According to recent news, one of the fastest-growing career opportunities -- if you want a great, interesting, high-paying job -- is Airline Pilot. Now, anyone who's followed the ups and downs of the airline industry over the last few decades (pardon the pun) is allowed a cocked eyebrow, at the minimum. This is a career field rife with furloughs, layoffs, and outright bankruptcies. But this time it’s different, as global commercial air travel is up in general and the pilot population is growing older and retiring, driving a job boom.

But for those of us with type 1 diabetes like myself, they aren't desperate enough (in the USA at least) to let us fly a big commercial Boeing Dreamliner. Not yet, that is.

That could be changing before long, if history and current events are any indication.

 

The "Medical" Requirement for Aviation

To understand where we are headed, you need to know where we’ve come from, and to do that we need to go back to 1949. That’s when the Federal Aviation Administration (FAA), which back then was known as the Civil Aeronautics Board, established the “just say no” rule for pilots who need insulin, or in the words of cold bureaucracy, insulin use was regarded as “an absolutely disqualifying condition” for getting a medical certificate of any kind.

Wait, what's the deal with a medical certificate for a pilot’s license? You need to understand that a pilot’s license isn’t like a driver’s license. A pilot’s license is more like a diploma. It’s proof that you’ve attained a specific level of skill and competence. But just as someone with an education degree still needs a teacher’s license to teach, a pilot’s license needs a few extras to be usable. Pilots are required to undertake specific recurrent training, plus they have to maintain special levels of currency to “exercise” the privileges of their licenses. Historically, they also had to have a valid medical certificate establishing that they were fit to fly. And it was this “medical” (for short) that for many decades grounded both potential pilots with diabetes and already-licensed pilots who got diabetes.

Considering the state of the art in diabetes treatment in 1949, it would be hard to argue with that decision. Those were the days of animal insulin, with no way to check current blood sugar. We only had pee strips to show where our glucose had been hours before. 

To their credit, as times changed, so did the FAA. In 1996 a change was made to the regulations to allow an exception to the old medical rules, called a “special issuance.” But it only went so far. There are three flavors of medicals, called 1st, 2nd, and 3rd. Generally speaking you need a 1st or 2nd to be paid to fly. The 3rd was for anyone flying smaller crafts for recreation or personal businesses. In ’96, the FAA opened the doors of the 3rd Class medical to people who need insulin, although it’s quite a process. Still, that meant insulin-using people with diabetes could fly -- but just not for pay.

This allowed hundreds of type 1 would-be pilots, including those who use insulin pumps, to get their wings through 3rd Class medical special issuances. Then in 2004, the FAA introduced a new category of lightweight two-person airplanes that didn’t require a medical; instead, any valid driver’s license would do (!)

 

My Own Experiences as a Pilot with T1D

Those rules are what allowed me to return to flying (I had a commercial pilot’s license pre-diabetes), to score a World Speed Record, and then become a two-time National Champion Air Racer.

And I’m not the only World Record-Holding D-pilot, either. Type 1 Douglas Cairns—who also flew around the world—and fellow T1 Thor Dahl set a most-states visited in 24 hours record, touching down in 29 states and thereby blowing the doors off the previous record of 23 states. InPen smart insulin pen inventor Sean Saint, like me, is a T1 Pilot. Other T1s have organized flying events over the past few years.

Then in Spring 2017, the medical rules evolved again with a complete overhaul of the 3rd Class medical called BasicMed that’s allowed many pilots who developed diabetes after getting a medical to keep flying without a burden of paperwork that outweighed their airplanes. 

So right now, there are three roads to the cockpit. But none to the cockpit of a Dreamliner. In the USA, insulin-using pilots are still prohibited from being paid to fly (with the exception of some types of flight instructors whom the FAA regards as professional teachers, not professional pilots). 

That’s not true in the rest of the world.

According to Pilots with Diabetes, we insulin users can fly commercially in Canada, the UK, Ireland, Austria, and Kuwait -- if we are members of a multi-crew operation. Actually, the Canadians, always a sensible lot, have been allowing it since 2002!

 

The ADA's Efforts, and Value of CGM

Will the USA join our friends to the north? Although it hasn’t happened yet, it is theoretically possible. Back in 2013 the FAA actually reached out to the American Diabetes Association to create some sort of system to identify pilots who “pose a non-zero, but insignificant risk of incapacitation from hypoglycemia.” I guess it makes sense to avoid certifying PWDs who might go lights-out hypo, but what are the odds the second (non-D) pilot would have a heart attack at the same moment?

The ADA came up with a series of recommendations that among other things called for 80% of BG readings to be between 70 and 250. The FAA rejected that as too lax, balking at certifying pilots “outside the normal glycemic range at least 20% of the time.” Yipes! But the whole episode at least served to introduce the FAA to the idea of CGM (continuous glucose monitoring), which back in 2013 wasn’t quite in its infancy, but was still a far cry from where it is today.

CGM went on to feature quite solidly in a long chain of litigation that wrapped up its latest round just this spring. A type 1 pilot named Eric Friedman sued the FAA when he couldn’t get a 1st Class medical. He ultimately lost, but reading the decision of Judge David S. Tatel, who denied Friedman’s case, I found that the FAA repeatedly asked Friedman to provide them with CGM data, which, bizarrely, he declined to do. I guess his legal strategy went another direction, or perhaps it was because he didn’t use CGM, nor did his doctors think he needed it. Reading between the lines, I wondered if he couldn’t get insurance coverage for it. Up until recently, often the only way to get CGM covered was if you had a wicked hypo risk. Of course, to get the FAA’s blessing in a case like this, you have to prove you aren’t a wicked hypo risk, so Friedman may have found himself between the Devil and the deep blue sea.

Regardless, the fact that the FAA was practically begging Friedman for CGM data tells me that they recognize the value of it. If we can come to the point where they are realistic about what it shows, and more importantly, how it can prevent the kinds of hypos they’re worried about, we might really get somewhere. 

I may fly that Dreamliner yet.

Actually, truth be told, I think I’d find that about as exciting as driving a Greyhound bus. But a 2nd Class medical is required to race at the National Air Races at Reno, and that is something I would like to do.

Meanwhile, according to court documents in the Friedman case, the FAA admitted that while they had never issued a special issuance of a 1st or 2nd Class medical certificate, that it hoped in the future it may be able to safely certify a “subset” of insulin treated-diabetics at those levels. They also state that they don’t have a blanket ban of PWDs (people with diabetes), and still claim to being open to issuing a certificate on an “ad hoc” basis in the meantime.

I do believe that sooner or later there will be insulin in the cockpit of a Dreamliner. And when that day comes, even the sky won’t be the limit for people with type 1 diabetes.