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People with diabetes who take insulin have been barred from becoming commercial airline pilots -- until now.

Last week, the diabetes world -- and maybe the rest of it as well -- was rocked when CNN reported on a major sea change from the Federal Aviation Administration (FAA), the branch of government that issues and regulates pilot’s licenses in the United States. The agency announced it is establishing a process whereby insulin-using people with diabetes (PWDs) will be allowed to pilot jet airliners in the near future.

And just like that, one of the last remaining “closed doors” to PWDs blew wide open!

Historically, the concern of course was that a pilot dependent on insulin could be distracted or even pass out from an extreme high or low blood sugar. But many have argued that newer CGM (continuous glucose monitors) provide enough of a safety net, keeping constant watch on a pilot’s blood sugar. Now, the FAA finally seems convinced.

"Advances in the treatment of diabetes and the management of blood sugars have mitigated that risk," Federal Air Surgeon, Michael Berry stated in a recent court filing on the topic. "Recent advances in technology and diabetes medical science have allowed the FAA to develop an evidence-based protocol that can both identify a subset of low-risk applicants whose glycemic stability is sufficiently controlled and also ensure these pilots can safely maintain diabetic control for the duration of a commercial flight."

Recreational pilots and aviation enthusiasts with type 1 diabetes like myself have cause to celebrate!

 

Diabetes and aviation: a brief history

For decades, the FAA didn’t let insulin-using people become pilots. Worse, they took away the flying privileges of licensed pilots who developed diabetes and required insulin.

  • In 1996, things started to change, when the FAA started allowing some insulin users to fly private planes. I won’t bore you with the details, but suffice it to say there was a LOT of paperwork and expense involved.
  • Later in 2004, things lightened up even more, with many insulin users permitted to fly very light planes if they had a valid driver’s license.

Still, the door to the cockpit of an airliner remained firmly closed and locked -- at least in the USA. In much of the rest of the English-speaking world, things had already started changing.

In 2012, a more enlightened approach was taken, starting with the Canadian aviation authorities. They realized that: 1) given the diabetes treatment technology available today, the risk of a well-controlled PWD passing out from a hypo is unlikely; and 2) even if it did happen, airliners have two pilots.

(To be clear, while Canada was on the forefront of letting currently licensed pilots keep their privileges after diagnosis with insulin-dependent diabetes, it was only earlier this year that they opened up the doors to letting new insulin users begin flight training.)

In short order, other countries like Australia, New Zealand, and the UK followed Canada's lead in allowing insulin in the cockpits of their airliners.

But there was no joy for insulin-using pilots in the USA who dreamed of flying big jetliners. And what made this situation somewhere between utterly bizarre and completely outrageous was the fact that insulin-using airline pilots from Australia, Canada, New Zealand, and the UK were allowed to operate in US airspace, but US insulin-using pilots were not granted the same privilege.

That now changes.

"Blanket bans based on diagnosis alone are never appropriate, even in safety sensitive positions," said Sarah Fech-Baughman, Director of Litigation, Government Affairs and Advocacy for the American Diabetes Association (ADA) in a statement. "Not all persons with diabetes are fit to pilot a commercial aircraft, but certainly some are, and they should be afforded individual assessment of their medical condition and qualifications. The ADA has been working to dismantle this blanket ban by educating and negotiating with the FAA for a decade. It is our hope that a policy concerning insulin-treated commercial pilots will be finalized soon and that it is in step with current diabetes science and treatment."

 

New FAA Protocols for Insulin-Users

The FAA has unveiled the new guidelines, explaining the above history as well as the specific protocols that will now be put in place for those insulin-dependant PWDs wanting to obtain a commercial pilot's license. Those went online Nov. 6. Specifically, here's what the FAA says is required:

  • initial comprehensive report from the treating, board-certified endocrinologist
  • initial comprehensive laboratory panel
  • fingerstick blood sugar (FSBS) glucose monitoring data
  • continuous glucose monitoring (CGM) data for at least the preceding 6-month period (using a device legally-marketed in the United States in accordance with FDA requirements and containing protocol-specific features needed for appropriate in-flight monitoring).
  • Excel spreadsheet or similar that identifies CGM data for all flights for the past 6 months and any actions taken to address low or high glucose levels
  • eye evaluation (from a board-certified opthalmologist)
  • cardiac risk evaluation (from a board-certified cardiologist)

The FAA also states: PWD-applicants interested in more information about applying for a special issuance to fly commercially should consult the specific ITDM protocols (including CGM features needed for proper in-flight monitoring) by searching “ITDM” in the Guide for Aviation Medical Examiners online.

 

What about public safety?

So how safe is it for an insulin-using PWD to pilot an aircraft with hundreds of people aboard?

Beyond the excellent track record of private flying with insulin since 1996, thanks to the countries that allow airline pilots who use insulin to keep flying, we have hard data to answer that question. One study tracked the blood sugar readings of 26 of the “early” insulin-treated UK pilots in over 4,900 flight hours, and found that only 0.2% of readings were off-target, and in none of those cases was the pilot incapacitated.

Bear in mind, this was before CGM became prevalent in diabetes treatment.

Not everyone agrees, however. In a recent dissenting opinion published in the prestigious medical journal The Lancet, a group of endocrinologists stated that they don’t feel insulin users should be allowed to fly. They don’t feel it is safe, either for the traveling public (citing diabetes-related automobile accident statistics, as there are no negative statistics to cite on T1D pilots), or for the pilots themselves -- as these doctors feel that the target BG levels the UK uses for insulin-using pilots are too high, and may lead to long-term complications.

I might concede the second point, but I don’t think using driving data to make assumptions about flying is fair. For one thing, the bar for getting a driver’s license is pretty low. The bar for getting the highest level of aviation medical clearance with insulin is going to be high indeed. Although the details are still pending, I’m quite sure that only the very best controlled PWDs will make it though this process. That hunch is backed up by the CNN reporting, which quoted court documents citing FAA Federal Air Surgeon Berry stating that he believes the FAA can identity “a subset of low-risk applicants” whose “glycemic stability is sufficiently controlled” for safe flight.

So these new medical clearances won’t be granted to all low-risk pilot applicants, but rather just a “subset” of those determined very low risk. In other words, not just any PWD will be able to fly airliners, which makes sense. After all, not just anyone off the street is allowed to, either. There's A TON that goes into to training and certification.

Meanwhile, the anti-PWD pilot docs are in the minority. Even before the news broke, professional airline pilots across the country were actively supporting the change. This June, the International Federation of Air Line Pilots’ Associations issued a position statement supporting insulin-using pilots, and other aviation organizations like AOPA (the aviation political power house equivalent to the AARP) has been advocating for letting insulin into more cockpits for years. And as noted, the American Diabetes Association was supportive as well, reiterating to CNN that, “Blanket bans based on diagnosis alone are never appropriate, even in safety sensitive positions.”

 

Diabetes community reaction

Judging by social media activity, the D-Community's reaction to this news has been mostly rejoicing that yet another barrier has come crashing down. Of course for some aviation enthusiast PWDs like myself, this news is -- literally -- life-changing.

Longtime type 1 Andrew Crider in Virginia, whose childhood dream of flying airliners was crushed by diabetes, told DiabetesMine that the FAA's change of heart “translates into one of the most beautiful moments of my life.” He says he can finally pursue his dream, adding, “It’s a day I never thought would come.”

Though not being able to fly commercially, Crider found his way into aviation another through another route. Graduating with an economics degree, Crider says his first job was at a private jet center cleaning toilets on those jets along with washing the SUVs and limos for the pilots. Then, he started cleaning floors and doing other janitorial work in hangers and fueling jets, and eventually moved into light maintenance and updating avionics on the planes. He also earned his private pilot's license.

Crider's found his calling at the Virginia Department of Aviation, where his job is to "promote aviation" in general and provide grants and scholarships to classrooms. Part of his job involves doing career expos, where he talks to kids and teens about possibilities that exist in the field. With the latest FAA decision, Andrew says he's eager to share that young people with diabetes can now also pursue their dreams of becoming a commercial pilot.

Some others in the community are more restrained, still reeling from the news.

For example, type 1 Angela Lautner in Tennessee (whom we profiled here at the 'Mine in 2017) is pleased, but is waiting to see the details behind this FAA decision. Lautner was well on her way to becoming a commercial airline pilot in the summer of 2000 when she developed type 1 diabetes, which shot down her career aspirations. While she says the change by the FAA is “great news,” she’s waiting to see what the specific protocols—which won’t be announced for at least a week—will be. She says, “I belong to a Facebook group of pilots with T1D and most of us are holding our collective breath to see what will be required.”

Lautner, who went on to work as a flight dispatcher, told us, “This news is actually such a shock to me that I am still thinking through what this means for my future career plans. I honestly thought we were fighting through this for the long-haul, so that others would benefit from change.”

There are many questions still unanswered at this point, especially as it relates to how the new protocols will be interpreted and applied practically. That all remains to be seen. But very soon, for some PWDs, the sky will no longer be the limit.

 


Will Dubois lives with type 1 diabetes and is the author of five books on the illness, including "Taming The Tiger" and "Beyond Fingersticks." He spent many years helping treat patients at a rural medical center in New Mexico.

An aviation enthusiast, Wil earned his commercial pilot's license in 1984 but after his T1D diagnosis wasn't allowed to fly commercially. He later obtained his private pilot's license and has flown in multiple competitions across the U.S. Just recently, Wil took a position as a ground instructor in Colorado.