Seafarers on the shore: issues raised by Australian doctors treating seafarers

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

Delayed presentations

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.

Follow‐up

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.

Infectious diseases

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.

Acute presentations

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

Challenges

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.