According to a recent report from the American Diabetes Association, more than 18.2 million people in the United States suffer from some sort of medical condition that can be diagnosed as diabetes. The same report estimates that 5.2 million of those Americans aren't even aware they have the disease — that's one in three.

The statistical prognosis is staggering. The Centers for Disease Control and Prevention estimate that for children born in 2000:

• 32.8% of boys and 36.5% of girls will develop diabetes during their lifetime.
• 40.2% of boys and 49% of girls who are non-Hispanic black will develop diabetes.
• 45.4% of boys and 52.5% of girls who are Hispanic will develop diabetes.

According to the American Diabetes Association, if diagnosed at age 40, men will lose 11.6 years of life and 18.6 years of quality life and women will lose 14.3 years of life and 22 years of quality living as a result of the disease.

What's more alarming is that cases of reported diabetes rose 40% in the 1990s. By 2050, unless there is a reversal of current trends, experts predict an increase of more than 160%. With these troubling statistics, if your fire department hasn't faced hiring someone with diabetes or dealing with a current employee who has acquired the disease already, it's only a matter of time.

Physiology of diabetes

Diabetes is a disease in which the body no longer produces the hormone insulin or produces it in such a reduced quantity that it no longer meets the needs of the body. Insulin is used by the body to break down sugar, starches and other food into energy (glucose) needed for daily living functions. The result of the body being unable to break down these sugars is a buildup of glucose in the bloodstream. This causes the blood to thicken and gives it the affinity to stick and clog along the walls of the circulatory system. Both genetic and environmental factors, such as obesity, are believed to contribute to diabetes. However, what exactly causes the pancreas to slow down or stop the production of insulin is a mystery.

There are three major forms of diabetes:

Type I diabetes is sometimes referred to as juvenile diabetes because the onset usually occurs during childhood or adolescence. Type I diabetes, considered an auto-immune disease, is where the pancreas no longer produces insulin. Individuals with Type I diabetes are insulin-dependent and require routine injections to facilitate the use of glucose in their system and keep their blood sugar within a normal range.

Type II diabetes is the most common form of diabetes and is responsible for 90-95% of the reported cases. Type II diabetes results from the body becoming resistant to insulin that is being produced or simply not producing enough insulin. For most individuals with Type II diabetes, oral medication and a controlled diet and exercise can keep the condition under control.

Gestational diabetes is brought on by pregnancy and usually ends with the delivery. For someone with gestational diabetes, the body's reaction will be similar to a Type I or II condition. This only affects about 4% of all pregnant women.

The results and the reaction of the body's inability to use sugar because of diabetes can be slow and gradual or rapid and dramatic. Over a long period of time, excessively high blood sugar, or hyperglycemia, can lead to poor eyesight and even blindness, renal failure, nerve damage, and various cardiac and circulatory disorders.

Low blood sugar, or hypoglycemia, can be a result of excessive insulin or not enough sugar in the body. This is a rapidly developing condition and can become a life-threatening acute emergency if left untreated. These individuals at first can experience disorientation, lack of coordination and poor decision-making, and in worst cases, unresponsiveness, seizure and even death.

NFPA standards

Considering all of the protective clauses and libraries of laws and policies that now govern equal employment opportunity and discrimination in the workplace, the debate over whether someone with diabetes, specifically Type I insulin-dependent diabetes, can be a firefighter is still unclear. The first and last question that should be asked in this debate is whether or not the person can perform essential job functions. Anything more gives the appearance of being discriminatory.

For its part, the National Fire Protection Association has established medical requirements for firefighters and firefighter candidates in NFPA 1582, Comprehensive Medical Program for Fire Departments, which was revised in 2003. In NFPA 1582 are the minimum medical requirements for candidates and information on essential job functions that can assist a department physician when making a decision to support a recommendation to hire or not hire a candidate. The main question here is if the candidate can perform the required duties of a firefighter and maintain a reduced risk of occupational injury or illness associated with his or her condition.

In the medical evaluations portion of NFPA 1582, which includes a candidate's history, examination and lab results, if a candidate presents a pre-existing medical condition like diabetes, he or she falls under the “Medical Condition Affecting Ability to Safely Perform Essential Job Tasks” section of the standard. In this section are all medical-related conditions that can potentially affect an individual's ability to safely perform the essential job tasks of a firefighter.

Each condition has an A and B designation. The A group represents individuals whom, by their medical condition's definition, the standard won't certify as meeting the minimum medical standards of a firefighter. The B group represents individuals who can be certified under the condition that “they can perform the essential job tasks without posing a significant safety and health risk to themselves, members, or civilians.”

The section covering diabetes is 6.18 of the standard: Endocrine and Metabolic Disorders. The A group list includes diabetes mellitus treated with insulin (Type I) and any endocrine condition that doesn't allow a person to safely perform the job function. The standard's B group list includes diabetes mellitus that is controlled by oral medication, exercise and diet — essentially Type II diabetes.

Pros and cons

Insulin-dependent diabetic proponents, including the American Diabetes Association, argue that individuals with the disease can function in a normal manner in almost any job setting, even that of a firefighter. Their assertion is that when realistically reviewing the tasks associated with the job of a firefighter, disciplined Type I diabetics can manage the schedule of their insulin injections to be expandable within certain time parameters. Additionally, this flexibility allows their food intake schedule to be flexible as well. And food intake and insulin injections are the biggest obstacles facing a diabetic firefighter or firefighter candidate.

But there are concerns over what happens if an insulin-dependent diabetic who is working as a firefighter gives him- or herself an insulin injection just before the alarm sounds, and those concerns are well - founded. Because injections often are given just prior to eating, diabetic's blood-sugar levels generally are low at this instance because of the elapsed time since last eating. If the insulin is not counteracted with food within a short time, blood sugar will quickly drop, resulting in hypoglycemia. Does the firefighter miss the run and stay behind to eat or try and overcome the potential problem by consuming a nutritional bar or some other sort of high-carbohydrate snack on the way to the call?

Opponents of diabetics in the fire service are most worried about an episode while driving to or from an emergency scene. Other concerns include the firefighter's ability to rescue him- or herself and/or others in the event of an episode during fireground operations, and decision-making in life-and-death situations. Will any of this actually occur? There is no exact way of telling. With so many variables related to hypo- and hyperglycemia, including each diabetic's metabolism and physical wellness, there is no one answer.

It's this uncertainty that leads most public safety organizations to have policies that are painted with a very broad brush and designed to be all-inclusive of disqualifying insulin-dependent diabetics. But is it fair to judge all Type I diabetics and their ability to perform based on the worst-case scenario of what might happen?

Technological advances

Recently there have been major advancements in the way insulin-dependent diabetics can receive their required daily medication. These advancements are touted by their manufactures and diabetic support organizations as offering Type I diabetics the ability to function in a normal capacity without having to worry about a spike or rapid drop in blood sugar or having to administer daily injections. The most heralded of these new breakthroughs is the insulin pump.

With the advent of the insulin pump, some experts will argue that the safety concerns for an organization employing or considering employing a Type I diabetic are debatable. This new technology allows Type I diabetics the independence and freedom of not having to administer insulin through shots but instead places the drug into a small, pager-sized container that provides a continuous flow of insulin to the body. The pump is battery-powered and operates through a computer chip, allowing the user to control exactly how much insulin the pump delivers.

Insulin pumps are designed to deliver insulin for a 24-hour period and are preprogrammed according to individual needs. The pump keeps an individual's insulin level in the desired range between meals and overnight through a cannula inserted just under the skin. The use of the pump along with frequent blood-sugar monitoring has been shown to be extremely effective in maintaining blood-sugar levels, even in adverse conditions.

Diabetic firefighter/EMT Brandon Curtis of the East Farmington Volunteer Fire Department, Farmington, Conn., began using the pump in 2000. Curtis has been with the department since 1996 and says that the pump and its ability to maintain a constant and consistent flow of insulin allows him to perform intense exertion for extended periods of time without the worry of his blood glucose getting too low.

Initially there was some concern among diabetic specialists on just how well the an electronic device would hold up under the extreme and adverse conditions in which firefighters work, including intense heat and long hours of physical labor. According to at least one manufacturer, Medtronic Minimed, the pumps have “passed with test flying colors.” They even offer several firefighter testimonials on their Web site www.minimed.com.

Curtis, who wears his insulin pump on his calf underneath his bunker gear at fire scenes, says he has never experienced an episode where the pump presented a problem related to his firefighting duties. “My confidence in responding to a scene and not having to worry about my diabetes getting in the way has greatly increased since the pump,” says Curtis. He also says that he has much more control over his sugar levels now that he can handle the extreme swings in activity levels that firefighting often presents.

Legal considerations

Just where does the fire service stand when considering the issue of employing insulin-dependent diabetics? Historically, when a department didn't hire a Type I diabetic, the Equal Employment Opportunity Commission sided with the organization. However, recent court cases and the new technology of the insulin pump are forcing some, even in government, to reconsider this position.

The American with Disabilities Act is a civil rights law that was created in 1990 and designed to protect individuals with disabilities from job discrimination. The law bans discrimination against otherwise qualified individuals in application procedures, hiring, firing, promotions, pay and training.

The ADA defines disability in three ways: if you have a physical or mental impairment that greatly limits one or more major life activity; if you once had such an impairment; and/or if others regard you of having such an impairment. If an insulin-dependent diabetic's condition never has been disabling and an employer discriminates against him or her, then he or she would fall into the last of the three definitions and be entitled to protection under the act.

In the reasonable-accommodation segment of the ADA, it stipulates the employer can't discriminate against people if they are qualified for the job and they can do the essential functions with or without reasonable accommodation. In the case of most insulin-dependent diabetics, this reasonable accommodation would be allowing them to inject themselves or wear an insulin pump, which would allow them to perform the essential job functions.

Diabetics are not required by law to disclose their condition to a prospective employer. If a medical physical is a condition of employment, attending physicians must make their recommendations objectively based on their medical findings and render their opinions about performing the essential job functions of the occupation thereto. However, it's important to note that the ADA will protect from discrimination only individuals who have disclosed their condition to their employer.

In 2002 the U.S. Court of Appeals held in Kapche v. City of San Antonio, 176 F.3d 840 (5th Cir. 1999), that “an individualized assessment of [the] present ability to safely perform the essential functions of an SAPD police officer is required.” Jeff Kapche applied and was disqualified for employment with the San Antonio Police Department in 1994 based only on the fact that he was an insulin-dependent diabetic. The physician cited that driving was an essential job function and that drivers who use insulin were considered to be a safety risk. For the record, studies have shown that as a whole, people using insulin are no more likely to have an accident than anyone else in the general population.

Kapche held San Antonio used the broad-brush approach and classified all diabetics in one category, regardless of their medical history and ability to properly perform the essential job functions of the position. The physician was not a diabetes specialist, and no one assessed Kapche's ability to perform the job functions. The city simply ruled that because Kapche was an insulin-dependent diabetic, he was disqualified.

The Kapche ruling was seen as a victory for diabetes advocates because it stuck down and essentially trumped the last court-sanctioned blanket ban on diabetics in the workplace in this country: Chandler v. City of Dallas, 2 F.3d 1385 (5th Cir. 1993). In that ruling, the Fifth Circuit Court of Appeals said that the rights of the plaintiff, Lyle Chandler, had not been violated when he was demoted from a position that required driving because he was an insulin-dependent diabetic.

Diabetes is a medical condition that affects millions of Americans. Because most fire departments, acting in their role as EMS provider, have exposed firefighters to patients with diabetes, there may be an unconscious discrimination based on this limited exposure. Additional information is available to educate firefighters of the positive and productive role that diabetics play in society, and the fact is that most diabetics are able to function day-in and day-out like everyone else.

The fire service is not alone in facing this tough issue, but it has the opportunity to demonstrate true leadership by reviewing all available information and opinions and gain a clear understanding about diabetes. This knowledge, coupled with the extraordinary technological advances in controlling diabetes, should allow the fire service to make an educated and fact-based decision when considering a candidate with diabetes. At the very least, fire departments should grant diabetic applicants an audience and the opportunity to succeed on their own merits, and not base their employment decision on an all-inclusive, subjective and possibly discriminatory point of view.

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Brian A. Crawford is an assistant chief within the administrative division of the Shreveport (La.) Fire Department and currently serves as the assistant to the fire chief. Crawford is a National Fire Academy resident instructor in the Management Science's Division and is currently a third-year participant in the academy's Executive Fire Officer Program. He serves on the IAFC Human Relations Committee. Crawford holds an associate paramedic degree, a bachelor of science in organizational management and a master of arts degree in industrial/organizational psychology from Louisiana Tech University.

For More Info

To learn more about diabetes visit :

The American Diabetes Association www.diabetes.org

National Diabetes Information Clearinghouse www.diabetes.niddk.nih.gov

Center for Disease Control www.cdc.gov/diabetes