Abstract

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The purpose of this article is to introduce non-verbal tools as a way to initiate the psychosocial support response after a major disaster. The psychosocial interventions that follow the application of the Non Verbal Tool in its different configurations are based on the principle of fostering and strengthening the social and psychological attributes among the community members. The various psychosocial support techniques can be grouped into five categories according to the use of the Non Verbal Tool and frequency of usage. The article presents the development methods, cross cultural validation and the psychometric qualities of the original non-verbal tool. The article concludes that these type of intervention should be included in the repertoire of strategies used to develop  and implement a psychosocial support program.

Introduction

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The impact of natural disasters affects individuals, families and whole communities. Those fortunate to survive such tragic experiences are at risk of suffering from a fear of the future and loss of hope. Natural events such as the effects of an earthquake and tsunami that occurred in South Asia in 2004  and recent earthquake in Somoa and Indonesia remind us of the traumatic effects of such events on whole communities.

Most mental health and psychosocial interventions (IASC, 2007) focus on alleviating the psychological and emotional symptoms of individuals experiencing distress. How the individual responds to traumatic experiences is largely triggered by the influences and reality of one’s ecological context. The field of psychosocial support is challenged with the  development of  intervention models that not only respond to the emotional, psychological, and physical needs of disaster survivors but that also consider the importance of the socio-cultural, linguistic, and systemic characteristics of the geographical region where tragedy strikes. The goal of any model of intervention is to respond to the specific needs of a target population as well as address its unique socio-cultural and linguistic characteristics,  Therefore the development of the most  appropriate interventions must include the voice of those that would ultimately benefit from the intervention and its intended services (SPHERE, 2004).

The initial project attempted to design, implement, and evaluate a non-verbal tool composed of drawings  based on community psychology principles and practices (McMillan and Chavis, 1986).  The initial instrument was developed as a result of a W.K. Kellogg Fellowship in Guatemala and El Salvador in 1983-1984. This project was a modification of the SACAR methodology that is a community empowerment process initiated in 1970. This methodology foster a learning process based on local experiences of the community members. This is a methodology that focuses on practical adult education techniques. It attempts to help the participants participate in gathering data about the community, conduct needs assessments, identify priorities, and develop projects that are implemented, monitored and evaluated by the affected communities themselves. The methodology relies on drawings so that it can be used  as high skill development and low literacy tool.

The project had the following objectives and outcomes:

• Develop, implement, and evaluate a non-verbal tool based on positive psychological practices that respond to local, cultural, spiritual, and linguistic realities of the community.

• Provide training to use the non-verbal tool with survivors of the civil wars using local resources.

• Develop the community’s natural support network to assist with the basic psychosocial interventions.

• Engage local mental health practitioners, community leaders, volunteers, disaster affected people  in the development, implementation, and evaluation of a non-verbal tool and subsequent community based interventions

Design, Development and Practical Use

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Initial non-verbal tool (1984)

The initial non-verbal tool was developed in Guatemala (Prewitt Diaz & Lopez Martinez, 1984). The tool consisted of 192 drawings that represented situations in the community prepared by Mauricio Valladares and Angel Barahona. Scenes were represented in such a way that they are open to many different interpretations. The facilitator who prepares this material should not have any one story line in mind. These drawings are "non"-serialized, i.e. they are not numbered in any set order,  disaster affected participants can rearrange them in any sequence they choose. Continuity in terms of characters, clothes, etc may encourage the use of the same drawing for making different stories.

The project consisted of four (4) phases:

1.  Engagement Phase , the host-country partners were engaged in the research project’s mission. Goals and objectives were articulated, roles and responsibilities were defined, and time schedules were elaborated. In addition, the targeted communities were selected, trainees were recruited, and client beneficiaries were interviewed and engaged.

2.  Developmental Phase , involved the development of the non-verbal tool using drawings (in conjunction with the conflict affected people)  together with psychological first adi techniques (Slakieu, 1990)  to ensure  receptiveness to the intervention. In addition, an instruments needed to be designed to correspond to cultural and social characteristics of the target population and a training curriculum was developed to train the Guatemalan trainees to implement , and follow up with the Non-Verbal Tool.

3.  Implementation Phase , a “train-the-trainer”  activity was conducted in Quiche to teach the sue of the Non-Verbal Tool  by the trainees to selected client beneficiaries for four intervention group sessions. The researcher maintained a close communication link with the field team offering on-going feedback and coordination.

4.  Conclusion Phase ,  the local stakeholders  were actively involved in collecting post-intervention data, reflecting on learned experiences, and participated in the dissemination of the project’s findings.

 The drawings represented five characteristics of community based psychosocial support activities (self-esteem (15 items), associative strength (15 items), resourcefulness (15 items), action planning (15 items) , and responsibility for follow through (12) ). The field testing was conducted in ten (10) villages in El Quiche, Guatemala by community organizers from the Ministry of Health.  The final non-verbal tool was composed of  seventy two (72)  drawings.

The initial project focused primarily on developing a non-verbal tool that would assist conflict affected people to share their feelings with others and to develop, with the assistance of the affected people, community based psychosocial intervention protocols that required only the skills of para-professionals and/or “untrained” community workers to meet basic mental health and psychosocial needs of disaster affected people.

 Alpha coefficient of reliability were obtained for all five sets of drawings. A total coefficient  alpha of .92 was obtained based on the five sets of drawings. A point biserial correlation for each drawing with both sub- sets of drawings and the total set of drawings (Non-Verbal Tool) as a whole were calculated as another indicator of internal consistency of the Non-Verbal Tool. A summary of the drawings showed that in all sets the drawings were generally ordered from the least complex in terms of representation to the most complex.   This exercise suggested that twenty two drawings should be revised and/or reordered.

There were three uses for the Non-Verbal Tool: (1) three pile sorting, (2) story with a gap, and (3) force field analysis.

Three pile sorting was used to assess participants' knowledge and perspectives on a given issue. The tool features a set of drawings (sub tests from the non-verbal tool)  depicting disaster affected people behaviors or community conditions that can be interpreted as good, bad, or in-between (usually due to special circumstances). In the case of community psychosocial issues, for example, participants place each card in one of three piles, representing psychological behaviors, social behaviors and somatic behaviors. Common behaviors that can be illustrated on the cards include children playing around  the community, elderly excluded from activities, people not being able to sleep, people exhibiting physical symptoms, religious ceremonies, people organizing themselves, participatory decision making.
Alternatively, the drawings  depicted a set of problems previously identified by  members of the affected community. In this case the cards can be sorted according to whom the group feels has responsibility to address or solve the problem, such as (i) the household, (ii) the local government, or (iii) both together. Many other adaptations of this tool are possible. The exercise can also provide a starting point to further the participants' analysis. For example, the facilitator might ask which of all of the bad feelings identified are commonly found in the community as a whole, and what might be done to mitigate their effects. Or in cases where a behavior is not seen as either good or bad, the group might discuss why. The facilitator could then inquire what might be done in this situation.

Story with a gap was a particularly useful exercise for generating community awareness about a problem, and stimulating discussion about how to achieve solutions. This technique makes use of a pair of pictures illustrating a "before" situation and an improved "after" scenario.  Participants then discuss both drawings and "fill the gap" by identifying the steps that helped in achieving what is represented in the improved picture.
Alternative interpretations and suggestions were gathered by dividing the participants into several small focus groups (for example of women and men, young and old people, or other categories) and giving each the same set of pictures. After analyzing the drawings, the focus groups can come together to report on their discussions and compare their views. 

Force-field analysis is another visual technique based on "before" and "after" scenarios. Force-field analysis  proved to be  useful in workshops with project staff  and community leaders  as a way of generating a shared vision of a future goal and an agreed strategy for achieving the goal. The technique also facilitates the identification of potential barriers to change. To stimulate discussion of the possibilities and constraints to improving the psychosocial well being, for example, a "before" scenario that illustrates a  destroyed community with disoriented people could be contrasted with an "improved" picture of a community participating in joint activities such as community feast, religious activities or play. These techniques can be adapted for use with communities, using pictures instead of text.

Non-verbal cards are modified into “Guia de Preparacion comunitaria para desastres (2000)

In 2000, the non-verbal tool was adapted in El Salvador with a grant from USAID/MIRA (Mitch Integrated Reconstruction Activity). The drawings were reorganized into seven units representing the disaster planning cycle (Morales Carbonell, Castaneda Matta, Adonay Garcia, Prewitt Diaz & Ramirez, 2000).  There was an increase in drawings to one hundred and ninety eight (198). The cumulative drawings were used as a tool for training community members.  The drawings were divided into nine groups (some of the drawings were used more than once): (1) Perceptions of what is a disasters (16 drawings), (2) Identify causes of different types of disasters and how the affect the community (80 drawings), (3) Identification of types of threats in the community (33 drawings), (4) Risk scenarios (11 drawings), (5) Risks in the community (31 drawings), (6) Mitigation activities (22 drawings), (7) Actions before, during and after a disaster (71 drawings), Levels of organization and community participation (15 drawings), (8) Social actors in the community (23 drawings),  and (9) Steps in planning (7 drawings). The process of re- grouping the drawing in the non-verbal tool led the community members in a systematic study of the community using “disasters” as the focus of their study and subsequent actions.    

The non-verbal tool is used to develop a psychosocial strategy where the tool is used for rapid assessment of individual and community needs (2001-2002)

The American Red Cross recovered the original seventy two (72) drawings and used the instrument widely in Nicaragua, El Salvador and Guatemala (2000-2003).   The drawings in the Non-Verbal tool were reorganized into five sets of drawings.  The drawings were grouped into five sets following the BASIC Model proposed by Slaikeu (1990): (1) behavioral functioning, (2) affective functioning, (3) somatic functioning, (4) interpersonal relationships, and (5) cognitive functioning.  A panel of three psychiatrists and two psychologists for content representation then evaluated the subsets of drawings. The question was: Which area of functioning does these drawings belong? The drawings were included in each area of functioning and in some cases discarded because it didn’t fit into the areas of functioning.  

The final non-verbal tool consisted of 15 stimuli drawing per sub set.  The final version of the Non-verbal tool was administered to a group of 120 University students at the University of Leon, Nicaragua.  The alpha co-efficient of reliability were as follow: behavioral functioning = .70; affective functioning = .75; somatic functioning = .96; interpersonal relationships = .82; and cognitive coping = .71.  The non-verbal tool was widely used throughout Central America (Prewitt Diaz, Flores & Morales, 1999). 

The use of the non-verbal tool followed a four step process outlined below:

1.  Red Cross volunteers introduced the non-verbal tool in the target communities as a medium of exploring feelings, strengths, and ways that the affected population could initiate their recovery by exploring community coping mechanism through free association with the drawings.  The affected community members were involved in using their creativity to look at their present situation caused by the disaster in new ways and to build their capacity for self-expression. Then, they identified ways and developed tools for investigating and analyzing their reality in more detail. Finally, they develop skills in gathering information, making decisions, planning, implementing, monitoring and evaluating community initiatives. This initiative contributed in the development of a specific, culturally sensitive, model of intervention that responds to the basic mental health and psychosocial needs of disaster affected people.

2.  The non-verbal tool and the model of intervention included the active participation and close collaboration of the host National Society, local stakeholders, and the affected communities. The result of using the drawing in the non-verbal tool and the community planned psychosocial interventions responded to local, cultural, spiritual, and linguistic realities of the disaster affected people.

3.  The use of the non-verbal tool to generate healing metaphors has been used as a cognitive approach with disaster affected people to help them normalize their emotional experience. The culturally-relevant metaphors provided as a result of using the drawings in the non-verbal tool provided disaster-affected people with the opportunity to identify with socially accepted values, symbols, and rituals of the their collective culture (sense of place). This exercise assisted the disaster-affected people to cope better with their losses and ultimately achieve healing.

4.  Participants have reported the use of the drawings format in the non-verbal tool, to allow disaster-affected people to maintain comfortable psychological distance from issues of stress while facilitating pre-conscious processing. The use of metaphors and stories generated as a result of the stimulus provided by the drawings was used in counseling sessions as a means to elicit self-confidence and sense of self-control to manage stressful events.  Intervention groups done with disaster survivors within their own communities promoted catharsis, generating a sense of identification within all segments of the community and facilitating three main functions: remembrance, teaching, and motivation.

The Non-Verbal Tool is transferred to South Asia

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In late 2002, with the transfer of Dr. Prewitt Diaz to India some of the tools that had been in use in Central America were transferred with him.  The issues which arose were related to whether the drawings served as a tool for providing cultural and psychosocial explanations to behaviors exhibited by the disaster affected people and communities. The three questions that arose was: Are the drawings in the Non Verbal Tool equivalent to actions related community based psychosocial support in Gujarat and Orissa, India (functional equivalence)? Are the drawings culturally appropriate (cultural equivalence)? What is the best way to use the Non-Verbal Tool in the target communities?

Reaching equivalence

 There were challenges in the development of illustrations that were culturally and contextually appropriate. The question was: How do we transfer the information from a written to visual format, while maintaining the integrity of the message? Obtaining equivalence across formats and cultures became an important task. The meaning of behavior is dependent on the cultural context in which it occurs. Three types of equivalence were established: (1) conceptual equivalence, (2) functional equivalence, and (3) cultural equivalence. 

To answer the question of conceptual equivalence, that is are the concept represented in the drawings representative of the same concept.  For this task the National Institute of Mental Health and Neurosciences, Bangalore, India were engaged.  The two question addressed by the faculty at NIMHANS were concerned with (1) the value of the drawings to address culture, feelings, and expressions. (2) Were the drawings expressive of cultural and emotional appropriate ways of dealing with traumatic events?   Thirty seven (37) drawings were selected through this process in three categories: psychological, social, and somatic.

In functional equivalence the question to answer is:  if the drawing is modified will the feeling and expressions, and cultural nuances be understood by the target population in India. The psychosocial personnel meet with groups of affected people to identify drawings that conveyed the same meaning in the local scene (i.e. a mosque in Maldives, a church or stupa in Sri Lanka).

Once the drawings were developed, the immediate use was through focus groups, and key informant interviews.  Direct observation served to triangulate the information obtained from affected persons using the illustrations. One of the findings from field-testing the drawings immediately after the 2004 South Asia tsunami was that the visual stimuli might encounter the existence or non-existence of the “concept” in the target country and among the affected people.

In establishing cultural equivalence the question is: Does the visual stimuli have the same meaning to members of a particular cultural group versus another?  The drawings were presented to groups of affected people. The initial use of the visual cues determines how appropriate or inappropriate the interpretation of responses is. The use of the drawings provide a medium to identify ways affected persons deal with their families and communities, and in their values, perspectives, customs and rituals after a disaster.

The results of establishing equivalence lead to highlighting the importance of visual literacy amongst the affected people. By attempting to use MHPSS universally, stakeholders developed the ability to (1) understand and make visual statements, (2) allow to understand the world around us visually, (3) understand relationships, and systems of which we are part off, and (4) integrate personal experience and imagination with social and psychological experience.

Developing a Non Verbal Tool in India

 The initial Non Verbal Tool in Asia was developed in New Delhi for use with affected people in Gujarat and Orissa (Prewitt Diaz, Dayal-Rajesh, & Mewari, 2003).  Mewari visited both Bhuj and Orissa and held drawing competitions with affected community members addressing a plethora of community topics. Dayal-Rajesh developed a trifold (Share Your Feelings) with community members in Bhuj, Gujarat that depicted local characters. 

The first tool was a Community Participatory Assessment Tool in the form of a flip chart consisting of 127 drawings.  The use of this material was relatively simple. A small group of community members would get together (6-8), and look at the drawings, the participants develop stories based on the drawings, the responses are written in news print by the facilitator, once they have finished the set of drawings that are being discussed (usually 10-15), then a collective story is developed based on the responses.

Trifolds were developed to one way to assist Red Cross volunteers and paid staff with easily available information while doing fieldwork. Among the most often used illustrations were ‘share your feelings’ (Prewitt Diaz & Lopez Martinez, 2001) and ‘Psychological First Aid’ (Dash & Dayal, 2004). The contents have been contextualized for use with communities and schools in at least 11 countries. Other leaflets that are also widely used are those depicting: ‘Crisis to Recovery’; ‘The road to resilience’; and ‘Guidelines for Operational Training (Prewitt Diaz et al. 2004a).

 Assessment Visual Stimuli Cards The 2004 South Asia tsunami brought the need to engage disaster affected people with the tools to assess disaster related stress. The challenge was that quantitative measures were not readily available. Therefore, visual stimuli cards were used to conduct initial individual and group assessment. In India, an effort was made through the initiative ‘apni kahani tasvirn ki zubani’ (speaking from the Heart) (Prewitt Diaz, et al., 2004b).

In Sri Lanka, based on the work of Slaikeu (1990)  a series of 30 stimulus cards (‘Joe cards’) were used to screen psychological and social symptoms were developed (Dayal, 2005). Red Cross volunteers used the cards extensively as an initial screening tool with individuals and focus groups in affected communities. The tool assists affected communities to determine the target groups to be initially served by the Psychosocial Support Programme.

In Indonesia, the Non Verbal Tool was composed of 74 cards divided into four sections: (1) disaster preparedness and response, (2) participatory assessment, planning, and implementing of community projects, (3) psychological, social, and somatic needs, and (4) self care.

Community Flip Charts There are five community flip charts:

(1)    The first flip chart is composed of 68 illustrations and focuses on assessment, psychological first aid, self care for Red Cross volunteers and paid staff and psycho education.

(2)    The second flip chart is composed of 16 illustrations and focuses on attachment to place and how to enhance competence and self sufficiency.

(3)    The third flip chart is composed of 196 illustrations divided into three major groups: (a) civic engagement; (b) community participation; and (c) broadening and deepening social capital.

(4)    The fourth flip chart is composed of 11 illustrations about the comprehensive MHPSS response and focuses on moving the community forward in the process of establishing healthier and safer communities.

(5)    A Flip Chart entitled “A Tool for Community Development” (Prewitt Diaz, 2007) was developed as a training tool for Red Cross personnel engaged in the India Integrated Project in Kanya Kumari, Tamil Nadu, India. This 112 page flip chart was divided into a theory base section and seven sets of drawings: (1) sense of place, (2) coordination, (3) community assessment, (4) traditional interventions, (5) psychological first aid, (6) stress management and self care, and (7) delivery of brief educational packages. This instrument supported a 35 hour training program for community members and Red Cross volunteers.

Pictorial versions of the guidelines In 2005, staff members participated in the core group that was formulating the guidelines. Staff members of four countries discussed the first draft of the guidelines at a regional meeting in Sri Lanka and decided to develop a visual tool that would take the guidelines to the tsunami affected persons in the four countries represented. Illustrations were elicited covering the three core functions of the guidelines (common functions, core mental health and psychosocial domains, and social considerations in other sectors). This tool was field tested with the tsunami affected population in Sri Lanka, the Maldives and Indonesia. The revision of the tool generated quite a bit of activity in the participating communities. This tool was widely disseminated in South Asia. The South Asian pictorial versions of the guidelines were shared with colleagues of the Pan American Health Organisation (PAHO) in Colombia and Peru, who have since adapted it for use in Latin America, using both sections of the text of the guidelines and illustrations (Rivera Holguin, 2008).

Psychosocial Interventions

The psychosocial interventions which follow the application of the Non Verbal Tool in its different configurations are based on the principle of fostering and strengthening the  social and psychological attributes among the community members. Such a process enabled the development of the disaster affected people's own capacities for self-direction and management and enhanced the quality of participation among all community members based on documentation of participation on activities.

The various psychosocial support techniques can be grouped into five categories according to the use of the Non Verbal Tool and frequency of usage. While there is no set order in which these techniques are used, the five types of techniques were often applied progressively, having a cumulative effect. The five techniques were:

• Creative techniques involve the use of open-ended Non-Verbal tools such as trifold, mapping , and  posters (among the most used) to encourage participants to break out of conventional ideas and routine ways of thinking.
• Investigative techniques such as pocket charts, trifolds, and multifolds  were designed to help participants do their own needs assessment by collecting and compiling data on problems and situations in their community 
• Analytical techniques  including three pile sorting of the drawings and pictorial gender analysis tools enabled participants to prioritize problems and opportunities and to examine a problem in depth, allowing them to better understand its causes and identify alternative solutions 
• Planning techniques were used to simplify the planning process so decisions could be made, not only by the more prestigious and articulate participants (such as community leaders or project staff), but also by the less powerful, including non-literate community members. Planning techniques include story with a gap, force-field analysis and software-hardware exercise. 
• Informative techniques help gather information and use it for better decision-making.

Summary, Lessons Learned and Recommendations

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The development and use of a series of pictures grouped into a Non Verbal Tool has been a breakthrough in assisting disaster affected people in expressing informally using the drawings as stimulus their feelings, emotions, and plans to move forward.  It is a non intrusive tool where community members can express their feelings individually and collectively. The points below are generated after more than 20 years of development of this simple technology.
Summary
The Psychosocial Support model of intervention after a disaster, which uses the drawings in the  Non Verbal Tool in its different configurations should:
• be preventative rather than curative in nature;
• be responsive and adaptive to the spiritual, cultural, racial, and ethnic differences of the population which is intended to be served;
• allow for active disaster affected community participation and disaster affected decision-making at all levels of its implementation;
• be highly accessible and visible to a large number of people needing immediate emotional supports;
• facilitate communication, cooperation, and collaboration among all partners and stakeholders in a targeted community where traumatic events have occurred;
• use the least disruptive methods of intervention possible in the personal lives of individuals and communities to meet the basic psychosocial support needs (such as psychosocial first aid) of disaster affected people shortly after a disaster has occurred; and
• support the capacity development  of an affected community to be able to continue to provide basic emotional supports to disaster affected people through its own resources long after the initial psychosocial support  intervention has taken place after a disaster.
Summary of Lessons Learned
A number of lessons have been learned as a result of the development of the pictures included in the Non Verbal Tool. The following is a summary of the lessons learned.
• Psychological pain and suffering and associated physical symptoms continues long after a tragic experience has occurred especially if no psychosocial intervention opportunity is provided (Finding based on using the Non Verbal Tool as a baseline and end line intervention in El Salvador, 2001).
• The feelings of fear and anxiety of disaster affected people associated with a particular disastrous event is very much a subjective and personal experience that can come to light using the Tool.
• The survivor’s perceptions towards improved health and state of well being is an important outcome determinant to measure the success for a particular intervention strategy (GIDC, Bhuj, Gujarat, 2004).
• Creating a context for hope and possibility is key to any successful intervention strategy for dealing with the pain and suffering of victims of natural disasters (Sri Lanka, February, 2006).
• The importance of visioning positive outcomes from tragic experiences is an essential element in the recovery process. (Mota Village, Orissa, 2004)
• Creating and maintaining a strong sense of community among disaster affected people is an essential ingredient in helping survivors cope with every day stress. (Galle, Sri Lanka, 2006)
• The use of dialogue with family, friends, and neighbors is one of the most frequently
utilized strategy used by the disaster affected people for dealing with everyday feelings of stress  and anxiety associated with a tragic event. (El Quiche, Guatemala, 1983).
• The creation and maintenance of strong supportive community-based social networks is an important ingredient in any successful model of intervention when dealing with the psychosocial support needs of disaster affected people. (Las Casitas, Leon, Nicaragua, 1999).
• The use of a local legend as the metaphor was found to be a useful in engaging disaster affected people with  Non Verbal Cards (Joe Cards in Sri Lanka) process as well as being culturally significant to the targeted group.
• Group intervention strategies with Non Verbal stimulus cards and psychosocial support techniques can be implemented by untrained natural community leaders if they are given support and training that includes a strong experiential component for the practice of newly learned skills and an opportunity to receive ongoing feedback from group facilitating experiences by using the appropriate Flip Charts.
• The use of community leaders as group facilitators resulted in higher service delivery
satisfaction levels than with the use of trained mental health professionals as group
facilitators (El Salvador, 2001). The use of drawings in the form of a Non Verbal Tool has been used for over 25 years. The initial development of the intervention was through a grant from the W.K. Kellogg Foundation as part of a National Fellowship Program.   Much of the field experience gathered in these pages has been through the American Red Cross International Services.  I have tried to document the evolution of the Non Verbal Tool and its diverse uses. It is important to note that the original drawings with modifications to make them culturally appropriate still permeate the diverse number of configuration of this Tool. Of one thing we can be certain this has been a valuable contribution to the development of early psychosocial interventions in disaster affected communities.
Recommendations
It is recommended that the Non Verbal Tool be included in the “a Psychoscial Support Toolkit” as a strategy of assessment, early intervention and community mobilization during rehabilitation and reconstruction. The use of this tool as in the baseline study, and during the life of the project as well as the end line survey may yield valuable qualitative information. Some sets of drawings may be used by the evaluators,once a psychometric study to determine validity and reliability, to gather information from among disaster affected people, with limited literacy skills.

References

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Source(s) of Funding

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This article was funded by the Indian Red Cross and the American Red Cross India Delegation

Competing Interests

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none

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