The authors have monitored terrorist and piracy threats at sea for almost a decade. In many cases medical and psychological implications of such acts have received little or no attention, despite the appalling conditions for both crew and pirates. At sea comprehensive medical care facilities are usually out of reach and search-and-rescue services are confined to coastal areas. They will probably be overwhelmed if they need to respond to the medical consequences of a terrorist attack, an armed conflict with pirates or other criminals or an epidemic among a ship’s crew.

Lack of medical support may destabilize any situation at sea, and that is why the authors recommend including medical expertise in any precautionary planning and in the management of actual incidents. Even the construction of safe rooms (citadels) aboard to keep the crew and attacking parties apart require suitable food and air management as well as sanitation and medical equipment sufficient for the time taken for security forces to arrive.
The distances involved at sea as well as weather conditions may seriously affect timelines for outside help. The crew, therefore, has to be self reliant in terms of extended first aid and medical care training (including the use of telemedical support and collaboration with outside rescue services) as well as of psychological preparedness.

 There has yet to be a major disaster with a ship out of control after an attack . Terrorists might attempt to cause such a disaster by setting an oil, gas or chemical tanker on fire - thus blocking a port entry or a strait used by shipping. Or they might consider hijacking a cruise ship (15,16). In the seventies numerous aircraft were hijacked. The ‘Achille Lauro’ has so far been the only passenger liner to fall victim to such an attack. Since the mid-nineties five pirate attacks on cruise ships have been reported; it may be only a question of time before there is another serious incident.

Authorities responsible should be prepared to deal with all aspects of an incident – including medical ones.

Medical and psychological professionals – members of seagoing rescue services, police or armed services, those in private security services and last but not least those on board of passenger ships and shore facilities dealing with ships should be equally prepared, equipped and trained together with all others involved.

Crisis management in all cases should be supported by medical and psychological advisors.

An interesting new approach is the development of preventative training courses for crewmembers. For example International Maritime Bureau (IMB) and other security training institutions are holding intensive courses on Piracy for Masters and crewmembers. Such training courses aim to provide meaningful and practical responses for coping with piracy on an operational level. It is appropriate to integrate medical and psychological aspects in such specialised pre-boarding training. Sailors should be taught not only how to evade abduction but also how to survive when held hostage.

Naval crews also need complementary training on how to interact with merchant ship crews before, during and after incidents of terrorism, piracy or other crime.