TIM CARTER, SUZANNE STANNARD
The terms maritime health and maritime medicine are often used interchangeably. There are, however, important differences. Maritime health practice can best be considered to include all those investigations and interventions adopted to secure improved health of those at sea. This will include the design of both living and working environments to meet this end as well as management practices aimed at reducing risks and improving health by measures such as secure employment, adequate periods of rest, appropriate food, and exercise.
Maritime medicine is a term normally applied to those aspects of maritime health risk management and medical intervention that are within the skill set of medical and related clinical professions such as nursing and psychology. There is overlap between the two terms and this is well seen when topics such as the recognition, evaluation and control of workplace health risks are considered – here a mix of technical knowledge and an appreciation of the natural history of disease are both essential.
Effective multidisciplinary collaboration is needed to solve all but the simplest and most routine of health issues arising in the maritime setting. The term maritime medicine tends to obscure this and over-emphasize the dominance of the clinical mindset.
A.3.1 Clinical and preventative aspects of maritime medicine
Maritime medicine is practiced in many ways in a variety of settings. These include:
Pre Employment Medical Examination (PEME) Clinics
As stated in the Maritime Labour Convention (MLC) 2006[1], ‘The competent authority shall require that, prior to beginning work on a ship, seafarers hold a valid medical certificate attesting that they are medically fit to perform the duties they are to carry out at sea.’ In addition, ship owners and P&I clubs often require that seafarers also undergo an ‘enhanced PEME in order to work on their ships (see PEME section).
PEMEs are performed by doctors authorized to do so by the flag state, shipping company etc. and training may be required. The doctor may perform PEMEs as his sole scope of practice or may do so in addition to other work such as a primary care physician, occupational health physician. The examination may include input from other professionals employed in a large clinic or may be carried out solely by the doctor.
Occupational health services
Occupational health services for seafarers and fishers vary widely between countries and companies. Services are provided by company doctors, state run programs and by independent providers. Again these services may be solely run by a doctor or may involve input from occupational nurses etc. Some services may also include non-clinical specialists such as occupational hygienists and ergonomists
Health care practioners on board ships
As stated in the MLC 2006, ‘ships carrying 100 or more persons and ordinarily engaged on international voyages of more than three days’ duration shall carry a qualified medical doctor who is responsible for providing medical care; national laws or regulations shall also specify which other ships shall be required to carry a medical doctor, taking into account, inter alia, such factors as the duration, nature and conditions of the voyage and the number of seafarers on board; cruise ships and others as required TMAS services’. Such other ships may include research vessels, expeditionary ships etc.
In addition to any legal requirement, companies may elect to have a health care professional on board it’s ship in other situations. One example is the Color Line ferry from Oslo to Kiel that carries a paramedic on board to assess and manage any medical emergency.
Telemedical Maritime Assistance Services
As stated in the MLC 2006, ‘the competent authority shall ensure by a prearranged system that medical advice by radio or satellite communication to ships at sea, including specialist advice, is available 24 hours a day; medical advice, including the onward transmission of medical messages by radio or satellite communication between a ship and those ashore giving the advice, shall be available free of charge to all ships irrespective of the flag that they fly’. Such a service may be provided by the state or by private companies. Further information is available in Ch xx (TMAS) and Ch xx (competencies).
A.3.2 Non clinical aspects of maritime health practice
Once a ship has been built many of the features and potential risks to health have already been built into it and will remain throughout its life. Specification of important health related aspects such as ventilation, food preparation and the siting of the ship’s hospital as well as the risks from work at heights and entry requirements for confined spaces need to be considered by naval architects, often advised by more specialized engineers and, particularly in relation to the design of safety-critical tasks by ergonomists. Classification societies (cross ref) have a role in this and there is scope for more intensive consideration of health-related aspects of design during their inspections of both ships being built and those for sale in the second-hand market.
New risks may arise during the service life of a ship, for instance from toxic cargoes, new and noisy equipment or wear leading to increased vibration. It may often be possible to predict such risks and to plan preventative measures. Sometimes they will not be anticipated and pose immediate health problems for those aboard. Engineering, occupational hygiene and toxicological expertise will often be essential resolve them.
Patterns of ill-health, poor performance or distress in ship’s crew can be complex, they may be identified by ship managers, seafarer unions or health professionals. To evaluate such observations, aspects such as age, gender and ethnicity have to be considered, while to draw any valid conclusions it is essential to compare the incidence or prevalence of events with those in similar populations with different patterns of exposure (cross reference knowledge base). Such information can be vital to preventing future harm as well as to giving those who may be at risk a true and fair view on their position. Epidemiological and bio-statistical skill are need for these tasks.
It is for those responsible for managing maritime operations to take overall decisions on risk management on board, in general guided by the ISM (International Safety Management) Code (cross ref). To be effective a well-established safety and health corporate culture is needed, not least because there may be conflicts between immediate operational and economic decisions and best practice in terms of health protection. National regulatory authorities will, in some cases, also be pro-active in ensuring that ships are managed to minimize health risks.
A.3.3 Collaboration on maritime health
Many aspects of maritime medical and health practice involve collaboration between the different stake holders within the maritime industry, including maritime health professionals. Examples are in the setting of national and international policies for healthy working and living conditions, decisions on fitness to work at sea and arrangements for responding to medical incidents on board ship. The stake holders involved include
- Ship owners and their representatives
- National governments
- Seafarer’s organisations
- UN agencies, and
- International Maritime Health Association
An example of such an initiative was the development of the ‘Guidelines for Conducting Pre-sea and Periodic Medical Fitness Examinations for Seafarers’ in 1997 that were later superseded by the ‘Guidelines on the medical examination of seafarers’ published in 2013[2]. These Guidelines aimed to harmonise the sometimes inconsistent standards that had previously been developed collaboratively at national level.
The Maritime Labour Convention (MLC) 2006, established minimum working and living standards for all seafarers working on ships flying the flags of ratifying countries. The Convention is comprehensive and sets out, in one place, seafarers' rights to decent working conditions. It was the result of several years of international collaboration that included input from maritime health professionals, and it is the main international instrument that aims to secure good maritime health practice for the benefit of seafarers working in maritime transport. A parallel convention covers the fishing sector. (cross reference)
The most recent example of such collaboration is the shipping industry’s response to the COVID-19 pandemic. As a result of a series of initiatives, guidance and information has been produced to provide information to both seafarers and ship owners on best practice. These include[3]:
- Guidance for Ship Operators for the Protection of the Health of Seafarers
- Vaccination for Seafarers and Shipping Companies: A Practical Guid
A.3.4 Education and research opportunities
Education for health professionals in the field of maritime medicine and research to support changes in practice within the industry are essential to ensure best practice. Further information can be found in Ch xxx. Organisations contributing to education and research include:
- International Maritime Health[4]
- International Maritime Health Foundation[5]
- University of Cadiz[6]
- NIVA[7]
- World Maritime University[8]
[1] https://www.ilo.org/global/standards/maritime-labour-convention/text/WCMS_763684/lang--en/index.htm. Accessed November 14th 2021.
[2] https://www.ilo.org/sector/Resources/codes-of-practice-and-guidelines/WCMS_174794/lang--en/index.htm. Accessed November 14th, 2021
[3] https://www.ics-shipping.org/supporting-shipping/covid/. Accessed November 14th 2021