Why is maritime health an

international issue? Should

medical examinations remain a

national responsibility?

Tim Carter

Norwegian Centre for Maritime Medicine

Bergen

Maritime health – prevention

and care 1. Fitness to work at sea

2. Prevention of risks from disease and injury – at sea, in port, on leave

3. Management of medical incidents at sea

4. Health care ashore – foreign ports, home country

5. Special health care needs of former seafarers.

All have both national and an international components. Their importance depends on trading patterns and structure of the maritime sector.

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A paradox! The shipping industry has been around the globe for several

hundred years. Its health problems have long been international ones.

Ships are extensions of national territory in terms of legal jurisdiction. This model fitted when ships were owned, mainly crewed and registered in a single country. Historically maritime health has been regulated and practiced within national boundaries.

National approaches have long been flawed. Infections have been carried across boundaries by ships, ill and injured seamen have been treated in foreign ports, training in the seafarer’s home country and the medical equipment for handling emergencies on board may be incompatible, unfit crewmembers can endanger the safety of other nations’ ships. Fitness standards are not consistently applied.

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Callao, Peru 1870

Boom town – Guano trade

Fish eating birds nesting on

desert islands.

Dried faeces mined.

Exported to Europe

and North America as a

fertiliser. NCMM

Voyage pattern

Coal – Cardiff, UK to

Aden or Columbo via

Cape of Good Hope.

Ballast - across Pacific

to Callao.

Guano – Callao to Europe

via Cape Horn

Small crews

Long sea passages

No fresh food in Aden

Long port stay in Callao

Away from home port > 1year NCMM

Survey of the condition of British Seamen

– replies from British Consuls worldwide

Dr Thomas Roe

Ex Royal Navy

of British Hospital, Callao

Case series of 606 seamen seen at

hospital 1865-9 reported by consul

251 scurvy – fresh food and juice absent

84 venereal – brothels of Callao

45 accidents – ship and port

40 fevers – malaria from tropics, typhus

from Callao

30 dysentery – most fr. tropical ports

26 rheumatism – living conditions at sea

23 phthisis (TB) – living conditions at sea

10 abscesses

97 other

Infections total 206 – 40% of total

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Lessons from Callao Trades change – guano peaked in late 19C

Health problems in seafarers may relate to job, to living at sea, to risks in ports.

The preventable (scurvy) may be unprevented.

Treatment provided in port, but it needs an ex naval doctor to know that statistics matter.

Who treated non-British seamen in Callao?

Risks and remedies transcended national boundaries even when fleets and crews were national

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Oslo, Bergen, Trondheim

1926 Norway had fast growing merchant fleet

Political concern for seafarers as they were main Norwegian casualties in First World War

Seeking international facilities to care of seafarers, rather than national ones.

Had a model for this in port clinics open to all seafarers- visited during conference.

Conference hosted by Norwegian Red Cross.

Recent ILO seafarers conferences, Brussels agreement- VD treatment

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A changing world 1 [UK Seafarer

Mortality 1925-

2005]

Infection and

respiratory

down by 1955.

- Immunisation

- Precautions

- Antibiotics Circulatory up and slow fall

- Lifestyle and age,

worse prognosis at sea.

- radiomedical not enough

Sources of risk?

Place of illness? NCMM

A changing world 2 Air takes over passenger transport

Containerisation

Flagging out – politics and performance of different flag

states

Crewing from low cost countries vs. home state supply

UN Agencies ILO/IMO/WHO increasing leverage on

international maritime health

BUT flag state and port state authorities are regulators.

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International Maritime Health Ship operators and insurers have economic reasons to maximise

performance and minimise ill-health within a contract period. The may not be concerned about discrimination or welfare in doing so.

Trade unions want fair deals for their members, but not all shipping is unionised and unions are strongest in traditional maritime nations not crewing countries. FoCs may not acknowledge role of unions.

Authorities want political peace, some want economic benefits, a few want better health – avoid big incidents, avoid harm to citizens. Often more concern for own nationals than others.

Health professionals have concepts of good practice and use of evidence, these differ by country. They can arouse suspicion in others, but are needed when health problems arise.

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Medical certificate SWOT Easy transaction seafarer/doctor/employer

Fit for work – meaning of ‘fit’: capable, reliable. All duties or

limited? Limits of prediction. How confidential?

Optional UK 1867 – little used, but employers introduced

their own systems. Seafarers hated them!

State systems 1990s – poor QA, inconsistent. Employers

mistrusted certificates, they and P&I Clubs introduced their

own systems. Equity? Corruption?

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Medical fitness now Employer/P&I medicals continue in crewing countries – often

incompatible with employment law in Europe/ N America.

ILO MLC – provisions consolidated in MLC 2006

IMO STCW Manila amendments. Principles for fitness assessment in more detail. QA requirements

ILO/IMO Guidelines. Detailed recommendations on procedures and on fitness criteria.

Aim is internationally consistent medical certificate based on fair and valid assessment.

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Colour vision – case study in

barriers to consistency. 1860s – red and green navigation lights introduced

1880s – multiple international reports of incidents from failure to identify colours correctly

1880s – early tests for officers introduced.

1900s – invalidity of test methods recognised

1910 onwards – better tests adopted: lanterns to simulate navigation lights, Ishihara plates.

Incidents from colour vision defects no longer seen.

But c 5% of males excluded from deck officer training

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Choice of tests Big variations internationally

Cheap option where failures can be discarded – Ishihara.

Cheap option where failures to be minimised but risk may be increased – colour sorting

Higher cost option when greater validity needed – lantern or Ishihara +lantern if failed

Alternatives: opthalmologist opinion, anomaloscopy

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Where are we now? Each country has its own seafarers tested in the

national way. Any change threatens them and adds

new costs.

Employers may discriminate to save costs.

New screen based tests now available, but not yet fully

validated

NO UP TO DATE ASSESSMENT OF

REQUIREMENTS FOR COLOUR VISION IN

LOOKOUTS

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Where may we go? IMO adopted CIE 143:2001 criteria. Protests from countries who don’t want or

need to change national practices.

Delay in implementing colour vision parts of STCW

Expert workshop in Kobe Jan 2014 to try and resolve. New tests have potential. First the acceptable level of deficiency needs to be found.

Passed back to CIE – international vision and lighting standards body. Action awaited!

Industry will need to fund studies on vision requirements to secure progress.

But the maritime sector is not organised to fund research.

Problems of national vested interests will remain

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Summary Maritime health always has been international.

With national fleets most parts could be based on national jurisdictions.

Now fleets do not respect national boundaries. Greater need for international consistency.

Principles are there for all aspects of health management.

People and interest groups are the barriers to realising the benefits of common international approaches.

Commerce is ahead of governments in global approaches, but is less concerned for interests of seafarers and more concerned with competitive advantage

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All my prejudices can be found in my new book,

out in November 2014!

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