OBJECTIVE: This paper reviews factors confounding the understanding of the past occurrence of anemia. Using the evidence gathered, a framework is presented of ways forward to enable greater confidence in diagnosing acquired anemia in paleopathology, facilitating insights into longer-term perspectives on this globally relevant condition. RESULTS: To date, porotic lesions have been central to paleopathological investigations of anemia. The fact that porotic bone lesions are omnipresent and have multiple causes but are likely to have a relatively low, age-related frequency in individuals with anemia, a condition that will have been common in past communities, is confounding. METHODS: Establishing frameworks that move away from porotic lesions is proposed to facilitate higher levels of more accurate anemia diagnoses in paleopathology. SIGNIFICANCE: Acceptance of the fundamental principle that anemia may be better considered as a condition requiring metric evaluation of bone structures, supplemented by careful consideration of lesions, will advance understanding of acquired anemia in past communities. Such an approach would provide a clear basis for further consideration of congenital conditions causing anemia, such as sickle-cell disease and thalassemia. LIMITATIONS: This paper simply opens the conversation on the better diagnosis of anemia in paleopathology; it starts the iterative process of achieving some consensus and progress on diagnosing anemia in paleopathology. SUGGESTIONS FOR FURTHER RESEARCH: Engagement with ideas presented, sharing data and development of metric parameters will assist in identifying the effects of marrow hyperplasia on bone, enabling more robust work on the important topic of anemia.
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