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
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)
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)
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
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’
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
Changes – work at sea Voyage time Job demands Communications Global ownership And crewing
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.
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.
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 spreadAt interface of ILO, IMO and WHO
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.
IMO key textSTCW 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 medicationProcedures for examination andcertification
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.
ILO key textMLC 1.2 medical certificate proceduresHearing and sightNo medical condition aggravated,leading to unfitness or risk to othersMLC 2.5 medical repatriationMLC 3.1 – 2 accommodation, foodMLC 4.1 – Medical care aboardMLC 4.3 – occupational health and safety
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.
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.
Users of Guidelines Maritime Authorities in preparing national regulations Maritime Authorities in adopting text as national law. Examining doctors as issuers of certificatesWill 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.
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’
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!!
Related health topicsLessons from joint work on medicalfitnessInternational Medical GuideMedical chestsEmergencies at sea – training,guides, telemedicine, evacuation,treatment, repatriation[Medical aspects of social security]
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!