Appropriate expertise, applied in an ethical way, is an essential requirement in all areas of maritime health. The chapters of this book indicate the need for such expertise across the wide range of topics that are relevant to the healthcare of those at sea. A range of professional disciplines is needed to provide good maritime healthcare and, to be effective, these have to form an integral part of decision-taking across several broad areas:
1. Development of regulatory frameworks, policies and procedures, internationally, nationally and locally, as well as by organisations such as ship owners and operators, insurers, maritime trade unions, professional bodies and research institutes (Chapters 4 - 6).
Practical experience of the risks present and the ways in which these can be mitigated is needed as well as an understanding of the priorities and socio-economic perspectives of those with whom maritime health experts work is essential.
2. The assessment of risks that result from working and living conditions at sea and advising on how these can be reduced. This may be done within the existing regulations or policies or may be based on assessments on particular ships. Input during design of vessels is also important to avoid building in avoidable risks.
A wide range of skills may be required: engineering, occupational hygiene, toxicology, ergonomics and psychology (Chapters 14-19, 28). A clinical perspective will contribute to the definition of health risks and to the implications of any harm that may arise.
3. Clinical assessment of seafarers. This is performed to assess fitness to work at sea, both in terms of ability to safely perform routine and emergency duties and to reduce the likelihood of foreseeable serious illness arising when distant from medical care (Chapter 7). When illness or injury arises at sea or ashore (Chapter 11) clinical diagnostic and treatment expertise is needed. On passenger ships there are also requirements for providing similar services for passengers (Chapter 9).
Medical doctors are often in the lead, but in large clinics performing seafarer fitness assessments and on large cruise ships nurses, physician’s assistants and medical technicians may also contribute. On non-passenger ships officers with training in first aid and medical care provide immediate support, with assistance from written medical guides and telemedical advisory services (Chapter 8). Specified facilities, medications and medical equipment must be carried and marine pharmacists based in ports know what is required and supply it.
4. Evaluation of risks and the adequacy of control measures. Quality assurance systems and inspection or audit processes play an important part in ensuring that regulatory requirements and good practice criteria are met within organisations such as clinics, ship operators and insurance providers.
Skilled assessors and inspectors are needed to perform these functions in a fair and valid way. More widely academic research contributes to the definition of risks and the determination of appropriate control measures. Skill requirements include the design of observational and experimental studies, epidemiology and statistics (Chapter 34).
The matrix of skills needed is quite complex and there can be a degree of flexibility on skill levels within any risk management system. For instance support by training, guides and telemedical services enables officers to manage health problems that would be handled by health professionals ashore. Similarly the detail with which fitness criteria are specified and the help available to advise on complex or novel problems will determine the skill level and the amount of training required by those clinicians who are performing seafarer fitness medicals.