Closer to godliness: a contextual study of osteoarchaeological and spatial patterns of diseased individuals in medieval Danish cemeteries

Introduction: Medieval Danish populations (c. 1050-1536 AD) faced numerous infectious diseases, including leprosy and tuberculosis, that shaped modern perceptions of medieval health crises. While previous studies explored disease spread and mitigating factors like leprosaria, it remains unclear how health status influenced burial treatment and placement within church cemeteries. Cemetery analyses may also clarify whether urban-rural mortality differences were affected by proximity to care institutions. This study integrates paleoepidemiology and spatial archaeology to examine health and death treatments in 939 adults from three urban and two rural medieval Danish collections.

Methods: Bone involving disease prevalence was estimated using probabilistic estimates of sensitivity and specificity from skeletal indicators of leprosy and tuberculosis, enabling spatial comparisons of infected and non-infected individuals across cemeteries. Differential survivorship and mortality hazards were evaluated using Kaplan-Meier and Cox regression analyses.

Results: Results showed no distinct patterns of clustering of skeletons with positive disease states that suggest specific treatment of disease sufferers in death, but notable variation was found in burial status distribution and survivorship between cemeteries with high status individuals having lower mortality. No significant survivorship differences existed between those with and without leprosy, whereas tuberculosis-positive individuals had significantly higher survivorship than non-lesioned peers (p < 0.001).

Discussion: The absence of leprosy sufferers in urban cemeteries reinforces leprosaria's selective effect on burial placement, while tuberculosis prevalence was high across all cemeteries, indicating no differential treatment. This study demonstrates medieval Danes' complex relationship with disease, status, and burial practices.

1 Introduction

The modern imagination often paints the European medieval period as a dismal existence for the majority of people, particularly those afflicted with disease. Indeed, this view is exemplified in the film Monty Python and the Holy Grail, where twentieth-century actors cosplay as medieval town and county folks, portraying the muck of medieval life between the bickering couple in the fields to Eric Idle's resounding call of “bring out your dead,” while townsfolk pile their plague-ridden family members on a dilapidated cart. This bleak scene also displays widely held beliefs about how medieval society responded to major health crises. To a twenty-first-century viewer, this reinforces a familiar narrative about medieval society, one that characterizes people as unknowledgeable and defenseless against a slew of diseases, such as bubonic plague, tuberculosis (TB), and leprosy (Hansen's disease). It also reinforces the pervasive notion that medieval cities were “constantly foul-smelling and full of filth, owing to the lack of closed sewers and private or public conveniences, to the custom of throwing refuse in the street, and to the failure of the municipal authorities to clean the pavements” (Thorndike, 1928). Whether medieval towns were homogenous cesspools of filth remains for a matter of historical debate (Thorndike, 1928; Lofrano and Brown, 2010; Ewert, 2007; Jørgensen, 2008, 2013, 2007, 2014; Rawcliffe, 2013), although most widespread efforts to implement systematic waste handling did not take effect until the late medieval period (Koch and Trolle, 2000). Nevertheless, medieval towns have been repeatedly associated with disease, which, to the medieval mind, was connected to the wellbeing of one's soul and the nature and location of its resting place after shuffling off this mortal coil.

Osteoarchaeological research has widened our understanding of medieval perceptions and treatment of certain infectious diseases (Boldsen and Mollerup, 2006; Boldsen, 2009; Roffey and Tucker, 2012; Roberts, 2017; Roberts et al., 2002; Roberts, 2020) and shed light on past disease patterns in urban and rural communities (Betsinger and DeWitte, 2020; Kelmelis et al., 2020; Betsinger and DeWitte, 2021; DeWitte and Wood, 2008; Graff et al., 2020; Kelmelis and Pedersen, 2019; Walter and DeWitte, 2017; Pedersen et al., 2019). However, there is limited understanding about whether our perceptions of medieval stigma attached to certain diseases, such as leprosy and TB, affected the manner of burial of the sick compared with those of the unafflicted. Specifically, we anticipate that those who were noticeably sick with stigmatized illnesses would be buried differently than those without those conditions, even within urban spaces where disease was seemingly more prevalent. For instance, Roffey and Tucker (2012) questioned some of the interpretations about the status of institutions like leprosy hospitals or leprosaria and the social perceptions of those who were interred in their cemeteries in St. Mary Magdalen in Winchester, England. Their findings indicate that individuals bearing skeletal evidence of leprotic infection were buried with similar levels of intention and respect that one would expect with respect to unaffected individuals, which is contrary to the traditional perception of leprosy patients as social pariahs and outcasts (Brenner, 2010; Touati, 2017; Brody, 1974; Covey, 2001). In Denmark, paleoepidemiological analyses of leprotic infection in rural and urban cemeteries have revealed a complex relationship between pathogens, people, and societal responses to stigmatized conditions (Boldsen and Mollerup, 2006; Boldsen, 2009; Kelmelis et al., 2020; Kelmelis and Pedersen, 2019; Pedersen et al., 2019; Boldsen, 2005b, 2001, 2005a; Kelmelis et al., 2017). Boldsen and Mollerup (2006) and Kelmelis et al. (2020) found that leprosaria in urban centers may have resulted in the decline in burials of individuals with severe, specifically facial, manifestations of leprosy in parish cemeteries. Kelmelis et al. (2020) also found that there were markedly different patterns of TB and leprosy prevalence in urban and rural communities, perhaps due to differing underlying disease epidemiology, social mitigation, and spreading factors. These findings support the notion that medieval diagnoses of infectious conditions—even if they lacked the precise knowledge of the contagion and its mechanics—were more accurate than originally believed, particularly for those individuals who had visible, often severe, symptoms. They also show that not everyone with infectious disease was segregated to a hospital cemetery, which challenges the assumption that those with stigmatized diseases were collectively relocated to such institutions. Rather, scholars have suggested that these institutions served less as confinement for afflicted souls and more as charitable organizations associated with religious houses and monasteries with the ability to care for those with disease and infirmity (Roffey and Tucker, 2012; Roberts, 2020; Brenner, 2010,?; Covey, 2001; Richards, 1977).

This scholarship presents a rather complex picture of the medieval mindset around disease and societal responses to those afflicted. On the one hand, there is the base assumption that the sick were ostracized and locked away from the rest of the world in life (Browne, 1975, 1962) and, as a result, in death because of their perceived sickness of the soul; that is, bodily disease was a symptom of sinful behavior, and isolating sinners was best for the broader community. On the other hand, critical scholarship indicates that medieval religious and charitable institutions were places of physical and spiritual care for the ill (Rawcliffe, 2013; Touati, 2017; Covey, 2001; Demaitre, 2007). Cemeteries associated with these institutions included individuals representing a much broader range of afflictions and demographic distribution than assumed. Furthermore, parish cemeteries in rural and urban communities demonstrate that not all individuals with evidence of disease were confined to hospital or monastic cemeteries (Roberts, 2020; Demaitre, 2007) but that, in many cases, those who were severely afflicted, particularly in urban settings, were buried within these institutional contexts (Boldsen and Mollerup, 2006; Segal, 2001). There is limited exploration, however, into the interpretation of the medieval social implications about disease in the osteoarchaeological and spatial arrangement of burials within non-leprosaria cemeteries, since leprosaria cemeteries were generally located in towns and could not support entire urban and adjoining rural populations. This study examines the paleoepidemiological and spatial patterns of individuals with skeletal evidence of TB and leprosy within five cemetery samples from urban and rural Denmark to explore how the arrangement of diseased individuals reflects medieval perceptions of disease. We focus on the identification of individuals with skeletal evidence of leprosy and TB, two chronic infectious diseases that were prevalent and purportedly stigmatized during the medieval period in Denmark. The cemetery samples included in this study date to the Danish medieval period (c. 1050–1536 AD) and are sourced from two urban centers, Ribe and Viborg, and rural villages in Jutland (Figure 1). We will discuss the osteoarchaeological and spatial arrangements of each cemetery within the discourse on death practice patterns as a response to socially perceived crises of health and morality.

Figure 1

Figure 1. Map of Denmark showing locations of sites contributing skeletal material to this study. Map: Edited by Dorthe Dangvared Pedersen, OpenStreetMap and QGIS.

1.1 Leprosy and TB pathogenesis

In medieval Denmark (c. 1050–1536 AD), along with much of Northern Europe, TB and leprosy were widespread and had a profound impact on the social and biological fabrics of medieval society (Boldsen, 2009; Kelmelis et al., 2020; Kelmelis and Pedersen, 2019; Pedersen et al., 2019; Boldsen, 2005b, 2001, 2005a; Kelmelis et al., 2017; Bennike, 1985; Stone et al., 2009; Roberts and Buikstra, 2003; Møller-Christensen, 1953, 1961, 1978, 1974). Both diseases have been widely correlated with urban landscapes in paleopathology and more broadly in bioarchaeology (Stone et al., 2009; Roberts and Buikstra, 2003). In particular, leprosy has been historically associated with medieval urbanization, poverty, and stigma (Roberts, 2020; Brody, 1974; Richards, 1977; Roberts, 2011; Richards, 1990). Leprosy is a chronic infection caused by the acid-fast bacteria Mycobacterium leprae, which affects the skin, nerves, bone, and adjacent tissues (Aufderheide and Rodríguez-Martín, 1998; Ortner, 2003; Pardillo et al., 2007; Ridley and Jopling, 1966; Roberts and Manchester, 2007). There are several expressions of the disease, including paucibacillary (tuberculoid), multibacillary (lepromateous), and borderline forms, although the appearance and severity of these largely depend on the host's underlying immune response (Aufderheide and Rodríguez-Martín, 1998; Ortner, 2003; Pardillo et al., 2007; Ridley and Jopling, 1966). For this and other paleoepidemiological analyses (Kelmelis and Pedersen, 2019), we consider those skeletal manifestations caused by the lepromateous form since these are most likely to appear on osseous materials (Aufderheide and Rodríguez-Martín, 1998). Leprosy is generally believed to be transmitted by infected droplets and has a long incubation period, with only a small proportion of individuals developing clinical symptoms (CDC, 2024; WHO, 2023). While there remain questions about how leprosy spreads between human, non-human primate, and other mammalian hosts and environmental sources (Hockings et al., 2021; Suzuki et al., 2011; Avanzi et al., 2016; Meyers et al., 1985; Truman, 2005), genomic studies have shown that there were likely multiple coexisting strains of M. leprae that caused this disease in the medieval world (Singh et al., 2015; Krause-Kyora et al., 2018; Schuenemann et al., 2018; Urban et al., 2021; Donoghue, 2013; Donoghue et al., 2015a). M. leprae affects specific areas of the skeleton by extension of the skin or mucosal lepromas or hematogenously (e.g., rhinomaxillary region or faces leprosa), although secondary infections can develop by extension of infected soft tissue (e.g., bones of the hands, feet, and lower limbs; Roberts et al., 2002; Møller-Christensen, 1953, 1961; Ortner, 2003; Roberts and Manchester, 2007). This propensity allows for paleopathological and paleoepidemiological assessment of leprosy in skeletal assemblages with the possibility of distinguishing it from other chronic skeletal infections (Boldsen, 2009, 2005b,a; Roberts and Manchester, 2007).

Mycobacterium tuberculosis is the main causative agent for TB in humans and is part of the broader Mycobacterium tuberculosis complex (MTBC) that includes nine human and animal lineages (Stone et al., 2009; Roberts and Buikstra, 2003; Roberts, 2011; Stone, 2017; Taylor et al., 2005; Senelle et al., 2023; Donoghue, 2017). TB is transmitted through airborne droplets, typically through the respiratory route, which can further disseminate into adjacent tissues including bone (i.e., ribs, vertebrae, and joint surfaces; Roberts and Buikstra, 2003; Ortner, 2003; Pedersen et al., 2019; DeWitte et al., 2022). The paleopathological criteria for identifying and distinguishing tuberculoid osseous lesions have been widely explored in archaeological materials (Kelmelis et al., 2020; Kelmelis and Pedersen, 2019; Stone et al., 2009; Roberts and Buikstra, 2003; Ortner, 2003; Pedersen et al., 2019) and modern samples (Pedersen et al., 2019; Kelley and El-Najjar, 1980; Kelley and Micozzi, 1984; Redman et al., 2009; Masiu et al., 2023; Santos and Roberts, 2006). While TB tends to have low skeletal involvement overall, likely as an effect of its high comorbidity with other infectious diseases [e.g., human immunodeficiency virus (HIV); Stone et al., 2009; Roberts and Buikstra, 2003], paleoepidemiological approaches have shown that tuberculoid lesions tend to manifest on skeletal elements associated with pulmonary infection and joint infection (Kelmelis and Pedersen, 2019; Pedersen et al., 2019,?; Milner and Boldsen, 2017). Similar to leprosy, TB has long been associated with unsanitary living conditions, diet, population growth, and urban intensification in archaeological analyses of past health (Roberts and Buikstra, 2003). Studies on the relationship between medieval urbanization and infectious diseases have provided some clarity on the host–pathogen interactions within the scope of rising populations, social inequality and stigma, competing epidemics, and climatic changes during the eleventh to sixteenth centuries in continental Europe (Kelmelis et al., 2020; Kelmelis and Pedersen, 2019; Stone et al., 2009; Donoghue, 2013; Barnes et al., 2011; Donoghue et al., 2015b). Relevant to this study, the body of work in medieval Denmark has painted a complex picture of how medieval urban and rural communities interacted with both diseases and how social and economic behaviors may have contributed to and mitigated their spread (Boldsen and Mollerup, 2006; Kelmelis et al., 2020; Kelmelis and Pedersen, 2019; Pedersen et al., 2019,?; Segal, 2001). For instance, Kelmelis and Pedersen (2019) showed that bone-involving TB was more prevalent among medieval populations compared to leprosy, which may reflect the selective function of leprosaria in towns where individuals with facial lesions took refuge and were buried (Boldsen and Mollerup, 2006; Kelmelis et al., 2020; Segal, 2001). Our analyses also showed that skeletal TB was more prevalent in rural populations, which could indicate increased contact with urban dwellers through town markets, excess survival to chronic disease stages, and community differences in competing causes of death. It is also worth noting that urban communities would have dealt with greater disease exposure, including the rising prevalence of TB during the medieval period, which might have led to greater comorbidity-related mortality for those who also carried the bacteria (Donoghue et al., 2005), although this is debated (Roberts, 2020; Crespo et al., 2019). TB, which is not well-observed skeletally prior to the medieval period, apparently increased in prevalence with population growth and agglomeration in Denmark (Pedersen et al., 2019,?).

1.2 Societal responses to victims of chronic infectious diseases in Denmark

Medieval Danes were undoubtedly exposed to a multitude of stressors in both urban and rural spaces, including episodic droughts and reoccurring epidemics, emerging diseases (e.g., the Second Plague Pandemic), conflict and revolts, and additional stressors of urban expansion. While leprosy and TB are often paired in the bioarchaeological literature (Stone et al., 2009; Roberts and Manchester, 2007; Donoghue, 2013; Donoghue et al., 2015b, 2005), knowledge about how medieval Danes responded to these epidemics is mostly focused on leprosy, while TB attracted considerably more attention during the early modern period. There is limited skeletal evidence that leprosy was a public health issue during the Viking Age (c. 800–1050 AD; Bennike, 1985). However, osteoarchaeological and historical evidence indicates that leprosy was, indeed, a reason for public concern by the medieval period (Boldsen, 2009; Bennike, 1985). The kingdom of Denmark saw a notable increase in leprosaria from 1250 to 1550 AD, with over 40 institutions by the time of Protestant Reformation (c. 1536 AD; Arentoft, 1999). This marked increase may have reflected the broad societal awareness of the growing prevalence of the disease as a consequence of increasing population size and density in the urban landscape (Arentoft, 1999). This response was by no means unique to Denmark as several other European countries increased their number of leprosaria, totaling over 19,000 by some accounts, in response to laws concerning those afflicted with leprosy [see, for example, the Edict of King Rothar, the Synod of Orléans (549 AD), the Third Council of Lyon (583 AD), and the Third Lateran Council (1179 AD); Richards, 1977; Wollina et al., 2025; Cule, 2002]. This series of papal and municipal mandates, along with biblical passages from Leviticus (13:46, 14:2), led nineteenth- and twentieth-century scholars to interpret afflicted individuals as social outcasts, although recent critiques have suggested that this perception is derived more from modern attitudes (Roffey and Tucker, 2012; Brenner, 2010; Touati, 2017; Tanner, 1990). It is also worth exercising caution with respect to interpreting the breadth and scope of these institutions and those who resided within their walls. Furthermore, leprosaria may have generally served as a place of refuge for individuals who suffered from any number of ailments aside from leprosy, especially during the late medieval period. These institutions acted as places where those with illness could find religious vocation (Brenner, 2010; Covey, 2001) and receive treatment in the form of rest, food, and prayer for bodily and spiritual ailments (Roberts, 2017; Roberts et al., 2002; Roberts, 2020; Wollina et al., 2025).

Nevertheless, leprosaria played an important role in the fabric of medieval life and in reconstructions of past disease prevalence. According to paleoepidemiological analyses in Odense, leprosaria may have added a filtering effect on disease prevalence estimates in parish cemeteries, where individuals with visible, severe symptoms were selectively removed from the “healthy” community to seek refuge and eventual burial in leprosaria (Boldsen and Mollerup, 2006). It is perhaps because of this selection bias that previous analyses found that rural cemeteries had a higher prevalence of leprosy in skeletal assemblages than those in urban cemeteries, since those with severe infection in towns would likely have sought refuge in leprosaria (Kelmelis et al., 2020; Boldsen et al., 2013). As such, rural community cemeteries and those associated with rural monasteries often included individuals both with and without evidence of disease. It is not clear, however, whether disease status in life afforded one differential burial placement within these cemeteries.

Little is known about the presence of TB and the perception of its sufferers in medieval Denmark. TB is, however, well-described from historical sources dating as far back as the third millennia BCE from other geographical regions (Herzog, 1998; Frith, 2014). Though the term TB was not introduced until the eighteenth century, a chronic lung disease and “wasting disease” is mentioned in ancient Babylonian and Chinese texts dated as far back as the third millennium BCE (Herzog, 1998). The ancient Greek physician Hippocrates (460–370 BC) describes the symptoms of the disease phthisis as a weakness of the lungs, causing fever and cough (Frith, 2014). Furthermore, Hippocrates mentions that it was the most common disease at the time and was usually fatal (Herzog, 1998). During the seventeenth century, the association between phthisis, consumption, and scrofula was described by Dutch physician Sylvius de la Boë (Herzog, 1998). Scrofula, tuberculous cervical lymphadenitis, is widely mentioned in medieval French and British texts. Here, it is described as a common but dreaded disease that was sought to be cured by the “Royal touch” by the time of King Clovis of France (487–511 AD). During the 25-year reign of British king Charles II (1660–1685 AD), more than 92,000 had been touched by the king in the hope of being cured, which reflects the extent of the disease (Bynum, 2012). As argued by Roberts and Buikstra (2003), TB sufferers would likely have been accepted in society because the disease, unlike leprosy, left no visible signs until very late in its progression when skeletal damage could arise. Those infected with TB would usually show symptoms such as coughing, chest pain, and general weakness that would not be easily detectable. With no recognizable signs of disease and likely no knowledge at the time about the mode of transmission, TB sufferers were likely not treated in any way different than those suffering from all sorts of pulmonary infections.

1.3 Medieval Danish urban landscape and mortuary behavior

By the mid-fourteenth century, the urban landscape in Denmark was essentially developed, with the population having doubled between the twelfth and thirteenth centuries in light of marked agricultural expansion (Benedictow, 2003; Bøgh, 2004; Fagan, 2008; Hybel and Poulsen, 2007; Johansen, 2002; Scott and Hoppa, 2019; Yoder, 2009). Estimates suggest that the population peaked at roughly 600,000–700,000 people, with the majority residing in rural communities and approximately 10% in towns (Kelmelis et al., 2020; Benedictow, 2003; Bøgh, 2004; Johansen, 2002). At the height of urban development, Denmark had roughly 60 towns (Dahlbäck, 2003; Petersen et al., 2006; Boldsen, 1996). The oldest towns, like Ribe, developed as permanent settlements during the Viking Age (c. 800–1050 AD; Andersson, 2003; Andrén, 1989, 1985; Kristensen, 2004) and became central points of economic, religious, military, and municipal importance with the state conversion to Christianity (c. 900s AD; Bøgh, 2004; Andersson, 2003). By the thirteenth century, Ribe and Viborg were established urban centers with administrative, ecclesiastical, and political distinction from outlying villages, while newer towns, such as Odense and Horsens, have gained recognition more slowly as formal townships (Kelmelis et al., 2020; Petersen et al., 2006; Andrén, 1989; Boldsen, 1989).

While medieval Danish towns are hardly “cities” in the modern sense, they were distinct from rural villages in their overall size, density, and heterogeneity, as well as their unique legal privileges to host a market (købstadsrettigheder; Andersson, 2003; Andrén, 1983; Kristensen and Poulsen, 2016). Towns also varied in their political, economic, and ecclesiastic resources such as royal mints, landsting (royal privileges), cathedrals, and multiple churches where urban dwellers could be buried. In terms of health resources, leprosaria and hospitals were established in larger towns during the thirteenth century and continued to increase as smaller towns grew in prominence (Kelmelis et al., 2020; Arentoft, 1999; Andrén, 1989; Kristensen and Poulsen, 2016; Thrane et al., 1982; Nielsen, 1985). Traditional Christian burial customs had already been introduced from the time when the process of conversion to Christianity began with Harald Blåtand in ca. 965 AD. Burials took place on consecrated ground in cemeteries surrounding churches, within monastic building complexes, or, in the case of those with leprosy, in leprosaria (Møller-Christensen, 1953, 1961). Graves were typically aligned east–west, with the dead placed in a supine position with the head to the west and feet to the east, symbolizing readiness to face Christ at the Second Coming (Grundvad, 2013; Madsen, 2013). The Viking customs of grave goods disappeared after Christianization, and the graves were often simple long-oval or rectangular pits, occasionally with a wooden coffin or brick- or stone-lined construction. However, certain details surrounding burial practices, such as coffin and grave types and the position of the arms of the dead in the grave, changed across the medieval period throughout the region (Kieffer-Olsen, 1993).

1.4 Social topography of medieval cemeteries

In Denmark, there was a major contrast between people at the high and low ends of the social hierarchy that typically characterized medieval feudalism. This system ranged from the nobility and clergy at the high end to the tradesmen, craftsmen, and farmers to the very lowest in society, such as servants, peasants, and the poor, at the other (Roesdahl, 2004). However, this distinction across the societal spectrum in life was not often readily visible in death because, to our knowledge, medieval Christian burial practices did not often create marked distinctions based on status. The dead were rarely buried with gifts or personal belongings that could reveal details about their social affiliation. Furthermore, most graves have little traces left of burial containers since wood-built coffins are not always preserved and other more advanced grave types, such as brick- or stone-lined graves, are rarely found outside the church walls.

Few historical texts describe the burial landscape during the medieval period in Denmark and in Scandinavia more broadly, and often the differences in status markers might not be evident when the grave is excavated hundreds of years later. However, two Norwegian law texts (Halvorsen and Rindal, 2008; c. 1100 AD) dictate how people of high status should be buried close to the church, and moving toward the outskirts of the cemetery, the middle-class should be buried followed by the lowest social classes closest to the cemetery borders. Graves within churches and monastery complexes were for a select few in the early medieval period. Hereafter, these areas were gradually offered to those who could afford the burial price, which included individuals from the highest social classes (Kieffer-Olsen, 1993; Mollerup, 1999; Madsen, 1990). The admittance of lay people for burial in monastery cemeteries, such as Øm Kloster, also came with a price, with individuals paying a quarter of the fee regulated to a regular parish priest (Mollerup, 1999). Historical documents from Ribe (1582 AD) specify the price of burials in different places in the cathedral cemetery and church area (Degn, 1981). The most expensive burial sites were located within the church, with slightly less expensive graves in other parts of the complex and the cheapest area in the lay cemetery. Archaeological excavations within the church reveal high numbers of stone- and brick-lined coffins, as well as sparse grave goods indicating high wealth and social status of the dead within the graves (Grundvad, 2013; Kieffer-Olsen, 1993; Mollerup, 1999; Kieffer-Olsen, 1990). While grave architecture and coffin types can be used as an indicator of status, it should be assessed in the context of the chronology of the cemetery and whether it is a rural or urban site, as the information regarding social stratification varies with time and geography.

The position of the grave based on cardinal directions within the cemetery also had some social significance. Several studies have found a division of the cemetery, where male graves were buried south of the church and female were buried north of the church (Kieffer-Olsen, 1993; Cinthio and Boldsen, 1984). This pattern seems to have changed around 1200–1300 AD, first in the western part of Denmark, then in the eastern (Kieffer-Olsen, 1993). Cinthio and Boldsen (1984) and Cinthio (1988) studied the north–south location of graves at the medieval cemetery Löddesköpinge located in modern Scania in Sweden. Based on measures of femoral lengths, which served as a proxy for status and adult health outcomes, they found that the shortest men were buried north of the church and, thus, interpreted as low-status men, and the tallest women were buried south of the church and, thus, interpreted as high-status women. Using stature as an indicator of social status relies on the assumption that high-status individuals are taller than low-status individuals as stature is often associated with differences in diet and in childhood growth and health (Steckel, 1995; Straaß, 1976), which has been debated (Hermanussen et al., 2018). The use of femoral lengths to establish height has also been questioned (Boldsen, 1990b,a; Andrén, 2000). Andrén (2000) presented a study that included material from Arcini (1999) showing a higher number of wooden coffins on a layer of charcoal in proximity to a church and more graves without coffins closer to the cemetery border, supporting the theory of higher status burials being close to the church. Another study in Viborg found that there were significant associations between mortality and burial placement, where individuals placed farther away from the church had elevated mortality (Kristensen, submitted).

The location of graves in proximity to structures within and outside the church or monastery seems to correlate not with only social status but also one's spiritual status. If we consider the outline of church structures, for instance, the nave can be viewed as the area of the church closest to God; hence, the area to the east of the nave where individuals are buried can also be seen as an area devoted to those of high status (Jonsson, 2009). Monastic houses, such as Øm Kloster, had specific regulations for burial practices and locations of cemeteries adjacent to abbeys (Mollerup, 1999). Cemeteries located to the east of the monastery were designated for abbots, while the northern cemetery was for monks, lay brothers, and the lay community. Archbishops, bishops, and noblemen were given burial within the church, which suggests that those buried here were symbolically closer to God than those outside the abbey walls. It is not clear whether lay cemeteries within monastery grounds have a division of social status similar to that observed in parish cemeteries around churches, and this has not been thoroughly explored, to our knowledge. However, Øm Kloster seems to have such an area located just west of the church connected to the lay cemetery, where four brick-lined coffins were found along with one of two grave swords, and the other one found in the church (Kristensen, 2020). It is possible that there are more nuanced differences in social status within these cemeteries, although determining this is not possible at this time.

Medieval Christian burial practices provide some insight into whether those who were ill were treated differently in death than those who were not. We expect that there might be variation depending on the type of church or religious institution responsible for burial rites. For instance, Cistercians, like those residing at Øm Kloster, had strictly enforced rules about burial rituals, including those who were sick. Individuals who died in sickness were given prayer by monastic folk to ease their passing, and their body was cleansed and given a procession for burial, with the grave having no adornment (Williams, 1998). This observation reinforces the Christian practice of simple graves and the idea that this was apparently not affected by their status of illness prior to death. However, there is archaeological evidence suggesting that some segregation of those with severe afflictions and differences in burial location did occur. Earlier studies by Arcini (1999) on skeletal leprosy were used to develop maps of individuals with skeletal evidence of leprosy from two cemeteries in Lund—Kattesund and Drotten (Andrén, 2000). In this study, individuals with skeletal evidence of leprosy were buried mostly north and a few east of the churches, but none within immediate proximity of the church. Analyses of two cemeteries in Sigtuna, Sweden, showed evidence of individuals with skeletal leprosy having been buried on the outskirts of the cemetery (Kjellström, 2005, 2012). Evidence of selective burial placement of sufferers of leprosy have also been found in medieval rural cemeteries in Tirup, Denmark, and Lauchheim in southern Germany; however, a precise description of where these burials are located in the cemetery is not included (Boldsen, 2005a, 2008). This pattern suggests a socially stratified society where poor or sick individuals were buried farthest away from the church, but it is not clear if this pattern held true for individuals with other afflictions.

2 Materials and methods

2.1 Skeletal samples and ethics statement

The human remains included in this study (n = 939) were derived from five medieval skeletal collections curated at the Unit of Anthropology (ADBOU), Department of Forensic Medicine of the University of Southern Denmark (Syddansk Universitet). These individuals were selected for this study based on their level of preservation and completeness, which allowed for skeletal age estimation and scoring pathological skeletal lesions consistent with criteria for estimating the prevalence of leprosy and TB in skeletal samples (Boldsen, 2005b, 2001; Pedersen et al., 2019). Samples were restricted to adult individuals since the selected criteria for estimating leprosy and TB prevalence have only been developed and tested on adult individuals, and it remains unclear whether these same criteria capture non-adult disease states. It is very likely that children, more often than adults, would have died in early stages of disease progression due to the immaturity of their immune systems as well as competing risks of other more acute childhood infectious diseases. As a consequence, non-adult skeletons will display a low degree of skeletal involvement (Roberts and Buikstra, 2003). Data collection was performed under the supervision and the permission of institutional and museum curatorial staff, and all data collection and use adhered to institutional ethical guidelines for the responsible handling of human remains. This research did not involve destructive sampling and did not constitute a risk to the living descendant community since we do not have access and do not share sensitive information.

The collections selected for this study represent communities that characterized different levels of urbanization during the Danish medieval period (c. 1050–1536 AD; Kelmelis et al., 2020). The dating of skeletons is based upon the archaeological and historical records of the period of use of the cemeteries. The relativity of the dating of the samples indicates that we cannot account for this source of variation in our analyses (Pedersen et al., 2020), and it is possible that our samples include individuals buried prior to the establishment of leprosaria given the early function of most cemeteries (Kjellström, 2012). However, our study focuses on the broad osteological and spatial trends of each cemetery, and for the most part, medieval Danish Christians continued to bury their dead in ways dictated by the church prior to the Protestant Reformation (Weise, 2009). Designations between villages and towns were, in part, based on the population size, density, and heterogeneity of those communities, focusing on documented town privileges and institutions, such as leprosaria (Kelmelis et al., 2020; Petersen et al., 2006; Andersson, 2003; Andrén, 1989; Kristensen and Poulsen, 2016). These criteria allow us to obtain robust comparative samples across urban categories to examine how these communities responded to different disease conditions in their burial practices.

2.1.1 Ribe Grey Friars (n = 399, ASR 1015)—Franciscan friary and urban parish cemeteries

Ribe is located on the southwestern coast of Denmark. At the time of its founding, c. 705–710 AD, it was one of a few urban settlements in Scandinavia (Hybel and Poulsen, 2007; Feveile et al., 2010). Ribe had a bishop appointed in 948 AD, and in the following centuries, the town thrived, and several church institutions were established. One of them, the Franciscan friary, was established in 1232 AD as the first of its kind in Denmark. The church, St. Laurentii, was consecrated in 1280 AD (Møller et al., 1984). Burial places were established within and adjacent to the friary buildings. Parish members were buried within the cemetery north of the complex, and friars, those connected to the bishopric, and friary benefactors were buried within the friary complex and the church. The friary was in use and burial activities continued until the Protestant Reformation in 1536 AD, and the demolition of the friary buildings began the following year (Møller et al., 1984). Archaeological excavations were carried out at the site in 1993, and 584 skeletons were recovered in graves from within the complex, church, and the parish cemetery (Jantzen et al., 1995; Andersen, 2003). Of the recovered in situ skeletons, 445 are adults, and of these, 399 (89.7%) were included in the present study. In recent times, these individuals are curated at ADBOU.

2.1.2 Sejet (n = 96, HOM 1046)—rural parish cemetery

Sejet is a medieval village located approximately 8 km southeast of the modern town of Horsens, which would have been classified as a medieval town with market privileges. The villagers of Sejet, however, were likely buried within a local parish cemetery that was in use from c. 1100 AD until its abandonment, likely during the fifteenth century (Kelmelis and DeWitte, 2021; Kjærgård, 2006; Pedersen, 2009; Pedersen and Boldsen, 2008). However, the abandonment of the cemetery is uncertain because a historical source mentions that the local landowner, Marshal of the Realm (Rigsmarsk) Holger Rosenkrantz, was granted permission to demolish the church in Sejet by the king as late as AD 1574 (Trap, 1898). The area was reused as, among others, a pig barn during the modern period, which largely affected the preservation of several burials (Gamble, 2014). However, the site was excavated under the auspices of the Museum Horsens in 2006, during which 555 graves were recovered, with skeletons in situ in 435 of them (Kjærgård, 2006; Pedersen and Boldsen, 2008; Nyborg and Poulsen, 2010). Of the in situ skeletons, 272 are adults, and of these, 96 (35.3%) were included in the present study. At present, these individuals are registered and curated at ADBOU and Museum Horsens.

2.1.3 Øm Kloster (n = 198, SMB 1053)—Cistercian monastery and rural parish cemeteries

Øm Kloster is located on the shores of Lake Mossø, near the town of Gammel Rye and approximately 32 km from Horsens (Kelmelis and Pedersen, 2019; Kelmelis et al., 2017; Mollerup, 1999; Gregersen, 2018; Gregersen and Jensen, 2003). The Cistercian monastery opened in 1172 AD and was closed in 1536 AD, but it functioned as an educational institution until 1560 AD. Cistercians at Øm had strict rules on burial practices, including the sick (Williams, 1998) and how and where cemeteries should be divided (Mollerup, 1999). In this study, the majority of our samples came from the north cemetery, with select individuals from the abbey proper, thereby representing the social breadth of individuals buried at Øm (Kelmelis et al., 2017; Yoder, 2009; Mollerup, 1999; Gregersen, 2018; Gregersen and Jensen, 2003; Rasmussen et al., 2008). Excavations since 1896 have yielded over 900 burials. Of 921 listed skeletons in graves, 242 were not lifted. Of the remaining 685 skeletons, 603 are adults, and of these, 198 (32.8%) were included in the present study. The skeletons from Øm Kloster are curated at ADBOU, University of Copenhagen, and the Øm Kloster Museum. Individuals in this study were sourced from ADBOU.

2.1.4 Drotten (I: n = 58, VSM F902; II: n = 47, VSM 09264)—urban parish cemetery

Drotten, also known as Trinitatis, was located within the medieval town center of Viborg. Viborg was a town with royal privileges during the medieval period and at the time was one of the larger towns in Denmark. Drotten was one of at least twelve parish churches in Viborg during the medieval period (Hjermind, 2010). It was likely one of the oldest churches in Viborg and was in use from approximately 1000 to 1529 AD (Hjermind, 2010). The church and part of the cemetery south of the church were excavated in 1963, 1977, and 1999 by the Viborg Museum (Keyes et al., 2007). During excavations in 1999 (VSM F902), 84 graves were uncovered inside and just south of the church. In 2006–2007, Viborg Museum excavated an area (VSM 09264) approximately 10 m northwest of the former Drotten cemetery (I) excavation and found the northeastern part of a cemetery (II). It was likely connected to Drotten church, but the orientation of the graves, grave density, and osteological studies show a rather notable difference between the two populations, suggesting that it is a separate part of the cemetery or possibly belongs to another church (Kristensen, submitted). The excavation uncovered 97 graves. Of 154 available skeletons, 109 are adults, and of these, 104 (95.4%) were included in the present study. All skeletons recovered from the excavations are curated at ADBOU.

2.1.5 St. Mathias (n = 141, VSM E804, VSM F906, VSM F855)—urban parish cemetery

St. Mathias is also one of at least 12 medieval parish churches in Viborg. It is in the western area of the medieval town. It is not possible to determine a precise period when the cemetery was in use, but as for other cemetery sites in Viborg, the St. Mathias church and cemetery were likely in use between 1000 and 1529 AD (Hjermind, 2010; Kristensen, 1987). Over the years, several excavations have been performed on the site, starting in 1994, when 71 skeletons were excavated (VSM E804). In 1999, two excavations uncovered 15 (VSM F906) and 151 skeletons (VSM F855), and in 2011, 10 more skeletons were excavated (VSM 09793) at the southern border of the cemetery. Of the 247 skeletons from the site, 185 are adults, and of these, 141 (76.2%) were included in the present study, none from the 2011 excavation (VSM 09793). All skeletons recovered from the excavations are curated at ADBOU.

2.2 Osteological methods

2.2.1 Age estimation

Skeletal age at death was recorded for all adult skeletons; no skeleton that displayed evidence of incomplete epiphyseal fusion of the spheno-occipital synchondrosis and/or acetabulum was included in the study. Adult age at death was estimated using the transition analysis method, experience-based age assessment, and the new indicators used in the revised transition analysis method. These methods have proven to display high agreement with recorded age compared to traditional methods (Boldsen et al., 2002; Milner et al., 2021; Milner and Boldsen, 2012).

2.2.2 Leprosy and TB lesion scoring criteria and prevalence estimation

The skeletal diagnosis of leprosy and TB is a prerequisite to understanding how past communities responded to these diseases. Criteria for scoring skeletal lesions consistent with leprotic and TB infection were based on those outlined by Boldsen (2001) and Pedersen et al. (2019). Lesions for each disease condition were scored dichotomously for each individual. For leprosy, six lesions were scored as absent or present based on descriptive criteria and estimated sensitivity and specificity scores: rounding of the edge of the nasal aperture, degeneration of the anterior nasal spine, degeneration of the alveolar process of the premaxilla, perforation and porosity of the palatine bone, hypertrophy of the fibula, and periosteal changes on the fifth metatarsal. For TB, six lesions were identified as being consistent with bony responses to TB infection: visceral surface of the ribs, ventral part of the thoracic and lumbar vertebral bodies, lateral body of the ilium, acetabular fossa, iliac auricular surface, and olecranon process of the ulna. Scores were given if the necessary elements were more than 50% complete and in good preservation; no score was given if the element was poorly preserved or not present.

These data were then applied to probabilistic statistics using known sensitivity and specificity measures of each lesion type to estimate the individual probability of having had either bone involving leprosy (λ) or TB (τ; Supplementary Table S1), which is then used as a metric for informing on past disease frequency. For definitional clarity, here we define sensitivity as the likelihood that an individual was affected by the disease given positive lesion scores and specificity as the likelihood that an individual was not affected by the disease given negative lesion scores (Boldsen, 2001; Pedersen et al., 2019). We summarize the statistical underpinning and provide the sensitivity and specificity scores for each lesion type in the Supplementary Material S1, and this has been used numerous times in medieval Denmark (Boldsen and Mollerup, 2006; Boldsen, 2009; Kelmelis et al., 2020; Kelmelis and Pedersen, 2019; Pedersen et al., 2019; Boldsen, 2005a; Boldsen and Freund, 2006). Based on outputs of individual probabilities of disease, λ and τ skeletons were allotted to two possible disease state categories, either negative or positive. In this study, those categorized as negative are those with a λ or τ value below 1, and those categorized as positive are those with a λ or τ value of at least 1. The categorization relies on the probability-based disease scores where the bony indicator sites available for scoring and how these were scored are considered. The criterion for a positive score is set at a rather high value of λ and τ, respectively. Therefore, among the skeletons with a negative disease state are those that may display bony indicators related to either of the diseases, but, ultimately, they were designated as “negative” because the diagnostic criteria did not lead to a score high enough where we can differentially diagnose the individual with confidence. On the other hand, the skeletons with a positive disease state have very convincing diagnostic criteria, and the risk of false positives is low. We used Pearson's chi-squared test to test the differences between burial location status and disease status for each cemetery. Statistics estimating prevalence and chi-squared tests were completed using IBM SPSS version 25.

2.3 Spatial distribution analysis

Information about the social stratification of individuals in graves can be difficult to derive from archaeological data because the association of socioeconomic status and available mortuary data, such as grave and coffin types, is not fully understood. Evidence from other studies shows that most information about social stratification from mortuary data is found in the position of graves, either their distance from the church in ordinary cemeteries or their position within a church or building complex in relation to monasteries (Halvorsen and Rindal, 2008; Jonsson, 2009). Therefore, in this study, we use the burial location from the visual maps of cemeteries to interpret the social status of individuals and, from this, the treatment in death of individuals who suffered from bone involving leprosy and TB. The disease-state categories are used to visually map the burial location of skeletons with either a negative or positive disease state of leprosy (green or orange, respectively) and TB (blue and orange, respectively) found in Figures 4–8. Graves without preserved skeletal remains or without preserved indicators of the disease in question are shown in white or marked with a black skeleton. The spatial distribution maps were prepared using MapInfo and QGIS. The archaeological GIS data files with information about the location of graves were merged with the data of disease state of the skeletons in the graves.

Social stratification is interpreted based on the position of the graves in the cemeteries and is divided into low-status and high-status groups marked with light green and light blue color on the maps in Figures 4–8. This division is broadly defined and is largely determined by the excavation activities within specific cemeteries. The division is based on the placement according to the distance from the church in parish cemeteries and presence inside building complexes in monasteries but does not consider potential local variations in cemetery mortuary traditions regarding the social division of cemetery. The graves found in what we define here as low-status areas will also have burials of people belonging to higher social classes, but the majority of graves would belong to low-status individuals. At Ribe Grey Friary, skeletons found in the northern parish cemetery are interpreted as low social status, and skeletons found in the monastery church and complex areas are interpreted as those belonging to people of high social status. At Sejet, there are no clear boundaries in the excavated southwestern area of the cemetery, and therefore, we cannot advance a clear interpretation about social stratification based on burial position. At Øm Kloster, skeletons found in the northern cemetery are interpreted as low status, and skeletons found in the monastery church and complex, as well as the cemetery east of the complex, are interpreted as high status. At Drotten, skeletons found in the northeastern corner of the cemetery (VSM 09264) are interpreted as low status, and skeletons found close to the church (VSM F902) are interpreted as high status. Finally, at St. Mathias, the excavated areas were likely both the burial areas of rather high-social-status people; however, here we consider skeletons found east of the church (VSM E804) as being of people socially positioned lower than skeletons found south of and inside the church (VSM E855 and VSM F906). The maps are used to visually assess potential patterns in the spatial distribution of individuals with or without disease. Based on the maps, crosstabs of data between cemeteries and within cemeteries were made and potential differences were tested using Pearson's chi-squared tests.

2.4 Statistical methods

Kaplan–Meier analyses with log-rank tests and Cox regression hazard analyses were used to test for differences in survival and mortality hazards associated with having been buried within urban or rural contexts and for each cemetery, respectively, using estimated age-at-death point estimates. Additionally, we tested for differences in survival and mortality risk associated with yielded λ and τ outputs for each individual assigned to three disease state categories: negative, possible, and positive. We also tested for differences in survival and mortality hazards associated with both disease status and cemetery sites to disentangle the effects of disease epidemiology and cemetery context. Finally, we compared survivorship and hazard ratios between burial location status for the entire sample and within each cemetery context. Kaplan-Meier and Cox regression models are useful non-parametric and semiparametric approaches for comparing past patterns of mortality from skeletal assemblages and death records without imposing age-specific or cause-specific parameters on the death sample (Kelmelis and DeWitte, 2021; Cox, 1972; Kaplan and Meier, 1958; DeWitte, 2017; van Doren and Kelmelis, 2023). Kaplan-Meier and Cox regression analyses were conducted in R (R Team Corp, 2018), and we interpret our results with an ɑ = 0.05.

3 Results

3.1 Age distribution of samples

Figures 2, 3 display the skeletal age distributions for the total sample and for each respective cemetery using the transition analysis maximum likelihood age estimates to assign individuals to 5-year age bins. Table 1 also displays skeletal age for each cemetery in 10-year age bins. The high proportions of adult individuals are typical of archaeological samples given their tendency to preserve better than those in younger and older age groups and the effect of selective mortality (DeWitte and Wood, 2008; Gordon and Buikstra, 1981; Wood et al., 1992, 2002; Boldsen et al., 2022). However, the under-enumeration of our samples does not affect our study since we exclusively focused on adults for scoring and estimating the prevalence of leprosy and TB.

Figure 2

Figure 2. Skeletal age distribution for total sample based on transition analysis maximum likelihood estimates in 5-year age bins with the overall probability density curve.

Figure 3

Figure 3. Skeletal age distribution for each cemetery based on transition analysis maximum likelihood estimates in 5-year age bins with the overall probability density curves.

Table 1

Table 1. Age distribution for each cemetery in 10-year age intervals.

3.2 Leprosy and TB prevalence and spatial distribution thereof in cemetery assemblages

Figures 4–8 present the spatial distribution of skeletons in the cemeteries where those with either a negative or positive status for leprosy and TB are marked. The frequencies of leprosy and TB non-sufferers and sufferers between the cemeteries are presented in Table 2 and by burial location status within the cemeteries in Table 3. The overall frequencies of disease states for leprosy and TB and burial location status are presented in Table 4. Though the maps of the cemeteries show no distinct patterns and clustering of burials with either leprosy or TB sufferers, there are significant differences in the frequencies of the diseases between the cemeteries (Table 2). For leprosy, the test results confirm a significant difference (p = 0.032) where the urban parish cemeteries in Viborg, Drotten, and St. Mathias has a very low leprosy load (3.4% and 4.6%, respectively) compared to the rural sites of Sejet and Øm Kloster (13.0% and 11.9%, respectively). Leprosy frequency at Ribe Grey Friars falls between the urban and rural sites displaying an 8.9% frequency of leprosy. For TB, the significant differences (p < 0.001) between cemeteries are primarily caused by the very high disease load in Drotten (51.6%) compared to the remaining sites with frequencies between 21.8% and 32.0%.

Figure 4

Figure 4. Maps of graves at Ribe Grey Friars. (A) Skeletons unaffected and affected by leprosy (black: not included, green: without pathology, orange: with pathology). (B) Skeletons unaffected and affected by TB (black: not included, blue: without pathology, orange: with pathology). Green box: low-status burial location, blue box: high-status burial location. Maps: Data provided by Museum Vest, edited by Dorthe Dangvard Pedersen.

Figure 5

Figure 5. Maps of graves at Sejet. (A) Skeletons unaffected and affected by leprosy (black: not included, green: without pathology, orange: with pathology). (B) Skeletons unaffected and affected by TB (black: not included, blue: without pathology, orange: with pathology). The gray area to the southwest is part of the western cemetery border, and the gray area to the northeast is the southern corner of a foundation of a church stilt tower. Maps: Data provided by Museum Horsens, edited by Dorthe Dangvard Pedersen.

Figure 6

Figure 6. Maps of graves at Øm Kloster. (A) Graves with skeletons unaffected and affected by leprosy (white: not included, green: without pathology, orange: with pathology). (B) Graves with skeletons unaffected and affected by TB (white: not included, blue: without pathology, orange: with pathology). Green box: low-status burial location, blue box: high-status burial location. Maps: Data provided by Museum Skanderborg, edited by Anders Hagen Mørk.

Figure 7

Figure 7. Maps of graves at Drotten. (A) Skeletons unaffected and affected by leprosy (black: not included, green: without pathology, orange: with pathology). (B) Skeletons unaffected and affected by TB (black: not included, blue: without pathology, orange: with pathology). Green box: low-status burial location, blue box: high-status burial location. Maps: Data provided by Viborg Museum, edited by Lars Agersnap Larsen.

Figure 8

Figure 8. Maps of graves at St. Mathias. (A) Skeletons unaffected and affected by leprosy (black: not included, green: without pathology, orange: with pathology). (B) Skeletons unaffected and affected by TB (black: not included, blue: without pathology, orange: with pathology). Green box: low-status burial location, blue box: high-status burial location. Maps: Data provided by Viborg Museum, edited by Lars Agersnap Larsen.

Table 2

Table 2. Distribution of TB and leprosy disease states in cemeteries.

Table 3

Table 3. Distribution of TB and leprosy disease states on cemeteries divided into burial location status.

Table 4

Table 4. Distribution of TB and leprosy disease states between individuals of varying burial location statuses.

The distribution of burial location statuses is reported with a total of 322 burials designated as high-status location burials and 521 being low-status location burials, not including burials from Sejet since no information about the social statuses associated with burials is available. By site, the proportions of high- to low-status individuals vary considerably and are a consequence of excavation activities at the different sites. The Ribe Grey Friars sample has 281 (70.4%) low-status burials and 118 (29.6%) high-status burials. The sample from Øm Kloster has 156 (78.8%) low-status burials and 42 (21.2%) high-status burials. Drotten has a similar distribution, with 47 (44.8%) low- and 58 (55.2%) high-status burials, while St. Mathias has notably fewer low-status burials (n = 37, 26.2%) than high-status burials (n = 104, 73.8%). When testing the differences between disease prevalence in the different burial location statuses within the cemeteries, the only statistically significant difference was found for TB within the two assumed social status areas at Ribe Grey Friars (p < 0.001; Table 3). Here, 32.6% at the low-status northern parish cemetery compared to 12.0% at the high-status church and monastery complex were affected by TB. The burial location statuses were merged across the sites in Table 4, and no significant differences between the high and low-status graves for either leprosy or TB were found.

3.3 Kaplan-Meier and Cox regression results

Kaplan-Meier survival and Cox hazards regression results comparing survivorship and mortality hazards between urban and rural samples, cemetery sites, and disease states are shown in Table 5 and Figures 9–12. The survival curves between urban and rural pooled samples show a significant difference in survivorship based on skeletal age at death (p = 0.03). Urban and rural individuals have comparable survivorship until their early 40s when rural individuals show increased survivorship with senescence compared to their urban counterparts. The Cox hazards regression analysis showed that urban individuals experienced significantly higher mortality risk than their rural age peers (p = 0.02).

Table 5

Table 5. Kaplan-Meier and Cox hazards regression results for comparing survivorship and mortality between urban and rural sites, each cemetery site, and individuals of varying disease states for leprosy and tuberculosis.

Figure 9

Figure 9. Kaplan-Meier survival curve with 95% confidence intervals for urban and rural samples.

Differences in survivorship between the five cemeteries were highly significant (p < 0.0001; Table 5, Figure 10). The most notable divergence in survivorship begins in the late 20s to early 30s, with Sejet having decreased survivorship, although this pattern shifts in the late 50s with Sejet having notably higher survivorship than other sites. Grey Friars appears to have overall lower survivorship compared to other sites, with Drotten having higher survivorship during adult years. The Cox proportional hazards analyses, using Grey Friars as reference, show that there are statistically significant differences in mortality risk between cemetery sites (Table 5, Supplementary Figure S1). All sites showed significantly lower mortality hazards compared to Grey Friars with Drotten having the lowest hazard ratio (approximately 40% lower hazard), followed by Sejet (39% lower hazard), St. Mathias (24% lower hazard), and Øm Kloster (23% lower hazard). Despite both being located within the same town, Viborg, Drotten, and St. Mathias have markedly different mortality hazard ratios; in fact, Drotten has ratios similar to those of the rural parish cemetery of Sejet. Conversely, Øm Kloster, a rural Cistercian monastery, has hazard ratios similar to those of urban cemeteries St. Mathias and, more closely, Grey Friars compared to the other cemetery assemblages. These results indicate that the cemetery site variable was an important factor in differing mortality hazards and may reflect heterogeneity in the populations burying their dead in each respective cemetery.

Figure 10

Figure 10. Kaplan-Meier survival curve with 95% confidence intervals for each cemetery site.

Kaplan-Meier and Cox regression analyses for testing for differences in survivorship and mortality between leprosy disease states were not statistically significant (p = 0.4; Table 5, Figure 11). Kaplan-Meier results show highly significant differences between TB disease states (p < 0.0001), with individuals with skeletal evidence of TB having increased survivorship compared to their non-lesioned age-peers (Table 5, Figure 12). The Cox proportional hazards analyses showed that individuals scoring positively for TB (p < 0.0001) had significantly lower mortality hazards than those who scored negatively for TB.

Figure 11

Figure 11. Kaplan-Meier survival curve with 95% confidence intervals for individuals scored as “negative” and “positive” for leprosy.

Figure 12

Figure 12. Kaplan-Meier survival curve with 95% confidence intervals for individuals scored as “negative” and “positive” for tuberculosis.

Analyses were then conducted to include cemetery and disease-state variables to test for significant differences in survivorship and mortality hazards (Table 6, Supplementary Figures S2–S5). The results showed there were highly statistically significant differences in survivorship (p = 0.0001) for the combined model (Table 6, Supplementary Figure S2). The Cox regression results revealed that leprosy status remained a non-significant effect when controlling for cemetery (p = 0.23), while cemetery remained a significant factor, with all sites having lower hazards compared to Grey Friars (Supplementary Figure S3). In this study, Drotten (p < 0. 001) and Sejet (p = 0.0003) also have significantly lower hazards compared to the baseline, followed by St. Mathias (p = 0.003) and Øm Kloster (p = 0.005). This result shows that the cemetery remains significant and independent of leprosy in mortality hazards. The results examining TB and cemetery survivorship showed there were highly statistically significant differences in survivorship (p < 0.0001; Table 6, Supplementary Figure S4). Cox regression analyses showed that TB and cemetery continued to have strong, but independent, effects on mortality. Individuals who scored positively for TB had significantly lower hazards (p < 0.0001; Supplementary Figure S5, indicating that those individuals who developed skeletal lesions associated with TB, on average, lived longer than their non-lesioned age peers, which could be an artifact of the chronic infection and with competing hazards not factored here). TB's association with lower hazards appears to be independent of the cemetery site, which continues to have a significant effect and one similar to previous results. In addition, Sejet (p = 0.0006) and Drotten (p = 0.002) have similar hazard ratios, both being significantly lower than Grey Friars, followed by Øm Kloster (p = 0.002). St. Mathias' hazard ratio is marginally insignificant compared to the baseline (p = 0.08).

Table 6

Table 6. Kaplan-Meier and Cox hazards regression results for comparing survivorship and mortality between individuals of varying disease states between each site.

Finally, the Kaplan-Meier and Cox regression results for comparing survivorship and hazard ratios between low and high burial status locations and for each cemetery are reported in Tables 7, 8 and Figure 13. Figures displaying results for each cemetery site comparison are in the Supplementary Figures S6- S14. Sejet was not included in these analyses since no information about the social statuses associated with burials is available. These results do not show statistically significant differences for high and low-status survivorship and hazards (Table 7, Figure 13, Supplementary Figure S6). However, there appears to be heterogeneity in burial location status survivorship and hazards between cemetery sites (Table 8, Supplementary Figures S7–S14). For the Grey Friars sample, burial location status does not appear to be associated with different mortality patterns with low- and high-status individuals having similar survivorship curves and high-status individuals having slightly lower hazard ratios, but these are not significant (Supplementary Figures S7, S8). Kaplan-Meier results show that high- and low-status individuals at Øm Kloster did not have statistically significant differences in survivorship, although survivorship trends show that high-status individuals had markedly higher survivorship than low-status individuals between the ages of 20 and 40, respectively (Supplementary Figure S9). Cox regression results were also not significant, but the trend of high-status individuals having lower hazards was maintained (Supplementary Figure S10). The Mantel-Cox test and Cox regression analysis for burial status location differences at Drotten were marginally insignificant (p = 0.07), with high-status individuals having reduced hazard ratios compared to low-status individuals, particularly for adults over 30 years of age, and with high-status individuals having lower hazards compared to low-status individuals (Supplementary Figures S11, S12). Like Grey Friars, St. Mathias showed no significant differences in survivorship or mortality between burial status locations; however, it is worth noting that high-status individuals had a slightly higher hazard risk, although not significant (Supplementary Figures S13, S14).

Table 7

Table 7. Kaplan-Meier and Cox hazards regression results for comparing survivorship and mortality between individuals of varying burial location statuses.

Table 8

Table 8. Kaplan-Meier and Cox hazards regression results for comparing survivorship and mortality between individuals of varying burial location statuses for each site.

Figure 13

Figure 13. Kaplan-Meier survival curve with 95% confidence intervals for pooled low and high burial location status classes.

4 Discussion

Our findings show that medieval Danish burial practices reflect a complex relationship between human and pathogen behaviors and the medieval Christian mindset about disease and status. In this study, we demonstrate that living in an urban environment may have elevated mortality risks, likely correlated to recurring epidemics in medieval towns, in particular those relating to person-to-person transmission (Petersen et al., 2006). However, this should not be taken at face value as our site-by-site analyses demonstrated that there was considerable variability in survivorship and hazards between cemeteries beyond the urban–rural distinction, and this may reflect the population heterogeneity that contributed to their death assemblages. Our survival analyses showed that there were several points of overlap and distinction between the urban and rural cemetery curves, with elevated mortality risk of urban cemeteries being driven by specific cemeteries (Figure 10). Ribe Grey Friars had the lowest survivorship from middle to late adulthood, although Sejet, our rural parish, had notably low survivorship in young adulthood but elevated survivorship in senescence, potentially indicating age-specific hazards in urban and rural environments or the possibility that middle-aged individuals were migrating from rural to urban spaces. Drotten stands out with the lowest mortality risk compared to the other cemeteries, which complicates a direct interpretation that urban environments overall had greater mortality risks. Rather, urban cemeteries such as Drotten represent variation in the haves and have-nots in the medieval urban landscape. The many parish churches in Viborg likely caused division into specific social segments of town dwellers using specific churches and their cemeteries. As such, our results may reveal that the Drotten cemetery was more frequently patronized by those of higher status compared to other parishes, such as St. Mathias (Kristensen, submitted). A town with fewer parish churches would have had to serve a wider range of social statuses. The elevated mortality risk in Ribe Grey Friars is a clear contrast and perhaps disproportionately served patrons of low status. Our results showed that Øm had low survivorship and elevated hazards compared to Sejet, our other rural cemetery, and similar to St. Mathias, our other urban Viborg cemetery. Although our sample includes approximately 33% of the total burials, Øm Kloster's burial pattern reflects a spectrum of monastic burial practices in rural communities, where burial placement within and adjacent to the church was reserved for high-ranking clergy and for noble persons who could afford it while members of the lay community and lay brothers were buried in the north cemetery without burial costs (Kelmelis et al., 2017; Mollerup, 1999). With approximately 200 individuals, we find that our sample is robust enough to examine general trends in monastic burials with community representation, particularly since the majority of our sample is derived from the north cemetery. However, it cannot be ruled out that the poorer preservation, which, in part, caused the low inclusion percentage, has influenced the results obtained on Øm and Sejet. Poor preservation could cause selectivity in the available skeletal material as preservation biases would tend to affect the oldest burials, as well as children and fragile remains (Gordon and Buikstra, 1981; Wood et al., 1992).

Our results support previous findings suggesting that leprosaria acted as a selective force on sick individuals in medieval Danish towns but that this was not necessarily a mitigating factor for rural settings or for other diseases like TB. The overall prevalence of leprosy was low compared to that of TB; however, the distribution showed statistically significant (p = 0.032) differences in urban and rural prevalence rates, with Viborg having the lowest prevalence (Drotten 3.4%, St. Mathias 4.6%), followed by Ribe (8.9%) and Øm Kloster (11.9%), while Sejet (13%) had the highest, although this may be partially influenced by the sample selection process. We suspect that rural areas would have higher leprosy prevalence than towns where leprosaria are integrated into the urban landscape. The use of leprosaria for burials of leprosy victims in connection with urban areas removed the probability of investigating whether the unhygienic state of the towns influenced the prevalence of the disease, which could be expected. As two of the oldest and largest towns in medieval Denmark, Viborg and Ribe had at least one leprosarium to accommodate their growing populations with Viborg's leprosarium dating to sometime between 1159 and 1263 AD and Ribe's dating to 1270 AD (Kelmelis et al., 2020; Arentoft, 1999; Nielsen, 1985). The precise date of when Viborg's leprosarium was established is debated. A hospital is mentioned by 1159 AD, but this was not distinctly described as a leprosy hospital until 1263 AD, which is consistent with the timing of other Danish leprosaria (Arentoft, 1999; Kristensen, 1987). Both urban parish sites in Viborg have significantly lower proportions of individuals with skeletal leprosy compared to the rural sites and the monastery complex in Ribe. This trend likely reflects the selective effect of the Viborg leprosarium, where sufferers were more often sequestered to this institution. In addition, this finding indicates that a large proportion of the skeletons in our samples are likely dated to after the leprosaria were established. If a restrictive policy of selection to the leprosarium was enforced, it may be argued that the graves of leprosy sufferers at Drotten and St. Mathias represent early burials of individuals buried before the leprosarium in Viborg was established and before it had its own dedicated cemetery. Sejet, despite being within eight kilometers from Horsens, had the highest prevalence of leprosy in our burial sample, which shows that villages were (a) not immune to leprosy and (b) home to individuals who died with signs of the disease but who were not differentially buried compared to those without the disease [see comparative examples like Tirup (Boldsen, 2005a)]. It is possible that the high proportion of leprosy in this sample is an artifact of sampling, since approximately 35% of Sejet's burials were represented. Another possibility is that individuals who contracted leprosy and survived long enough to develop lesions are, in a manner, more robust than their non-lesioned age peers, although directly testing this hypothesis would require more robust model approaches (e.g., multistate hazard models; Kelmelis et al., 2017). Nevertheless, individuals at Sejet were certainly exposed to this disease and were buried in a manner comparable to their neighbors.

It should be noted that the neighboring town of Horsens received town privileges later than Viborg and Ribe and did not establish a leprosarium until 1492 AD, when the disease was already in decline (Kelmelis et al., 2020). Øm Kloster was also located at some distance from a town with a leprosarium and had an infirmary where perhaps sick community members could seek palliative care. In terms of what kinds of care were offered, Cistercians, like many Benedictine monastic orders, did not explicitly engage in medicinal arts of a surgical nature, but they could employ basic treatments (e.g., preparing herbal or chemical treatments, bathing, prayer) for those of their order and sometimes the sick or elderly. A previous study by Rasmussen et al. (2008) at Øm showed elevated levels of mercury in individuals with skeletal evidence of leprosy and venereal syphilis, indicating that the Cistercian monks may have prepared mercury medicine to treat individuals with these diseases. Their findings also showed elevated mercury levels in monks buried in the cloister walk without signs of leprosy, which the authors suggest may be attributable to the preparation of mercury-containing medicine for infirmary occupants or to having had access to the scriptorium where monks used mercury-infused red ink to illustrate their manuscripts.

Our results here and elsewhere show that TB was comparatively more prevalent than leprosy in our samples, even in rural areas where individuals may have been exposed by virtue of expanding economic trade networks and migration (Kelmelis et al., 2020; Kelmelis and Pedersen, 2019). While TB was clearly a widespread illness, individuals with this disease were probably not selectively moved to leprosaria or hospital-like settings for treatment and burial. We also show that individuals with skeletal evidence of TB have higher survivorship than those without lesions. This observation should not be directly interpreted as meaning that individuals with TB were “better off,” as this runs counter to established understandings about disease epidemiology. Rather, we must consider the specific lesion-formation processes of the disease and its implications within the context of archaeological assemblages. Host-pathogen interactions in relation to TB are complex and, as a result, complicate direct inferences in skeletal assemblages (Stone et al., 2009; Roberts and Buikstra, 2003; Pedersen et al., 2019; DeWitte et al., 2022). TB tends to have low skeletal involvement because of, among other things, competing comorbidities such that only affected individuals who survive long enough to develop lesions will be counted in archaeological contexts (Roberts and Buikstra, 2003; DeWitte et al., 2022). In addition, unlike leprosy, TB is the kind of disease that, if left untreated, most people will die from within a relatively short period of time, although this varies significantly with host risk factors and comorbidities, such as HIV (Roberts and Buikstra, 2003). Morbidity and mortality of TB are associated with socioeconomic factors, such as unsanitary and crowded living conditions, poor diet, and comorbidities with other infectious diseases and maladies (Stone et al., 2009; Roberts and Manchester, 2007). Individuals living under these poorer conditions and having early-stage TB are likely to have higher mortality hazards and, therefore, will unlikely have clear skeletal involvement at death. In our study, rates of TB were lower among high-status individuals than among lower-status individuals, but those who showed bony involvement had elevated survivorship compared to their non-lesioned peers. In this study, our model essentially captures those individuals who had TB and survived long enough to develop lesions but not those individuals who had TB, including latent TB, and died prior to skeletal involvement either from TB or from other competing causes. Moreover, a majority of people likely lived with latent TB infection, but, with age and the accompanying weakening of the immune response, they could have developed active disease, so an older segment of the population would have been at risk. This may be what is reflected in the pattern of survival of older individuals with bone TB. In the Ribe Grey Friars cemetery, low-status individuals in the northern cemetery have a higher prevalence of skeletal TB than those in the monastic complex, which could reflect the greater disease burden of lower-status groups in this urban environment. Also, the northern lay cemetery at Ribe Grey Friars that holds the low-status group could, as mentioned earlier, have belonged to an unknown parish church and not the monastery (Kieffer-Olsen, 1996). This could explain the considerable differences in TB load between the social statuses in Ribe. If we consider our result that showed individuals with skeletal TB had higher survivorship, it is possible that the proportion of individuals with skeletal TB in either status group may represent individuals who were comparatively more robust compared to those who died without lesions, likely because they had low immune resilience, and therefore died in the early disease stage or other acute infections. The Drotten parish, on the other hand, represents a cemetery that serviced mainly high-status individuals, where TB transmission and infection were high but that individuals had some kind of advantage, possibly as a factor of their elevated social status, where they lived longer with the infection, thus appearing more “sick” than other parishes. This kind of osteological paradox, as discussed by Wood and colleagues (Wood et al., 1992), emphasizes that pathological lesions related to infectious diseases and the counts thereof cannot be directly interpreted as signs of poorer health given that all individuals in archaeological assemblages are inherently frail because they are dead and lesion-formation processes rely on an individual having survived the insult long enough to develop skeletal lesions. When we consider the age distribution and mortality experiences of individuals without those lesions, not to mention other hidden sources of frailty and competing hazards, it is possible that skeletal involvement from chronic conditions may reflect the survival and resilience of a person who lived with that disease, at least for a period of time (Wood et al., 1992).

While the urban landscape likely contributed to the differences in disease prevalence and their impact on differential mortality risks, did they lead to differences in burial treatments within these contexts? Spatial analysis of diseased and unafflicted individuals in our cemetery samples did not reveal distinct clustering of those with leprosy and TB apart from those who scored negatively for either disease. Previous studies within the region and beyond showed instances where individuals of diseased status were located farther away from church structures, but then others suggested that this was not the case and, perhaps, disease status was not as pivotal in burial practices as one's social status in life. We should state up front that it is important to bear in mind that there are inherent difficulties in comparing results between different studies of this sort as there are differences in the methods of osteological detection of the diseases and determining whether individuals were non-sufferers or sufferers. Analyses of medieval Swedish cemeteries showed that individuals with evidence of leprosy were buried on the periphery or in distinct areas of burial grounds (Andrén, 2000; Kjellström, 2005, 2012). Arcini (1999) analyses of leprosy in medieval cemeteries in Lund and later syntheses by Andrén (2000) found that early Christians who died in the late Viking Age (c. 900–1020/30 AD) were buried in the outer edges of the cemetery, although later burials of leprosy sufferers (c. 1300–1526 AD) were buried within the church cemetery. Other studies found that individuals with leprosy were often buried within normal cemetery contexts. In rural Lauchheim, southern Germany, there was differential spatial distribution in the burials containing sufferers of leprosy (Boldsen, 2008). Sufferers displaying the characteristic facies leprosa were found most frequently in the eastern area of the cemetery. Mays' (1991) osteoarchaeological analyses of burials at the Blackfriars cemetery in Suffolk, England revealed that four individuals with skeletal evidence of leprosy were buried in the nave and the south aisle of the church, indicating that these people were considered to have occupied places of higher status in life and were buried in line with that status, despite having likely displayed evidence of sickness (Roberts, 2020). Other studies from Hungary showed that individuals with skeletal evidence of both leprosy and TB were interred in a manner similar to that in which non-sufferers were buried, consistent with the cultural and temporal norms of the region (Lee et al., 2012; Marcsik et al., 2002, 2006; Csóri et al., 2009; Marcsik and Pap, 2000; Taylor and Donoghue, 2011). Even studies within leprosaria contexts suggest that sufferers were buried in normative medieval Christian fashion. Segal (2001) conducted a comparative analysis of burials from the St. Jørgensgard leprosy hospital in Odense and previous reported findings from non-leprosarium contexts in Denmark. They found that individuals in leprosaria were buried in the supine position with the head oriented to the west, which is typical of medieval Danish Christian burials, and several in wooden coffins with variable grave goods, similar to Mollerup's (1999) observations at Øm Kloster. Segal's findings suggest that there may have been stricter segregation of individuals with severe signs of leprosy in urban settings than in rural ones, similar to Boldsen and Mollerup (2006).

It might be tempting to suggest that the lack of burial distinction relates to medieval individuals' inability to accurately identify and diagnose certain diseases. There is ample discussion about whether medieval people could accurately differentiate leprosy from other skin diseases and how this may or may not affect estimated prevalence of individuals with leprosy in bioarchaeological contexts (Rawcliffe, 2013; Roberts, 2020; Richards, 1977; Browne, 1975; Demaitre, 2007; Crane-Kramer, 2000), but equal attention is not afforded to skeletal TB. Part of this discussion is dedicated to whether medieval people's ability to identify and isolate those with leprosy contributed to its decline in much of Europe from the late medieval period onward (Donoghue, 2017; Donoghue et al., 2005; Crespo et al., 2019; Duncan, 1994; Hohmann and Voss-Böhme, 2013; Lietman et al., 1997; Manchester, 1984; Wilbur et al., 2002), with a notable exception being Norway, where the disease remained a public health crisis until the nineteenth century (Irgens, 1973, 1980, 1981; Irgens and Bjerkdal, 2006). While this is not the primary focus of our study, we have reason to believe that medieval Danes could identify whether a person had advanced stages of leprotic infection, and this affected the distribution of diseased individuals in our samples, along with their proximity to leprosaria. It bears noting that medieval people did not singularly rely on physicians to diagnose illness; instead, they could turn to other positions of authority like the clergy, magistrates, and village elders for guidance (Browne, 1975; Magilton, 2008; Magilton et al., 2008). Certainly, leprosy was a recognizable disease both within and beyond the medical profession, to the extent that diagnostic criteria were being developed by the thirteenth century. These early criteria emphasized skin and, by extension, bony lesions of the face (Roberts, 2020; Demaitre, 2007). This emphasis on facial lesions likely led to a selective bias where individuals with these symptoms, primarily those with the lepromatous form, were selected out of the normative burial contexts to find refuge and eventual burial in leprosaria settings (Boldsen and Mollerup, 2006; Kelmelis et al., 2020; Kelmelis and Pedersen, 2019; Segal, 2001). This selective bias may have contributed to the overall decline of leprosy in Denmark, particularly in urban areas (Boldsen, 2009; Lynnerup and Boldsen, 2012). Of course, leprosaria were unlikely to have been the only contributing factor to the decline of leprosy in Denmark (see discussion on leprosy–TB co-immunity and co-infection in (Roberts, 2020 as well as Donoghue et al., 2005; Crespo et al., 2019; Duncan, 1994; Hohmann and Voss-Böhme, 2013; Lietman et al., 1997; Manchester, 1984; Wilbur et al., 2002), but these collective findings, especially given their statistical applications, contextualization, and rural comparisons, make a compelling argument that leprosaria and similar institutions reflect a widespread societal response to this disease within growing urban settings.

The emphasis on facial lesions indicates that individuals with different forms, primarily those with lesions on the lower extremities, less severe infection, or even asymptomatic status, may not have been buried in leprosaria. The shift in diagnostic criteria to include other areas of the body did not occur until the sixteenth century (Demaitre, 2007), which is largely after the Danish medieval period (c. 1050–1536 AD), the focus of our studies and those of our colleagues (Boldsen and Mollerup, 2006). It is also largely by this point that we see a decline in leprosy in Denmark and much of Europe; as a result, leprosaria relaxed their entry requirements to include individuals without the disease, including the elderly and infirm. As such, not everyone with this disease ended up in leprosaria (Rawcliffe, 2013; Roberts, 2020; Demaitre, 2007), nor is it reasonable to believe that 100% isolation of the sick was feasible given inconsistent segregation of the sick and the heterogeneous immunological landscape (Crespo et al., 2019). However, the ability for medieval people to identify this disease is evident in the relatively high number of individuals with leprotic lesions in leprosaria cemeteries and, conversely, the low number of such individuals in non-leprosaria burial contexts (Boldsen and Mollerup, 2006; Richards, 1977; Segal, 2001; Møller-Christensen, 1961, 1978). Magilton (2008) suggests that the general absence of individuals with evidence of leprosy in normal medieval cemeteries supports the idea that medieval people could identify early stages of the disease, even in early stages of infection. It also suggests the possibility that leprosy decreased in urban centers prior to communities in the rural hinterland, where diagnosis was less frequent and villages were a greater distance from leprosaria (Lynnerup and Boldsen, 2012).

Medieval burial customs were dictated by one's social status and the affordability of what churches and monasteries could offer in one's final rite of passage. Our spatial division of social classes for each cemetery, except for Sejet, seemingly suggests that individuals of elevated status were more likely to be buried in close proximity to church or monastic structures. While this may be true in some instances, such as Øm Kloster, where spatial divisions reflect Cistercian burial regulations according to certain class lines, we cannot guarantee that this holds true for our other cemetery samples from Ribe and Viborg, given the selective excavations conducted at these sites. The selection criteria we used in this study allowed for broad comparisons of geographical spaces and loosely defined status categories. As such, there is likely greater nuance in our samples than we have captured here, and bringing out that nuance will require additional exploration at each site. For instance, St. Mathias has a high proportion of high-status vs. low-status individuals, which may account for the marginally higher mortality hazard of high-status burials. This result may be an artifact of excavation sampling and how we divided the cemetery where the eastern area was included as a low-status area and the southern area and within the church as high-status areas. As shown in Figure 8, the eastern area is close to the church, and the social gap between those buried there and those buried south of the church was likely not very wide. For Sejet, on the other hand, we made no spatial distinction within the cemetery, although there were likely wealthy landowning families among the lay burials. However, the burial locations of those landowners could not be distinguished within the excavated area. We can say, at least for our samples, that individuals with these diseases were buried much as their peers in their respective social classes were. This trend was observed in both urban and rural monastic settings, where both high- and low-status groups had individuals displaying skeletal evidence of these diseases. For our urban samples, there is the possibility that more wealthy individuals with leprosy or with severe cases of TB could afford a physician's treatment and could be relocated to a place of care like leprosaria. We should note that we do have notably fewer high-status individuals with leprosy than low-status individuals, which may be a consequence of wealthier people having access to physicians and being moved to leprosaria (Roberts, 2020).

In this study, we endeavored to explore the osteoarchaeological and spatial evidence of differential mortuary treatment of sufferers of leprosy and TB in urban and rural cemeteries in medieval Denmark. We hypothesized that those perceptively ill individuals, meaning those who were sick long enough to develop skeletal lesions, buried within non-leprosaria contexts would be differentially treated in death (e.g., burial location) compared to their non-lesioned peers and would have greater mortality risks by comparison. We also considered the effects of urban environment and social status as factors that may have an impact on burial location and disease state. Our findings revealed that the notably low frequencies of individuals with leprotic infection in urban cemeteries support previous findings and may suggest that leprosaria in medieval towns may have contributed to the apparent decline of leprosy during the late medieval period. While leprosaria did welcome individuals without leprosy toward the end of the medieval period, TB was a prevalent disease in urban and rural settings and individuals were apparently not segregated to hospital cemeteries in death. Furthermore, our results indicate that social status, rather than disease status, was a predictor for spatial patterning in medieval Christian burials in both urban and monastic settings in Denmark. Ultimately, this study illustrates that the mortuary landscape of medieval Denmark was heterogeneous in some ways but consistent in others. Counter to our modern assumptions, being “sick” was not necessarily a damning factor in one's burial placement or necessarily in their treatment prior to death. One of the important virtues of medieval Christianity was charity, and the treatment of the sick was a communal act of charity for institutions like leprosaria and monastic houses. In the case of monastic orders, it is possible that many of those who were buried were cared for before their death and afforded burial rites, at a price, of course. To that end, perhaps the ticket to being buried closer to God was to be able to afford it.

Data availability statement

The data analyzed in this study is subject to the following licenses/restrictions: Some of the data belongs to one of the author's dissertation and is not yet publically available. Requests to access these datasets should be directed to c2FpZ2Uua2VsbWVsaXNAdXNkLmVkdQ==.

Ethics statement

Data collection was done under the supervision and permission of institutional and museum curatorial staff, and all data collection and use adhered to institution ethics guidelines of responsible handling of the remains. This research did not involve destructive sampling and did not constitute a risk to the living descendant community since we do not have access to nor are sharing sensitive information.

Author contributions

SK: Funding acquisition, Visualization, Formal analysis, Project administration, Writing – original draft, Data curation, Writing – review & editing, Investigation, Conceptualization, Methodology. VK: Writing – review & editing, Investigation, Writing – original draft, Project administration, Conceptualization, Data curation, Formal analysis, Methodology. LL: Data curation, Writing – review & editing, Visualization, Resources. MK: Resources, Writing – review & editing, Data curation. LM: Writing – review & editing, Resources, Data curation, Visualization. LS: Resources, Writing – review & editing, Data curation. DP: Writing – original draft, Formal analysis, Visualization, Project administration, Resources, Conceptualization, Funding acquisition, Methodology, Data curation, Investigation, Writing – review & editing.

Funding

The author(s) declared that financial support was received for this work and/or its publication. Data collection for this research was financed by the National Science Foundation (Kelmelis: BCS-1825362), Wenner-Gren Foundation (Kelmelis: #9604), the American-Scandinavian Foundation (Kelmelis), the Velux Foundation (Pedersen), and the Independent Research Fund Denmark (Pedersen and Kristensen: DFF 6107-00284).

Acknowledgments

We are very grateful for the partnership and assistance of the various institutions that contributed to this research and for providing access to their curated collections.

Conflict of interest

The author(s) declared that this work was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Generative AI statement

The author(s) declared that generative AI was used in the creation of this manuscript. Generative AI was used in the assistance of dealing with R coding errors. No AI was used in the creation of the manuscript itself.

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Supplementary material

The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fearc.2025.1699370/full#supplementary-material

References

Andersen, L. (2003). Ribe Gråbrødrekloster – det sidste kapitel. Mark Montre 39, 23–40.

Google Scholar

Andersson, H. (2003). “Urbanisation,” in The Cambridge History of Scandinavia, ed. K. Helle (Cambridge: Cambridge University Press), 312–342. doi: 10.1017/CHOL9780521472999.017

Crossref Full Text | Google Scholar

Andrén, A. (1983). Städer och kungmakt—en studie i Danmarks politiska geografi före 1230. Scandia 49, 31–71.

Google Scholar

Andrén, A. (1985). Den urbana scenen: städer och samhälle i det medeltida Danmark. Malmö Bonn 13.

Google Scholar

Andrén, A. (1989). State and towns in the Middle Ages: the Scandinavian experience. Theory Soc. 18, 585–609. doi: 10.1007/BF00149493

Crossref Full Text | Google Scholar

Andrén, A. (2000). Ad sanctos – de dödas plats under medeltiden. Hikuin 27, 8–26.

Google Scholar

Arcini, C. (1999). Health and Disease in Early Lund. Lund: Medical Faculty Lund University.

Google Scholar

Arentoft, E. (1999). De Spedalskes Hospital. Odense: Odense City Museums.

Google Scholar

Aufderheide, A. C., and Rodríguez-Martín, C. (1998). The Cambridge Encyclopedia of Human Paleopathology. Enhanced Credo Edition. Cambridge: Cambridge University Press.

Google Scholar

Avanzi, C., del-Pozo, J., Benjak, A., Stevenson, K., Simpson, V. R., Busso, P., et al. (2016). Red squirrels in the British Isles are infected with leprosy bacilli. Science 354, 744–747. doi: 10.1126/science.aah3783

PubMed Abstract | Crossref Full Text | Google Scholar

Barnes, I., Duda, A., Pybus, O. G., and Thomas, M. G. (2011). Ancient urbanization predicts genetic resistance to tuberculosis: urbanization and infectious disease. Evolution 65, 842–848. doi: 10.1111/j.1558-5646.2010.01132.x

Crossref Full Text | Google Scholar

Benedictow, O. (2003). “Demographic conditions,” in The Cambridge History of Scandinavia, ed. K. Helle (Cambridge: Cambridge University Press), 237–249. doi: 10.1017/CHOL9780521472999.015

Crossref Full Text | Google Scholar

Bennike, P. (1985). Palaeopathology of Danish Skeletons: A Comparative Study of Demography, Disease and Injury. Copenhagen: Akademisk Forlag.

Google Scholar

Betsinger, T. K., and DeWitte, S. N. (2021). Toward a bioarchaeology of urbanization: demography, health, and behavior in cities in the past. Am. J. Phys. Anthropol. 175, 79–118. doi: 10.1002/ajpa.24249

PubMed Abstract | Crossref Full Text | Google Scholar

Betsinger, T. K., and DeWitte, S. N., (eds.) (2020). The Bioarchaeology of Urbanization: The Biological, Demographic, and Social Consequences of Living in Cities. Cham: Springer International Publishing (Bioarchaeology and Social Theory). Available online at: http://link.springer.com/10.1007/978-3-030-53417-2 (Accessed December 23, 2020).

Google Scholar

Bøgh, A. (2004). “Samfundet,” in Dagligliv i Danmarks middelalder, ed. E. Roesdahl (Aarhus: Aarhus Universitetsforlag), 24–53.

Google Scholar

Boldsen, J. (1989). Vejen til byen - En skitse af de befolkningsmæssige relationer mellem land og by I det middelalderlige Jylland belyst ved skeletfund. Land og by I Middelalderen 5, 127–159.

Google Scholar

Boldsen, J. (1990a). “Height variation in the light of social and regional differences in Medieval Denmark,” in From the Baltic to the Black Sea: Studies in Medieval Archaeology, eds. L. Alcock and D. Austin (London: Unwinn and Hymann), 181–188. doi: 10.4324/9780203598320-12

Crossref Full Text | Google Scholar

Boldsen, J. (1990b). Population structure, body proportions and height prediction. J. Forensic Med. 6, 156–165.

Google Scholar

Boldsen, J. (1996). Patterns of childhood mortality in medieval Scandinavia. Rivista Anthropol. 74, 147–159.

Google Scholar

Boldsen, J., and Freund, U. (2006). Osteological leprosy - epidemiology and diagnosis. Scandinavian J. Forensic Sci. 67–72.

Google Scholar

Boldsen, J., and Mollerup, L. (2006). Outside St. Jørgen: leprosy in the medieval Danish city of Odense. Am. J. Phys. Anthropol. 130, 344–351. doi: 10.1002/ajpa.20363

PubMed Abstract | Crossref Full Text | Google Scholar

Boldsen, J. L. (2001). Epidemiological approach to the paleopathological diagnosis of leprosy. Am. J. Phys. Anthropol. 115, 380–387. doi: 10.1002/ajpa.1094

PubMed Abstract | Crossref Full Text | Google Scholar

Boldsen, J. L. (2005a). Leprosy and mortality in the Medieval Danish village of Tirup. Am. J. Phys. Anthropol. 126, 159–168. doi: 10.1002/ajpa.20085

PubMed Abstract | Crossref Full Text | Google Scholar

Boldsen, J. L. (2005b). Testing conditional independence in diagnostic palaeoepidemiology. Am. J. Phys. Anthropol. 128, 586–592. doi: 10.1002/ajpa.20133

PubMed Abstract | Crossref Full Text | Google Scholar

Boldsen, J. L. (2008). Leprosy in the early medieval Lauchheim community. Am. J. Phys. Anthropol. 135, 301–310. doi: 10.1002/ajpa.20744

PubMed Abstract | Crossref Full Text | Google Scholar

Boldsen, J. L. (2009). Leprosy in Medieval Denmark - osteological and epidemiological analyses. Anthropologischer Anzeiger. 67, 407–425. doi: 10.1127/0003-5548/2009/0031

Crossref Full Text | Google Scholar

Boldsen, J. L., Milner, G. R., Konigsberg, L. W., and Wood, J. W. (2002). “Transition analysis: a new method for estimating age from skeletons,” in Paleodemography: Age Distributions from Skeletal Samples, eds. J. W. Vaupel and R. D. Hoppa (Cambridge: Cambridge University Press), 73–106. (Cambridge Studies in Biological and Evolutionary Anthropology). Available online at: https://www.cambridge.org/core/books/paleodemography/transition-analysis-a-new-method-for-estimating-age-from-skeletons/B77A3B20D1891369419EB9C34E793283 (Accessed January 24, 2021). doi: 10.1017/CBO9780511542428.005

Crossref Full Text | Google Scholar

Boldsen, J. L., Milner, G. R., and Ousley, S. D. (2022). Paleodemography: from archaeology and skeletal age estimation to life in the past. Am. J. Biol. Anthropol. 178, 115–150. doi: 10.1002/ajpa.24462

PubMed Abstract | Crossref Full Text | Google Scholar

Boldsen, J. L., Rasmussen, K. L., Riis, T., Dittmar, M., and Weise, S. (2013). Schleswig: medieval leprosy on the boundary between Germany and Denmark. Anthropol. Anz. 70, 273–287. doi: 10.1127/0003-5548/2013/0318

PubMed Abstract | Crossref Full Text | Google Scholar

Brenner, E. (2010). Recent perspectives on leprosy in medieval Western Europe. Hist. Compass. 8, 388–406. doi: 10.1111/j.1478-0542.2009.00674.x

Crossref Full Text | Google Scholar

Brody (1974). The Disease of the Soul: Leprosy in Medieval Literature. Ithaca, NY: Cornell University Press.

Google Scholar

Browne, S. G. (1962). Leprosy: the Christian attitude. Expository Times 73, 242–245. doi: 10.1177/001452466207300805

Crossref Full Text | Google Scholar

Browne, S. G. (1975). Some aspects of the history of leprosy: the leprosie of yesterday. Proc. R. Soc. Med. 68, 485–493. doi: 10.1177/003591577506800809

PubMed Abstract | Crossref Full Text | Google Scholar

Bynum, H. (2012). Spitting Blood. Oxford: Oxford University Press, 13, 17, 18, 33–39, 56–62, 104, 106–107, 110.

PubMed Abstract | Google Scholar

CDC (2024). Hansen's Disease (Leprosy). About Hansen's Disease (Leprosy). Available online at: https://www.cdc.gov/leprosy/about/index.html (Accessed August 27, 2025).

Google Scholar

Cinthio, H. (1988). “En kyrkogård från 1000-talet i Löddeköpinge,” in Rapport från arkeologidagarna 13–15 Januari 1988, eds. E. Iregren, K. Jennbert, L. Larsson (University of Lund, Institute of Archaeology, Report Series), 32, 121–126.

Google Scholar

Cinthio, H., and Boldsen, J. (1984). Patterns of distribution in the early Medieval cemetery at Löddeköpinge. Meddelanden från Lunds universitets historiska museum 5, 107–115.

Google Scholar

Covey, H. C. (2001). People with leprosy (Hansen's disease) during the Middle Ages. Soc. Sci. J. 38, 315–321. doi: 10.1016/S0362-3319(01)00116-1

Crossref Full Text | Google Scholar

Cox, D. R. (1972). Regression models and life-tables. J. R. Stat. Soc. Ser. B 34, 187–220. doi: 10.1111/j.2517-6161.1972.tb00899.x

Crossref Full Text | Google Scholar

Crane-Kramer, G. M. M. (2000). The Paleoepidemiological Examination of Treponemal Infection and Leprosy in Medieval Populations from Northern Europe. Calgary. Available online at: https://prism.ucalgary.ca/handle/1880/40461 (Accessed March 13, 2019).

Google Scholar

Crespo, F., White, J., and Roberts, C. (2019). Revisiting the tuberculosis and leprosy cross-immunity hypothesis: expanding the dialogue between immunology and paleopathology. Int. J. Paleopathol. 26, 37–47. doi: 10.1016/j.ijpp.2019.05.005

PubMed Abstract | Crossref Full Text | Google Scholar

Csóri, Z., Donoghue, H. D., and Marcsik, A. (2009). Leprosy in the 10th−13th century AD in Eastern Hungary. Annuaire Roumain d'Anthropologie 46, 3–11.

Google Scholar

Cule, J. (2002). “The Stigma of leprosy: its historical origins and consequences with particular reference to the laws of Wales,” in The Past and Present of Leprosy Archaeological, Historical, Palaeopathological and Clinical Approaches, eds. C. A. Roberts, M. E. Lewis, and K. Manchester (Bradford: University of Bradford), 149–154. (British Archaeological Reports International Series).

Google Scholar

Dahlbäck, G. (2003). “The towns,” in The Cambridge History of Scandinavia, ed. K. Helle (Cambridge: Cambridge University Press), 611–33. doi: 10.1017/CHOL9780521472999.030

Crossref Full Text | Google Scholar

Degn, O. (1981). Rig og fattig i Ribe. Økonomiske og sociale forhold i Ribe-samfundet 1560-1660. Arhus: Universitetsforlaget i Aarhus.

Google Scholar

Demaitre, L. (2007). Leprosy in Premodern Medicine: A Malady of the Whole Body. Baltimore, MD: JHU Press. doi: 10.1353/book.3308

Crossref Full Text | Google Scholar

DeWitte, S., Kelmelis, S., and Wang, R. (2022). “Plagues and pandemics,” in Handbook of Paleopathology (Routledge), 576–592. doi: 10.4324/9781003130994-34

Crossref Full Text | Google Scholar

DeWitte, S. N. (2017). Stress, sex, and plague: patterns of developmental stress and survival in pre- and post-Black Death London. Am. J. Hum. Biol. 30:e23073. doi: 10.1002/ajhb.23073

PubMed Abstract | Crossref Full Text | Google Scholar

DeWitte, S. N., and Wood, J. W. (2008). Selectivity of Black Death mortality with respect to preexisting health. Proc. Natl. Acad. Sci. U.S.A. 105, 1436–1441. doi: 10.1073/pnas.0705460105

PubMed Abstract | Crossref Full Text | Google Scholar

Donoghue, H. D. (2013). Insights into ancient leprosy and tuberculosis using metagenomics. Trends Microbiol. 21, 448–450. doi: 10.1016/j.tim.2013.07.007

PubMed Abstract | Crossref Full Text | Google Scholar

Donoghue, H. D. (2017). Insights gained from ancient biomolecules into past and present tuberculosis—a personal perspective. Int. J. Infect. Dis. 56, 176–180. doi: 10.1016/j.ijid.2016.11.413

PubMed Abstract | Crossref Full Text | Google Scholar

Donoghue, H. D., Marcsik, A., Matheson, C., Vernon, K., Nuorala, E., Molto, J. E., et al. (2005). Co–infection of Mycobacterium tuberculosis and Mycobacterium leprae in human archaeological samples: a possible explanation for the historical decline of leprosy. Proc. R. Soc. B 272, 389–394. doi: 10.1098/rspb.2004.2966

PubMed Abstract | Crossref Full Text | Google Scholar

Donoghue, H. D., Michael Taylor, G., Marcsik, A., Molnár, E., Pálfi, G., Pap, I., et al. (2015a). A migration-driven model for the historical spread of leprosy in medieval Eastern and Central Europe. Infect. Genet. Evol. 31, 250–256. doi: 10.1016/j.meegid.2015.02.001

PubMed Abstract | Crossref Full Text | Google Scholar

Donoghue, H. D., Spigelman, M., O'Grady, J., Szikossy, I., Pap, I., Lee, O. Y. C., et al. (2015b). Ancient DNA analysis – An established technique in charting the evolution of tuberculosis and leprosy. Tuberculosis 95, S140–S144. doi: 10.1016/j.tube.2015.02.020

PubMed Abstract | Crossref Full Text | Google Scholar

Duncan, K. (1994). Climate and the decline of leprosy in Britain. Proc. R. Coll. Phys. Edinburgh 24, 114–120.

PubMed Abstract | Google Scholar

Ewert, U. C. (2007). Water, public hygiene and fire control in medieval towns: facing collective goods problems while ensuring the quality of life. Hist. Soc. Res. 32, 222–251.

Google Scholar

Fagan, B. (2008). The Great Warming – Climate Change and the Rise and Fall of Civilizations. New York, NY: Bloomsbury Press.

Google Scholar

Feveile, C., Søvsø, M., Nyborg, E., and Etting, V. (2010). “Landskabet og byrummet,” in Ribe Bys Historie, bind 1 – 710-1520, ed. S. Christensen (Esbjerg: Esbjerg Byhistoriske Arkiv), 20–102.

Google Scholar

Frith, J. (2014). History of tuberculosis. Part 1 - Phthisis, consumption and the White Plague. J. Milit. Veterans' Health 22, 29–35.

Google Scholar

Gamble, J. (2014). A Bioarchaeological Approach to Stress and Health in Medieval Denmark: Dental Enamel Defects and Adult Health in Two Medieval Danish Populations. Winnipeg: University of Manitoba.

Google Scholar

Gordon, C. C., and Buikstra, J. E. (1981). Soil pH, bone preservation, and sampling bias at mortuary sites. Am. Antiquity 46, 566–571. doi: 10.2307/280601

Crossref Full Text | Google Scholar

Graff, A., Bennion-Pedley, E., Jones, A. K., Ledger, M. L., Deforce, K., Degraeve, A., et al. (2020). A comparative study of parasites in three latrines from Medieval and Renaissance Brussels, Belgium (14th−17th centuries). Parasitology 147, 1443–1451. doi: 10.1017/S0031182020001298

PubMed Abstract | Crossref Full Text | Google Scholar

Gregersen, B. (2018). The Greatness Before the Fall: Øm Kloster at the Reformation Time (translated). Skanderborg Museum. Available online at: http://www.museumskanderborg.dk/storheden-f%C3%B8r-faldet (Accessed January 27 2019).

Google Scholar

Gregersen, B., and Jensen, C. (2003). Øm Kloster- kapitler af et cistercienserabbedis historie. Odense: Øm Kloster Museum and the University of Southern Denmark.

Google Scholar

Grundvad, B. (2013). Højmiddelalderens grave på Lindegården i Ribe. By Marsk og Geest 25, 63–73. doi: 10.7146/bmg.v25i1.132726

Crossref Full Text | Google Scholar

Halvorsen, E., and Rindal, M. (2008). De Eldste østlandske kristenrettene. Tekst etter håndskriftene, med oversettelser. Oslo 55−57, 137.

Google Scholar

Hermanussen, M., Bogin, B., and Scheffler, C. (2018). Stunting, starvation and refeeding: a review of forgotten 19th and early 20th century literature. Acta Paediatrica 107, 1166–1176. doi: 10.1111/apa.14311

PubMed Abstract | Crossref Full Text | Google Scholar

Herzog, H. (1998). History of tuberculosis. Respiration 65, 5–15. doi: 10.1159/000029220

Crossref Full Text | Google Scholar

Hjermind, J. (2010). “På sporet af Viborgs middelalderlige sognekirker,” in Stiftet og byen Viborg Stift 1060-2010, eds. J. Hjermind and E. Jørgensen (Vibord: Norhaven), 81–103.

Google Scholar

Hockings, K. J., Mubemba, B., Avanzi, C., Pleh, K., Düx, A., Bersacola, E., et al. (2021). Leprosy in wild chimpanzees. Nature 598, 652–656. doi: 10.1038/s41586-021-03968-4

PubMed Abstract | Crossref Full Text | Google Scholar

Hohmann, N., and Voss-Böhme, A. (2013). The epidemiological consequences of leprosy-tuberculosis co-infection. Math. Biosci. 241, 225–237. doi: 10.1016/j.mbs.2012.11.008

PubMed Abstract | Crossref Full Text | Google Scholar

Hybel, N., and Poulsen, B. (2007). The Danish Resources C. 1000–1550: Growth and Recession. Leiden: BRILL.

Google Scholar

Irgens, L. (1973). Leprosy in Norway: an interplay of research and public health. Int. J. Lepr. Other Mycobacterial Dis. 41, 189–198.

Google Scholar

Irgens, L. (1980). Leprosy in Norway. Lepr. Rev. 1, 1–130. doi: 10.5935/0305-7518.19800038

PubMed Abstract | Crossref Full Text | Google Scholar

Irgens, L. (1981). Epidemiological aspects and implications of the disappearance of leprosy from Norway: some factors contributing to the decline. Lepr. Rev. 1, 147–165. doi: 10.5935/0305-7518.19810066

PubMed Abstract | Crossref Full Text | Google Scholar

Irgens, L., and Bjerkdal, T. (2006). “Epidemiology of leprosy in Norway: the history of the National Leprosy Register from 18 until today,” in Leprosy, eds. L. Irgens, Y. Nedrebo, S. Sandmo, and A. Skivenes (Norway: Selja Forlag), 25–31.

Google Scholar

Jantzen, C., Kieffer-Olsen, J., and Madsen, P. (1995). De små brødre. SKALK 2, 11–16.

Google Scholar

Johansen, H. C. (2002). Danish Population History: 1600-1939. Odense: University Press of Southern Denmark.

Google Scholar

Jonsson, K. (2009). Bodily dimensions in medieval burials: on age- and gender-structures in socially stratified churchyards. Stockholm Stud. Archaeol. 48, 119–144.

Google Scholar

Jørgensen, D. (2007). Private need, public order: urban sanitation in Late Medieval England and Scandinavia (Doctoral dissertation). Department of History, Charlottesville: University of Virginia.

Google Scholar

Jørgensen, D. (2008). Cooperative sanitation: managing streets and gutters in late medieval England and Scandinavia. Technol. Cult. 49, 547–567. doi: 10.1353/tech.0.0047

PubMed Abstract | Crossref Full Text | Google Scholar

Jørgensen, D. (2013). “The medieval sense of smell, stench and sanitation,” in Les cinq sens de la ville du Moyen Âge à nos jours, eds. U. Krampl, R. Beck, and E. Retaillaud-Bajac (Tours: Presses Universitaires François-Rabelais, 2013), 301–313.

Google Scholar

Jørgensen, D. (2014). Modernity and medieval muck. Nat. Cult. 9, 225–237. doi: 10.3167/nc.2014.090301

Crossref Full Text | Google Scholar

Kaplan, E. L., and Meier, P. (1958). Nonparametric estimation from incomplete observations. J. Am. Stat. Assoc. 53, 457–481. doi: 10.1080/01621459.1958.10501452

Crossref Full Text | Google Scholar

Kelley, M. A., and El-Najjar, M. Y. (1980). Natural variation and differential diagnosis of skeletal changes in tuberculosis. Am. J. Phys. Anthropol. 52, 153–167. doi: 10.1002/ajpa.1330520202

PubMed Abstract | Crossref Full Text | Google Scholar

Kelley, M. A., and Micozzi, M. S. (1984). Rib lesions in chronic pulmonary tuberculosis. Am. J. Phys. Anthropol. 65, 381–386. doi: 10.1002/ajpa.1330650407

PubMed Abstract | Crossref Full Text | Google Scholar

Kelmelis, K. S., Kristensen, V. R. L., Alexandersen, M., and Dangvard Pedersen, D. (2020). “Markets and mycobacteria – a comprehensive analysis of the influence of urbanization on leprosy and tuberculosis prevalence in Denmark (AD 1200–1536),” in The Bioarchaeology of Urbanization: The Biological, Demographic, and Social Consequences of Living in Cities, eds. T. K. Betsinger and S. N. DeWitte (Cham: Springer International Publishing), 147–182. (Bioarchaeology and Social Theory). Available online at: https://doi.org/10.1007/978-3-030-53417-2_7 (Accessed January 4, 2021).

Google Scholar

Kelmelis, K. S., Price, M. H., and Wood, J. (2017). The effect of leprotic infection on the risk of death in medieval rural Denmark. Am. J. Phys. Anthropol. 164, 763–775. doi: 10.1002/ajpa.23314

PubMed Abstract | Crossref Full Text | Google Scholar

Kelmelis, S., and DeWitte, S. N. (2021). Urban and rural survivorship in pre- and post-black death Denmark. J. Archaeol. Sci. Rep. 38, 103089. doi: 10.1016/j.jasrep.2021.103089

Crossref Full Text | Google Scholar

Kelmelis, S., and Pedersen, D. (2019). Impact of urbanization on tuberculosis and leprosy prevalence in medieval Denmark. Anthranz 76, 149–166. doi: 10.1127/anthranz/2019/0962

PubMed Abstract | Crossref Full Text | Google Scholar

Keyes, G., Iversen, M., and Hjermind, J. (2007). VSM 09264: Sct. Trinitatis/Drotten, Sct. Leonis Gade 12, Viborg. Viborg: Viborg Museum.

Google Scholar

Kieffer-Olsen, J. (1990). Middelalderens gravskik i Danmark. Hikuin 17, 85–112.

Google Scholar

Kieffer-Olsen, J. (1993). Grav og gravskik I det middelalder Danmark: otte kirkegårdsudgravninger. Århus: University of Århus.

Google Scholar

Kieffer-Olsen, J. (1996). Ribe Gråbrødrekloster. Hikuin 23, 107–116.

Google Scholar

Kjærgård, A. (2006). Udgravningsrapport. HOM 1046, Sejet Ødekirkegård. Museum Horsens.

Google Scholar

Kjellström, A. (2005). The urban farmer: osteoarcheological analysis of skeletons from medieval sigtuna interpreted in a socioeconomic perspective (PhD dissertation). Stockholm: Department of Archaeology and Classical Studies; Stockholm University.

Google Scholar

Kjellström, A. (2012). Possible cases of leprosy and tuberculosis in medieval Sigtuna, Sweden. Int. J. Osteoarchaeol. 22, 261–283. doi: 10.1002/oa.1204

Crossref Full Text | Google Scholar

Koch, H., and Trolle, A. (2000). Middelalderens gader. Kuml 2000, 239–306. doi: 10.7146/kuml.v2000i14.114022

Crossref Full Text | Google Scholar

Krause-Kyora, B., Nutsua, M., Boehme, L., Pierini, F., Pedersen, D. D., Kornell, S. C., et al. (2018). Ancient DNA study reveals HLA susceptibility locus for leprosy in medieval Europeans. Nat. Commun. 9:1569. doi: 10.1038/s41467-018-03857-x

PubMed Abstract | Crossref Full Text | Google Scholar

Kristensen, H. (1987). Middelalderbyen Viborg. Viby: Centrum.

Google Scholar

Kristensen, H. (2004). “Land, by og bygninger,” in Dagligliv i Danmarks middelalder, ed. E. Roesdahl (Aarhus: Aarhus Universitetsforlag), 54–81.

Google Scholar

Kristensen, H. (2020). Øm Kloster, Vol. III. Aarhus University Press. Available online at: https://doi.org/10.2307/jj.423448 (Accessed August 8, 2025).

Google Scholar

Kristensen, H., and Poulsen, B. (2016). Danmarks byer i middelalderen. Aarhus: Aarhus University Press. doi: 10.2307/jj.608318

Crossref Full Text | Google Scholar

Kristensen V. (submitted). Population heterogeneity in the medieval town of Viborg, Denmark (Unpublished doctoral dissertation). University of Southern Denmark..

Google Scholar

Lee, O., Bull, I., Molnár, E., Marcsik, A., Pálfi, G., Donoghue, H., et al. (2012). “Integrated strategies for the use of lipid biomarkers in the diagnosis of ancient mycobacterial disease,” in Twelfth Annual Conference of the British Association for Biological Anthropology and Osteoarchaeology, eds. P. D. Mitchell and J. Buckberry (Cambridge: Department of Archaeology and Anthropology, University of Cambridge), 63–69.

Google Scholar

Lietman, T., Porco, T., and Blower, S. (1997). Leprosy and tuberculosis: the epidemiological consequences of cross-immunity. Am. J. Public Health 87, 1923–1927. doi: 10.2105/AJPH.87.12.1923

PubMed Abstract | Crossref Full Text | Google Scholar

Lofrano, G., and Brown, J. (2010). Wastewater management through the ages: a history of mankind. Sci. Total Environ. 408, 5254–5264. doi: 10.1016/j.scitotenv.2010.07.062

PubMed Abstract | Crossref Full Text | Google Scholar

Lynnerup, N., and Boldsen, J. (2012). “Leprosy (Hansen's disease),” in A Companion to Paleopathology, ed. A. Grauer (Oxford: Wiley-Blackwell), 458–471. doi: 10.1002/9781444345940.ch25

Crossref Full Text | Google Scholar

Madsen, P. (1990). Han ligger under en blå sten. Om middelalderens gravskik på skrift og i praksis. Hikuin 17, 113–134.

Google Scholar

Madsen, P. (2013). “Sygdom og død,” in Dagligliv i Danmarks Middelalder – En arkæologisk kulturhistorie, ed. E. Roesdahl (Copenhagen: Gyldendal), 324–351.

Google Scholar

Magilton, J. (2008). “History of the hospital,” in Lepers Outside the Gate: Excavations at the Cemetery of the Hospital of St James and St Mary Magdalene, Chichester, 1986-87 and 1993, Vol. 10, CBA Research Reports, eds. J. Magilton, F. Lee, and A. Boylston (York: CBA Research Reports) 1–20.

Google Scholar

Magilton, J., Lee, F., and Boylston, A. (eds.), (2008). Lepers Outside the Gate: Excavations at the Cemetery of the Hospital of St James and St Mary Magdalene, Chichester, 1986-87 and 1993, Vol. 10. York: CBA Research Reports.

Google Scholar

Manchester, K. (1984). Tuberculosis and leprosy in antiquity: an interpretation. Med. Hist. 28, 162–173. doi: 10.1017/S0025727300035705

PubMed Abstract | Crossref Full Text | Google Scholar

Marcsik, A., Fóthi, E., and Hegyi, A. (2002). Paleopathological changes in the Carpathian Basin in the 10th and 11th centuries. Acta Biol. Szegediensis 46, 95–99.

Google Scholar

Marcsik, A., Molnár, E., and Szathmáry, L. (2006). The antiquity of tuberculosis in Hungary: the skeletal evidence. Mem. Inst. Oswaldo Cruz 101, 67–71. doi: 10.1590/S0074-02762006001000012

PubMed Abstract | Crossref Full Text | Google Scholar

Marcsik, A., and Pap, I. (2000). Paleopathological research in Hungary. Acta Biol. Szegediensis 44, 103–108.

Google Scholar

Masiu, R., Pedersen, D. D., Hill, L., and Steyn, M. (2023). The association between skeletal lesions and tuberculosis in a pre-antibiotic South African sample. Int. J. Paleopathol. 40, 20–32. doi: 10.1016/j.ijpp.2022.11.001

PubMed Abstract | Crossref Full Text | Google Scholar

Mays, S. (1991). The Medieval Burials of Blackfriars Friary, School Street, Ipswich, Suffolk. English Heritage. London: Report No.: Ancient Monuments Laboratory Report 16/91.

Google Scholar

Meyers, W. M., Walsh, G. P., Brown, H. L., Binford, C. H., Imes, G. D., Hadfield, T. L., et al. (1985). Leprosy in a mangabey monkey–naturally acquired infection. Int. J. Lepr. Other. Mycobact. Dis. 53, 1–14.

PubMed Abstract | Google Scholar

Milner, G. R., and Boldsen, J. L. (2012). Transition analysis: a validation study with known-age modern American skeletons. Am. J. Phys. Anthropol. 148, 98–110. doi: 10.1002/ajpa.22047

PubMed Abstract | Crossref Full Text | Google Scholar

Milner, G. R., and Boldsen, J. L. (2017). Life not death: epidemiology from skeletons. Int. J. Paleopathol. 17, 26–39. doi: 10.1016/j.ijpp.2017.03.007

PubMed Abstract | Crossref Full Text | Google Scholar

Milner, G. R., Boldsen, J. L., Ousley, S. D., Getz, S. M., Weise, S., Tarp, P., et al. (2021). “Chapter 6 - Great expectations: the rise, fall, and resurrection of adult skeletal age estimation,” in Remodeling Forensic Skeletal Age, eds. B. F. B. Algee-Hewitt and J. Kim (Academic Press), 139–154. Available online at: https://www.sciencedirect.com/science/article/pii/B9780128243701000110 (Accessed February 26, 2022). doi: 10.1016/B978-0-12-824370-1.00011-0

Crossref Full Text | Google Scholar

Møller, E., Nyborg, E., and Poulsen, N. (1984). Franciskanerkirken S. Laurentius. Danmarks kirker Ribe Amt XIX, 846–858.

Google Scholar

Møller-Christensen, V. (1953). Ten Lepers from Naestved in Denmark, 2nd Edn. Copenhagen: Danish Science Press. (Med. Monograph).

Google Scholar

Møller-Christensen, V. (1961). Bone Changes in Leprosy. Copenhagen: Munksgaard.

Google Scholar

Møller-Christensen, V. (1974). Changes in the anterior nasal spine and the alveolar process of the maxillae in leprosy: a clinical examination. Int. J. Lepr. 42, 431–435.

Google Scholar

Møller-Christensen, V. (1978). Leprosy Changes of the Skull. Odense: University Press.

Google Scholar

Mollerup, L. (1999). Begravelserne ved Øm Kloster. Afd. for Middelalderarkæologi og Middelalderarkæologisk Nyhedsbrev. Aarhus Aarhus University.

Google Scholar

Nielsen, I. (1985). Middelalderbyen Ribe (Projekt Middelalderbyen. Statens Humanistiske Forskningsråd). Copenhagen: Centrum.

Google Scholar

Nyborg, E., and Poulsen, N. (2010). Sejet Kirke, Danmarks kirker XVII. Vejle Amt. 3, 1087–1094.

Google Scholar

Ortner, D. J. (2003). Identification of Pathological Conditions in Human Skeletal Remains. San Diego, CA: Academic Press.

Google Scholar

Pardillo, F. E. F., Fajardo, T. T., Abalos, R. M., Scollard, D., and Gelber, R. H. (2007). Methods for the classification of leprosy for treatment purposes. Clin. Infect. Dis. 44, 1096–1099. doi: 10.1086/512809

PubMed Abstract | Crossref Full Text | Google Scholar

Pedersen, D. (2009). Focal Osteolytic Syndrome – The Definition and Epidemiological Analysis of Newly Recognized Pathological Condition in Danish Medieval Skeletons. Odense: University of Southern Denmark.

Google Scholar

Pedersen, D., and Boldsen, J. (2008). Antropologisk Rapport: HOM 1046, Sejet Ødekirkegård. Odense: University of Southern Denmark.

Google Scholar

Pedersen, D., Tarp, P., Søvsø, M., Petersen, H., Milner, G., Boldsen, J., et al. (2020). A millennium of population change in pre-modern Danish Ribe. Anthropologischer Anzeiger 77, 13–25. doi: 10.1127/anthranz/2019/0952

PubMed Abstract | Crossref Full Text | Google Scholar

Pedersen, D. D., Milner, G. R., Kolmos, H. J., and Boldsen, J. L. (2019). Tuberculosis in medieval and early modern Denmark: a paleoepidemiological perspective. Int. J. Paleopathol. 27, 101–108. doi: 10.1016/j.ijpp.2018.11.003

PubMed Abstract | Crossref Full Text | Google Scholar

Pedersen, D. D., Milner, G. R., Kolmos, H. J., and Boldsen, J. L. (2019). The association between skeletal lesions and tuberculosis diagnosis using a probabilistic approach. Int. J. Paleopathol. 27, 88–100. doi: 10.1016/j.ijpp.2019.01.001

PubMed Abstract | Crossref Full Text | Google Scholar

Petersen, H., Boldsen, J., and Paine, R. (2006). Population Relationships in and Around Medieval Danish Towns. Tuscaloosa: University of Alabama Press, 110–120. doi: 10.2307/jj.30347275.11

Crossref Full Text | Google Scholar

R Team Corp (2018). R: A language and Environment for Statistical Computing [Computer software]. R Foundation for Statistical Computing. Available online at: https://www.R-project.org/

Google Scholar

Rasmussen, K. L., Boldsen, J. L., Kristensen, H. K., Skytte, L., Hansen, K. L., Mølholm, L., et al. (2008). Mercury levels in Danish Medieval human bones. J. Archaeol. Sci. 35, 2295–2306. doi: 10.1016/j.jas.2008.03.003

Crossref Full Text | Google Scholar

Rawcliffe, C. (2013). Urban Bodies: Communal Health in Late Medieval English Towns and Cities. Woodbridge: The Boydell Press.

Google Scholar

Redman, J. E., Shaw, M. J., Mallet, A. I., Santos, A. L., Roberts, C. A., Gernaey, A. M., et al. (2009). Mycocerosic acid biomarkers for the diagnosis of tuberculosis in the Coimbra Skeletal Collection. Tuberculosis 89, 267–277. doi: 10.1016/j.tube.2009.04.001

PubMed Abstract | Crossref Full Text | Google Scholar

Richards, P. (1977). The Medieval Leper and His Northern Heirs. Cambridge: Boydell and Brewer.

Google Scholar

Richards, P. (1990). Leprosy: myth, melodrama and mediaevalism. J. R. Coll. Phys. London 24, 55–62. doi: 10.1016/S0035-8819(25)02154-3

Crossref Full Text | Google Scholar

Ridley, D. S., and Jopling, W. H. (1966). Classification of leprosy according to immunity. A five-group system. Int. J. Lepr. Other Mycobact. Dis. 34, 255–273.

PubMed Abstract | Google Scholar

Roberts, C. (2011). “The Bioarchaeology of Leprosy and Tuberculosis,” in Social Bioarchaeology, eds. S. Agarwal and B. Glencross (John Wiley & Sons, Ltd.), 252–281. doi: 10.1002/9781444390537.ch9

Crossref Full Text | Google Scholar

Roberts, C. (2017). “Applying the ‘index of care' to a person who experienced leprosy in late medieval Chichester, England,” in New Developments in the Bioarchaeology of Care: Further Case Studies and Expanded Theory, eds. L. Tilley and A. A. Schrenk (Cham: Springer International Publishing), 101–124. Available online at: https://doi.org/10.1007/978-3-319-39901-0_6 (Accessed August 26, 2025).

Google Scholar

Roberts, C. (2020). Leprosy: Past and Present. Gainesville, FL: University Press of Florida. doi: 10.5744/florida/9781683401841.001.0001

Crossref Full Text | Google Scholar

Roberts, C. A., and Buikstra, J. E. (2003). The Bioarchaeology of Tuberculosis: A Global View on a Reemerging Disease. Gainesville, FL: University Press of Florida, 343p.

Google Scholar

Roberts, C. A., Lewis, M., and Manchester, K., (eds.) (2002). Past and Present of Leprosy: Archaeological, Historical, Paleopathological and Clinical Approaches: Proceedings of the International Congress on the Evolution and Paleoepidemiology of the Infectious Diseases 3 (ICEPID), University of Bradford, 26–31 July 1999, BAR International Series. Oxford: Archaeopress, 311.

Google Scholar

Roberts, C. A., and Manchester, K. (2007). The Archaeology of Disease. Ithaca, NY: Cornell University Press.

Google Scholar

Roesdahl, E. (2004). Dagligliv i Danmarks middelalder – en arkaeologisk kulturhistorie. Århus: Århus Universitetsforlag.

Google Scholar

Roffey, S., and Tucker, K. (2012). A contextual study of the medieval hospital and cemetery of St Mary Magdalen, Winchester, England. Int. J. Paleopathol. 2, 170–180. doi: 10.1016/j.ijpp.2012.09.018

PubMed Abstract | Crossref Full Text | Google Scholar

Santos, A. L., and Roberts, C. A. (2006). Anatomy of a serial killer: differential diagnosis of tuberculosis based on rib lesions of adult individuals from the Coimbra identified skeletal collection, Portugal. Am. J. Phys. Anthropol. 130, 38–49. doi: 10.1002/ajpa.20160

PubMed Abstract | Crossref Full Text | Google Scholar

Schuenemann, V. J., Avanzi, C., Krause-Kyora, B., Seitz, A., Herbig, A., Inskip, S., et al. (2018). Ancient genomes reveal a high diversity of Mycobacterium leprae in medieval Europe. PLoS Pathog. 14:e1006997. doi: 10.1371/journal.ppat.1006997

PubMed Abstract | Crossref Full Text | Google Scholar

Scott, A. B., and Hoppa, R. D. (2019). The ice age with little effect? Exploring stress in the Danish Black Friars cemetery before and after the turn of the 14th century. Int. J. Paleopathol. 26, 157–163. doi: 10.1016/j.ijpp.2018.12.004

PubMed Abstract | Crossref Full Text | Google Scholar

Segal, K. (2001). Bioarchaeological analysis of St. Jorgensgard, a medieval leprosy hospital in Odense, Denmark (PhD thesis). University of Chicago, Chicago, IL, United States.

Google Scholar

Senelle, G., Sahal, M. R., La, K., Billard-Pomares, T., Marin, J., Mougari, F., et al. (2023). Towards the reconstruction of a global TB history using a new pipeline “TB-Annotator“. Tuberculosis 143:102376. doi: 10.1016/j.tube.2023.102376

PubMed Abstract | Crossref Full Text | Google Scholar

Singh, P., Benjak, A., Schuenemann, V. J., Herbig, A., Avanzi, C., Busso, P., et al. (2015). Insight into the evolution and origin of leprosy bacilli from the genome sequence of Mycobacterium lepromatosis. Proc. Natl. Acad. Sci. U.S.A. 112, 4459–4464. doi: 10.1073/pnas.1421504112

PubMed Abstract | Crossref Full Text | Google Scholar

Steckel, R. (1995). Stature and the standard of living. J. Econ. Literat. 33, 1903–1940.

Google Scholar

Stone, A. C. (2017). Tracking a Killer: The Origin and Evolution of Tuberculosis. Russell E. Marker Lectures in Evolutionary Biology. Pennsylvania, PA: Pennsylvania State University.

Google Scholar

Stone, A. C., Wilbur, A. K., Buikstra, J. E., and Roberts, C. A. (2009). Tuberculosis and leprosy in perspective. Am. J. Phys. Anthropol. 140, 66–94. doi: 10.1002/ajpa.21185

PubMed Abstract | Crossref Full Text | Google Scholar

Straaß, G. (1976). Sozialantropologie - Prämisen - Fakten - Probleme. Jena: V.E.B. Gustav Fischer Verlag.

Google Scholar

Suzuki, K., Tanigawa, K., Kawashima, A., Miyamura, T., and Ishii, N. (2011). Chimpanzees used for medical research shed light on the pathoetiology of leprosy. Future Microbiol. 6, 1151–1157. doi: 10.2217/fmb.11.97

PubMed Abstract | Crossref Full Text | Google Scholar

Tanner, N., (1990). Decrees of the Ecumenical Councils, Vol. 1, Nicaea I to Lateran V. London: Sheed and Ward Limited and Washington, DC: Georgetown University Press.

Google Scholar

Taylor, G. M., Young, D. B., and Mays, S. A. (2005). Genotypic analysis of the earliest known prehistoric case of tuberculosis in Britain. J. Clin. Microbiol. 43, 2236–2240. doi: 10.1128/JCM.43.5.2236-2240.2005

PubMed Abstract | Crossref Full Text | Google Scholar

Taylor, M., and Donoghue, H. D. (2011). Multiple loci variable number tandem repeat (VNTR) analysis (MLVA) of Mycobacterium leprae isolates amplified from European archaeological human remains with lepromatous leprosy. Microbes Infect. 13, 923–929. doi: 10.1016/j.micinf.2011.05.003

PubMed Abstract | Crossref Full Text | Google Scholar

Thorndike, L. (1928). Sanitation, baths, and street-cleaning in the Middle Ages and renaissance. Speculum 3, 192–203. doi: 10.2307/2848055

PubMed Abstract | Crossref Full Text | Google Scholar

Thrane, H., Nyberg, T., Grandt-Nielsen, F., and Venge, M. (1982). Fra boplads til bispeby. Odense til 1559. Odense: University Press of Southern Denmark.

Google Scholar

Touati, F. (2017). “Contagion and leprosy: myth, ideas and evolution in medieval minds and societies,” in Contagion, eds. L. I. Conrad and D. Wujastyk (London: Routledge), 179–201. doi: 10.4324/9781315259505-9

Crossref Full Text | Google Scholar

Trap, J. (1898). Bjærge herred. Kongeriet Danmark 5:330.

Google Scholar

Truman, R. (2005). Leprosy in wild armadillos. Lepr. Rev. 76, 198–208. doi: 10.47276/lr.76.3.198

PubMed Abstract | Crossref Full Text | Google Scholar

Urban, C., Blom, A. A., Pfrengle, S., Walker-Meikle, K., Stone, A. C., Inskip, S. A., et al. (2021). One health approaches to trace mycobacterium leprae's zoonotic potential through time. Front. Microbiol. 12:762263. doi: 10.3389/fmicb.2021.762263

PubMed Abstract | Crossref Full Text | Google Scholar

van Doren, T. P., and Kelmelis, S. (2023). Contextualizing pandemics: respiratory survivorship before, during, and after the 1918 influenza pandemic in Newfoundland. Am. J. Biol. Anthropol. 181, 70–84. doi: 10.1002/ajpa.24678

Crossref Full Text | Google Scholar

Walter, B. S., and DeWitte, S. N. (2017). Urban and rural mortality and survival in Medieval England. Ann. Hum. Biol. 44, 338–348. doi: 10.1080/03014460.2016.1275792

PubMed Abstract | Crossref Full Text | Google Scholar

Weise, S. (2009). The Medieval Cemetery St Jörgen in Malmö: A Paleodemographic Analysis. Odense: University of Southern Denmark.

Google Scholar

WHO (2023). Global Leprosy (Hansen Disease)? Update: Elimination of Leprosy Disease is Possible – Time to Act!. Available online at: https://www.who.int/publications/i/item/who-wer9937-501-521 (Accessed August 27, 2025).

Google Scholar

Wilbur, A. K., Buikstra, J. E., and Stojanowski, C. M. (2002). “Mycobacterial disease in North America: an epidemiological test of Chaussinand's cross-immunity hypothesis,” in Proceedings of the 3rd International Congress on the Evolution and Palaeoepidemiology of Infectious Diseases, eds. C. Roberts, M. Lewis, and K. Manchester (Oxford: Archaeopress), 251–262.

Google Scholar

Williams, D. H. (1998). The Cistercians in the Early Middle Ages: Written to Commemorate the Nine Hundredth Anniversary of Foundation of the Order at Cîteaux in 1098, Under the Patronage of Blessed Vincent Kadłubek, Bishop of Kraków (1208–18), monk of Jȩdrzejów (1218–1223). Leominster: Gracewing.

Google Scholar

Wollina, U., Hoenig, L. J., Parish, L. C., and Pierce, S. E. (2025). Leprosy in the Middle Ages: a European perspective. Clin. Dermatol. 43, 431–439. doi: 10.1016/j.clindermatol.2025.01.005

PubMed Abstract | Crossref Full Text | Google Scholar

Wood, J. W., Holman, D. J., O'Connor, K. A., and Ferrell, R. J. (2002). “Mortality models for paleodemography,” in Paleodemography, 1st Edn., eds. R. D. Hoppa and J. W. Vaupel (Cambridge: Cambridge University Press), 129–168. Available online at: https://www.cambridge.org/core/product/identifier/CBO9780511542428A014/type/book_part (Accessed June 9, 2021).

Google Scholar

Wood, J. W., Milner, G. R., Harpending, H. C., Weiss, K. M., Cohen, M. N., Eisenberg, L. E., et al. (1992). The osteological paradox: problems of inferring prehistoric health from skeletal samples [and comments and reply]. Curr. Anthropol. 33, 343–370. doi: 10.1086/204084

Crossref Full Text | Google Scholar

Yoder, C. J. (2009). The Late Medieval Agrarian Crisis and Black Death Plague Epidemic in Medieval Denmark: A Paleopathological and Paleodietary Perspective. Available online at: https://oaktrust.library.tamu.edu/handle/1969.1/ETD-TAMU-1725 (Accessed January 24, 2021).

Google Scholar