CTWPG: Dr Fatoumatta Jarjusey Talks Women’s Health

追加: 2026-05-10

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[00:04:46]Dr. Fatima Jajushi is a Gambian trailblazer in medicine, recently becoming the country's first female graduate of the University of the Gambia to earn fellowship status in obstetrics and gynecology with the with the West African College of Surgeons. She's now a consultant obstitrician and gynecologist at Edward Francis small teaching hospital recognized for her pioneering role in women's health and medical specialization and Dr. Jagui has chosen to start her week here with us on coffee time to answer questions and will make herself known more to all of us. Welcome to coffee time Dr. Jaji and congratulations.

[00:05:28]>> Thank you so much uncle Peter. Thank you for having me. take us back to your early schooling. Uh what shaped your decision to pursue medicine?

[00:05:37]>> Uh thank you so much sir. So um back in I from a village girl. I did my primary school in the village. I stayed with my grandmother. Then I came over to the comos and went to >> which of the many villages >> from Kala. So Kinala is in Kang Central.

[00:05:54]Yes. Whatever where my mom is from and my grandmother brought me up. Then I did my junior school in Charles J Memorial Academy. We were at the first batch um of students. Um the school just started.

[00:06:05]Then I went to >> a true pioneer.

[00:06:07]>> Yes. Then I went to St. Joseph's high school, old girl school. Then from there I went to UTG in 20 in 2003 and completed medical school in 2010. Then um UTG was just here. We had Dr. Bet and Co as the first B of medical. There are two Dr. B.

[00:06:24]>> Dr. Bet.

[00:06:27]Yes. my boss and the CMD. So they had the first batch um to go to medical school in the Gambia. I think this was in 1999.

[00:06:34]>> So we also joined the medical school. I started in 2003 and completed in 2010.

[00:06:39]Um did medical school and then started my house job. Um did house job for 2 years. Um and interestingly my my last rotation was in pediatric that has to do with children. Uh Dr. Bet actually Mustafa Bet is the one who dragged me to OMG OBGYn that's of studies and gynecology to become a medical officer there. Then I took um after the house man job that's for 2 years you do a house job for 2 years then you have to go under being a medical officer then I took some break I went to UK to do a masters in public health and health promotion then I came back and then continue as a medical officer in um OBGYn. Um at that time we didn't have any residency program so you are just a medical officer for as long as it takes.

[00:07:24]Um thank you to Dr. B, Dr. Keta. Um they came back from Ghana and then encourage us to start um this residency training coupled with so many it took the whole village for this residency program to start. Then residency we started in 2018. Um so it took us about 3 to four years to become a specialist um in obsessed gynecology. We went through um so many um training, so many exams um which most of them are not done in the Gambia. You either have to go to Nigeria or Ghana to do your exams. Then we did these exams in 2022 to become a specialist in obsessian gynecology. Then I wanted to further specialize and be a fellow or consultant in obs gynecology.

[00:08:06]But I had passion for women's health. Um it's one of my passions I've ever had since I was a kid. So I went through the fellowship exams. Um this training took us another 3 to 4 years very intensive training occup and then um so many you need um so many um infrastructure you need finances um most of them we are not done here we had to go to Ghana we have to go to Nigeria and they they have to bring some consultants here because sometime it's cheaper for them to bring them all of us traveling to um Ghana or Nigeria then um April last month um we did the fellowship exams and alhamdulillah uh We are here today as a consultant obsessed and gynecology.

[00:08:46]>> Fantastic. So you were leaning towards pediatrics. Yes, I was.

[00:08:49]>> What did Dr. Bet see in you the CMD today um to sway you to obstetrics and gynecology.

[00:08:56]>> Yes. So he kept saying we need women in this field you know we need to help our own women and someone has to start. We can all be running away. It's demanding.

[00:09:05]Obset gynecology is demanding. You can imagine they are dealing with two lives.

[00:09:08]The mother the baby and the family. So it's so demanding like we need our own women. They have to be comfortable. They have to be talking to their own women.

[00:09:16]This will help them. You know our culture and society sometimes you don't want men touching your woman or your wife. So it's like somebody has to start and unfortunately I had to be digging a pick and here we are. Alhamdulillah.

[00:09:30]>> Okay. Um becoming the first UTG trained fellow in obstetrics and gynecology is of course historic. Um how did you navigate the challenges of training exams and um specialization?

[00:09:46]>> It wasn't easy sir. Alhamdulillah we are here. It's you know people didn't see what happened behind the closed doors.

[00:09:53]Like I said it took the whole village um is very demanding being married um having a family and then have to go long hours. Um sometimes you in the hospital for more than 24 hours >> mostly more than 24 hours. In the morning you wake up and the work has to continue. Patient do they not understand that labor doesn't wait for that the labor doesn't know whether you are tired or not the baby must come if the baby wants to come so it's very challenging long hours and it the money is not much probably they have to put more incentives and all but then yes we are here >> yes >> and what does it mean to be a consultant I think you call it >> OB obg consultant OBG in Gambia today >> it's um it's very demanding But it's it's it's it's a good thing uh because now um it means um we have more more areas to concentrate on and two also um the patient waiting time with the juice.

[00:10:49]We can do most of our surgery here.

[00:10:51]Patients don't have to travel to Sagal or even overseas to look for treatment and also it's very important because um we are here to serve as mentors as training. We are already lecturers. I'm a lecturer too in the University of the Gambia and also involved in nursing school. They also invite us to give lectures and also we have a residency program that's 3 years and you have year one year to year two then you have to continue teaching. I mean it's important because you also have to maintain the knowledge that u uh you've gained before. So yes it's demanding but it's a good thing for the Gambia and the hospital because we are here probably more gaps will be filled more surgeries will be done and then patients going out will be reduced significantly in >> okay and in terms of um you know the job itself uh your daily experiences what are some of the more pressing maternal health challenges that you face every day at um Edward Francis small teaching hospital >> yes so talking back around 5 years ago we are more worried about postpartum hemorrhage That is women bleeding in pregnancy after delivery. But right now, alhamdulillah, that's no more our problem. The main problem we are facing now is women having hypertension in pregnancy.

[00:12:03]>> So we cause it hypertensive disease in pregnancy.

[00:12:05]>> So they were not hypertensive before pregnancy.

[00:12:08]>> Before pregnancy, most of them are not hypertensive in pregnancy. But they um >> they become hypertensive become hypertensive 20 weeks of pregnancy. And you have some who had already been hypertensive. Again this is been um manifested more in pregnancy.

[00:12:22]>> Is there an explanation for this?

[00:12:24]>> Um unfortunately initially we had so many risk factors that were identified in the literature like getting married early um changing partners and being a hypertensive patient but now these things are not even you know are not the ones the patients are manifesting with.

[00:12:39]So we have so many um patients presenting with hypertensive disease in pregnancy. So now right now it's our major problem in um pregnancy. So we don't normally now postpartum hemorrhage is the thing of the past. I'm not saying women are not having it but now our main concern is hypertensive. Then you have so many other things medical conditions probably our lifestyle our you know way of life but yes hypertensive in pregnancy it's our main problem.

[00:13:05]>> I understand you've done some research work on HPV which has um uh drawn attention. um what are some of the key findings um of the research and why are they important?

[00:13:18]>> Yes sir. So HPV is human papilloma virus. Um so this is the virus that is responsible for causing cervical cancer in women. Um which is a very um concerning disease and it's a public health concern. Um unfortunately it's something that you can screen for and it can be treated if they come to the hospital early. So it's really sad.

[00:13:37]Women usually will present very late and you can barely do anything about it. So I did the study as part of my dissertation and human papilloma virus is still very common in a Gambia and the prevalence was 10.4 and so you have a higher risk type and a lowrisk type. The higher risk types are the one that will cause cervical cancer and my study found out 52 which is a form of higher risk type was the most common prevalent in women presenting to the clinic. We still have very um high um prevalence of papaloma virus and then that means cervical cancer we still have a long way to go.

[00:14:12]>> So how are we to tackle this? I'm sure you must have you know you identified the problem you must have proposed solutions to the problem.

[00:14:18]>> Yes sir. So screening screening screening it's very important and it's very cheap even with the common vinegar that we used to cook with. Okay.

[00:14:26]>> Yeah. You can use it um to screen um and then this will tell you there is an infection going on. this can be treated and then the woman will not develop cervical cancer but again public health awareness um I did in my master studies I did just knowledge awareness of women including even the health workers sadly they don't usually come for their screenings because most of them say they are not even aware so we need to do more public health awareness so this is one of my priority areas now to um collaborate with radio stations like uh west coast um GSM companies so that we will encourage and educate um the public on the importance of coming for their cervical cancer screen because we cannot the vaccination is another important thing but it's very expensive and for now it's only um usually they are given to school girls and most most of them are donations we cannot afford it but screening and public health awareness at least those things we can but >> and the woman can walk into any any health facility and be screened >> any health facilities and currently the human papilloma virus in the gamb we have the screening for the human papilloma virus and you don't screen again until 5 years Oh, it's once every five.

[00:15:32]>> Yes, every 5 years. Others like the vinegar, we call it via and then also papsmear is very common. You do it every 3 years. But for the HPV, you don't do screening until 5 years. That is a long time. And if you have the infection, at least it may take up to 10 years before it can actually manifest as cervical cancer. So that's why it's sad that women are coming advanced state because this something you can detect early and it can be treated in the Gambia.

[00:15:56]>> Okay. I was speaking to a politician last week on the program >> and she flagged maternal mortality as still, you know, a major concern. If it is still a major concern, what systemic gaps do you believe need urgent attention?

[00:16:14]>> Yes, it is true. It's still um a concern, but the data have shown it has significantly reduced. Um the last census um the number was 289 per 100,000. we are talking about 400 500 previous um census. So it's coming down significantly but yes there are still room for improvement. One is our antiatal care. Um Gambia have a very good antal care but we have to improve on the quality of antiatal care. Yes we have many doctors coming up but yes still we have so many areas in the provinces in the up quantities that have to be manned by medical doctors. So they having the antital care but the quality have to be improved on. Like I was saying about the hypertensive disease sometimes you will see um the the women will be seen the blood pressure will be high. They will be tackled that the health provider will know this blood pressure is high but they might not know what next to do for the patient until they present very late. So our quality of antennal care should be improved.

[00:17:12]again our men you people have to help us >> in Bundong um they have a very good um um uh system there men usually accompany their wives to antal care and they've seen so much improvement because you will be in that room you will know what the woman will need and then the support will be there both financially and socially so our men also have to help us in bringing our women you know in Gambia I mean many you have to depend on the man to say yes you have to do this no you have to do this till now so if they are involved This will also help and then continuous training continuous training continuous training and provision of infrastructure and also equipment. These are the things that will help for us to reduce more maternal mortality. But yes, we are getting there.

[00:17:56]>> Okay. Yes.

[00:17:57]>> Congratulations. I hope you get there you know sooner than uh you.

[00:18:00]>> Do we have a national uh strategy for women's health and if we don't have why should we prioritize one? uh I I may be stand I stand to be corrected but I don't think there is any for now but it's very very important for us to have it because this will help us the service providers to know what to do and what not to do and it will help us inform these women where what can be done what cannot be done and the ways of so I think if it is not available like I said I stand to be corrected we need to have it this will help us um in a very good way >> okay all right uh Dr. Um who should start the process? The CMD.

[00:18:37]>> Yes. CMD should start.

[00:18:39]>> Start the process.

[00:18:40]>> He should start >> assuming there is no national.

[00:18:42]>> Yes. Assuming that he should start. Yes.

[00:18:45]Yes.

[00:18:45]>> Now, how do you see the relationship between medical specialization and health policy?

[00:18:51]>> Yes.

[00:18:52]>> You're now a specialist. Um does the national health policy, you know, enable your work? Does it make it easy? Does it um facilitate um your work?

[00:19:02]>> Yes, sir. It it it facilitate our work.

[00:19:05]Uh because if there is a health policy as things like natural a national health um insurance scheme and all those policies, this will help because some of these women they cannot even afford the quality of the anti care we are talking about. In government hospitals is really cheap but then sometimes the materials are not available and you may have to have the the the the manpower but sometimes the facilities are not available, the medications are not available. So you need to go outside and get it and some of them you know they are like many of us um average Gambians and they may not be able. So if we have these national health policies and insurance scheme this will go a very long way in talking in uh tackling the quality of antal care we are talking about but that's when we can tackle our maternal mortality the quality of care is there we wouldn't be talking about so many complication that leads to these women dying.

[00:19:55]>> Okay. All right. Now, as a woman breaking barriers in uh a male-dominated field, what message do you have for young Gambian girls aspiring to careers in medicine?

[00:20:07]>> Yes, I wouldn't lie. It's not easy and it has not been easy, but it's something that is doable and I think I'm a testament to that. Um, with determination, with focus, you can do it. um you just have to prioritize what you want and then just so I would not say just some years of your life maybe it took the entire time of my life but you have to juggle with everything that is happening and then you should be able to get there it's very doable >> and would you say it's easier for them now knowing that they have people like yourself already in there providing training >> yes actually I would say that when we started we didn't have this kind of mentorship like I said it was Dr. Keta and Dr. Mustafa came back from Ghana and we didn't have our first exams we did we had to go to Nigeria and did the exams then come back here and wait for another two three years to start the residency program six of us and then Kajali and other from other departments so now they have that you have a 3 years residency program by the time you start you have somebody from year 1 year 2 year three and so many consultants to help we didn't have this so yes it should be easier and we are here to help them through that >> well you're a lecturer you lecture at the UTG do you see a lot of promise miss among um you know the female medical students you you're lecturing >> actually I see like currently in our third year student we have 80% of them are women yes so 80% of them are women in in coming few years no not few years few months we'll have two more consultants in obsidian gynecology which are female as well so yes it's promising >> okay and in terms of doing the job what innovations or alternative approaches whether it's tele medicine solar powered clinics could help bridge healthcare gap Perhaps in um in rural areas especially >> definitely tele medicine you mentioned it's very important because these you these women can be sitting in their homes whilst we the consultants or the health providers can be talking to them and giving them what the quality of women living in the comos are having is very very important. So yes tele medicine is something that we can actually invest in and they don't have to travel all the way from Bansang from Bas to come to EFS to get their screening done or to get their other um test done. So yes, tele medicine is one thing and also research. I think uh there are so many gaps there are so many questions that we need to answer and this can only be done by research so that we know what our local problems are and the ways forward how we can tackle them.

[00:22:26]>> What are some of the biggest questions that still need to be answered?

[00:22:30]>> The biggest >> if you were to embark on a research for instance what three key questions would you want you know the research to find answers to? One is how to significantly reduce our maternal mortality and mobility. Okay, that's one. Two, how do we increase our uptake of cervical cancer screening? Like I said, cvical cancer women don't have to die from cervical cancer in 2026. So, we need to find ways on how we can increase their uptake of coming for their cervical cancer screening and also three the antiatal care. How do we improve the quality of antiatal care? Do you care at all about men?

[00:23:11]>> Uncle Peter, I did. That's why I say you people have to help us in our antal care. Improving the quality of antital care. That's when we have Uncle Peter bringing auntie to the antal clinic. Um, so it's very important. We need you people. I mean, you people are the heads of the family and your words really matter. So we need you to come on board and support us so that we can get where we want to get. You people are important. Back in the 80s during the Jawara time, primary health care used to you know be you know a dominant talking point the way primary healthcare was being uh promoted.

[00:23:45]>> Um what's the place of primary health care today and why is it not getting you know the attention it got in the 80s '90s? Yeah, actually they still saying uh we have got the best primary health care in the ST region and yes so it you know we have so many now we have community medicine doctors know that graduated and they supposed to be in the community but I think we still not get there and we have midwives that can go to the houses and our vaccination coverage also these are all part of the primary healthcare so I think we still in the sub region we still have a very good primary healthcare it needs to be strengthened and it will help a lot and also So we have family medicine coming up. Um recently they've graduated um specialist and this will also help it to fill the gap because when you have family medicine most of them will be dealing with the primary healthcare problems that will not get to the tertiary hospital. So yes it needs to be strengthened but it's a good one I think >> just maybe to emphasize the importance of primary healthcare if we build on what we have already. I mean you say we have the best primary healthare system in the sub region but if we were to even >> further improve on it would it >> answer some of the questions you have for instance relating to maternal health sorry maternal mortality cvical cancer address most of the problems so they wouldn't have to come to secondary healthare or tertiary healthare so yes it will address >> and isn't it cheaper to focus on primary healthcare >> way cheaper like saying uh prevention is better than cure and the primary health care will help with you know the preventive measures. So >> so Dr. Dr. B put more attention in private you have to private healthare.

[00:25:24]Yes sir.

[00:25:25]>> Looking ahead what's your vision for women's health in the Gambia say over the next 5 to 10 years.

[00:25:32]>> Yes sir. So u my vision is to produce more consultants like myself and encourage women to go into sciences and it doesn't have to be medicine. I mean if you go into other stems I think it will go a long way but my priority now is more women coming into medicine. One of my colleagues say we don't want any man to be specializ in OBGYn and so which means we have to encourage more women to come over. So yes um hopefully in the next um like I said a month in 6 months or one year we should be having two more consultants female and then we have like the residents third year residents now 80% of the female and so this will serve as an inspiration to younger generation. So we have more women that our women will be comfortable when you walk into the clinic you will see faces of women not men dealing with your problem. So yes.

[00:26:18]>> Okay. All right. And again just to I I know you you know you touched on it at the beginning of this conversation but for somebody just tuning in I mean you were an obstitrician and gynecologist for many many years but now you carry the additional title of consultant. Um what's the difference between an just an obstitrician and gynecologist and a consultant >> obstitrician and gynecologist?

[00:26:44]>> Yes. So when you are just an obstacian like a specialist um you are involved in your work um some training and also mentorship but being the consultant um the the the the pressure is higher. Oh, >> so many expectations. Um, so you have involved now and also not just being a consultant but also leadership and management training and mentorship. So so many um responsibilities have been added to my work now and so yes still I'm still involved fully involved in patient care clinics um doing on calls and all the on calls might not be hectic. The on calls are it's every doctor's nightmare. So being a consultant at least is lessens but in OBGYn and unfortunately the more problematic the condition is the more you require the consultants to set in.

[00:27:30]So the night hours will still continue but yes more responsibility.

[00:27:34]>> Okay. And finally on a personal note what keeps you motivated in the face of challenges and what legacy do you hope uh to leave?

[00:27:42]>> Yes unclea. So if I deliver a woman and then that smile on their face means everything to me. They always do. I am too old.

[00:27:51]>> I forget about what how many hours I worked for. Or you have an old woman escort that gives me $10 from her pocket. I mean that woman that $10 it it means everything to her. It's better than you coming and giving me $5 million.

[00:28:06]>> So you have an old woman, you know, escorting somebody to the hospital. You deliver them, they are happy and they take out a $10 here and say, "Doctor, >> if you refuse that $10, they are like is the money small that's why you don't want to." I said, "No, no, grandma." No, no, you have to.

[00:28:20]So that smile on their face, it means everything to us. It keeps us motivating and they are prayers too. It's hard, but at the end of the day, you go home and then you're like, "Okay, I've saved somebody life." And then that's what keeps motivating us, sir.

[00:28:33]>> Yes.

[00:28:34]>> You seem to be blessed with um the ability to speak multiple local languages. You speak very good waf. I'm sure you speak good fooler.

[00:28:41]>> Actually, I don't speak my walaf is not very good. I'm from K by the way. They have sal. because I was just in Queen I speak more of Mandinka. So Dr. B will be laughing at my wal just try to say something in Waf and on Mandinka about you know these developments you know in in your sector because very often when you talk about the health sector you know you get you get very bad press and so on and so forth. So I mean inform them in in in our languages about some of these West Coast Radio.

[00:29:55]So consulty which mean any associated with that. So our main when it comes to women's health and then we will get there.

[00:30:51]Wow.

[00:30:54]Wow.

[00:31:08]Dr. Dr. K.

[00:31:38]Wow.

[00:31:47]very long time.

[00:31:53]So these are some of the things added advantage.

[00:32:10]Yes, definitely you know. Well, definitely my department so many people are looking up to me.

[00:32:23]Alhamdulillah and I hope I'll be able to meet their expectations.

[00:32:34]Then go maternity leave.

[00:33:02]Hopefully next.

[00:33:18]Wow.

[00:33:31]So it was very difficult.

[00:33:42]So they will be inspiring others and then so that University of the Gambia College of Surgeons.

[00:34:02]Wow. So West African College of Surgeons um main body responsible for all the almost about 10 or 11 West African countries um Gambia, Nigeria, Ghana, Liberia Niger.

[00:34:41]college exams. It has to be certified by the West African College of Surgeon.

[00:35:06]body responsible foration for certifying and also supervising what is going on.

[00:35:12]So they come will be able to um provide that uh it took the whole village for us to be here today. We want to start with Edward Francis people like Dr. Mustafa, Dr. Ka when they came back um they met so we started this program then we had so many consultant Dr. Idoko Dr. Patrick Dr. a and all of them helped with this training program and also we had so many help from the Cubans because most of our medical school we had when we started it was just the Cuban that were here and then China so come like we have something called minimal invasive surgery and they also program six months continuously which is ongoing then apart from we also have the world bank the world bank helped ministry of health. So the ministry of health has been the main sponsor for our program.

[00:36:30]They've been there. So we travel to Ghana or Nigeria maybe five times six times going for exams going and it's very expensive. So we have to go there.

[00:36:38]So the ministry of health with the their main partner I think the world bank that helped and then the government also had been very helpful. So it took the whole village for us to be here today.

[00:36:51]private practice. Wow.

[00:37:03]Private practice.

[00:37:14]But the good thing is private practice. Just know that after working hours or anywhere is our main priority exposure only teaching hospitalrivate practice but most of them it's after working hours at 400 p.m. or 5 p.m.

[00:37:39]So yes, we doing private parties but our main concentration is Edward Francis small and other allied hospitals.

[00:37:50]Excuse me from maybe some surgeries whatever just to round off everything. Any final message Dr. J? Uh, thank you so much, Uncle Peter. I just want to say I'm a big fan by the way, but just the listening part, not the talking part.

[00:38:14]So, >> you've not joined the talking part.

[00:38:16]You'll be bringing me here more often.

[00:38:18]>> Yes. So, um I'm happy to be here. Like I said initially, um we are here to improve the maternal health service of the Gambia. That's why we are here and we are hoping um we will um the next time we here probably we're talking about maternal mortality being not less than zero but you know a very drastically improve and we hope to improve the quality of maternal and child health in the Gambia >> and to people who you know whenever people come here and criticize the health system and I tell them just go to Edward Francis Mo teaching hospital and look at the you know impressive build and they go yeah but yeah nice building but people are still you know lying three in a bed they Hey, three in a bed.

[00:38:57]>> Uh three, four, you know, I mean, premature babies in in an incubator, people lying on the floor and all of that.

[00:39:06]>> Yes, these are realities. But considering how many patients are, you have only one teaching hospital in the Gambia and every health center, every is to this. We don't have the capacity to maintain all these patients. Yes, they are working on expansion. Yes, there are so many works ongoing. But the public just have to bear with us. And in as much as patient as here in we try to as much as possible to give them the quality of care that they deserve. Yes, we will get there and so yes Dr. M and the minister probably listening or they will listen but they are doing a very good job and the public just has to bear just not you have three patients on a bed but we give them the best room was not built in a day.

[00:39:46]>> Yes. Exactly.

[00:39:47]>> You make the point that we have only one teaching hospital. Can we have more and if yes why are we not having more?

[00:39:53]>> Yes we can. upgrade Canifing General Hospital for instance to teach >> us. Yes definitely we can and so with this postgraduate and residency program and having more consultants on the ground we should be able to upgrade places like Cardiffing even Bansang to hospital and this will actually improve the quality of Z and also reduce the workload and also social media attack on EFS stage and Dr. B. So yes hopefully with this training and also the postgraduate more consultants coming up we should be able to have because you need to have specific number of consultants in one place for you to be for a teaching hospital >> about how many seven >> uh maybe yeah so I can't remember the figure but for each let's say about maybe if we have three residents you need to have at least one consultant to be able to train those people.

[00:40:39]>> Okay. So there's the three of you you named Ka and B before so that's five at least.

[00:40:44]>> Yes we have at least five. Yes. But we have almost 20 residents or more than that in training in EFT and we have to go outside. So just not you have to go outside to do a ruler posting. I did mine in Bama. So it means when I'm there for that 3 months a consultant has to be attached to me. So which mean you have only four in Bul and then we still have to refer them. So we will get there like you said was not built in one day. So but we will get there. Yes. Can be a teaching hospital and this will help.

[00:41:12]>> Congratulations.

[00:41:13]>> Thank you so much uncle Dr. Fatum Motor Jagu thanks for being here this morning and um yeah he she's a consultant obstetrician and gynecologist whose pioneering journey has broken barriers hopefully inspired a new generation of Gambian doctors.

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