibell (1896)
Tarkhan
Mainly Nagada III period,

with some First Dynasty
Petrie (1914)
Abydos - Tombs
of the Courtiers
First Dynasty
Petrie (1924)
16
Figure 4 - Map showing the locations of the populations sampled (Adapted from:
(Grajetzki & Quirke 2001))
Figure 5 - Timeline of the periods studied (Created by the author dates taken
from (Shaw 2002))
N.B. Nagada III and Protodynastic are just different names for the same time period.
17
To reconstruct the original archaeological context of the skeletal material the

Duckworth Collections records were initially consulted. However, these did not
contain sufficient information. Therefore, the original excavation reports and
previous studies in which the material had been used were investigated instead.
Particular attention was paid to grave numbers written either on the material itself
or on the boxes, so that individuals could be traced back to the excavation reports
more easily. Importantly, and in contrast to previous approaches to investigating
Egyptian skeletal remains, the social context from which the population originated
was investigated in detail before samples were taken, with specific cemeteries within
the overall population region being sampled if at all possible. To assist with this,
tables linking grave details (if recorded) with the skeletal material were compiled
(see Appendix A).
2.1.1. El-Badari (Appendix A1)

The material from El-Badari is from several Badarian period (c. 4400-4000 BC)
cemeteries excavated by Brunton and Caton-Thompson (1928); by noting the four
digit grave numbers written on boxes, the skeletal material could be traced
specifically to cemeteries 5100, 5300, 5400, 5600, 5700 and 5800. Badarian period
graves generally consisted of a single individual buried in an oval or rectangular pit
(Trigger 1983). The body was wrapped in matting, cloth and animal skin and was
placed in a contracted position on its left side, with the head oriented to the south,
but facing west. Some graves contained the remains of reeds, which probably
formed some kind of roofing over the body. Graves were generally rich in burial
goods: a variety of pottery types including red-polished, black-topped vessels, bone
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tools, various ivory items such as bracelets and rings, bone and ivory combs,
siltstone palettes, ostrich egg shell vessels, shell and stone beads, and copper items
such as pins (Midant-Reynes 2000; Brunton & Caton-Thompson 1928). There has
been debate as to the level of social stratification that Badarian period graves
represent. Trigger (1983) suggests that although graves were differentiated in size,
there were no strong wealth distinctions in terms of burial goods because rich
burials of children were not found; certainly, the concept of inherited status had not
developed at this point. Anderson (1992) argues against this and suggests that there
were burial good differences and that this argues against the traditional view of
Badarian society being largely egalitarian in its structure. Regardless of this though,
social status differences in tombs become much more evident in the latter half of
the Predynastic Period, as the ideological foundations of Egyptian kingship were
developing amongst a powerful elite class.
2.1.2. Hierakonpolis
The Predynastic material from Hierakonpolis is the most difficult to assign a
detailed provenance to, as the Duckworth records are the sparsest for this collection
and little has been done to investigate the provenance in previous studies where the
material has been used. Most of the individuals sampled have different one, two or
three digit grave numbers written on the skulls. A few have 232 E written on them
instead and some have the same number, 318. An entry by an unknown author in
the records lists three archaeological excavations where the material could have
come from: Egypt Research 1898, Petrie 1898 and Green & Quibell 1899. The
Egyptian Research Account, formed by Petrie, dispatched Green and Quibell to
19
salvage the Predynastic site at Hierakonpolis in 1897 (The Friends of Nekhen n.d.),
from which two excavation reports, Hierakonpolis I (Quibell 1900) and Hierakonpolis
II (Quibell & Green 1902) were published. The next expedition to Hierakonpolis was
in the 1905-06 season by Garstang and Jones (The Friends of Nekhen n.d.).
Therefore, it seems likely that the material originated from Quibell and Greens
excavations. They investigated two main Predynastic burial areas: one within the
Fort region and one at the south of the desert site. The latter was a Nagada II
cemetery in which the Painted Tomb (tomb 100) was found (Wilkinson 2000),
which possibly belonged to an early king (Case & Crowfoot Payne 1962). This
represented the main Predynastic cemetery area, and so is the most likely place
from which the material sampled in this study originated. However, in their report,
Quibell and Green make little mention of graves other than the large, brick-lined
ones to which tomb 100 belonged. They are quoted as saying:
The rest of the graves were mere rough rectangular excavations in the hard desert
sand varying in depth from 2.0 m. to 0.5 m. The roofs had in many instances been
made out of wood as the remains of the ends of the beams were found in some
cases Nearly all had been robbed, and most of those that had escaped contained
little except pottery (Quibell & Green 1902, p.22).
It is not clear how many graves they were referring to, though Crowfoot Payne
(1973) mentions a series of 150 Predynastic graves in a manuscript register compiled
by Green and suggests that they are from the tomb 100 cemetery. The contents of
most of these graves seem to have been published in (Adams 1974). However,
20
hardly any of the grave numbers associated with the skeletal material sampled in
this study are mentioned.
As a result of the material not being recorded in any detail, it is not possible to
make any significant statements about the social status of the individuals
represented in the skeletal material sampled at Hierakonpolis. All that can be said is
that most were probably of lower status than tomb 100 and other similar graves
(although one skull labelled with the number 100 could possibly have belonged to
the person buried in this tomb). As it is not possible to be completely sure that all of
the skeletal material originates from this one cemetery, but it is fairly certain that it
all came from the excavations of Quibell and Green, the Hierakonpolis group has
been labelled as a general Mid Predynastic-Protodynastic group, which could include
Nagada I and III period material (the Fort cemetery was used over these periods
(Wilkinson 2000)) in addition to that from the Nagada II period.
2.1.3. Nagada B (Appendix A2)

One set of material from Nagada is from Cemetery B, a predominantly Nagada II
period (Bard 1994) (c. 3500-3200 BC) cemetery of 144 graves excavated by Petrie
(Petrie & Quibell 1896). It was distinguished from the other Nagada material by the
two or three digit numbers preceded by B written on boxes. Most Cemetery B
graves were rectangular pits, with some oval or round ones. In general, bodies were
contracted and were positioned on their left side, with their head to the south and
facing west (Petrie & Quibell 1896). Grave goods included pottery, particularly of the
red and black type, beads, shell, stone vases and slate palettes (Petrie & Quibell
1896; Baumgartel 1970). A detailed comparison of mortuary practices in the three
21
different cemeteries at Nagada by Bard (1994) points towards Cemetery B being for
lower status individuals than Cemetery T and N West on account of the smaller
average grave size, greater density of graves and lower number of rich graves. Bard
suggests that the cemetery was for middle-class individuals living in a nearby farming
village.
2.1.4. Nagada T (Appendix A3)

The second set of material from Nagada is from Cemetery T, which was mainly in
use during the Nagada II and III periods (Bard 1994) (c. 3500-3000 BC), and was also
excavated by Petrie (Petrie & Quibell 1896). The material was identified as belonging
to this cemetery by the one or two digit numbers preceded by T written on the
boxes. Cemetery T was the smallest cemetery at Nagada, with just 69 graves (Bard
1994). It seems to be well accepted among the literature that Cemetery T was a
high-status, elite burial ground, where perhaps the early leaders of Nagada were
buried (Case & Crowfoot Payne 1962; Kemp 1973). As well as its separate location,
Cemetery T had the lowest density of graves out of all of the Nagada cemeteries, the
largest average grave size and, in the Nagada II period, the highest average number
of pots per grave (Bard 1994). Many of the tombs contained large quantities of
pottery and luxury high-status goods, including slate palettes, beads made of
precious stones and shell, and hard stone vessels (Baumgartel 1970; Petrie & Quibell
1896), all representing a significant investment of resources. There were also several
larger, brick-lined tombs containing multiple burials, including those of children,
which ties in with what was observed during data collection for the present study:
adult skeletal material was often associated with that of infants from the same
22
tomb. The similar treatment of subadults as adults in burial suggests a degree of

inherited rather than acquired status (Wilkinson 2000), something which was not
evident in the Badarian period graves discussed earlier.
2.1.5. Tarkhan (Appendix A4)

The material from Tarkhan was excavated by Petrie (1914), from a large
cemetery of over 2000 graves dating to the Nagada III period and First Dynasty. The
material sampled from the Duckworth is mainly from the Nagada III period, with a
small number of individuals from the First Dynasty. Most individuals could be traced
back to grave entries in Petries excavation report on the basis of the two, three or
four digit grave numbers written on boxes (preceded by F due to a previous
classification system). Petrie organised all the graves excavated at Tarkhan by
sequence date based on pottery, assigning S.D. 77 and 78 to the Nagada III period (or
Dynasty 0 as he called it), and 79-62 to the First Dynasty. Five of the individuals
sampled did not have entries in the report, but it was assumed that they were from
either the Nagada III period or the First Dynasty. Most of the graves sampled were
square or oval pits and commonly contained pottery and beads. Other items
included were slate palettes, stone vessels, and sometimes copper and ivory objects.
Grajetzki (2004) notes that the cemetery at Tarkhan is notable for the range of
different social classes that its graves represent; the poorest graves being just 1.5
1.8 m deep and containing pottery and sometimes jewellery, and the richest graves
having coffins and/or large mud-brick superstructures. There was also a spatial
distinction in that the most important tombs were carved into rocks overlooking the
valley, whereas the densely distributed graves occupying the middle valley were of
23
poorer people. Given that the graves associated with the material sampled in this
study are from a variety of different locations within the cemetery, and contain a
variety of different types and numbers of grave goods, the sample is likely to contain
individuals of a range of different social classes.
2.1.6. Abydos (Appendix A5)

The skeletal material from Abydos was excavated by Petrie (1924) and is from the
subsidiary burials situated around the funerary enclosures of three First Dynasty
kings of Egypt, Djer, Djet and Merneith (the majority from the former two). The
graves are brick-lined and it has been suggested that they were once surmounted by
a brick superstructure (Kemp 1966). Similar subsidiary burials were also found
around several royal tombs of the First Dynasty kings. Kemp (1967) suggested that
the purpose of all of the subsidiary burials was so that the individuals could serve the
kings in the afterlife, and although it is debated, it is possible that at least some of
the individuals were killed for this purpose (OConnor 2009). Some individuals
appear to have been minor officials, on the basis of titles such as seal-bearer and
the presence of high status burial goods such as ivory combs and cosmetic
implements (Petrie 1924). More recently it has been proposed that many of the
individuals were court artisans (Bestock 2007; OConnor 2009), suggested by the
inclusion of copper tools in many burials. Bestock has also suggested that there is
some degree of spatial grouping of burials containing specific types of objects (e.g.
arrowheads, model granaries, ivory game pieces) possibly relating to different
functions that the kings wanted these individuals to perform in the afterlife. The
apparent close relationship with the early kings of Egypt and the high level of
24
resource investment represented by the burials suggests that these individuals were
accorded a special high status.
2.2. Sampling procedure

A total of 179 individuals were sampled. The fragmentary nature of the skeletal
material was an important factor in choosing which individuals were sampled:
individuals were excluded from sampling if preservation was very poor or if the
material was very fragmentary. The final sample size is shown below (Table 2).
Table 2 - The skeletal sample taken in this study
Population
Total number
of individuals
sampled
Number of
individuals
observable for
porotic
hyperostosis
Number of
individuals
observable for
cribra
orbitalia
Number of
individuals
observable for
LEH (at least 1
scorable
tooth)
El-Badari
30
30
30
30
Hierakonpolis
39
39
39
29
Nagada B
24
24
20
24
Nagada T
24
24
23
15
Tarkhan
30
30
29
28
Abydos
32
32
30
31
TOTAL
179
179
171
157
2.3. Assigning age and sex

2.3.1. Age
Where possible, only adults were sampled, with subadults or individuals with
undefined age only being included if insufficient adult skeletal material was present
for a population; only 14 out of the 179 individuals sampled were classed as
25
subadults or undefined. For the purposes of this study, distinction between different
age categories within adults was not made, as aging an individual from only cranial
material is considered to be an inaccurate method (Dr J.T. Stock, personal
communication) and because of the time constraints of the study. Adult status was
assigned primarily on the basis of dental status. Dental status was assigned for each
tooth using and adapting the scoring system developed by Dr J.T. Stock (personal
communication):
O - In occlusion/fully erupted tooth present (adapted in this study to include cases
where only part of a tooth was present because of post-mortem damage)
E - Emerging
U - Unerupted
CO - Crypt open (i.e. tooth about to emerge)
P - Postmortem loss
A - Antemortem loss
M - Missing for unknown reason
An individual was considered an adult if at least one fully erupted third molar was
present, or in the case of postmortem tooth loss, where there was evidence of one
having been present; the third molar (wisdom tooth) emerges from the age of 18
years (White & Folkens 2005). However, this method is limited in that third molar
emergence can be delayed by several years into adulthood, with the timing varying
between individuals within a population. Evidence of extensive cranial suture fusion
was also occasionally used to assign adult status if either no evidence of fully
erupted third molars was present or if there was insufficient dental material.
Subadult status was assigned if it could be confirmed that no fully erupted third
26
molars were present. If for any reason age status could not be confirmed, the
individual was recorded as undefined.
Table 3 - The age distribution of the individuals sampled
Population
Number of adults
Number of
subadults
Number of
individuals of
undefined age
El-Badari
30
Hierakonpolis
39
Nagada B
24
Nagada T
11
10
Tarkhan
30
Abydos
31
TOTAL
165
11
As can be seen from Table 3, the age distribution of individuals sampled varied
between populations. This is a common challenge faced by palaeopathologists and is
important to be aware of because it can affect the prevalence of stress markers
observed in each group. In the case of cribra orbitalia and porotic hyperostosis, a
sample with an overall older age distribution could theoretically exhibit a lower
prevalence than a sample with a younger age distribution. This is because both are
thought to form in childhood, but can then remodel and heal later in life (StuartMacadam 1985). LEH does not suffer from the same bias, as tooth enamel does not
remodel after its initial formation (Goodman & Rose 1990), but it should be
remembered that a skeletal sample will only consist of the individuals who survived
periods of childhood stress. For the samples used in the present study it was not
possible to see whether the prevalence of any of the stress markers changed
27
significantly with age. However, the inclusion of mostly adults minimises any bias
that could have arisen from higher prevalences among subadults.
3.1.2. Sex
Each individual was assigned a sex to enable any differences in health between
males and females to be identified in data analysis. Sex was determined from each
cranium using the standard method of Buikstra and Ubelaker (1994), in which five
sexually dimorphic cranial features (Figure 6) are given a score of 1-5 based on their
robusticity, where 1 is hyperfeminine and 5 is hypermasculine:
Rugosity of the nuchal crest
Size of the mastoid process
Thickness of the supraorbital margin
Prominence of the supraorbital ridge
Size of the mental eminence
The scores are then averaged to give an overall sex. An individual with an average
score of 1-2.5 was recorded as female and 3.5-5 as male. Those individuals with
scores of 2.6-3.4 were recorded as undefined (Starling 2005). Where preservation
of material was poor, an individual was required to have a minimum of three out of
the five (i.e. more than half) cranial markers present for sex to be assigned with
confidence. If not, they were recorded as undefined. Any pre-assigned sex written
by previous researchers on either the skulls or boxes was also noted, as well as those
recorded in the original excavation reports.
28
Figure 6 - Sexually dimorphic cranial features (Source: (Buikstra & Ubelaker 1994))
2.4. Measuring the skeletal stress markers

2.4.1. Linear enamel hypoplasia
For the purposes of this study, linear enamel hypoplasia was defined as a
horizontal (or near horizontal) groove occurring on the enamel surface (Goodman &
Rose 1990). In addition, a linear sequence of pits occurring on the enamel surface
(these were rare) was also counted as linear enamel hypoplasia because in practice it
is difficult to distinguish these two defects from one another.
For each individual, all scorable teeth were scored for the presence of LEH bands
on the enamel surface which faces outwards (as is shown in Figure 1). For a tooth to
29
be considered scorable, it needed to have at least half of its enamel surface present
and visible (Starling 2005). The poor preservation of tooth enamel was a significant
problem in this study. A 10x magnifying glass was used to examine teeth for LEH, but
a tooth was only recorded as having LEH if the band was visible with the naked eye
too. The distance of the LEH band, or the most severe one in the case of multiple
bands, from the cemento-enamel junction (Figure 7) was measured using a pair of
digital callipers. This was so that the approximate age at which the growth disruption
had occurred could be calculated; tooth enamel formation begins from the top of
the tooth. This was done using the formulae presented by Goodman and Rose
(1990).
Figure 7 - Location of the cemento-enamel junction (Source: (Spiller 2000))

If an individual had a complete or at least 50 % complete cranial vault with at
least one side of each cranial bone present they were scored for the presence and
severity of porotic hyperostosis, using the standard scoring system laid out by
Ubelaker & Buikstra (1994), which has been frequently cited in previous studies
30
(Table 4). In cases where porotic hyperostosis of multiple severity levels was present
in the same individual, only the most severe was scored.
Any individual with at least one orbit present was scored for the presence and
severity of cribra orbitalia, using the same scoring system as for porotic hyperostosis
(Table 4). Again, only the most severe manifestation of the condition was scored if
multiple severity levels were present. Only one orbit was required to be able to
measure cribra orbitalia because of its noted bilateral distribution (Stuart-Macadam
1989). An incomplete orbit could still be scored for cribra orbitalia as long as the
orbital roof was present, where cribra orbitalia usually appears (White & Folkens
2005). If both orbits were present and of sufficient preservation, only the most
severe occurrence of cribra orbitalia was recorded, but it was also noted whether
cribra orbitalia appeared in one or both orbits.
Table 4 - The scoring system used for measuring cribra orbitalia and porotic
hyperostosis (Buikstra & Ubelaker 1994)
Score
Criteria
No porosity present
Indistinct porosity/barely visible
True porosity
True porosity with coalesced foramina

(i.e. pores which have joined up)
True porosity with coalesced foramina

and thickening of the bone surface
31
2.5. Data analysis

Data was analysed using Microsoft Excel and the statistics software SPSS 19.0.
The relative frequency of each skeletal health marker within the six populations
sampled was calculated and any statistically significant trends were identified.
Differences between males and females were also assessed, as well as the degree of
association between each stress marker. Before analysis, tests were run on the data
to assess whether it showed a normal distribution, as many statistical tests require
that data is normalised in order to make accurate conclusions about statistical
significance. If the data was not normally distributed, non-parametric tests were
carried out instead of parametric ones.
32
CHAPTER 3 RESULTS
N.B. The raw data collected in this study can be found in Appendix B.
3.1. Inter-population differences in stress markers

3.1.1. Cribra orbitalia
3.1.1.1. Prevalence
Significant differences were observed in the prevalence of cribra orbitalia
between populations. When the percentage of individuals with cribra orbitalia,
severity scores 1 or above was compared (Figure 8), Tarkhan had the highest
percentage of affected individuals (72.41 %), though this was only marginally higher
than that found at Hierakonpolis (71.79 %). Conversely, Abydos had the lowest
percentage (40.00 %), but again this was only slightly lower than that of Nagada T
(43.48 %). Overall, the differences between the populations were found to be
statistically significant (Kruskal-Wallis test: X2=11.766, df=5, p<0.05).
However, a more accurate and reliable measure of variation in cribra orbitalia

prevalence is achieved by calculating the percentage of individuals with severity
scores 2 or above. This is because it has been suggested that not all cases of the
indistinct porosity represented by severity score 1, for both cribra orbitalia and
porotic hyperostosis, may be caused by environmental stress, and that some could
be related to natural variations in bone growth (Keita 2003). When this was
compared between populations, notable differences were observed (Figure 9),
though these were not statistically significant (Kruskal-Wallis test: X2=2.221, df=5,
p=ns). Abydos had the lowest percentage of affected individuals (16.67 %), whereas
33
El-Badari had the highest percentage (30.00 %), though this was only slightly higher
than Hierakonpolis (28.21 %) and Tarkhan (27.59 %). There was also very little
difference between the two Nagada groups (20.00 % vs 21.74 %).
by population
34

by population
3.1.1.2. Severity
There were also differences in the severity of cribra orbitalia between
populations; the overall severity distribution is presented in Figure 10. Both Tarkhan
and Hierakonpolis had the highest average severity (1.10) and Abydos had the
lowest (0.57) (Figure 11). Nagada T also had a lower average severity (0.78) than
Nagada B (0.95). It should be noted though that these differences in average severity
were quite small and not significant (Kruskal-Wallis test: X2=9.045, df=5, p=ns).
Interestingly, Abydos was the only population in which the most severe occurrence
of cribra orbitalia, severity scores 3 and 4, was not observed, whereas Nagada B had
the highest percentage of individuals with these scores (15.00 %) (Figure 12).
Furthermore, Nagada T (8.70 %) had a lower percentage of individuals with severe
35
cribra orbitalia than Nagada B. Again though, these differences were not significant
(Kruskal-Wallis test: X2=4.310, df=5, p=ns).
Figure 10 - Percentage of individuals with each severity score of cribra orbitalia, by
population
36
Figure 11 - Average severity of cribra orbitalia in each population
Figure 12 - Percentage of individuals with severe cribra orbitalia (scores 3 & 4), by
population
37
3.1.1.3. Temporal trends

In order to identify whether the prevalence of cribra orbitalia changed over time,
the six populations were arranged into three time period categories (Figure 13):
Early Predynastic (El-Badari), Mid Predynastic-Protodynastic (Hierakonpolis, Nagada
B & Nagada T) and Proto-Early Dynastic (Tarkhan & Abydos). The sample size of each
group was different and this may have influenced the perceived prevalence. The
prevalence of cribra orbitalia (severity score 2 or above) decreased all the way from
the Early Predynastic to the Proto-Early Dynastic. The differences in prevalence over
time were not significant though (Kruskal-Wallis test: X2=0.680, df=2, p=ns), for all
population comparisons.
by time period
38
3.1.2. Porotic hyperostosis

3.1.2.1. Prevalence
As with cribra orbitalia there were substantial differences in the prevalence of
porotic hyperostosis between populations. A comparison of the percentage of
individuals with porotic hyperostosis, severity scores 1 or above (Figure 14) revealed
that the highest percentage of affected individuals occurred at Hierakonpolis (92.31
%), whereas the lowest percentage occurred at Abydos (65.63 %). Overall these
differences were not significant (Kruskal Wallis test: X2=9.319, df=5, p=ns).
When the more accurate measure of porotic hyperostosis prevalence was used,
i.e. the percentage of individuals with severity scores 2 or above (Figure 15), the
highest percentage of affected individuals occurred at El-Badari (50.00 %), which was
much higher than the second highest percentage found at Hierakonpolis (28.21 %).
Nagada B and Nagada T both had the lowest percentage (8.33 %) and Abydos the
second lowest (18.75 %). Overall the differences between populations were highly
significant (Kruskal; Wallis test: X2=18.861, df-=5, p=0.001).
39

above, by population

above, by population
40
3.1.2.2. Severity
Similar to cribra orbitalia, the severity of porotic hyperostosis showed
differentiation between populations; the overall severity distribution is presented in
Figure 16. El-Badari had the highest average severity (1.50), and Nagada B (0.83),
Nagada T (0.83) and Abydos (0.84) had the lowest (Figure 17). Again, these
differences were fairly small, although highly significant (Kruskal Wallis test:
X2=17.779, df=5, p<0.005). El-Badari, Tarkhan and Hierakonpolis were the only
populations to have any individuals with the most severe porotic hyperostosis scores
(3 and 4), whereas Nagada B, Nagada T and Abydos all had no such individuals
(Figure 18). Overall though, these differences were not significant (Kruskal Wallis
test: X2=5.590, df=5, p=ns).
Figure 16 - Percentage of individuals with each severity score of porotic
hyperostosis, by population
41
Figure 17 - Average severity of porotic hyperostosis in each population
Figure 18 - Percentage of individuals with severe porotic hyperostosis (scores 3 &

4) by population
42

Porotic hyperostosis prevalence (severity score 2 or above) decreased
substantially from the Early Predynastic to the Mid Predynastic-Protodynastic, the
same trend observed with cribra orbitalia (Figure 19). Prevalence then increased
slightly in the Proto-Early Dynastic, in contrast to the slight decrease found for cribra
orbitalia. However, it was only the Early Predynastic group which was significantly
different to both later groups (Mann-Whitney tests: U=877.500, Z=-3.528, p<0.001;
U=210.000, Z=-3.245, p<0.001).
above, by time period
43
3.1.3. Linear enamel hypoplasia

3.1.3.1. Prevalence
The percentage of scorable individuals with at least one tooth with LEH was
compared between populations (Figure 20) and the differences observed were
found to be highly significant (Kruskal-Wallis test: X2=26.279, df=5, p<0.001). ElBadari had the highest percentage of individuals (76.67 %), whereas Nagada B had
the lowest (25.00 %). Nagada T (40.00 %) also had a substantially higher percentage
than Nagada B. In contrast to the patterns indicated by the prevalence of cribra
orbitalia and porotic hyperostosis, Abydos had the second highest LEH prevalence
(74.19 %).
A similar overall pattern was observed when the average percentage of scorable
teeth with LEH per individual was compared between populations (Figure 21). ElBadari and Abydos still had the highest LEH prevalence and Nagada T still had a
higher prevalence than Nagada B. Tarkhan also still had a higher prevalence than
both Hierakonpolis and Nagada B. Again the overall differences observed were highly
significant (Kruskal-Wallis test: X2=18.392, df=5, p<0.0025).
44
Figure 20 - Percentage of individuals with LEH in each population
Figure 21 - Average percentage of scorable teeth with LEH per individual, by

population
45

When analysed by time period, the percentage of individuals with LEH decreased
from the Early Predynastic to Mid Predynastic-Protodynastic, then increased again to
the Proto-Early Dynastic, but to a lower level than the earliest time period (Figure
22). Overall, the differences were highly significant (Kruskal-Wallis test: X2=22.959,
df=2, p<0.001), for all population comparisons. The pattern observed was more
similar to that for porotic hyperostosis than for cribra orbitalia prevalence.
Figure 22 - Percentage of individuals with LEH, by time period
3.1.3.3. Preservation bias

In order to see whether the differential preservation of teeth between
populations had a significant effect on the observed LEH prevalences, a number of
tests were performed. Firstly, the average number of scorable teeth per individual
was found to differ substantially between populations (Figure 23). This graph shows
46
a similar overall pattern to the initial graph for LEH prevalence (Figure 20),
suggesting that the likelihood of recording LEH in an individual was affected by the
number of scorable teeth that that individual had; the populations with the three
highest average numbers of scorable teeth per individual, El-Badari, Abydos and
Tarkhan, also had the highest percentage of individuals with LEH. This was confirmed
by the finding that individuals with LEH had a higher average number of scorable
teeth than individuals without LEH in all populations (Figure 24). Finally, there was a
highly significant association between the number of scorable teeth per individual
and the number of those teeth with LEH in the overall sample (excluding individuals
with no scorable teeth, who would always have no teeth with LEH) (Kendalls tau
correlation test: =0.516, p<0.001 (1-tailed)) (Figure 25). All of these tests together
suggest that LEH prevalence was affected by preservation bias.
Figure 23 - Average number of scorable teeth per individual in each population
47
Figure 24 - Average number of scorable teeth in individuals with LEH and without
LEH, by population
48
Figure 25 - Association between number of scorable teeth per individual and

number of teeth with LEH, whole sample
49
A more specific source of preservation bias was that the overall number of
posterior teeth, i.e. molars and premolars (see Figure 26 for tooth types) was much
higher than the number of anterior teeth, i.e. canines and incisors (Figure 27). It has
been shown that anterior teeth have a greater susceptibility to developing LEH than
posterior teeth (Goodman & Armelagos 1985), and indeed in this study anterior
teeth were preferentially affected by LEH over posterior teeth (Figure 28). This could
have resulted in the prevalence of LEH being overestimated in the populations
where more anterior teeth were preserved. Indeed, the three populations which
show the highest LEH prevalence, El-Badari, Abydos and Tarkhan (Figure 20), do
have the highest numbers of preserved anterior teeth.
Figure 26 - Diagram of tooth types (Adapted from: (White & Folkens 2005))
50
Figure 27 - Average number of posterior and anterior teeth per individual in each
population
Figure 28 - Percentage of each tooth type with LEH, whole sample
51
3.1.3.4. Minimising preservation bias

To minimise the bias of differential tooth preservation, both in the number and
type of teeth preserved, LEH prevalence was then analysed using just the posterior
teeth (Figure 29); these were preserved in far greater numbers across the whole
sample than anterior teeth. The results revealed a similar pattern to that observed
when the whole dentition was considered (Figure 20) and overall this was highly
significant (Kruskal-Wallis test: X2=27.541, df=5, p<0.001). El-Badari and Abydos still
had the highest percentage of affected individuals (63.33 % and 70.97 %) and
Nagada T still had a higher percentage (33.33 %) than Nagada B (25.00 %). Tarkhan
though now had the lowest percentage (17.86 %), in contrast to the third highest
found previously. When LEH prevalence using just posterior teeth was compared by
time period (Figure 30) the same overall pattern as before (Figure 22) was observed,
although only the difference between the Early Predynastic and Mid PredynasticProtodynastic was significant (Mann-Whitney test: U=674.000, Z=-3.146 p<0.0025)
(though the difference between the Mid Predynastic-Protodynastic and Proto-Early
Dynastic was nearly significant (Mann-Whitney test: U=1678.000, Z=-1.896,
p=0.059)).
52
Figure 29 - Percentage of individuals with LEH in posterior dentition in each

population
Figure 30 - Percentage of individuals with LEH in posterior dentition, by time period
53
LEH prevalence by individual tooth type was explored to try to minimise

preservation bias further. Choosing individual teeth still allows a comparison of the
percentage of individuals with LEH in each population, but all bias of differential
tooth susceptibility is removed. The highest frequency tooth from each of the four
main tooth types (molars, premolars, canines and incisors) was chosen and the
percentage of each with LEH was calculated (Table 5). It was not possible to get the
same number of individuals represented from each population due to differential
preservation, but this method ensured greater consistency in tooth preservation
than the above method. Unfortunately, the analysis was not particularly revealing as
there was no population which had the highest or lowest LEH prevalence across all
tooth types. Although Hierakonpolis had the lowest (or among the lowest) LEH
prevalence for three out of the four teeth tested, this comparison is made redundant
by two of them only having one tooth present in the whole population. It is
potentially interesting though that Abydos had the highest LEH prevalence in two
teeth, in addition to having the highest percentages in the previous analyses (Figures
20 & 29).
Finally, LEH prevalence was compared across the two most frequently preserved
molars, the right maxillary second molar and left maxillary second molar (Table 6);
molars have often been used in previous studies to compare LEH prevalence (Keita &
Boyce 2001; Keita & Boyce 2006). Tarkhan had the lowest LEH prevalence for both
teeth, as was found in the earlier comparison of posterior teeth (Figure 29), but this
was the only apparent consistency between the two teeth. As these comparisons of
individual tooth types didnt show any overarching trends, the earlier comparison of
54
posterior teeth should be viewed as most accurate and feasible way of comparing
LEH prevalence between populations (Figures 29 & 30).
Table 5 - Percentages of the highest frequency molar, premolar, canine and incisor
with LEH, by population
Population
Left maxillary
second molar
Right
maxillary
second
premolar
Right
maxillary
canine
Right
maxillary
second
incisor
El-Badari
8.70 % (2 of
23)
9.52 % (2 of
21)
31.58 % (6 of
19)
16.67 % (1
of 6)
Hierakonpolis
6.67 % (1 of
15)
0.00 % (0 of
10)
0.00 % (0 of
1)
0.00 % (0 of
1)
Nagada B
7.14 % (1 of
14)
0.00 % (0 of 5)
Nagada T
9.09 % (1 of
11)
25.00% (1 of
4)
0.00 % (0 of
1)
100.00 % (1
of 1)
Tarkhan
4.55 % (1 of
22)
12.50 % (2 of
16)
53.33% (8 of
15)
53.85 % (7
of 13)
Abydos
16.00 % (4 of
25)
0.00 % (0 of
21)
87.50 % (7 of
8)
50.00 % (3
of 6)
TOTAL
9.09 % (10 of
110)
6.49 % (5 of
77)
47.73 % (21
of 44)
44.44 % (12
of 27)
N.B. If a box has been left blank, no scorable teeth were present.
55
Table 6 - Percentages of the two highest frequency molars with LEH, by population
Population
Left maxillary second

molar
Right maxillary second

molar
El-Badari
8.70 % (2 of 23)
16.67 % (4 of 24)
Hierakonpolis
6.67 % (1 of 15)
10.53 % (2 of 19)
Nagada B
7.14 % (1 of 14)
8.33 % (1 of 12)
Nagada T
9.09 % (1 of 11)
28.57 % (2 of 7)
Tarkhan
4.55 % (1 of 22)
5.00 % (1 of 20)
Abydos
16.00 % (4 of 25)
7.41 % (2 of 27)
TOTAL
9.09 % (10 of 110)
11.01 % (12 of 109)
3.1.3.5. Age of linear enamel hypoplasia formation

The average age of LEH formation per individual (Table 7) and for the four teeth
chosen earlier (Tables 8, 9, 10 & 11) was compared across populations. No overall
trends between populations were apparent.
Table 7 - Average age (years) of LEH formation per individual (averaged across all
LEH bands), by population
Population
Average age (years)
El-Badari
4.48
Hierakonpolis
4.98
Nagada B
5.00
Nagada T
4.83
Tarkhan
4.03
Abydos
4.45
TOTAL
4.50
56
Table 8 - Average age (years) of LEH formation in left maxillary second molar, by
population
Population
Average age (years)
El-Badari
6.93
Hierakonpolis
7.03
Nagada B
6.71
Nagada T
6.04
Tarkhan
6.84
Abydos
5.87
TOTAL
6.40
Table 9 - Average age (years) of LEH formation in right maxillary second premolar,
by population
Population
Average age (years)
El-Badari
4.59
Hierakonpolis
Nagada B
Nagada T
4.35
Tarkhan
4.76
Abydos
TOTAL
4.61
57
Table 10 - Average age (years) of LEH formation in right maxillary canine, by

population
Population
Average age (years)
El-Badari
4.20
Hierakonpolis
Nagada B
Nagada T
Tarkhan
4.10
Abydos
3.49
TOTAL
3.93
Table 11 - Average age (years) of LEH formation in right maxillary second incisor, by
population
Population
Average age (years)
El-Badari
3.35
Hierakonpolis
Nagada B
Nagada T
3.76
Tarkhan
3.36
Abydos
2.92
TOTAL
3.28
3.2. Intra-population variation in stress markers

3.2.1. Sex
The prevalence of each stress marker in males and females was analysed. In the
overall sample, there were 33 males, 95 females and 51 individuals of undefined sex.
58
Overall, there was no significant difference between males and females in the
prevalence of cribra orbitalia (severity score 2 or above) (Fischers Exact test: p=ns),
the prevalence of porotic hyperostosis (severity score 2 or above) (Fischers Exact
test: p=ns), or the prevalence of LEH (posterior teeth) (Fischers Exact test, p=n). This
was consistent across populations as well as in the overall sample. Although this lack
of difference may be suggestive, these results must be treated with caution as the
sample size of individuals with assigned sex was very small for many of the
populations and it is difficult to assign sex accurately using just cranial remains. Thus,
the same statistical tests were also run using the pre-assigned sex values recorded in
the original excavation reports. Again there were no significant differences between
males and females in the prevalence of any of the stress markers.
3.2.2. Age
Although the variation in the stress markers by age was not assessed in this
study, the potential bias of including a small number of subadults in the sample was
measured. Apart from one individual in the Abydos group, it was only the Nagada T
group which contained any individuals that classified as either subadults or
undefined age. However, no significant differences were found between adults and
undefined individuals when the frequencies of the different stress markers were
compared within the Nagada T group (Mann-Whitney tests: U=50.000, Z=0.000,
p=ns; U=15.000, Z=-0.522, p=ns; U=11.000, Z=-0.264, p=ns) (it was not possible to
carry out adult to subadult comparisons because of the small subadult sample size).
This suggests that the effects of having a potentially younger age distribution (at
least in terms of subadults vs adults) than the other populations was probably small.
59
3.3. Association between different stress markers

The level of association between the different stress markers was measured. In
the overall sample, cribra orbitalia presence (severity score 2 or above) was found to
be highly significantly associated with porotic hyperostosis presence (severity score 2
or above) (Pearson Chi-Square test: X2=5.504, df=1, p<0.025), suggesting that an
individual with one of these stress markers was also likely to have the other stress
marker too. However, neither cribra orbitalia nor porotic hyperostosis presence
(severity score 2 or above) were significantly associated with LEH presence (in
posterior teeth) (Pearson Chi-Square tests: X2=2.476, df=1, p=ns; ; X2=4.304, df=1,
p=ns), though the latter association was close to being significant (p=0.056).
60
CHAPTER 4 DISCUSSION
4.1. Health and cultural changetemporal trends in the stress markers
4.1.1. The Badarian period
When viewed temporally, the results of this study show that health changed
substantially over the period of state formation in Egypt. The population from ElBadari, which represent the first predominantly agricultural society to inhabit Upper
Egypt, has the highest prevalence (severity score two or above) and among the
highest average severities of both cribra orbitalia and porotic hyperostosis, as well
one of the highest prevalences of LEH (just using posterior teeth) of all the
populations sampled. The high prevalence of all three skeletal stress markers in the
population strongly suggests that their overall health was poor. Although it is not
possible to say on the basis of this data how health changed from the period
preceding the Predynastic, the poor health among the Badarian population supports
the current thinking that the transition to agriculture in many regions of the world
resulted in an initial decline in overall health. Documented health problems that
arose with agriculture include increased prevalence of dental caries (cavities) due to
the increase of starch-based foods in the diet, the increased prevalence of infectious
disease as a result of increased population density and sedentism, and an increase in
nutritional disorders because of reduced diversity and nutritional content of some
agricultural products (Larsen 1995).
The high prevalence of all three stress markers suggests overall poor health
among the Badarian population, but in particular the high cribra orbitalia and porotic
hyperostosis prevalences could plausibly be linked to an increased prevalence of
61
iron-deficiency anaemia with agriculture. The predominant crops to be introduced

with agriculture were emmer wheat and 6-row barley (Wengrow 2006), which are
naturally low in iron. If not combined with enough meat and vegetables, an irondeficient diet could ensue. Thus, if children are weaned onto a diet which is low in
iron, they are susceptible to iron-deficiency anaemia and this susceptibility could be
further increased if infectious disease is prevalent within the environment (as has
been documented for the agricultural transition), through the increased likelihood of
infant diarrhoeal infections (Facchini et al. 2004). An iron-deficiency anaemia
hypothesis is also likely given that the parasitic disease schistosomiasis, which causes
substantial iron-loss, is thought to have been prevalent in ancient Egypt (Keita 2003),
and has been identified in mummy remains from the Predynastic Period (Deelder et
al. 1990). The disease is prevalent in Egypt today and infection is strongly associated
with exposure to infected water. It has therefore been postulated to have become
more prevalent with agriculture in Egypt because of prolonged exposure to Nile
floods and the development of basin irrigation.
4.1.2. The Nagada I period onwards

The prevalence of each stress marker then decreases in the subsequent Mid
Predynastic-Protodynastic (with the decrease in porotic hyperostosis and LEH being
statistically significant), suggesting that there was a general improvement in health
around the middle of the Predynastic Period. A similar improvement in health was
found by Starling and Stock (2007), with LEH prevalence initially decreasing after the
Badarian period. Interestingly, the decrease occurs in all three of the populations
which make up the Mid Predynastic-Protodynastic time period grouping. Given that
62
these groups represent different social groups of Egyptian society, this suggests that
the overall improvement in health occurred regardless of social status.
This improvement is most likely nutritional in origin as the result of agricultural
diversification and a wider range of foods being incorporated into the diet. A review
by Greene (2006) of recent evidence, including that from archaeobotanical studies,
states that vegetables and fruits known to have first appeared during the
Predynastic Period include fig, watermelon, cucumber, turnip, lentil, chickling vetch,
grape, pea and date palm. Several of these, i.e. pea, lentil and watermelon are rich in
iron, and a greater bioavailability of iron may explain why the prevalence of porotic
hyperostosis and cribra orbitalia decreased after the Badarian period. Another
important addition to the diet in the Mid Predynastic was beer, made by fermenting
barley. The earliest evidence for beer production comes from locality HK-21A at
Hierakonpolis, dating to the transition between the Nagada I and Nagada II periods,
with the discovery of a brewery containing beer residues (Geller 1992). Beer was
nutritionally-rich, containing vitamins, protein, starch and calories, as well as having
a low alcoholic content that would have disinfected the water used to make it
(Samuel 1993; Greene 2006), and along with bread became a dietary staple for the
ancient Egyptians. Fragmentary evidence makes it difficult to document any change
in the level of animal protein consumed, but it is plausible that as agriculture became
better established within the Nile Valley meat was eaten on a more regular basis.
Furthermore, there is evidence for increasing dietary uniformity across Egypt after
the Badarian period: on the basis of archaeobotanical and archaeozoological remains
from various Upper and Lower Egyptian sites dating to the early fourth millennium
63
Wengrow (2006) has argued that a broadly similar diet was eaten, consisting of
cultivated cereals, flax, lentil and pea, wild root-foods, figs and berries, animal
products from cattle, sheep, goats and pigs, and a limited amount of acquatic fauna.
Certainly, there is an overall picture of the diet becoming more diverse as the
Predynastic Period progressed.
It is also likely that the increasing ability to produce agricultural surplus brought
greater nutritional security against food shortages resulting from unpredictable Nile
flooding, and therefore fewer episodes of nutritional stress. The large reduction in
LEH prevalence observed after the Badarian period signifies that fewer children were
suffering from severe growth disruptions which could have been caused by
nutritional stress. Undeniable evidence that agricultural surplus was being produced,
and in increasing quantities, is suggested by the growth of craft specialisation
throughout the Nagada I,II and III periods, as this indicates that segments of the
population no longer had to work as farmers (Bard 2008). This is apparent from the
appearance of specialised craft areas associated with settlements, such as locality
HK29A at Hierakonpolis (Nagada II) which is associated with debris from flint working
and drills for making beads and vessels (Wengrow 2006). There was also an
increasing focus on specialist, high-quality objects placed in elite burials (Bard 1989).
As mentioned before, the decrease in skeletal stress markers occurred regardless of
the social status of the groups sampled and so may suggest that the growing ability
of elites to control resources and divert agricultural surplus to producing specialist
prestige goods for their own benefit did not pose a significant threat to the health of
the general population.
64
4.1.3. The Protodynastic (Nagada III) and Early Dynastic periods

The trend observed in the last time period grouping is less clear though. Cribra
orbitalia prevalence shows a further decrease in the Proto-Early Dynastic, whereas
the prevalences of both porotic hyperostosis and LEH increase. It should be noted
though that only the increase in LEH prevalence is of a sizable magnitude, whereas
the changes in cribra orbitalia and porotic hyperostosis are very small. As the same
trend is not apparent in all three stress markers, the increase in LEH should also be
viewed with caution because of the likely influence of differential tooth
preservation, discussed earlier, and thus the increase may not have been as large as
it appears. However, if LEH prevalence did indeed increase, then it suggests that
between the Nagada I/II and Early Dynastic periods overall health declined.
The most plausible reason for this decline is the growth of urbanisation. There is
a well-established link between health and urbanisation among both ancient and
modern societies with the theory that population aggregation favours the spread of
infectious diseases because of increased contact between individuals. More cramped
living conditions and the inability of societal infrastructure to keep up with changes
in population demography can also result in decreased sanitation and thus increased
potential for disease spread. The potential for resource competition between
individuals and groups may also be increased.
Within the context of early Egypt, the origins of urbanism can be traced to the
Nagada I period, in which the first permanent settlements appeared: an important
early site is Maadi, at which a series of buildings made of mud-brick and stone, and
surrounded with storage pits have been found (Wengrow 2006). By Nagada I/II,
65
there is evidence of settlement growth at sites such as Hierakonpolis (Hoffman et al.

1986). However, a dramatic change in the pace and pattern of urbanisation is
documented in the Protodynastic Period (Nagada III)the period from which the
decline in health is observedwith a notable increase in the density and tightness of
settlement evident at Hierakonpolis (Hoffman et al. 1986). The increase in
population density that this development suggests would have increased the
potential for disease spread and thus the risk of disruptions in child growth that LEH
represents.
When considering the sites sampled in the present study, Memphis (presumably
where the individuals buried at Abydos lived for a large proportion of the year) and
Tarkhan were both urban centres around the time of state formation. Memphis was
the new political capital of the First Dynasty kings and so would most likely have
been a relatively densely populated centre. Tarkhan too was probably a highly
populated urban settlement in the Protodynastic and Early Dynastic periods because
of the large size of the cemetery there (Grajetzki 2004); a general pattern apparent
at several early urban centres within Egypt is the location of cemeteries close to
settlement areas.
One caveat of this interpretation is that the increase in LEH prevalence is
dominated by Abydos, with Tarkhan having a much lower prevalence. However,
when all teeth are considered, Tarkhans prevalence is much closer to that of
Abydos. Tarkhan also still shows relatively high prevalences of the other two stress
markers. Moreover, this variation could actually indicate that the negative effect of
urbanisation on health differed depending on the location. It would be expected that
66
the effect would be more severe at Memphis than Tarkhan because this was the new
political capital. Furthermore, during the time period in which the majority of the
individuals sampled from Tarkhan lived (Protodynastic/Nagada III period), political
power and thus probably settlement was focused on Upper rather than Lower Egypt
(Tarkhan is in Lower Egypt). One might therefore expect that urbanisation would
have a less severe effect on health at Tarkhan than at sites in Upper Egypt.
This decline in health has important implications for our understanding of the
process of urbanisation in early Egypt and the effects it had on society. This is a topic
for which we know relatively little compared to other aspects of state formation and
the growth of urbanisation in other early states such as Mesopotamia, largely due to
poor preservation of early settlements and the technical difficulties of accessing
them. Population aggregation undoubtedly brought many advantages to those
involved, including the increased security of living in a larger settlement and more
permanent and strategic positioning for trade (Bietak 1979). Urban centres also
provided strategic foci at which elites could materialize their power, a process that
was essential to state formation. However, the results of this study suggest that
these developments occurred at a cost to peoples physical wellbeing. Moreover, it
seems that there was a threshold at which urbanisation had a negative impact on
health, as although settlement growth was already evident by the Nagada II period
in Egypt, it is only from the Protodynastic (Nagada III) period that a health decline is
observed in this study.
The negative effects of urbanisation on health were probably exacerbated by
possible warfare that has been suggested in the lead up to political unification. There
67
is growing evidence that the internal power struggles represented by constantly

shifting elite cemeteries were not entirely peaceful, with the suggestion of significant
military activity between competing power bases. One rock-cut scene at Gebel Tjauti
in the Western Desert dating to the early Nagada III period shows prisoners and
several royal motifs such as the Horus-falcon, indicating a possible military victory of
one power centre over another (Wilkinson 2000). Such activity would undoubtedly
have caused some degree of social instability, which could have disrupted access to
basic resources such as food and healthcare, as well as lead to a decline in general
living conditions. In combination with growing urbanisation, this social disruption
could have led to the growth of both malnutrition and disease.
4.2. Health and social statusis there a link?

Although investigating temporal trends within the data is useful and is necessary
in order to place each population within the context of overall developments that
were occurring within Egypt during state formation, it is also important to view the
observed differences in health within an individual population context. The
population samples represent different social groups as well as being separated in
time and space, and this variation could have affected health.
4.2.1. Servants to the First Dynasty kingssubsidiary burials around the royal
funerary enclosures
The Abydos group is of great interest for the discussion of social status and health
as it represents a group of individuals with a relatively clearly defined social context
and unusual burial pattern. It is first worth pointing out that the picture of health
that is revealed for these individuals is for their childhood; this is obviously the case
68
for all of the populations studied, but in the case of Abydos the social context that
we have built up for them is based on their adulthood occupations. Therefore, it is
not possible to assess their health when they were working as artisans and officials
for the king. However, given that there is evidence that social status in the broadest
sense was inherited rather than acquired in early Egypt (for example, wealthy burials
of infants as well as adults have been found in several Predynastic elite cemeteries,
including at Abydos (Wilkinson 2000)), it would be reasonable to assume that
artisans and officials working for the royal court would have come from families
which had a similar relationship to the king and thus social status. We can also place
this in the context of what we know from later periods that the social standing of a
typical elite family would be largely based on the social standing of the male head of
household, most likely determined by his position within the administrative
hierarchy and thus relationship to the king (as most officials were male). Thus, we
can infer that the health of these individuals when they were children was related to
their social status as adults.
When compared to all of the other populations sampled, the Abydos group has
the lowest cribra orbitalia prevalence and average severity, the second lowest
porotic hyperostosis prevalence and the lowest porotic hyperostosis average
severity alongside the Nagada groups. These results are supported by the low values
of cribra orbitalia and porotic hyperostosis found by Keita and Boyce (2006) on the
same skeletal material. When considered in isolation, these results indicate that the
Abydos group had a good level of childhood health when compared to the other
populations. If both of these markers are indeed caused by iron-deficiency anaemia,
69
this could indicate that either the families in which these individuals grew up had
more nutritionally-rich food resources than the other groups sampled in this study
and/or that there were better social buffers within the group to protect against or
treat outbreaks of disease which lead to the loss of iron. The low average severity
scores for both stress markers indicate that even when individuals did suffer from
poor health, it tended to be of lower severity than other the populations sampled.
Moreover, the high status Abydos group appears healthier for cribra orbitalia and
porotic hyperostosis than the Tarkhan group, which most likely represents a mixture
of different social classes. Tarkhan is the closest group temporally to Abydos and so
such a comparison is particularly revealing as it minimises the effects of more
general changes in health through time. Thus, there is an argument for high status,
as defined by a close relationship with the king, correlating with good health.
Evidence from later Dynastic tomb scenes certainly indicates that high status
individuals would have eaten well and that the general diet suggested would have
provided adequate nutrients (including enough iron) to ensure good health (Duhig
2000). In Old Kingdom elite tombs, scenes commonly depict agricultural or food
production activities, which the owner is often portrayed as overseeing. Rich food
offerings are also displayed and although such scenes are usually considered as
being highly idealised they are presumably a reflection to some degree of what were
considered luxurious foods in life. Suggestion that high status individuals ate well is
also indicated by some relief and sculptural depictions of the tomb owner, in which
they are portrayed as being overweight (Darby et al. 1977). Thus, we might assume
70
that the high status individuals at Abydos would have had access to the best, and
most nutritional, food resources available during the First Dynasty.
However, in contrast LEH prevalence is very high. As the three stress markers do
not show the same trend, it is quite difficult to assess health accurately. The LEH
results need to be considered with caution as they were undoubtedly affected by the
high preservation level of teeth in comparison to other populationsAbydos had the
second highest average number of scorable posterior teeth per individualmeaning
that LEH had a higher chance of being recorded than several of the other
populations sampled.
If LEH prevalence was high in comparison to the other stress markers among the
Abydos group, this could suggest that the causes of LEH, and cribra orbitalia and
porotic hyperostosis were different and therefore that they represent different
aspects of childhood health. One possibility is that LEH was caused predominantly by
disease, but cribra orbitalia and porotic hyperostosis were predominantly nutritionbased. Such a scenario would be possible if the individuals were given better food
resources than the general population because of their enhanced family status, and
thus fewer individuals were vulnerable to cribra orbitalia and porotic hyperostosis,
and yet were still predisposed to high disease levels because they lived in a highdensity settlement. Given that the royal court was located in the capital Memphis
(Bard 2008) (Abydos was the mortuary capital at this time, not the political capital),
settlements with a large population density would be feasible, and even if the
Abydos individuals grew up in settlements other than Memphis before they took on
roles in the royal court, the general growth of urbanisation and population
71
aggregation within Egypt at the time discussed earlier would have increased the
chances of disease spread in many regions. Further investigation is needed before
any definite conclusions can be made and it is beyond the scope of this study to
examine the exact causes of poor health in detail. However, the picture gained so far
is that although these individuals might have gained some health benefits from their
high status, it was not enough to protect against the most severe stresses of the
physical environment that caused growth disruption (resulting in high LEH).
Another possible reason as to why the Abydos individuals did not have as good a
level of health as might have been expected is that they were still essentially
servants to the king. This is supported by the belief that the primary function of royal
subsidiary burials was provision for the afterlife (Kemp 1967; Bestock 2007;
OConnor 2009). The importance of having servants in the afterlife is supported by
the later appearance of servant statues within tombs. Furthermore, the subsidiary
burials represent a substantial matarialisation of power, a central theme in Egyptian
kingship to demonstrate the power of the king over the elite classes. However, in
ancient Egypt the role of kings servant was actually a very privileged position to
hold. This loyalty to the king is well demonstrated in the later Sixth Dynasty
autobiography of an official called Weni (Lichtheim 1975), who expresses great pride
in his various roles in service of three different kings. Thus, the earlier hypothesis
that the high LEH prevalence among the Abydos individuals could have been the
result of increased disease spread with urbanisation is strengthened.
72
4.2.2. High status elites and leaders of NagadaCemetery T

An analysis of the high status Nagada T group is also of interest to the issue of
health and social status in early Egypt. When analysed in the context of all of the
populations sampled in this study, Nagada T has among the lowest prevalences and
average severities of porotic hyperostosis and cribra orbitalia, and a fairly low LEH
prevalence. This may at first seem to indicate that high status did result in some
degree of good health. However, it would be more accurate to compare the Nagada
T group with the other two from the same time period grouping, in order to
minimise the effects of general changes in health over time. As it was not possible to
reconstruct the social context of the Hierakonpolis group due to poor recording of
the material when it was originally excavated, the most valid comparison is with the
Nagada B group. Such a comparison is useful as the influence of different
environmental factors between the groups is minimised due to their same location.
Earlier it was proposed that Cemetery B at Nagada was a middle-class cemetery,
whereas Cemetery T was for high status elites, probably including the early leaders
of Nagada. If the link between social status and health is accepted, the Nagada T
group would be expected to show better health than Nagada B. The results do not
support this. The two groups do not show any differentiation in the prevalence or
average severity of porotic hyperostosis, and in fact both prevalences are very low
anyway. Furthermore, only negligible differentiation is apparent in cribra orbitalia
prevalence, although Nagada T does have a lower average severity than Nagada B.
However, there is differentiation in LEH prevalence and in contrast to what is
expected; Nagada T has a higher LEH prevalence than Nagada B. Differential tooth
preservation between the groups is unlikely to have had a large effect on the
73
observed differences as it was actually Nagada B that had a higher number of

scorable posterior teeth per individual. When all results are considered, the higher
status Nagada T individuals do not have a better level of health than the lower status
Nagada B individuals, and in fact it could be tentatively suggested that their health is
poorer.
Why should high status elites not have a better level of health than lower status
individuals? The most likely explanation is that both groups still grew up in (see
earlier discussion on how childhood health is linked to adult social status) and lived
in the same region of Nagada, which was the centre of one of the suggested protostates (Kemp 2006) at the time and thus an important urban centre. Therefore, both
were subjected to the same health risks that this entailed, i.e. higher disease
prevalence and perhaps poorer sanitation than a more rural area. On this logic, the
higher LEH prevalence in the Nagada T group could be due to the presence of
individuals who lived during the Nagada III period, in which we see increased
urbanisation. It could thus be said that high social status did not buffer individuals
from the negative effects of urbanisation on health, a suggestion also relevant to the
Abydos individuals. It is nonetheless surprising that cribra orbitalia and porotic
hyperostosis did not occur at significantly lower prevalences among the Nagada T
individuals than the Nagada B individuals, if they are indeed caused by irondeficiency anaemia. Even if the anaemia was caused predominantly by disease, the
biological environment of the two groups would have been similar given their same
location. One would expect that the higher status Nagada T individuals would have a
more nutritionally-rich diet, which included more iron-rich foods.
74
4.2.3. Health and gender

Gender is an interesting issue related to social status in ancient Egypt because
although women had the same legal rights as men, in reality they seemed to not be
able to exercise these rights to the same extent (Fischer 1989; Ward 1986). This may
suggest that their social status was lower than that of men. In this study no
significant differences were observed in the prevalence of any of the stress markers
between males and females. Although this result must be treated with caution as the
number of individuals assigned female status far outnumbered the number of males,
this observation does suggest that there were no obvious distinctions in the overall
health of males and females in childhood. Other studies of skeletal health in early
Egypt and Nubia have found a similar lack of differentiation by sex (Keita & Boyce
2006; Starling 2005). The lack of differentiation in all three stress markers is
suggestive of similar food resources, healthcare and/or living conditions among
children of both sexes in early Egypt; we may also infer that this was the case in
adulthood too. Studies of burial practices in Predynastic Egypt support this claim in
that there appear to be no consistent differences between males and females. One
study by Podzorski (1993), which examined tomb size, burial good richness and
diversity, and artefact preferences in relation to age and sex in the Predynastic
cemetery at Naga-ed-Der, found no significant wealth differences between men and
women through time. The lack of sex distinction in health found in the present study
tentatively suggests that in some aspects of life, men and women were of a similar
social status in early Egypt.
75
CHAPTER 5 SUMMARY AND CONCLUSION

This study has measured skeletal stress markers caused by disease and
malnutrition to quantify health differences between populations occupying early
Egypt. The results have suggested that health did indeed change over the period of
state formation. After an initially high level of skeletal stress apparent among the
first agriculturalists, health appeared to improve in the Mid Predynastic period as the
diet became more nutritionally diverse and agricultural surplus was being produced.
The decline in skeletal stress was seen in groups of different social status, indicating
that the new food resources were not being diverted solely to the powerful elite
classes. Health then declined again in the Nagada III period as Egypt became more
urbanised and the population aggregated towards key settlements and political
centres. This is likely linked to increased disease prevalence and decreased sanitation
due to increasing population density. Moreover, it has been speculated that
urbanisation did not begin to have a negative effect on health before the Nagada III
period. Thus, the period of political unification of Egypt was a difficult time for its
inhabitants.
This study has revealed that high social status did not necessarily confer better
health on individuals in early Egypt. The court officials and artisans buried at Abydos
do seem to have gained some protection against ill-health from their association
with the royal court, probably through having access to a more nutritional diet, but
this was evidently not sufficient to buffer them from the more severe stresses of the
environment caused by urbanisation. Moreover, the high status elites and possible
early leaders buried in Cemetery T at Nagada did not appear to be healthier than the
76
lower status individuals from Cemetery B. Again, this may suggest that the health
risks associated with urbanisation had a negative impact on people regardless of
their social status.
The relationship between the health and the environment is complex and there
are obviously limitations in what skeletal data can reveal about cultural change.
Perhaps the biggest hindrance arises from the general neglect of the earliest
excavations in Egypt to record skeletal remains with the level of detail they require.
Multiple interpretations are also possible from the measurement of stress marker
frequencies and their exact causes are still debated, but by linking the data closely
with the archaeological evidence the most important causes of the observed
differences in health can be ascertained. This study has gone further than others in
relating the skeletal material back to its original context as much as possible.
The results of this study have raised several issues that need to be addressed in
more detail in future research, such as whether urbanisation had the same effects
on health across the whole of Egypt and whether or not there was a relationship
between health and social status in later periods. Where time allows, larger sample
sizes of the same skeletal populations examined in this study would increase the
reliability of the statistical analyses used. Future research should continue to focus
on investigating changes in skeletal health over relatively short periods of time. Only
by doing this can the most likely cultural factors underlying any changes be revealed.
Most importantly, by looking at social status a number of new questions have been
raised, demonstrating the promise of this approach.
77
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APPENDICES
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Skeletal Health in Early Egypt MPhil Thesis Sarah Musselwhite

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SKELETAL HEALTH IN EARLY EGYPT

The Effects of Cultural Change and Social Status

2. DATA AND METHODS

The Nagada I period onwards

5. SUMMARY AND CONCLUSION

Figure 19 - Percentage of individuals with porotic hyperostosis severity score 2 or

1.2. What determines health?

1.3. Health and cultural change

1.4. Health and social status

1.5. How do you measure skeletal health?

1.5.1. Skeletal stress markers

1.5.2. Linear enamel hypoplasias

Figure 1 - Linear enamel hypoplasia bands (Adapted from: (Larsen 1998))

1.5.3. Porotic hyperostosis and cribra orbitalia

not remodelled. Thus they are indicative of childhood health (Stuart-Macadam

Figure 2 - Porotic hyperostosis (Source: (Gregg & Gregg 1997))

1.5.4. Childhood health

1.5.5. The osteological paradox

1.6. Previous studies of skeletal health in Egypt

1.7. Research aims and contribution

CHAPTER 2 DATA AND METHODS

Table 1 - Origins of the skeletal material used in this study

Excavator(s) of skeletal material &

El-Badari Badarian graves

Brunton & Caton-Thompson (1928)

Hierakonpolis Prehistoric &

Mainly Nagada II period,

Quibell & Green (1902)

Mainly Nagada II period

Petrie & Quibell (1896)

Nagada II & III period

Petrie & Quibell (1896)

Mainly Nagada III period,

To reconstruct the original archaeological context of the skeletal material the

2.1.1. El-Badari (Appendix A1)

2.1.3. Nagada B (Appendix A2)

2.1.4. Nagada T (Appendix A3)

tomb. The similar treatment of subadults as adults in burial suggests a degree of

2.1.5. Tarkhan (Appendix A4)

2.1.6. Abydos (Appendix A5)

2.2. Sampling procedure

2.3. Assigning age and sex

Rugosity of the nuchal crest

Size of the mastoid process

Thickness of the supraorbital margin

Prominence of the supraorbital ridge

Size of the mental eminence

2.4. Measuring the skeletal stress markers

2.4.2. Porotic hyperostosis and cribra orbitalia

Indistinct porosity/barely visible

True porosity with coalesced foramina

True porosity with coalesced foramina

2.5. Data analysis

3.1. Inter-population differences in stress markers

However, a more accurate and reliable measure of variation in cribra orbitalia

Figure 9 - Percentage of individuals with cribra orbitalia severity score 2 or above,

Figure 11 - Average severity of cribra orbitalia in each population

3.1.1.3. Temporal trends

3.1.2. Porotic hyperostosis

Figure 14 - Percentage of individuals with porotic hyperostosis severity score 1 or

Figure 15 - Percentage of individuals with porotic hyperostosis severity score 2 or

Figure 17 - Average severity of porotic hyperostosis in each population

Figure 18 - Percentage of individuals with severe porotic hyperostosis (scores 3 &