EILIF DAHL

A.9.1 Passenger Health

Passenger or seafarer?

The Maritime Labour Convention of 2006 (MLC) [1] states that seafarers are entitled to the same quality of care as workers ashore. It defines a seafarer as any person who is employed or engaged or works in any capacity on board a ship. Any other person on board is to be considered a passenger. Of interest, after the advent of cruise ships, cruise companies have widely replaced the term ‘passenger’ with ‘guest’. The status of scientists, technicians, security contractors and embarked maintenance staff (riding crew) is not always clear, but those who have been assigned a crew number and duties to perform during crew emergency drills and actions, are seafarers.

The International Maritime Organization (IMO) states that a passenger ship is a seagoing vessel carrying more than 12 passengers and if on international voyages it must comply with the International Convention for the Safety of Life at Sea (SOLAS) [2], a maritime safety treaty for shipping nations.

The category includes yachts, ferries, ocean liners, and cruise ships. The category may also include cargo ships with adequate facilities to carry a substantial number of passengers and that act as freighter cruises. Passenger ships have also been commissioned as navy ships on numerous occasions to meet the requirements of naval forces.

A.9.2 Passenger and seafarer health

Passenger Health Expectations

Passenger health is closely connected to the health of the seafarers on the same vessel. Passengers are treated by the same medical staff and with the same equipment available for the seafarers on board according to IMO and flag State rules and regulations.

Crew as Health Providers for Passengers

The International Convention on Standards of Training, Certification and Watch keeping for Seafarers (STCW) of 1978  [3] paved the way for greatly enhanced seafarer standards as well as giving IMO itself powers to check Parties' compliance with the Convention. The STCW Convention, as amended since 1995, includes specific training requirements for crew on passenger ships, such as training in crowd management for use in an emergency evacuation.

In addition, as part of their basic training, maritime officers must have completed courses to ensure their handling of medical emergency conditions on board at a reasonable level of competence. Ships that do not carry a medical doctor are required to have either at least one seafarer on board who is in charge of medical care and administering medicine as part of their regular duties, the officer responsible for medical care, or at least one seafarer on board competent to provide medical first aid. The officer responsible for medical care has the option of getting help from tele-medical medical assistance services (TMAS), that provide medical, including specialist, advice by radio or satellite communication from ashore, available 24 hours a day free of charge to all ships irrespective of the flag that they fly. However, regardless of the advice given, the ship´s master is ultimately responsible for the health issues of all persons aboard. Further information on the training of seafarers is available in Ch 4.3 and 5.3. 

Passenger Pre-Sea Medical Examination?

All seafarers are of working age and every two years, they must undergo a medical examination to confirm they are fit to work at sea. Passengers may well be from a wider age range and have pre-existing medical conditions not seen in seafarers. Passengers with pre-existing conditions should seek medical advice regarding their fitness to travel, well before their planned travel dates. The evaluating doctor should be aware of any planned activities, the ship´s itinerary, the limited medical care available on board and evacuation options before advising. Discussion with the company’s medical department, if available, is to be advised.

Ships with and without a medical doctor on board

Traditionally, a ship on international voyages with more than 12 passengers had to have a physician aboard. However, MLC states that all ships carrying 100 persons or more and ordinarily engaged on international voyages of more than 3 days’ duration must carry a qualified medical doctor [1]. It does not mention other medical professionals, such as nurses or paramedics.

It follows that ships with less than 100 persons on board even on long international voyages, for example, private yachts, smaller expedition ships and most merchant vessels, do not have to carry a doctor. Domestic coastal vessels, as well as large international ferries with hundreds of persons aboard but with ports of call less than 3 days apart, can sail without a doctor. However many companies do choose to put a doctor or other health care professional on board vessels depending on the risk assessment.

Tele-medical medical assistance services (TMAS) for Passengers

On ships without a physician, the officer responsible for medical care on board is advised to contact TMAS early if medical situations arise. Follow-up should be frequent, especially when the patient is very young, of more advanced years and/or has pre-existing conditions. Ship’s doctors may find it useful to use local TMAS when considering where to disembark a passenger or seafarer, especially if there is the need for an emergency medical disembarkation.

A.9.3 Types of passenger ships

Luxury Yachts

Most luxury yachts are privately owned and carry the owner´s family members, friends and other guests of all age groups as passengers. Many yachts are so small that they are not subjected to international maritime regulations regarding seafarer health, but usually have superior communication equipment as well as the means for quick evacuations, such as speedboats and even helicopters on board. Although the owner occasionally commands them, they all have maritime professionals on board such as former cruise ship captains. These seafarers are experienced in handling emergencies and can communicate well with TMAS, coast guard organisations and port authorities around the world.

Individuals or groups of travellers can also charter fully crewed yachts. Regardless, yacht passengers and crew will be treated similarly when it comes to the management of medical issues on board.

The medical equipment on board is at the owner´s discretion, and even the smaller yachts may carry medication and medical emergency equipment in excess of that found on many cruise vessels with medical professionals well trained to use it. The owner´s personal physician(s) may be among the guests or part of the crew.

Further information on the yachting sector and medical issues that can arise is available in Ch 3.2.3.

Expedition Ships

Expedition ships include research vessels and ships on adventure or pleasure voyages that often visit remote areas with inherently risky activities ashore. 

Arrangements are required to assess and minimise the risks to passengers both on board and ashore. Such arrangements may include the medical screening of passengers before boarding and risk management for high-risk activities. The passengers must be made aware in advance that evacuation or diversion to land for the care of seriously ill or injured patients can be complex and costly and may take days, if it is possible at all.

Without breaching international regulations, expedition ships with less than 100 persons on board can operate worldwide without carrying a doctor. Research vessels may have medical doctors as part of the research teams on board, but on ships without one, the officer responsible for medical care must handle all medical emergencies among passengers and crew.

In practice, even smaller adventure expedition ships usually carry a physician or other health care professional. However medical care and equipment may be limited and one doctor without further medical assistance may be easily overwhelmed and exhausted, for example if 24-hour monitoring of a patient is necessary for many days. Therefore, at the beginning of the voyage, the ship´s doctor should ensure that selected crewmembers are familiar with the location and set-up of all available medical equipment on board so that the necessary equipment can be brought promptly to any emergency. He should also motivate and prepare the crew to assist during procedures ranging from cardiopulmonary resuscitation to the routine nursing of bedridden patients. It is also recommended that, at an early stage, he finds out what kind of medical expertise is available among the passengers on board, and to what extent they may be willing to assist during emergencies. 

Whenever emergencies occur in remote areas, regardless of the medical expertise aboard, early contact with shore side medical staff or TMAS is beneficial to explore options for medical treatment on board and any evacuation possibilities to local ports or nearby ships with adequate medical facilities.

Ferries

Ferries are vessels for day-to-day or overnight short-sea trips moving passengers and road and/or rail vehicles. They usually sail in coastal waters and for short periods, but many carry large numbers of people of all ages between countries. The passenger:crew ratio is higher on ferries than on cruise ships, see below, because many of the hotel functions, such as housekeeping, can be done daily by land-based workers in port during turn-around.

As long as their international voyages last less than 3 days, ferries do not have to carry a doctor aboard, and only have to carry the medical remedies and equipment that are required for regular merchant ships of the flag State. Crew may be asked to assist with illness and injuries in children, old people and those who have an exacerbation of a long-term illness or disabilities. However, standard ship’s medical stores and the training of seafarers  do not meet the requirements for care in these groups. The ship´s Master may decide to call for any health professionals among the passengers to help, brief them on the practicalities of care on board and then formally ask them to assist. This will simplify the position of the health professional if the quality of care is questioned later.

If no professional help is available, the officer responsible for medical care will need to manage the situation as best he can. The basic recommendations are to make early contact with TMAS and give no medication to children without their advice. As most ferries will be within helicopter range of shore and will reach their destination within a few hours, the preferred option is usually for the initial stabilisation of any serious health condition or injury and early referral for care ashore. However, as ferries usually repeat their itinerary daily, they establish good communications and understanding with frequently used TMAS and evacuation services and they tend to have a far lower threshold for arranging helicopter evacuations than regular cruise ships [4].

To improve service beyond the regulations, some ferries on the longer passages carry a qualified nurse or paramedic who is provided with appropriate stores, e.g. a ‘doctor’s bag’ containing medicines and equipment for the stabilisation of casualties on board. There may also be Automated External Defibrillators (AEDs) prominently displayed in several public areas, for prompt use by confident passengers and crew in case of suspected cardiac arrest.

Ocean Liners

An ocean liner is the traditional form of passenger ship and is typically a passenger or passenger-cargo vessel transporting passengers and often cargo on longer line voyages. Once such liners operated on scheduled line voyages to all inhabited parts of the world. With the advent of air travel for passengers and specialized cargo vessels for hauling freight, line voyages have almost ceased. Nevertheless, with their decline came an increase in sea trips for pleasure and fun, and in the second part of the 20th century ocean liners gave way to cruise ships as the predominant form of large passenger ship.

The ocean liners carried large numbers of passengers for days to weeks all year around, often in rough weather lasting several days. Serious medical conditions and severe injuries were not uncommon. Fracture reduction, wound repair and types of abdominal surgery, such as an appendectomy, were procedures done on board. The doctors had extensive surgical experience, and were often known as ship´s surgeons, and they had well-trained nurse assistants. Although there were mostly separate medical facilities for passengers and crew, and the crew doctor was usually the younger colleague, the same treatment was, on principle, available for all.

Cruise Ships

Cruise ships often transport passengers on round-trips, in which the trip itself and the attractions of the ship and ports visited are the principal attraction. Cruises may last from a few days to many months, around the world, and may carry from a few hundred to more than 8000 persons, more than 6000 passengers and more than 2000 crew, with a passenger:crew ratio of 1.5-3:1. On some ships, most passengers will be of the same nationality, on others many nations are represented, with subsequent difficulties in understanding language and customs.  Crew come from over 100 different countries, although all are expected to understand the ship’s operating language, usually English, for safety reasons. 

As required by MLC [1], all regular cruise ships have at least one qualified medical doctor aboard. However, the term ‘medical doctor’ is not defined, and no qualifications are specified. Most cruise ships also carry one or more nurses, some have paramedics too, and there may be a medical secretary assigned to the medical facility. But none of these professions are mentioned in MLC or other international regulations, and passenger health is not addressed.

The Development of Pleasure Cruising

In the mid 1960s more passengers crossed the Atlantic by airplane than by ocean liners, making the liners economically unviable. Transforming ocean liners to full-time cruise ships proved successful and smaller cruise ships were built, specifically for short, 3-14 days, cruises in the Caribbean. From the late 1980s successive classes of ever-larger ships have been ordered, turning cruising into mass tourism. While ocean liners valued speed and traditional luxury, cruise ships value amenities such as swimming pools, theaters, ball rooms, casinos, sports facilities, etc., rather than speed. In addition, ocean liners were typically built to cross the Atlantic Ocean between Europe and the United States or travel even further to South America or Asia while cruise ships typically serve shorter routes with more stops along the coastlines or in various islands. These priorities produce different designs, also regarding medical facilities. Many cruise companies have not prioritized surgical and ward facilities, even though many of their vessels now cruise worldwide and may, on relocation voyages, spend weeks at a time without visiting ports with modern hospitals. On the other hand the cruise industry is maybe the only area of the maritime industry where medical professionals maybe involved in the design of the ship.

In 2019, there were more than 300 cruise ships globally [5]. They were of all sizes, including 5 megaships of more than 220,000 gross tonnage, carrying more than 8,000 persons aboard. Whilst in 1990 less than 4 million passengers went on cruises, 30 million passengers were expected to cruise in 2019. About 14 million passengers come from North America, 7 million from Europe, 6 million from Asia Pacific, and 2 million from South America. Popular destinations included the Caribbean, 34% of passengers, followed by the Mediterranean, 17%, and other European ports, 11% [5].

References

1. International Labour Organisation. Maritime Labour Convention 2006

https://www.ilo.org/global/standards/maritime-labour-convention/text/WCMS_763684/lang--en/index.htm (Accessed 21 June 2021)

2. International Maritime Organization. International Convention for the Safety of Life at Sea (SOLAS), 1974. https://www.imo.org/en/About/Conventions/Pages/International-Convention-for-the-Safety-of-Life-at-Sea-(SOLAS),-1974.aspx (Accessed 27 June 2021)

3. International Maritime Organization. International Convention on Standards of Training, Certification and Watchkeeping for Seafarers (STCW). https://www.imo.org/en/OurWork/HumanElement/Pages/STCW-Conv-LINK.aspx (Accessed 27 June 2021)

4. Holt T-E, Tveten A, Dahl E. Medical emergencies on large passenger ships without doctors: the Oslo-Kiel-Oslo ferry experience. Int Marit Health 2017; 68, 3:153-158

5. Cruise Lines International Association.  https://cruising.org/-/media/research-updates/research/clia-2019-state-of-the-industry-presentation-(1).ashx (Accessed 26 June 2021)