Reading the Grand Jury Report on the Gosnell Case
MrsDarwin has done the public service of reading through the entirety of the Grand Jury Report on the Gosnell case. The following is a reprint of her post.
Tell me yourself, I challenge you — answer. Imagine that you are creating a fabric of human destiny with the object of of making men happy in the end, giving them peace and rest at last, but that it was essential and inevitable to torture to death only one tiny creature — that baby beating its breast with its fist, for instance — and to found that edifice on its unavenged tears, would you consent to be the architect on those conditions? Tell me, and tell the truth.
pg. 101: After the baby was expelled, Cross noticed that he was breathing, though not for long. After about 10 to 20 seconds, while the mother was asleep, “the doctor just slit the neck,” said Cross. Gosnell put the boy’s body in a shoebox. Cross described the baby as so big that his feet and arms hung out over the sides of the container. Cross said that she saw the baby move after his neck was cut, and after the doctor placed it in the shoebox. Gosnell told her, “it’s the baby’s reflexes. It’s not really moving.”
The neonatologist testified that what Gosnell told his people was absolutely false. If a baby moves, it is alive. Equally troubling, it feels a “tremendous amount of pain” when its spinal cord is severed. So, the fact that Baby Boy A. continued to move after his spinal cord was cut with scissors means that he did not die instantly. Maybe the cord was not completely severed. In any case, his few moments of life were spent in excruciating pain.
Gosnell was an eager butcher, one who was willing to torture babies for women under the desperate illusion that they could attain “peace and rest at last” through this “foundation of the unexpiated blood of a little victim”, as Ivan puts it. He had a psychopathic distain for the external nicetices of the abortion business: the sterile clinic, the efficient staff, the quiet, hidden murder and the quick disposal of the bodies. It was all in the open at 3801 N. Lancaster St., insanely blatant in the sheer horrific scale of murder, murders of babies born alive, infanticide, violations of the Controlled Substances Act, hindering, obstruction, and tampering, perjury, illegal late-term abortions, violations of the Abortion Control Act, violations of the Controlled Substances Act, abuse of corpse, theft by deception, conspiracy, corrupt organization, and corruption of minors.
Think I’m exaggerating? Those are the charges recommended against Gosnell and members of his staff by the appalled Grand Jury (pg. 219).
This case is about a doctor who killed babies and endangered women. What we mean is that he regularly and illegally delivered live, viable, babies in the third trimester of pregnancy – and then murdered these newborns by severing their spinal cords with scissors. The medical practice by which he carried out this business was a filthy fraud in which he overdosed his patients with dangerous drugs, spread venereal disease among them with infected instruments, perforated their wombs and bowels – and, on at least two occasions, caused their deaths. Over the years, many people came to know that something was going on here. But no one put a stop to it.
Let us say right up front that we realize this case will be used by those on both sides of the abortion debate. We ourselves cover a spectrum of personal beliefs about the morality of abortion. For us as a criminal grand jury, however, the case is not about that controversy; it is about disregard of the law and disdain for the lives and health of mothers and infants. We find common ground in exposing what happened here, and in recommending measures to prevent anything like this from ever happening again. (pg. 1)
The outrage of the Grand Jury is palpable throughout the entire document. Although it beggars belief, the report was even more terrible than the brief clips you may have seen quoted in articles make it out to be. For those interested in the case who want to read it, but are (like me) not eager to view graphic photos, I’ve noted down the pages on which the most disturbing images appear:
page 47 — sealed trash bags containing fetal remains (not graphic, but conceptually disturbing)
page 74 — baby feet in jars
page 85 — baby girl, intact (looks like a newborn, stretched out, no cord, no visible mutilations)
page 102 — baby boy A (baby curled in a box with his cord, no visible mutilations)
page 115 — baby boy with back of his neck slit
There are other photos of the exterior and interior of the clinic in the report, and though people of conscience will be appalled that anyone was treated in such squalid circumstances, the above photos are only ones that are of babies.
Many reporters and bloggers have quoted passages on the horrors of Gosnell’s practice — the gruesome deaths of babies; the callous treatment of women; the underage employee who was sometimes the only staff member in the clinic while women were being medicated and delivering babies; the filthy clinic with its fetal remains in refrigerators, its bloody recliners and blankets for laboring women, and the stench of cat urine permeating the air — and I won’t detail those again here. Every unbelievable incident is there in the report, and is even more horrifying read in the context of Gosnell’s for-profit “baby charnel house” (pg 2):
The people who ran this sham medical practice included no doctors other than Gosnell himself, and not even a single nurse. Two of his employees had been to medical school, but neither of them were licensed physicians. They just pretended to be. Everyone called them “Doctor,” even though they, and Gosnell, knew they weren’t. Among the rest of the staff, there was no one with any medical licensing or relevant certification at all. But that didn’t stop them from making diagnoses, performing procedures, administering drugs.
Because the real business of the “Women’s Medical Society” was not health; it was profit. There were two primary parts to the operation. By day it was a prescription mill; by night an abortion mill. A constant stream of “patients” came through during business hours and, for the proper payment, left with scripts for Oxycontin and other controlled substances, for themselves and their friends. Gosnell didn’t see these “patients”; he didn’t even show up at the office during the day. He just left behind blank, pre-signed prescription pads, and had his unskilled, unauthorized workers take care of the rest. The fake prescriptions brought in hundreds of thousands of dollars a year. But this drug-selling operation is the subject of separate investigation by federal authorities.
Our focus was on the other side of the business.
Murder in plain sight
With abortion, as with prescriptions, Gosnell’s approach was simple: keep volume high, expenses low – and break the law. That was his competitive edge.
Unlicensed personnel dispensing dangerous overdoses of drugs sounds like a bad, if rather remote, charge to the medically untrained ear, but section V of the report, The Death Of Karnamaya Mongar (pgs. 117-136), not only makes vividly clear what the practice and consequences of that behavior look like, but is gripping reading.
This financial angle is clear from Appendix B, a copy of the clinic’s Anesthesia for Surgery form, which allows patients to select their level of medication based on price, up to an additional $150 charge for “custom sleep”, which involved dosages of medications (never tailored to the individual woman) which horrified external medical examiners. The consent form and price list includes these introductory guidelines, which I’ve typed from the photocopy in the appendix:
You have already decided that a procedure is best for you. (Next words unclear from the copy; probably “Now you need to assess the”) type of pain relief. It will probably be best to pay the extra money and be more comfortable if some of the following conditions are true for you:
1. The decision to have the procedure is a difficult decision.
2. Medication is usually (unclear; probably “necessary for your menstrual cramps.”)
3. Your decision has been forced by your parents or partner.
4. Your family members or friends “don’t like pain.”
Guidelines 3 and 4 make it pretty clear that Gosnell cared more about profiting from sales of medication than about the health and safety of the women who sought his care. One of the appalling factors in the case is that Kermit Gosnell had a decades-old reputation for the horrific treatment of pregnant women seeking abortions.
pgs. 96-97: Randy Hutchins testified that Gosnell told him about what has been called the “Mother’s Day Massacre.” According to a February 25, 2010, article in The Philadelphia Inquirer, Gosnell offered to perform abortions on 15 poor women who were bused to his clinic from Chicago on Mother’s Day 1972, in their second trimester of pregnancy. Unbeknownst to the women, Gosnell planned to use an experimental device called a “super coil” developed by a California man named Harvey Karman, who had run an underground abortion service in the 1950s. Hutchins related what Gosnell explained to him:
“At the time that he agreed to do this, there was a device that he and a psychologist were working on that was supposed to be plastic – basically plastic razors that were formed into a ball. All right. They were coated into a gel, so that they would remain closed. These would be inserted into the woman’s uterus. And after several hours of body temperature, it would then – the gel would melt and these things would spring open, supposedly cutting up the fetus, and the fetus would be expelled.
“The problem was that they never tested it. They didn’t test it on any animals. They never did any – any – any other human trials. This was not something that was sanctioned by the FDA. This was just something that he decided – he and this guy decided they were going to use on these women. ”
Hutchins actually was mistaken in his belief that no other human trials been conducted. According to the Philadelphia Inquirer article, Karman had tested his device on hundreds of Bangladeshi women who had been raped by Pakistani soldiers. Those women suffered a high rate of complications. Nonetheless, Karman brought his “super coil” to Philadelphia, where he found an ally in Gosnell.
It’s impossible that none of these horrors could have escaped official attention, and indeed, the report finds that time and again, complaints were ignored, inspections were either not made or were too cursory to be serious, and those entrusted with public safety willfully turned a blind eye to Gosnell and his practice because his practice was abortion. The sheer scope of the malfeasance is staggering. The Grand Jury names names and calls out officials at every level of government.
pgs 215-217WHO COULD HAVE PREVENTED ALL THIS DEATH AND DAMAGE?
Had state and local officials performed their duties properly, Gosnell’s clinic would have been shut down decades ago. Gosnell would have lost the medical license that he used to inflict irreparable harm on women; to illegally abort viable, late-term fetuses; and to kill innumerable babies outside the womb.
Had DOH treated the clinic as the ambulatory surgical facility it was, DOH inspectors would have assured that the staff were all licensed, that the facility was clean and sanitary, that anesthesia protocols were followed, and that the building was properly equipped and could, at least, accommodate stretchers. Failure to comply with these standards would have given cause for DOH to revoke the facility’s license to operate.
If inspectors had looked solely for violations of Pennsylvania’s abortion regulations, there would have been ample grounds to revoke the approval of Gosnell’s clinic as an abortion provider – as was demonstrated when DOH inspectors finally entered the facility in February 2010.
Had state inspectors reviewed patient files, they would inevitably have noticed that Gosnell was routinely performing abortions without informed consent from patients or signed consent from parents. His files revealed that he was performing numerous illegal abortions at “24.5 weeks,” in itself a confession of criminality. Gosnell, moreover, almost never had the required pathology reports for second-trimester abortions.
Had DOH inspectors spoken to the workers, they might well have discovered that Gosnell’s procedure included severing the spinal cords of babies born alive. Revoking his approval to perform abortions would have been simple. But no one from DOH set foot in Gosnell’s clinic for over 16 years.
The Department of State prosecutors did not even need to go looking for reasons to revoke Gosnell’s medical license. Complaints came to them. Marcella Choung, the former Gosnell employee, spelled out his entire criminal operation for them. Complaints of perforated uteruses and bowels; of a patient’s death from a botched procedure that resulted in a $900,000 settlement; and of family members physically barred from summoning emergency help, were all sent to Department of State attorneys. Yet the department considered none of these complaints serious enough to take action against Gosnell.
Had the Philadelphia Department of Public Health reported to state officials all that its employees knew or suspected about filthy facilities, fraud, the unlicensed practice of medicine, anesthesia chosen by patients based on cost, infectious waste improperlyhandled and stored, and vaccines stored next to medical waste, perhaps state authorities would have taken action against Gosnell and Women’s Medical Society.
And had fellow doctors, the ones who treated the women after Gosnell butchered them, demanded the attention of DOH and the Board of Medicine, that too might have made a difference.
We don’t know. We only know what happened when none of these people did what they should have.
It’s not uncommon to hear, during the reporting on some scandal, the complaint, ”If only women has been in charge [of the Catholic Church, of the government, of the police force, etc.], none of this would have happened.” Well, here we are: an industry that purports to be about women’s health, and from the Departments of Health and State down to the doctors at nearby hospitals and the local pharmacy, no one did anything. Complaints were ignored or buried — by women.
pg 142: According to DOH witnesses, sometime after 1993, DOH instituted a policy of inspecting abortion clinics only when there was a complaint. In fact, as this Grand Jury’s investigation makes clear, the department did not even do that.
Janice Staloski, one of the evaluators of Gosnell’s clinic in 1992, 10 years later was the Director of DOH’s Division of Home Health – the unit that is inexplicably responsible for overseeing the quality of care in abortion clinics. In January 2002, an attorney representing Semika Shaw, a 22-year-old woman who had died following an abortion at Gosnell’s clinic, wrote to Staloski requesting copies of inspection reports for any on-site inspections of the clinic conducted by DOH. Staloski wrote to the attorney that no inspections had been conducted since 1993 because DOH had received no complaints about the clinic in that time.
Except that it had. In 1996, another attorney, representing a different patient of Gosnell’s, informed Staloski’s predecessor as director of the Home Health Division that his client had suffered a perforated uterus, requiring a radical hysterectomy, as a result of Gosnell’s negligence. The Home Health director discussed this patient with DOH Senior Counsel Kenneth Brody, and the complaint report was documented in records turned over to the Grand Jury. It was surely available to Staloski when she inaccurately told the attorney in January 2002 that DOH had received no complaints regarding Gosnell’s clinic.
pg 149-152: Without regular inspections, providers like Gosnell continue to operate; unlawful and dangerous third-trimester abortions go undetected; and many women, especially poor women, suffer. These are all consequences of DOH’s abdication of its responsibility.
Moreover, even if Staloski was instructed not to conduct regular, annual inspections, that does not explain why she failed to order inspections when complaints were received. It is clear to us that she was made aware, numerous times, that serious incidents had occurred at Gosnell’s clinic. These incidents, which evidenced alarming as well as illegal long-standing patterns of behavior, warranted investigation. Yet, in all the years she worked at the department, Staloski never ordered even one inspection.
Not even Karnamaya Mongar’s death triggered an inspection or investigation.
On November 24, 2009, Gosnell sent a fax to the department, followed by a letter addressed to Staloski, notifying DOH that Karnamaya Mongar had died following an abortion at his clinic. (Gosnell’s letter inaccurately stated that the second day of her procedure was November 18.) Darlene Augustine, a registered nurse and health quality administrator in the department’s Division of Home Health, received the fax.
Augustine, who supervises surveyors who respond to and investigate complaints at health care facilities, testified that she immediately notified her boss, Cynthia Boyne. (Boyne had become director of DOH’s Division of Home Health in 2007, when Staloski was promoted to head the Bureau of Community Licensure and Certification.) Augustine said that she told Boyne on November 25 that DOH should immediately go out to the clinic and initiate an investigation. Augustine acknowledged that she generally had the authority to send surveyors out to investigate – and she often did so within an hour of receiving a notice of a serious event such as a death. She testified, however, that she felt she needed Director Boyne’s approval because Gosnell’s notice involved an abortion clinic.
Boyne did not give her approval. Instead, she went to the bureau director, Staloski, to discuss the matter. Augustine explained that abortion clinics were treated differently from other medical facilities because Staloski had for years overseen the department’s handling of complaints and inspections – or lack of inspections – relating to abortion clinics. Staloski, according to Augustine, was “the ultimate decision-maker” with respect to whether DOH would conduct an inspection or investigation. Augustine testified that neither Boyne nor Staloski ever gave her approval to conduct the investigation that she thought was appropriate.
Boyne blamed Staloski. She said that her boss told her that DOH did not have the authority to investigate Mrs. Mongar’s death. Staloski apparently reached this decision on her own, without ever consulting Brody, the legal counsel. Staloski, according to Boyne, was only interested in making sure that Gosnell filed an on-line report in accordance with a 2002 law, the Medical Care Availability and Reduction of Error (MCARE) Act. That law requires health care facilities to report serious events, including deaths to DOH. 40 P.S. §313.
Staloski’s plan, Boyne said, was to then charge Gosnell with failing to file the report in a timely and proper manner. This is absurd, and Boyne should not have accepted such a ridiculous idea. Gosnell had reported Mrs. Mongar’s death to DOH on November 24, 2009. While this was three or fours days late, and the notification came by fax and letter rather than computer, it is preposterous to think that Staloski, who had ignored two deaths and other serious injuries at the clinic, would take action against a doctor for filing a report three days late. Staloski was absolutely wrong about DOH’s lack of authority to investigate Mrs. Mongar’s death.
Appallingly, the chief counsel for the department of health, Christine Dutton, defended Staloski’s inaction following Mrs. Mongar’s death. Dutton testified that she had reviewed the emails and documents showing that Staloski and her staff were communicating with Gosnell’s office to get him to file the MCARE form. Based on these very minimal efforts, Dutton insisted: “we were responsive.” Pushed as to whether the death of a woman following an abortion should have prompted more action – perhaps an investigation or a report to law enforcement – Dutton argued there was no reason to think the death was suspicious. “People die,” she said.
Not only was a probe into Mrs. Mongar’s death authorized and appropriate under the Abortion Control Act, it was required under the MCARE law. 40 P.S. §306. Yet DOH did not investigate. Staloski told the Grand Jury that she remembered reviewing with Boyne the letter in which Gosnell notified DOH of Mrs. Mongar’s death. Staloski said that it was really Boyne’s responsibility to order an investigation, but acknowledged that she, as the bureau director, also failed to do so. Instead of conducting an investigation, Staloski and Boyne concerned themselves with badgering Gosnell to re-notify them of Mrs. Mongar’s death.
Bureau Director Staloski, in fact, readily acknowledged many deficiencies in DOH’s, and her own, oversight of abortion facilities. But her dismissive demeanor indicated to us that she did not really understand – or care about – the devastating impact that the department’s neglect had had on the women whom Gosnell treated in his filthy, dangerous clinic. Staloski excused the DOH practices that enabled Gosnell to operate in the manner that killed Ms. Shaw, Mrs. Mongar, and untold numbers of babies. She simply said the abortion regulations – written by DOH – do not require DOH to inspect abortion clinics.
When DOH inspectors finally entered Gosnell’s clinic in February 2010, not at Staloski’s direction but at the urging of law enforcement, Staloski seemed more annoyed than appalled or embarrassed. On the morning after the raid, she received a copy of an email that Boyne wrote to Brody the night of the raid. Boyne reported to the department’s senior counsel that, at 12:45 a.m., she had told the Department of Health staff members at the clinic to “wrap it up and secure lodging in the interest of their safety.” Boyne told Brody that the “staff walked into a very difficult setup.” She complained that a representative of the District Attorney’s Office was “badgering” DOH staff to shut down the facility immediately. Boyne was seeking Brody’s legal guidance.
Staloski’s response to Boyne’s email was: “I’d say we were used.” Boyne’s reply: “Bingo.”
Staloksi, the woman most directly responsible for the department’s oversight of abortion facilities, told the Grand Jury: “I haven’t been in any facilities in probably – in an abortion facility in many, many years.” The citizens of Pennsylvania deserve far better from those charged with protecting public health and safety.
The malfeasance is in evidence at every level, from the policy of turning a blind eye to abortion clinic management at the highest levels to Philadephia’s banal, revenue-grabbing bureaucratic infectious waste management plan program:
pgs 204-207: Years earlier, in August 2003, another branch of the city’s health department had received an anonymous complaint about Women’s Medical Society. Mandi Davis, a sanitation specialist in the environmental engineering section, wrote a memo to a colleague at the department, Ken Gruen, with a copy to then-Assistant Health Commissioner Izzat Melhem. She informed them that she had received a “rather disturbing” complaint of aborted fetuses stored in paper bags in an employee refrigerator at Gosnell’s clinic.
Davis requested that a site visit be conducted to assure that proper infectious- waste handling and disposal practices were in place. Davis further instructed Gruen: “I am not expecting a ‘wild goose chase’ for aborted fetuses.” Current Philadelphia Health Commissioner Donald Schwarz testified that notations on the memo seem to indicate that a site visit was, in fact, made.
The city health department, however, could not produce any report of that site visit. Nor is there evidence that the department took any action against Gosnell for his dangerous handling of medical waste, or for his failure to have an approved infectious waste plan, as is required by the city Health Code.
A year later, Gosnell still had no approved disposal plan. On March 28, 2004, Davis sent Gosnell a letter stating that a “plan” he had submitted was “incomplete.” In fact, it was completely blank, except for the name and address of the clinic, some contact information, and an indication that it was a medical facility. On May 3, 2004, Davis sent another letter. This one was a form letter. Davis wrote:
Several years ago all Doctors practicing in Philadelphia received a letter from former Health Commissioner Estelle B. Richman explaining the need for the Department to have an infectious waste handling and disposal plan from your practice. The Commissioner’s letter explained the necessity for infectious waste to be properly containerized, stored, transported, and disposed in a manner to preclude any hazard to you, your staff, and patients, the community or the environment.
The letter noted that the city had never received a plan or a fee from the clinic. On May 7, 2004, a city health department inspector was sent to the clinic. His
report stated that proper labels were missing from areas where waste was stored; that red bag containers for infectious waste were not lidded; that marked boxes of infectious waste were sitting on the basement floor – not raised as they should be; that red bags for pick-up were not properly stored in the basement; and that the clinic did not provide a contract with a disposal company.
Gosnell subsequently produced some more paperwork, including a copy of a contract for disposal. However, he never paid his fee. The city never approved his medical waste plan. And he never cleaned up the infectious waste. Yet five years later, he was still operating. When the Grand Jurors toured the facility in 2010, boxes of waste were still sitting on the basement floor. Gosnell still stored aborted fetuses in plastic containers in the freezer. Employees described a stench emitted by bags of fetal tissue that piled up in the clinic.
Commissioner Schwarz tried, unsatisfactorily, to explain why the city never enforced the regulations that purport to protect staff, patients, the community, and the environment. Protection of the public, according to Dr. Schwarz’s testimony, was not the real intent behind the regulations. The impetus for requiring doctors to have infectious waste plans approved by the city was not public health; it was revenue.
The city regulations required the city’s 10,000 providers to pay $100 for individuals, $250 for clinics, and $500 for institutions such as hospitals, schools, and nursing homes. But the regulations provided no guidance as to what the health department was supposed to do to enforce the plans once submitted. Dr. Schwarz related to the Grand Jury what he heard from people who were in the health department at the time:
The department was told, apparently, to collect the money, make sure the plan came in, get the fee, and not enforce, that is don’t take action against people but remind them. This is a revenue generating activity.
The department would only inspect or take action when there was a complaint about a provider’s infectious waste handling or disposal.
Then, according to what Dr. Schwarz was told, sometime in 2004 or 2005 – shortly after Davis sent to the clinic the form letter reminding delinquent medical providers to submit their waste plans and pay their fee – the department stopped trying to enforce the regulation against those who had not complied.
The health commissioner’s testimony might explain why the department did not pursue Gosnell for his failure to submit an adequate infectious waste plan or pay his fee. But it does not explain the department’s inaction after an inspector observed and reported Gosnell’s perilous storage and disposal of infectious waste in May 2004 (and probably in 2003, though we did not see that report).
There is no record to indicate that the health department ever checked to see if the dangerous conditions in the clinic had been remediated. It is clear from our investigation that they never were.
The report concludes with a series of fifteen recommendations for the prevention of future outrages — note that none of these are current practice:
1. There should be no statute of limitations for infanticide.
2. The statute of limitations for illegal abortions beyond 24 weeks should be extended to five years.
3. Impersonating a doctor should be a crime. (There were two such frauds at the Gosnell clinic, “unlicensed phonies administering dangerous drugs to unsuspecting patients”, pg. 248.)
4. The Abortion Control Act should be amended to prohibit the mutilation of fetal remains.
5. The Pennsylvania Department of Health should license abortion clinics as ambulatory surgical facilities.
6. The state Department of Health should update the regulations for abortion providers.
7. Pennsylvania’s Departments of Health and State should make their process for filing complaints against doctors and facilities simpler and more responsive.
8. Philadelphia’s Department of Public Health should develop a hotline to assist residents in filing complaints with the proper state and local authorities.
9. The Pennsylvania Departments of Health and State need to share information they receive that is pertinent to each other’s responsibilities.
10. The Department of State should train its prosecutors and provide the necessary tools so they can more effectively investigate complaints against doctors.
11. The Pennsylvania Departments of Health and State should be required to share with law enforcement information relevant to criminal investigations.
12. A task force including the Medical Examiner’s Office, the District Attorney’s Office, and the Police Department should work to improve protocols for investigating suspicious deaths.
13. The City of Philadelphia should enforce medical waste disposal plans that it requires from providers.
14. We recommend that the National Abortion Federation reconsider the inclusion of Atlantic Women’s Medical Services in Delaware in its membership. (Gosnell was affiliated with this clinic as well.)
15. The authorities responsible for overseeing, monitoring, or licensing Gosnell or his operation should conduct serious self-assessments to determine why their departments failed to protect the women and babies whose lives were imperiled at Gosnell’s clinic. Employees who failed to perform their jobs of protecting the public should be held accountable.
The report concludes:
pg. 261: It is not our job to say who should be fired or demoted. We believe, however, that anyone responsible for permitting Gosnell to operate as he did should face strong disciplinary action up to and including termination. This includes not only the people who failed to do the inspecting, the prosecuting, and the protecting, but also those at the top who obviously tolerated, or even encouraged, the inaction. (emphasis: original)
The Department of State literally licensed Gosnell’s criminally dangerous behavior. DOH gave its stamp of approval to his facility. These agencies do not deserve the public’s trust. The fate of Karnamaya Mongar and countless babies with severed spinal cords is proof that people at those departments were not doing their jobs. Those charged with protecting the public must do better.
Yes, they must.