Received: 10 December 2018 Revised: 24 June 2019 Accepted: 7 July 2019 DOI: 10.1002/oa.2805 RESEARCH ARTICLE Applying the Index of Care to the Mississippian period: A case study of treponematosis, physical impairment, and probable health‐related caregiving from the Holliston Mills site, TN Molly K. Zuckerman1 Nicholas P. Herrmann3 Kelly R. Kamnikar2 | | | Anna J. Osterholtz1 | Jay D. Franklin4 1 Department of Anthropology and Middle Eastern Cultures, Mississippi State University, Mississippi State, MS, USA 2 Abstract Bioarchaeologists and palaeopathologists have recently turned their attention Department of Anthropology, Michigan State University, East Lansing, MI, USA towards one critical aspect of the study of the history of disease: health‐related 3 caregiving. In response, an approach, the bioarchaeology of care, and, within it, Department of Anthropology, Texas State University, San Marcos, TX, USA 4 Department of Sociology/Anthropology, East Tennessee State University, Johnson City, TN, USA Correspondence Molly K. Zuckerman, Department of Anthropology and Middle Eastern Cultures, 340 Lee Blvd, Mississippi State University, Mississippi State, MS 39762. Email: mkz12@msstate.edu the web‐based Index of Care (IoC) have been developed to enable the identification and interpretation of past caregiving. Here, we apply the IoC to Burial 86, a young adult (18–25 years) female from the late Mississippian period, Dallas cultural phase Holliston Mills site (40HW11; ca. AD 1348–1535), TN. Burial 86 exhibits pathologies specific to treponematosis. They also exhibit a suite of pathologies indicative of physical impairment, including a varus angular deformity in the right tibia that is potentially the result of a malaligned pathological fracture. Following the IoC, we determine that Burial 86 probably experienced moderate clinical impacts on several domains (e.g., musculoskeletal system) with various functional impacts on essential activities of daily living. This means that Burial 86 likely had a disability and likely received caregiving, though it is impossible to determine if the care was efficacious. That care was provided likely reflected the community of Holliston Mills' more egalitarian socio‐political structure, which was unusual for the late Mississippian. It may also reflect Burial 86's agency, the presence of adequate resources at the site, as indicated by high frequencies of high status mortuary artifacts, or a combination of these factors. The mortuary program for Burial 86 does not indicate that they were marked as being different—in status or other social categories—than other community members. This study highlights how bioarchaeological evidence can be used to explore the downstream effects of chronic infections, such as treponematosis, throughout the body and across the life course, and the opportunities for health‐related caregiving in past societies that these processes can potentially create. K E Y W OR D S bioarchaeology, bioarchaeology of care, palaeopathology, social status, treponemal disease, treponematosis, yaws Int J Osteoarchaeol. 2019;1–11. wileyonlinelibrary.com/journal/oa © 2019 John Wiley & Sons, Ltd. 1 ZUCKERMAN 2 1 As 2 I N T RO D U CT I O N | Tilley and colleagues (2017, p. 2; 2015) articulate, bioarchaeologists and palaeopathologists, long engaged in the study | ET AL. B A C KG RO U N D 2.1 | The late Mississippian period and the Dallas phase of past disease, have only recently focused on one critical aspect of this subject: health‐related caregiving. Drawing extensively The late Mississippian period in East Tennessee possessed a distinc- upon other bioarchaeological and palaeopathological scholarship on tive set of characteristics (Bense, 1994); Dallas, which is a late Missis- caregiving sippian temporal and spatial cultural context specific to parts of (see Tilley, 2015; Tilley & Schrenk, 2017), the bioarchaeology of care (BoC) was developed to enable identification present‐day Georgia, Kentucky, and Tennessee (Bense, 1994), shares and interpretation of past caregiving. The BoC comprises the analy- these characteristics. They include intensive maize agriculture; high sis of human remains relative to their corresponding lifeways in population density, permanent settlement in aggregated villages; cen- order to identify and interpret experiences of disability and associ- tralized systems of power; and incipient Chiefdoms (Schroedl, 1998). ated caregiving. It can also grant insight into the agency and social Within this, Dallas phase settlements ranged from earthen mound identity of past individuals and communities (Tilley & Schrenk, centres, with palisades and central plazas, to smaller settlements such 2017). Although evidence of disease is often found within skeletal as small villages. Socio‐politically, the mound centers likely exerted material (Tilley, 2017, p. 11), sometimes it indicates that an individ- control over the smaller settlements (Meyers, 2015). Dallas phase ual's lived experience of disease greatly compromised their ability burials occurred within villages (e.g., pits near domestic structures). to function independently or appropriately participate within their They were semiflexed and accompanied by diverse mortuary artefacts physical and social environments. In these circumstances, it is rea- (Schroedl, 1998); sex and age‐related patterns within these, along with sonable to infer that caregiving occurred and the BoC becomes an ethnohistoric evidence, suggest gendered power differences within appropriate lens through which to consider this evidence (Tilley, public versus private domains (Lloyd, 2017). 2017). The Holliston Mills site (Figure 1), on the north bank of the Holston Here, we consider evidence surrounding Burial 86 from the late River, has been primarily dated to the Dallas phase based on the styles Mississippian period (AD 1300–1600), specifically the Dallas phase of recovered ceramics (Franklin, Price, & Langston, 2010). It repre- (1300–1550) Holliston Mills site (40HW11; ca. 1348–1535) in sented a relatively large town, with 100 to 125 occupants at any time north‐eastern Tennessee, whose circumstances raise the question during its 200‐year occupation. Like other Dallas sites, there is evi- of caregiving. Burial 86 exhibits pathologies specific to treponema- dence of a public structure, several palisades and domestic structures, tosis, as well as other pathologies indicative of physical impairment. village‐interred burials, and intensive maize agriculture. Atypically, it The Tennessee Archaeological Society excavated over 660 burials from Holliston Mills between 1968 and 1972, but only Burial 86 and two other crania remain available; Burial 86 is the focus of this case study. We apply the Index of Care (IoC), a web‐based application designed to support BoC research, to the evidence available for reconstructing Burial 86's lifeways. We aim to cautiously reconstruct Burial 86's lived experience of disease and the degree to which they may have experienced disability and caregiving. Within the BoC (Tilley, 2017), disability is a state arising from impaired bodily function or structure associated with limitations on activity and/or restricted participation in activities. As such, disability has specific meaning relative to the context in which the disease is experienced; as Tilley (2017) emphasizes, disability can therefore be conceptualized as being produced by interactions between the physical features of disease and the social and physical environments in which the disease is experienced. Care is defined as the provision of what is necessary for the health, welfare, maintenance, and protection of someone or something. Health‐related caregiving is the delivery of varying degrees of assistance to individuals experiencing disability related to disease (Tilley, 2017). As ethnohistoric and historical evidence for beliefs surrounding treponematosis in the later Mississippian are limited, we employ archaeological and ethnohistoric data to reconstruct some aspects of the disability, caregiving, agency, and social identity that Burial 86 might have experienced. FIGURE 1 Map of the Holliston Mills site. From Franklin et al. (2010) [Colour figure can be viewed at wileyonlinelibrary.com] ZUCKERMAN ET AL. 3 lacks mounds and mound structures. The mortuary culture also individuals means that yaws should be reconsidered as potentially departs from the Dallas pattern. As detailed below, the absence of having posed a profound functional cost for past individuals and spatial segregation and age and sex‐related patterning in the burials communities. is atypical. This suggests that the community was corporately struc- Cross‐culturally, there is ambiguous evidence for yaws‐associated tured, or community‐based, not hierarchical. This may indicate that stigma. In areas where yaws has long been endemic, such as West the community of Holliston Mills possessed cultural practices and life- and Central Africa (Mitjà et al., 2015), it is primarily found in remote, styles distinct from other late Mississippian communities in the region rural, indigenous populations with inadequate health care access. (Franklin et al., 2010), which is consistent with the diversity of Dallas Some researchers have reported that in these communities—pres- phase cultural identities (Sullivan & Harle, 2010). ent‐day and historically—bodily impairment and disfigurement from yaws, especially on the face and extremities, is stigmatized (Asiedu 2.2 | Treponematosis Treponematosis (e.g., yaws, bejel, and syphilis) comprises chronic and/or episodic and disfiguring multistage conditions1 (Powell & Cook, 2005b). All three produce overlapping clinical and skeletal manifestations and are therefore not macroscopically distinguishable in dry bone (Ortner, 2003). Here, however, we focus on yaws. This is because phylogenetic and bioarchaeological data unambiguously demonstrate that syphilis evolved only very recently (Arora et al., 2017) and that pre‐Columbian treponematosis was nonsexually transmitted, likely yaws or a yaws‐like condition (Cook & Powell, 2005; Hutchinson & Richman, 2006). Yaws, which is caused by Treponema pallidum subspecies pertenue, is transmitted through skin‐to‐skin contact in warm, humid environments (Mitjà, Asiedu, & Mabey, 2013). Yaws is typically acquired in early childhood (2–10 years) with tertiary lesions usually manifesting 2 to 10 years after infection. Primary stage features an ulcer. Secondary stage, which follows weeks to sometimes years later, can feature malaise, joint pain (Mitjà et al., 2013), transient subperiosteal new bone deposition (i.e., periosteal reactions), and ulcerative and thickened skin lesions. These can affect the gait when they form on the feet (Gip, 1989). Asymptomatic (latent) infection follows but, left untreated, approximately 10% of cases develop tertiary infection within 5 to 10 years (Hackett, 1953). Tertiary lesions include osteitis, an inflammatory process within bone; periosteal reactions; and gummatous nodules, or tumour‐like areas of necrotic tissue destruction. These can affect any organ system, including the skeleton, and cause debilitating scarring and contracture of tissues, including joints (Mitjà et al., 2013). Tertiary yaws manifestations can profoundly impair bodily function and structure. Mid‐20th century, tropical medical studies are replete with examples of musculoskeletal changes, including deep bone pain, joint contracture, pathological fractures, and gummatous joint destruction attributable to yaws (Powell & Cook, 2005b, p. 15). All of these were associated with impaired bodily function and mobility (e.g., Goldman & Smith, 1943; Hackett, 1951). Bioarchaeologically, Buckley and Tayles (2003) determined that tertiary yaws caused impaired bodily function and structure, such as permanent bony ankylosis of upper arm joints, in multiple individuals from a large prehistoric Pacific sample. Buckley and Tayles (2003, p. 1313) emphasize that although tertiary yaws is sometimes considered to be benign, the chronic suffering and impaired bodily structure and function evident in these 1 Pinta, the fourth variant, does not affect the skeleton and so is not discussed here. et al., 2008). This can limit affected individuals' family and community participation and, especially because it mostly affects children, have life‐long negative effects on their opportunities (e.g., economic) (Agana, Kwakye‐Maclean, & Tabah, 2016; Asiedu et al., 2008). Others, as indicated by Hofstraat and van Brakel's (2016) meta‐ review of reports of stigma associated with neglected tropical diseases, which includes yaws, have found that unlike other neglected tropical diseases, there is limited to no documented evidence of stigma associated with yaws. Overall, yaws seems to be stigmatized in some cultural contexts (e.g., Narain, Jain, & Venkatesh, 2015) and not in others (e.g., Saxena, 1985). Beliefs surrounding treponematosis in late Mississippian society are even more ambiguous. Treponemal lesions are ubiquitous in late prehistoric, eastern, and south‐eastern North American skeletal samples (Powell & Cook, 2005a). This is arguably due to the increased sedentism and aggregated settlement that co‐occurred with intensive agriculture (post‐1000 CE), as these created conditions conducive to endemic treponematosis (Betsinger, Smith, Helms Thorson, & Williams, 2017; Smith & Betsinger, 2013). As only a small proportion of a population (10–13% of cases) affected by treponematosis will manifest tertiary skeletal lesions (Giacani & Lukehart, 2014), the high prevalence suggests that late Mississippian societies experienced a heavy treponemal disease burden (Smith & Betsinger, 2013). Dallas societies seem to have socio‐politically adapted to this burden, with status and social roles interacting complexly with treponematosis. Smith and colleagues (2013; 2011) have found that individuals with tertiary lesions were interred in mounds alongside unaffected individuals at multiple Dallas sites. This suggests that some affected individuals presumably possessed higher rank or status at their death. However, they also found that these individuals exhibited significantly lower frequencies of treponemal lesions than did village‐buried, lower ranked individuals. Based on previous work at the sites, Smith and colleagues suggest that higher ranked individuals had better baseline health than did lower ranked, making them less susceptible to tertiary infection. Individuals unaffected by tertiary treponematosis may also have been able to advance more socio‐politically than unaffected individuals, as socially valued accomplishments may have been predicated on good health in Dallas societies (Smith, Betsinger, & Williams, 2011, p. 193). They further found an apparent bias towards young adults (approximately 18–34) with treponematosis, suggesting that infection may have affected young adult mortality. Overall, these findings suggest that Dallas individuals with tertiary treponematosis could be high status, but being affected may have interfered with attaining both middle to ZUCKERMAN 4 ET AL. late adulthood and high status (Smith et al., 2011; Smith & pathology(ies), estimating the functional impact(s), and whether this Betsinger, 2013). might have necessitated care (Tilley, 2017; Tilley & Cameron, 2014). Although not directly related to treponematosis, other late Missis- If no disability can be identified, analysis concludes. If disability can sippian sites in Tennessee indicate that caregiving could occur in be identified, both Stage 3 and Step 3 involve constructing a “model response to physical impairment. Specifically, the late Mississippian of care,” which includes identifying the characteristics of care likely DeArmond site (ca. 1400–1500) yielded one female individual with provided. The fourth stage and step involve interpreting the agency asymmetrically shortened elements consistent with achondroplasia, involved in the provision and reception of caregiving and as well as Osgood–Schlatter's disease, caused by repeat trauma to reconstructing the recipient's social identity (Tilley, 2017). Here, Burial the tibial tuberosities (DiGangi, Bethard, & Sullivan, 2010). The clinical 86's available evidence was imported into the IoC (http://www. literature indicates that the asymmetry would have produced bodily indexofcare.org), following Tilley and Cameron (2014). impairment, including an “obvious” limp. However, the individual was The inventory for Burial 86 followed established standards (Buikstra mound‐interred, along with unaffected individuals, and possessed a & Ubelaker, 1994). Skeletal sex and age were estimated via epiphyseal typical mortuary context. DiGangi and colleagues (2010) suggest that fusion rates (Scheuer & Black, 2004) and sexually dimorphic pelvic fea- this shows that caregiving occurred in response to physical impair- tures (Buikstra & Ubelaker, 1994), as the cranium is unavailable. Patho- ment in the late Mississippian and that at least this individual's impair- logical skeletal lesions were assessed against descriptions in Ortner ment did not affect their perimortem social status in an (2003) and Hackett (1976). Lesions associated with treponematosis archaeologically identifiable way. were scored to estimate the certainty of a diagnosis following Harper and colleagues (2011). These scores range from 0 to 5, encompassing 3 | METHODS AND MATERIALS lesions inconsistent with, consistent with, suggestive of, and specific to (i.e., diagnostic of) treponematosis (see Tables 1 and S1). The methodology of the BoC involves four stages of analysis, which correspond to the four steps of the IoC (Tilley, 2017). The first stage 4 RESULTS | in the BoC comprises documentation of the individual under study, their pathologies, and available information about their lifeways. In 4.1 | Step 1: Describe, diagnose, and document the IoC, Step 1 includes a differential diagnosis and documentation of the individual's context (e.g., cultural and mortuary) (Tilley & Cameron, 2014). The second through fourth stages and steps hinge upon 4.1.1 | Skeletal inventory and description of pathologies the first. Stage 2 entails establishing the impact of the individual's disability to determine whether caregiving may have occurred. In the IoC, The overall elements present for observation and the location of Step 2 includes identifying the clinical characteristics of the lesions on Burial 86 are depicted in Figure 2 (see Table S2, Figures TABLE 1 Scoring criteria for the certainty of diagnosis of treponemal disease Score Criteria 0 Lesions consistent with a non‐treponemal process (e.g., taphonomic process and noninfectious aetiology). 1 Lesions consistent with treponemal disease on one or more skeletal elements (periostitis, tibial pseudo‐bowing, polsters, and grenzlinie). 2 Lesions suggestive of treponemal disease on a single element [Hackett's (1976) on trial characteristics: Finely striated nodes and expansions; coarsely striated and pitted expansions; and rugose nodes and expansions on long bones]; or Stages 1–3 caries sicca lesions (clustered pits, confluent pits, and focal superficial cavitation). 3 Lesions suggestive of treponemal disease on multiple skeletal elements. 4 Lesions specific to treponemal disease [Hackett's (1976) diagnostic criteria: Stages 4–6 caries sicca lesions (serpiginous cavitation, nodular cavitation, and caries sicca) or nodes/expansions with superficial cavitations on long bones] on a single skeletal element. 5 Lesions specific to treponemal disease found on multiple skeletal elements or in the presence of lesions suggestive of treponemal disease on other skeletal elements. Note. From Harper et al. (2011). ZUCKERMAN ET AL. 5 FIGURE 2 Skeletal inventory for Burial 86 [Colour figure can be viewed at wileyonlinelibrary.com] S1 & S2). Burial 86 represents a young adult female (approximately 18 FIGURE 3 Radiograph (a) and photograph (b) of right femur, anterior aspect, showing rugose nodes and expansion of the bone at the distal diaphysis [Colour figure can be viewed at wileyonlinelibrary.com] to 25 years), as evidenced by multiple unfused epiphyses (sternal portion, left clavicle; first to third sacral segments) and postcranial non- elements are present for observation meaning that any asymmetry, metric traits consistent with female sex. such as in element length, cannot be assessed for the lower limbs. Burial 86 exhibits multiple lesions specific to treponematosis, Burial 86 also presents several activity markers. Rugose earning a score of 4. Macroscopic evidence of sclerotic, remodeling enthesophytes are present at the origin of the obliquus internus pathological bone, and radiopacity within the radiographs of the abdominis muscle, an ipsilateral rotator, and on the left iliac crest lesions indicates that the infection was chronic or episodic. The right (Figure 5); the right iliac crest is taphonomically eroded (Supporting femur exhibits sclerotic gummatous osteoperiostitis, with a large, Information). Several thoracic and lumbar vertebrae also exhibit wedg- perforating lytic lesion and rugose nodes with fusiform expansion ing (Figure 6). Together, these suggest an altered gait, likely a down- of the distal, posterior diaphysis (Figure 3). The left ulna especially stream effect of the tibial malalignment. The upper limb elements are also also very gracile and somewhat asymmetrical. Both clavicles exhibit exhibits extensive well‐remodelled periosteal reactions (Figure 8). diaphyseal thinning, especially the right (Figure 7). Both humeri exhibit The right tibia exhibits plaques of microporous, recently depos- reduced cortical bone density, especially the right. The deltoid tuberos- ited reactive bone and well‐remodeled superficial cavitations, par- ity on the right is also less developed than on the left. These suggest tially obscured by taphonomic surface erosion. It also exhibits varying degrees of disuse atrophy. The right humerii's attachment site approximately 38° of medial angulation (malangulation) in the proxi- for the pronator teres, the medial supracondylar ridge, is porous and mal metaphysis in the sagittal plane relative to the element's midline. remodelled, suggesting limited right forearm pronation; the correspond- This is clinically described as a varus angular deformity (Kristensen, ing site on the left is taphonomically eroded (Figure 8). The left ulna's Kiér, & Blicher, 1989). The location and angulation greater than superior articular surfaces also display extensive remodelling when 20° are highly consistent with fracture malunion (Kristensen et al., compared with those on the right (Figure 9). These upper limb patholo- 1989; Mullaji, Marawar, & Sharma, 2007); the fracture was likely gies suggest that Burial 86 may have experienced impaired upper limb predisposed by the cavitations (pathological fracture). According to function. consultation with a radiology technician (Cory, 2015), Burial 86 4.1.2 | Differential diagnosis yields no clear radiographic evidence of fracture, but the chronic remodeling, evident as radiopacity, throughout the region would The differential diagnosis for Burial 86, specifically the etiology of obscure evidence of a fracture (Figure 4). None of the left leg the right tibial and femoral lesions, includes pyogenic osteomyelitis, ZUCKERMAN 6 ET AL. FIGURE 6 First lumbar vertebrae, heavily taphonomically eroded, displaying wedging of the centrum [Colour figure can be viewed at wileyonlinelibrary.com] new bone but typically affects only a single element (Ortner, 2003) rather than the several affected here; there are also no cloacae or involucrae present. Sclerosing osteomyelitis of Garré was also excluded because of the multielement involvement (Ortner, 2003). Periosteal reactions can be generated by a number of causes, but FIGURE 4 Radiograph (a) and photograph (b) of the right tibia, anterior aspect, showing nodes and superficial cavitations and a varus angular deformity, with the medial angulation indicated [Colour figure can be viewed at wileyonlinelibrary.com] the accompanying nodes, expansions, and superficial cavitations render them highly likely to be associated with treponematosis (Hackett, 1976). Lastly, tuberculosis was excluded because Burial 86's vertebrae and ribs were unaffected but also because proliferative—not just lytic—processes are evident, which is uncharacteristic of tuberculosis (Ortner, 2003). 4.1.3 | Documentation There is extremely minimal available contextual information for Holliston Mills, including for Burial 86 (Franklin et al., 2010). A local physician estimated age for 488 and sex for 292 of the burials, though the accuracy of these is unknown. These yielded an equal sex ratio, a wide age range, and no obvious age skewing in the sample (Franklin et al., 2010, p. 255). The burials were flexed to varying degrees, including Burial 86, and recovered from within the periphery of the original village, without obvious spatial segregation (Figure 10), including by demographic factors (age and sex). Burial 86 was recovered from within the site (Figure 10). Mortuary artifacts, such as shell beads, bone artifacts, celts, and pottery, were FIGURE 5 Lateral aspect of the left ilium with rugose enthesophytes on the iliac crest indicated (arrows) [Colour figure can be viewed at wileyonlinelibrary.com] recovered from 40% of the burials. Mortuary artifacts associated with high status Dallas burials at other sites, such as shell beads, were common, and there was no spatial segregation of burials with these items. Burial 86 was recovered with several ceramic sherds sclerosing osteomyelitis of Garré, nonspecific periosteal reactions, and a limestone hoe. Overall, the community of Holliston Mills did and tuberculosis. However, all of these were excluded in favor of not seem to make greatly distinguish high from more low status treponematosis because of the specificity of the lesions to this con- burials, but some individuals have a larger array of items than others dition. Furthermore, pyogenic osteomyelitis can generate profuse (Franklin et al., 2010, p. 256). ZUCKERMAN ET AL. 7 FIGURE 7 Radiograph (a) and photograph (b) of the right clavicle and photograph of the left (c) clavicle, all superior aspect, showing diaphyseal thinning [Colour figure can be viewed at wileyonlinelibrary.com] FIGURE 8 Radiograph (a) and photograph (b) of the right humerus and photograph of the left (c) humerus, all anterior aspect. The right humerus displays reduced cortical density underdevelopment of the deltoid tuberosity (arrows) and (d) inset: remodeling of the pronator teres insertion site, medial aspect (arrows) [Colour figure can be viewed at wileyonlinelibrary.com] FIGURE 9 Radiograph (a) and photograph (b) of the left ulna and photograph (c) of the right ulna, all medial aspect. The left shows extensive periosteal remodeling [Colour figure can be viewed at wileyonlinelibrary.com] ZUCKERMAN 8 ET AL. FIGURE 10 Holliston Mills site map showing Burial 86 (excavation block outlined in bold/red), burials with and without mortuary artfacts, and palisade lines and structures. From Franklin et al. (2010) 4.2 | Step 2: Determine disability of basic object manipulation, such as self‐dressing and feeding, and mobility over a very limited distance. The greatly reduced mobility 4.2.1 | Potential clinical and functional impacts of the pathologies associated with the gummata and malalignment might also have complicated basic personal hygiene—exacerbated by the risk of secondary infection of the gummata—and self‐provisioning of food. But more Following the IoC, Burial 86's suite of treponemal and nontreponemal specifically, Burial 86's pathologies likely substantially impacted their pathologies had probable, moderate clinical impacts on several ability to participate in their community's subsistence strategy and domains. They likely affected Burial 86's musculoskeletal system and more physical social and labor roles, particularly as a young adult. Bio- movement‐related functions, and sensory functions and nervous sys- mechanical data from skeletons from Toqua (ca. 1300–1550 tem, specifically through pain and altered balance. For clinical impacts, gest that both males and females, increasingly from young (15– the gummatous osteoperiostitis displayed by Burial 86 has clinical cor- 30 years) to old ages (45–55+ years) engaged in activities involving relates of destructive, tumour‐like areas of necrosis in the overlying intensive, repetitive use of the arms, especially the shoulder girdle tissue, extensive scarring, and deep bone pain (Mitjà et al., 2013). (i.e., deltoid muscle) (Lloyd, 2017). Toqua is a Dallas site with evidence Additionally, clinical cases of varus angular deformity (malalignment of fluid social roles and horizontal power relationships highly similar to >5°) experience chronic joint pathologies in the affected limb because Holliston Mills. Ethnohistoric evidence from the Cherokee, which are of the malalignment and altered gait (Milner, Davis, Muir, Greenwood, the most relevant ethnographic analogues for Dallas societies & Doherty, 2002; van der Schoot, Den Outer, Bode, Obermann, & Van (see Lloyd, 2017; Sullivan & Harle, 2010), suggests that women Vugt, 1996). Those with severe malalignment (>15°) experience pro- engaged in generalized foraging, domestic (e.g., pottery production), foundly reduced mobility and significant pain (Bae, Song, Heo, & Tak, and agricultural labor throughout the year, with participation in field 2013). Burial 86, with a 38° malalignment, likely experienced a pro- labor stretching from young to old ages. Men engaged mainly in spe- foundly altered gait, substantiated by the iliac enthsophyte; the pain cialized, seasonal agricultural and hunting and fishing labour (see cannot be substantiated. Additionally, Burial 86 likely experienced lim- Lloyd, 2017). Burial 86's impairment would likely have impeded partic- ited use of the upper limb, especially the left. The latter is likely related ipation in many of these, except for highly sedentary physical activi- to the left ulnar periosteal reaction, which is likely treponemal. Much ties, such as tilling—done while seated—and pottery production. Both like what Buckley and Tayles (2003) observed bioarchaeologically could be indicated by the hoe and sherds included with Burial 86; and Mitjà and colleagues (2013) documented in modern populations women used hoes to till, whereas men primarily knapped them affected by yaws, this lesion might have impaired the use of their left (Thomas, 2001). However, there is no unambiguous evidence suggest- arm. Together, all of these indicate systemic bodily impairment. ing that Burial 86 would have been unable to (or limited) participate in AD) sug- Burial 86's pathologies likely had various functional impacts. For community life, interpersonal relations, or learning and applying essential activities of daily living, they2 would likely have been capable knowledge (e.g., storytelling) (see Tilley, 2017). Combined, Burial 86 likely experienced a minor disability relative to essential activities of 2 The pronoun “they” is used for Burial 86 as insufficient evidence exists to reconstruct Burial 86's gender. daily living, meaning that they probably required some degree of caregiving. Accordingly, we proceed to Step 3. ZUCKERMAN 5 ET AL. DISCUSSION | 9 “decision path” (Tilley & Cameron, 2014) for caregiving cannot be reconstructed with the available evidence. But the overall frequency 5.1 | Step 3: Constructing a model of care of artifacts associated with high status at the site—and the availability of resources that this suggests—and Franklin and colleagues' charac- Following the IoC, Burial 86 likely experienced direct care for several terization of Holliston Mills as a synthetic, relatively egalitarian society months (approximately 4–6 months) following the tibial fracture, may suggest that Burial 86's care (even over the long term) was not based on the degree of remodeling, as well as a limited accommoda- overly taxing. However, even in a large town, Burial 86's relative tion of difference. During this time, Burial 86 probably experienced inability to engage in subsistence activities and physical labor that provisioning of food and water; maintenance of personal hygiene; were consistent and intensive for other adult community members, monitoring of health status, given their likely immobility postinjury; especially in adulthood (see Lloyd, 2017) may have incurred a drain and mobility assistance. After the fracture healed, they probably on some community resources. Furthermore, there is no reason for employed minor equipment to facilitate daily living and self‐ Burial 86 or their community to think that they would eventually be maintenance (e.g., crutch). It is not possible to infer whether they “cured.” Neither the fracture, especially once healed, nor the trepone- experienced other aspects of direct care, such as facilitation of rest matosis could have been resolved with available medical technologies (see Tilley, 2015). No documented botanical materials were recovered (see Mooney & Olbrechts, 1932; Noé, 2002). Treponematosis also a from Holliston Mills. However, based on abundant ethnohistoric chronic condition (Mitjà et al., 2013). Therefore, even though the evidence for traditional Cherokee medicine, Burial 86 may have expe- probable long‐term caregiving was “low cost” (Tilley, 2017), the rienced care in the form of shamanistic medicinal rituals and plant‐ community's motivation in providing care may have reflected Burial based therapies, possibly for sores/gummata, infection, and pain relief 86's agency in pursuing it, their value as a person, the community's (e.g., Arnica and Biennial wormwood) (Mooney & Olbrechts, 1932; synthetic ethos or a combination of these. Noé, 2002). These could have involved extra costs and effort for Few secure interpretations can be made surrounding Burial 86's Burial 86 and their family. That Holliston Mills was a sedentary com- social identity. Although Smith and colleagues (2011) found that indi- munity probably meant that Burial 86's initial immobility and later lim- viduals with treponematosis at other Dallas sites were more likely to ited mobility involved relatively little adjustment (e.g., resources) by be low status than high, this finding cannot be securely extrapolated their family and community. However, as noted above, Burial 86's lim- to Holliston Mills. First, the community was quite horizontal in its ited physical participation could have incurred a drain on family and socio‐political organization relative to other Dallas communities. Sec- community resources, though Burial 86 may have been fully socially ond, there is no comparative evidence on health for Holliston Mills. engaged and active. Notably, whether treponematosis, or yaws specifically, was stigma- There is insufficient evidence, however, to determine whether tized in Dallas cultures is also unknown. South‐eastern indigenous Burial 86's care was efficacious. Their age at death—18 to 25 years— societies, and Cherokee societies specifically, did consider the was typical for the community; 51% of burials with age estimates from aetiology of disease, including yaws, to be retribution (e.g., failure to Holliston Mills were between 18 and 35 years. Therefore, Burial 86's observe rituals) or victimization (e.g., witchcraft) (see Fogelson, 1975; age may not have been related to their impairment or care. But their Mooney & Olbrechts, 1932; Swanton, 1928). Health was a proxy for age is consistent with the apparent young age bias amongst individ- virtue (Smith et al., 2011, p. 193). Therefore, Burial 86's chronic dis- uals with treponematosis that Smith and colleagues (2011) found at ease and physical impairment could have translated into a decline in other Dallas sites. Treponematosis, especially yaws, is not typically their status, and potentially, that of their family. Additionally, Burial fatal (Mitjà et al., 2013), but for Dallas individuals, it may have carried 86's limited participation in subsistence activities and physical labor, a biological vulnerability. Specifically, it may have been a primary especially that involving the upper limbs, may have distinguished them cause of morbidity or represented a proxy for underlying chronic from other members of their age and gender cohorts (see Lloyd, health issues (Smith et al., 2011). No information on treponematosis 2017). However, if this impacted Burial 86, evidence of it did not pen- frequencies exists for Holliston Mills, but Burial 86's age may indicate etrate the fabric of Holliston Mills' uniform mortuary program, which that they experienced the same potential vulnerabilities experienced marked the recovered burials as being effectively the same—in status by those in other Dallas communities. and other social categories—as other community members. 5.2 6 | Step 4: Interpretation | CO NC LUSIO N What can this particular case of health‐care related caregiving tell us As we demonstrate here, the BoC and, within it, the IoC can be used about the agency of the community of Holliston Mills? What can it tell to generate finely detailed insights into lived experiences for past indi- us about Burial 86's agency and social identity? As Tilley (2015) advises, viduals and their communities, including disease, impairment, and dis- if Burial 86 experienced caregiving, it reflects that their family and/or ability, in particular for a community whose archaeological traces are community deliberately decided to provide it and/or that Burial 86 otherwise pursued it. Care also presumably occurred over the longer term. The bioarchaeological evidence can be used to explore the downstream relatively faint. This case study highlights how ZUCKERMAN 10 effects of chronic infections, such as treponematosis, throughout the ET AL. body and across the life course and the opportunities for health‐ Giacani, L., & Lukehart, S. (2014). The endemic treponematoses. Clinical Microbiology Reviews, 27, 89–115. related caregiving in past societies that these processes may create. Gip, L. (1989). Yaws revisited. Medical Journal of Malaysia, 44, 307–311. 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Applying the Index of Care to the Mississippian period: A case study of treponematosis, physical impairment, and probable health‐related caregiving from the Holliston Mills site, TN. Int J Osteoarchaeol. 2019;1–11. https://doi.org/10.1002/oa.2805