Unsanitary Urbanism? Rethinking Pathology in Imperial Rome
K. Killgrove, UNC Chapel Hill

Paper presented at the Paleopathology Association Meetings, April 12, 2011, in Minneapolis, MN.


Life in Imperial Rome was by all accounts crowded, unsanitary, violent, and impoverished. In an often-cited article on sanitation, Alex Scobie (1986) undertook a textual and archaeological assessment of lower class Roman living conditions. He suggested that diseases such as cholera and typhoid were likely widespread owing to food and water contamination from open latrines in the kitchen and defecation and urination in the streets. There is also ample historical evidence from such ancient authors as Celsus and Pliny the Younger attesting to the presence of diseases like malaria, leprosy, and tuberculosis in the population. A growing collection of skeletal evidence from Rome, particularly the Imperial period, is now allowing bioarchaeologists to approach the question of health from a biological standpoint. Nevertheless, in recent articles comparing skeletal health in the Empire, the authors ignore data from Roman cemeteries with low rates of pathologies, and conclude that a poor diet, unsanitary living conditions, and endemic malaria were the norm in Rome. This afternoon, I'm going to talk about the two most common pathologies used to investigate skeletal health (CO and LEH). I'll present their frequencies in two populations I studied from Rome, and then I'll compare my data to those from other published Imperial Roman cemeteries. My goals with this research are to call into question the standard narrative of poor Roman health and to bring into better focus the quality of life of the lower classes in Rome.

Image 1


At the height of the Roman Empire, the capital city had around 1 million people, meaning it had a population density comparable to modern-day Mumbai, and the suburbs of Rome included another half a million people. For religious and hygienic reasons, burials were made outside the city walls. My research involves two cemeteries that date roughly to the 1st-3rd centuries AD and that are dominated by lower-class burial forms. Periurban Casal Bertone was found 2km east of the city walls of Rome. In 2000, excavators on this salvage project uncovered an Imperial-period mausoleum and a necropolis, which yielded 138 skeletons. The second population, Castellaccio Europarco, comes from more of a haphazard burial area located about 12km south of Rome in its suburbs, and this site yielded 45 individuals.

Image 2

The demographics of the skeletal populations can be seen here. In general, the distribution of age-at-death is what we might expect from a preindustrial population. As you can see, there is an underrepresentation of adult females in both populations, with males outnumbering females 2:1 at Casal Bertone and more than 3:1 at Castellaccio. We might also expect to see more subadults than we do here, and this underrepresentation may be a result of, for example, intramural burial of infants in Rome.

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Methods and Results

I collected pathological data from all 183 skeletons based on guidelines in Standards. Most of these data, however, were not comparable to other published sites in the Roman suburbs owing to underreporting, lack of analysis, or differences in methodologies. Two key indicators of poor skeletal health - cribra orbitalia and enamel hypoplasias - could be fairly compared with frequencies at other sites around the province of Latium.

Hematopoietic. Bioarchaeologists who work in the Italian peninsula are especially interested in porotic hyperostosis, specifically CO, as evidence of endemic malaria and hereditary hemolytic anemias. J.L. Angel was the first to show high PH frequencies in the Mediterranean, and numerous researchers since then have used PH as an indicator of malaria, poor diet, and lack of sanitation. Most osteologists record CO as either the crude prevalence rate (# of individuals with CO / # of individuals in population) or the true prevalence rate (# of eye sockets with CO / total # of eye sockets examined) - I did both. The frequency of cribra orbitalia in the two study populations are similar: 17.5% and 14.5% at CB and 13.6% and 15.4% at CE. Neither population has any evidence of the disease process in females, although this sex is underrepresented in the sample. At CB, roughly 37% of all subadults were affected by CO, and at CE roughly 30% were. I scored the lesions using both Standards and Hengen. The orbital lesions are mostly inactive or healing, with only one that may have been an active hyperostotic lesion at death (pic). Image 4
The Imperial sites that provide comparative palaeopathological data are seen here, arranged based on increasing distance from the city walls of Rome, with the study sites highlighted in bold. There appears to be no clear pattern to the frequency data on porotic hyperostosis. The sites of Basiliano, Osteria del Curato, Vallerano, and Lucus Feroniae have been reasonably well published and all present high crude prevalence rates of cribra orbitalia in the populations. Of the well-studied sites, Casal Bertone and Castellaccio Europarco present the lowest crude prevalence rates of cribra orbitalia.

Interestingly, a publication by Ottini and colleagues (2001) notes that Quadraro, about midway between the two study sites geographically, had a cribra orbitalia frequency of 8%. The authors further note that Gabii and San Vittorino, located a few dozen kilometers past Rome, had absolutely no indication of cribra orbitalia. However, both Italian and British researchers who have tried to take a comparative perspective on Roman health have strangely ignored this publication (Gowland & Garnsey 2010; Gowland & Redfern 2010), perhaps because of the small sample sizes. Nevertheless, the sex ratios in two of the samples were balanced, and subadults were included as well. Without the information from these three sites, the overall frequency of CO in the Roman population appears to be quite high, ranging from 50-80%. Gowland and Garnsey, for instance, conclude from these data that Romans had a poor diet and insanitary living conditions in the city, and also propose that the distribution of CO in the Rome area is related to endemic malaria.

The CO data from Casal Bertone and Castellaccio, as well as from the small samples of Quadraro, Gabii, and San Vittorino, directly contradict the assumption that all Romans were unhealthy. These vast differences could be related to observer method or error, or to the taphonomy of the sample. However, they could also mean a real, underlying heterogeneity in the populations of Rome and its suburbs, and in the disease ecology of the region.

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Enamel Hypoplasia. In the bioarchaeological literature, linear enamel hypoplasia frequencies are often reported as general indicators of the health problems and physiological stresses experienced by children while their teeth were forming. Because of the assumed poor diet and unsanitary living conditions in Rome, it would not be unusual to see high frequencies of LEH within the skeletal population. Most osteologists working in Rome report LEH as true prevalence rate (# of teeth with LEH / # of teeth observable), and they score all teeth, not just anterior teeth. At Casal Bertone, 2.2% of the teeth (TPR) examined had evidence of LEH. Out of the individuals who presented at least one adult tooth (CPR), 19% had at least one hypoplasia. At Castellaccio Europarco, 2.5% of teeth (TPR) presented a linear enamel hypoplasia, and 16% of the population (CPR) had at least one hypoplasia. There were too few individuals with hypoplasias to investigate meaningful sex or age differences in their frequency. Image 6
Again based on increasing distance from Rome, the comparative data can be seen here. LEH is not as widely reported from Roman populations as CO. Frequencies (TPR) of enamel hypoplasias have been reliably reported from only Basiliano, Vallerano, and Lucus Feroniae, but they are all shockingly higher than the ones from Casal Bertone and Castellaccio Europarco. Cucina and colleagues report quite thoroughly on the Vallerano teeth, and, as noted before, this sample is clearly comparable in terms of geographic location, age-at-death, sex, and sample size to Castellaccio in particular.

It is, of course, possible that differences in inter-observer identification or recording practices for LEH contributed to these numbers (e.g., mistaking large perikymata for LEH). I would suggest instead, though, that a variety of factors, such as nutrition, water sources, and disease ecology, contributed to the differential enamel hypoplasia frequencies at these four Rome-area sites.

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In terms of comparative health measures for populations around the Roman suburbs, only CO and LEH are reported widely enough to provide data from different locations. It is currently unclear what specifically caused the anemic reactions evident from CO, making it difficult to draw conclusions about the relative health of the populations based on this single marker of nonspecific disease. It is surprising, then, that Gowland and Garnsey, for example, reached the conclusion that "[With] high levels of health stress as attested by the prevalence of CO and LEH [...] Rome was an unhealthy place to live" (2010, p. 149). Their comparative study specifically posits that endemic malaria is responsible for the high frequencies of CO in Roman skeletal populations. The distribution of malaria may indeed have been related to the topography of the hilly city and to living near the Tiber River, meaning we would expect to see differences in disease ecology throughout the city and suburbs. The pathology data from CB and CE strongly support differences in physiological stress within the Roman population. However, it's also key to note that CB and CE were both within 2kms of sites with high frequencies of CO, meaning topography cannot be the only explanation for the differences observed. For example, comparing the data published from periurban Basiliano with that from periurban Casal Bertone indicates that CB was much healthier using this metric. And when we combine the CO data with LEH frequencies, suburban Castellaccio Europarco appears to have been a much healthier population than the neighboring suburban site of Vallerano.

Some of the people from periurban Casal Bertone and even suburban Castellaccio likely lived in the urban area of Rome at some point in their lives. As presumably lower-class individuals, their accommodations might have been in slums or other poor housing conditions. The possibility of geographical movement both to and within Rome and its suburbs, however, is extremely important in creating the skeletal assemblages we see in the bioarchaeological record. Immigration brought people from all ends of the Empire to Rome, along with new pathogens and differential susceptibility to disease. Movement around the city likely included visits to public baths and other sanitary conveniences not enjoyed by most preindustrial societies. The less-crowded suburbs might have promised a better quality of life compared to the city, or, conversely, its role in heavy industry disallowed within the city walls (such as lead production) could have made parts of the suburbs a worse place to live.

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Conclusion It is therefore short-sighted to make the blanket statement that life in Rome was nasty, violent, and short. Rather than glossing over the frequencies that don.t match the expectations of a population-dense urban center, it is imperative that we take a closer look at CO, LEH, and other pathologies within Roman populations. The lives of the lower classes were complex, and people living in Rome and its suburbs had wide-ranging, heterogeneous experiences in the urban center. To the extent that these experiences are written on their bodies, it is possible to explore differential exposure to pathogens, levels of physiological stress, and health outcomes. Investigating possible reasons for the heterogeneity seen in the palaeopathological record of Rome will allow us to gain a better understanding of the average Roman.s quality of life.

Selected Bibliography


This research was supported by grants from the NSF (BCS-0622452) and the Wenner-Gren Foundation. Thanks are extended to Paola Catalano of the Soprintendenza Archaeologica di Roma for access to the skeletons.

Author's Contact Information:

Kristina Killgrove, PhD
University of North Carolina
Department of Anthropology
108-A Alumni BLDG, CB#3120
Chapel Hill, NC 27599 USA