Except in the case of the ‘Achille Lauro’ terrorist attacks on ships have not had a static phase. In piracy as described above, and possibly during acts of organized crime, the initial seizure will be followed by a more or less extended phase when the ship will be held for ransom or re-use. The pirates will employ agents of their choice to assess the value of ship, cargo and crew (implying intelligence gathering at ports of call, at the location of the ship owner etc.). These or other agents will then establish communication with the government of the flag state or with the ship owner. The ship owner might employ a security firm to negotiate on his behalf. All this can take considerable time. In 2011 a German ship was in the hands of pirates for 121 days! (11)

 In waters off Somalia piracy for ransom will usually mean that rescue is delayed.  

Casualties incurred during the assault phase will then be reliant on first aid from their shipmates. Captain and officers may not be free to apply their (limited) medical knowledge and training because pirates – at least initially – may confine the crew and officers to different quarters and not allow communication.

In order to care for those needing medical attention the captain and/or officers need to negotiate to reestablish minimum ship operations, but this will be more difficult if the ship has tried to fend of the attack in the first place. Eventually initial distrust or anger usually fades as it becomes obvious to the pirates that they themselves will benefit from such cooperation.

However a merchant marine ship’s crew has only a very limited ability to care for those who are seriously ill or injured. It is therefore essential that a responsible organisation, such as a government, a company operating/owning the vessel or mediatory services employed by them, establish trusted communications that are acceptable to both pirates and the crisis response team or the representatives of both as soon as possible to get a picture on the situation on board, to determine any needs for outside help and to negotiate access to such assistance.

To assess the situation in order to determine the appropriate medical response they will need a physician as consultant who is aware of emergency medicine as well as shipboard conditions and means of rescue. A telemedical service may be able to fill this role. It is necessary that procedures are in place to ensure unhampered and real time dialogue between the medical staff and others involved in handling the situation.

 Initially the static phase depends on the building of relationship.   If a consensus can be reached to evacuate patients in critical need of medical attention this is a good indicator of stability. Careful deliberation about the means and personnel to be involved in an early medical evacuation is needed. While helicopter transport will usually be medically preferable it might be a primary target for any ‘warlord’ behind the pirates, either for himself or in order to bargain for a higher ransom. Medical personnel landing on the hijacked ship might become victims themselves. Therefore it may be less hazardous to take patients off the ship by boat – weather permitting - and hoist them to a helicopter later - even if that means more suffering for the patient. If a decision is made to evacuate by helicopter because of critical medical conditions the employment of special forces trained ‘medics’ can be considered. This should not be part of a liberation attempt, however.

While the term ‘static’ might suggest relative calm, for the crew that never is the case. In many instances they will be confined to spaces where they can be easily monitored; sometimes they may even be tied and blindfolded. Their access to sanitary facilities and to food and water may be constrained or even prohibited (12).

Often pirates do not understand the importance of or care little for normal shipboard systems including electrical power (air conditioning), water purification, sewage and waste disposal. With regard to hygiene they behave as they are used to at their own homes. In addition they are likely to carry infections endemic to their country, including animal borne disease from bringing livestock to be slaughtered onboard. After a while the situation on board of the ship is likely to deteriorate with accumulation of rubbish and human waste and crew hygiene will be impossible. Assessment of such risks needs health advice to assist in achieving a safe release of crewmembers. Infectious disease/public health expertise is required. It is recommended that this is obtained from health professionals who are familiar with shipboard conditions and who can bring in additional expertise as necessary. Such advice may be obtained through national Centres or Societies for Maritime Medicine as well as from port health authorities. The company and/or flag state crisis response cell should ensure that they have instant communication with such consultants at any time, preferably via a permanent medical advisor on their staff. Efforts should be made to avoid any critical health situation affecting crew or pirates that could compromise negotiating options, for instance by requiring urgent evacuation.

 Timely negotiations about evacuation of those adversely affected by conditions onboard may reduce the traumatic and destabilizing effects of emergency action During the negotiating stage preventive actions to reduce dissemination of infectious disease to people involved with transport , handling and treatment of the evacuees should be planned, and liaison with the onshore public health authorities need to be established.

 After successful evacuation of critically ill patients efforts should aim at establishing a minimal amount of hygiene in order to avoid deterioration of the situation in order to avoid desperate actions of crew and/or pirates. With an increasing number of crew ill or injured it may be desirable to bring personnel to ensure minimal operation of the ship - a health worker might be amongst them. If this is impossible the ship’s captain or most senior officer/rating should negotiate for radiomedical advice on disinfection, sanitation and prophylaxis. This might ensure eradication of any primary focus for infection. Provision of quality assured food for crew and pirates will help and this may increase trust and reduce any tendency to inflict physical or psychological abuse on the crew, thus stabilising the situation to the benefit of further negotiations.

 Reports indicate that pirates who doubt if they are being taken serious by company or other negotiators tend to turn their anger on to the crew to increase pressure on authorities responsible for the ship (13). Crewmembers have been forced to kneel on deck in the tropical sun without drinking for hours, subjected to fake executions, tortured etc. Such treatment may lead to serious medical or psychological problems: dehydration, skin lesions, injury, infection and psychological decompensation. Psychological advice should be available to the team of the crisis response cell. This psychologist should have knowledge of the shipboard environment, as well as intercultural experience and training in mediating in hostage situations ( see chapter 13) If negotiations aimed at improving conditions aboard are unsuccessful little can be done to render medical support. In order to safeguard the the life and health of the crew termination of the situation may become essential, whether achieved by an agreed deal or by force.

 A special case would be the hijacking of a passenger ship, as occurred in 2008 with the French sailing ship ‘Le Ponant’, which had a medical officer on board. [iv] A medical officer will be able to provide a better standard of medical care and can also help in assessing the physical and psychological condition of crew, passengers and pirates by giving professional advice to the captain and the company/flag state crisis response cell to assist with crisis management. They may not only be the responsibility for treatment and prevention of injury or disease but also for the organization and management of outside support and the evacuation of patients. They will, in accord with medical good practice, prioritise attention solely according to severity of problems, whether in crew, passengers or hijackers and thus contribute to diminishing tensions.
This task will probably go beyond the capabilities of the physician and their staff and so other crewmembers will need to assist. Preferably these will be from among the hotel staff. Assistants should be identified and trained advance in order to be able to collaborate effectively.