This document discusses the challenges faced by international bodies in developing regulations for maritime health. It provides perspectives from different stakeholders and examines the approaches taken by the ILO, IMO, and WHO. A key focus is the development of medical fitness guidelines through a collaborative process between these agencies, drawing on expertise from maritime authorities and organizations. The guidelines aim to harmonize fitness standards and support more acceptance of medical certificates internationally.

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!