The NCMM Sea Health Conference 2011 – MLC 2006

1. International bodies and the development
of regulations: challenges and results.
Case study of medical fitness criteria
Tim Carter
Norwegian Centre for Maritime Medicine
UK Maritime and Coastguard Agency
International Maritime Health Association

2. Perspectives (maritime health)
 Procedures and protocols of International
Agencies (ILO, IMO,WHO)
 Governments (maritime – national and open register,
health, social security)
 Employers, agents, insurers etc.(HR, crewing,
design, supply , P and I)
 Seafarers, trade unions etc.(working conditions,
equity, members benefits, claims)
 Subject experts (risks, remedies – evidence,
effectiveness)
 Professional bodies (good practice – jobs,
income, status)

3. Drivers for international
action
 Move from national to global crewing,
management, sourcing (fitness, repatriation)
 Move from integrated owners/employers to
contract management (less recruitment for
defined careers, QA needs)
 Inequities in risk and working conditions
(‘good and bad’ flags)
 Inefficiencies in current arrangements
(duplication – certification, costs of poor
decisions)
 Fairer basis for international competition (
less variation in crewing costs, social security needs)

4. Building on the past
 National arrangements – traditional
maritime nations and newer ones.
‘Protected’ and global flags
 Previous ILO, IMO, WHO initiatives
 Attitudes of employers, unions and
governments to health of seafarers
and its regulation
 Place of and trust in health advisers

5. Placing maritime health
 Specifics are a small part of MLC.
Whole convention contributes to it
 Small part of STCW. One element in
safety system
 Small and low priority part of WHO
work now.
 Topic with long and difficult history –
blame and gain.
 Expertise has single profession origin –
‘medical gaze’

6. Baggage!
 Seafarers: inequity. UK strike, ITF Tom Mann.
 Employers: free markets – capital and labour, no
state supervision.
 Unseaworthy seamen: alcohol, VD – UK
 Flag states: merchantilism: old UK, USA. New: India.
 Social security links and national interest – France,
Spain.
 Welfare – state: Nordic countries, E Europe. Missions:
Christian, other faiths.
 Predictive value of health assessment. Medicalised
view of capability
 Faith in certificates

7. Changes – work at sea
Voyage time
Job demands
Communications
Global ownership
And crewing

8. UN Agencies, goals and
constituents
 ILO: tripartite with social partners
dominant. Decent working conditions.
Negotiations
 IMO: flag states and NGOs. Maritime safety.
Power of veto. EU group, open registers,
USCG, newer maritime nations.
 WHO: source of UN health expertise. Not
organised by industry. Infection, nutrition,
care. Health ministries.Expert evidence
based review. Occupational issues low
priority unless profitable: IMGS.

9. UN Agencies -outputs
 Conventions – ratification as basis
for national law. (IMO – regulations
and mandatory A code)
 Recommendations – how to meet
convention requirements (IMO –
non-mandatory B code)
 Guidelines –official but subsidiary
 Technical guidance and handbooks –
non official. Authorities, other users.

10. Maritime health - scope
 Fitness to work at sea – maritime safety,
personal ‘risk’
 Managing medical emergencies at sea
 Onshore care, rehabilitation and repatriation
 Health education and promotion – personal,
environmental
 Safe and healthy working conditions
 Passenger risks
 Infections and spread
At interface of ILO, IMO and WHO

11. IMO approach
 STCW revisions. Sight and hearing
+physical capability (1995 on). General
criteria for fitness added (2012). Reluctance
to accept mandatory capability criteria,
acceptance for vision.
 STCW about issue of certificates –
dominance of these as communication
mechanism
 Did not wish to be involved in 1997
ILO/WHO Guidelines on medical
examinations. Now participating in
revisions.

12. IMO key text
STCW 2012 A-1/9
 Vision (standards)
 Physical capability (recommendations)
 Hearing and speech (recommendations)
 No impairing medical condition
 No medical condition aggravated,
leading to unfitness or risk to others
 No impairing medication
Procedures for examination and
certification

13. ILO approach
 MLC consolidated many earlier
conventions. Parallel convention on
fishing
 Health scattered through MLC:
certificates, medical care on board, care
and repatriation, working and living
conditions (weak on smoking, diet)
 Social security issues: keep the doctors
out!
 Leading role in supporting guideline
development 1997 and now.

14. ILO key text
MLC 1.2 medical certificate procedures
Hearing and sight
No medical condition aggravated,
leading to unfitness or risk to others
MLC 2.5 medical repatriation
MLC 3.1 – 2 accommodation, food
MLC 4.1 – Medical care aboard
MLC 4.3 – occupational health and safety

15. WHO approach
 Was major player. Maritime now low
priority.
 Active on infection control – International
Health Regulations.
 Profitable publication – IMGS. Fit for what
purpose? Should be key to international
harmonisation, linked to medical chest
requirments and to radiomedical advice
 Participated in 1997 Guidelines on medical
examination, not with current revision.
Issues on quality of evidence.

16. Developing good practice –
fitness examinations
 Text from MLC and STCW 2012 as basis.
 Shortcomings of 1997 Guidelines
 Experience of authorities and others
 IMHA w.g. on medical fitness criteria
 Special Adviser to ILO developed draft text
 Working group to review and modify – 2
meetings 2010 and 2011.
 Co-ordinated endorsement by ILO and IMO.

17. Users of Guidelines
 Maritime Authorities in preparing national
regulations
 Maritime Authorities in adopting text as
national law.
 Examining doctors as issuers of certificates
Will they make for more acceptance of
certificates internationally and by
employers? Text + application in practice.
Supporting initiative – QA of examiners,
additional professional guidance, training
for examiners, ethical framework.

18. Progress on guidelines
 Draft text developed, based on IMHA
wg, UK MCA, other administrations.
 Large measure of agreement at
meeting Oct 2010. Issues:
- harmonising with MLC and STCW
- regulatory pedantics vs. usefulness
- national perspectives
- seafarers and ‘risk’

19. Next steps
 Redrafted after meeting
 Inclusion of fishing?
 Circulation – any changed positions:
states, employers, TUs?
 Second meeting September 2011
 Endorsement up the line in ILO and
IMO.
 Publication!!

20. Related health topics
Lessons from joint work on medical
fitness
International Medical Guide
Medical chests
Emergencies at sea – training,
guides, telemedicine, evacuation,
treatment, repatriation
[Medical aspects of social security]

21. Common features
 Political interests and rational policies
 Social partners can influence but
maritime authorities have to
implement
 Expertise: not needed, on call, at
hand, partisan or neutral, dominant.
The human zoo – know the animals
before designing the cages!