DR. ALEX GODWIN COUTINHO EXCELLED ALL THE WAY FROM SCHOOL

Dr. Coutinho is executive director of the Infectious Disease Institute at Makerere University in Kampala, Uganda. From 2001 to 2007 he served as executive director of The AIDS Support Organisation of Uganda (TASO), the largest AIDS care and support organisation in sub-Saharan Africa. Prior to joining TASO, he worked in a range of capacities for the Royal Swaziland Sugar Corporation (RSSC) with progressively greater responsibility for community services, focusing especially on HIV. He established holistic prevention and care services, voluntary counselling and testing (VCT), management of opportunistic infections, a tuberculosis clinic, an AIDS clinic, a peer education programme as well as hospital management and palliative care for terminal AIDS patients. These services were implemented using a multisectoral approach that involved schools, communities, churches and unions in an expanded HIV prevention and care programme. He has provided counselling and care to hundreds of AIDS patients in Uganda and Swaziland. Dr. Coutinho was a member of the interim board of the Global Fund to Fight AIDS, Tuberculosis, and Malaria as the fund was established, and he served as the vice chair of the Global Fund Technical Review Panel for two years. He was vice chair of the board of the Regional AIDS Training Network and a member of the strategic advisory group for the WHO HIV/AIDS global strategy. He is currently a member of the scientific committee of the Academic Alliance for HIV/AIDS as well as a board member of the AIDS Information Centre — the largest VCT nongovernmental organisation in Africa. He has published a number of articles on AIDS service provision. He holds an MB ChB and an MSc from Makerere University and an MPH from the University of the Witwatersrand. 

Ugandan doctor honoured in Japan 

Publish Date: Jun 02, 2013

President Museveni talking to Dr. Alex Coutinho

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By Felix Osike in Yokohama, Japan

A  Ugandan medical expert Dr. Alex Coutinho who recently won a $1m (sh2.5b) prestigious health award has been honoured and received his prize in Japan.

He won the prize for pioneering efforts to expand access to life –sparing medicine to people infected with HIV virus.
Coutinho, who jointly won the 2nd Hideyo Noguchi Africa award with former, UNAIDS Executive Director Dr.Peter Piot of Belgium told journalists in Yokohama that he would spend the money on leadership training of Uganda health workers where he has identified a gap.
They formally  received  the prize  on  Saturday  evening  from  the  Japan  Prime Minister  Shinzo Abe, at a colourful  function  attended by the Japanese Emperor Akihito and a host of other  international guests attending the Tokyo International  Conference on African Development (TICAD).  The prize is composed of a citation, a medal and a honorarium of 100m yen ($1m) each.
Coutinho, who retires next year as the Director of Infectious Diseases Institute, Makerere University was recently named one of the 20 most influential Ugandans in the fight against HIV/Aids.
“I thank the Japanese government for the prize. The Japanese government has been a player to the many African countries in the areas of health and infrastructure,” he stated.
He said since he was awarded the prize for work he did with other people, he would use the money for mentoring and training hundreds of health workers and a cross section of community care givers. “There is a missing ingredient in leadership among health workers to sensitize and mobilize them to deliver services. I will replicate this in Uganda. I will invest in leadership skills of particularly rural doctors and midwives,” he explained.
But he expressed worry about the rise in the HIV prevalence rate in Uganda from 6% to 7%. He attributed the increase to complacency. “Some people have begun to take risks, having multiple partners and unprotected sex.
 “There is still work to be done. I appeal to the Government of Japan to continue in this global partnership and the African countries to put more resources to tackle these diseases.”

Coutinho makes a speech. Photo by TICAD
Coutinho has been selected to deliver the Noguchi commemorative address at the United Nations University in Tokyo on June 4. He will talk about his experience in expanding access to medical treatment for HIV sufferers in Uganda, while Dr. Piot will address global health challenges.
Before joining IDI, Dr. Coutinho spent six years as the Executive Director of The Aids Support Organisation (TASO).  
Piot thanked the Japanese government for the award and interest in the healthcare in African countries.
Piot who is now the Director and professor of the London School of Hygiene and Tropical medicine was awarded the prize because of  his work with  diseases endemic to much  of the African  continent  including  HIV,  Ebola, Tuberclosis and Gonorrhea. He told the New Vision he would use the money to provide scholarships to health workers to go for training in London and Japan.  
He was part  of the team  that discovered  Ebola in Zaire (now DRC) in 1976 and among the  first to confirm  the presence  of heterosexually  transmitted  HIV and pediatric  AIDS in Africa  as well as the  link between HIV and Tuberclosis.
Piot said there was no end in sight on getting the AIDS cure. He commented: “We had some hopes a few years ago, but recently  in April, the trials in the US had to be stopped  because  the vaccine  did not  show any  results. We should not hope that there will be one in the next few years.”
The Noguchi Africa prize honors individuals with outstanding achievements in the fields of medical research and services to combat infectious and other diseases in Africa. The prize was established  by the Government  of Japan  in July 2006 but first  awarded at TICAD IV meeting  in 2008 is in memory of  Dr.Hideyo Noguchi, a Japanese whose contribution to  medical advancement  and self-sacrificing activities  in Africa remain  a model of professionalism. It is awarded once every five years, coinciding with the convening of TICAD.

Coutinho. Photo by TICAD

"I am honored and thankful to receive this prize and for the recognition that it also brings to my colleagues at IDI and TASO and throughout Uganda. Great strides have been made in the fight against infectious disease – yet more work remains," commented Dr. Coutinho. "We must continue building the healthcare infrastructure in Africa so that Africans are prepared to combat HIV and other infectious diseases for the long-term."

Dr. Coutinho is the Sande-McKinnell Chair and Executive Director of the Infectious Diseases Institute (IDI) at Makerere University in Kampala, Uganda. Established by Accordia Global Health Foundation and a diverse coalition of partners, IDI is now an African-owned and -led Center of Excellence in health that combines locally-relevant and innovative research, training, and clinical care services to drive best practices and strengthen health systems throughout the region. 

Dr Coutinho: Working to rid the country of HIV/Aids

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Dr Coutinho in his office at Infectious Disease Institute at Mulago hospital. The doctor has received a prize of 100 million yen (Shs2.8b). Photo by Faiswal Kasirye.  

By Gloria Haguma

Posted  Wednesday, March 27  2013 at  00:00

In Summary

Dr Alex Coutinho’s first experience with HIV/Aids was in 1982, at Mulago hospital. Since then, he has been involved in the fight against the epidemic, earning himself an award along the way.

When I was assigned to profile the Hideyo Noguchi African Prize recipient, Dr Alex Godwin Coutinho, I didn’t think that it would take just one phone call to get me booked in with him for an appointment.

Not only is he a very busy doctor, he is also a man that just became 100 million yen (Shs2.8b) richer, meaning he would be having many other individuals lobbying for interviews. However, all it took was that one call and I was given a 7.30am appointment by the doctor himself.

When I get to his office at the Infectious Disease Institute, in Mulago, I am unsure of what to expect. From first impressions, he looks like the tough kind of man, the kind that will answer my questions with questions.

To my surprise, he is very welcoming and even smiles as he ushers me into his office. His very spacious and well put together office looks befitting of its owner, who is wearing a blue striped shirt and tie. After I am seated, we exchange greetings and he actually offers me a handshake which I gladly receive.

A family man
All this time, my attention is captivated by the portraits that hung on the left side of his office wall. At the top is a black and white photograph of the doctor as a toddler and this is followed by a number of portraits of his children, then one of himself with his wife, and mother. There are also portraits of Dr Coutinho at various functions, including one with President Museveni.

I am taken aback by his accent that is every bit Ugandan, despite the fact that his skin colour is close to white. I later get to learn that the medical doctor, who has been practising for over 30 years, has Portuguese lineage. His grandfather, Anthony Coutinho, came from Gowa, in India and settled in Hoima. He later on married a Munyoro woman.

Dr Couthinho was born on June 19, in 1959 to Alex Eugene and Martha Carmelina Coutinho. Unfortunately for him, he never had the opportunity to know his father as he passed on when he was still young.

Later, the family relocated to Jinja, where his mother took on a nursing job at Jinja hospital. Coutinho went on to enrol for his primary education at Victoria Nile Primary School and after went to St. Marys’ College Kisubi for his secondary education.

“After leaving Kisubi, I joined Makerere where I trained as a medical doctor,” he says.

He goes on to tell me how his career choice was not only influenced by his environment, having grown up in Jinja hospital staff compound, but also by his mother. It is hard not to notice the pride, respect and above all devotion that is evident on on his face when he speaks of his mother. He attributes all that he is today to her, having been able to provide for him and his two siblings.

“Sometimes I would visit my mother whenever she was in the maternity ward and in the outpatients ward, and also when she was a tutor at Jinja Nursing School,” he adds.

I later on learn that the profession may be an aspect that runs in the family, as his elder brother also happens to be a medical doctor, as well as his uncle, Dr Paul D’Arbela, the first Ugandan to head the Department of Medicine at Makerere.

Dr Coutinho’s nomination in the medical services category for the Hideyo Noguchi African Prize was in great recognition of his pioneering efforts to expand access to life-sparing medicine for people infected with HIV.

Since he graduated from Makerere in 1983, he says he has been dealing with HIV cases for over 30 years, having seen his first HIV case in 1982, in the cancer institute.

“At that time, we did not realise it was HIV, but looking back now, I know it was Aids. The woman had Kaposi’s sarcoma, a tumour caused by human herpes virus 8. 

“By the time I graduated, the first signs that there was a new disease in Uganda were coming out. Later on, I joined Nsambya hospital as an intern, and during that year, we began seeing many cases of ‘slim disease’, as it was called at the time. When the NRM government came in to power, President Museveni began talking openly about the disease because before then, people were covering it up. They feared that probably tourists would stop coming to Uganda,” he says, adding that in 1984, Prof Nelson Ssewankambo, Prof David Sserwada and others described this disease in Rakai as the same as the one that had been discovered in America.

“Later on, the country was able to begin responding to the epidemic and I was involved in numerous campaigns, like going around numerous schools, talking about HIV to the young people and this was sponsored by Unicef. Of course at the time, there were no proper tests and drugs and generally those that contracted the disease died. So the main message was abstinence and being faithful. Even the condoms came in later on,” he adds.

However, the medical doctor had bigger dreams and wanted to become a surgeon, so in 1989, he moved to South Africa to pursue his dream. “I wanted to change careers, so I left Uganda, essentially to become a surgeon. I have always admired surgeons. At that time, I had a Master’s degree in physiology from Makerere. In South Africa, I was admitted in the surgical programme,” he says.

His dream was however cut short by apartheid in South Africa at the time. He then relocated to Swaziland, with his wife where he worked until 2001. Here he worked for the royal Swazi Sugar Corporation and was closely involved in HIV awareness and testing campaigns.

On his return to Uganda, he worked as the director of The Aids Support Organisation (Taso) for six years. Here, through the initiatives, he saw more people come to the centre (the number of Aids cases at the centre rose to 10,000 people) and oversaw the testing of over one million people. He was also serving on the board of the International Aids Vaccine Initiative and subsequently sat on the founding board of the Global Fund, among many others.

He later joined the Infectious Disease Institute in 2007 and has been working there for five and a half years.

“For the years I have been at IDI, I have helped to scale up many services for HIV positive people with over 10,000 people on treatment, and we also work in over 50 districts. Other projects include circumcision and programmes that train people mainly in caring for HIV positive people,” he says.

Positive efforts to check the epidemic
He adds that he is glad with the efforts that have been put in to check the epidemic.

“Clearly we have come a long way, we have over half a million people on treatment and many people know how to avoid it. However not every one that has HIV knows they are positive. Many people still do not want to get tested. Testing is important because for instance if you’re a woman, you are able to know how to prevent transmission to your unborn baby,” he says.

He, however, points out that there is need for more awareness, or else there will be a resurgence of the epidemic.

The other sectors that he fills need more attention are maternal health, because the health infrastructure of Uganda is improving slowly but not fast enough to catch up with the number of mothers giving birth.

“The demand for maternal health is also Influenced by the cultural beliefs as many women and men believe that they need to give birth at home with the traditional birth attendants, so we are encouraging many women to attend antenatal and also deliver in a health centre,” he points out.

One of the biggest challenges facing the medical fraternity in Uganda is the lack of adequate manpower, as many of the trained doctors and nurses seek greener pastures abroad and very few are willing to settle and work here in Uganda. Dr Coutinho attributes this to pull and push factors.

“It’s true that many doctors leave the country and many don’t come back. I personally left but I came back after 12 years. The reasons why people leave or don’t come back are very complex.

“The commonest denominator why people leave may be to pursue further studies like PhDs, Masters, and most times, when they are outside the country, they start families and it becomes hard for them to come back. The other issue would the money issue. Doctors in neighbouring countries like Kenya, Sudan, and Rwanda tend to be paid better than doctors here,” he says.

He is then quick to point out that one does not become a doctor for money and states that one needs to have a burning desire to serve the people. He believes that doctors need to be even more patriotic than other citizens, majorly because they (doctors) are a scarce but essential commodity.

“I personally believe, for instance that patients should not pay for medical care. Medical care should be free at the point of delivery. There should be other mechanisms like government or health insurance that provide the payment,” he adds. He believes that health is a human right.

He also points out that the migration of doctors is not only external, but also internal.

“Many of the young doctors are not comfortable with working outside Kampala.

“Some of it is to do with money, housing and the like. For those with children, they fail to find good facilities like schools in the rural areas, “he adds.

He recommends recruiting the young doctors early.

“The key is to recruit the young doctors before they start families, and encourage them to serve in rural areas. After this they can be provided with a scholarship to come back and further their studies.

“They can serve in the rural areas for two to three years after which they are given the scholarship for a Master’s degree. I think that will be the greatest inducer to keep our doctors in Uganda and getting them to work in rural areas. We also need to encourage the doctors, especially those in rural areas, to do distance learning. I have a Masters in Public Health from South Africa that I got through distance learning,” he adds.

Dr Coutinho also points out that many o young doctors these days tend to be recruited from the same exclusive schools.

“When you come to medical school, you will find that many of the students are from Gayaza, Budo, and many of these are elite children that have grown up in Kampala. This makes it hard for such a person to relocate to rural areas,” he says.

On getting his award
The doctor is clearly happy about being awarded. He speaks proudly about Hideyo Noguchi African Prize that he is to receive in June, this year and credits this to his team over the years and all Ugandans for their combined efforts in fighting HIV and Aids.

“This award recognises individuals or institutions that have played a big role in improving the health of the people of Africa. I was very pleased but very humbled to be nominated. And I think in this case, the award was recognising the 30 years I have spent dealing with HIV But it also recognises Ugandan as a whole for their efforts in trying to combat HIV,” he says.

When asked what he wants to do with his prize money, he says he hopes to use it to invest in the medical services in improving the health of the people of Uganda.

In his leisure time, the medical doctor plays golf and squash. He also mentors and helps young golfers improve their skills. He also loves reading inspirational books, fiction and non-fictional. He adds that he does not socialise a lot apart from the weekends.

As I walk out of his office, I am still amazed by his determination and great love for the profession. It is hard not to notice the zeal and energy with which he carries out his work. 

With his retirement around the corner (he retires next year), his bosses are going to be faced with the task of finding a replacement with his kind of passion.

Television was not a big deal

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Dr Alex Coutinho recieved the Second Hideyo Noguchi Africa Prize for Medical Services. It was in recognition for his pioneering efforts to expand access to life-sparing medicine for people infected with HIV/Aids. PHOTO BY FAISWAL KASIRYE 

By GLORIA HAGUMA

Posted  Sunday, April 21  2013 at  01:00

In Summary

My childhood. Dr Alex Coutinho, the executive director of the Infectious Disease Institute, Makerere University,may not be able to go fishing anymore but he cherishes the memories of the experience.

When and where were you born?
I was born on June 19, 1959. My name Coutinho, comes from my grandfather who was originally from Gowa, in India. He came to Africa around 1910 and he never went back. My grandmother was a munyoro. My mother is alive and lives in Jinja. My father died when I was still very little, so I don’t know much about him.
As soon as I was born, we moved to Jinja, where my mother got a job as a nurse at Jinja Hospital.

What kind of child were you?
I am told I was a curious child. I loved to read and at the same time loved to play. I had an elder brother, so I was very competitive.
Whenever he brought his reading books, I would also try to read them. I think this enabled me to learn how to read and write at an early age. I joined nursery school at the age of four in Jinja, and later joined Primary One at Victoria Nile in 1965 at the age of five.

Tell us about your first time in boarding school.
My first time in boarding school was when I joined St. Mary’s College, Kisubi. And I must say it was quite a shock. First of all, it was an all- boy’s school, while my primary school had been a mixed school, then you had to stay in the dormitory, you were not with your parents, at meal time you had to scramble for food. Luckily, St. Mary’s never had the culture of bullying. We were teased but not bullied.

Any special memories of Kisubi?
Those six years were very formative, we were very disciplined. They also taught me about work ethics, and time keeping. I was an altar boy, and always served at the morning mass for all the years that I was in Kisubi. I also participated in many other sports activities like swimming and playing tennis.
I also enjoyed our socials, especially with Namagunga and Gayaza, and those dances were some of the highlights of our stay in Kisubi. I was also the Head prefect and so, perhaps, some of my leadership traits were developed here.

How was life growing up without your father?
There were moments when I was curious on what difference it would have made if I had a father. But I have a lot of respect for my mother because she made sure my siblings and I were well provided for.
Paradoxically, when I would visit some of the households of my friends, I would find out that some of their fathers were irresponsible, they were drunkards, and there was a lot of quarreling in their homes. And so I was grateful that none of this chaos was in my home.

What was your idea of fun?
I rode a bicycle, we went fishing in the River Nile, played cricket, marble and tennis. There was little homework those days, so we played after school. There was no traffic jam so we would walk back home from school and we played along the way.

What are some of your fondest childhood memories?
My fondest memories are my friends and I am still in touch with a number of them. Many of them left Uganda, and are in Canada and the USA. I think out of my childhood friends below the age of 10, there is probably none left. However, we are still in touch.
My other fondest memory was fishing. I loved fishing and still go fishing even today, when I get the time. I also loved going for the midnight mass on Easter.
The sad memories would be the times when we sometimes run out of money at home. A nurse was not paid a lot of money, so my mother sometimes struggled to make ends meet.

Do you feel there is anything the children of today are missing out, in comparison to your childhood?
Well, I grew up without a television because we could not afford it. Even those that had it had one channel, which would start at 6 pm. So this meant we had to invent our own games, and entertainment.
I think the children of today watch too much television and this does not allow their social skills to develop sufficiently. Social skill develops partly through, playing, interacting, and competing and so on. We also had a lot of freedom.
Also the education system during my time, taught us how to learn, not to cram. Schools today encourage the children, to cram: you have to get four points at Primary Seven, or 12 in O’ level.
At the end of the day, the children are learning how to cram to pass exams, not to learn.

gloriahaguma@gmail.com

editorial@ug.nationmedia.com

 

IDI Partners with Mulago Hospital
during Deadly Ebola Outbreak

In late 2007, an Ebola outbreak claimed the lives of 37 people in western Uganda; among them, eight healthcare workers. When Uganda’s national referral hospital, Mulago Hospital in Kampala, received its first case of Ebola, it turned to its partners, including the Infectious Diseases Institute (IDI), for help in establishing an Ebola crisis response center.

Dr. Steven Kijjambu, Deputy Dean of Education, Faculty of Medicine, Makerere University; and Dr. Alex Coutinho, Executive Director of IDI; deliver protective gear to Dr. Edward Ddumba, Director of Mulago Hospital.

Responding immediately to stop the spread of the virus

IDI quickly moved into action with Mulago Hospital to set up protocols for the care of infected patients to prevent the spread of the virus. In addition, IDI worked to procure equipment to protect Mulago’s doctors and nurses.

Mulago is the teaching hospital for the Makerere University Faculty of Medicine and provides care at a very low cost to those most in need. It caters almost exclusively to Uganda’s poor—those who cannot afford to get care anywhere else. Before the Ebola outbreak, Ward 4A—the Infectious Diseases Ward— had already been struggling to meet the overwhelming and increasing demand for care—and the Ebola epidemic stretched its resources even further.

Disaster preparedness includes planning for adequate protection for healthcare workers

Preventing doctors, nurses, and other medical professionals from contracting infectious diseases while caring for their patients is among the most essential responsibilities that any hospital or clinic has to its workers. In resource-limited settings such as sub-Saharan Africa, however, adequate protection is not always readily available where and when it is needed most.

To improve the protection of healthcare workers in the future, IDI donated protective clothing and gear to Mulago hospital for disaster preparedness. The Deputy Dean of Education in the Faculty of Medicine at Makerere University, Dr. Steven Kijjambu, and the Executive Director of IDI, Dr. Alex Coutinho delivered protective gear worth over $13,000 to Dr. Edward Ddumba, the Director of Mulago Hospital. The items donated by IDI included examination gloves, surgical gloves, disposable face masks, chemical splash safety goggles, plastic aprons, gumboots, disposable head gear, heavy duty rubber gloves and domestic bleach.

An important step in a growing international alliance to support Mulago Hospital

The donated gear, worth over $13,000, included examination gloves, face masks, and more.

The resources IDI provided to Mulago during the Ebola outbreak are only the beginning of a growing international effort to respond to the needs of Ward 4A. Under the leadership of Mulago hospital, IDI and Accordia Global Health Foundation are actively participating in a broad collaboration between local and international organizations, including Johns Hopkins University, Mulago-Mbarara Teaching Hospital’s Joint AIDS Programmer, Yale University, and others (see IDI Supporter Climbs to New Heights, page 4). These combined efforts will result in upgrading the physical condition of the Infectious Diseases Ward; providing volunteer care for indigent patients without family support systems; and mentoring and training the doctors, nurses, and students that provide care on the Ward.

With each organization providing unique expertise and resources, Accordia Global Health Foundation is confident that Mulago will be further strengthened to respond not only to the daily needs of its patients but also to be prepared to overcome any future infectious disease threats.

UNA-USA Honors Leaders In The Global Fight Against HIV-AIDS

The 2003 Award recipients included the Global Leadership honoree, Henry A. McKinnell, Jr., Ph.D., Chairman and CEO of Pfizer, Inc. and the Global Humanitarian Action Award honoree Alex Godwin Coutinho, M.D., M.P.H, the Executive Director of The AIDS Support Organization (TASO), based in Africa.

The honoree for UNA-USA's 2003 Global Humanitarian Action Award, Alex Godwin Coutinho, M.D., M.P.H., a native Ugandan, is the Executive Director of The AIDS Support Organization. (TASO). Established in 1987, TASO is now one of the largest indigenous HIV/AIDS non-governmental organizations in Africa with over 80,000 registered patients and 22,000 people receiving direct care and support. TASO's integrated approach recognizes that HIV/AIDS is not only a medical problem but also an issue that crosses familial and cultural boundaries. "We continue to help people to live positively, in dignity, and with hope," said Dr. Coutinho of TASO's work.

 

Uganda: Dr. Alex Coutinho: New HIV/AIDS Care Center
				14 Oct: PR Newswire (New York). The AIDS Support Organization (TASO), with support from Pfizer Inc, opened a new AIDS counseling and training center in Uganda today … Speaking at the dedication ceremony, Dr. Alex Coutinho, Executive Director of TASO, said,"We are delighted that our partnership with Pfizer has once again expanded TASO's ability to provide care and support for people living with and affected by AIDS”  Message By Dr. Alex Godwin COUTINHO 　I am overjoyed and overwhelmed at receiving the news of my becoming the second Hideyo Noguchi laureate for the Medical Services category for 2013. This recognition by the Japanese government and the Japanese people honouring the memory of Dr. Hideyo Noguchi represents the highest recognition for a medical doctor in Africa. 　The life of Dr. Hideyo Noguchi is an inspiration that needs to be told over and over again to the world and I pledge to do this. I have practiced medicine and public health in Africa focusing primarily on HIV, TB and Malaria for the past 30 years and today this prize makes all the sleepless nights and stressful days worthwhile. 　This prize would not have been possible without the collaboration, trust, support and partnerships with people living with HIV, my teachers, fellow health professionals as well as the wonderful institutions like TASO and IDI that I have had the privilege to lead. I wish to acknowledge them and give thanks and respect to all of them. 　This prize now places an obligation on me to uphold the memory of Dr.Hideyo Noguchi as well as to invest this prize into further improving the health of the people of Africa and I pledge to work tirelessly to make this happen. 　I thank the people of Japan and its leadership for the vision to honor the memory of your noble son while inspiring those of us who will continue with his work in Africa. 　Dr Coutinho standing in the HIV clinic of IDI. Dr Coutinho with the staff of IDI looking at the chest X-ray of a patient co-infected with HIV and Tuberculosis. Dr Coutinho mentoring a joint meeting. Dr Coutinho showing laboratory staff how to detect malaria parasites and categorize the malaria strain.untry.