Heightened Expectations is a groundbreaking history that illuminates the foundations of the multibillion-dollar human growth hormone (HGH) industry. Drawing on medical and public health histories as well as on photography, film, music, prose, and other examples from popular culture, Aimee Medeiros tracks how the stigmatization of short stature in boys and growth hormone technology came together in the twentieth century. This book documents how the rise of modern capitalism and efforts to protect those most vulnerable to its harmful effects contributed to the social stigmatization of short statured children. Short boys bore the brunt of this discrimination by the mid-twentieth century, as cultural notions of masculinity deemed smallness a troubling trait in need of remedy. These boys became targets of growth hormone treatment, a trend accelerated by the development of effective HGH therapy in the late 1950s. With a revisionist twist, Medeiros argues that HGH therapy was not plagued by a limited number of sources of the hormone but rather a difficult-to-access supply during the 1960s and 1970s. The advent of synthetic HGH remedied this situation. Therapy was available, however, only to those who could afford it. Very few could, which made short stature once again a mark of the underprivileged class. Today, small boys with dreams of being taller remain the key customer base of the legitimate arm of the HGH industry. As gender and economic class disparities in treatment continue, some medical experts have alluded to patients’ parents as culprits of this trend. This book sheds light on how medicine’s attempt to make up for perceived physical shortcomings has deep roots in American culture. Of interest to historians and scholars of medicine, gender studies, and disability studies, Heightened Expectations also offers much to policy makers and those curious about where standards and therapies originate.
About the Author
Aimee Medeiros is an assistant professor of the history of health sciences at the University of California, San Francisco.
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The Rise of the Human Growth Hormone Industry in America
By Aimee Medeiros
The University of Alabama PressCopyright © 2016 University of Alabama Press
All rights reserved.
Making Short Stature a Medical Matter
Lewis Hine was in Rock Hill, South Carolina when he photographed Charley Brazell and Floyd Brown. Charley and Floyd stood for the camera without emotion. Their bare feet conveyed their poverty while their oversized clothes emphasized their small stature. The boys, aged thirteen and fourteen respectively, worked in the textile industry and together served as evidence documenting the harmful health effects of child labor. During the ten years Lewis Hine worked as the photographer for the National Child Labor Committee's (NCLC) campaign to end child labor, he snapped thousands of photographs of working children and collected field notes from the conversations he had with those he photographed. When Lewis interviewed Charley and Floyd, the latter admitted that he had "been sweepin and doffin' unto four years," and Charley suggested that the work had compromised their stature: "the mill has kep' us from growin." As this testimony provided additional evidence of the dangers of child labor, Hine hoped that Charley and Floyd's evocative answers and small bodies would convince the public that factory work was harmful to children's health and needed to be abolished.
US history books and relevant websites still use Hine's photographs as a record of the experiences of poor working-class children in the early decades of the twentieth century. Often featuring little white bodies next to large factory machines, the photos depict the desperation of impoverished children stuck at dangerous work sites. Even so, one must not overlook the calculated composition of the images and the power they have had in popularizing the idea that imperfect bodies tell us that something is wrong. It is not by chance that Charley and Floyd bore no emotions on their faces, wore no shoes, and appeared small in stature for their ages. This formulaic pathetic portrayal of working children was a staple of Hine's work and has stood the test of time.
This chapter explains how the photo of Charley Brazell and Floyd Brown has maintained its cultural value. It begins by shedding light on how efforts by concerned reformers in Europe and then the United States contributed to the modern social stigmatization of short stature and the medicalization of children's height by turning small stature into an indicator of ill health. Next, it looks at how the practice of measuring children moved beyond the world of nineteenth century reformers, exploring how it was used and understood by scientists who hoped to assess population-level health by rounding up children en masse for growth surveys. The data from these surveys were then used to establish standards that doctors used to evaluate individual children. As pediatricians assumed an authoritative role in the supervision of children's health by the 1930s, public health officers and educators championed the popularization of measurement and celebrated averages as healthy norms, thereby stigmatizing short stature. In the end, although discrimination against short stature can be traced back to antiquity, the modern trends detailed in this chapter ushered in a unique sensibility of this cultural bias, one influenced by the rise of capitalism, championed by reformers, endorsed by scientific medicine, popularized by public health campaigns, and taken up as an effective tactic in the medical observation of children.
Industrialization transformed the lives of millions of children in the United States during the nineteenth century. Already in the antebellum period, the market economy ushered in many changes — including new employment opportunities in mass manufacturing. Thousands of Americans abandoned the farm and made their way to the factory. Although native-born males formed the largest group of early manufacturing laborers, women and children also found work in the first large-scale mills erected in New England in the 1820s. According to historian Thomas E. Cone, "in 1820 about half of all textile workers in Massachusetts, Connecticut, and Rhode Island were children, and in 1832, boys under twelve comprised 43 percent of cotton mill workers." This trend continued throughout the century and had a particular impact on poor young people's lives. Impoverished children worked long hours and struggled to reap the rewards of public education. Starting with Massachusetts, states tried to regulate child labor during the antebellum period, but the number of children working in factories only grew.
Reformers were outraged by the high rate of working children. American educator and politician Horace Mann stated that "it is obvious that children of ten, twelve, or fourteen years of age may be steadily worked in our manufactories, without any schooling, and this cruel deprivation may be preserved for six, eight, or ten years, and yet during all this period, no very alarming outbreak will occur to rouse the public mind from its guilty slumber." Still, child labor persisted and intensified after the Civil War, when America's industrial revolution went into high gear.
As industrialization exacerbated inequalities between the rich and the poor, the government failed to create any type of social safety net, forcing many poor families to send their children off in search of industrial employment. Young people found jobs delivering newspapers, making brooms, working in mills and mines, and helping their parents with piecework at home. Although agricultural employment dominated child labor from the 1880s to the 1930s, it was the flow of young people toward this new type of urban, industrial work that angered American union organizers, social reformers, and public health officials.
Nineteenth-century organizers against child labor used the standard strategies of reformers — including anecdotal evidence and moral suasion — to convince their contemporaries to support legislation regulating the practice. Perhaps one of the most compelling pieces published at the time documenting the horrible working and living conditions of the poor was Jacob Riis's How the Other Half Lives. Published in 1890, Riis's book portrayed the poverty children endured in New York City, although it did not prove scientifically the ill effects of industrialization on the poor. Still, his wildly popular publication convinced enough New York City legislators to pass local regulatory laws.
In 1900 the regulatory accomplishments of Riis and his supporters were overshadowed by the US census, which indicated (incorrectly) a rise in child labor. This apparently bad news inspired a new crop of reformers to take a more scientific approach to ending child labor. Known as Progressives, these reformers believed they could influence public opinion and move average citizens to demand action from authorities through public campaigns and investigative reporting that documented the horrors of child labor. Throughout the nineteenth century, a similar approach had already been used in Britain and France with much success. Thus, at the turn of the century, the anti-child labor movement in the United States took a decidedly scientific turn and began collecting what activists perceived as indisputable evidence in order to prove the need for federal legislation abolishing child labor.
EUROPEAN EFFORTS TO PROTECT WORKING CHILDREN
Progressives were encouraged by British reformers' success in getting laws regulating child labor passed. During the late eighteenth and early nineteenth centuries, British public health officials identified children as the most innocent victims of the harsh realities of industrial work and focused on persuading government to pass ameliorative legislation. Public health officers and social reformers collected scientific data to document the impact of brutal working conditions on children. They conducted surveys, in which they measured and compared the stature of working children to that of their non-working peers. The results demonstrated how industrial work was harmful to the former, as children working in the factories were found to be smaller — and therefore less healthy — than children who did not work.
Reports based on these surveys influenced public policy throughout Europe, with Britain being the first to pass regulatory laws aimed to protect working children and women. These "Factory Acts" limited the number of hours women and children could work, restricted where they could be housed, and provided maximum hours for specific ages, all in the hopes of improving the health of the workers. While reformers were successful in getting legislation passed, it was difficult to enforce the compliance of the components meant to protect children. Non-compliance by business owners ran so high that the British government assigned public health reformer Edwin Chadwick to orchestrate a project investigating the level of misconduct. Chadwick asked medical commissioners to measure working children's height, weight, and overall stature; the results were then compared to data collected from non-working children. As expected, the measurements showed that factory children were, on average, shorter than other children. This data substantiated accusations made about the causal relationship between unsafe working conditions and poor health in children. It also became the basis of Chadwick's 1833 Report on the Employment of Children in Factories and inspired the passing of the Factories Regulation Act that same year.
The 1833 Act strengthened already existing restrictions on child labor and linked the health of children to working conditions. It prohibited children under nine years of age from working in various types of factories, required special accommodations for workers between the ages of nine and thirteen, and demanded that children be examined by "a surgeon or medical man who shall certify on inspection of the child that he believes it be of the full growth and usual condition of a child of the age prescribed." It also made factory inspectors responsible for conducting checks to make sure factories in their district adhered to the new, stricter regulations. Still, even though the law specified punishment for non-compliance, many factories failed these inspections.
The success of Chadwick's work and the publication of his findings complemented similar child labor reform projects throughout Europe and helped transform short stature into an indicator signaling substandard working and living conditions. By the mid-nineteenth century, short stature joined a series of other somatic realities — including small frames and waif-like body types — to constitute a system of reference used by reformers and legislators to document the harm done to children by industrialization.
As British government officials continued to conduct surveys to assess the impact of industrialization on children, French reformers began collecting similar data. Well-known public health advocate Dr. Louis-René Villermé led the charge. In 1832, he was appointed by the Académie des Sciences Morales et Politiques to examine the health of working children in textile factories throughout France. His fieldwork included measuring and comparing the height of working children to non-working children; his reports documented the deficiency in height of the former and advocated for the end of their exploitation. Even before his work was completed, Villermé expressed his conviction of the need for a law specifying the "maximum duration of work for children in factories" and suggested that it should be "a copy of one passed in England." In 1840 his findings were issued in a report titled Tableau de l'état Physique et Moral des Ouvriers: Employés dans Le Manufactures de Cotton, de Laine et de Soie; a year later France passed its first child labor law. While the legislation was weakly enforced, Villermé continued to conduct field studies, publish reports, and work with other reformers to convince the government of the need for more restrictions, based on the belief that "the circumstances which accompany poverty delay the age at which complete stature is reached and stunt adult height." In 1871, several years after Villermé's death, France finally passed a law restricting child labor. The measurements of thousands of working children contributed to the law's passage as Villermé and other reformers used small frames, waif-like body types, and short stature as a system of reference signaling mistreatment.
Chadwick's and Villermé's success inspired Progressive reformers in the States. By the 1880s the meaning of short, frail, tiny bodies in France and Britain transcended mere numbers on a ruler or a scale, serving instead as indicators of the impact of the poverty and exploitation inflicted upon helpless children by industrialization. Twentieth century Progressives hoped to follow the example of their European counterparts in their quest to convince all levels of government to regulate child labor.
THE PROGRESSIVE MOVEMENT'S ANTI-CHILD LABOR CAMPAIGN
By 1900 New York City was at the heart of the Progressive anti-child labor movement in the United States. Home to over thirty settlement houses, countless humanitarian organizations, impoverished immigrant enclaves, and unprecedented wealth, the city led the way in implementing local-level regulatory legislation in child labor. In 1902, proud of the New York state-level child labor laws already in place, Progressive reformers created a temporary committee to investigate their effectiveness. Led by Florence Kelley and Lillian D. Wald, the committee found that the laws had in fact failed and child labor was rampant in their state; they therefore lobbied for stricter legislation. Legislators complied and this political success led Kelley, Wald, and others to extend their efforts further. In 1904 the committee was renamed the National Child Labor Committee and its anti-child labor crusade went national.
The NCLC aimed to "properly inform" the public about the prevalence and perversity of child labor and to inspire a "national sentiment upon the subject" that would persuade the passage of legislation detailing increased government regulation. The organization created a model law based on sections of existing legislation and advocated for its passage state by state. In addition, its members also campaigned for passage of the model law at the federal level.
With these goals in mind, NCLC activists organized a passionate anti-child labor campaign incorporating their own notion of childhood. NCLC members lectured audiences across the country about how child labor was un-American in the way it exploited the most vulnerable members of society and contributed to degeneracy by not allowing children to experience "normal birth," "physical protection," "happiness," "useful education," and "the right to progress" — all components of what the NCLC termed the "new view of the child." This new vision promoted the concept of a normal childhood — meaning an upbringing that would mold children into healthy, happy, educated citizens ready to lead the next generation — and served as the backdrop for the anti-child labor movement.
Like other Progressive organizations, the NCLC used investigative reporting to persuade Americans to demand the abolition of child labor in the United States. The NCLC's leaders traveled to areas where many industries notorious for their exploitation of children were located and lobbied locally for an increase in government regulation, organized anti-child-labor committees, and presented eyewitness accounts of the horrors of child labor. In order to increase the credibility of their claims about child labor and the potency of their message, the NCLC hired Lewis Hine as its official full-time photographer in 1908.
Hine was no stranger to investigative photography. While a teacher at the Progressive-minded Ethical Culture School in New York City, he had photographed immigrants being processed at Ellis Island. He had also previously free-lanced for the NCLC, worked for the National Consumers League, and taken photos for the Progressive project, the Pittsburgh Survey. Heavily funded by the Russell Sage Foundation, the Pittsburgh Survey aimed to use social science methods to document working conditions in an industrial city, and to employ the data collected in convincing its audience about the need for reform. The survey's organizers also hoped their study would serve as a model for future projects, which it did. The NCLC anti-child labor campaign employed similar strategies and personnel, including photographer Lewis Hine.
Excerpted from Heightened Expectations by Aimee Medeiros. Copyright © 2016 University of Alabama Press. Excerpted by permission of The University of Alabama Press.
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Table of Contents
List of Figures vii
1 Making Short Stature a Medical Matter 13
2 The Era of Early Growth Hormone Therapy in the United States 47
3 Short Stature as a Psychosocial Risk Factor in Need of an Effective Cure 79
4 Living the Promise of Human Growth Hormone Therapy 102
Epilogue: A Billion Dollar Industry 131
Selected Bibliography 179