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Monday, January 17, 2000
By Steve Twedt, Post-Gazette Staff Writer
For thousands of diabetics, insulin is a lifesaver.
For diabetics working in safety-sensitive jobs, insulin also can signal the end of their professional careers.
Commercial airline pilots cannot be approved to fly if they use insulin to treat their diabetes. Private pilots can.
A locomotive engineer using insulin may keep his job, if he can demonstrate to his company's medical examiner that he can keep his blood sugar under control.
But commercial truck and bus drivers cannot drive if they use insulin.
When the Federal Highway Administration launched a pilot program granting insulin waivers to select diabetics in 1993, a federal judge stopped it, saying the agency hadn't shown it would not pose a public safety risk. Only those already holding waivers could continue.
There is a growing movement, however, to re-evaluate the federal government's blanket ban on commercial drivers using insulin. In 1998, Congress called for a study of whether "a practicable and cost-effective screening, operating, and monitoring protocol" could be developed for insulin-treated diabetics who want to drive commercial vehicles. That report is due in coming months.
Part of the argument for change has a legal basis: In case law since the 1992 adoption of the Americans with Disabilities Act, a consistent tenet has held that disqualification based on a disability should be decided on a case-by-case basis.
In 1996, Rhode Island truck driver Antone Borges III persuaded a federal judge to let him get his commercial driver's license back, paving the way for the state Legislature to say insulin cases must be decided on an individual basis.
Twenty-six states allow diabetics to drive commercially, as long as they don't cross state lines.
But the simmering question remains: Do truck and bus drivers using insulin to treat their diabetes pose a danger to public safety?
Medical and legal experts are still debating the question.
Just last summer, a 29-year-old Dallas man was killed by a diabetic truck driver who'd forgotten to take his medication. According to witnesses, the driver ran two red lights before colliding with a car, fatally injuring Bill Whittaker. Two children, ages 3 and 6, were also injured.
At the same time, people in the trucking industry say they know diabetic drivers, including some who use insulin surreptitiously, who have worked safely for decades.
The most oft-cited reason for continuing the insulin ban is the strain and uncertainty of the trucker's life.
"Given the lifestyle and tasks required of the truck driver, I don't think it's a good idea," said Dr. Natalie Hartenbaum, a Philadelphia-based occupational medicine specialist and one of the country's foremost experts on medical qualifications for commercial drivers.
"When you have a driver who's working cross-country, who keeps his log books and uses every hour of service available to him, he may have a hard time with his meals, his rest, and getting enough sleep." Perhaps with close monitoring, allowing diabetics to drive could be done safely, she said, but she wonders how practical that would be.
Dr. Pamela Gianni, an occupational medicine specialist in Scottdale, Westmoreland County, was troubled by the idea, too.
"Because of the nature of the disease itself, the number of diabetics who have tight, tight control over their diabetes is very small. And the types of damage it does to your body affects exactly those organs that you need working on the road."
Besides diabetes' extreme effects, such as losing consciousness, it also can affect a person's vision and concentration.
For years, groups such as the American Diabetes Association and the Owner-Operator Independent Drivers Association have pushed for the federal government to consider allowing diabetic drivers on a case-by-case basis.
With improvements such as fast-acting insulin, monitors that are smaller and easier to use, and better injection devices, "you can identify a group of people who are quite safe," said Dr. Kenneth Quickel, president of the Joslin Diabetes Center in Boston.
Quickel noted that studies of diabetic drivers show they have a lower accident rate than the general population. Critics say those studies are too small to be considered conclusive and are tainted because the drivers knew they were under scrutiny and so were especially careful. And other research, including a 1995 study of truck drivers in Quebec, found a two-fold greater risk of a crash among diabetics.
When researchers at Carnegie Mellon University and the University of Pittsburgh looked at diabetic truck drivers, they found there is increased risk among diabetics who have had trouble recognizing the onset of a hypoglycemic episode. But that was not true for other insulin-using diabetics.
The risks, said CMU's Lester Lave, seemed well within the range of other acceptable risks society allows, such as licensing teen-agers and retirees despite their higher accident rates, or allowing high speed limits on two-lane rural roads.
But he understands the reluctance.
"When any one of us sees that 18-wheeler on the highway, we know that guy can do us in. That thing has so much mass that your car is not going to stop it."
There's a social aspect as well. It's one thing to tell a 21-year-old that he can't start a career driving trucks, Lave said, and quite another to end the career of someone who has been driving for 25 years and has no other marketable skills.
While federal officials look at the issue, 26 states offering insulin waivers for intrastate drivers -- who, because of their limited driving and more regular hours, are better able to control their blood sugar -- report no noticeable increase in accidents among that group.
"We're not asking for anyone and everyone who has diabetes -- and takes insulin -- to be able to drive commercial vehicles. There is risk," said Ann Albright of the American Diabetes Association, which in 1996 helped persuade the Federal Aviation Administration to lift a 37-year-old blanket ban on private pilots who use insulin.
"But people should be treated individually and assessed individually. People should be able to prove they're safe and not have others make that decision for them," Albright said. "Now, it's almost as if someone is guilty until they are proven innocent."
One irony in the current ban is that the no-insulin rule sometimes prompts drivers to make unsafe decisions.
Dr. George Schmieler of Washington, Pa., recalled that two years ago, state troopers brought a trucker into his clinic who'd been found stumbling around at an Interstate 70 rest area. During the routine exam, they found the driver had a blood sugar level of about 300 -- three times the normal level.
"He was hyperglycemic. He had ketoacidosis [build-up of sugar plaque]. He had trouble breathing," Schmeiler said.
You're diabetic, they told him. I know, he said. You're not supposed to drive trucks if you're diabetic and use insulin, they told him. His reply: "When I drive, I don't take my insulin."
Dr. Patricia Bononi, staff physician at The Western Pennsylvania Hospital's Joslin Center in Pine, said her office sees commercial drivers referred once their Department of Transportation physical shows they have high blood sugar.
One recent patient, a Port Authority Transit bus driver, had to leave his $20-an-hour driver's position for a $10 an hour job in PAT's maintenance department because of his diabetes. "He's agreed to go on insulin, but he's not happy about it," Bononi said.
More worrisome are drivers who call before making an appointment, to ask how they can avoid taking insulin.
"You give them the risks and benefits, then they make their own choice," Bononi said. But usually, if there's disagreement, we don't see them again.
"I suspect they're out there driving."
Rigged for disaster, Part II: 
Interstate trucker rules hammer diabetic drivers Ignorance of regulations paves way for unfit drivers