An Australian archaeologist contends that compassionate care for the disabled seems to be a hallmark of our humanity. For several years, Lorna Tilley has been studying a prehistoric burial site in northern Vietnam. In this exclusive interview, she observes that people in the Neolithic age can teach contemporary governments some lessons about standards of care.

MercatorNet: Tell us about M9. You must be very familiar with him by now… His community seems to have been extraordinarily compassionate.

Lorna Tilley: Man Bac Burial 9’s story is compelling -- even though we can only ever know a part of it, and that part is only known through what his bones suggest about his life within a small Neolithic community in northern Vietnam. This was about 4,000 years ago.

Here are the basics. M9 was a quadriplegic when he died, but he was not a quadriplegic from birth. He was, however, born with Klippel-Feil Syndrome (Type III), a rare condition which left him with a fused block of vertebrae (the bones making up the spine) extending from the first cervical down to the third thoracic -- or from the top of his neck to just below his shoulders. Adding to this, his first cervical (neck) vertebra was fused to the base of his skull -- a condition known as occipitalisation -- and his first and second cervical vertebrae were not only fused, but fixed in a twisted position.

M9 was visibly different from infancy onwards. His head was tilted slightly upwards and rotated to the right, and because there was no intervertebral disc space his neck was abnormally short. His neck and upper back were inflexible -- to nod, shake or turn his head he would have to move his whole upper body. We can’t be sure, but it’s likely these restrictions delayed aspects of normal motor development, such as learning to walk and run, and playing with other children. It would certainly have made these activities more difficult.

When M9 was around 14 years old he became a quadriplegic. This was probably the result of trauma causing the fused block of vertebrae to move across the ‘free’ vertebra underneath, which damaged M9’s spinal cord and led to permanent paralysis.

M9 lost all movement in his lower body. He retained some use of upper limbs, but tasks requiring strength or dexterity were beyond him. He required other people to bathe and toilet him, to supply food and shelter, to monitor his health status and to nurse him through periods of health crisis, and to regularly reposition and massage him to encourage regular body system function and to avoid pressure sores. He probably required a special diet to combat problems associated with immobility, and it’s likely he needed assistance to eat and drink. Towards the end of his life -- he died about 10 years after becoming a quadriplegic -- he was probably unable to sit up without help.

I’ve gone into this level of detail because it helps in understanding some part of what M9 experienced -- and to get some insight into what he may have been like as a person. And M9 must have been quite extraordinary. He confronted enormous physiological and psychological challenges and, for around a decade, he survived these. Living with limitations from childhood (although these may not have been thought of as ‘disabling’ -- as we use this term -- by his community) he was left paralysed in adolescence, watching on as his peers moved into adulthood, but unable to take part.

In whatever way M9 was able to rationalise his condition, at times it must have been a source of almost overwhelming unhappiness, longing, and frustration -- as well as physical pain.

In modern times, the third most common cause of death following serious spinal cord injury is suicide resulting from severe depression -- this ‘suicide’ often takes the form of refusing to cooperate with care. Depression also has physical implications -- such as reduced immune, respiratory and cardiovascular function -- all vulnerable areas for paralysed individuals, and particularly so in the technologically primitive Neolithic context.

So M9's survival suggests a very strong will to live, an ability to adapt to circumstance, courage and a healthy self-esteem. These character traits don’t occur in a vacuum, so despite extreme disability he must have kept an active interest in the world around him -- and have been supported in this by other group members. And his ability to inspire this support, in combination with the quality of care he received, suggests he had a positive -- and engaging -- personality.

His survival also reflects on M9's carers -- coming to the part of your question about ‘compassionate community’. The fact that the long-term, continuous, and frequently resource-intensive care needed by M9 was given, and given successfully, over such a long period argues for a community capable of generosity, as well as one experienced in providing healthcare. Does this mean it was also ‘compassionate’?

‘Compassion’ is defined as sympathy for, and desire to alleviate, the suffering of another. Compassion is a motivation. Scientific orthodoxy asserts that it’s impossible to infer motivation from material culture (including from skeletal remains), and the association of ‘compassion’ with ‘caregiving’ has been a sticking point for some in archaeology and anthropology over the last few decades.

But it’s legitimate to ask ‘why did the Man Bac community choose to provide costly care for M9, when almost from first onset of paralysis it would be clear he was never going to recover and would be likely to need increasing levels of support?’ Maybe care-giving was the norm -- an unthinking response, simply ‘automatic’ behaviour. Maybe it was 'reciprocal altruism' in action -- behaviour ensuring that, having given care, the givers would receive care when they needed it. Maybe it was love, respect, sense of duty, personal connection. Most probably it was a combination of some or all of the above. Caregiving, particularly when it takes place over an extended period of time, is a very complex behaviour. The motivation that sustains it is going to be equally complex.

Personally, I would say that compassion -- as defined above -- must have played a large role in M9’s care.

How did you get interested in the bioarchaeology of care? I don’t see it on many LinkedIn resumes…

I’m not sure that you’re going to see it on any LinkedIn résumés. The ‘bioarchaeology of care’ is a term I coined to describe a four stage approach for identifying and interpreting cases of health-related caregiving; the methodology is based on analysing skeletal evidence for disability and care within the lifeways context in which these were experienced. My PhD thesis* elaborating the theory and practice of the bioarchaeology of care was approved a couple of months ago, and I graduate this December.

How did I get interested? A lot of my working life before archaeology focused on some aspect of healthcare -- hands-on nursing, occupational health and safety, and health status and health outcomes assessment. The experience of disability and the provision (and receipt) of care are everyday events -- but the way that these events are managed have the scope to tell us a lot about ourselves and the society we live in. Many archaeologists, coming before me and with far greater skills, had identified the likelihood of care in case studies across a wide range of disabilities. But few studies had gone into detail, and none had looked systematically at implications arising from the observation that ‘this person likely received care’. There was a gap -- and I was lucky enough to get the chance to fill it!

Some authors contend that the kind of care that M9 received was not evidence of compassion, but just an evolutionary adaptation. After all, chimpanzees care for disabled to some extent.

This question contains a number of different premises! There’s not the space to address them as they deserve, but I’ll make a few quick points.

To begin with, we can’t assume compassion automatically whenever there is evidence suggesting care. As I said earlier when discussing M9, compassion is a motivation -- a desire to relieve another’s suffering -- and the motivations behind health-related caregiving (as most of us will know from our own experiences) are multiple and complicated. Motivations for past caregiving can never be fully knowable in the present. It’s a much easier proposition to look at the evidence for disease in the skeleton, try to estimate what the functional disability impact might have been, and then work out the basics of healthcare assistance the individual needed in order to survive until their age at death.

However, having said all this, in those cases where healthcare provision required the application of time, energy and material resources that could have been spent elsewhere, I believe it’s quite justifiable to suggest the desire to relieve suffering -- or ‘compassion’ -- was one of the factors driving care.

Jumping to your statement of ‘chimpanzees caring for disabled chimpanzees to some extent’, there’s actually very little evidence for non-human primates (chimpanzees and others) providing active healthcare to group members. There are a few reports of individual instances of ‘tolerance’ (usually defined in terms of lack of aggression) shown to disabled group members among some species, and there are a number of studies across a range of non-human primate groups documenting the nurture of orphaned or disabled infants. What we do have from non-human primate studies, however, is powerful evidence of preference for cooperation over competition. If we are going to look for an evolutionary basis for caregiving, perhaps this is where we should start.

I’ll now step back to the notion of health-related caregiving as ‘just an evolutionary adaptation’. Attempting to explain a sophisticated, complex and demanding behaviour primarily in terms of evolutionary determinism is really an abuse of evolutionary theory. A short paragraph obviously can’t do justice to the issues involved in this debate, which -- in the most simplistic analysis -- could be reduced to ‘nature versus nurture’. We need to bridge this gulf. We may well have an evolved preference for cooperation, as non-human primates have been shown to do, and this makes sense when we think about the easiest way to survive as a species. This would support an impulse to give care. But when we make the decision to provide care we do this consciously, and this intentional choice to give care, and the nature of the care we give, reflect the behaviours, norms and values that are the product of social learning.

Some anthropologists claim that it is impossible to draw conclusions about the moral life of the individual or the community from skeletal remains. Is this just a technical issue, or are there deeper philosophical issues involved in this dispute?

You’re raising a fundamental philosophical issue here -- absolutism versus relativism in relation to what constitutes ‘morality’. I’m not qualified to even begin addressing this. As an archaeologist, my approach is that we can’t assess the ‘moral’ worth -- the ‘goodness’ or otherwise -- of actions undertaken in different lifeways contexts that we are lucky to even partially understand. In terms of providing health care, for example, is it always morally ‘good’ to keep someone alive if their quality of life is so poor that they themselves wish to die? I don’t think it is, but others would disagree with me.

So the short answer is: I don’t believe it’s possible to draw conclusions about the moral life of an individual or a community from their bones. But because we are all human, and we all have our own beliefs and values, it’s inevitable that sometimes we’ll do it anyway -- particularly in cases that touch on behaviours like caregiving, which in our society most of us view as ‘morally good’. The important thing in archaeology is to be as explicit as possible about the potential bias we bring with us to our research. It’s probably quite clear, for example, that in most cases I would consider caregiving to be a ‘good’ thing.

When did this "standard of care" enter human history? I once reported on the discovery of remains in Spain dating back 530,000 years.

As you point out, we’ve got examples of possible caregiving extending way before anatomically modern humans came onto the scene. The earliest example for which care is claimed (that I’m aware of) is that of Dmanisi 3444/3900 (Homo erectus/ Homo georgicus), an adult male from Georgia, represented by his skull and mandible, and dating back to around 1.77 million years ago. He had lost all but one tooth before death, and it was suggested that group members had provided nutritional assistance to enable his survival.

Following Dmanisi 3444/3900 came Homo ergaster KNM-ER 1808, an adult female dating back 1.5- 1.7 million years. Her remains show evidence of chronic hypervitaminosis A, a condition causing musculoskeletal and vascular complications associated with intense pain. Researchers have suggested that she lived possibly months with this disease, in no condition to fend for herself -- so her survival relied on provisioning and protection by others.

There are at least four or five convincing cases of caregiving among Neandertal remains, and more cases of caregiving among remains from some of the earliest groups of modern humans. Health-related care provision has a long pedigree.

Can we draw any lessons from caregiving in the past for contemporary society?

I think we can -- and this was illustrated by the amazing global response to the short article on M9 which appeared in the New York Times at the end of last year. The story was picked up by print media, archaeology internet sites and personal blogs around the world -- I had a huge number of requests for more information on M9, about examples of care in the past generally, and about the bioarchaeology of care methodology. That we humans have a history -- a prehistory -- of caring for each other touched a chord; people were comparing the treatment of M9 with the priority given to caring for those with disabilities by modern governments, and the comparison wasn’t flattering to the latter.

Obviously there are immensely improved medical knowledge and technologies available today, and none of us would swap these for prehistoric care. But the strength of response I experienced suggests to me a feeling of anger and regret for loss of community in certain parts of society -- however romanticised this notion of community may be.

A lot of social commentators have written about this phenomenon in great detail, so I won’t elaborate. I’ll finish with the observation that perhaps -- as humans -- we are willing to care for others more than we give ourselves credit for, and sometimes more than we are encouraged to do by our governments. For example, in Australia both Labor and Liberal parties have demonized asylum seekers for political purposes, and we now have one of the most cruel treatment regimes in the world, incarcerating young, old, male, female, sick and healthy without any compassion at all. Yet consider the massive public support for the National Disability Insurance Scheme launched recently -- a policy that will obviously be a cost to all tax payers, but one that was seen as the right thing to do and was overwhelmingly embraced.

Maybe one of the ways we can use the story of M9 -- and similar narratives of care -- is to think about how we can be better as a society than we currently are.

Lorna Tilley works at the School of Archaeology and Anthropology, Australian National University, in Canberra.

Notes

For those interested in more information, the reference for the full report on M9’s disability and care is: Tilley, L. and Oxenham, M.F. 2011 Survival against the odds: modeling the social implications of care provision to seriously disabled individuals. International Journal of Paleopathology 1:35-42. Anyone with problems in accessing this can contact Lorna Tilley for a copy at lorna.tilley at anu.edu.au.

* The PhD thesis: Tilley, L. 2013 Towards a bioarchaeology of care: a contextualised approach for identifying and interpreting health-related care provision in prehistory. Unpublished PhD Thesis, Australian National University.