Governance Research Paper

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In the recent decades, the changing scene of social affairs, including the increasing emergence of markets and networks that in many cases substituted hierarchical institutions, such as states and governments, has led to increasing theoretical focus on governance as the process rather than government as the institution. The concept of governance recognizes all the role-players in managing social affairs, including governments, intergovernmental organizations, and nongovernmental and civil society actors. In the global scene, the concept of global governance has replaced the older concepts such as international relations or world order. Health-related affairs, also, have been a subject of global health governance at the global scale. The ethical principles that are relevant to global health governance are broader than the traditional sets of beneficence, nonmaleficence, respect for autonomy, and justice. They include other principles such as equality, justice, and equity, respect for cultural diversity and pluralism, solidarity and cooperation, social responsibility and health, and sharing of benefits. The main challenges of global health governance, such as double standards, bilateralism, and exploitive research, can be theoretically and practically explored and solved with adherence to this more inclusive and comprehensive ethical perspective.


Pursuing different goals on the scene of human social life, such as peace, health promotion, environmental protection, and antiterrorism, necessitates collaboration and coordination among different acting parts or elements, aimed at achieving those goals. All these involved parts and elements and their activities need to be orchestrated by one or multiple influential bodies. This orchestrating, either by a sole leading actor or by multiple role-players, actualizes the concept of governance in the reality of the human social life.

Governance, in various forms, exists in different fields of collective human life, including organizations, activities, and outcomes, and in any level of it, including family, team, tribe, community, nation-state, and globe. Therefore, there are countless types of governance mentioned and described in the literature, for example, public governance, organizational governance, corporate governance, global governance, nonprofit governance, project governance, environmental governance, health governance, and information technology governance. Among all these various types, one of the most relevant types to global bioethics is global health governance. Therefore, the main focus of this entry will be on this field as an example to be explored in more details.

The ever-increasing complexity of human collective life and emergence of new patterns of social interactions and social life have led to newly emerging ubiquity of the term and concept of governance in the scholarly and political literature in the beginning of the twenty-first century. This ubiquity is especially obvious in the field of global affairs. The absence of a single government or a single hierarchical order in the global scene, and the presence of serious problems that cannot be solved within the borders of sovereign states, and the emergence of numerous non-state and nongovernmental and non-intergovernmental role-players on the scene have led to an abundant reliance on the concept of governance for describing and understanding the current state of global affairs.

Because of the ethical nature of many of the abovementioned problems, solutions, and procedures, especially in the global health sector, this field is of a special relevance to global bioethics. As a matter of fact, the current state of global bioethics, and its theoretical and practical challenges, cannot be comprehensively understood and analyzed without taking the concept of global governance into serious theoretical consideration.

A Historical And Conceptual Review

Governance is the process of governing, by formal or informal bodies, including governments; in different frameworks, including hierarchy, market, and network; through different measures, including laws, regulations, norms, money, communication, or exchanges; and over different sorts and aspects of collective human life.

The origin of the word governance is the Greek word kubernάo (kubernáo) that means to steer. Governance with the meaning of the process of governing has been used in different English texts such as the book titled The Governance of England by Charles Plummer that was published in 1885. However, this word has become popular and viral in political, social, economic, and ethical discourses, since not sooner than early 1990s.

Governance can be simply defined as “the process of governing.” It is important, however, to notice that this term not only refers to the process of governing by governments but also to the more dynamic, sophisticated, and sometimes subtle processes of governing by corporations, organizations, religious bodies, media, pressure groups, lobbyists, coalitions, civil society actors, activists, and other formal and nonformal role-players. In this sense, governance encompasses all the processes of social organization and social coordination. This function is provided not only by governments but also by other social and civil arrangements such as markets and networks.

The key point in understanding the underlying theoretical and practical causes and implications of the emergence of this concept is realizing why in the past decades, the focus of analysts changed from the states and institutions that govern (governments) to the processes of governing (governance). This phenomenon was mainly because of the increasing emergence and importance of markets and networks as the major providers of governance both in the domestic and global scenes, all over the world (Bevir 2012).

In scholarly literature, the concept of governance without government was used to denote, understand, and describe one important aspect of the changing scene of social and global affairs. This aspect can be portrayed as the increasing emergence, importance, and influence of non-state actors on the scene of human social life. An implication of this change has been the shift from hierarchy to market and network models in shaping organizations and approaching social issues.

It was in the previous few decades that states and other major role-players in the global scene started to accept and adopt this concept in their formal discourse. An early example was the Swedish government’s policy-oriented Commission on Global Governance that was established in 1992 (Weiss 2013, p. 2). A next-coming example was the European Union’s White Pages on Governance.

The history of global heath governance – as a field that is very relevant to global bioethics – can be reviewed as an example that mirrors the abovementioned historical changes.

After World War II, two main international organizations have played major roles in global health governance: the World Health Organization (WHO) and the World Bank. To act as the leading organization in international health related affairs, WHO was founded in 1948. Its constitutional ratification meeting was held in New York City in 1946, and the first meeting of the body was held in Geneva in 1948. WHO has been the most important institution and focal point of global health governance in the twentieth century. The World Bank also has started funding global health-related programs a few decades ago and became a major role-player in global health governance.

The international coalitions for global health governance, however, are dated back to the nineteenth century. The pandemics and epidemics of various infectious diseases, like cholera, yellow fever, smallpox, and typhus, parallel with revolutionary scientific discoveries like the germ theory of disease, ended up to some international meetings aimed to establish international institutions and guidelines for preventing the spread of such diseases (Markel 2014).

In 1851 delegations of 12 European governments met in Paris to convene the first international sanitary agreement. This meeting along with multiple other ones in the second half of the nineteenth century and the first two decades of the twentieth century paved the way for establishing the WHO. Among the meetings that played an important role to shape the concept of global health governance before the foundation of WHO, in addition to the aforementioned First

Sanitary Conference in Paris conference in 1851, one can mention the following: (1) Second Sanitary Conference in Paris, 1859; (2) Third Sanitary Conference in Istanbul, 1866; (3) Fourth Sanitary Conference in Vienna, 1874; (4) Fifth Sanitary Conference in Washington, 1881; (5) Sixth Sanitary Conference in Rome, 1885; (6) The North Sea Liquor Convention, venue unrecorded, 1887; (7) Seventh Sanitary Conference in Venice, 1892; (8) Eighth Sanitary Conference in Dresden, 1893; (9) Ninth Sanitary Conference in Paris, 1894; (10) Tenth Sanitary Conference in Venice, 1897; (11) Liquor Traffic in Africa in Brussels, 1906; (12) Opium in Shanghai, 1909; (13) Twelfth Sanitary Conference in Paris, 1911; (14) Opium in the Hague, 1911; (15) Opium in the Hague in 1913 (Dodgson et al. 2002)

These meetings, although paving the way for the establishment of WHO, were not successful in founding effective and viable international health related organizations or coalitions. The reasons of this failure were:

  1. The political conflicts among great European powers during the second half of the nineteenth century and first decades of twentieth century. In the presence of mistrust and frequent battles among countries, it was difficult and even impossible to accomplish a sustainable health-related coalition or organization (Markel 2014).
  2. The theories of infectious disease causation that competed with the germ theory of disease and still existed at that time. Without a scientific consensus on the ways of preventing diseases, it was impossible to formulate international common interventions and programs (Markel 2014).

Around the time of establishment of WHO as the United Nations (UN) specialized agency for health, other international organizations contributing to health were as follows: the UN Relief and Rehabilitation Administration (UNRRA) established in 1943, UN International Children’s Emergency Fund (UNICEF) founded in 1946, and UN High Commissioner for Refugees (UNHCR) founded in 1949. However, in the second half of the twentieth century, WHO remained the most important institution and focal point of global health governance. Now it is obvious that it is losing its leading role in the global health governance and needs reforms to regain and preserve its leading role (Lee and Pang 2014).

The main role-players in global health governance are international organizations (IOs), nation-states, and nongovernmental organizations (NGOs). Among the IOs, the role of the WHO and the World Bank is sketched above. In recent decades, however, the role of nation-states, especially the United States, in global health governance has increased. This role is mainly played through bilateral programs (instead of the multilateral ones launched through the IOs). A remarkable instance of the conductors of such bilateral programs is the US Government’s Global Health Initiative (previously the President’s Emergency Plan for AIDS Relief or PEPFAR). Also, among the NGOs, noteworthy examples include the Bill & Melinda Gates Foundation, Oxfam GB, the People’s Health Movement, and Doctors Without Borders (MSF) (Woods et al. 2013).

The expanding and increasing roles of such bilateral programs and NGOs in global health governance raised serious questions about the efficacy, relevance, and the central role of the WHO, as a major intergovernmental organization, in the twenty-first century. It seems that in the previous decades, the global health governance has been actualized through a vast network of nation-states, IOs, and NGOs. This network model has completely replaced the hierarchical role expected from WHO by its founders in the 1940s.

Global Governance

Global governance can be defined as the way in which different role-players in the regional or global spheres exert different sorts of power to manage various affairs at the international level.

After the end of the cold war, in scholarly works on global affairs, the concept of international relations was replaced by the concept of world order. The concept of world order, however, was criticized as being top-down and static. Therefore, the concept of world order was soon substituted by the more dynamic and describing concept of global governance (Weiss 2013, pp. 1–26).

The reasons behind the emergence of this concept were as follows:

  1. The occurrence of some problems with a global nature that could not be solved without a globally coordinated operation. For example, the phenomenon of climate change is not limited to any geographic area or national borders and cannot be dealt with effectively in the absence of globally coordinated action plans. As another instance, pandemics and outbreaks, such as the recent outburst of Ebola virus disease in West Africa, demand highly coordinated global reactions. The local governments usually are not able to implement effective measures in a timely manner. International organizations and foreign aid providers need to be coordinated to act effectively and according to a well-planned road map. Coordinating all these resources and reactions is done through global governance.
  2. In some serious world problems, such as the recent Ebola outbreak, the formal intergovernmental organizations proved weak and lagged behind the other role-players. The important role of non-state actors in managing such crises showed that instead of governments and intergovernmental organizations, there is sophisticated global governance in place, with various actors and numerous ways of action, that shapes the global approach to such crises and global emergencies.

In sum, through the past decades, the concept of “international relations” has gradually been replaced by the concept of “global governance.” The emergence of nongovernmental role-players and their influential input in governing global affairs, in addition to the relative shortcoming and stumbling of formal international organizations in the same areas, led to the emergence of a new understanding of the way by which the global affairs are being governed.

Global Health Governance

The newly shaped conceptual and practical profile of global governance is perfectly mirrored and exemplified in global health governance. As historically reviewed above, global health governance has been practiced in numerous ways. The various means and models of realization of global health governance in the contemporary globalized world include (but are not limited to) the following: promulgating health or healthcare ethics related international instruments, including binding and non-binding guidelines, declarations, resolutions, rules, and regulations; forming bilateral or multilateral coalitions on health affairs; establishing and running international health related organizations, including regional and global ones; funding health-related program in other countries; conducting international biomedical research; and providing healthcare or emergency interventions in crises in other countries/ regions.

Each of the main categories of actors in global governance (states, IOs, and NGOs) encompasses a various array of role-players. Sometimes, an international organization officially takes the leading role in one of the global affairs, for example, the WHO is the organization in charge for global health issues. Such international organizations, including the WHO, work on the basis of consensus among the member states. Although managing everything according to broad consensus seems to be the most democratic way of managing global affairs, there are some instances where more powerful or wealthy members of such international organizations decide to play unilateral roles.

When a nation-state decides to play a role beyond its borders and intervene in the international sphere, that nation-state is playing a role in global governance. For instance, launching health-related initiatives and programs in other countries for fighting outbreaks or preventing diseases in an international level is part of global health governance. These efforts raise the problem of bilateralism that sometimes is considered as a threat to multilateral global health governance.

Many countries, mostly in the developing world, cannot afford the healthcare needed by their people. In the case of disasters, like outbreaks, famine, or drought, this gap becomes wider. These countries usually depend on international sources, like assistance provided by wealthier countries for basic healthcare. According to the WHO’s estimate, 23 countries of the world receive more than 30 % of their health budgets from sources outside their borders (Woods et al. 2013, p. 9). This monetary aid usually comes with price tags; the least of them is the power bestowed to the wealthier countries to govern health affairs in developing help-receiving countries. Having financial leverage, either in international organizations or in bilateral relations with other countries, makes it possible for richer and more powerful countries to play their own role in global health governance.

The Relevant Ethical Principles

Global health governance, as the most related field to global bioethics among various fields of governance, has its own ethical issues and controversies. Although a comprehensive ethical analysis of governance is way more extensive than just of global health governance, for portraying the relevance of global bioethics to the concept and practice of governance, taking a deeper look at this field seems to be sensible.

Every analysis and conclusion on the concept of global health government cannot be conducted or reached beyond or free of ethical considerations. As a matter of fact, our thinking on global heath governance should be guided by the principles and norms of global healthcare ethics. For obtaining the most multilateral and inclusive accounts, one should rely on the most consensual sets of such principles/norms. Fortunately, such a consensual set of principles of global healthcare ethics does exist.

The Universal Declaration on Bioethics and Human Rights has been compiled and finally adopted by acclamation by the General Conference of the United Nations Educational, Scientific, and Cultural Organization (UNESCO) in October 2005 (Matsuura 2009). It is noteworthy that many of the principles presented by this instrument are the ones that were proposed by delegates of developing countries to the previously existing classical sets of principles, which had been developed and introduced by Western bioethicists.

A set of principles for biomedical ethics had previously been presented at the time of drafting the Universal Declaration on Bioethics and Human Rights. This set of principles presented by Beauchamp and Childress is called the four principles approach (or the Georgetown approach) to biomedical ethics. They include: (1) Respect for autonomy, which demands the healthcare providers to respect the informed decisions made by patients or their legal representatives; (2) Beneficence, which denotes that the main purpose of healthcare should be maximizing good results and outcomes for the patients; (3) Nonmaleficence, which implies the old motto that says “first, do not harm” and implies the obligation of healthcare providers to minimize harms for their patients; (4) Justice, which can be discussed at different levels from the bedside to the entire health system of the country or even global health governance (Beauchamp and Childress 2009, pp. 99–287)

In the Universal Declaration on Bioethics and Human Rights, all the above principles exist, but other ones are added which are more relevant to global health governance. Therefore in discussing this very issue, it seems that this declaration provides the best available – and internationally agreed upon – framework of values and norms in the form of a set of principles.

Among the principles presented by this international instrument, some of them are the most relevant ones to this analysis of global health governance. These principles are equality, justice, and equity, respect for cultural diversity and pluralism, solidarity and cooperation, social responsibility and health, and sharing of benefits. These principles are the ones that should guide global health governance to avoid its existing and alleged problems and challenges and to achieve better results and successes and less failures in future pandemics.

Equality, justice, and equity: Governance, in every account or field, deals with moral issues that are related to justice. Global health governance is not an exception. The Universal Declaration on Bioethics and Human Rights explicitly states that the fundamental equality of all human beings in dignity and rights is to be respected (d’Empaire 2009). As described below, under the title of double standards, it seems that inequality rules in the contemporary international sphere. Mass media play a significant role in shaping the public opinions and sensitivities toward different issues including the health-related ones. Being located and controlled by developed countries, the most influential media does not usually put equal emphasis on the deaths and disabilities resulting from outbreaks in the developing versus developed world. This discrimination and double standard shows itself in many other aspects of global health governance and in the behavior of its major role-players.

Respect for cultural diversity and pluralism: During the recent outbreak of Ebola, one of the most disabling challenges the health providers encountered was the lack of trust among local affected people. This lack of trust always exists in societies who live under nondemocratic political regimens. The historical legacy of colonialism also contributes to the mistrust among local people of “foreigners.” This challenge is a huge burden on the shoulder of global health governance in dealing with health crises, especially the ones that require trustful collaboration with local people.

The pandemic of HIV/AIDS is also a good example for showing the importance of this principle. A major part of the preventive efforts directly deal with some social and cultural taboos about human sexuality and sexual behaviors. An absolute prerequisite for a successful preventive and controlling program for HIV/AIDS is observing and taking into account the cultural/religious sensitivities of the target societies. The existence of such sensitivities is not limited to the general population patients and their families. Even skilled healthcare providers and health-related leaders and policy makers share such cultural believes and attitudes. Therefore, considering cultural diversity in every aspect and step of a health-related program, especially when it is dealing with long-lasting cultural taboos, is an absolute requirement for every successful transnational health-related program (Revel 2009). It should be added that the principle of respect for the cultural diversity and pluralism has been emphasized in the Universal Declaration on Bioethics and Human Rights with some necessary caveats for preventing of misuse of this principle against human dignity and fundamental rights and freedoms. The declaration rightfully sets human dignity and human rights above the culture-specific norms and conventions. Global health governance has to deal with challenges of both sides of this balance: on one hand, observing the fundamental entitlements of people like patients and research participants to their basic rights like autonomy and confidentiality against the possible unjust demands of local powers and on the other hand respecting cultural norms and conventions despite the enormous difficulties it might generate for the ongoing processes.

Solidarity and cooperation: Some forms of global governance in the contemporary world are alleged to act in an imperialistic and colonialist way. Such attributes in global health governance may result in huge failures. The spirit of international collaboration and interaction should be inspired by the ethical principles of solidarity and cooperation to be sustainable and successful. This very fact has been mirrored in the Universal Declaration on Bioethics and Human Rights (Elungu 2009).

This principle is already mirrored in the functions of health-related IOs with the best instance being the WHO. Fighting pandemic and transnational outbreaks like HIV/AIDS and Ebola, in addition to preserving national interests of every nation-state in stopping such threats before reaching its borders, is definitely out of the spirit of solidarity among all human beings. Mass media and social media, as major actors in global governance, play crucial roles in evoking solidarity among people of the world, especially in the face of urgent needs that happen after catastrophes like pandemics.

Participation of developing countries with limited resources in global fights with emerging health crises is a clear reflection of this principle in the real world. Among them, one can mention the efforts of Cuban healthcare workers in fighting Ebola in African countries in the recent outbreak of this virus.

Social responsibility and health: The article, which presents this principle in the Universal Declaration on Bioethics and Human Rights, states that the promotion of health and social development for their people is a central purpose of governments that all sectors of society share. The explicit mentioning of “government” is an extra emphasis on this fact that these principles are addressed to states. However, in the contemporary world, governance is not limited to nationstates, but global governance plays an important role and should be guided by the same norms and principles. This research paper also mentions that other requirements like “access to quality healthcare and essential medicines,” “access to adequate nutrition and water,” and “elimination of the marginalization and the exclusion of persons on the basis of any grounds” should be provided and advanced by “progress in science and technology” (Martinez-Palomo 2009).

The aforementioned ethical norms and requirements are of special relevance to global governance of diseases like HIV/AIDS and Ebola. Scarcity or lack of vital medicines and skilled healthcare workers, marginalization and stigmatization of affected people and patients, and lack of sufficient and effective nutrition and hydration for patients have been among the main problems experienced by communities who face these outbreaks. In the absence of adequate capacities, capabilities, or will (of local governments) to provide these necessary elements to people in need, it is the responsibility of global governance to take action and play its ethical role.

Sharing of benefits: This principle is mostly related to the benefits achieved by biomedical research and innovations and has been inspired by the discussions about HIV/AIDS research in some developing countries (mostly in Africa) in 1990s. The problem was that the people of the communities which hosted the research facilities and provided research participants for them could not afford to use the products resulting from the research. They had a big share of the burdens of research but did not have any share of its benefits. That situation obviously violated moral norms.

According to the Universal Declaration on Bioethics and Human Rights, benefits resulting from any scientific research and its applications should be shared with society as a whole and within the international community, with special attention to developing countries. Consequently, it is the ethical obligation of global health governance to observe this principle as a major lesson learned from the experience of the HIV/AIDs pandemic and what happened in the research enterprise in dealing with this pandemic (Galjaard 2009).

Problems And Challenges

Global health governance, as it operates in the real world, has been subject of various criticisms. The following part of this entry briefly assesses some (but not all) of the most relevant criticisms that show how the lessons learned from the major challenges and crises, in the light of principles of global bioethics, can pave the way for optimizing the global health governance in the future.

Double standards: In almost every subject which involves interaction between the developing and developed world, the issue of double standards may arise and may really have a footprint in the reality. The media and political institutions of the developing world are alleged to have double standards in a way that life, health, welfare, and liberty of people who live or are born in the developing world are not considered as equally important as the life, health, welfare, and liberty of people who live in the developed world (Macklin 2008).

When it comes to global health governance, this problem mirrors itself in numerous historical experiences. For instance, biomedical research with human subjects on HIV/AIDS conducted in African countries in the 1990s imposed the burdens of research on people living on low-income countries while the end products of the research (antiretroviral drugs) were not affordable for people of those countries. Even inside the developed countries, debates over discrimination against some members of the community created so-called HIV/AIDS activism (Killen 2008). This example is explained with further details under the title of research activities and intellectual property below. In addition, some cases of violation of the rights of human research participants occurred in research conducted on human subjects in developing countries. These activities imply that in the perspective of some researchers and research institutions, the human research subjects in developing world are not equal with their counterparts in the developed countries in terms of fundamental rights and freedoms. The principles of “equality, equity, and justice,” “solidarity and cooperation,” and “sharing of benefits” provide the way out of this problem.

It seems that the most straightforward solution for the problem of double standards is relying on global/international consensual ethical values/norms/principles. Leading global health governance and its interventions in health crises like pandemics by multilateral international organizations ensure avoiding double standards as much as possible. These multilateral programs should preserve their abidance to the ethical principles of bioethics and human rights as described above.

Bilateralism: IOs like the WHO have been established based on the very concept of multilaterality. Acting based on consensus among member states guarantees the democratic nature of such organizations. These IOs are also responsible for observing the ethical principles of global bioethics in their instruments and interventions. In recent years, however, some major and powerful players in global health governance have launched bilateral programs. One of the most prominent examples of such bilateral programs is the US Government’s Global Health Initiative (previously the President’s Emergency Plan for AIDS Relief or PEPFAR) (Woods et al. 2013). These bilateral programs, although being so fruitful in fighting serious pandemics like HIV/AIDS, have allegedly weakened the multilateral role-players, and in the case of global heath governance, the threat was mostly pointed to the WHO.

Having financial control in bilateral relations with other countries makes it possible for richer and more powerful countries to play their own role in global heath governance. Avoiding the possible abuse of this power in political affairs is another reason behind the existing need to move toward more multilateralism. Multilateralism in global health governance makes it possible to make sure that the values of solidarity and benefit sharing (rather than political agendas of powerful countries) rule in managing global health affairs and in practicing global health governance.

Exploitation and helicopter research Exploitation is one of the most important and discussed concepts in biomedical research. Helicopter medical research entails “researchers from HIC [HighIncome Countries] institutions flying into a LMIC [Low and Middle-Income Countries], taking patient specimens and data, and flying out without providing any benefit to the host community” (Millum et al. 2013, p. 4).

The significant increase in the number and size of research projects, including clinical trials, conducted in the LMICs in the past decades raised the issue of exploiting vulnerable populations. It has been claimed that the lower ethical obligations in addition to lower costs of recruiting research subjects and keeping them in research projects have been the main drives of the pharmaceutical companies and other research bodies to conduct many of their clinical trials in the LMICs. These trials are not aimed to respond to the health needs of the hosting countries, even are not aimed to benefit them by its potential results and products, because these products are too expensive to be purchased and used by the local patients or their countries’ health sectors. The so-called 10/90 gap is another explanation of this problem. It has been internationally noticed and recognized that only a small proportion of global spending on biomedical research addresses the major health problems and needs of large vulnerable, marginalized, and disadvantaged populations.

In the clinical trials conducted in the LMICs, there have been many instances of not observing the rights and freedoms of research subjects as asserted in the related laws, regulations, and guidelines.


The changing social theories and practices in recent decades pave the way for the dissemination of the concept of governance in social and political discourse, both in academic literature and in the media. This focus on process rather than institution has been the result of increasing importance of markets and networks as major role-players and, in some cases, as substitutes of hierarchies and governments in managing social affairs. In the global sense, also, the process of globalization has entailed a similar shift in both theory and practice. Global health governance has been a good example for this shift.

In the first half of the last century, different IOs appeared and stayed on the scene of global health governance. In the last decade of the twentieth century and the first decades of the twenty-first century, however, the NGOs proved their dominance and became the major role-players in global health governance.

Global health governance embodies a specific set of challenges, mostly of ethical nature. Dealing with these challenges necessitates appealing to a broader perspective than the traditional four principle approach of global bioethics. For this purpose, the ethical principles discussed above in this entry provide a wide-ranging framework. However, the dynamic nature of governance (as exemplified by world governance and world health governance) requires enduring analysis and exploring to detect new problems and weaknesses and elaborate new ethical frameworks to deal with them.

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