A paleoepidemiological approach to the osteological paradox: Investigating stress, frailty and resilience through cribra orbitalia

Objectives: The Osteological Paradox posits that skeletal lesions may differentially be interpreted as representing resilience or frailty. However, specific consideration of the etiologies and demographic distributions of individual skeletal indicators can inform the criteria on which to differentiate stress, frailty, and resilience. Adopting a life history approach and adaptive plasticity model, this study proposes a framework for the analysis and interpretation of a commonly reported skeletal lesion, cribra orbitalia, which considers the underlying mechanisms of the condition, the clinical and epidemiological literature relating to anemia and malnutrition, and the bioarcheological evidence. Materials and methods: Data were extracted from the European (n = 33 populations) and American (n = 19 populations) modules of the Global History of Health Project. Kaplan–Meier and Cox regression analyses were applied, where time was the age-at-death, and the factor or covariate was presence or absence of cribra orbitalia. Results: Of 37 samples that produced significant results, 21 demonstrated a change in relationship when the subadults were excluded from analysis. When subadults were included, individuals with cribra orbitalia present had statistically significant lower survival time. With subadults excluded, the relationship either became nonsignificant or was reversed. Discussion: We demonstrate that in many cases the inclusion of subadults in analysis impacts upon the apparent mortality associated with cribra orbitalia. Examining cribra orbitalia in children and adults has two separate goals: in children, to determine the prevalence and risk of death associated with active lesions and stress; and in adults, to determine whether childhood health assaults that cause cribra orbitalia are associated with frailty or resilience.