A.8.1 The practice of Naval Medicine


One of the world’s most famous spokesmen for sea power, Alfred Thayer Mahan (1840-1914), noted that ‘… the necessity of a navy ... springs, therefore, from the existence of a peaceful shipping, and disappears with it.”[1] Therefore, there is an interdependence between navies and shipping, but they are not the same.

A.8.2 Definition


Navy is much more than a dark blue colour. Navy is the part of the armed forces of a state that conducts military operations at sea. A navy consists of the people trained to conduct naval operations and the platforms they use. A navy is also dependant on logistics usually supplied from naval bases, an on-shore organization. The naval organization is often divided into 2 parts, the first part producing, training and leading a navy and the second specialised to conduct naval operations. Frequently operations are conducted with groups of ships, assembled from several nations. Some navies have their own air assets such as fighter aircraft, maritime patrol aircrafts and helicopters. Most navies have integrated helicopters on larger ships. Some navies also conduct coast guard operations and sea rescue operations as separate organisational services. A Coast Guard is often a part of the armed forces and is employed to protect the nation’s coast and waters, to carry out rescue operations and to conduct police work along the coast.  

Naval medicine

Naval medicine is the armed part of maritime medicine. The task of naval medicine is to ensure and support the operative capability of the ship by taking care of its crew. The only exception is rescue operations where the patients are mostly civilians.

A.8.3 Characteristics of naval medicine

Naval medicine is a special area of maritime medicine, but what is so special about it? The essence of naval medicine comes from the fact that naval ships are war ships. A war ship is a political tool whose effect is dependent on the ability to conduct war. War ships are constructed and manned differently from ordinary ships and the way they operate also differs greatly from merchant ships.

Small and crowded ships

Naval ships are relatively small, but they have a proportionally large crew compared with most civilian ships. Even if the crews on many nations´ war ships have shrunk during recent years due to the policy of lean manning and reduced costs, they are still more crowded than most merchant ships. The small size of the ships has the advantage of making them smaller targets. The concept of being a target, and therefore being able to defend themselves, has obvious consequences both for ship construction, damage control, weapon systems and the crew, including their medical service. On the other hand, small ships with large crews can expect larger groups of casualties if hit or otherwise damaged, because the traditional army strategy of dispersion of people is not possible inside a ship.

Demanding selection of personnel

The naval personnel, officers and crew, often have many jobs. They have to do the traditional maritime tasks that are integral to all ships, but in addition, they have to be prepared and possibly fight a war. Multi-tasking is often necessary. The risks are higher and often sought after. The consequence of these demands is that the selection of personnel is challenging, including competence, skills, training and not least health. It is important not to be ill, but perhaps even more important to be healthy and fit for the job. Negative selection is not enough, positive selection is essential. Selection of the right person for the right job, medically and psychologically, is a very difficult task when the scientific basis is not sufficiently developed. The navies of the world have developed and practiced detailed rules for selection of personnel for many hundreds of years, partly based on traditions and partly on experience and science. Navies have medical departments that further develop these procedures with medical reporting systems and sufficient institutional memory to convert identified lessons into current practice. Further information on medical selection in general is available in Ch 4.9.

Limited comfort from Geneva

In war, medical services are immune and protected from attack according to international law. The idea is old, but became more general and more respected after the founding of the Red Cross and their first Geneva Convention, passed in 1864. In 1907 and 1949 these international conventions were developed further to also cover war at sea. Unfortunately, the principle of separation between fighting forces and non-combatant forces, which makes it possibly to practice the immunity in land war, does not fit very well at sea.  Supposedly protected medical personnel inside a ship that is a legal target do not get any real protection at all. Only specially marked and operated hospital ships will enjoy immunity from attacks at sea. Thus, the medical personnel and facilities on board navy ships are as exposed to attack and injury as is everybody else on the ship. The ship´s doctor, and any casualties, face the same risk as everybody else if the ship sinks.

More medical personnel on-board

On board navy ships, there are not only a relatively large number of people, but also many different types of specialised people. There is a wide variety of skills available on board and almost all navy ships have medical personnel. The number, type and skills of the medical personnel varies according to ship and crew size. Equally, comparing similar types of ships within NATO, there are huge differences in medical staffing. For example, a frigate from one NATO nation will have a medical doctor, an anaesthesia nurse and a trained medic on board, yet in the same force a frigate from another NATO nation may only have a medic, or Independent Duty Corpsman.

All ships have people trained as medics to conduct first aid. In addition, these medics are often trained in prolonged care (different from land forces) since the evacuation routes from ships are longer and more insecure - if available at all. Larger ships often have medical petty officers, nurses, and doctors as the ship´s medical officers. Some nations also have a dentist on the larger ships. Most nations also have a certain degree of flexibility concerning the number and type of medical staff serving on board, and will increase size of the medical department on board when needed. The need will be determined based on a risk analysis made as a part of the operational planning, see below.

More robust land organizations

A navy is a part of the state. In many nations, the navy has played an important role in defining and providing a foundation for the state itself. Seagoing nations often have a navy that is old in terms of when it was established. If we compare navies with shipping companies, one of the characteristic differences is that navies have much larger, broader and more versatile land organisations than shipping companies. The background for this very visible difference is not only the absence of profit requirement in a navy, but more importantly the operational use and purpose of navies.

Most navies have medical heads of service, often designated as surgeon generals of the navy, and integrated medical departments. In the civilian maritime world, maritime medicine is seldom an in house capability. Naval medicine usually includes an organisation tasked to take care of implementing the lessons learned from experience and research and continuously develop the science of naval medicine.  Since there exists a sizable and important, but often misunderstood or underestimated, difference in the practice of naval, and maritime, medicine compared with ordinary land-based medicine, in house medical departments are more important than many realize.

A long tradition of rules and regulations

Navies are institutions with centuries of rules and regulations that often predate similar civilian regulations by hundreds of years. There is a hierarchy of rules and regulations and most navies have developed doctrines to describe the nature of the way they work. In these times of peace and in the post-cold-war world, the consequence of reduced budgets has forced forward joint doctrines in many navies. ‘Joint’ meaning common for the different services of the armed forces, for example army, navy and air force. The doctrines are often also combined, meaning activity done jointly between nations. Due to this development, pure naval doctrine can be hard to find except in large military nations.

Extensive international naval medical cooperation

For many nations, NATO takes care of the issue of doctrine by providing policy documents covering most relevant areas. All nation members must approve the NATO doctrines, and the other rules and regulations of NATO.

The naval doctrine of NATO is an Allied Joint Publication (AJP) with the title Allied Joint Maritime Operations (AJP 3.1). For naval medicine, the doctrine is joint and named Allied Joint Health Service Support Doctrine (AJP-4.10), but contains a chapter on naval medicine. On the level below you will find several Allied Joint Medical Publications (AJMP), among them the Medical Planning Doctrine (AJMEDP-1) which also has a chapter on naval medicine. Further down in the hierarchy there are Allied Medical Publications (AMedPs) and STANdardization AGreement (STANAGs). Most of the medical publications are unclassified.[2] In summary, these NATO publications define the service form doctrine level down to specific standardization agreements, and they are the basis for cooperation, interchangeability and most importantly, operational planning and the direction of exercises and operations.

The art of naval medical planning

One important part of the planning of naval operations is the need to tailor the medical capacities on board and the support capability in the air and on land. Previously, medical planners used historical data assembled in naval conflicts from the Second World War and up to, and including, the Falklands War.[3] Since the Falklands War in 1982 there have been few to no instances of traditional naval war between professional forces. This is different from armed conflict on land. Thus, the use of old experience-based numbers in planning was deemed outdated and a new planning concept was developed. The NATO Naval Medical Panel are the medical experts within the organisation and they have developed a new edition of the planning guide, based on a risk assessment approach.[4] Several parameters are included in the process, for example

  • type of operation,
  • types and number of casualties expected,
  • distance to bases,
  • single ship or fleets, etc.

The types of casualties are very different in naval and land warfare. The difference between casualties incurred in the civilian maritime fleet and naval casualties is smaller, but the differences in protection, personnel and procedures that a navy ship offers, compared with a merchant ship, will have a bearing on the number and distribution of casualties.

Several nations successfully tested this approach to naval medical planning, ‘war gaming’ and NATO now uses it routinely. Based on the planning tools, the navies and their operational headquarters decide the size, numbers and skills of the medical support in naval operations on a case-by-case basis for operations and in the vast number of contingency plans that have been developed. NATO divides maritime levels of care into 5 from the lowest level (1) which is international requirements for merchant ships to the highest level (5) with a hospital ship with specialised care and dedicated MEDEVAC resources. See NATO. 20218. AJMedP-1 Allied Joint Medical Planning Doctrine.[5] Level (1) of medical support in the doctrine, equivalent to that in civilian shipping, is used only when there is no significant operational risk and sufficient medical support from shore.

Medical flexibility and tailoring

Almost all naval ships have more medical personnel and more medical equipment on board than civilian ships of the same size. The only exception may be cruise ships who have more medical capacity on board due to the number of people on board, mostly passengers. During the recent smaller international conflicts the need for flexibility has been more prominent. In addition, navies have assumed roles in humanitarian support, international policing and similar tasks in addition to the traditional naval warfighting, patrolling and escorting. An example of tailored naval medicine is the deployment of small surgical teams on board frigates to support the small boat operations of special forces to combat piracy on the high seas. Naval ships are also used for the removal of chemical weapons and regulating the flux of maritime migration, to mention just two examples. In both these instances, the medical department has been tailor made for the occasion and has been a success. Some nations still have dedicated white hull hospital ships, and these have been used in different humanitarian and support operations in an effort to ‘win hearts and minds’ where the medical services have taken a prominent position. Examples include the Indian Ocean earthquake tsunami of 2004 and the earthquake that devastated Haiti in 2010[6]. Further information on maritime support for onshore major incidents is available in Ch. 9.11.

Your own medevac helicopter

The main challenge with casualties on board ships is isolation without easy access to ambulance evacuation and hospital care. In many cases, what you do not have on board, you will not have available. However, the availability of helicopters on board many naval ships makes evacuation more accessible than on civilian ships. Naval ships regularly sail in fleets and rarely as single ships. In groups of ships, the pooling of medical resources will make support more available, especially since transportation between ships by helicopter is convenient and fast.

A.8.4 History: A short note from a Norwegian perspective.

Norwegian history is a good example to underline the differences between naval and maritime medicine. Norway is a maritime nation where the sea has always had, and probably always will have, a major influence on both Norwegians and Norway, their lives, successes and tragedies. Norway has the longest coastline in Europe and the second longest in the world. Norwegian waters are almost the size of the Mediterranean ocean. The Norwegian economy is dependent on activity on, in and under the sea and transportation to, from and along the Norwegian coast are predominantly maritime. The present navy was established in the 1400s as a joint Danish-Norwegian Navy. The first ship´s doctor sailing on one of its navy ships embarked in 1493. The first surgeon employed on the main naval base in Copenhagen started working in 1536 and the first naval hospital opened its doors in 1570. The Admiralty was established in 1655 and 3 years later, the admiral got his first surgeon general for the navy. In 1659, a trust was set up to pay for the naval medical service covering expenses for doctors and hospitals, sick and disability benefits and even the building of hospitals. Contributions from all personnel and by collecting fines and gentle gifts, such as donations and voluntary support, supported the trust financially. In 1700, the first dedicated hospital ships were outfitted and up until 1807, 28 hospital ships were in service. The navy sailed to India and the West Indies, to Africa, to the East and on expeditions to the South and North. In 1807 the whole navy was lost in the Napoleonic War. A coastal navy was hastily built and, with the end of the war, Denmark and Norway separated. On 10th April 1814, a separate Norwegian navy was established.

There are two clear examples of how early the navy started with health regulations in comparison with merchant vessels.

  • All seamen in Norway, not only the ones employed by the navy, had to be examined by the navy and were conscripted both in peace time and times of war, depending on the needs of the navy. Examined sailors were not allowed to take jobs on ships sailing outside of Norway without the permission of the Navy. This structure can be traced back to the 16th century. In 1816, the King declared that the cadets had to have sufficient health to serve. In contrast, the first civilian Norwegian regulation of seamen’s health came in 1903.
  • In the Navy, provisions and diet were regulated in detail. King Christian III (1536-1559) was the first commander in chief who decided on the detailed amount and type of food given to his naval personnel and the diet of the navy has been continuously regulated since. In contrast, the first civilian Norwegian regulation of seafarer’s diet came in 1894.

A.8.5 Summary

The differences between civilian and naval practice in maritime medicine are many, the most important being:

  • the difference between a war ship and a civilian ship – its war fighting capability
  • the willingness and duty to take greater risks than civilian ships since navy ships are tools of security, sovereignty and foreign policy
  • the vast number of medical professionals of different types, both on board and in the medical departments on land, together making up medical knowledge bearing institutions capable of developing the science of naval medicine. 

Civilian shipping mainly focuses on handling single sailors becoming ill or injured on board a single ship and evacuating the sailor to shore with the sailor’s health as the priority. In case of a major incident, this may extend to the entire crew. On the other hand, naval medicine mainly focuses on handling the injuries of many after an act of war, often based upon resources found on board other ships in the same fleet and sometimes with keeping operations running as a priority over the health of the seafarer.

Having said that, there are also very many similarities. Therefore, many naval doctors also work within civilian maritime medicine. The opportunities for more productive civilian maritime and naval medical cooperation and development seem to be manifold and not exhausted. 

There is also an important lesson from earlier wars that ought to be noted. Merchant navy, civilian ships become commingled with naval ships in times of war. The merchant navy transports all the goods the navies and the rest of the warring nations need to fight, and thus become targets. Perhaps this sad, but historically consistent fact, should teach us to work for closer cooperation and more similar selection procedures.

There are differences, but also similarities, and in war, these are not so different after all.


[1] Till, G. 2013. The Economics of Sea Power. Testing Maritime Narrative for the 21st Century. In Forbes, A. The Naval Contribution to National Security and Prosperity. Proceedings of the Royal Australian Navy Conference 2012. Canberra, Sea Power Centre; 39-58.

[2] NATO Standardization Office at https://nso.nato.int/nso/nsdd/main/list-promulg

[3] NATO. 1992. Maritime Medical Planning Guide.

[4] NATO. 2014. Maritime Medical Planning Guide. Later included as a chapter in NATO. 2018. Medical Planning Doctrine (AJMEDP-1).

[5] NATO. 20218. AJMedP-1 Allied Joint Medical Planning Doctrine.

[6] Haiti Quake Day 9: Hospital Ship Arrives | The New York Times - YouTube

petty officer (PO) is a non-commissioned officer in many navies and is given the NATO rank denotion OR-5 or OR-6. In many nations, they are typically equal to a sergeant in comparison to other military branches. Often they may be superior to a seaman, generally they are lower ranks in a navy, and subordinate to a more senior non-commissioned officer, such as a chief petty officer.

Petty Officers are from different branches,for example POME (Petty Officer Marine Engineer), POHY(Petty Officer Hydrographer), POM(Petty Officer Medical).