29 Epilogue – The health of merchant seafarers, Norway and beyond

Som en passende avslutning på historien om maritim medisin sett fra et norsk perspektiv, har jeg bedt professor Tim Carter om å skrive noen ord om norsk innsats for faget gjennom tidene sett fra et utenlandsk ståsted. Tim er professor emeritus i maritim medisin og har i tillegg hatt en livslang interesse for historie.

Jeg har valgt å la hans bidrag trykke på engelsk slik at vi lettere kan føle et det er et utenlandsk perspektiv vi får servert.

While studying the history of British seafarers’ health I came across the report of the Norwegian Red Cross conference held in 1926 on the health of merchant seamen*Red Cross. 1926. Report of the Oslo Conference, convened by the Norwegian Red Cross and the League of Red Cross Societies on the health of merchant seamen. June 28th-July 5th 1926. Paris. . This report was a revelation! It showed how Norway was putting itself in the lead in terms of developing an international agenda for maritime health. In large measure this agenda remains the basis for worldwide action right up to the present day.

I discussed the context of this conference with historians and maritime doctors in Norway and also researched the wider international concerns that led to it*Carter T. 2014. Merchant Seamen’s Health, 1860–1960. Medicine, Technology, Shipowners and the State in Britain. Woodbridge, Boydell Press; 131-135.. I came to see it as a key moment, both for Norway and for the world. My aim here is to explore two complementary aspects of this investigation: how has Norway seen itself in terms of international maritime health developments and how has the rest of the world seen Norway? Because of my own background in maritime history many of these comparisons will be based on contemporary events in Britain.

Prior to 1914 a large proportion of Norwegian registered shipping was under sail, at a time when other nations were progressively moving to steam power. There were, however, exceptions such as the Hurtigruten coastal service. Much of the fleet was tramping, carrying cargoes such at timber and coal. Indeed Norwegian ships were among the commonest foreign vessels carrying British coal exports. Ship losses were frequent and consequential seafarer mortality high*Personal communication: Roberts S, University of Swansea, 2019.. There seem to have been few measures taken to remedy this, for instance the active parliamentary debates in Britain that led to the adoption of the Plimsoll line did not seem to have any parallels, although the concept of load lines soon came to be adopted internationally*Jones J. 2006. The Plimsoll Sensation. The Great Campaign to Save Lives at Sea. London, Little Brown. . In this setting concern about the health of Norwegian seamen was limited at best and mainly focused on the risk of seafarers as a source of infectious diseases in port towns. Norwegian cargo shipping was known in the nineteenth century to be a graveyard for old ships from other countries, inevitably also as for their crews.

The fishing sector was little better, with British Lady Factory Inspectors called to visit Norwegian fish processing ships in the Shetland Islands in 1905 because of the appalling working conditions on board*Chief Inspector of Factories. 1906. Factories and Workshops: Annual Report for 1905. London, HMSO; 312.. Those at risk were women engaged by the fish merchants who chartered the ships. They lived and worked on them for several months at a time, returning to Bergen or other ports briefly when the holds were filled.

Missions for Norwegian seafarers were an early feature and provided practical and spiritual welfare, with some early churches, such as the one in the major coal exporting port of Cardiff in South Wales, remaining as evidence for this. The mission workers played an important part in supporting ill and injured seafarers who went ashore for care, but without being in a position to take wider strategic approaches to securing their health, beyond exhortations about the risks of excess alcohol and of venereal disease from casual sex.

The First World War was a transformative period for Norwegian shipping and seafarers. Norway remained neutral and the sector made large profits out of war transport. These were re-invested as soon as peace returned in modern, mainly diesel, vessels. More significantly for maritime health, seafarers were almost the only group of Norwegian nationals to suffer casualties, especially after the introduction of unrestricted submarine warfare. In consequence concerns about their health, safety and welfare were an important political issue in the 1920s. This did not happen in other countries that were combatants, as deaths of merchant seamen were small compared with other battle casualties. The Norwegian government put welfare measures in place specifically targeted at seamen and, additionally the state had a very direct interest in their health as it was responsible for benefit payments in those who had conditions that led to long delays in their return to work*Koren ES. 2011. In a peculiar position: merchant seamen in Norwegian health policy 1890–1940. In Fischer LR, Lange E (eds) New Directions in Norwegian Maritime History. Research in Maritime History No. 46. St Johns: International Maritime Economic History Association; 83-99..

Dr. Harald Engelsen, a naval surgeon, activist and polymath, was the moving force behind the 1926 conference*Engelsen H. Biografi i Sommerfelt-Pettersen,J.et al. 2006. Enda en folkefiende. http://www.sms1835.no/arkiv/Sommerfelt-Pettersen%20J.pdf . He saw the need for there to be international arrangements for both preventive and curative healthcare for all seafarers and his vision was that the conference should be the vehicle for achieving this. The international climate was positive. The Red Cross was no longer involved in war-related relief and was seeking new areas of action; the International Labour Office had been established and had already had a programme of work on seamen’s working conditions, and the League of Nations had been set up and had yet to experience the setbacks that befell it later.

Most of the main European maritime nations of the time sent representatives as well as China, Costa Rica, Japan and the United States. The conference opened in Oslo with king Haakon VII attending. Later it had sessions in Bergen and Trondheim, to enable delegates to visit the healthcare and welfare centres for seafarers in these ports.

Engelsen’s idea was to set up a worldwide network of similar centres, open to seafarers of all nationalities, supplemented by consistent approaches to fitness assessment and to treatment of common conditions such as tuberculosis and venereal diseases. He saw the Red Cross as the natural provider of such services.

These ideas were discussed in some detail and there were sessions on ship hygiene, venereal diseases and the concept of a health passport for seafarers. Individual countries also provided information on how they responded to the health needs of seafarers. Herein lay the difficulty; some of the larger and longer established maritime nations, especially Britain, France and the United States already has their own international networks for seafarer healthcare, usually in the hands of local consuls and shipping agents. Also some of them had political pressure groups, who insisted on a moral rather than a public health approach to venereal disease.

These entrenched positions made for a limited consensus at the end of the conference, with little support for harmonising health care arrangements, but with enthusiasm for developing a network of welfare centres in ports that could build on existing mission activity. Taking the long view, the conference brought all the interested parties together and did produce an international agenda for some initiatives, while highlighting the need for every maritime nation to take steps to make arrangements for those items where international agreement was not achieved. Specific initiatives were taken forward, for instance the production of the first international medical guide for use on board*Medecine a Bord. Paris, Ligue des Societies de la Croix-Rouge (undated)..

Other Red Cross conferences followed and their work laid the ground for ILO initiatives from the 1930s onwards and for actions taken by the World Health Organization and the International Maritime Organization following their foundation after the Second World War. The principle of international organisations developing conventions that are then ratified and adopted into the law of individual states, has now become the accepted way to create a slow convergence towards worldwide standards for protecting and treating seafarer’s health.

During the interwar years Norway moved to have one of the most modern fleets in the world and remained in the lead in terms of the measures taken to secure the health of its seafarers. Its network of welfare centres spread to major ports around the world, but it had to continue to rely on ad hoc arrangements in foreign ports for the treatment of ill or injured seafarers. Some activities, such as whaling in the Southern Oceans, led Norway to establish more comprehensive healthcare arrangements for both ship crews and processing workers who were thousands of miles away from civilisation for a large part of each year. Other whaling fleets such as those of Britain, had to take similar steps, but this was a matter for the companies rather than for state intervention.

With the Nazi invasion of Norway in 1940 the fleet in home waters came under their control. However most of what was largely an international fleet was directed by the government in exile to sail to Allied ports, and its ships became an indispensible part of the Allied merchant fleet. It suffered ship losses and crew casualties in the Battle of the Atlantic, while seafarers from Norway and other invaded countries also had to cope with years of separation from their families and homes. They spent up to five years putting themselves at risk, based in foreign parts when not at sea, while having little or no contact with their relatives at home.

Welfare support for all Allied seamen was a priority in the ports of countries such as Britain, USA and Canada. Detailed policies for fitness and for medical care were developed and shared by all the Allied merchant fleets. These agreements were the result of the governments in exile working closely with Allied host countries*Carter T. 2014. Merchant Seamen’s Health, 1860–1960. Medicine, Technology, Shipowners and the State in Britain. Woodbridge, Boydell Press; 136-152.. Some cultural problems did however remain, such as the readiness of countries like Norway to give frank advice on using condoms for casual sex, while others like Britain still clung to moral exhortations.

One figure who played an important part in advocating the advantages of a high standard of health and welfare provision for all Allied seamen was Karl Evang, a socialist physician and politician who was an adviser to the Norwegian government in exile*Norsk biografisk leksikon. https://nbl.snl.no/Karl_Evang . After the war he became one of the founding members of the WHO and, for a time its board chairman. During this period, he helped to initiate a continuing dialogue between WHO and ILO with regular joint meetings on seafarer health and welfare. These played an active part in developing preventative and treatment methods for infectious diseases taking advantage of the potentials of the recently introduced antibiotics for treating acute infections, venereal diseases and tuberculosis*Carter T. 2014. Merchant Seamen’s Health, 1860–1960. Medicine, Technology, Shipowners and the State in Britain. Woodbridge, Boydell Press; 166.. These were also concerned with other aspects of seafarer health such as fitness for work as a seafarer and the need for compatible medical guides, medical chests and telemedical advice for ships at sea.

In the aftermath of the Second World War the Norwegian fleet had to rebuild its strength more slowly, but with a reputation to maintain, not least in relation to health, welfare and safety, of being a quality flag.

The growth in bulk liquid transport was a field that Norway actively moved into. It was a trade that had its own risks from flammable, toxic and environmentally harmful cargoes and this called for access to specialist technical and scientific skills. The need for new skills was also a feature of other developments such as the growth in offshore support vessels for the energy industries.

The demise of passenger transport and the growth of cruising is another area where Norway has led the way. Others following and have now come to dominate the business. Maritime health expertise has played an important part in all these developments, and other maritime nations have subsequently benefited from the application of Norwegian technical and health expertise in new and changing sectors of the industry.

How does Norway compare to other maritime nations on maritime health at the present day? It is one of the very few countries that have a dedicated centre for national expertise, the Norwegian Centre for Maritime and Diving Medicine at Haukeland University Hospital in Bergen*http://www.ncmm.no . This serves the sector with advice, research and training and is active internationally, notable with its web-based Textbook of Maritime Medicine, which is accessed worldwide and is now in the process of going into its third edition*http://textbook.ncmm.no . The Centre has split responsibilities to government, with maritime safety topics being under the Norwegian Maritime Authority, while healthcare, including the provision of telemedical advice is the responsibility of the Health Directorate. Neither of these organisations, in contrast to those in Britain, Netherlands, Canada and USA, have in house expertise in maritime health, hence advice on policy development is not always integrated with policy development or accessed at the optimum time.

Outside Norway an extensive network of doctors is approved to perform seafarer medicals and this poses challenges for quality assurance. There remain some seafarer welfare centres, but many have gone or been integrated with those serving seafarers of other nations. Those with maritime health expertise from Norway continue to make significant contributions to the work of international agencies such as ILO, IMO and WHO. The world is short of such expertise and active engagement is one of the best ways for Norway to continue to be seen by all as both a caring and a quality flag.