JAN SOMMERFELT-PETTERSEN AND TIM CARTER.
CONTRIBUTIONS FROM BOB BRIDGER AND MARGARETHA HOLENSDOTTER LÜTZHÖFT (MARPOL)
‘Shipping is perhaps the most international of all the world’s great industries and one of the most dangerous’.
Humans are naturally land animals. To be at sea is to be away from the environment in which we evolved and in which most people live. People may be at sea to work in maritime transport, fishing or specialist roles, as passengers, or pursuing leisure activities such as yachting.
The maritime environment may impose risks on them, including illnesses or injuries. It may also make demands on them, mostly relating to the tasks that workers perform, but some, such as remoteness from medical care, are relevant to everyone at sea. Travel itself may lead to risks from climatic extremes and from exposure to novel infections. Isolation and the work demands within the maritime setting can threaten wellbeing.
The recognition, evaluation and management of the risks and demands of being at sea are all components of maritime health. A range of disciplines is involved in identifying, preventing and managing the risk and thus ensuring that maritime work and leisure activities can be fulfilling while minimising adverse health effects. Disciplines include designers, engineers and managers as well as professional practitioners in medicine, psychology, occupational safety and health and related subjects.
Maritime health professionals require certain specialist skills in addition to those skills required for working ashore, including knowledge of the maritime living and working conditions. Practitioners have an important part to play in identifying health risks on board and in recommending ways of minimising them, usually in collaboration with other disciplines. To do this they may work as national or international policy makers, as company or trade union advisers, or as independent practitioners. It is important that they work within a framework of ethical standards such that their first duty is caring for the health of all who go to sea. More information on the ethical aspects of maritime health is available in Ch 2.9.
Maritime medicine is, in its essence, a global practice and historically, it was the start of international medicine. Maritime medicine comprises all the medical sciences relevant to sailors and their workplaces as well as to ships, harbours and docks and practitioners need to have clinical skills in the assessment of fitness and an understanding of the practicalities of delivering emergency treatment at sea. They may work ashore or sometimes on board a ship. There is not a clear, easy or precise definition of maritime medicine, but it can be described as
a discipline of medicine that is practised outside medical institutions. The patient is often treated on a ship in the middle of the ocean. The ship as a workplace is seldom at rest. The ship will not only roll and pitch, but sail in many, sometimes hostile, environments; physically, climatically and culturally.
The ship is more than a workplace that moves. It is at the same time, a home and a place for leisure. The ship is a 24-hour society, often with representatives of many different cultures on board and long periods of isolation from loved ones, friends and family. Ships are also isolated in the sense that what is not taken on board will not be available. Another special feature is that medical personnel do not usually practise medicine on board - non-medical personnel with very limited education in first aid and medical treatment deliver care on board the majority of ships. The patient will be a colleague and very often first aid is not enough, prolonged treatment is required because evacuation is impossible at that time. From a legal perspective, the ship is strange, complex and globalised. International conventions often provide minimum rules and regulations, national rules and regulations apply according to flag and, when the ship literally sails to different national legal systems, unexpected and dynamic legal challenges can arise. More information on the regulation of the shipping industry is available in Ch 2.10.
The institutional anchor for maritime medicine is fragile. In most university hospitals, there are departments, consultants and professors covering almost any and all medical specialities, except maritime medicine.
Maritime medicine is special and so extreme that it is necessary to consider the interface between health, safety and risk. All on board are dependent on the safety and integrity of the ship thus safety is sometimes more important than health. It is important to ask which focus will be most efficient, medical treatment or medical prevention. From a public health perspective, the issue is important, and the historical examples given in this chapter will stress the point.
Knowledge of maritime medical history makes it easier to understand maritime medicine in general and today’s challenges in particular. The history of maritime medicine is long and will not be presented chronologically, but thematically in four themes - the sea, the ship, maritime medicine and the sailors.
H.12.1 The sea
‘The complex and all-consuming Ocean feeds man, but also feeds upon men. The flat calm that gently digests my troubles is capable of violent turbulence and of enough gluttony to chew up and spit out vessels of the strongest steel. Often swallowing men and ships
Everyone with a connection to the sea has heard the saying ‘The sea gives, and the sea takes away’. The sea can be a dangerous place, and many have found a wet grave. The sea covers more than 70 % of the surface of the earth and slowly man has learnt to be able to travel over the sea in safer and healthier ways.
From a Norwegian perspective, up to 90 % of all export from and import to Norway takes place on ships and shipping, fisheries and the pumping of oil and gas from the seabed are central to the Norwegian economy and society. The sea is an important factor for life and health and thus of central importance in maritime medicine. Internationally around 90 % of all goods transported are transported by sea. 
Prehistoric peoples crossed seas as settlement spread around the globe and by classical times, the Mediterranean was the theatre for both regular trade routes and for occasional naval battles. Similar patterns were seen around the coasts of Asia, while the navigational achievements of Polynesians in settling on remote islands in the Pacific Ocean took place around the same time. Viewed from a Norwegian perspective the recorded history of maritime activities is a long one. Around the year 1000, Leif Erikson and his crew (ca. 973 - ca. 1020) sailed westward and became the first European to set foot on the American continent. They sailed close to the coasts, did not stay for extended periods at sea and there is nothing to indicate any health problems during the voyage. Several sagas document the trip, but it was disputed for a long time until proven by archaeological excavations at L’Anse aux Meadows in Newfoundland in 1960. Leif Erikson demonstrated the possibilities of exploration and long travels at sea and in time these became a substantial challenge to the health of seafarers.
The sea opens a world of challenges and possibilities. Dry fish has been a very important industry since Viking times. Dry fish is usually dried cod and drying fish was the preferred method for conservation until affordable salt from Southern Europe became available in the 16th century. Clip (salted and part dried) fish then became an alternative. In the 9th century, dry fish was the most important export commodity from Norway and in Egil Skallagrimsson’s saga we can read about the headman Torolv Kveldulvsson’s export of dry fish from North Norway. In 875 he sailed with cod from Lofoten to England “to buy clothes and other necessities” In the 10th century the dominant position of Bergen and its merchants was established, based on this export business. Dry fish was an important source of food both on board and on land.
Ownership of the sea
From around 1300 onwards the Atlantic facing nations of Europe, first Spain and Portugal and then later Britain, France and the Netherlands, embarked on oceanic voyages, discovering new lands, often plundering them and fighting with one another over the spoils.
In 1493 Pope Alexander VI (1431-1503) drew a line of demarcation 550 km west of the Cape Verde Islands and gave control of territory to the west of the line to Spain and east of the line to Portugal. Portugal contested the decision and in 1494, after negotiations with Spain, the line was moved to 2055 km west of the Cape Verde Islands according to the Treaty of Tordesillas. Portugal used this treaty when Pedro Alvares Cabral (1467-1520) discovered Brazil for Portugal in 1500. No other countries accepted this treaty and many countries started claiming different parts of the ocean. Denmark-Norway laid claims to the North Sea, Kattegat and the Baltic Sea. In his book Libre marum (1609), the Dutch thinker Hugo Grotius (1583-1645) gave his arguments for the view that the sea was free for all. The arguments were most useful for Dutch economic interests and the successful expansion of the first multinational company in the world - the Vereenigde Oost-Indische Compagnie (VOC). The English did not accord and demanded sovereignty over the waters around their island. In Mare clausum (1635), John Selden (1584-1654) argued that the sea could be occupied in the same way as land areas. In his ‘De Dominio Mmaris of 1702, Cornelius van Bynkershoek (1673-1743) contended that a country could claim sovereignty as far out from the coast as a canon could shoot. This idea became the internationally accepted principle of a three-mile limit defining a country's territorial waters.
Freedom of the seas was gradually accepted as a part of international law. Today, these rules are incorporated in the United Nations Convention on the Law of the Sea, UNCLOS, of 1982. For ships sailing on the open - and free – seas, the principle is that flag state regulations apply. More information on the law of the sea is available in Ch 2.10.
Techniques of navigation improved as voyages lengthened. Methods for taking sights on the sun and stars were developed. Charts plotting water depths and coastal profiles were produced, both in Europe and in Asia, where for a short period Zeng He, a Chinese admiral explored widely.
One of the most serious threats to life at sea is shipwreck. On October 22nd 1707, four naval ships were wrecked on the Scilly Islands, southwest of Cornwall off the English coast. The fleet of 21 naval ships was under the command of Admiral Cloudesley Shovell (1650-1707) and he perished, along with the complete crew of his flagship, a total of 800 men. The reason for the mishap was navigational, they had not managed to estimate their position correctly. Subsequently, in 1714 the British Parliament passed the Longitude Act and a Board of Longitude was established. The Board announced a reward of £20 000 to anyone who could find a reliable method of determining the longitude at sea, equivalent to £2.89 million in 2018.
Many tried to find a solution to the problem. One method that worked was astronomical, but it was too difficult for navigators to use. The watchmaker John Harrison (1693-1776) solved the problem by inventing a very accurate clock, a ships’ chronometer, to estimate the longitude. The Board of Longitude never gave him - or anybody else - the award. The issue was hotly debated for a long time, and when Harrison had turned 80 the Parliament awarded him £8 750 for his work. Harrison’s chronometer solved the problem and was a huge step forward in navigational safety. His invention has saved the lives of countless seafarers. The Board of Longitude was dissolved in 1828 because its purpose had been fulfilled.
Since this time, navigational aids have continued to improve with the publication of detailed charts, the building of lighthouses and placing of buoys, culminating in digital charts and global positioning satellites that enable positions and courses to be plotted to within a few metres.
One of the great risks of seafaring is bad weather. Experienced sailors have respect for the weather, but a storm can surprise those already at sea. A weather forecast is a meteorological prognosis on the upcoming weather. Thanks to Samuel Morse, (1791-1872) and the invention of the telegraph in 1837, it became possible to collect many real time observations of the weather in a large area and this increased the quality of weather forecasts. Around the same time, the Irish hydrographer and Admiral, Francis Beaufort (1774-1857) invented a scale to standardise wind measurements. At The Battle of Sevastopol in 1854, an unforeseen storm destroyed many French and British naval ships. This tragic event encouraged the Admiral to do more and he organised the first successful network of ground observation posts for weather in the mid-1800s. He also influenced the English Vice Admiral, hydrographer and meteorologist Robert FitzRoy (1805-1865) who developed a special type of barometer and distributed the instruments to several ports. In 1862, FitzRoy organised the first storm warning weather service based on information collected through telegraph messages.
The Norwegian physicist Vilhelm Bjerknes (1862-1951) developed a cyclonic model to explain atmospheric air movements in the early 1900s. He discovered the physical explanation for polar fronts and introduced the concepts of warm and cold fronts. His research group, called the Bergen School, and the models they developed are still accepted and in general use. Bjerknes is described as the father of weather forecasting.
Improvements in meteorological science and in communications, starting with the deployment of weather ships and balloons carrying instruments into the upper atmosphere and now complemented by satellite observations and computer modelling of air movements have improved the predictive value of forecasts. But major weather events such as hurricanes do still put ships and crews at risk.
Avoid landing on a stormy day
Figure 1 Landing ships putting cargo ashore on Omaha Beach, at low tide during the first days of the operation. Photo: https://commons.wikimedia.org/w/index.php?curid=2263487
The Allied invasion of Normandy was originally planned to start on June 5th 1944. It was the largest amphibious operation ever conducted. The Norwegian meteorologist Sverre Petterssen (1898-1974) was one of the experts asked to do the important weather forecast for this risky amphibious operation. He concluded that the weather would be too bad by using the methods of the Bergen School.
“Petterssen managed to pull the brake on June 4th … and he was right. On the 5th of June a heavy storm ravaged the channel”.
The Germans expected bad weather and relaxed their readiness. Petterssen convinced General Dwight D. Eisenhower to postpone the operation one day. There is substantial disagreement about the weather forecasts prior to D-day. Three different meteorologist centres produced forecasts, using the same set of observations, but varying in methodology. One day before the invasion was planned Petterssen managed to convince the Admiralty to support his position and to postpone the invasion. The Americans disagreed. Stagg summed up the recommendations, two against one, and presented the majority view to Eisenhower. The invasion was delayed one day. 
President John F Kennedy once asked Eisenhower why the invasion of Normandy became a success. His reply? ‘Because we had better meteorologists than the Germans’. The invasion, Operation Overlord, was one of the biggest military operations ever conducted. 24 000 paratroopers were dropped over the target, 156 000 soldiers were transported on around 700 ships and 5 400 fighter planes, and 3 000 bombers flew 14 000 sorties the first day.
H.12.2 The ship
For sailors the ship is their world. For the ship owner the successful completion of the voyage is essential. For both, the safety of the ship is paramount. These truths have remained, but ships have changed markedly over the years.
Shipbuilding was a skilled trade in the ancient world and wood was the chief raw material. Wooden ships became larger and more seaworthy as voyages lengthened and building techniques improved. Cargo carrying ships needed maximum cargo capacity, those carrying urgent and valuable goods needed speed, while ships designed for fighting needed the speed, manoeuvrability and the capability to ram, board or later fire at the enemy.
Until the late eighteenth century wood remained the main construction material and propulsion came from the wind on sails or human muscles pulling oars. The development of the steam engine and improvements in iron and then steel making led to a massive transformation in ships between 1800 and 1900. They became larger, faster and able to steer predictable courses to a predetermined timetable. While the risks of crew death and injury were less than on sailing ships, the increase in speed and size, and hence crew and passenger numbers made the worst-case disaster scenario ever greater.
The ocean liner RMS Titanic collided with an iceberg on April 25th 1912 and disappeared from the surface three hours later. At the time, Titanic was the world’s largest ship and on her maiden voyage from Southampton to New York. She had 20 lifeboats launched with 705 people (of which 675 were women and children) and three pets. There were enough life jackets and when Titanic disappeared from the surface, around 1 500 persons were in the cold Atlantic. It was a quiet night and around zero degrees Celsius. Everybody in the sea perished from exposure and hypothermia.
Figure 2 RMS Titanic departing Southampton on April 10, 1912. Photo: F.G.O. Stuart (1843-1923) - https://commons.wikimedia.org/w/index.php?curid=2990792
Because of this disaster, the first Safety of Life at Sea (SOLAS) convention was signed on January 20th 1914. SOLAS requires, amongst other things, that all ships have enough space in the lifeboats for all passengers and that all ships always have an obligation to listen to radio. This convention was the beginning of a new era of international collaboration on maritime safety.
The beginnings of similar international collaboration on maritime health can be identified. By 1920, many major maritime states had specified requirements for medical care at sea including fitness to work, medicines, a medical guide and training for officers. In the 1920s the Red Cross and the newly established International Labour Office, took several initiatives to promote the health of sailors. In Norway, the Red Cross asked Lieutenant Commander and doctor Harald Engelsen (1883-1954), then head of the Navy Bacteriological Laboratory, to take on this important work. In 1924, the general assembly of the International Red Cross passed a resolution tasking the Norwegian Red Cross to make an international medical guide for ships and a standardised medical chest on board all ships. If all ships had a medical guide and medical supplies on board, radio medical advice would be greatly simplified for all. 
Dr Engelsen presented the work done to the International Conference on Sailor’s Health in Oslo, Bergen and Trondheim in 1926. He presented an International Medical Guide for Ships along with a special set of medical code signals for use over radio. He also proposed a standardised medical chest for ships. This Norwegian medical guide for ships was translated into French, but getting the book internationally accepted by all nations was difficult. However, it was widely distributed and in 1927 it was authorised for use on all Norwegian vessels. At the same time the Norwegian Parliament decided to further the efforts to improve sailors’ health by donating the large sum of 200 000 Norwegian kroner to the Red Cross work for sailors At the Red Cross international conference in Tokyo in 1934, the International Medical Guide for Ships was recommended for all nations.
Following World War II work continued and finally, in 1967 that the ILO, World Health Organisation (WHO) and the International Maritime Organisation (IMO), published the first edition of the International Maritime Guide for Ships. The second edition was published in 1988 and translated into more than 30 languages, the third edition was published in 2008.
International Code of Signals
Figure 3 The flag for "w"
The aim of the International Code of Signals (ICS) is to ‘provide ways and means of communication in situations related essentially to safety of navigation and persons, especially when language difficulties arise.’
ICS has a long history and the signals can be sent in many ways, from using light to flags or radio. The code “W”, means ‘I require medical assistance’.
In 1930 a new version of the international code of signals was produced and passed by the International Radiotelegraph Conference in Madrid in 1932. Because of Engelsen’s initiative for sailor’s health, the medical section was approved by the Office International d’Hygiene Publique in Paris.
The oil tanker SS Torrey Canyon was wrecked just off Lands’ End in southwest England on March 18th 1967. The weather was fine. The wreck was attributed to a navigational error, the human factor was to blame. The ship was large, 120 000 dwt, and the largest vessel ever to run aground. Several attempts were made to save her, but on March 27th, the salvage party had to abandon their attempt because of poor weather. After eight days the ship broke in two. To limit the oil spill from the huge ship she was bombed and eventually sunk by air assets from the Royal Navy. The cargo was crude oil and the spill polluted large areas in South England, the Channel Islands and Bretagne.
The accident with SS Torrey Canyon was the largest oil pollution disaster ever at that time and it led to the development of international conventions to combat oil pollution and institute contingency measures to limit the effects of oil spills. An International Convention for the Prevention of Pollution from Ships (MARPOL) was developed in 1973. Again, we see that serious accidents are necessary to change rules and regulations.
H.12.3 Maritime Medicine
Admiral Richard Hawkins (c. 1562-1622) called scurvy ‘the plague of the Sea, Scurvy is probably the disease that has killed more sailors than any other cause. Today scurvy is an extremely rare disease and most doctors have never seen such a patient. Scurvy is characterised by ‘… prominent cutaneous signs (petechiae, perifollicular haemorrhage, and bruising), gingivitis, arthralgias, and impaired wound healing, appearing within a few months of a vitamin C-deficient diet.’
Scurvy became a common problem for explorers during the long voyages in the 15th century. With the exception of some Vikings 4-500 years earlier, the Portuguese were the first to encounter scurvy. Vasco da Gama (c. 1460-1524) left Lisbon with a fleet of four ships and 160 men on 8th July 1497. He sailed to find the new route to the east and he reached India. After a couple of months on board, scurvy appeared and da Gama lost over 100 of his 160 men to scurvy. No efficient treatment was known.
Only three years later, Pedro Alvares Cabral (1467-1520) described an efficient treatment for this terrible ailment in a travelogue. He stated that in Mombasa his scurvy patients got treatment and ‘the oranges made them well again’. The solution to the problem was found, forgotten and found again, many times.
George Anson’s first circumnavigation
Commander George Anson (1697-1762) sailed from England with a fleet of seven ships in 1740. When he returned four years later, only 145 of the original crew of 1955 were alive. Around 1300 of more than 1800 deaths were caused by scurvy. The expedition was viewed as one of the largest medical catastrophes in its time. This was also the first time scurvy became a problem discussed in public. The ship’s surgeon thought salt meat and laziness were to blame. The College of Physicians recommended vinegar against the illness and the Admiralty accepted their recommendation. Anson himself wrote a report, ‘Voyage Round the World in the Years 1740-44’, published in 1748 and it became so popular it was reprinted several times during the first year after its publication.
Figure 4 A portrait of Scottish doctor James Lind (1716–1794) by Sir George Chalmers, c 1720-1791. Photo: https://commons.wikimedia.org/w/index.php?curid=32922810
During the Seven Years’ War (1756-1763) out of a total number of 184 899 men, the British Royal Navy lost 1 512 (0,8 %) men in war and 133 708 (72 %) to illnesses. Scurvy was the major cause of death. Obviously there were a number of good reasons why the “the plague of the Sea” should be stopped. The problem was, it could not be solved because it could not be understood.
James Lind and the world’s first controlled medical experiment
In 1746, the Scottish surgeon James Lind (1716-1794) signed on as a ship’s surgeon on HMS Salisbury. The ship had a crew of 350 men and that year they had a large outbreak of scurvy with more than 80 taken sick. Next year they again had an outbreak of scurvy and Lind conducted an on-board medical experiment. He isolated twelve sailors with scurvy and gave them all the same diet. Then he divided the patients into groups of two and gave these groups different additional diets for 14 days. The six additional diets were
‘Two of these were ordered each a quart of cider a day. Two others took twenty five gutts of elixir vitriol three times a day, upon an empty stomach; using a gargle strongly acidulated
with it for their mouths. Two others took two spoonsful of vinegar three times a day upon an empty stomach; having their gruels and their other food well acidulated with it, as also the gargle for their mouth. Two of the worst patients, with the tendons in the L arm rigid, (a symptom none of the rest had) were put under a course of sea-water. Of this they drank half a pint every day, and sometimes more or less as it operated, by way of gentle physic. Two others had each two oranges and one lemon given them every day. These they eat with greediness at different times, upon an empty stomach. They continued but six days under this course, having consumed the quantity that could be spared. The two remaining patients took the bigness of a nutmeg three times a day, of an electuary recommended by an hospital-surgeon, made of garlic, mustard seed, rad. raphan. Balsam of Peru, and gum myrrh; using for common drink, barley water well acidulated with tamarinds; by a decoction of which, with the addition of cremor tartar, they were gently purged three or four times during the course.’
Lind tells us that the two who got oranges and lemons swiftly became better and could take part in the nursing of the other patients. The two who got cider also improved and after two weeks
‘the putrefaction of their gums, but especially their lassitude and weakness were somewhat abated ... As to the elexir of vitriol, the mouths of those who had used it by way of gargarism [as a gargle] were in much cleaner and better condition than many of the rest, especially those who had used vinegar; but I perceived otherwise no good effects of its internal use upon the other symptoms ... There was no remarkable alteration upon those who took the electuary and tamarind decoction, the sea-water, or vinegar, upon comparing their condition, at the end of the forthright, with others who had taken nothing but a little lenitive [pain-killing] electuary and cremor tartare, at times, in order to keep their belly open; or a gentle pectoral [cough syrup] in the evening, for relief of their breast.’
Lind concluded that ‘oranges and lemons were the most effectual remedies for this distemper at sea’. Lind started his experiment on 20th May 1747 and Professor of Public Health, Dag S. Thelle asserts that Lind’s experiment was the first ever, controlled experiment. James Lind has been awarded the honour of being named the “father of naval medicine” and 20th May has been named International Clinical Trials Day in his honour. Maritime medicine has certainly made some positive impact outside the field of naval medicine.
Change of diet
The Royal Navy did not introduce citrus fruits into the diet of their sailors until many years later, in 1795 when navy surgeon Gilbert Blane (1749-1834) succeeded in convincing the Admirals to do so. When First Lord of the Admiralty, Admiral George John Spencer (1758-1834), visited the Royal Navy Hospital at Haslar in 1797, there was not a single patient in the hospital with scurvy. Usually they accounted for up to 50 % of the patients. Scurvy was defeated, the blockade against Napoleon was possible to carry through so Napoleon could be defeated - and the British sailors got the nickname ‘limeys’.
The discovery of nutritional disease
Unfortunately, scurvy later reappeared and was a most feared disease in arctic expedition - a field where Norwegians were prominent.
Around 1900, two Norwegian doctors, Axel Holst (1860-1931) and Theodor Frølich (1870-1947) became interested in beriberi, which ravaged Norwegian ships, but was seldom seen on ships from other nations. They suspected that the illness could have a connection to the sailors’ diet. They established an animal model using guinea pigs to study the effects of different diets, and, to their surprise, rather than developing beriberi, the guinea pigs got symptoms of scurvy on a diet of products from grain, but not if they added fresh cabbage or lemon juice to the diet. They also showed that animals already sick from scurvy could be cured by the same diet. Holst and Frölich concluded that scurvy was an illness of nutrition. At this time in history, the idea of nutritional disease was not yet invented. In 1907, they published their findings in the international Journal of Hygiene and met a lot of opposition from colleagues who did not subscribe to any idea of deficiency disease or any theory of disease caused by nutrition. Poisoning and infection were causes that were much more popular at the time. They did not get any acknowledgement or prizes for their research and consequently moved on to other fields.
In 1912, Casimir Funk (1884-1967), a Polish chemist doing research at the Lister Institute in London, presented an unusual hypothesis. He asserted that scurvy, pellagra, rickets and beriberi, all represented a class of diseases caused by deficiencies in the diet. The lack of certain nitrogen’s with the ‘amine’ structure caused each of these diseases. He called these structures vitamins (short for vital amines) and became the name giver for a new concept of vitamins as important substances in health.
The Hungarian Albert von Szent-Györgyi Nagyrápolt (1893-1986) managed to isolate ascorbic acid and identify the acid as vitamin C. He was awarded the Nobel Prize in 1937 for his important achievement. The fight against the plague of the sea was finally crowned with victory.
Sudden death of immersion victims
During the efforts to salvage SS Torrey Canyon in 1967, there was an explosion on board the tanker and people from the salvage teams ended up in the water. Navy doctor and then lieutenant, Frank Golden was on duty at the nearby Naval Air Station. The Royal Navy search and rescue helicopter rescued the salvage team from the sea but unfortunately, Captain HB Stal died after he was hoisted from the sea. This sad fact frustrated Golden and he was even more disturbed by the lack of medical understanding of what happens when personnel are rescued from immersion in the sea. The knowledge on details around immersion in cold water was insufficient. Golden enlisted in a PhD programme at the University of Leeds and the theme of his dissertation was the effect of cold immersion. His lifelong interest and effort in the field resulted in new and improved procedures for rescue from the sea and test procedures for maritime survival equipment. Of special importance was his discovery that it is a huge risk to hoist people from the sea in a vertical position. Rescue from the sea must be made in a horizontal position to avoid possible deaths caused by post-immersion collapse. This form of death was mentioned as far back as James Lind and the Second World War highlighted it. Nevertheless, it was not until Golden’s effort that the procedures were both understood and changed.
H.12.4 The sailors
The maritime sector depends on competent and reliable seafarers. Maritime health interventions contribute to this in many ways, these require a range of technical, operational and clinical (medical and psychological) skills.
Figure 5 A sailor on his way to the doctor at the Norwegian Public Health Office in New York. Photo: Official Norwegain War Photo
Some say that personnel are the most important resource. Sailor’s skills are important for the job they are doing. It is essential to have the right man or woman in the right place to ensure that the task is accomplished safely. Most accidents at sea seem to be a result of the human factor. Medical selection is one important tool to ensure that the sailor is fit for duty.
Medical selection is a tool used to get the right man or women in the right place at the right time. A prerequisite for successful selection is not only medical knowledge, but just as important, is the doctor’s knowledge of the workplace and the procedures used at work. When you add sailors with illnesses or injuries to the equation the seaman’s doctor must consider if the sailor is fit for work with the illness or injury, the assessment becomes even more complicated. Before deciding if the sailor is fit for work, the seafarer’s doctor should assess the risk for the ship, the risk for others and the risk for the sailor himself depending on the function, the job, the ship and the circumstances. This is a very complex matter and differs significantly from providing ordinary medical treatment.
There is a long history on the selection of sailors leading to present day practice, more information on which can be found in Ch 4.8.
Health of gunners and cadets
The Navy made the oldest known health prerequisites for service at sea. In the 1600s, gunners in the Danish-Norwegian Navy had to be found seaworthy to be enrolled. The Naval Academy of the Danish-Norwegian Navy was established in 1701 and after the separation of Norway from Denmark in 1814 a Norwegian Naval Academy was built in Fredriksvern. A Royal Decree of 1816-12-23 laid down the regulations for the academy and these contained requirements for the cadet’s health and mobility. They demanded normal ability of speech, hearing and eyesight and if any cadet did not meet any of these standards, they should be dismissed.
Health requirement for the merchant navy
Civilian maritime health regulations started with requirements concerning normal eyesight, hearing and the absence of contagious diseases. For navigators and deck crew there was also a requirement for normal colour vision. The health requirements were gradually extended to include an assessment of the risk of getting ill and need for repatriation because of illness. The Insurance Company Skuld established a more comprehensive system for pre employment health examinations in cooperation with the authorities. The Skuld system started June 10th 1938. During the Second World War the Norwegian Government in exile took over the Skuld system and established Norwegian Public Health Offices in relevant ports.
In 1946, International Labour Organisation passed a convention on medical examination of sailors. The convention requires health examination before entering service and requires sufficient sight, hearing and absence of contagious diseases. See Ch. 4.8
War and mental health in seafarers
During the Second World War, the Norwegian merchant navy was one of the biggest in the world and the Norwegian ship owners had invested heavily, especially in tankers. After the German attack on Norway on April 9th 1940, the government ordered all Norwegian ships to proceed to ports controlled by the allied forces. Norwegian ships outside Norwegian waters were organised into a single government shipping company called NORTRASHIP and all of them sailed in support of the allied war effort. The sailors, around 35 000 men and some women, suddenly became a part of the war effort without ever being medically selected for this task. On the other hand, the merchant navy was Norway’s most important contribution to the allied war effort. In 1941, the British admiral Gerald Charles Dickens stated that ‘were it not for the Norwegian Merchant Marine, we might as well have asked Hitler for his terms’
In addition, the merchant navy earned a lot of money and thus the Norwegian government in exile had substantial economic freedom during the war and a solid basis for the rebuilding of Norway after the liberation. On the other hand, the handling of the Norwegian wartime sailors after the war ended appears more like a public health disaster.
Hoffman conducted one of the earliest surveys of the health of wartime sailors in 1945. He studied 155 sailors admitted to convalescent homes in America. He found 61 sailors with conditions assessed as due to war experiences. The symptoms were insomnia, jumpiness, tremor, vegetative dysfunction and depression. There were very few hysterical reactions. Hoffman also showed that most of the sailors got their problems after repeated exposure to trauma and not after single experiences.
Shortly after the Second World War, a Danish group of researchers under the direction of Dr Per Helweg-Larsen who studied concentration camp prisoners demonstrated a typical clinical picture the so-called KZ-syndrome. The group had higher morbidity and problems with concentration, irritability, nervousness, depression, insomnia and headache. Some of them had immediate onset of symptoms while others developed symptoms later.
These investigations were among the earliest to identify the symptoms that are now widely recognised as characterising post-traumatic stress disorders.
Maritime health is in its essence both international and global. It cannot be sufficiently understood within a narrow medical perspective, but must include the technical, economic and cultural aspects of shipping. Solutions internal to the shipping industry or internal to individual nations cannot solve today’s challenges in maritime health. Problems cannot be solved in splendid isolation, but by international cooperation. Maritime medicine, unlike much specialised onshore clinical practice, includes care of the healthy and, as such, is close to public health and occupational health. However, when sailors get ill or injured or end up with late onset ailments, maritime medicine needs to include the relevant elements of all specialities of medicine.
International maritime health initiatives and cooperation must be based on sound and solid medical knowledge. Institutional competence in this field is scarce and there is a need for many more centres of maritime health and medicine to serve as anchors for maritime medicine practice and research. Shipping is one of the economic sectors with the highest mortality and morbidity, and more research is needed to guide efforts to further the health of the sailor and the whole maritime sector. This chapter has given some examples of successful and unsuccessful initiatives in the past; may the future developments make the lessons identified into lessons learned.
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 “Scurvy could not be cured because it could not be understood” (Bown, 2003; 11).
 “… water-gruel sweetened with sugar in the morning; fresh mutton-broth often times for dinner; at other times puddings, boiled biscuit with sugar etc. and for supper, barley and raisins, rice and currants, sago and wine, or the like.” Lind, J. 1753. A treatise of the scurvy. Edinburgh; 191.
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 Golden, F. Et al. 1997. Review of rescue and post immersion problems - a medical ergonomic viewpoint. Guildford, Robens Institute, University of Surrey. 41 pp. IMO has also developed a guide for survival in cold water (IMO. 2012. Guide for cold water survival).
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Pop up: October 9th is designated Leif Erikson Day by the American Congress in 1964. The date was selected because it was the date in 1825 when the ship «Restauration» from Stavanger arrived in New York with 52 Norwegian immigrants on board - the first organized emigration from Norway to North America.
Pop up: King Håkon Håkonsson (1217–1263) gave the Bergen merchants a monopoly on trade with Northern Norway, a monopoly that held until 1715. Dry fish made Bergen one of the biggest trading centre at the time.
Pop up: VOC was founded on March 20th 1602 and closed down In 1799. VOC was the first company to issue shares that could be bought by anybody (https://en.wikipedia.org/wiki/Dutch_East_India_Company Visited: 2018-10-15). Many Norwegians took employment on VOC ships VOC (Sogner, S. 1994. Ung i Europa. Norsk ungdom over Nordsjøen til Nederland i tidlig nytid. Oslo, Universitetsforlaget).
Pop up: The territorial limit is today 12 nautical miles. In addition, costal states have 200 miles economic zone. Before 1982 there was a lot of disputes on borders at sea and especially on the issue of fishing rights. One example is the three cod wars between Great Britain and Iceland (1958-1961, 1972-1973 and 1975-1976). (https://en.wikipedia.org/wiki/Cod_War Visited: 2018-10-15).
Pop up: Robert FitzRoy var commanding officer on HMS «Beagle» on which Charles Darwin sailed to South America in 1833.
Pop up: Sverre Petterssen was professor at Massachusetts Institute of Technology (MIT) from 1939-41. He was asked to come to England to support the meteorological institute with weather forecasts for the Royal Air Force. He was lieutenant colonel in the Technical Board of the Norwegian Joint Defence Command [Forsvarets Overkommandos Tekniske Utvalg] 1942-45). His forecasts were important for operations against Tirpitz and operation Shingle in Italy. Before the war he had been in charge of the weather forecasting in Western Norway. Litterature: Petterssen, S. 1974. Kuling fra Nord. En Værvarslers Erindringer. Selvbiografi. Oslo, Aschehoug. American edition: Petterssen, S. 2000. Weathering the Storm. The D-Day Forecast and the Rise of Modern Meteorology. American Meteorological Society.
Pop up: “The first International Code was drafted in 1855 by a Committee set up by the British Board of Trade. It contained 70,000 signals, it used eighteen flags and it was published by the British Board of Trade in 1857 in two parts; the first containing universal and international signals and the second British signals only. The book was adopted by most seafaring nations.” (The Naval Marine Archive. The Canadian Collection. 2012-03-21, http://navalmarinearchive.com/research/history_international_code_signals.html Visited: 2018-10-30). Before the middle of 1800s there was a host of different systems of signalling, but all of these systems were either private or naval.
Pop up: To which extent scurvy was known in ancient times is debated. The problem is that if we look for diagnoses, we pose an unhistorical question. Doctors did not “think” in diagnosis, but in symptoms. The symptoms were not combined into illnesses or diagnosis’. Classification as a scientific tool was an invention of the Swedish doctor Carl von Linnés (1707-1778). As a side it is interesting to note that he also was the surgeon general of the Swedish navy. Dr Thomas Sydenham (1624-1689) extended Linnés large project of classification to medicine.
Pop up: Hoffmann did not find many studies on war neuroses in sailors. The only one he found was a study of 40 sailors having been torpedoed. Margolin, S. Et. Al. 1943. Acute Emotional Disturbances in Torpedoed Seamen of the Merchant Marine, who are continuing at sea. War Medicine. 3; 393-408.