- Dr. med. Jens Tülsner, MD (Marine Medical Solutions)
- Prof. Dr. Philipp Walther (Hochschule Fresenius – University of Applied Sciences)
- Prof. Dr. Alexander Hermenau (Hochschule Fresenius – University of Applied Sciences)
- Sophia Zander (Universität Bayreuth)
With the continuous growth of the cruise industry, questions from the field of maritime medicine are becoming increasingly important. It is no longer just a question of how acute medical problems can be solved at sea. The ageing of Western societies, digitalisation and increasing diversification within the cruise industry are becoming relevant. Which questions are asked and how they are answered is mostly based on assumptions and economic interests and all too rarely on the actual wishes and needs of the guests. The literature on “Medicine in Cruises” is sparse. This paper is based on a survey of 1000 German cruise guests. The aim was to evaluate the needs, expectations and areas of interest in the field of on-board health services.
In 2017, a total of 26.75 million guests travelled on ocean-going cruise ships; 26% of these were from Europe (1). The industry is growing constantly. It expands territorially, e.g. the expansion of the cruise market in Asia or the expansion of the destinations into the Arctic and Antarctic zones. Shipyards such as Fincantieri, Meyer-Werft and others are fully booked with new builds for the next few years. Various trends observed in the cruise industry also have an influence on the medical services offered on the ships:
- The trend towards ever larger ships is contrasted by the rediscovery of smaller ships with lower passenger numbers, greater individuality and fewer limitations in the selection of ports of call.
- The main countries of origin of cruise passengers are the USA, China and Germany (1). The population of the industrialized countries is getting older. It is therefore foreseeable that a large proportion of guests will continue to be of an advanced age in the future, despite the increasing adaptation of offers to different age groups. Statistically, in Germany citizens in the 50 to 64 age group have more than two chronic illnesses (2).
- The population’s demand for health, wellness and prevention services is growing, across all generations. In particular, younger people are willing to use and self fund such services, something which is well documented on land (5).
- Digitalisation is widespread in the maritime sector – from navigation to fuel consumption and all aspects of port operations. However, contrary to traditional land settings, digitalisation in maritime health care is still in its infancy.
Material & Methods
In May 2018, 1010 people were interviewed online. The main inclusion criterion was previous participation in a cruise.
Table 1: Distribution of responder’s age
|18 - 29 y
|30 - 39 y
|40 - 49 y
|50 - 59 y
|60 - 69 y
|> 70 y
After the age of 50, more than half of those surveyed had chronic illnesses. The same trend was seen for regular medications: more than half of the over-50 took at least one daily regular medication. It was remarkable that this was also the case for 40% of 18-29 year olds. 8% of responders said they suffered from a disability and/or were chronically in need of care. The most common aid requirements were walking frames, wheelchairs, lifts and shower chair, as well as carers.
Graph 1: Chronic diseases of the participants by organ system.
Graph 2: Chronic diseases of responders by age
Medical care on board
23% of responders stated that they had received medical care on board the ship during their last cruise. In 53.4% of the cases the reason was an acute illness. Of 232 respondents who were treated on board, 93% were satisfied with the experience. Reasons for dissatisfaction were the perceived level of competence of the on-board physician, incomplete or ineffective treatment and incorrect diagnosis.
Graph 3: Acute illness as reason for onboard medical consultation.
Demand for additional medical services
Participants to the survey were asked to rate their interest in additional medical services (other than traditional health care) on a scale from 1 (very low) to 5 (very high), with an option for “don’t know”. Across the various medical services options, 40% of respondents chose the “don’t know” option, which increased to 60% for the plastic surgery and palliative medicine options. Responders who needed constant medical care or had received medical treatment during a cruise were on average more interested in additional services. When asked to list additional services of interest, other than those included in the survey, the proposals were: alternative therapies / TCM, lectures, coaching / psychological counselling / nutritional counselling. 43% of the responders would be willing to self-fund the additional services (60% of 30-39 year olds, 31% of >70 year olds).
Graph 4: Interest in additional medical services.
Information about medical services on board
65% of respondents said they would be happy to receive more information about the range of medical services on board before their trip. The preferred means of communication was e-mail (73.7%), followed by more detailed information in catalogues and magazines (36.98%) – multiple responses were possible.
While 13.06% of the respondents stated that they already used a wide variety of “health apps” such as TK-App, Apple Health App, Contour Diabetes, Fitbit and others, more than half (53.6%) were generally open to the use of digital solutions for the personalized storage of health data. 56.2% of the respondents were open to the use of telemedical support, e.g. as video consultation hours.
The cruise industry will be able and required to approach the issue of medical care on ships in a new way. Considering, that this survey has included German former passengers only lots of conclusions taken won’t be applicable internationally. In line with demographic trends, both the absolute number of cruise passengers and the percentage of older ones will increase. This will have several consequences: The range of chronic diseases to be treated will increase. The current personnel and technical equipment of the ships, based on the ACEP Guidelines (3), will be able to guarantee this to a large extent. Even if the requirements regarding medical experience and expertise differ, doctors and nurses still have a broad general medical expertise, supplemented by emergency medical experience. In addition, many of the cruise lines have established programs for medical support that help to validate unclear findings and make appropriate decisions. The willingness to self finance additional medical services, independently of health insurance policies is increasing. On the one hand, this leads to guests having higher expectations with regard to the variety of available offers, procedures and services. On the other hand, in view of the land-based growth of the first and second health care markets (4), this also holds considerable economic potential for the shipping companies. The survey showed that the interest of the guests is concentrated on three areas:
- Supportive offers in the area of health maintenance and “wellness” – from preventive medical check-ups to nutritional advice and a wide range of physiotherapeutic services. The corresponding equipment requirements are purely a question of investment; the range of offers here is broad. On the other hand, the challenge lies in identifying suitable providers, as the medical staff on board rarely have the additional skills required. Further market analyses would be necessary to justify the hiring of additional personnel.
- Offers that make travel on cruise ships accessible to people with more serious disabilities, such as care offers and the expansion of the capacity and equipment of cabins for disabled people. Providing individualised health care on a cruise ship is challenging – it is beyond the core competence of a cruise company and, requires a changed structure and number of medical personnel.
- Dialysis possibilities. Apart from possible limitations due to national or international regulations (e.g. flag state), machines available today allow hemo-dialysis to be carried out independently of a centralised water supply. In cooperation with specialized medical providers, this makes it possible to organize appropriate trips without central structural changes.
The number and equipment of disabled accessible cabins is a structural and costly decision. There is limited potential to add more disabled cabins or upgrade existing facilities (e.g. number of sockets, distances between furnishings, storage facilities for wheelchairs and other equipment, …). The guests have a great need for information. This applies both to the area of treatment – what medical care is available on board? and to the “Service” area – what can I do on board for my health? Considering the fact that many people like to use the time of a holiday to complete wellness and fitness programs, health check-ups, …, there is great potential for all involved as long as they are appropriately communicated and advertised. The use of digital solutions will continue to spread. Many cruise shipping companies already have different telemedical programs that help diagnosis and treatment. All of them are well suited to receive support from land-based experts in acute situations. These will certainly be expanded in the future not only with regard to the specialisation of the onshore experts consulted, but also with regard to the use of technical possibilities – from the “real-time” transmission of vital data to the use of video options (e.g. for neurological diseases). These programs do not support the acquisition of knowledge about a patient’s past medical history and investigations results – both pillars for the assessment of the situation, the diagnosis and the therapy to be initiated. Of course, guests have reservations about making their health data completely accessible to representatives of a tour operator prior to a trip – the available knowledge is correspondingly incomplete in the event of an acute medical event. There are digital solutions which enable the guests to store all their data and to make them available only “on demand” to the medical staff on the ship. Offering such solutions on board would benefit all parties involved: patients, on board and shoreside medical staff, and ultimately the cruise industry. The survey has shown that the guests are not only interested but also willing to use these services.
- CLIA, The Contribution of the International Cruise Industry to the Global Economy in 2017, published 2018 (https://cruising.org/-/media/CLIA/Research/Global%202018%20EIS)
- Robert-Koch-Institut; Wie gesund sind die älteren Menschen? 2015, (https://www.rki.de/DE/Content/Gesundheitsmonitoring/Gesundheitsberichterstattung/GBEDownloadsGiD/2015/08_gesundheit_in_deutschland.pdf?__blob=publicationFile)
- ACEP – Health Care Guidelines for Cruise Ship Medical Facilities, 2013, (https://www.acep.org/patient-care/policy-statements/health-care-guidelines-for-cruise-ship-medical-facilities/)
- Dostal & Partner; Deutscher Gesundheitsmarkt bis 2020: Innovationen, Herausforderungen, Trends und Potentiale für die Akteure, 2016, (https://www.dostal-partner.de/wp-content/uploads/2018/01/Leseprobe-Gesundheitsmarkt-bis-2020.pdf)
- Statistisches Bundesamt https://www.destatis.de/DE/ZahlenFakten/GesellschaftStaat/Gesundheit/Gesundheitsausgaben/Tabellen/Ausgabentraeger.html
- P. Walther, A. Hermenau, J. Tülsner, S. Zander „Stand und Entwicklungsperspektiven Maritimer Medizin auf Kreuzfahrtschiffen“, cooperative study, Fresenius- Hochschule Hamburg / Marine Medical Solutions, 2018