All of the medicines, medical supplies and equipment, that ships without a doctor on board are required to carry whilst at sea is commonly referred to as the ‘medicine chest’. This is because historically, the medicines carried on board during the age of sail were kept inside wooden chests.
While international requirements to carry a medicine chest are in place, no single formal list that specifies its contents exists, except for ships carrying dangerous goods. In 1944, the International Maritime Organization (IMO) mandated this in their Medical First Aid Guide for Use in Accidents Involving Dangerous Goods (MFAG) publication .
This lack of standardization was first addressed by the World Health Organization (WHO) in 1967 with the publication of the first edition of the International Medical Guide for Ships (IMGS) which included a list of the minimum recommended medicines, medical supplies and equipment that must be present on board . However, this list was only a recommendation and has remained as such in the subsequent 1988  and 2007  editions of the IMGS.
The required contents of medicine chests relate to the treatment needs of seafarers on board in emergencies. They do not include medicines needed for the long term treatment of disease, nor do they necessarily meet the needs of passenger vessels, in particular for the treatment of children
D.4.2 International Statutory requirements
The following lists, in chronological order, the international standards, requirements, regulations and recommendations that apply to the ship’s medicine chest.
- 1947: The International Labour organization (ILO) in its Accommodation of Crews Convention  states in Part III, Article 14.7 that ‘An approved medicine chest with readily understandable instructions shall be carried in every ship which does not carry a doctor’.
- 1958: The ILO in its Ships' Medicine Chests Recommendation  contains an annex which details the contents of the medicine chest as well as requiring the presence of a guide to explain how the contents of the chest are to be used.
- 1966: The ILO in its Accommodation of Crews (Fishermen) Convention  states on Article 13 that ‘An approved medicine chest with readily understandable instructions shall be carried in every vessel which does not carry a doctor
- 1987: The ILO in its Health Protection and Medical Care (Seafarers) Convention  states the requirement for the carriage of a medicine chest, the labelling specifications of its contents, the requirement for inspection at regular intervals and the obligation of specific antidotes to be carried on board when dangerous cargo is carried.
- 1994: The IMO published its Medical First Aid Guide for Use in Accidents Involving Dangerous Goods (MFAG)  with subsequent revisions of the guide being reproduced in the Supplement of the International Maritime Dangerous Goods (IMDG) code. This guide is meant as a chemicals supplement to the IMGS published by the WHO.
- 2006: The ILO in its Maritime Labour Convention (MLC 2006)  states in standard A4.1 the requirement for the carriage of a medicine chest, the requirement for inspection at regular intervals, the presence of specific antidotes depending on the cargo carries as well as the determination of the medicine chest’s contents by taking into account the recommendations of the IMGS published by the WHO.
- 2007: The WHO published the 3rd edition of the IMGS  that was followed up by the publications of a Quantification Addendum in 2010  which listed the medicines, medical supplies and equipment as well the quantities that are recommended to be on board ships without a doctor on board and calculated for voyages of one month.
- 2007: The ILO in its Work in Fishing Convention  and Work in Fishing Recommendation  established minimum standards for the medical care of fishers at sea.
In summary, ships must have medicines, medical supplies and equipment on board which must be:
- Adequate in quantity that depends on, the distance travelled from the closest shore, the duration of the voyage, the number of crewmembers and the nature of the cargo being transported.
- Kept in good condition, clearly labelled in a language understood by the crew (usually English) and readily available for use.
- Be periodically inspected in intervals not exceeding 12 months by a competent person.
If the ship meets all of the above requirements, the supplying pharmacy issues a Medicine Chest Certificate (MCC) of compliance. This is signed by a maritime pharmacist who is also responsible for the inspection of the ship’s medicine chest.
1. Medical First Aid Guide for Use in Accidents Involving Dangerous Goods. London: International Maritime Organization; 1994.
2. International Medical Guide for Ships 1st ed. Geneva: World Health Organization; 1967.
3.International Medical Guide for Ships. 2nd ed. Geneva: World Health Organization; 1988.
4. International Medical Guide for Ships. 3rd ed. Geneva: World Health Organization; 2007.
5. C092 - Accommodation of Crews Convention (Revised). London: International Labour Organization; 1949. https://www.ilo.org/dyn/normlex/en/f?p=NORMLEXPUB:12100:0::NO::P12100_ILO_CODE:C092
6. R105 - Ships' Medicine Chests Recommendation. London: International Labour Organization; 1958. https://www.ilo.org/dyn/normlex/en/f?p=NORMLEXPUB:12100:0::NO::P12100_ILO_CODE:R105
7. C126 - Accommodation of Crews (Fishermen) Convention. London: International Labour Organization; 1966. https://www.ilo.org/dyn/normlex/en/f?p=NORMLEXPUB:12100:0::NO::P12100_ILO_CODE:C126
8. C164 - Health Protection and Medical Care (Seafarers) Convention. London: International Labour Organization; 1987. https://www.ilo.org/dyn/normlex/en/f?p=NORMLEXPUB:12100:0::NO::P12100_ILO_CODE:C164
9. C188 - Work in Fishing Convention. London: International Labour Organization; 2007 https://www.ilo.org/dyn/normlex/en/f?p=1000:12100:0::NO::P12100_ILO_CODE:C188
10. R199 - Work in Fishing Recommendation. London: International Labour Organization; 2007
11.https://www.ilo.org/dyn/normlex/en/f?p=NORMLEXPUB:12100:0::NO::P12100_ILO_CODE:R19911. Maritime Labour Convention. London: International Labour Organization; 2006. https://www.ilo.org/global/standards/maritime-labour-convention/text/WCMS_763684/lang--en/index.htm
12. Quantification Addendum: International Medical Guide for Ships 3rd Edition. Geneva: World Health Organization; 2010.
D.4.3 Regional, National and Industry requirements
In Council Directive 92/29 , The European Union (EU), specifies the contents of the medicine chest in terms of the classes of medication that need to be included but has left the individual member states to specify the generic substances and quantities of the medicines, medical supplies and equipment that must be carried on board the vessels of each flag state.
Other countries outside the EU that have regulated the contents of their medicine chests with country-specific legislations are the United Kingdom,  Australia and Norway with the latter also having specific requirements for offshore fixed installations & standby vessels.
Countries that have not passed specific legislation, usually comply with the recommendations set out in the IMGS 3rd edition  and the Quantification Addendum  as published by the WHO. Examples of these countries are Panama, the Marshall Islands and Liberia.
However, apart from regional and national requirements, industry requirements or recommendations also apply, as for example in the following sectors:
- Cruise line sector, where the American College of Emergency Physicians (ACEP) Cruise Ship Medicine Section (CSMS) has established industry specific guidelines in cooperation with the Cruise Lines International Association (CLIA) . Further information on cruise ship medicine is available in Chapter A.4.10
- Oil & Gas sector with specific additional requirements for offshore fixed installations & standby vessels. Some of the countries that have adopted these are Denmark, the Netherlands, Norway and the United Kingdom (6).
1. European Union. Council Directive 92/29 On the Minimum Safety and Health Requirements for Improved Medical Treatment On Board Vessels. European Economic Community; 1992.
3. International Medical Guide for Ships. 3rd ed. Geneva: World Health Organization; 2007.
4-. Quantification Addendum: International Medical Guide for Ships 3rd Edition. Geneva: World Health Organization; 2010.
D.4.4 Medication for known health conditions
It is the responsibility of seafarers and all those travelling on board to ensure that they take sufficient quantities of their own medication to last for the duration of their trip. It is also important that they bring a copy of their prescription as supporting documentation for local authorities and in case they need to obtain additional supplies of medication for any reasons.
It is almost impossible to include medications for all eventualities within the medicine chest whilst ensuring the chest is of a reasonable physical size and not over complicated to be managed on board by the officer responsible for medical care. In addition, international seafarers have many cultural differences and this includes their expectation as to what should be available on board in case of the need for treatment. Examples are Chinese traditional medicines and various folk remedies. Oher challenges in the management of the medicine chest include but are not limited to:
- Contraband medications brought aboard by crew.
- The problems with different proprietary names, packaging and tablet sizes, and with poor quality medication or fraudulent products in some countries. Hence limitations of purchase through local agents or by using web-based pharmacy services.
- Managing expiry dates and the safe disposal of expired medicines, especially controlled drugs.
- Variable restrictions on some controlled and related drugs in some countries. Dangers for individuals, ship masters and ships from non-compliance with local rules.
D.4.6 Role of the maritime pharmacy
This includes all activities involved in supplying ships with medicines, medical supplies and equipment in order for them to comply with their flag state medicine chest requirements.
Usually, a maritime pharmacy is located in close proximity to a harbour or a major shipping port and supplies vessels with medicines, medical supplies and equipment either by:
- Directly selling them to the crews of the vessels that visit the actual premises.
- Dispatching them to the vessels that are docked in the port close to where the pharmacy is located.
- Dispatching them via air, land or sea freight to vessels calling in ports around the world.
The last method of dispatch is the most challenging as the logistics involved must be very precise since the ‘vessel-customer’ is constantly on the move and many factors must be perfectly synchronized in order for the supplies to arrive on time. Other difficulties faced are the supply of controlled (narcotic), refrigerated or hazardous items which have different supply and transportation restrictions depending on the country of destination.
Further information on the role of the maritime pharmacist is available in section A.6.10.