Vulnerability and social determinants of health among internally displaced persons (IDPs) in Myanmar post-military coup

doi:10.21203/rs.3.rs-2308391/v1

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Vulnerability and social determinants of health among internally displaced persons (IDPs) in Myanmar post-military coup

https://doi.org/10.21203/rs.3.rs-2308391/v1

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Across the globe, the COVID-19 pandemic has aggravated particular challenges for internally displaced persons (IDPs). In Myanmar, over 1.4 million people are internally displaced due to the escalation of armed conflict post the military coup in February 2021. However, the plight and the well-being of IDPs in Myanmar under this military regime and the unprecedented COVID-19 pandemic have not garnered much attention locally, regionally, or globally. The current study examines how the military coup has exacerbated the health and well-being of the IDPs in Myanmar more vulnerable and increasing the risk of disease and COVID-19 infection. The study was conducted using Non-Government Organizations (NGOs) referrals, and purposive sampling. A total of 17 IDPs participated in the depth interview. The finding reveals that the IDPs are experiencing anxiety and fear every day which adversely affected their mental health due to the intensification of the armed conflict and attacks on civilian places including the IDP shelters. It has increased their risk of contracting COVID-19, malaria, and dengue fever during precarious living environments. Additionally, the military's restriction of all humanitarian aid, including basic health care, medicine, and food has negatively affected their health and well-being due to food shortages and insufficient access to healthcare. The findings indicated that a major human health disaster and a humanitarian catastrophe can be prevented only if the international community takes immediate action to end the military brutality against its citizens and extends humanitarian assistance, including vaccines to all IDPs.

COVID-19

Myanmar

Military coup

Internally Displaced Persons (IDPs)

Armed conflict

Humanitarian Crisis

According to United Nations High Commissioner for Refugees, more than 82.4 million global populations have been forcibly displaced from their homes because of armed conflict, violations of human rights, or environmental catastrophes (1). In 2020, 55 million of the world’s population were (IDP), of whom 48 million were displaced from their homes due to conflict and violence, and 7 million were displaced from natural disasters (2).

Myanmar has been engaged in one of the world's longest civil wars since the country's independence in 1948. Political unrest and an armed conflict between the military and ethnic groups have forced hundreds of civilians to flee their homes. At the end of 2020 December, approximately 505,000 of the country's population were IDP in Myanmar (3). Following the military coup in February 2021, the military forces murdered over 2,444 peaceful protesters and civilians and detained over 16,156 civilians arbitrarily for opposing the coup as of 11 November 2022 (4).

Furthermore, over 1.4 million people in Myanmar have been displaced from their homes into the surrounding forest for refuge due to the intensified armed conflicts between the military, anti-coup civilian forces, and ethnic armed groups. Children constitute more than half the population. Among them over half of the population are children (5). Many of those IDPs are elderly, children, and women, including pregnant women, despite no reliable statistics being available. However, the neighbouring countries such as the Thai and Indian governments refused to accept them and were deported. For example, Thai authorities refused to accept over 3,000 Karen State residents who crossed the Salween River in search of refuge on the Thailand border after the Myanmar military attacked civilians with heavy weapons and aerial bombardment (6). Similarly, the Indian government refused to receive over 20,000 Chin people who fled to Mizoram State, India (7); instead, it deployed the border security police to block people from Myanmar from entering India (8).

A displaced person is an individual who does not cross their nation's border, as opposed to a refugee, who migrates in search of protection to a foreign country. Therefore, they are more vulnerable and less protected than refugees because they must rely on government authorities which may cause them to be displaced (9). They face structural and institutional barriers to accessing social protection and healthcare services (10), and access to healthcare services had been a heavy burden for IDPs worldwide due to financial difficulties, long distances, a lack of designated healthcare centres, and discrimination in host communities (11). They are facing risks of exposure to the infectious virus and other illnesses such as malaria, dengue fever, diarrhoea, and malnutrition are prevalent among IDP children aside from their mental health and depression (12–14). In particular, during this COVID-19 pandemic, they are the most vulnerable group to contracting COVID-19 due to their precarious living conditions, lack of proper hygiene, and insufficient access to healthcare services (15–17). In Myanmar, the number of IDPs has significantly increased during the past decade. However, few imperial studies have been conducted on their plight and access to healthcare. This study explored how the military coup exacerbated the vulnerability and barriers to accessing healthcare among the IDPs in Myanmar. The findings of this study attempt to inform national authorities, international organizations, and communities regarding potential interventions to improve health and well-being as well as prevent infectious diseases and the spread of COVID-19 among IDPs in Myanmar and other countries with significant IDP populations.

2.1 Study design and participants

The present study was based on a qualitative online in-depth telephone interview with seven camp administrators and ten IDPs, from Chin, Karen, and Kachin states in Myanmar. In terms of gender, all camps in the leader are male, seven IDPs are female, and three IDPs are male. To recruit the participants, the researcher relied on the referrals of several NGO workers and snowball sampling. As a former NGO worker, the researcher contacted friends and colleagues who work in NGOs and INGOs to recruit participants. As a second step, after obtaining contact information for IDP camp leaders, the researcher contacts them via phone call, WhatsApp, or Signal as convenient, all of which provide end-to-end encryption and protection. As part of the interview, the researcher explains the objectives of the study and the procedures for withdrawal at any stage during the interview without hesitation. In this study, participants provided oral consent, informing them that their identity and location would remain anonymous and confidential throughout the research process. Likewise, after interviews with the IDP camp in charge, the researcher relied upon them for assistance in recruiting participants from IDP members in their respective camps. To maintain confidentiality, the participants’ names were removed and assigned pseudonyms throughout the data transcription, coding, and analysis.

2.2 Data collection and analysis

Interviews were conducted between June and September 2022. Each interview lasted between 20–35 minutes. In all the interviews, the researcher interviewed in the Burmese language. Using Excel, the data were analysed according to the inductive qualitative analysis described by Braun & Clarke (18). The researcher listened to the audio recording multiple times prior to transcribing to familiarize himself with the data deeply. Afterward, the interview was transcribed verbatim and checked against the audio recording for authenticity. The researcher translates all interviews into English as he is bilingual in Myanmar and English, and has worked as a translator and interpreter for over six years. Then, the researcher read the transcribed data line by line while the coding theme for an initial ideal. After that, the researcher analyses the coded data thematically by merging the similarities into a unified theme.

3.1 Experiencing constant fears and anxieties

Since the military coup in the country, the armed conflict has escalated significantly between ethnic armed groups and the military. Moreover, the Myanmar military raided several homes and interrogated individuals, particularly at night. Several them were killed during interrogation, and some of their bodies have never been returned to their families. Many women and children are at risk of being raped by military forces.

" Since the military has taken control of the state, we are in greater danger and are less secure wherever we go. The military forces have raped women and tortured them to death in many places"- IDP female

" At night, we are more afraid of what will happen to us. It is especially stressful if the dog barks. No one can sleep and no one knows what to do "-IDP female

Furthermore, the Myanmar military carried out indiscriminate attacks on unarmed civilians, including IDP camps. As a result of this adversity, the mental health and well-being of the IDP populations have been negatively affected.

"During the time my wife was delivering a baby in the IDP camp, I heard a military helicopter in the sky. I was terrified as I was unable to immediately relocate my wife inside the bunker I dug to protect myself from military airstrikes. Furthermore, the bunker was not constructed systematically, and as a result, cannot provide us with protection from an explosion if we are attacked by the military"- IDP male

"When we hear the sound of a military jet, we rush into the bunker, much like chickens fleeing into bushes when they see an eager bird above. Some children are dissatisfied with such a situation and they cried inside the bunker. There are no words to express how upset and terrified I am"-IDP male

"Our lives were filled with uncertainty daily. The elderly and children are especially vulnerable and insecure. There is never a state of calm or peace in my mind. My mind is thinking where should we flee repeatedly to safeguard our lives? We live every moment with terror and vigilance in our minds"- IDP female

This indicates that the Myanmar military forces' actions exacerbated life insecurity for the IDPs living in Myanmar and created a constant fear for their safety. Furthermore, the participant expressed concern that the military coup has displaced women and children into a more vulnerable position. They are living in fear for their safety and at substantial risk of sexual abuse since the military has raped and killed many women in various places, including many Rohingya women in Rakhine State who reported gang rape or rape in 2017.

3.2 Precarious living and infection of disease

Many of the displaced persons were newly displaced, living in precarious conditions in the forest following the military coup. A camp leader in Chin State in charge of approximately 140 IDP houses, reported that they had suffered many health problems due to the precarious living situation and unclean drinking water.

"Currently, we are experiencing many difficulties. Our camp is constructed of anything we can find in the jungle, such as banana leaves. When it rains, our tent does not protect us from the downpour. Furthermore, we used the forest steam to drink water. However, the water becomes dirty and muddy after rain. However, we are unable to obtain clean drinking water” IDP camp in charge

Participants from different locations report similar circumstances and hygiene problems.

"Many of our people suffer from stomach problems and numerous illnesses due to the lack of a good toilet or proper hygiene in the camps for internally displaced persons"- IDP camp in charge

Further, near the Thai border, another IDP camp leader from Karen State stated that the unsanitary water and unprotected shelters put the people at a higher risk of contracting various diseases.

"Our location in the jungle is a breeding ground for disease transmission, particularly malaria and dengue fever, caused by mosquitoes. There are many people here who do not have a mosquito net, and they have been sick with malaria and dengue fever, including my wife and children. I have just been recovered from sickness as well"- IDP camp in charge

This situation was also reflected by other participants in this study. Several IDPs took refuge in local churches and farmlands, while others were trapped in the forest and fled to neighboring countries' borders. They encountered numerous challenges as the military blocked all supplies so that they could not get support from NGOs or international non-governmental organizations. Furthermore, during the rainy season in Myanmar, they do not have any protection against the monsoon rain, making them susceptible to flooding.

3.3 Surge of infectious disease and COVID-19 cases among IDPs

The participants in this study reported that they live in fear since they have been attacked by the military and have experienced an increase in infectious diseases and cases of COVID-19 in their camps. Participants who were living in IDP camps before the military coup mentioned that they had occasionally received health treatment from various non-governmental organizations (NGOs). The military, however, blocked and restricted all humanitarian supplies, including the medical workers of the NGO, so they could not receive medical treatment, support, or protection equipment despite some IDP members already suffering from COVID-19 symptoms. It was further reported that the army had arrested some philanthropy health workers who were providing informal health care to IDPs. Therefore, the elderly population in the camp is at a greater risk of contracting COVID-19 because they may have pre-existing health conditions such as paralysis, hypertension, and digestive problems.

"As an older adult living in an IDP camp, I am concerned about their welfare. There is no assistance available to the elderly in IDP camps, except for the WFP's monthly contribution of 15000 Kyats (9 USD). If the patients become ill or test positive for COVID-19, 15000 kyats would not be sufficient to cover the cost of medical treatment. Workers from the NOGs are no longer able to reach IDP camps, the elderly are no longer able to receive assistance due to the failure of the banking system, and the military has blocked all roadways since the coup"- IDP in charge

In particular, the participant in this study from Kachin State reported that many IDP camps had been confirmed to be positive for COVID-19. They expressed their helplessness, as they lacked personal protective equipment (PPE), medicine, healthcare workers, and access to a healthcare facility. In this manner, the camp in charge of an IDP camp expressed his concerns and worries regarding the potential outbreak:

"I am afraid for the safety of everyone who tested positive for Corvid-19 and the remaining members of the camp. We are unable to do social distancing and do not have a proper soup for hand washing. There are no PPE suits, no medicine, and no vehicle to transport the patient to the hospital"- IDP camp in charge

After the military attack on health facilities and healthcare workers after the military coup, other participants transported the patient to the nearest health centre on motorbikes and tricycles. However, they were denied admission to the hospital due to overcrowded patients and a limited number of healthcare workers during the outbreak in the last year 2021. Besides, they were unable to afford to go to a private hospital due to insufficient funds. This forced them to rely on self-medication, which ultimately resulted in their deaths according to some participants.

3.4 Lack of food supply and substantial risk of hunger

According to the participants in this study, their living conditions have become more difficult since the military coup and the subsequent political turmoil during this pandemic. Amid this pandemic, they are experiencing food insecurity and cannot even consume rice twice a day. Additionally, they live in fear of heavy weapon attacks since armed conflict frequently occurs near their shelter. As a result, they do not have any food left to eat, and their children are already malnourished.

"We were displaced from our homes to save our lives by abandoning everything of our belongings. We do not have anything to eat in the jungle. I cannot express in words how I feel hopeless now"- IDP female

"We feed our children anything we can get our hands on. A little bean and rice soup now and again. Life is tough. Our kids are malnourished—everything price rises following the military takeover, especially rice prices. We cannot afford to eat rice since a sack costs (40000–50000) Kyats, equivalent to (24–30) USD. The price of cooking oil has also risen. We have no place to borrow money. We will die from starvation"- IDP female

On the other hand, some IPDs have lived in the camp for over ten years. Before the military coup, they were able to find daily basic labour to sustain their lives and had received 15000 Kyats (9 USD) from the World Food Program (WFP) for one household, as well as other support from a variety of donors and non-governmental organizations (NGOs). Since the military restricted all humanitarian assistance, they are experiencing food insecurity. Meanwhile, all donors, including the World Food Programme, are unable to reach them. The following are some examples of how IDPs have described their living conditions and vulnerability before and after the military takeover:

" Before the military coup, we were able to find labour daily to support ourselves. In the current climate of gunfire, heavy weaponry, and deadly pandemics, finding food has become exceedingly difficult "- IDP male

"As a result of the military coup, we have been left with nothing to eat during the COVID-19 surge. We have been unable to obtain a monthly subsidy of 15000 Kyat (9 USD) from the World Food Programme because the military has restricted all humanitarian supplies. Every day is filled with agony as there is no source of income"- IDP female

3.5 Longing peace to return home safely

The study participants reported that the military coup had undermined the hopes of the entire population in Myanmar. In particular, the escalating armed conflict following the military coup has robbed them of their hopes and dreams of returning home.

"If the military coup had not taken place, we might have been able to return to our homes and no longer be in a prolonged state of uncertainty. However, now we have lost everything, including our hope and dream. We live in an increasingly dangerous and challenging environment daily. Our current situation is that we do not know where to get food, and we are living each day with hundreds of thousands of worries"-IDP camp in charge

"Despite living in IDP camps for the past ten years, I wish to return to my home country. I have never been pleased to be here. I long for the day when I will be able to return to my old house, even though it is old now"- IDP female

In addition, participants in this study were concerned and frightened about returning home due to military forces stationed in civilian schools, churches, and hospitals and arbitrarily arresting and killing villagers and civilians.

"Our school and hospital buildings have been occupied by the army, so we are afraid to return home. Additionally, we learned that the military killed many civilians and arbitrarily arrested villagers. Our lives are in danger if we return home, although we long to see it"- IDP camp in charge

" The military is killing civilians even in their homes and arbitrarily arresting villagers. It is very difficult for me to return home and I am filled with more anxiety than I can express in words "-IDP female

This study explored the vulnerability and well-being of internally displaced persons (IDPs) in Myanmar during the COVID-19 pandemic and after the military coup. The findings of this study reveal that IDPs in Myanmar live in terror day and night that negatively impacts their mental health and well-being because of the intensifying escalation of armed clashes, mass torture, killing, and human rights violation across the country post the military coup as reported by (19). Moreover, a military air attack on civilian places and IDP camps resulted in the deaths of many individuals, including children (20–22). They are vulnerable since they seek refuge primarily under a big stone and several caves in the forest to hide from airstrikes since they do not have the materials to build camps. In particular, the elderly, women, and children are vulnerable. They dug a bunker to protect themselves from military airstrikes since the military frequently attacked IDP camps with heavy weapons (23, 24). As of 1 November 2022, there were over 1.4 million newly displaced persons, over half of whom were children, who were affected by the conflict (5). In addition, the Myanmar military persisted in using gang rape and other forms of sexual violence as a weapon of war across the entire country (25, 26), including a woman with disabilities in the Sagging region (27). However, Myanmar military brutality and war crimes are not new to the people of Myanmar as they have been committing the same crimes for years without impunity. Before this military coup, for instance, the Myanmar military gang-raped a 37-year-old mother of four children in Rakhine State (28) and killed two teachers from Kachin State in 2015 (29), and massacred Rohingya women in Rakhine State in 2017 (30). The IDP populations are therefore living in fear due to their concern over their safety from sexual exploitation, which has detrimentally impacted their mental health and well-being.

On the other hand, a recent report from the World Health Organization indicated that the COVID-19 pandemic had exacerbated the threat to global security and economic development, and lower public health investments had undermined health and welfare worldwide (31). However, the Myanmar military blocked lifesaving and humanitarian aid as well as medical workers from reaching a million internally displaced people amidst the global pandemic COVID-19 instead of providing healthcare. This places individuals, especially those who have been injured by indiscriminate air strikes and who require medical attention, at the risk of losing their lives (32–34). Additionally, the military raided and occupied several hospitals. medical personnel have been assaulted and arrested for providing care to the people and have been barred from access to aid and medical supplies (35–37). As of May 2022, the Myanmar military has reported attacking over 492 health workers and destroying ambulances in the past few months. The number of medical workers arrested has exceeded 564, 126 hospital raids have occurred, and over 36 health workers have been killed (38). In this regard, lifesaving aid and healthcare workers are unable to reach the IDP population in Myanmar to provide healthcare treatment. This puts the IDP population in Myanmar at a higher risk of infecting with infectious diseases and contracting COVID-19 due to a lack of access to medical and humanitarian aid. For instance, in the Chin State, there are over 6 IDPs who have died because of a lack of access to healthcare treatment promptly, including children, pregnant women, and elderly people (39), the number of deaths seems to be higher across the country despite no reliable data. The IDPs in Myanmar are facing two crises simultaneously: a military human rights violation as well as a global health catastrophe caused by COVID-19, unlike Ethiopia, whose health sector functions and humanitarian assistance, including medical supplies, are readily available (40).

As discussed above, the military coup has deteriorated IDPs' access to healthcare treatment among the IDP population in Myanmar more than ever before. Some participants in this study reported receiving healthcare services from non-governmental organizations (NGOs) despite the COVID-19 outbreak prior to the military coup in Myanmar. A study revealed that nearly all COVID-19 deaths in the United States were among unvaccinated people (41). However, in the wake of the military coup, the military has blocked all transportation, and they are unable to access the COVID-19 vaccination even though vaccine hesitancy is a global health concern among developed countries around the globe. As a result, several members of the IDP population have died from COVID-19, although reliable exact data are not available (42, 43). The Myanmar IDPs, therefore, are at higher risk of becoming the epicenter of the pandemic due to a lack of vaccination and a lack of resources to protect themselves, such as personal protective equipment, soup, masks, and other prevention resources, in addition to their precarious living conditions and difficulties accessing healthcare services.

Besides, it was reported that there is a high incidence of influenza, dengue fever, and diarrhea among children in the IDP camps. In addition, many elderly people lack medication for high blood pressure, diabetes, and heart problems, as well as pain relievers and saline water for self-medication in case of an emergency (44). Similarly, participants in this study reported they do not receive disease prevention measures, such as treatment for infectious diseases and immunization for infants. Several participants indicated that many of their family members were infected with malaria, dengue fever, and diarrhea due to precarious living conditions, inadequate mosquito nets, inadequate waste disposal and do not have any medicine even for self-medication.

In April 2020, the UN Special Rapporteur on the Human Rights of Internally Displaced Persons (IDPs) urged governments to recognize that "IDPs are the most venerable people and should not be forgotten by governments in their response to the pandemic" (45). However, after the military coup, Myanmar does not have a legitimate government until today. The military arbitrarily arrested the President State Counsellor and other prominent political leaders who were democratically elected to serve as government officials for the 2021–2025 term. The World Bank (46) stated that IDPs are highly vulnerable to loss of livelihood and economic hardship compared to the host communities globally. In September 2022, there were 15.2 million people facing food insecurity in Myanmar due to the military coup and the WFP could only assist 2.7 million of them(47). The IDP population is particularly at risk of food insecurity due to the military blocking and restricting all international humanitarian supplies, rather than providing humanitarian assistance or medical supplies to the IDP population. For instance, the military has deliberately blocked the UN High Commissioner for Refugees from delivering humanitarian assistance and medical supplies to Chin IDPs in Mindat Township, Chin State (48). Thus, IDPs in Myanmar have been unable to receive humanitarian assistance, including the WFP's existing monthly support of 15,000 Kyats (9 USD). The living conditions have become difficult for them, and they do not have enough income to feed their hunger under the military bullet and deadly pandemic. Their children become malnourished, and their mental health and health issues decline, significantly threatening their quality of life. In March 2021, the UNDP report projected that 12 million people would be living under the national poverty line by 2022 (49). This number could grow to 25 million or more than half of the country's population if the political turmoil situation in Myanmar is not resolved immediately.

The study highlighted that the welfare of the IDP will be underserved if this situation continues, and a significant number of them will die from the pandemic and starvation if the situation does not change in Myanmar. It is therefore imperative that the international community and various actors collectively intervene urgently to halt military brutality against its citizens and to provide immediate humanitarian assistance to IDPs, including vaccines to prevent the spread of viruses among the IDP population. As of 15 November 2022, it is undeniable that over 6.6 million people have lost their lives worldwide because of this unprecedented global health crisis that has occurred in countries where doctors are allowed to work, public health systems function, and government institutions function (50). IDPs in Myanmar, however, are in a more vulnerable position than ever due to the military's destruction of the healthcare sector and restrictions on humanitarian supplies. It is imperative that Myanmar receives urgent help to end the health and political crises there to prevent widespread consequences for public health initiatives locally, regionally, and globally since COVID-19 is not bound by national boundaries.

There are several limitations to this research. The participants in this study were primarily from the Chin, Kachin, and the Karen States of Myanmar. Therefore, the results of this study could not be representing the vulnerability condition of all IDPs in Myanmar. Secondly, NGO referrals and snowball sampling methods to recruit participants and social media platforms (WhatsApp and Signal applications) to interview participants have limited the ability to connect diverse participants given the lack of Internet and mobile signal connectivity to reach several IDP shelters. Second, despite the in-depth interview providing a deeper understanding of the participants' experiences, the researcher may have been influenced by translation bias in using words when transcribing the audio recording into English. Thirdly, although the participants expressed frequent fear and anxiety about adversely affecting their health eventually, the findings are limited in scope in understanding mental health coping methods among IDPs. It is, therefore, necessary to conduct more comprehensive research on the psychological condition of IDPs, their mental health, and their coping strategies, using a mixed-method approach, to gain a better understanding of their psychological state.

Internally Displaced People in Myanmar are living in constant fear, and military airstrikes with heavy weapons during the pandemic have exacerbated their vulnerability. The increasing widespread rape and torture of women and children by the military makes their lives extremely difficult daily, adversely affecting their mental health and well-being. Additionally, they are also suffering from food insecurity and are susceptible to infectious diseases since international humanitarian aid, including lifesaving and medical supplies, has been blocked by the military since the coup in 2021. The situation has left some IDPs resulted to death and living in hazardous conditions as they are unable to receive even basic medical treatment. The precarious living conditions and unhygienic sanitation place them at substantial risk of infection with influenza, malaria, and other infectious diseases including COVID-19. Therefore, the international community and organizations must cooperate to halt the ongoing crisis and provide humanitarian aid, including the COVID-19 vaccine to stem the unprecedented global health crisis and human catastrophe in Myanmar.

Ethical approval and consent to participate

Ethical approval was obtained from the Postgraduate Student Committee (PSC) of Lingnan University Research Ethics Committee/Institutional Review Broad (IRB) in Hong Kong. Oral informed consent from all participants was obtained before conducting an interview and audio recording aligned with the research ethics. All the participants’ names were assigned pseudonyms. All methods are well carried out by relevant guidelines and regulations.

Experimental protocols: This study did not require any experimental protocols.

Availability of data and material: All data generated or analyzed during this study are included in this published article.

Competing interest: The author of this manuscript declares no conflict of interest regarding this paper's publication.

Consent for publication: Not applicable

Funding: No specific funding was obtained for this study.

Author’s contribution: The author conducted the following activities: literature review, study design, data collection, data transcription, and data analysis.

Acknowledgment: The author would like to acknowledge his sincere gratitude to all the internally displaced participants and individuals who assisted during data collection.

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Vulnerability and social determinants of health among internally displaced persons (IDPs) in Myanmar post-military coup

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Abstract

1. Introduction

2. Methodology

2.1 Study design and participants

2.2 Data collection and analysis

3. Results

3.1 Experiencing constant fears and anxieties

3.2 Precarious living and infection of disease

3.3 Surge of infectious disease and COVID-19 cases among IDPs

3.4 Lack of food supply and substantial risk of hunger

3.5 Longing peace to return home safely

4. Discussion

5. Practical Policy Implication

6. Limitation And Future Research Direction

7. Conclusion

Declarations

References

Additional Declarations

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