Doctors and pilots. Hard to find a group more at odds. Doctors, in the person of aviation medical examiners (AMEs), put aviators holding Class I medical certificates through thorough examinations every six months. Aviators view these exams as one of the stiff prices they pay for the privilege of flying for pay.

What other profession is forced to submit to a biennial medical exam that can mean the end of a career with the stroke of a pen? Does the threat of medical certificate revocation represent the most serious professional threat faced by pilots?
Sadly, yes. But not as often as one might think, especially in these times of increased health awareness, better medication and treatments and, amazing to some, an FAA that’s much more inclined to say “yes” to a pilot with medical issues than it is to say “no.”

Professional pilots are caught in a real Catch-22 when it comes to health. Flying modern aircraft is a sedentary job, made even more sedentary as airplanes become more automated and the distances routinely flown nonstop become greater. Squads of physicians and stacks of studies have shown that an inactive lifestyle, the simple act of sitting still for long periods of time, is one of the biggest threats to health, contributing to obesity, high blood pressure, cardiovascular problems and back, spine and skeletal disorders, just to name a few. At the same time, no other profession is called upon to routinely maintain such a high level of general health.

How Do Pilots Compare?
And yet, most pilots manage to do it. But how well are they doing it? What changes are affecting the interrelationships of professional flying and personal health? Those are murky, complex questions, but there are some indicators. AIN contacted many aviation advocacy groups for this article, as well as the FAA aeromedical branch, in what became a fruitless effort to lock down authoritative data on the overall documented health of the pilot population, data that could then be contrasted to the general population for a better idea of how professional aviators stack up.

“To my knowledge, no study like that has ever been done,” said Dr. Jon Jordan, Federal Air Surgeon. “Most everyone believes that overall pilot health is superior to good.

With regular medical assessments at six-month intervals, I think we can be fairly confident that in terms of overall health, pilots are far better than average compared with the general population.”

Claims submitted to “loss of license” insurance underwriters are a somewhat more precise way of judging the several health professional aviators. According to figures from Harvey Watt & Company, a major loss-of-license insurance provider, claims for cardiovascular disease (CVD) are number one by far. Following in descending order are orthopedic illness and injuries; cancers of all types; neurological illness, especially Meniere’s disease, an inner ear condition that causes severe vertigo, hearing loss and tinnitus (ringing in the ears). The fifth major cause of loss-of-license claims are mental and nervous complaints extending across a broad pshycological/neurological spectrum.

First of all, as a population, the U.S. is getting older. The baby-boomer generation (officially those born between the years 1946 and 1964) is approaching retirement age, according to U.S. census data.

The median age in America is at its highest point ever: 35.3 years, up from 32.9 years in 1990, and 28 years in 1970, according to recently released data from Census 2000. By “median age,” the Census Bureau means that half of the American people are now older and half younger than 35.3 years. The increase in median age from 32.9 years in 1990 to 35.3 in 2000 reflects a 4-percent drop in the number of persons between 18 and 34 years old combined with a 28-percent increase in the population between 35 and 64 years of age.

The most rapid Census 2000 increase in the size of any age group was the 49-percent jump in the population 45 to 54 years old. This increase, to 37.7 million last year, was fueled mainly by the entry into this age group of the first of the baby boomers.

It’s a sad fact of life that an older population gets sick more often and more seriously. And by far the leading cause of illness is CVD. According to data from the American Heart Association and the federal government’s Centers for Disease Control (CDC), one out of every 2.5 deaths in America is attributable to CVD. As a primary or contributing cause of death, CVD was mentioned on 1.4 million death certificates in 1998, the latest year for which validated data is available.

As if these numbers weren’t chilling enough, there are more:
• Since 1900, CVD has been the number-one killer in the U.S. every year except 1918 (when American deaths from CVD were outnumbered by a deadly combination of World War I and a terrible influenza epidemic that swept through the country in the days before antibiotics).

• More than 2,600 Americans die of CVD every day, an average of one death every 33 sec.

• CVD claims almost 10,500 more lives every year than the next six leading causes of death combined (cancer, 541,532; accidents, 97,835; AIDS, 13,426.

• In the U.S. in 1998, CVD claimed the lives of 445,692 males and 503,927 females, while cancer killed 282,065 males and 259,467 females.

As a nation, the U.S. places ahead of England, Austria and New Zealand
in terms of CVD-related deaths, but scores well below the CVD rates of Germany, Denmark, Greece, Norway and, in fact, much of the rest of the Western world. (Who’s number one? The Russian Republic, leading the world in CVD deaths with a rate nearly three times that of the U.S.)

Relax, We’re Healthier Than You Thought
Despite these gloomy numbers, there is cause for hope. According to the U.S. Department of Health and Human Services, National Institutes of Health, age-adjusted death rates since 1940 per 100,000 persons for diseases of the heart (coronary heart disease, hypertensive heart disease and rheumatic heart disease) have decreased from a peak of 307.4 in 1950 to 134.6 in 1996, an overall decline of 56 percent. Age-adjusted death rates for coronary heart disease continued to increase into the 1960s, peaked, then declined. In 1996, some 621,000 fewer deaths occurred from coronary heart disease than would have been expected had the rate remained at its 1963 peak.

Likewise, age-adjusted death rates for stroke have declined steadily since the beginning of the century. Since 1950, stroke rates have dropped 70 percent, from 88.8 in 1950 to 26.5 in 1996. Total age-adjusted CVD death rates have declined 60 percent since 1950 and accounted for approximately 73 percent of the decline in all causes of deaths during the same period.

The Reasons Why
The reasons for these declines are many. One of them has a lot to do with the fact that you probably didn’t have bacon for breakfast this morning or followed (or preceded) that morning cup of coffee with a cigarette. In short, the U.S. population is healthier because:
• Cigarette smoking among adults age 18 years or older declined from approximately 42 percent in 1965 to 25 percent in the late 1990s.

• There’s been a decrease in mean blood pressure levels in the U.S. population.
• Mean blood cholesterol levels have also decreased.

• Surveys suggest that consumption of saturated fat and cholesterol has decreased. Data from the National Health and Nutrition Examination surveys suggest that decreases in the percentage of calories from dietary fat and the levels of dietary cholesterol coincide with decreases in blood cholesterol levels.

• Diagnosis and treatment has improved, driven significantly by better medications and in more severe cases by more advanced surgical techniques.

Data collected by MedAire provides one of the few business aviation-specific glimpses into the health of the corporate pilot and what it sees looks very good. The Phoenix, Ariz.-based aeromedical services and products provider has been providing National Business Aviation Association show-goers with free cholesterol screening from its exhibition hall booth since 1990. While nationwide levels of low-density lipoprotein [LDL, also known as the “bad” cholesterol as opposed to the high-density lipoprotein (HDL) or “good” lipoprotein] are gradually declining, LDL levels among corporate aviators, at least those who go to NBAA conventions, are declining far more sharply. According to the U.S. Department of Agriculture and Health and Human Services’ Report on Health Monitoring, 20 percent of Americans still have dangerously high levels of serum cholesterol. Not so among MedAire’s admittedly random NBAA show sample, who have seen their high-risk cholesterol levels decrease steadily from the 1990 level of 22 percent to a mere 5 percent in 1999.

The Growing Danger of Diabetes    
While there is cause for hope on the cardiovascular front, there is another, less well known killer lurking in the wings. The incidence of diabetes is growing, that much is sure. In just two years, from 1995 to 1997, the number of Americans with diagnosed diabetes jumped from 8 million to 10.3 million. On top of that are those who either don’t know the symptoms of diabetes or haven’t yet been examined. According to the National Diabetes Information Clearinghouse, a total of 15.7 million Americans, 5.9 percent of the population, have diabetes (assuming 5.4 million as-yet-undiagnosed cases), with 798,000 new cases diagnosed every year. Ironically, the split between diabetes incidence among men and women is 50-50, with 8.2 percent of both populations stricken with the disease.

Based on death certificate data, diabetes contributed to 193,140 deaths in 1996 (the last year for which conclusive data is available).

New data that’s especially disturbing focuses on the prevalence of diabetes among younger people. Using CDC data, the number of diagnosed cases of diabetes among Americans under age 44 per 100,000 and has climbed steadily from 974 in 1980 to 1,371 in 1996. For the record, diabetes is defined as having a fasting blood glucose level of 126 milligrams per deciliters or more measured on two occasions. The American Diabetes Association recommends that all adults have a fasting blood glucose test at age 45. If results are normal, the patient should then be tested at least every three years after that.

Surprisingly, for all its reputation as a hard-nosed “rough ’em and cuff ’em” enforcement agency, the FAA is among the most progressive aeronautical authorities when it comes to certifying pilots diagnosed with illnesses.

“Of all the ICAO countries, we are by far the most lenient,” said Gary Crump, medical director for the Aircraft Owners and Pilots Association (APOA). “In the negotiations between the FAA and the European Joint Aviation Authorities (JAA), there’s been a lot of pressure for the FAA to be more conservative in its medical criteria but so far we’ve been resisting that, partly because we rolled over to them on so many other issues, such as airspace classification. In areas such as diabetes and coronary artery disease, bypass issues and any type of coronary blockage, our rules are much more forgiving.”

Under the basic rules for issuance of a medical certificate to a pilot diagnosed as diabetic, a first- or second-class certificate is out of the question. However, a regulation passed in 1996 allows the Federal Air Surgeon to authorize issuance of a third-class certificate on a case-by-case basis, not only for diabetics controlling their illness with oral medication and diet but also for more seriously affected diabetics being treated with insulin. And that’s a first.

“This attitude is decidedly more relaxed than in any of the JAA countries,” said Federal Air Surgeon Jordan, “but it’s consistent with the FAA’s overall philosophy of trying to both keep the system safe and to keep those who want to fly qualified to do so.

“Diabetes is serious, no doubt about it,” Jordan continued. “Undetected it’s a silent killer. But like so many other illnesses, with early diagnosis it’s easy to control–if you catch it up front.”

The benefit of the doubt Jordan can extend toward a diabetic pilot is summarized in the regulation itself: “…the Federal Air Surgeon considers the freedom of an airman, exercising the privileges of a private pilot certificate, to accept reasonable risks to his or her person and property that are not acceptable in the exercise of commercial or airline transport pilot privileges, and, at the same time, considers the need to protect the public safety of persons and property in other aircraft and on the ground.”
Or, as Jordan put it: “Private pilots can control when he or she flies whereas a commercial pilot flies at the behest of someone else’s schedule. Private pilots can therefore control their diet and monitor their blood sugar to fly at the times that are best for them.”

The upshot of the new reg is that while insulin-treated diabetics and those using diet and oral medications are all allowed to fly, they can fly only under both the restrictions of a third-class medical with some other operational riders tacked on, such as a ban on flying outside U.S. airspace.

The new rule has not exactly opened the application floodgates. Jordan reports that of the 620,000 pilots holding active medicals, a total of 4,500 are active Type II diabetic aviators managing their illness using oral medication and diet control, and only 340 insulin-using diabetics have been approved for flight.

Not Exactly Dr. No
The Oklahoma City, Okla. home of the FAA’s Aeromedical Branch is where all medical certificate applications go for resolution and recording. Tracking the aeromedical paper trail of 620,000 aviators is a daunting task, which is why, five years ago, the FAA launched a program to computerize several decades’ worth of data into an online format that would, it was hoped, save time and money while easing the process of filing and reviewing medical certificate applications. At the same time, the FAA pressed AMEs to file all their aeromedically relevant data electronically, especially certificate applications. As anyone who has ever tried to put online a process that used to be done primarily on paper (such as adapting one’s household finances to a computer bookkeeping program) can testify, it’s a time-consuming and laborious process.

“It’s been a very complex process,” seconded Jordan, who likened the changeover to building a new freeway atop an old one, while keeping the old road in service. “Not only did all the old records have to be input, but we had to educate some 5,600 AMEs to become computer literate and willing to use the service. And, trust me, not all of them were receptive to this change. But now, five years later, we’re up to a 90-percent transmission rate, meaning that 90 percent of the 450,000 medicals we’re getting in from the field every year come in via computer.”

Computer processing is no magic wand that can be waved at paperwork to make it go away. “A year ago,” Jordan reported, “we were looking at a backlog of some 82,000 applications. Now we’re down to 10,000 and the number is decreasing.” In terms of real time, that works out to an average 12-week delay.

The office of aerospace medicine that Jordan oversees is doing what it is tasked to do by Congress with a staff of 400 and an annual appropriation of $42 million ($32 million for operations, $10 million for research). “And that appropriation has stayed flat, with no real increases since 1995,” Jordan said. “Out of that we run regional offices, the drug-abatement and drug- and alcohol-control programs (which consume a lot of our budget), conduct aeromedical education and perform the medical certification function…it’s a bunch of things to do.”

Despite the aeromedical certification process’ sometimes forbidding image, Jordan stressed that the overall philosophy is to say “yes” to pilots’ applications as often as it can. “Out of 100 applications, we routinely approve 95. Of the 5 percent that encounter problems, the appeals and review process results in most of those being okayed. Advances in surgery and medication let us do that. We can’t always give them the class of medical certificate they want, and yes, that can end a career. But we don’t want to do that. We say ‘yes’ far more often than we say ‘no.’”
All that works out to roughly 1,800 refused applications a year out of 450,000. Of those disapproved, by far the biggest cause is related to some sort of heart disease.

Drugs and Alcohol
When it was started a decade ago, the FAA’s DUI-DWI (driving under the influence/driving while intoxicated) investigations program drew howls of protest from pilots. Many asked: “How dare the FAA link data from the National Driver Registry (NDR), the database of all motor vehicle violations in the U.S., to the aeromedical certificate renewal and issuance process.”

The Department of Transportation’s Inspector General’s office stood firm against this opposition, pointing to an audit it had conducted of pilots who had records for drug- or alcohol-related motor vehicle violations. What the IG was looking for was whether those pilots had reported those violations on their medical certification applications, as required by law. When the IG announced a general amnesty, giving those pilots who had falsified their data a chance to avoid enforcement action if they fessed up by a given date, the result astonished even the suspicious types in the IG’s office.

Thousands of pilots admitted to violating the regulations. The old “honor system” of voluntary admission had obviously broken down and the DOT directed the FAA to get tough. The FAA did this by sending the name of every medical certification applicant (some 400,000 a year) to the NDR.

In the last 10 years, more than four million submissions of pilot names have been made to the National Driver Registry. The names of 100,000 pilots–mostly flying general aviation aircraft–have appeared on the register with drug- or alcohol-related motor vehicle violations. These pilots were subsequently investigated by the FAA and more than 8,300 enforcement actions meted out. So far some 3,000 pilots have lost their medical and airman certificates as a result of these investigations, nearly one third of all revocations issued by the FAA.

The word is evidently out that faking it doesn’t work. According to Mark Sweeney, manager of the FAA’s compliance and enforcement branch of the civil aviation security division, the number of violations has decreased in the last three years an average of 15 percent per year. “The number of enforcement actions we’ve been forced to take over the past three years has decreased from 1,286 in 1998, to 958 in 1999 and 877 in 2000,” Sweeney reported. “At the same time, the number of compliance letters, sent in by pilots reporting violations has gone up, with 952 coming in 1998, a total of 1,264 in 1999 and 1,330 last year. And I can tell you that the total for this year will be even higher than those for last year.”

Jordan sees no hope of discontinuing anytime soon the regular random drug and alcohol screening the FAA conducts. “As the regulations stand, and they’re regulations mandated by law, laws passed by Congress that a regulatory agency such as the FAA cannot change on its own, 10 percent of the safety-related employees of Part 121 and 135 operators have to be regularly but randomly tested for drug use and alcohol influence. In terms of pre-employment, all new hires have to be tested. And there’s nothing in the works to change that.”

But given the relatively low number of positive tests, isn’t the whole program, variously estimated to cost employers close to $500 million a year, an experiment in overkill? “I’ll admit that the number of positives is very low,” conceded Jordan. “Something on the order of less than one percent of those tested show up positive and virtually all of those are pre-employment tests.”

Breathe Easy
From both statistical and anecdotal data, it seems clear that the general public and aviation professionals in particular are healthier than ever before. Just how much healthier is an area that could stand much more research, but research costs money and that isn’t something aeromedical researchers have much of nowadays.
Suffice it to say that every middle-aged person you see going for a run in the park or an after-work ride on the bike is a vote for a healthier lifestyle and an indication that, as a people, we are taking better care of ourselves than ever before. Judging by the small number of disapproved medicals, it seems safe to conclude that aviators are healthier than ever and seem committed to staying that way.