The Norwegian Sea Health Conference 2014, Bergen, 27-28th August 2014

1. International Medical Examination Standards
Are these enough or do we require additional standards of
the Insurers, Ship-owners and Manning Agencies
Dr Robert David Dungan
NSHC 2014
Bergen
Norway

2. It used to be so easy: Seafarer Recruitment
FIT DRUNK
Brawler
NO PEME
Dead Quite
soon
Strong
Scurvy
No ILO, IMO, SFM, ITF
Syphilis

3. INTERNATIONAL LABOUR ORGANIZATION
INTERNATIONAL MARITIME ORGANIZATION
Sectorial Activities Programme
ILO/IMO/JMS/2011/12
Guidelines on the medical examinations of seafarers

4. With national fitness standards for seafarers varying widely, the set of international guidelines adopted in 1997 (the Guidelines for Conducting Pre-sea and Periodic Medical Fitness Examinations for Seafarers) was a first attempt towards harmonization. The increasing internationalization of shipping makes such harmonization even more desirable. Medical practitioners performing such examinations should have a clear understanding of the special requirements of seafaring life, as their professional judgment is often critical to the lives of seafarers. All concerned should be able to trust a seafarer’s medical certificate as having been issued in accordance with the relevant applicable international standards.

5. ILO and IMO introduced the new guidelines to medical fitness to work at sea. This was then backed up by the STCW and the Manila Convention(2006). These came into play in October 2013.

6. Disseminating these Guidelines and ensuring their implementation should contribute towards harmonizing the standards for medical examinations of seafarers and improving the quality and effectiveness of the medical care provided to seafarers.
Intention of these Guidelines

7. Purpose and scope of the Guidelines
1. Seafarers are required to undergo medical examinations to reduce risks to other crew members and for the safe operation of the ship, as well as to safeguard their personal health and safety.
2. The MLC, 2006, and the STCW Convention, 1978, as amended, require a seafarer to hold a medical certificate, detail the information to be recorded and indicate certain specific aspects of fitness that need to be assessed.
3. These Guidelines apply to seafarers in accordance with the requirements of the MLC, 2006, and the STCW Convention, 1978, as amended. They revise and replace the Guidelines for Conducting Pre-sea and Periodic Medical Fitness Examinations for Seafarers, published by the ILO and WHO in 1997.

8. 4. When implementing and utilizing these Guidelines, it is essential to ensure that:
(i) the fundamental rights, protections, principles, and employment and social rights
outlined in Articles III and IV of the MLC, 2006, are respected;
(ii) from the point of view of safety of life and property at sea and the protection of the marine environment, seafarers on board ships are qualified and fit for their duties; and
(iii) medical certificates genuinely reflect seafarers’ state of health, in light of the duties they are to perform, the competent authority shall, after consultation with the ship owners' and seafarers’ organizations concerned, in giving due consideration to applicable international guidelines referred to in Guideline B.1.2 of the MLC, 2006, prescribe the nature of the medical examination and certificate, as outlined in Standard A.1.2.2 of the MLC, 2006.

9. 5. These Guidelines are intended to provide maritime administrations with an internationally recognized set of criteria for use by competent authorities either directly or as the basis for framing national medical examination standards that will be compatible with international requirements. Valid and consistent guidelines should assist medical practitioners, ship-owners, seafarers’ representatives, seafarers and other relevant persons with the conduct of medical fitness examinations of serving seafarers and seafarer candidates. Their purpose is to help administrations establish criteria that will lead to equitable decisions about who can safely and effectively perform their routine and emergency duties at sea, provided these are compatible with their individual health-related capabilities.

10. 6. These Guidelines have been developed in order to reduce the differences in the application of medical requirements and examination procedures and to ensure that the medical certificates which are issued to seafarers are a valid indicator of their medical fitness for the duties they will perform. Ultimately, the aim of the Guidelines is to contribute to health and safety at sea. And avoid the conflict- ------- Competent Authority vs.
1.Insures.
2. P&I clubs.
3.Ship-owners.
4. Manning companies.

11. IV. Seafarer medical fitness examinations
16. The aim of the medical examination is to ensure that the seafarer being examined is medically fit to perform his or her routine and emergency duties at sea and is not suffering from any medical condition likely to be aggravated by service at sea, to render him or her unfit for service or to endanger the health of other persons on board
17. Medical examination findings are used to decide whether to issue a medical certificate to a seafarer. Consistent decision-making needs to be based on the application of criteria for fitness that are applied in a uniform way, both nationally and, because of the global nature of seafaring and marine transport, internationally.
18. The medical certificate is neither a certificate of general health nor a certification of the absence of illness. It is a confirmation that the seafarer is expected to be able to meet the minimum requirements for performing the routine and emergency duties specific to their post at sea safely and effectively during the period of validity of the medical certificate.
19. The ability to safely and effectively perform routine and emergency duties depends on both a person’s current degree of fitness and on the likelihood that they will develop an impairing condition during the validity period of the medical certificate.

12. Question:
Do you consider the guidelines to be sufficient or do we need to add tests to avoid unhealthy crew working and endangering themselves and fellow crew members?
Many of the insurers, ship owners and manning agents request a number of additional tests, many that are invasive and may in some cases compromise the crewmembers employability

13. Maritime Labour Convention 2006
1.…..prior to beginning work on a ship , seafarers hold a
valid medical certificate attesting that they are medically
To perform their duties they are to carry out at sea
2. The certificate genuinely reflect seafarers state of health
In the light of the duties they are to perform.
3. The certificate will be issued in lines with STCW (Manila Convention)
4.The certificate is issued “Duly qualified medical practitioner”

14. So what differs between the standards of the Competent Authorities described and the standards of the Insurers, ship-owners and crewing companies ?

17. The following was requested by a crewing agent recently
Full medical
CXR
Ultrasound Abdomen
HIV
VDRL
CBC
U&E
Liver function test
Glucose and HBA1c
Uric Acid
Hep B sAg.
Hep C.
Lipogram
Malaria Test
TB Test ?
PSA in crew older than 40yrs
Blood type
Drug and Alcohol test
Lung function test
ECG (First time medical and then over 50)
X-ray Lumbar spine

18. What are your thoughts?
1.These are all defendable ?
2.Do you become unfit if you have a positive result ?
3.Are these ethical?
4.Costs?
1.Situation that we have all faced: Passed National Medical standards and failed Company/ Insurer/ Crewing medical standards

19. Are all these additional invasive tests needed?
Are they justifiable?
Are they Evidence Based?
Are they to protect ? And who are they protecting?

20. Super Crew
HIV
PAP Smears
Sudden incapacitation
Accidents
Do these tests make the crewmember more employable and do they determine that the crewmember will not get ill?

21. IS THIS WHAT IS
REQUIRED???

22. AD
Crew member

25. South African Perspective
South African guidelines based on the ILO/IMO document.
SAMSA has identified that there is a specific disease profile in the country and have decided to limit the duration of the SAMSA seafarers certificate to 1 year.
The challenge we have is that we are one of the world leaders in the occurrence of HIV/TB. Whilst HIV does not exclude a crew member from working it is essential to determine the status of the immune system.
It is however, forbidden to perform pre-employment or annual medical HIV screening

26. The SAMSA Certificate is needed fro the following
1.Crew members
2.Stevedores
3.Dock workers

27. 1.There is a doctor approval process.
South African Maritime Safety Authority
2. There is a facility approval system.
3. There is an appeal process.
4. There is no QA

28. So all the boxes are ticked: Right ?
1.Doctor approval:
a.Registered with HPSCA
b.Diploma in Occupational Health (No Maritime focus)
c.Or “some experience in maritime health”
2. Facility Approval: a. Performed by a maritime surveyor who is generally a ex ships Engineer
3. Appeals Process: a. The appeals process is well established and there were 7 appeals last year. The weakness of the system however is that there is no Maritime Physician on the board.
NO Quality Assurance / Peer review Process

29. DO THESE MEET THE INTENDED
NORM?????

30. How are the “short falls being addressed?

31. 1. We are developing an additional maritime module that we hope will be added as an optional module to the Occupational Health Diploma for students that want to become AD in SA
2. We are looking at a group of doctors to do the accreditation. ? The biggest challenge with this?
3. We have motivated to have a maritime specialist on the appeals board.
4. QA is still an enormous stumbling block

32. I believe that the international guidelines are complete, self explanatory and sufficiently evidence based to give all parties a basic standard to determine a seafarer’s “FITNESS TO WORK” as laid out in the ILO/IMO. The weakness in the system is the different “Competent Authorities” determination of an AD approval and medical facility. The challenge that has been taken up by the insurers, manning agents and Ship-owners is their uncertainty at the QA/ Approval of the “Duly qualified medical practitioners’ and their facilities. I have no doubt that the guidelines are sufficient and there is no need to add the demands of the other interested parties if there can be consensus on the approval of AD’s and an internationally accepted QA process

33. QUESTION OR COMMENTS PLEASE
This is an extremely exciting concept and all comments will be greatly appreciated