Universiteit Leiden

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Research project

Respiratory health and disease in the Netherlands

Studying the impact of urbanisation on the respiratory health of past Dutch populations (1200-1850 CE).

2020 - 2025
Maia Casna
NWO PhDs in the humanities NWO PhDs in the humanities


Today, respiratory disorders are among the greatest contributors to the global burden of disease and constitute one of the most recurring causes of impairment in the Netherlands. These disorders have many causes (e.g., poor air quality, tobacco consumption) and can be observed on human skeletal remains in the form of pathological lesions within the paranasal sinuses and on the ribs. In archaeological populations, the analysis of these lesions provides an historical perspective on the impact socio-economic changes and urbanisation had on people’s health, highlighting how less-populated environments tend to show lower frequencies of respiratory disorders when compared to more densely populated ones.

Previous osteological research on respiratory disease has shaped the trope of how life dramatically worsened with urban development. However, the urbanisation movement was markedly variable throughout Europe and it affected people’s lives in, presumably, extremely different ways. In the Northern Low Countries specifically, cities grew rapidly over a short period of time but never reached the size of other European economic centres, which makes these contexts interesting microcosms of urbanization and industrialization.

This research investigates respiratory health in the skeletal remains of six different populations from the Northern Low Countries dating from the late medieval (1200-1449 CE) to early modern (1500-1850 CE) period, with a nuanced lens focused on the biosocial products of urbanisation. In addition to gleaning a new narrative of Dutch social history, this study will provide a multidisciplinary and contextually driven perspective on respiratory health, which is of increasing concern today across the world.

The impact that the physical environment has on our health is directly observable in the quality of the air we breathe. In the past few years, there has been growing concern about the possible effects of air pollution on the respiratory health of people living in newly industrialized centres: in 2016, respiratory disorders affected 12% of the Dutch population and caused the death of more than 5000 people. We need clean air to breathe but, throughout history, achieving the balance between human endeavour and health has proved to be a challenge. 

In the Netherlands, the urbanisation of centres started around the 13th century and caused several medical concerns on the respiratory health of Dutch citizens. The intensification of industrial production and urban development brought severe impacts on Dutch air quality, whose consequences are still observable today on human skeletal remains in the form of small lesions within the nasal cavity and on the ribs.
With this study, a more complete understanding of the impact of urbanisation and social changes over people’s respiratory health in the Netherlands will be developed, together with a new, more attentive historical narrative of the Lowlands social past. Having an insight of how people responded to exposure to bad air quality in the past will help scholars to better comprehend respiratory conditions and to define future health policies, limiting a problem that is of increasing concern in today’s world. 

Bone lesion within the maxillary sinus, indicative of sinusitis.

The main aim of this project is to understand whether urbanisation had an impact on the respiratory health of past Dutch citizens. To do so, six skeletal populations dating from the medieval and post-medieval periods were selected. 

On human remains, bony changes in specific locations are considered as the result of the inflammation of the respiratory tract, a consequence of several disorders such as pharyngitis, sinusitis, and chronic lung infection. Maxillary sinuses and internal surfaces of the ribs will be observed to detect lesions associated with respiratory conditions.

In order to better approach the main aim of this study, four different factors that could have played a role in the spread of respiratory disease and that are notoriously involved with the urbanisation process in the Netherlands were identified, namely: 1) malnutrition/physiological stress; 2) housing patterns; 3) tobacco consumption; 4) childhood.

Physiological stress

Physiological stress can be defined as any external or internal condition that challenges our wellbeing, such as hunger, malnutrition, or disease. Recent historical analyses of urbanisation processes have pointed out an increase in social inequalities, famine, medical and sanitary problems within most European cities.
In this research, individuals presenting signs of physiological stress are expected to show higher rates of respiratory infections. This is because a less healthy individual may physically react to a condition that would provoke a very small immune response in a healthier individual.

Cribra orbitalia, a bony lesion within the orbit which is usually considered indicative of physiological stress.

Housing patterns

Indoor air pollution is a long-known factor for respiratory infections and is linked with houses’ inadequate ventilation and humidity levels. 

Based on historical sources, it is expected that individuals from late-medieval, Dutch urban settlements will show more lesions associated with respiratory disease than individuals from rural settlements from the early modern period. As larger, stone-built houses became into fashion among rural communities in the early modern period, it is likely that overall better respiratory health conditions will be observed in individuals from the latter context.

Early-modern Dutch tobacco advertisement.

Tobacco consumption

Today, smoking is perhaps considered the major cause for respiratory diseases.
In Europe, tobacco was not available throughout the medieval period, but came into fashion in the Lowlands among all social classes around the 17th century. Therefore, we expect to observe a strong correlation between the presence on bones of tobacco-use markers and a high prevalence of respiratory infections. 


Until recent times, children have been largely invisible in historical records, as their perspectives have always been filtered through the eyes of adults. However, today clinical scholars agree that children tend to be more vulnerable to respiratory diseases than adults for various social and physiological reasons. This project will investigate whether this was the case in the past as well.

In the past decade, archaeological human remains have proven to be an excellent source of evidence for studying past people’s lifeways. As the number of archaeological human remains available for research is usually large, scholars have been able to study communities as whole, highlighting how in most cases the social environment had a consistent impact on health and vice versa. This study not only adds to current bioarchaeological knowledge on respiratory health but uses a palaeopathological approach in combination of historical data to obtain a better understanding of people’s physical response to the unique urban development patterns that occurred in the Netherlands. By taking the first step towards a new narrative of urbanisation, this multidisciplinary and diachronic approach will open a useful window on the health and welfare in the past Northern Low Countries. 

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