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 spread

At 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 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

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 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

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 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.

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 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]

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!