Cruise Ship Blues: The Underside of the Cruise Ship Industry (14 page)

In 1998 two cases of Legionnaire’s disease occurred on Direct Cruises’
Edinburgh Castle,
which was operating in the UK. The problem was traced to the water purification system — the first time a water supply system was implicated in transmission of this disease.
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The system was disinfected and the ship was placed back into service.

But overall, ship-associated cases of Legionnaire’s disease are rare. Most studies recommend that ship owners, operators, and captains be diligent in maintaining the water and air-conditioning systems on their vessels. Whirlpool spas are identified as requiring particular care and maintenance.

Pregnant Women Beware

In 1998 the Canadian Medical Association issued a warning on the risks of rubella (German measles) infection aboard cruise ships, after a similar advisory from the US Centers for Disease Control (CDC).
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Before going on a cruise, women of childbearing ages were advised to have their immunity to the disease checked, and if necessary, to be vaccinated.
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This advisory followed several outbreaks of rubella on cruise ships. The CDC estimated that 75 percent of the crew members on a ship were susceptible to rubella — consequently a case of the disease within the confined environment of a cruise ship would pose a serious threat to passengers. Based on the number of female cruise ship passengers who were pregnant and/or of childbearing age, the CDC stated that one case of congenital rubella syndrome could occur every week during an onboard outbreak. Congenital rubella syndrome can result in severe birth defects, including deafness, cataracts, heart defects, and mental retardation.

However, the cruise industry says vaccinating its employees against rubella — thus protecting passengers — would be too expensive. The medical director for Holland America Line suggested it would cost $600,000 to inoculate all crew on Holland America Line and Windstar Cruises.
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More Health Risks

Dirt and lint in ventilation ducts present health risks, including aggravation of allergies and a breeding ground for airborne organisms. These ducts gather an incredible amount of lint, dirt, dust, and debris — one aircraft carrier has an estimated 60 tons of debris in its vent ducts, according to a study by the uS Navy. The dirtiest ducts are in the laundry, the galley, and accommodation areas, in that order.
⁶⁵
And this debris poses a health risk and a risk to safety. A series of recommendations regarding lint in laundry vents followed the National Transportation Safety Board investigation of the 1998 fire aboard Carnival Cruise Line’s
Ecstasy.
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As in any social setting, risks of disease exist onboard cruise ships. The public only becomes aware of the problem after something happens. For example, in January 2002 Australian health officials issued an urgent warning to hundreds of passengers returning from a nine-night cruise on P&O’s
Pacific Sky.
Within a week of the cruise’s end, a young man in Sydney had died from meningitis and another passenger in Adelaide was hospitalized and diagnosed with the same illness.
⁶⁷

Granted, communicable diseases are spread every day in varieties of settings. However, cruise ships present a unique situation because of the closed nature of the environment and the high level of social interaction among passengers.

MEDICAL CARE IS NOT REQUIRED

Surprisingly, international maritime law does not explicitly require that a cruise ship provide medical services. However, International Labor Organization Convention 164, entitled “Health Protection and Medical Care for Seafarers,” requires that ships “engaged in international voyages of more than three days’ duration shall carry a medical doctor as a member of the crew responsible for providing medical care.” Another related legal requirement is set forth in the International Convention on Standards of Training, Certification and Watchkeeping for Seafarers (SCTW), which stipulates only that certain crew members have various levels of first-aid and medical training.

Regardless, all modern cruise ships do maintain an infirmary. The people dispensing onboard medical care are concessionaires, and the cruise line assumes no liability for their actions. Their precise qualifications can vary widely, too. Some small cruise ships may have a nurse but no doctor; some large ships may have two doctors as well as two or more nurses.

In 1996 the ICCL adopted industry guidelines for medical facilities and personnel on cruise ships. The guidelines were a response to pressure from the American Medical Association (AMA), which had that year called on Congress urging the development of medical standards for cruise ships. Based on a number of cases of disease, including an outbreak of gastroenteritis that year on Carnival Cruise Line’s
Jubilee
in which 150 passengers became ill and one person died, the AMA also called for greater awareness of the limited medical services available aboard ships. The AMA position was supported by a survey administered by two Florida doctors to 11 cruise lines.

The doctors found that 27 percent of doctors and nurses did not have advanced training in treating victims of heart attacks, the leading killer on ships, and 54 percent of doctors and 72 percent of nurses lacked advanced training for dealing with trauma. Fewer than half of shipboard doctors — 45 percent — had board certification, an important credential that is granted after three to seven years of residency and a written examination in a specialty or its equivalent.. As for equipment, the survey found that 63 percent of ships did not have equipment for blood tests for diagnosing heart attacks, and 45 percent did not have mechanical ventilators or external pacemakers. “What we found was that the quality of maritime medical care was less than adequate, from the medical facilities to nurse and physician credentials.”
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The AMA has continued to lobby for government regulation of health care on cruise ships, but to date without success.

Are ICCL Guidelines for Medical Care Enough?

In May 2000, when I was sailing on the
Radisson Diamond
, I was given a tour of the ship’s infirmary. Spotting a sign on a door that read “Caution: X ray in Use,” I commented that I was impressed to see that the ship had an X-ray machine — equipment not technically required for a ship of the
Diamond
’s size and age. My impression shifted from positive to negative, however, when I was told that the X-ray machine had broken down a number of years ago and had never been repaired, presumably because of the cost. The X-ray room was now an all-purpose storage closet.

Most cruise lines marketed to North Americans subscribe to ICCL guidelines for medical facilities and medical staff. These guidelines are entirely voluntary and are not intended to establish standards of care for the industry: “They simply reflect a consensus among member lines of the facilities and staffing needs considered appropriate aboard cruise vessels.”
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The ICCL guidelines suggest that ships have onboard one infirmary bed per 1,000 passengers and crew, and one intensive-care-unit bed per ship. As well, the guidelines recommend having a variety of equipment, including two cardiac monitors; two defibrillators; an electrocardiograph (ECG); advanced life support medications sufficient to run two complex codes; capability for measurement of hemoglobin/hemocrit, urinalysis, pregnancy tests, and glucose tests; X-ray machines onboard ships delivered after January 1, 1997, with capacity for more than 1,000 passengers; and a range of emergency medications and supplies. Despite these recommendations, the actual equipment onboard varies depending upon the itinerary, size of the ship, and anticipated demographic makeup of passengers.

Infirmaries on ships are equipped to deal with minor injuries, including workplace injuries of crew. They are also able to stabilize a patient having a heart attack or suffering other acute conditions. But realistically, the ship’s infirmary is more like a neighborhood clinic than a hospital emergency room. It can deal most effectively with routine problems such as scrapes and cuts, sunburn, and indigestion. It also is equipped to serve as the “family doctor” for all the ship’s crew, treating anything from a common cold or flu to high blood sugar or hypertension.

By necessity, the infirmary also deals with emergency situations. Ninety percent of the 60 onboard deaths reported by cruise ships sailing out of Miami between September 1996 and September 1999 were attributed to a heart attack or heart-related problems. With a fleet of seven ships at the time, Holland America Line indicated in 1996 that it had between 325 and 375 emergency evacuations — 40 by air ambulance — per year.
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These numbers, applied industry-wide, suggest that there could have been as many as 4,000 evacuations in 1996 and potentially more than 6,000 in 2001.

Meet the Medical Staff

The training and background of medical personnel varies widely. Several cruise lines, such as Holland America Line, Princess Cruises, and Norwegian Cruise Line, draw their physicians only from the United Kingdom, the United States, and/or Canada, and pay salaries of $8,000 to $10,000 a month; all physicians are board-certified in one of these countries. In contrast, some cruise lines hire medical personnel from a range of countries and pay salaries reportedly as low as $1,057 a month; often those hired are not board-certified. A 1999
New York Times
article reports that only 56 percent of the doctors on Carnival Cruise Line’s ships had board certification or equivalent, while 85 percent of the physicians on Royal Caribbean Cruise Lines were board-certified.
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Board certification in itself may not be altogether reassuring. I knew a physician on one cruise ship whose 30 years of practice had been as an anesthesiologist; his ability to deal with some of the potential emergency situations on a cruise ship was untested. I met another physician whose specialty was oncological colorectal surgery. Although well respected within his specialization, he had not been regularly required to exercise the skills needed in emergency medicine.

ICCL guidelines recommend that medical staff are skilled in advanced life support and cardiac care; they do not, however, require that medical personnel be certified in Advanced Cardiac Life Support (ACLS) — a standard requirement for any doctor working in emergency medicine in North America. There is a wide difference between claiming a skill and demonstrating that skill through recertification, which for ACLS is required every three years.

Recent technology has brought telemedicine systems — satellite hook-ups from the ship to a medical center ashore — onboard cruise ships. These systems provide expertise that may not otherwise be available aboard the ship. For example, Princess Cruises’ MedServe program provides a link with onshore radiology experts who provide diagnostic support on all X-ray images taken onboard; the program is being expanded to include other medical specialties. The system runs on a cost recovery basis with a consultation beginning at $500. In the system’s first year of operation, 300 telemedicine consultations were conducted.

Code Alpha and Other Medical Emergencies

Medical staff onboard a ship deal with both routine and emergency situations, and in most cases, the required treatment is provided. But there have been times when medical care has fallen short. A two-part 1999
New York Times
article discusses several of these cases.
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In one, the doctor on the Carnival
Ecstasy
failed to diagnose a 14-year-old girl whose appendix had ruptured, causing a massive infection. After the third visit and the doctor’s continued assurances that the problem was not the girl’s appendix, the parents contacted their family physician. On his advice, they returned home midway through the cruise. The daughter underwent emergency surgery and will have lifelong medical problems as a result of the infection from a ruptured appendix.

In another case, a woman and her husband were on Carnival Cruise Line’s
Sensation
for their honeymoon. They returned to the ship from a walk ashore and headed to the infirmary because the woman, a diabetic, felt flushed. The nurse and doctor checked her blood sugar and because it was very high, administered fast-acting insulin to bring the blood sugar down. The husband recalled, “Instead of getting better, she got worse and worse.. She was totally unconscious and went into a diabetic coma and was wringing wet. I called for the nurse and she said she’d come around. I waited and she started jerking real bad.”
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He rushed back to their cabin to get his wife’s glucose meter and returned to the infirmary to measure her blood sugar himself. He found that her blood sugar was not too high but rather, too low. The nurse administered glucose and the woman regained consciousness about 15 minutes later. The couple claims that the incident caused brain damage, leaving the woman disoriented and unable to return to her job.

Still another case involved a 47-year-old woman on Celebrity Cruises’
Zenith,
who went to the infirmary complaining of difficulty breathing and chest pain. The physician took a chest X ray and diagnosed an upper-respiratory tract infection and acute bronchitis. Because her condition failed to improve over the next three days, she made additional visits to the doctor. After the cruise ended, she returned to New York and was hospitalized the following day. She died in intensive care. The woman’s family claims that failure of the ship’s physician to properly treat a heart attack led to an increased risk of a second, fatal heart attack. The two physicians providing care on the ship were trained in Colombia; neither was licensed to practice in the United States, and neither had advanced training in cardiac care.