Water-cooler talk in a doctor's office often revolves around patients. Not long ago a colleague of mine, a pediatric endocrinologist, mentioned that she had met with parents who wanted to put their child on growth hormone (GH), a drug used to treat short stature. The parents believed their elementary-school son wasn't tall enough and worried about what that would mean for him now and down the line.
My colleague has been reluctant to consent to these requests. In this case, she sent the parents home without a prescription. But no matter. It's likely the family will find somebody willing to give them what they want if they doctor-shop long enough.
Stories like this are not uncommon in the almost quarter-century since synthetic GH became widely available. Prior to this, GH, a naturally produced hormone that plays a key role in helping children grow tall, had been scarce, available only from the pituitary glands of cadavers. It was prescribed only for those who were lacking it. But over time, scientists discovered how to synthesize GH in the lab, leading to its eventual mass production in 1985.
GH treatment for children was originally approved for use by the Food and Drug Administration for very narrow reasons. To receive the synthetic hormone, a child had to be short (defined medically as less than 2.25 standard deviations below the mean height for their age and sex), and that shortness had to be the result of either an inherent deficiency of GH or certain genetic disorders.
Then, in 2003, getting GH got a whole lot easier when the FDA approved it for a condition called idiopathic short stature (ISS). This refers to kids who are short (again, the medical definition), but for no discernible reason and with no underlying diagnosis. Just like that, GH went from being a drug that doctors prescribed with great discretion to something entirely different -- a lifestyle drug used not to cure or manage disease but to improve someone's perceived quality of life.
Current studies don't pin down how many children are receiving GH, but according to one recent report, "some 40 percent of children on GH appear not to be GH-deficient." In general, kids receiving the synthetic growth hormone range from elementary-school age to teenagers.
Today, pediatricians hear parents ask for GH because their son (and it's usually sons) is as "short as I was in grade school," or "is the shortest one on the team," reinforcing the stereotypes about being short: lower self-esteem, getting bullied, lower grades, a poor love life and less professional success than taller people.
Conventional wisdom backs up some assertions about height and society. It's been noted that Fortune 500 company CEOs are on average 6 feet tall. Most U.S. presidential elections have been won by the taller candidate; on the other hand, a rogues gallery of dictators -- from Napoleon to Kim Jong Il -- are shorter than average.
Many doctors accept these assertions. In one survey, 56 percent of doctors believed that being short impairs a child's emotional well-being. In another, 32 percent of doctors stated they believed that giving a child GH would improve the quality of his or her life.
However, our assumptions about height may not be as true as we believe. When studies take into account external factors, like education or race, those stereotypes fall apart. It turns out that many previous height studies focused on children from specialty medical clinics, who had disorders in which their intellectual or emotional intelligence was adversely affected. This biased the results and helped create adverse impressions about shortness.
Studies looking at short but normal children haven't led to the same conclusions. One, the Wessex Growth Study, compared short and healthy children with kids of average stature over many years. In her conclusion, Dr. Linda D. Voss, one of study's authors, wrote that she saw no evidence of "maladaptation or psychosocial dysfunction, before, during or after puberty, in these youngsters who were, by current standards, very short indeed."
So the truth is counter to the conventional wisdom. But let's say you're a doctor who believes GH will improve the quality of a short child's life, or one who gives into parental pressure and prescribes it for a short but otherwise normal child, whether he or she meets the definition of ISS. Will that medicated child suddenly bloom into a confident kid with better grades, a prom date and a starting spot on the basketball team? According to most available evidence, no. While GH can make anybody grow taller, it won't improve social adjustment.
Then there's the cost, financial and otherwise, of using GH in a short but normal child. Here's what that child will have to endure: self-administered injections of GH, three times a week, for up to four years. The reward? According to one 2004 study, 1.5 inches. The cost? Somewhere around $20,000 per child. For teens who start the treatment after puberty, the cost may exceed $50,000.
There is an ethical dilemma to consider about GH and the entire lifestyle drug market. Once a lifestyle drug is readily available and widely consumed, it can lead to a shift in what society considers normal. If height can be enhanced by "plastic endocrinologists" for the right price, we're redefining normal, and leaving those who can't afford these services behind.
What's the X-factor when it comes to height and success? Let's look at the Dutch, who, on average, are the world's tallest people. In Holland, we find a combination of early-nutrition programs, child health initiatives and more equal distribution of wealth across social groups. This suggests that if we took the dollars we spend on GH for a few kids, and redirected the money to level socioeconomic disparities, we could better influence the height, health and success of many more kids than we are now in this country.
Then there's the risk and benefit of a diagnosis. Give something a label like "erectile dysfunction" or "ISS" and suddenly you've turned a normal condition into a malady. That's the magic of lifestyle drugs: You create vast new markets with the fruits of your labor by feeding into people's insecurities and fantasies of success. You sell medicine by offering the false promise of better living through pharmacology. The strategy is working -- lifestyle drugs have helped to drive drug industry profits for the better part of this decade.
In the case of GH, sales between 2002 and 2006 by one of GH's makers, Eli Lilly, jumped 40 percent, to $460 million. In some cases, drug companies have crossed the line. In 1999, another GH maker, Genentech, pleaded guilty to federal criminal charges that it had improperly promoted GH, and ended up paying a $50 million fine. Nevertheless, many other lifestyle drugs continue to grow in sales at double-digit rates.
The United States is the only country that allows GH to be used for ISS. It's not a pretty picture. What other country in the world can offer pricey enhancements and call it medical care, and at the same time have millions of children unable to get access to basic medical services? Perhaps we could answer that question if we had a genuine healthcare system rather than a healthcare market.
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