‘The company will fire you because you are too expensive’: a photo-ethnography of health care rights among Filipino migrant seafarers

The study investigates how Filipino migrant seafarers access and experience their legally guaranteed healthcare rights amid hazardous working conditions and complex legal-jurisdictional frameworks. Despite international and US laws (e.g., MLC 2006, Jones Act, maintenance and cure) that ostensibly ensure medical care for seafarers, overlapping jurisdictions, flags of convenience, mandatory arbitration clauses, and labor export policies may hinder actual care-seeking. Framed through structural violence, the research asks how de jure rights translate (or fail to translate) into de facto healthcare access and what this means for workers’ health and employment security on short-term contracts in a high-risk industry.

Background literature highlights seafaring as a hidden yet essential industry responsible for over 90% of global trade, with fatal injuries nearly six times that of all US occupations and elevated risks of cardiovascular disease, accidents, drownings, disasters, suicides, and violence. Legal frameworks such as the Maritime Labour Convention (MLC 2006), maintenance and cure, and the Jones Act historically provide medical protections and compensation regardless of nationality when operating under US jurisdiction. However, court precedents (e.g., Bautista v. Star Cruises; Francisco v. STOLT ACHIEVEMENT MT) have shifted claims toward mandatory arbitration (often in the Philippines), limiting compensation and access to US courts. The Philippine state’s labor export program structures contracts and remittance regimes that contribute to precarity for Filipino seafarers. Scholarship documents shortened port stays, increased ship size and cargo, and reduced time ashore, producing intensified workloads and stress. The literature situates seafarers within neoliberal globalization, deregulation, and precarious employment as social determinants of health, where rights on paper are undermined by economic and contractual pressures that penalize care-seeking.

Design: A co-produced photo-ethnography within a broader project on human rights and healthcare access, framed by structural violence. Setting and period: A US Gulf of Mexico port; fieldwork from December 2016 to October 2017 on a reefer vessel with weekly dockings, sailing under a flag of convenience in international waters. Participants: All-male, English-speaking Filipino migrant seafarers (n=14) on 9-month contracts. Additional key informants: a port chaplain and a former lawyer engaged with seafaring human rights organizations. Data collection: Semi-structured interviews (14 with seafarers; plus 2 key stakeholders), participant observation on-board in port and at a local seafarers' center, transport to local shops, field notes, and photovoice (6 projects; 3 using film cameras, 3 using mobile phones; one film roll was underexposed and unusable). Seafarers photographed aspects of their work and life over 4–6 weeks; subsequent elicitation interviews explored meanings and health relevance of images. Access/logistics: Researcher obtained TWIC, Escort Pass, captain’s approval, and daily port guard clearance. Due to US laws, the researcher could not sail; weekly port visits facilitated longitudinal engagement across the crew’s contract. Photovoice sampling: After interview participation to build rapport; purposive selection across ship hierarchy and roles: captain, second officer, second engineer (film underexposed), able-bodied seaman, chief cook, and mess man. Ethics: IRB-approved; informed consent obtained; confidentiality preserved via pseudonyms; participants received guidance on photo use/disclosure; collaborative review and ethical representation emphasized. Analysis: Two-stage inductive approach: (1) open thematic coding across interviews and materials to identify themes on injury, illness, and healthcare access; iterative refinement of subthemes; (2) discourse analysis of rationalities and rhetoric. Reflexivity addressed through attention to positionality, power, and representation; ongoing communication with participants, member-checking elements (sharing findings/manuscripts).

- Underreporting and self-management: Seafarers routinely underreport injuries and illnesses and self-treat (e.g., a seafarer self-stitched a hand laceration without anesthesia) due to fear of being deemed “not fit to work,” losing immediate assignment, or future contracts. - Employment risk shapes care-seeking: Participants reported that seeking medical care—especially in the US where costs are high—can mark them as expensive or unhealthy, risking non-renewal (“twice” seeking care could harm rehire prospects). A chaplain recounted a captain’s stress-induced heart attack and subsequent replacement, illustrating punitive employment consequences for health events. - Hazardous conditions and schedule pressures: Work hazards include dangerous ropes and equipment, storms (including a major storm, a tropical storm, and a hurricane during the study year), and fatigue from long or erratic shifts (e.g., 6-on/6-off rotations; chief officer on 24-h call). The route (Guatemala–US Gulf) was ~1,700 miles with 18–23 h in port and ~2.5–3 days at sea each way; fast turnarounds intensified workload and reduced rest. - Documented adverse events in the study period: Three longshoremen died in area ports; one seafarer and one longshoreman were severely injured. - Organizational and contractual pressures: Overtime without pay; emphasis on on-time delivery of perishable cargo increased pressure to work through storms and fatigue. Implicit policies and employment practices discouraged medical utilization despite formal rights under MLC/maintenance and cure. - Psychosocial strain: Prolonged separation from family, sleep deprivation, and onboard interpersonal tensions contributed to stress and emotional burden, though crews also cultivated community through celebrations. - De jure vs. de facto rights gap: Although legal frameworks theoretically guarantee care and compensation, overlapping jurisdictions, flags of convenience, and mandatory arbitration—combined with short-term contracts—produce de facto denial of care through self-censorship and avoidance of healthcare utilization.

Findings show that Filipino migrant seafarers internalize and embody structural violence through avoidance of medical care, self-medication, and working while ill or injured to protect future employability on short-term contracts. Economic liberalization, deregulation, and the Philippine labor export regime create precarious employment conditions where exercising health rights risks job loss. Thus, de jure protections (MLC, maintenance and cure, Jones Act) are neutralized by de facto constraints: jurisdictional mazes, mandatory arbitration, cost concerns, and employer practices that penalize care-seeking. The accelerated port turnarounds and intensified schedules increase fatigue and injury risk, while neoliberal logics of individual responsibility shift blame onto workers for health outcomes produced by organizational imperatives. The study illuminates how global labor policies and political-economic structures translate into bodily harm and reduced healthcare-seeking among seafarers, addressing the research question by demonstrating the mechanisms through which structural violence constrains access to health rights.

This photo-ethnography demonstrates that Filipino migrant seafarers face an untenable choice: forego needed medical care to maintain employability or seek care and risk contract loss and long-term livelihood impacts. Short-term contracts, mandatory arbitration, flags of convenience, and profit-driven scheduling collectively erode the practical realization of health rights, producing embodied health disparities and psychosocial strain. The study contributes an in-depth, participant-centered account of how structural violence and neoliberal labor regimes shape care-seeking behaviors at sea. Future research could: (1) evaluate policy and contractual reforms (e.g., protections against retaliation for medical use, limits on arbitration for injury claims); (2) assess organizational interventions to mitigate fatigue (crew complements, scheduling, rest enforcement) and expand onboard/telehealth capacity; (3) compare experiences across nationalities, vessel types, and routes; and (4) examine the roles of unions, flag states, and manning agencies in enabling genuine worker representation and safe reporting without employment penalty.

- Single-vessel, single-route case in a US Gulf port limits generalizability; all participants were male Filipino seafarers (n=14), potentially constraining diversity of perspectives. - Researcher could not sail with the crew due to regulations; reliance on weekly port visits and participant-generated images may omit at-sea events between port calls. - Photovoice participation was selective; one film roll was underexposed; visual data are not exhaustive representations. - Potential observer and social desirability biases; power/positionality dynamics may have influenced disclosures despite reflexive and collaborative strategies. - Lack of quantitative health outcomes and reliance on self-report limit measurement of prevalence and causality.