First published in ITIJ 135, April 2012
As cruise ships get ever larger and embark on ever more ambitious itineraries to more distant seas, what are the implications for medical assistance companies?
This year did not start well for the cruise industry. Were 2012 not the centenary of the world’s most infamous maritime tragedy, the media spotlight on the capsizing off the Italian coast of the cruise ship Costa Concordia on Friday 13 January might have been a little less intense. But a frenzy of comparisons with the sinking of the supposedly unsinkable Titanic on its maiden voyage 100 years ago was inevitable.
“It was just like the Titanic!” trumpeted the headlines. No, it wasn’t. The Concordia ran aground within sight of land and rescue was quick to arrive. Some survivors even swam ashore. Of a complement of 4,200 passengers and crew, fatalities were put at 32. Each such death is, of course, a tragedy. But when Titanic went down in the early hours of April 15, 1912, 375 miles out into the North Atlantic, the toll was 1,517 lost out of a complement of 2,223 passengers and crew. The fate of Titanic did not spell the end of transatlantic liner travel. It took two world wars and the advent of affordable air travel to do that. Concordia’s mishap seems equally unlikely to deter many from taking an ocean voyage.
The only way is up
On the contrary, cruising is increasing in popularity. In the UK alone, the cruise market has more than doubled in the past decade, reaching 1.62 million passengers in 2010 and set to reach 1.7 million in the near future. At the annual convention of the Cruise Lines International Association (CLIA), industry leaders representing 26 of the world’s largest lines predicted they would carry more than 17 million passengers in all this year – a five per cent year-on-year increase. New ships are coming down the slipway, too, with 14 cruise vessels to be launched this year and 10 more by 2015. And while the majority of cruises still operate in the familiar waters of the Caribbean, the Mediterranean and the Atlantic, a growing number of ships now sail the Pacific, the Indian Ocean, the South China Sea and – perhaps most challenging of all from the medical assistance standpoint – the freezing seas of the Antarctic and Arctic regions.
With new products such as all-inclusive holidays, cruising is no longer perceived purely as a pastime for the wealthy, but as an affordable holiday offering value for money. In the UK, Southampton is probably the most popular port of departure for these cheap, short cruises. Vessels are rarely far from European soil, so this type of cruise arguably poses no more problems for travel insurers and assistance companies than a typical package holiday. Similarly, from the US, most short cruises – typically only three or four nights long – operate out of Miami and Fort Lauderdale to the Bahamas and back, so vessels are never far from the US mainland.
That said, there is also healthy demand for ‘ultra luxury’ cruises, with cruise lines responding to the economic downturn by bundling added value elements – such as travel insurance, drinks, excursions and tips – into the price.
The sheer size of these floating cities must make minor and major medical emergencies on board statistically more likely than on smaller vessels
And the ships are getting bigger. Royal Caribbean International’s (RCI) sister ships Allure of the Seas and Oasis of the Seas, launched last year, are the world’s largest, each with space for 6,296 passengers, but there are currently at least 30 vessels with a capacity of 3,000 or more, and at least 16 ships with space for 2,500 to 4,000 people are currently under construction. The sheer size of these floating cities must make minor and major medical emergencies on board statistically more likely than on smaller vessels.
As numbers and itineraries expand, passenger profiles are changing too, as cruise lines succeed in attracting a younger clientele. According to the Passenger Shipping Agency (PSA), which speaks for the cruise industry in the UK, the average age of the UK cruise passenger is a sprightly 54, brought down by a growing number of families with children. However, cruising still attracts a very substantial number of older clients. According to Dr Kate Bunyan, medical director of Carnival Cruises, 33 per cent of UK cruise passengers are over the age of 65. This in itself poses some challenges for cruise lines and for insurers. Relatively few cruise passengers travel solo – mainly because of the high cost of a single-occupancy cabin. Onboard medical and service staff are usually aware of the need to keep a tactfully close watch on older solo travellers in case of health problems, and cruise lines normally use pre-departure screening questionnaires to help identify and meet the needs of passengers with details of necessary medication, existing health issues or mobility problems, but Dr Bunyan notes that these are only useful if completed fully.
“Booking terms may state that insurance is a must, but it is often not feasible to confirm accuracy,” she says. Onboard, particular challenges include medication that is forgotten or deliberately not taken, multiple co-morbidities that increase the change of a medical emergency, and above all a limited resource environment – these ships are designed to offer emergency medical management, not long-term care.
The CLIA requires its members to comply with American College of Emergency Physicians (ACEP) levels of care, with medical facilities staffed by trained and licensed medical staff with at least three years of clinical experience, including minor surgery and emergency care. Many ships are now incorporating telemedicine, with onboard doctors using new technologies to communicate with specialists on land.
Several Caribbean islands – including Guadeloupe and Martinique, which are French ‘overseas departments’; St Martin and St Barthelemy, which are French ‘overseas collectivities’; and Aruba and Curacao, which belong to the Netherlands – are part of the European Union (EU), and that therefore means visiting EU nationals holding a European Health Insurance Card are entitled to the same level of care as local residents. In addition, the UK has reciprocal healthcare agreements with former British islands including Anguilla, the British Virgin Islands, Barbados, and Turks and Caicos.
Standards of private and public medical provision vary widely across the Caribbean nations, with US-administered Puerto Rico, the larger French-administered islands, and former British possessions such as Jamaica, Trinidad and Barbados generally offering adequate standards of care in private hospitals and clinics. Mexico, too, has adequate private hospitals in cruise ports and resorts such as Cancun (and in most ports of call on its Pacific coast), so airlift to the US is not always an automatic first option for assistance companies, says Adam Hvid, operations manager Denmark, SOS International. “Depending on where in the Caribbean the injured party might be, different evacuation possibilities present themselves as ‘preferred’. We co-operate with hospitals in Mexico and in Venezuela that provide the care needed, securing costs and quality,” Hvid says. At the other end of the scale, Haiti’s health infrastructure does not meet international standards, and some of the smaller and less prosperous island nations have only limited hospital facilities. In part, this is a result of the Caribbean’s proximity to North America: travelling to the US or Canada for treatment has always been an option for better-off island residents.
Meanwhile, Mediterranean cruise passengers requiring evacuation and treatment on land have relatively easy access to high-quality private care in EU countries, and can be quickly transferred by air ambulance from ports in North Africa and the Middle East, where high-quality care may be less readily accessible.
while the cruise lines often include their extensive medical facilities as part of their advertising, there are no clear standard as to when a patient should be disembarked, or what considerations are undertaken first
With wide variations in the levels of care even in Caribbean waters, longer itineraries to remoter destinations – many of them in developing countries where public sector healthcare may be rudimentary and private hospitals are thin on the ground – create special challenges for insurers. Most of the Caribbean, the inshore waters around the US, the UK and the Mediterranean are well within the range of rescue rotorcraft such as those operated by the US Coast Guard or Britain’s Royal Navy and Royal Air Force, but even when a vessel is well within the operational envelope of helicopters such as the Coast Guard’s Sikorsky H460J Jayhawk or Britain’s Sea King, hoisting a patient, sometimes in darkness, from a ship as tall as a 16-storey building and moving at around 20 mph is a risky business. Not surprisingly, such operations are regarded as a last-resort option.
More remote destinations (such as Alaska) within developed countries also need different evacuation and repatriation plans. Polar seas, with their extreme weather conditions and vast distances to be covered, create perhaps the biggest challenges of all. Even the familiar transatlantic voyage can pose problems: helicopter evacuation is quite feasible in smaller seas such as the Mediterranean or the Caribbean, but Atlantic cruise ships may be out of the range of evacuation helicopters for most of their journey.
A similar issue arises in the South Pacific, according to Kirsty Bell, international operations manager for New Zealand-based assistance company First Assistance. “Every year we see the cruise lines competing with cheaper and cheaper package deals and this is prompting many, especially the retired community, to flock to cruises for their winter breaks. Real issues arise with this as, while most cruise companies encourage or insist on travel insurance, few make clear the pitfalls of exclusions or limitations of the policies – especially the risk of pre-existing medical conditions being declined. This causes serious issues in the event of a medical emergency as the cruise line expects full responsibility to sit with the insurer and their assistance company,” says Bell. “Sometimes this can be life-threatening.”
Furthermore, the South Pacific has no medical centre of reasonable size or standard, Bell says, and opportunities for repatriation using scheduled airlines are very limited. “Almost all patients disembarked would require an air ambulance, but as there are no air ambulances stationed in the South Pacific, all missions need to be staged from New Zealand or Australia, causing delays where the patient must be cared for in port.”
Bell recalls a case of an Australian passenger being offloaded in Vanuatu, an extremely popular cruise destination with limited medical facilities.
“The cruise ship doctor contacted First Assistance to arrange an urgent medevac, only to discover that the passenger’s heart condition had been excluded under their insurance policy, through their pre-travel medical screening. This left the cruise company, and the assistance company, in a predicament of being unable to evacuate the passenger (except at their own cost – which was declined by the patient) and the patient having to remain in a facility with limited care for three days until the next cruise ship arrived in port and re-boarded the passenger. In this case, Bell says, the patient remained stable and was able to safely continue the journey. “This raises serious issues for all parties. It also raises the point that if the patient was able to re-board a later cruise, should they have been off loaded in the first place?"
hospitals may resist repatriation, and it may even be easier to evacuate from a cruise ship than from a medical facility on land
Bell’s observation is that while the cruise lines often include their extensive medical facilities as part of their advertising, there are no clear standard as to when a patient should be disembarked, or what considerations are undertaken first.
Cruising with care
As cruise ships have become bigger and ever more sophisticated, so too have their onboard medical facilities. Typically, large cruise ships offer a wide-range of non-invasive intensive care and diagnostic facilities, fully stocked pharmacies, cardiac monitoring and defibrillation equipment, and staff trained according to ACEP guidelines. For example, RCI’s Allure of the Seas and Oasis of the Seas each have three doctors and five nurses offering round-the-clock emergency services. Through telemedicine and the line’s affiliation with the Cleveland Clinic in Weston, Florida, the onboard team can also offer 24-hour consultation in a variety of areas, and all RCI’s Radiance-class, Voyager-class, Freedom-class and Oasis-class vessels have dedicated medevac helipads from which critical cases can be airlifted up to 150 miles offshore.
Writing in The Trauma Professional’s Blog, Dr Michael McGonigal, director of trauma services at the Regions Hospital in St Paul, Minnesota, says he is impressed by the Allure’s medical centre and its staff. “They are also in tune with the capabilities of the hospitals in the various ports of call and have well thought out procedures [regarding] who can be taken care of on the ship and who needs to be transferred ashore,” he notes.
At the other end of the size scale – and on the other side of the world – smaller cruise ships (most of them carrying no more than 100 passengers) operate in the extreme conditions of Antarctica. Here, extreme climate and long distances from departure ports create some special requirements.
Steve Wellmeier, executive director of the US-based International Association of Antarctica Tour Operators (IAATO), points to a clear divide between smaller ‘expedition’ vessels that carry from 12 up to 500 passengers and that land their passengers on the Antarctic continent by inflatable landing craft, and larger, conventional cruise ships whose passengers must stay onboard and that do not venture so close to land. Expedition vessels, Wellmeier says, normally carry a medical doctor and have an onboard medical suite, and their operators typically require all passengers to have at least US$250,000 of emergency medical and evacuation/repatriation coverage. Medevac from King George Island, in the South Shetlands archipelago, the nearest airstrip to Antarctica, is usually handled by air ambulance from Punta Arenas, in southern Chile.
“When a passenger’s medical requirements are more than can be handled by the physician aboard, the expedition ship will usually divert to King George Island and transfer the passenger to the airstrip, where they are expected and the ambulance service has been notified,” Wellmeier says. “There is a limit as to medical equipment and staff that can be carried aboard a small expedition ship carrying 85 to 200 passengers, but those procedures work quite well. IAATO members also share a contingency plan, outlining procedures and protocols of assistance to one another in emergencies.”
Expedition ships must also be more rigorous when screening passengers for pre-existing medical conditions and special medical needs before departure, Wellmeier says, requiring all passengers to have a certificate of health from their own physician. “Occasionally, passengers are turned down if the vessel operator feels the pre-existing conditions might cause a problem.”
Larger cruise vessels venturing into polar waters, Wellmeier says, normally have medical facilities and staff that are quite capable of handling emergencies for the medium term, even in Antarctic waters. “Really, how is Antarctica any different than being in the middle of the Atlantic, where there is nowhere to go? The larger ships are prepared for this.”
Clash of opinion
Worldwide, once a customer in need of medical care has been disembarked – whether by emergency helicopter, or at the vessel’s next port of call – there is the risk of a clash between travel insurers, cruise lines, medical assistance companies and indeed the patient’s own wishes. The cruise line’s first priority is likely to be keeping the vessel on schedule, and that rules out delaying departure for the next port of call, even for passengers who may be quickly discharged from hospital after treatment for relatively minor ailments or injuries. Those passengers may well be aggrieved at being left behind, and their cases and claims need diplomatic handling.
SOS International’s Adam Hvid says it’s important for assistance providers to be involved from the beginning of any incident. “It’s critical for us to intervene early, on behalf of our clients, the insurance companies,” Hvid says. “This is not always possible, but very beneficial. I’m sure most assistance companies would agree with this point of view.”
Carnival’s Dr Kate Bunyan notes that challenges include complaints of abandonment if the cruise company fails to meet the customer’s expectation of quick repatriation. Language and cultural barriers may also become an issue: a major selling-point for many cruise passengers (especially older travellers) is the sense of safety and familiarity onboard a vessel that is in many ways a microcosm of home. Being disembarked and hospitalised in a much more alien environment can be traumatic in itself. Meanwhile, hospitals and clinics in some popular ports of call stand accused of over-treatment to maximise their own revenue. In some cases, according to Dr Annette Girad-Claudon, medical director of International West Indies Assistance, hospitals may resist repatriation, and it may even be easier to evacuate from a cruise ship than from a medical facility on land.
As the number of cruise ships increases, this personal relationship between the assistance company and the medical staff of the ships gets harder to maintain
Ensuring a smooth handover of responsibility at each stage – disembarkation or medevac, hospitalisation, repatriation and swift settlement of claims – can be key to the process. Just as the most dangerous time for a diver is not deep underwater but on the surface, the critical time for all parties involved in resolving cruise passenger insurance issues is not far out at sea but at the interface between ship and shore care.
The key to successfully managing a medical emergency on the cruise ships, according to Kirsty Bell, is to involve the insurer and the assistance company doctor as early as possible. Many cruise lines have port agents who will arrange the disembarkment, but if the insurer isn’t involved in the decision making this is going to cause delays, as well as stress and risk for the patient. “Open communication from the start between our doctor, the ship’s doctor and the patient can result in a much more favourable outcome”. Bell recalls cases where cruise ship doctors have disembarked passengers with their own oxygen and medical staff to care for them in ports with poor standards of medical care. The assistance company can facilitate the return and reuniting of cruise ship equipment and staff. Often a ‘ship to wing’ transfer can be arranged by keeping the passenger on board until a port opportunity where the assistance company can arrange them to be transferred directly to a plane, rather than having to overnight in a primitive hospital.
Maintaining good relationships with the cruise doctors is also critical.
“During the peak cruise season we can see four to six patients disembarked off a single cruise ship,” says Bell. “It gets to the point where my team are on a first name basis with the ship’s doctor.” As the number of cruise ships increases, this personal relationship between the assistance company and the medical staff of the ships gets harder to maintain, but Bell says it the key to working through issues when they arise in an emergency.
SOS International’s model could provide a template for assistance companies worldwide. “An increasing number of clients, including maritime companies, are interested in having a plan for how to provide medical assistance and/or crisis management solutions,” says SOS International’s Adam Hvid. “An enhanced co-operation and sharing of information would definitely be beneficial for all parties.”
The company offers shipping lines a two-track service that includes a customised report on any given route, identifying the nearest preferred medical facilities, according to diagnosis, based on its SOS Providers Network database. “All eventualities are drawn up and a number of recommendations prepared, so the company would, in the case of a medical emergency, know who to turn to, which port to call upon, contact information, standard of medical facility, and so on,” says Hvid. “Considerations about evacuation recommendations are also included. This solution provides a static but detailed view of the company’s needs in any given medical emergency situation.”
Meanwhile, SOS World Wise provides web access to SOS International’s Providers Network, offering access to relevant and update information needed to address acute medical situations. “SOS World Wise provides much of the same information that a customised report would do,” Hvid says. “The difference is that it’s dynamic and updated frequently.”
Kirsty Bell has the final word. “At the end of the day we are all professionals and have to put the patient first. This doesn’t mean that an insurer is going to evacuate a patient who is outside of policy benefit, or that a cruise ship doctor is going to keep a patient onboard when they feel it’s not appropriate, but open co-operative communication is going to get us the best possible outcome, even when options are limited.”