As seafaring is a global business the Agencies of the United Nations and even before them the International Labour Office (ILO) of the League of Nations have played an active part in the arrangements for seafarer fitness. The requirement for seafarers to have a certificate of medical fitness is stipulated on both ILO and International Maritime Organisation (IMO) conventions. The rationale for the ILO has always been to ensure good conditions of work, with particular attention to minimising the risks of seafarers becoming ill while distant from medical care and also preventing them going to sea with conditions that might create a risk for others. These requirements are expressed in general terms on conventions – most recently in the Maritime Labour Convention of 2006 (12) The IMO has focused on the requirement for those who undertake watch keeping duties to be fit to do so. These requirements have been codified in the 2012 amendments to the Convention on Standards for Training, Certification and Watchkeeping (13). The WHO, apart from its continuing interest in preventing the spread of infectious disease by land, air and sea transport, collaborated with ILO to produce the 1997 Guidelines for Conducting Pre-sea and Periodic Medical Fitness examinations(14) These give more detail on appropriate examination procedures, on appeal mechanisms and on vision and hearing requirements. They also include a list of medical conditions to be ’taken into consideration’ but do not contain any detailed standards or criteria. Work to review these and to bring them into line with the Maritime Labour Convention and with revisions to the IMO Standards for Training and Watchkeeping Convention due out in 2012 has now been completed and is awaiting approval by ILO and IMO (15).
These international conventions are addressed to the competent authorities (normally the maritime regulatory body or, sometimes for medical fitness standards, the health ministry) in the countries that ratify the conventions, and each country then produces its own regulations that have to meet the minimum standards in the conventions, but can be more demanding if this is the country’s wish. Most of the major maritime countries have medical fitness standards that cover broadly the same range of conditions, but they differ in the line that is drawn between who is fit and who is either restricted to a limited range of jobs or is unfit. These differences, as well as perceived variations in the quality of assessments done and the supervision of those assessments by the maritime authority mean that, while the principle of the ILO and IMO conventions is mutual recognition of certificates by all those countries that have ratified, in practice many countries only accept their own certificates or those from a limited number of other states in whom they have confidence. This creates barriers to the free movement of seafarers as well as creating opportunities for seafarers who have failed their medical in one country to try again elsewhere where there is a more lenient approach to their condition. One of the aims of current moves to revise the ILO/WHO 1997 Guidelines and to have IMO involved in the process is to achieve greater mutual recognition of certificates. This is in addition to the primary aim of having criteria in place that are as far as possible evidence based and which can be readily and fairly applied.
Regional groupings such as the European Union and the European Economic Area currently have little detailed involvement in the criteria for the fitness assessment of seagoing seafarers and there are considerable variations in the arrangements for examination between different member countries. There is a requirement for free movement of labour and of the professions between states of the EU and this has recently led to legal judgements that make mutual recognition of seafarer certificates, including those for fitness, mandatory. There is now pressure to ensure greater conformity in fitness examination arrangements to ensure that all EU seafarers are assessed against common criteria. Seafarer fitness assessment arrangements have also been used to implement other aspects of the EU social agenda, such as requirements for medical surveillance of those doing ‘night work’. International inland waterways such as the Rhine/Danube system have had common medical fitness requirements in place for many years.
National statutory systems
Most maritime states have national medical fitness standards in place, although some smaller countries and the large open registries take a free ride on the back of the systems of larger countries with similar legal traditions. The relevant authority, usually either the transport/maritime administration (UK, Norway, Canada etc), the health ministry (Philippines) or the seafarers social security fund (Germany, Spain), specifies the arrangements for the conduct of medicals, approves those who are empowered to do them and may audit their performance, publishes standards applicable to the commoner medical conditions. They also make arrangements for the provision of certificates in an approved form plus other guidance and procedural documentation, including arrangements for seafarers to appeal if they wish to challenge the fitness decision made (16)
The arrangements differ in detail between countries. The commonest approach is based on using a network of approved medical examiners who should have an understanding of the job requirements of seafarer and who issue a fitness certificate at the end of the medical. These doctors may be full time maritime physicians either employed by the authority or by maritime employers or they may be independent practitioners who either work full or part time in maritime health. A few countries allow any doctor to do the medical (Singapore, Greece, USA), but some of these then centralise the issue of certificates based on a review of the reported findings. Sometime they do not issue a certificate but make medical fitness a condition for issuing a Certificate of Competence to work as a specified grade of seafarer (USA). In reality any of these national frameworks for medical examination can work well if they are well led by the competent authority and regular audit takes place, but all can fail if there is indifference to the quality of processes or if limitations on formal payments open the way to corrupt practices. Where a limited list of examiners is used, they will understand the job requirements, but may have to rely on the seafarer’s version of their medical history, whereas when the seafarer’s usual doctor performs the assessment, they are likely to be ignorant about seafaring, but should have full access to the person’s medical history.
Employer and insurer systems
While every seafarer is required to have a certificate of fitness issued in a format and in a way approved by a national maritime authority, there are situations where employers and their insurers (including P and I Clubs) have additional company requirements. This is limited by law in some countries and rarely done where employers have confidence in the national statutory scheme, but is common practice in some of the larger crewing countries where there is less confidence both in the national arrangements and in the likelihood that seafarers will disclose any damaging aspects of their medical history.
Where the additional content of such medicals has been developed in a rational way, there can be benefits for the employer in terms of risk reduction and fewer seafarers having to be treated at the employer’s expense during their time at sea. However, it is very easy to do a battery of clinical tests and simply reject those who have any abnormalities. Within such a system, particularly in a low-wage crewing country, it is almost impossible for a seafarer to challenge such a decision, even if it is based on invalidated or even unethical assessment methods. Examples being HIV and hepatitis B testing in cruise ship crew members not because of personal risk but because of company liability in the event of any passenger claiming that they were infected through having sex with a crew member. A less extreme but (also) common example is the use of audiometry not to protect the seafarer from noise induced hearing loss, but to avoid liability for any hearing damage claim at a later date.