In sickness and in health

Seafarers are entitled to the same access to medical care as workers ashore

By Felicity Landon

Covid-19 has thrown a harsh spotlight on seafarers’ rights, not least their rights to medical care. Stories have emerged of desperately ill seafarers refused permission to come ashore because of local Covid rules, left to suffer on board until their ship reaches a port that will allow them to access a doctor or hospital treatment.

But if we take the pandemic out of the picture for a moment, what should happen when a seafarer falls ill or is injured on board? The answers lie in the Maritime Labour Convention 2006 (MLC) – and, as with so much else, the reality depends on implementation.

The MLC sets out the duties of shipowners in respect of medical care for any seafarer working on board their ships, stating that they must have prompt access to medical care on board ship and ashore, at no cost to the seafarer. It states: “In principle, these measures should ensure that seafarers have access to medical care which is, as far as practicable, comparable to that which is generally available to workers ashore.”

Ships must carry a provision of medical stores and have crew on board who are trained in first aid and medical care.

Nearly 100 states have signed up to the MLC, but during the pandemic there has been a clash between the requirements of the Convention and the World Health Organization’s (WHO) International Health Regulations, which are intended to “prevent, protect against, control and provide a public health response to the international spread of disease”, says Natalie Shaw, director of employment affairs at the International Chamber of Shipping. She describes the situation as “two opposite parallels operating at the same time”.

“Health authorities in many countries are following the WHO regulations to prevent further disease, whereas the maritime industry and IMO are saying no – these countries have signed up to the MLC and therefore seafarers should be provided with medical care,” says Shaw. “It is a matter of conflicting laws and who wields the power in the government that is applying it. For example, the health ministry, the department of transport or the labour ministry.” Which is the ‘correct’ law? “We would argue the MLC, and the right to medical care is also enshrined in SOLAS.”

Besides the need for emergency dentistry and other physical medical care, there is the issue of seafarers who have Covid-19. “A lot of port States are saying ‘we don’t want to take you into our hospitals, we are already over capacity, you manage on board’, which is clearly in breach of international responsibilities.”

Medicare rules

Fabrizio Barcellona, seafarers’ section coordinator at the ITF, says that the rules on medical care are fit for purpose; the issue is that although 99 countries have ratified the MLC, they have not all applied what they have signed up for. “That was the result especially in 2020 when in non-Covid related medical emergencies, some countries would not allow the ship to call into port, despite a seafarer having had a stroke, heart attack or cancer needing an urgent operation. We believe there were people who died because of non-compliance with existing regulations. We do look at numbers, but it doesn’t matter how many – one is far too many.”

As he points out, it is crucial that a person who has had a stroke is taken to hospital as fast as possible. In one case a seafarer was still on board three days later; it was fortunate that (when eventually a port allowed him ashore) his life was saved.

Dental emergencies have been a notable problem during Covid, says Shaw. She knows of many cases where seafarers have been stuck on board with excruciating toothache. What are the choices? Tie one end of a piece of string around the tooth and the other around the handle of an open door then slam the door shut, hoping it pulls the tooth out; hope the master does something; “or suffer for weeks on end, which can then cause abscesses and become much worse and require more than just a dental appointment”.

Pre-Covid, the situation regarding medical care and MLC implementation was much better, says Barcellona: “There will be crew on board who have some kind of basic medical training and can administer medicine. If required, they can get in touch with a telemedicine provider who can do some diagnosis remotely and recommend the master either deviate the ship or administer medicine.”

The ITF has been pushing for a ‘health passport’ for seafarers, which would not only give details of Covid-19 vaccination status but would also (securely) incorporate the seafarer’s medical history, so that medical professionals could access this information in an emergency.

Because of the current crisis, the focus has been on vaccine certification, he says, “but we are trying to get the WHO to endorse or at least promote some kind of template of what they think a global health pass needs to look like.”

Fighting fit?

Do seafarers want to provide all of this information? Barcellona says: “There will always be someone somewhere who says they don’t want some of their record displayed but the issue is that most contracts for seafarers include a clause that if you have some health issue before joining the ship, and something happens on the ship, you are not liable to receive any compensation. So long as the information is absolutely private to the seafarers, I would have thought that is not the problem.”

As he points out, seafarers go through health checks far more regularly than most people: “They have a full check-up every two years to get a medical certificate and they have a pre-embarkation check-up as well every time before joining ship.”

However, if a seafarer falls ill at sea, perhaps days from the nearest port, what happens then? “Neither the master nor the shipowner are medical professionals, so sometimes if you leave them to make the decision on whether a seafarer needs to be hospitalised, it could be a bit risky; for example, a stomach ache – is it internal bleeding or did they just eat something?”

In such a case, information in a health passport could be invaluable, he says. “Because of technology and ship-to- shore connectivity, medical providers can now make a much clearer diagnosis by looking at a small blood sample/ saliva, rather than just taking second- hand information from the Chief Officer.”

Chirag Bahri, director of regions at the International Seafarers’ Welfare and Assistance Network (ISWAN), agrees that the MLC provides strong support for seafarers. “Everything is there in MLC about the rights of seafarers. It always needs to be updated, of course, and Covid has shown a new variety of challenges,” he says.

His concern is that seafarers are not always aware of their entitlements and rights concerning medical issues. “If you have a standard contract, you can expect a decent response from your shipowner. But we have seen that seafarers’ contracts are not always properly written down and there are issues around the conditions in which these contracts are provided.”

In their anxiety to get on board, seafarers often don’t look at what their contract says. They may not know what should be there – and there could be gaps, he says.

“We regularly have seafarers come to us who have been given a contract that has no name of owner and is not signed by anyone; it is not really a contract and you couldn’t challenge it in any court of law in the world.”

He also notes that there are gaps in implementation around the world: “In different countries, it is all about the person sitting in the port, who decides how they implement what is in MLC.”

Contract understanding

ISWAN has been trying to make seafarers more aware of the importance of signing a good contract that is properly worded, says Bahri, and he wants to see seafarers taught about MLC and their rights during their training.

“I think this all needs to be in the curriculum nowadays, so they have awareness. Whether ratings or officers, it doesn’t matter – each needs to understand about MLC and their rights and at least they will be able to see if something goes wrong. We need not hide anything from seafarers; they should be told each and every thing. Let’s be very transparent.”

The standard response when a seafarer falls ill is generally very good, says Bahri. But problems often arise later when the seafarer is on sick leave and perhaps not fully aware of their entitlements.

“Out of 100 seafarers, only ten will have read their contracts. We have had seafarers who have been injured and are on medical leave not knowing what they are entitled to, who is going to pay their sick wages, what are the future prospects, and so on. If a person is on sick leave, the company should give them a briefing, so they have an awareness of any steps they need to take and that they will be taken care of.

“On one side, the seafarer is getting treatment and is already stressed with that. They are worrying about finances and whether, if they recover, the company will take them back. All this creates more and more stress. If they were aware of all that, it would help them with their recovery and boost their wellbeing – and their families would be at ease that everything would be taken care of. Definitely there are companies taking good care but obviously there are areas where we need to do more.”

In the face of Covid, meanwhile, “we can’t give up” on seafarers’ health, he insists. “There are definitely some companies hiding behind Covid, saying you can’t sign off or not allowing medical care onshore, saying you have to wait. But there are also companies that have gone the extra mile and got the treatment seafarers need.”

Telemedicine options

Barcellona sees new technology and better connectivity improving medical provision on board with medical providers increasingly able to make a better diagnosis if they can access the seafarer with a camera or other instrument. Seafarers can also talk online to a medical professional.

However, Covid has impacted on current telemedical services, says Shaw. “If you are on board, you are literally limited to what is in the ship’s medical chest and relying on (for example) the Chief Engineer with three weeks’ medical training to provide care and assistance. They are trained to act in absolute emergencies with the support of telemedical services. However, a lot of telemedical services are provided by staff working in hospitals – and they have been stretched during the pandemic, and the ability to get advice has not been as easy as it was before.”

Bahri, meanwhile, wants to see more focus on mental health. “People talk about physical illness or injury, which they can see, but what about mental health – what programmes are in place to promote that kind of environment on board? Shipowners must provide the infrastructure on board for seafarers to be able to relax, involve themselves in different activities and socialise on board.”

Despite everything, he says, one of the points most often missed is MLC paragraph 4.4, which emphasises the importance of access to shore-based welfare facilities ‘to ensure that seafarers working on board a ship have access to shore-based facilities and services to secure their health and wellbeing’.

“This is very much a part of MLC that is not strongly reinforced, that ports must have welfare facilities inside the port. It is these small facilities that give seafarers at least a chance to step down onshore and maybe make a phone call to their families. These things are important for wellbeing and mental health.”

Working and living 24/7, confined on a ship, causes fatigue, he adds. “Being at sea, your body is going to get tired even if you are not at work.

We are land creatures – our body is not made for that. Let them step down from the ship; even stepping down from a ship gives a lot of energy to a person – even just a walk on the jetty.”