The Red Cross and Red Crescent must be one of the few organizations whose emblems have come to symbolize generically the core activity with which it is most closely associated: first aid. The general public might be a little hazy about exactly what the emblems mean when placed on a flag, or a door, or a building - whether they indicate an organization or just the status of something. But paint a red cross or crescent on a white metal box and anyone asked will say, "That's a first-aid kit."

"First aid is the foundation for what the Red Cross does in terms of the culture and principles of the Movement," says Alvaro Bermejo, a medical doctor and the director of the Federation's health department. "It's also the foundation in terms of service delivery. But we have to move beyond the 'blood and bandages' image in order to make it strategic."

Few National Societies have had the importance of first-aid skills brought home to them more dramatically than the Nigerian Red Cross Society, from whose Lagos branch volunteers dashed on the night of Sunday 27 January when they heard of the catastrophic explosions at the city's Ikeja military arms dump. Their confidence as first aiders had been strengthened by a British Red Cross project to help upgrade both standards and training methods. But they were severely hampered by exploding ammunition preventing them getting too close to the casualties, according to Lyn Covey, recruitment and training manager for the Surrey branch of the British Red Cross and the chief first-aid adviser to the Nigerians. She says the horrific accident at Ikeja was "a first-aid encyclopaedia in a single incident".

Ironically, most of the victims were killed, not by the explosions and fires, but by drowning when they stampeded into a nearby canal in a desperate effort to escape the lethal inferno. More than 1,000 people died. But the Nigerian Red Cross still emerged as the heroes of the hour. "The only agency on the ground was the Red Cross," Sola Ajayi, a Lagos resident, told the BBC.

The British project in Nigeria addresses the challenge of making the National Society more bankable as trainers, able to offer structured courses to private corporations for a fee, with first aid now established as an important form of marketable expertise for National Societies. And the Ikeja disaster, as effectively as any in recent years, also encapsulated both the classic importance of first aid in saving life after accidents and its vital role in preparing volunteers for humanitarian work in general.

Income generation

For Stephen Claffey, project manager of the Federation's first-aid global project, the "strategic importance of first aid to the Movement as a whole" is difficult to overstate. "The World Health Organization provides leadership on health issues, United Nations High Commissioner for Refugees on refugee concerns," he says unequivocally. "Red Cross and Red Crescent National Societies worldwide are primarily identified with first aid and perceived as providing leadership in first aid."

The project helps them implement the 1999 General Assembly policy enshrining the strategic importance of first aid for National Societies and communities. Now a key priority for the Federation, it seeks to facilitate knowledge and practice exchanges between National Societies and with their partners, and is intended to rationalize first-aid activities within the Movement. It will develop a set of standards for kits, training and delivery that will ensure the continuing quality of service based on communities needs and capacities.

Alvaro Bermejo stresses the revenue generation possibilities of first aid, and in particular many National Societies' virtually unassailable position as market leaders in first-aid training. "I remember when I was in Bolivia," he says, "seven out of nine branches were making a living from first-aid training." Since the 1999 General Assembly this approach has also been the official policy of the Federation, which notes that first-aid training is "beneficial for resource mobilization and income generation".
First-aid training in many countries worldwide - Germany for example - is fiercely competitive, almost a model of a free market in which the consumer is king. In Australia there are more than 250 providers, but in late 2000 the country's national marketing institute gave the Australian Red Cross an award for excellence in recognition of its success in converting its first-aid training service into a profitable commercial exercise. "With the help of corporate sponsors, we implemented a campaign focusing on branding, best practice and standardization of our services and products," said Jim Carlton, then secretary general of the society.

First-aid specialists flag the danger of instructors leaving the Movement once they realize how much their skills are worth in the private sector. There may also be a risk, some feel, of branch work being neglected in favour of for-profit tuition projects run from national headquarters. But the consensus is that, broadly speaking, National Societies are striking the right balance, using lucrative first-aid activities to support services to vulnerable communities.

And few have done more to advance the cause of first aid within their own borders and beyond them than the Danish Red Cross, which has trained over a million people in first-aid techniques and lobbied for first-aid training to be made compulsory in school and driving test curriculums. The Danes - determined that there should be at least one qualified first aider in every workplace in the country - last year reissued their highly successful interactive CD-rom for the training of first aiders. "The CD goes out free to companies and we follow up with a phone call to get managers to arrange Red Cross first-aid courses for employees," says Sven Hedegaard, the National Society's first-aid manager. "It reflects our commitment both to this core Movement activity and to our faith in up-to-date training methods using computers."

Claffey also sees the Regional First-Aid Day as "an important demonstration of the value of first aid, providing a focus for National Societies to promote first aid to the public". The next will be on 7 September 2002. "We are continuously challenged by the changing risks of our living environments," he says. "Effectiveness in life-saving has demanded we move beyond actions of immediate care to engage in prevention and preparedness activities in diverse situations, critical elements of the universal assistance required to protect and save life today."

"Classical, textbook Movement"

First aid has come a long way from its origins in military medicine and the capsarii in the Roman army of the first century BC - specialist battlefield bandage carriers who wore the uniform of the soldiers they treated. Chris Paul Giannou, the chief surgeon in the ICRC's health and relief division, is a man for whom the phrase "been there, seen it, done it" might have been coined.

The 52-year-old Greek-Canadian has never actually been an "ordinary" doctor, moving straight from medical school to what turned out to be a ten-year stint as a volunteer with the Palestine Red Crescent Society. His first mission as an ICRC delegate was in 1990 and he has served in Somalia, Cambodia, Afghanistan, Burundi, Chechnya and, in Nairobi, as surgeon for the whole sub-Saharan Africa region. He was also the medical coordinator of the ICRC's campaign to ban anti-personnel landmines.

Dr Giannou speaks passionately with a slight rasp in his voice. He emphasizes his arguments carefully, one of them being that there is little real distinction to be made between civilian and military first-aid skills, although the ICRC has developed slight modifications in advanced aid techniques for war wounded. "Battlefield medics do first aid," he says. "And we have long been using National Society people to train military stretcher bearers - in the last couple of years in the Democratic Republic of the Congo (DRC) and Uganda, for example." By the end of its current programme for DRC this year, the Congo Red Cross, with ICRC support, will have trained some 2,500 army medics, not just in the treatment and evacuation of casualties from battlefields but also, crucially, in "their rights and duties" as wearers of Red Cross armbands. "It's classical, textbook Movement," Giannou says.

Confidence to act

First aid, of course, is as old as the Red Cross itself; it is deeply rooted in its past, and in various forms represents its future, too. It has to be adapted to the much wider world of health and care in the community, evolve with changing environments and lifestyles, and absorb relatively new issues like psychological care, HIV/AIDS and renascent diseases, some of which can be conquered by volunteer-based immunization and prevention campaigns. Furthermore it implies healing not only "the wound" but also the wounded.

Rose Kinuka, the head of social mobilization for the Uganda Red Cross, is well placed to understand this evolution. Red Cross volunteers - thousands of them - were crucial to the success of a measles immunization drive in Uganda late last year. Not all the volunteers were trained first aiders, but the ones who were turned out to be "double-good", as she puts it. In a labour-intensive operation like mass immunization, something is needed beyond simple exuberance and a wil-lingness to don a Red Cross T-shirt, the Ugandans found, and the discipline of first-aid training used in an innovative way fitted this bill perfectly.

First aid is most associated with bandages and blankets. But increasingly, it is developing into a more holistic notion of care, providing both physical and psychological support. After the earthquakes that shook El Salvador last year, Red Cross psychological support teams found themselves trying to help people who said they had been traumatized by feelings of helplessness as much as the original disaster; lacking the confidence to act. "Older children especially were grappling with guilt," recalls Paul Keen, a San Salvador-based project manager for the Federation.

"In Nicaragua, which is still recovering from Hurricane Mitch," Keen explains, "the Red Cross is working at a school in the muncipality of Posoltega to address this issue. The children remember their terror as a landslide from a nearby volcano buried their village. As part of a first-aid course for teachers and children the school now carries out an earthquake simulation, with the older children providing treatment and organizing evacuation."

The Baphalali Swaziland Red Cross is a society which, by common consent, has throughout its history been seen as the leading provider of first-aid training in the small southern African kingdom, and is now marketing that expertise productively. "The latest figures show that 12 per cent of our income nationally comes from commercial first-aid training," says Secretary General Khanya Mabuza.

"But out in the branches it can be even higher - 70 per cent in Manzini, for example." First aid has also been one of the society's best recruiting sergeants, with youngsters at school often becoming Red Cross-trained first aiders before actually starting work as volunteers. Like other National Societies in southern Africa - a region with some of the highest HIV rates in the world - the Swazi Red Cross has been careful to "integrate" HIV awareness with first aid. "People were naturally wary of things like mouth-to-mouth resuscitation, so we have been careful to provide advice about exactly how HIV is transmitted - and how it isn't," says Mabuza. "If there are no surgical gloves available at an incident, look around for a sheet of plastic, but at the end of the day you cannot leave someone to bleed to death in the street."

For the crews of the Magen David Adom (MDA), the Israeli society which provides the country's main ambulance service, there is the intense strain of living with a campaign of at times daily suicide bombings and arriving on the scene in their immediate aftermath; of having to work amidst human body parts and hysterical bystanders; of making split-second triage decisions. MDA crews are also on occasion directly in the firing line. In March this year a suicide bomber walked into an ambulance station in Efrat, a Jewish settlement south of Bethlehem, and blew himself up. The volunteer who tried to stop the bombing was critically injured.

But the MDA's Jerusalem manager, Yoni Yagodovsky, says that although crews have been exposed to unbearably harrowing casualty scenarios, sometimes involving children and babies, the stress is eased by the knowledge that "they have a role - can do something". Tel Aviv and Jerusalem have also become laboratories for what might be called extreme first aid. "We have had some outstanding successes in treating very seriously injured or mutilated people who would be declared dead just about anywhere else - no breathing, no pulse, nothing," Yagodovsky says.

First-aid activities

The following is a short list of the numerous first-aid products and services National Societies offer worldwide.

• Emergency response to crisis
  
• Manning first-aid posts at large sporting or leisure events
  
• Hiking and camping safety
  
• Water safety
  
• Information and training for the elderly (fall prevention)
  
• Pet first aid both domestic and farm
  
• Tips for babysitters
  
• Healthy lifestyles
  
• First aid for farmers
  
• First-aid training for people with physical or mental disabilities
  
• Super first-aid kids
  
• Work safe

Two years after her underground first-aid training, Afghan Red Crescent volunteer Malaka can finally display her certificate and ID card.

Shortly afterwards, Anwar met volunteers from a village near Kabul where the night before a woman had bled to death during childbirth. The male volunteer in the village could do nothing. "I met the husband of this woman and he cried so much. He was left alone with eight children."

It was too much; Anwar felt he had to do something. And with international support, he did, organizing secret first-aid training for women. In December 1999, he put the first 25 women through a basic course.

In the post-Taliban era, the Afghan Red Crescent has been quick to start training female volunteers again. It is now holding two CBFA courses for nearly 60 women in Kabul and the northern town of Mazar-i-Sharif, with more planned. The participants are female teachers, who will start working in girls' schools when they re-open this spring for the first time since 1996.

Meanwhile, the 25 brave women who trained in secret three years ago have at last received their certificates and identity cards. Thirty-five-year-old Malaka says she did not hesitate to take part, despite the risks involved. "It means a lot to us to have our certificates," she says. "In order to influence people's health habits it is important to be able to show them you know what you're talking about."

Help in more ways than one

Pyhäjoki is a coastal settlement of nearly 4,000 souls in the remote north of Finland. In the mid-1990s it used to take ambulances more than 20 minutes to reach emergencies from their station 35 kilometres away - and they rarely attempted to treat patients until they got back to the station. All concerned regarded this situation as unsatisfactory. So the local branch of the Finnish Red Cross got together with the fire and lifeboat stations and started a "first response unit" in Pyhäjoki, Leena Kamaraïnen of the Red Cross recalls. "The purpose of this unit was to start life-saving treatment for emergency patients, prepare them for transport in the ambulance and assist the paramedics with their duties," she says. And the Red Cross did the first-aid training.

Within a year the response time had been cut drastically. Says Kamaraïnen: "When the community noticed how the Red Cross was helping, everybody wanted to contribute to the branch, either by donating money or by paying the membership fee. The number of members doubled."

Red Cross and Red Crescent first-aid training and practice is about instilling that vital confidence to act: who has not at some time in their lives stood on the fringes of an accident and wished they could do more to help? But in a world perceived to be getting more rather than less hazardous, and to be changing at an ever faster pace, the challenge for Movement first aid is to adjust to new realities on an almost daily basis whilst promoting both minimum technical standards, accommodating cultural variation and remaining faithful to the humanitarian spirit of first aid. First aiders are making a difference, not only between life and death, but also between apathy and empathy, and solidarity and indifference.

Alex Wynter
Alex Wynter is a London-based freelance editor and writer.