Seafarers have a unique set of health issues severely affected by the COVID‐19 pandemic
The presentation of seafarers to Australian emergency departments (EDs) is common.1 Across 8 years, we have treated multiple crew members weekly and observed trends relating to seafarers in our ED, situated nearby Australia’s largest bulk export port.2 Seafaring is one of the world’s most dangerous jobs.3 Long hours enduring hazardous working conditions result in injury and death. Access to primary care is limited, and crew members with simple ailments may wait weeks for medical review. Seafarers were found to be 26.2 times more likely to die during their duties.4 In 2005–2012, the Australian Transport Safety Bureau recorded 245 incidents resulting in seafarers being seriously injured or dying.5
We believe this vulnerable patient population faces under‐recognised health issues directly affecting Australian practitioners. The coronavirus disease 2019 (COVID‐19) pandemic shined the spotlight on international seafarer health. Following travel restrictions, many crew worked beyond their contracted time, which caused rising health complications.6 During the height of the pandemic, the International Maritime Organization estimated 400 000 seafarers were stranded on ships unable to be repatriated due to border restrictions.7
Eighty per cent of the global trade volume is carried by sea, and Australian ports cater for 30 000 commercial vessels annually.6 Many international crew members are from low income nations, with claims that some employees are paid as little as $2 a day.8
These workers are isolated, with basic English skills and limited finances. According to the Maritime Labour Convention, medical and repatriation costs are incurred by employers.9 Patients may feel workplace pressures regarding the financial implications of accessing health care via their employment. Notably, seafarers are still not recognised as essential workers by the Australian Maritime Safety Authority.10
Seafarers spend long periods at sea, with a lack of primary care and variable pre‐employment screening. Resultant delayed malignancy recognition and non‐communicable disease diagnosis are common. In addition, patients may present with escalating pain and constitutional symptoms.
Australian stopovers frequently last less than 24 hours, which creates diagnostic time pressures that have an impact on the continuity of care. Furthermore, health care is disjointed, with visits to multiple facilities in previous jurisdictions. Moreover, Australian clinicians receive foreign language medical records and may not have access to after‐hours interpreters.
Following up ordered investigations is another concern. Seafarers frequently depart before care completion and are difficult to contact with results. We have seen subsequent delayed diagnoses with poor outcomes, particularly concerning malignancy and infection. The need for multilingual digital transmission of medical notes aligned with privacy legislation would aid in maintaining continuity of care. More onus needs to be placed on the employer to ensure follow‐up is achieved.
Investigations also may reveal reportable communicable diseases not frequently seen in Australian practice; therefore, clinicians need to be mindful of presentations such as tuberculosis, malaria, infection with other arboviruses, and hepatitis. Documentation of previous ports visited can be useful in taking an infectious disease history. On occasion, our rural team has been notified of diseases such as meningitis which require contact tracing and staff chemoprophylaxis. This is difficult in seafaring workplaces given the geographical transience.
Pre‐departure information from commercial shipping agents is scant and void of vital information such as past medical history, medications used, vaccination history, and allergies. Again, an electronic medical record maintained by employers and accessible by clinicians would streamline care.
In addition to infections and malignancies, we frequently encounter acute presentations involving falls, maritime machinery accidents, contaminated wounds, ophthalmological trauma, inhalation of noxious agents, suicidal ideation, and substance misuse or withdrawal. Such time‐critical cases are often delayed and present with multiple organ system involvement.
Occasionally, patients who present with critical illness have been unwell for several days and attempted self‐treatment before alerting their colleagues. There may be hesitancy to report medical illness due to fear of lost income.2 A single seafarer’s salary may support multiple families, and in some cases, industrial relations regulations do not provide sick pay. Repatriation under the maritime labour convention states that shipowners need only pay for medical treatment rendering seafarers fit for travel.9
Contribution to a seafarer safety net could assist in covering the costs of emergent treatment in Australia, facilitating access to optimal care. Several charity organisations provide monetary and psychological support to seafarers in crisis and may remain unknown to health care providers:
- the International Seafarer’s Welfare and Assistance Network (http://seafarerswelfare.org/);
- SeafarerHelp (https://seafarerhelp.org); and
- the Mission to Seafarers (http://www.mts.org.au).
In recent years, the COVID‐19 pandemic has affected health care services for seafarers. Conflicting state and federal responsibilities and staffing shortages have resulted in poorer health outcomes. Processes developed after localised outbreaks among bulk carriers entering Australian waters produced difficulties in providing health care services for seafarers.11 These included increased staff call‐back processing COVID‐19 tests and utilisation of transport and policing resources. The authors observed higher frequencies of mental health presentations due to longer periods at sea. In Australian waters, clinicians can access Hunterlink, which provides support for international seafarers’ mental health and aims to provide ongoing care in the seafarer’s home country.11
At the most extreme end of the spectrum, mortality at sea can occur in sometimes tragic circumstances. The death of a colleague places an emotional toll on seafarers working in close‐knit groups. It is important for clinicians to facilitate pastoral care interventions for crew members and first responders in remote Australian regions.
In February 2022, the United Nations issued a call to action outlining ten critical actions for the global support of seafarers during the COVID‐19 pandemic. These actions included facilitation of medical evacuation, designation as essential workers, provision of personal protective equipment and vaccination, and internationally consistent application of agreed restrictions.6
The health care needs of non‐resident merchant seafarers have long been overlooked. This population is vital in maintaining a robust Australian resources sector, particularly highlighted during the COVID‐19 pandemic. Issues faced by Australian clinicians treating seafarers include linguistic barriers, fragmented enroute health care, limited medical documentation, delayed presentations and the impact of isolation and lack of psychological supports.
Smaller regional hospitals treat large numbers of these patients, who have significant occupational morbidity despite best efforts by seafarer support organisations. While resources are geared for wellbeing at sea, we believe more needs to be redirected towards medical care on land. To our knowledge, there is no framework for how Australian health professionals should approach the treatment, logistics and ethical limitations surrounding these patients. This is despite work completed in pandemic preparedness and border policies. Some key suggestions from our experiences are listed in the Box. We welcome action by governments and private enterprise to “clean up the seas”, making seafaring safer and treating these individuals with respect and dignity.
Box – Suggested interventions to improve quality and safety for seafarers
Electronic medical records
Shipping companies should maintain a basic electronic medical record for all staff which can be printed, translated and communicated to local health services in line with privacy legislation. Crucial details should include medication lists, prior medical diagnoses with International Classification of Diseases codes, next of kin details, recent procedures and investigations, and any advance care planning materials.
Mandatory information required at registration
Patients seeking treatment at Australian health care facilities should bring an acute log of recent movements, including ports visited; employer occupational health and safety representative details; and current primary health care provider contact details.
Expansion of existing services for utilisation in seafarer care
Health helpline services should be expanded (including video translation services) to provide advice for acute health conditions for employees on incoming vessels in Australian waters. This should include the ability to refer to appropriate local services, state trauma units, and crisis management communications if applicable.
Nominated contact for continuity of care
Each shipping agency should establish a named contact point for the communication of pathology and radiology results to/from Australia, reducing the risk of performing investigations when follow‐up is not feasible.
Planning for body expatriation
The acute services and structure for expatriation of bodies and support for emergency staff during crises should be considered in the risk register of major Australian ports.
Seafarer safety net
A nationwide “seafarer safety net” should be created using private industry funding to assist with the costs for sight, life or limb threatening interventions within the Australian health system which are beyond the cost employers are obligated to pay.
Clear documentation of treatment
Discharge summaries should be produced and dispensed to merchant seafarers after every episode of care in Australia and uploaded onto shipping companies’ electronic medical records.
Increased corporate awareness
Australian resources companies exporting overseas should become aware of the ethical issues faced by seafarers and should ensure that safety standards extend to contractors.
Education of health professionals
Australian health care workers should be educated on the issues faced by seafarers and the available resources to aid in their care.
Provenance: Not commissioned; externally peer reviewed.
- 1. Australian Maritime Safety Authority. AMSA coordinates multi‐agency response to medical emergency [media release]. Braddon: AMSA, 2020. https://media.amsa.gov.au/media‐release/amsa‐coordinates‐multi‐agency‐response‐medical‐emergency (viewed Aug 2022).
- 2. Birch L, Gudgeon K, Laschon E. Crew from coronavirus‐struck ship off Port Hedland in WA brought ashore. ABC News 2020; 23 Sept. https://www.abc.net.au/news/2020‐09‐25/covid‐19‐crew‐cargo‐ship‐port‐hedland‐coronavirus‐quarantine/12702932 (viewed Mar 2022).
- 3. Kaushik M. Challenges of shipping jobs. Marine Insight 2019; 13 Sept. https://www.marineinsight.com/life‐at‐sea/challenges‐of‐a‐job‐at‐sea‐difficulties‐of‐a‐shipping‐job/ (viewed Feb 2022).
- 4. Roberts SE. Hazardous occupations in Great Britain. Lancet 2002; 360: 543‐544.
- 5. Australian Transport Safety Bureau. Australian shipping occurrence statistics 2005 to 2012. Canberra: ATSB, 2013. https://www.atsb.gov.au/publications/2013/mr‐2013‐002/ (cited Feb 2022).
- 6. United Nations Conference on Trade and Development. United Nations bodies call for further action to end seafarer crisis [website]. Geneva: UNCTAD, 2022.https://unctad.org/news/united‐nations‐bodies‐call‐further‐action‐end‐seafarer‐crisis (viewed June 2022).
- 7. Kanungo S, Pohekar SD, Mundhra DD, Jacob W. An empirical study of behavioral pattern of seafarers: an Indian exploration. Chennai: Notion Press, 2018.
- 8. International Labour Organization. Building a future with decent work. Conference guide of the 105th Session of the International Labour Conference; Geneva (Switzerland), 30 May – 10 June 2016. https://www.ilo.org/wcmsp5/groups/public/‐‐‐ed_norm/‐‐‐relconf/documents/meetingdocument/wcms_477741.pdf (viewed Feb 2022).
- 9. Bailey R, Borovnik M, Bedford C. Stranded seafarers: an unfolding humanitarian crisis. Devpolicy Blog 2021; 3 June. https://devpolicy.org/seafarers‐in‐a‐covid‐world‐20210603/ (viewed Mar 2022).
- 10. Maritime Union of Australia. Maritime Union of Australia calls on the McGowan government to add seafarers to the essential workers list [media release]. 28 Oct 2021. https://www.mua.org.au/news/maritime‐union‐australia‐calls‐mcgowan‐government‐add‐seafarers‐essential‐workers‐list (viewed Feb 2022).
- 11. Hunterpink. Hunterlink — Employee Assistance Provider, 2022. https://hunterlink.org.au/about/employee‐assistance‐provider/ (viewed Aug 2022).