The key medical issue in piracy, terrorism and criminal violence is the infliction of harm - physical and/or psychological - with acute and/or chronic consequences to the health of crewmembers and their relatives as well as for mediators, security forces, rescue service personnel and others directly involved in an incident of piracy or of terrorism or organized crime at sea or in port. All three may occur as separate entities, but may also be correlated or even identical (2,3)   In most cases - with the exception of some acts of organized crime - there will be a sudden and probably total disruption of on board routines with little left to rely on, almost comparable to an unexpected collision or natural disaster. The situation will shift from a peaceful working routine to a warlike environment with physical injury or disease inflicted often with damage to the technical and social structure of the ship. Disruption of logistics and communication may occur. Outside help – critical at sea - may become unattainable or, sometimes, be unwanted.
In addition to the above factors the intrusion of pirates, almost always with a different cultural background is likely to jeopardize the hygienic conditions on board greatly, especially in extended hijackings (see chapter 13).

 To determine what kind of medical challenges can be expected to arise from acts of terrorism and piracy it is necessary to analyze possible scenarios to establish a clear picture of what may happen in these instances and what might be the medical issues. . Physicians at sea or otherwise responsible for medical care (company doctors etc.) need to determine what can be done with the means available on board, or how ship’s equipment needs to be supplemented or upgraded to respond to likely forms of emergency. Such planning will be a key element in minimizing the harm from an incident and needs to form part of the ship’s security plan. External expertise may be needed where medical skills are not available internally. Doctors and medical personnel ashore usually work in an environment optimized for up-to-date medical care. At sea, even on cruise liners, the limited facilities on board mean that such conditions are rarely found. If a ship experiences a violent intrusion standard procedures will need to be adapted and the medical professionals in charge – be they company or ship doctors - need to be prepared for this in order not to be caught with no options remaining for the provision of care (4)

For those ships crossing high-risk sea areas additional space should be identified for the treatment of multiple (critically) ill or injured personnel. These areas should be equipped so that they can quickly be converted and have access to additional stockpiles of medical equipment. A minimum of a three-day medical stockpile should be stored in a citadel or other safe area if such a facility is foreseen in the ship security plan.

It is recommended that in high risk areas one third of a crew should be trained and up to date in first aid/primary care (as laid out in the International Medical Guide for Ships and the Medical First Aid (see chapter 8eOn board medical professionals (cruise ships, research ships, warships) likewise have to be up to date in (pre-hospital) emergency medical care as well as basic surgical interventions and postoperative intermediate or intensive care if a hospital is available on board.

 Detailed medical planning in cooperation with the ship security officer is essential. Crewmembers should become familiar with relevant procedures by means of regular emergency drills. These drills should include cooperation with ship and shore based medical rescue services, as these will be the only services that can provide professional support during severe emergencies for the majority of commercial shipping (5)

 As already noted, there are three possible scenarios: terrorism, piracy and organized violent crime. Each of these scenarios may create circumstances that challenge those in charge of medical care in different ways.

 Currently acts of terrorism are usually are ‘hit and run’ in nature (6) The hit probably will be decisive and spectacular aiming at maximum damage and casualties in order to multiply psychological effects and thus to get maximum media attention . The usually sudden and short attack will then be followed by a recovery period, the speed of recovery depending on preparedness and professionalism of the crew and availability of outside assistance.

 In most areas of the world, piracy takes the form of armed robbery (7) As long as everybody keeps calm and the pirates get their ‘economic gain’, there is high probability that nobody will be hurt – except for the coastal region off Nigeria, where piracy seems to be intertwined with terrorism, and to have political as well as economic goals(8)

By definition piracy occurs ship to ship on the high seas. With an attentive crew, an attack can often be anticipated. There will be a build up of tension and maybe efforts to escape or fend off boarding. Thus the attack may be less sudden, usually less severe and longer in duration. Until the pirates either break away or have their bounty secured.

Piracy differs greatly (up to 1000 mi) off the East African (Somali) coast where the majority of attacks currently occur. Somali pirates have adopted the pattern of terrorist attacks of the 1970/80s. They hijack ships and take hostages for ransom. The attack phase therefore will be followed by a period of captivity that may last for weeks and months until ransom and release are negotiated. Usually Somali pirates do not aim to damage or harm ship or crew. However, torture and acts of anger and violence have been reported when negotiations were difficult (9) Here medical plans need to assume that care may need to be provided from the resources on the ship for prolonged periods and that ill-health resulting from infection or dietary limitations may arise. In addition any crewmember for whom medication is essential may be denied access to it.

 Organized crime may come in many forms on board ships and may range from armed robbery to insurance fraud. Sometimes ships are just seized and the crew dumped in the sea or on some desolate island. This happened in South East Asian waters and off Somalia, when pirates tried to seize fishery vessels as ‘mother-ships’ for their high sea operations. In these cases the attack may not be followed by a recovery phase on board and the medical issues will be similar to those of shipwreck but aggravated by any violence during the initial incident(7)

 Therefore generally an assault phase can be distinguished from a recovery phase. In between there may be a sustained (static) phase of exposure to the assailants that can last for months followed by a usually short but critical phase of disengagement. This static phase typically occurs in piracy attacks off the East African coast and may or may not offer opportunities for medical action as will be discussed in the following paragraphs.