Paid apps are history






This week marked an important moment in the evolution of the iOS app market. As Pages just slipped out of the iPad top 10 highest grossing apps chart, there are now no paid apps among the ten applications that generate most revenue on the iPad. When the iPad application market was born a few years ago, it was dominated by relatively stiffly priced applications, mimicking the PC software or game console software markets. But over the past couple of years, app vendors have realized that free apps with clever in-app purchasing hooks create much more revenue than paid apps.


[More from BGR: BlackBerry 10 browser smokes iOS 6 and Windows Phone 8 in comparison test [video]]






The same applies to the iPhone — there is only one paid app among the twenty highest grossing iPhone apps today. It is notable that some of the highest grossing apps have relatively low download volumes. Clash of Clans has been the top-grossing iPad application for all of January, but it is only ranked 53rd on the iPad download chart. Hay Day is the seventh-biggest application when it comes to revenue generation on the iPhone, but is only ranked at #104 when it comes to download volume.


[More from BGR: Galaxy S IV benchmarks may confirm 1.8GHz CPU and Android 4.2]


Leading app developers have figured out how to decouple download volume from revenue generation by creating free games that seduce their fans into paying steadily for in-app features. The types of of games that require a $ 0.99 or a $ 2.99 fee per download are turning into something resembling nostalgia items. For a stark example of how badly the revenue generation power of paid apps has faded, consider that the current #1 paid app on iPhone, Wood Camera, is 46th on the iPhone chart that lists top-grossing apps.  The future belongs to free apps.


This article was originally published on BGR.com


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Inspiring Singers Outshine American Idol's Feuding Judges






American Idol










01/17/2013 at 11:00 PM EST







From left: Randy Jackson, Mariah Carey, Ryan Seacrest, Nicki Minaj and Keith Urban


George Holz/FOX


The second episode of American Idol delivered more drama, but a handful of singers managed to eclipse the ongoing feud between new judges Mariah Carey and Nicki Minaj. And that's no easy task considering one of the battling divas is wearing a blonde and pink wig.

The night's most memorable contestant was Lazaro Arbos. As he entered the audition room, one thing became immediately clear: the 21-year-old from Naples, Fla., had a severe stutter. Arbos, who emigrated from Cuba when he was 10, told viewers that he had few friends growing up due to his speech impediment.

But something magical happened when he began to sing. His stutter vanished and he gave a moving performance of "Bridge Over Troubled Water." As the judges unanimously put him through to Hollywood, Arbos dissolved into tears.

Equally inspiring was Mariah Pulice, a 19-year-old restaurant hostess from Darien, Ind. The last two years have been difficult for Pulice, who told judges she was recovering from anorexia. "If there was no music," she said, "I would not be alive." After singing the Beatles' "Let it Be," the judges were unanimous in their praise. "I really, really, really felt that song coming from you," said Minaj.

Carey agreed: "You touched me," she said. "I know what it's like to have to sing through tears. I'm proud of you."

But it wasn't all drama and emotion. Minaj started a baffling trend of asking handsome singers if they had a girlfriend. (She also managed to charm the shirts off of a couple of them, although you get the feeling they were happy to show their abs on national TV.) "You have a hole in your pants," she told one contestant. "Why are you looking?" he shot back.

And poor Keith Urban. Sitting between Minaj and Carey, he found himself in the crossfire. "I feel like a scratching post," he said at one point, before repeatedly banging his head on the table.

The judges found a lot of talent in Chicago. All told, 46 contestants were put through to Hollywood. The competition will head to Charlotte, N.C., next Wednesday.

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Will Obama's order lead to surge in gun research?


MILWAUKEE (AP) — Nearly as many Americans die from guns as from car crashes each year. We know plenty about the second problem and far less about the first. A scarcity of research on how to prevent gun violence has left policymakers shooting in the dark as they craft gun control measures without much evidence of what works.


That could change with President Barack Obama's order Wednesday to ease research restrictions pushed through long ago by the gun lobby. The White House declared that a 1996 law banning use of money to "advocate or promote gun control" should not keep the Centers for Disease Control and Prevention and other federal agencies from doing any work on the topic.


Obama can only do so much, though. Several experts say Congress will have to be on board before anything much changes, especially when it comes to spending money.


How severely have the restrictions affected the CDC?


Its website's A-to-Z list of health topics, which includes such obscure ones as Rift Valley fever, does not include guns or firearms. Searching the site for "guns" brings up dozens of reports on nail gun and BB gun injuries.


The restrictions have done damage "without a doubt" and the CDC has been "overly cautious" about interpreting them, said Daniel Webster, director of the Center for Gun Policy and Research at the Johns Hopkins Bloomberg School of Public Health.


"The law is so vague it puts a virtual freeze on gun violence research," said a statement from Michael Halpern of the Union of Concerned Scientists. "It's like censorship: When people don't know what's prohibited, they assume everything is prohibited."


Many have called for a public health approach to gun violence like the highway safety measures, product changes and driving laws that slashed deaths from car crashes decades ago even as the number of vehicles on the road rose.


"The answer wasn't taking away cars," said Dr. Georges Benjamin, executive director of the American Public Health Association.


However, while much is known about vehicles and victims in crashes, similar details are lacking about gun violence.


Some unknowns:


—How many people own firearms in various cities and what types.


—What states have the highest proportion of gun ownership.


—Whether gun ownership correlates with homicide rates in a city.


—How many guns used in homicides were bought legally.


—Where juveniles involved in gun fatalities got their weapons.


—What factors contribute to mass shootings like the Newtown, Conn., one that killed 26 people at a school.


"If an airplane crashed today with 20 children and 6 adults there would be a full-scale investigation of the causes and it would be linked to previous research," said Dr. Stephen Hargarten, director of the Injury Research Center at the Medical College of Wisconsin.


"There's no such system that's comparable to that" for gun violence, he said.


One reason is changes pushed by the National Rifle Association and its allies in 1996, a few years after a major study showed that people who lived in homes with firearms were more likely to be homicide or suicide victims. A rule tacked onto appropriations for the Department of Health and Human Services barred use of funds for "the advocacy or promotion of gun control."


Also, at the gun group's urging, U.S. Rep. Jay Dickey, a Republican from Arkansas, led an effort to remove $2.6 million from the CDC's injury prevention center, which had led most of the research on guns. The money was later restored but earmarked for brain injury research.


"What the NRA did was basically terrorize the research community and terrorize the CDC," said Dr. Mark Rosenberg, who headed the CDC's injury center at the time. "They went after the researchers, they went after institutions, they went after CDC in a very big way, and they went after me," he said. "They didn't want the data to be collected because they were threatened by what the data were showing."


Dickey, who is now retired, said Wednesday that his real concern was the researcher who led that gun ownership study, who Dickey described as being "in his own kingdom or fiefdom" and believing guns are bad.


He and Rosenberg said they have modified their views over time and now both agree that research is needed. They put out a joint statement Wednesday urging research that prevents firearm injuries while also protecting the rights "of legitimate gun owners."


"We ought to research the whole environment, both sides — what the benefits of having guns are and what are the benefits of not having guns," Dickey said. "We should study any part of this problem," including whether armed guards at schools would help, as the National Rifle Association has suggested.


Association officials did not respond to requests for comment. A statement Wednesday said the group "has led efforts to promote safety and responsible gun ownership" and that "attacking firearms" is not the answer. It said nothing about research.


The 1996 law "had a chilling effect. It basically brought the field of firearm-related research to a screeching halt," said Benjamin of the Public Health Association.


Webster said researchers like him had to "partition" themselves so whatever small money they received from the CDC was not used for anything that could be construed as gun policy. One example was a grant he received to evaluate a community-based program to reduce street gun violence in Baltimore, modeled after a successful program in Chicago called CeaseFire. He had to make sure the work included nothing that could be interpreted as gun control research, even though other privately funded research might.


Private funds from foundations have come nowhere near to filling the gap from lack of federal funding, Hargarten said. He and more than 100 other doctors and scientists recently sent Vice President Joe Biden a letter urging more research, saying the lack of it was compounding "the tragedy of gun violence."


Since 1973, the government has awarded 89 grants to study rabies, of which there were 65 cases; 212 grants for cholera, with 400 cases, yet only three grants for firearm injuries that topped 3 million, they wrote. The CDC spends just about $100,000 a year out of its multibillion-dollar budget on firearm-related research, New York Mayor Michael Bloomberg has said.


"It's so out of proportion to the burden, however you measure it," said Dr. Matthew Miller, associate professor of health policy at the Harvard School of Public Health. As a result, "we don't know really simple things," such as whether tighter gun rules in New York will curb gun trafficking "or is some other pipeline going to open up" in another state, he said.


What now?


CDC officials refused to discuss the topic on the record — a possible sign of how gun shy of the issue the agency has been even after the president's order.


Health and Human Services Secretary Kathleen Sebelius said in a statement that her agency is "committed to re-engaging gun violence research."


Others are more cautious. The Union of Concerned Scientists said the White House's view that the law does not ban gun research is helpful, but not enough to clarify the situation for scientists, and that congressional action is needed.


Dickey, the former congressman, agreed.


"Congress is supposed to do that. He's not supposed to do that," Dickey said of Obama's order. "The restrictions were placed there by Congress.


"What I was hoping for ... is 'let's do this together,'" Dickey said.


___


Follow Marilynn Marchione's coverage at http://twitter.com/MMarchioneAP


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Housing, job data push S&P to five-year high; Intel down late

NEW YORK (Reuters) - Stronger-than-expected data on housing starts and jobless claims lit a fire under stocks on Thursday, pushing the S&P 500 to a five-year high and its third day of gains.


A pair of economic reports lifted investors' sentiment. The number of Americans filing new claims for unemployment benefits fell to a five-year low last week and housing starts jumped last month to the highest since June 2008.


Strength in the housing and labor markets is key to sustained growth and higher corporate profits, helping to bring out buyers even on a day when earnings reports were mixed.


Gains were tempered by weakness in the financial sector, with Bank of America down 4.2 percent to $11.28 and Citigroup off 2.9 percent to $41.24 after their results.


In other negative earnings news, shares of chipmaker Intel fell 5.2 percent to $21.49 in extended-hours trading after the company forecast quarterly revenue that fell short of analysts' expectations. Intel had ended the regular session up 2.6 percent at $22.68.


The S&P 500 ended at its highest since December 2007 and now sits just 5.6 percent from its all-time closing high of 1,565.15.


"Having consolidated really for the last two weeks, the fact that we broke out, I think that that is sucking in quite a bit of money," said James Dailey, portfolio manager of TEAM Asset Strategy Fund in Harrisburg, Pennsylvania.


The Dow Jones industrial average <.dji> was up 84.79 points, or 0.63 percent, at 13,596.02. The Standard & Poor's 500 Index <.spx> was up 8.31 points, or 0.56 percent, at 1,480.94. The Nasdaq Composite Index <.ixic> was up 18.46 points, or 0.59 percent, at 3,136.00.


Better-than-expected earnings and revenue reported by online marketplace eBay late Wednesday helped the stock gain 2.7 percent to $54.33.


In the housing sector, PulteGroup Inc shares gained 4.9 percent to $20.29 and Toll Brothers Inc advanced 3.1 percent to $35.99. The PHLX housing sector index <.hgx> climbed 2.4 percent, reaching its highest close since August 2007.


Semiconductor shares <.sox> rose 2 percent to the highest close in eight months.


Financials were the only S&P 500 sector to register a slight decline for the day.


Bank of America's fourth-quarter profit fell as it took more charges to clean up mortgage-related problems. Citigroup posted $2.32 billion of charges for layoffs and lawsuits.


Energy shares led gains on the Dow as U.S. crude oil prices jumped more than 1 percent. Shares of Exxon Mobil were up 0.8 percent at $90.20 while shares of Chevron were up 0.7 percent at $114.75.


S&P 500 earnings are expected to have risen 2.3 percent in the fourth quarter, Thomson Reuters data showed. Expectations for the quarter have fallen considerably since October when a 9.9 percent gain was estimated.


Volume was roughly 6.5 billion shares traded on the New York Stock Exchange, the Nasdaq and the NYSE MKT, compared with the 2012 average daily closing volume of about 6.45 billion.


Advancers outpaced decliners on the NYSE by about 22 to 7 and on the Nasdaq by about 2 to 1.


(Additional reporting by Chuck Mikolajczak; Editing by Kenneth Barry and Nick Zieminski)



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China Objects After Shell Is Fired From Myanmar





BANGKOK — China said Thursday that it had expressed “grave concern” to the Myanmar government after a shell, apparently fired during fighting between Myanmar troops and ethnic rebels, landed in Chinese territory, and a Chinese government spokesman called for an immediate cease-fire.




The Chinese response was unusually strong given the close ties between the two countries in recent years, and it suggested that China was growing increasingly impatient and nervous about the Myanmar government’s campaign against ethnic Kachin rebels.


“China has lodged urgent representation to Myanmar over the incident, to express grave concerns and dissatisfaction,” said Hong Lei, a spokesman for China’s Foreign Ministry, who called for a cease-fire, according to the official Xinhua news agency.


Daw Aung San Suu Kyi, the opposition leader in Myanmar’s Parliament, called for an immediate stop to the fighting. But her comments, reported by the Irrawaddy online news site, were equivocal. She said she could not help more forcefully to resolve the conflict because she was not on the ethics committee.


“That doesn’t mean that I don’t take responsibility for the matter or that I don’t care about it, but different committees should respect each other and not interfere in each other’s work,” she said.


Myanmar’s government has repeatedly said that it wants to negotiate with the Kachin rebels, “We want to reduce our offensive and return to talks,” U Ye Htut, a spokesman for President Thein Sein, said in an interview with The Irrawaddy online news site that was posted on Thursday.


But the military appears to be accelerating its campaign against the Kachin using heavy artillery, attack helicopters and other aircraft to flush out guerrillas from their positions surrounding Laiza, a town along the border with China tha is the headquarters of the Kachin Indepedence Army..


Human Rights Watch on Friday called on Myanmar to stop what it described as “indiscriminate” shelling of Laiza, where three civilians were killed earlier this week from what rebels said was an attack by government troops.


Xinhua said the artillery shell was the fourth “bomb” dropped inside China since Dec. 30, when three others landed in Chinese territory.


Bertil Lintner, a specialist on Myanmar’s ethnic groups, said China feared an influx of refugees and further damage to trade along the border. The fighting has disrupted a number of Chinese hydroelectric projects in Myanmar, as well as jade mining.


“They are getting increasingly annoyed with what’s going on at the border,” Mr. Lintner said. “But the Chinese don’t really know what to do. They can’t antagonize the K.I.A.,” he said, referring to the Kachin Independence Army, “and they can’t antagonize the Burmese government either.”


Kachin rebels still control swaths of territory along the border with China, including areas where Chinese companies own plantations.


The Chinese government dealt directly with the Kachin for more than two decades, including the 17-year period when a cease-fire with the government allowed the Kachin to control border trade and maintain a degree of autonomy. The cease-fire collapsed in June 2011.


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ASUS in talks with Microsoft to develop a Windows Phone 8 smartphone






The PC industry is in shambles and manufacturers have begun to explore new options to increase revenue. According to The Wall Street Journal, ASUS (2357) is in talks with Microsoft (MSFT) on a licensing deal to offer Windows Phone 8 device. This makes sense for ASUS since smartphone shipments increased by nearly 50% in 2012, compared to a mere 3.2% growth in computer shipments, and the company already has experience in the mobile world after developing a variety of Android tablets.


[More from BGR: Cable companies called ‘monopolies that stifle competition and innovation’]






Benson Lin, the company’s corporate vice president of mobile communication products, revealed in a recent interview that ASUS was hoping to bring its PadFone, a smartphone that can dock into a larger tablet, to the Windows 8 ecosystem.


[More from BGR: Clash of the bantams: The bloody smartphone battle that will take shape in 2013]


“With our Padfone concept, the phone plus tablet, I think it makes sense for Windows 8,” Lin said. “There is no target timeline…but we are interested in making Windows phones.”


The executive also said that ASUS has been in talks with a variety of American carriers in the hopes that its smartphones will launch in the United States in 2013.


This article was originally published on BGR.com


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American Idol's New Judges Make Their Debut






American Idol










01/16/2013 at 11:00 PM EST







From left: Randy Jackson, Mariah Carey, Ryan Seacrest, Nicki Minaj and Keith Urban


Michael Becker/FOX.


American Idol is back!

Season 12 premiered Wednesday night with the first auditions in New York City. And fans hoping to get a taste of drama from new judges Mariah Carey and Nicki Minaj were not disappointed.

"Right away we knew it was going to be an interesting couple of days," host Ryan Seacrest said at the start of the two-hour episode.

And he was right. (Spoilers ahead!) While fellow newbie Keith Urban and veteran judge Randy Jackson were all about the business of finding talented singers, there was immediate tension between Carey and Minaj, who wore a drum major's hat to her first day on the job.

"We can have accessories?" Carey said disapprovingly after taking her seat at the panel. "I didn't know that was allowed."

"Why did you have to reference my hat?" Minaj responded.

Later, when Carey boasted about her holiday hit, "All I Want for Christmas," Minaj clenched her fists, gritted her teeth and used the b-word. Carey's response? "I rebuke it," she said.

The two women talked over each other at times, rolled eyes and seemed to annoy one another. More than once Carey said "Nicki" like an frustrated mother calls her child out for misbehaving. And Minaj pushed Carey's buttons by talking in a British accent.

But as the two formerly feuding judges have said in recent interviews, the show should be about the hopeful contestants – and there were a handful of talented singers who earned golden tickets to Hollywood:

• Tenna Torres, who attended Camp Mariah and had previously sung for the singer, impressed the panel with her version of "You've Got a Friend," and made her idol very proud.

• Christina "Isabelle," who told a story of losing weight and finding confidence, had Minaj saying, "OMG! OMG!" with her version of "Summertime."

• Frankie Ford, who sings for change on the New York City subway system, stumbled at first but delivered a soulful version of the Eurythmics' "Sweet Dreams." "I like your big voice," Urban said. "There's a lot of musicality in the tone."

Added Carey: "You have an inner glow, which is always beautiful to see."

• Despite hearing loss in both ears, Angela Miller, who sang "Mama Knows Best" by Jessie J, was "definitely one of the best," according to Jackson.

• And Ashlee Feliciano thrilled the female judges with her version of Corinne Bailey Rae's "Put Your Records On." "So pretty," Minaj said. "I want to come to your show ... I'm so inspired by you."

"The potential is great. It was beautiful," Carey said. "You should be really proud of yourself."

At the end of the first two days of auditions, the re-invented Idol panel had done its job: the judges praised the talented singers and handed out 41 tickets to Hollywood; they sent home the kooky contestants (often sweetly) and offered constructive criticism and an invitation to come back next year to the ones still on their way to greatness.

"We gel well in a weird crazy way," Minaj said at the end of the show. Carey said, "I agree."

We'll see how long that lasts! Auditions continue Thursday (8 p.m. ET) on Fox.

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Large study confirms flu vaccine safe in pregnancy


NEW YORK (AP) — A large study offers reassuring news for pregnant women: It's safe to get a flu shot.


The research found no evidence that the vaccine increases the risk of losing a fetus, and may prevent some deaths. Getting the flu while pregnant makes fetal death more likely, the Norwegian research showed.


The flu vaccine has long been considered safe for pregnant women and their fetus. U.S. health officials began recommending flu shots for them more than five decades ago, following a higher death rate in pregnant women during a flu pandemic in the late 1950s.


But the study is perhaps the largest look at the safety and value of flu vaccination during pregnancy, experts say.


"This is the kind of information we need to provide our patients when discussing that flu vaccine is important for everyone, particularly for pregnant women," said Dr. Geeta Swamy, a researcher who studies vaccines and pregnant women at Duke University Medical Center.


The study was released by the New England Journal of Medicine on Wednesday as the United States and Europe suffer through an early and intense flu season. A U.S. obstetricians group this week reminded members that it's not too late for their pregnant patients to get vaccinated.


The new study was led by the Norwegian Institute of Public Health. It tracked pregnancies in Norway in 2009 and 2010 during an international epidemic of a new swine flu strain.


Before 2009, pregnant women in Norway were not routinely advised to get flu shots. But during the pandemic, vaccinations against the new strain were recommended for those in their second or third trimester.


The study focused on more than 113,000 pregnancies. Of those, 492 ended in the death of the fetus. The researchers calculated that the risk of fetal death was nearly twice as high for women who weren't vaccinated as it was in vaccinated mothers.


U.S. flu vaccination rates for pregnant women grew in the wake of the 2009 swine flu pandemic, from less than 15 percent to about 50 percent. But health officials say those rates need to be higher to protect newborns as well. Infants can't be vaccinated until 6 months, but studies have shown they pick up some protection if their mothers got the annual shot, experts say.


Because some drugs and vaccines can be harmful to a fetus, there is a long-standing concern about giving any medicine to a pregnant woman, experts acknowledged. But this study should ease any worries about the flu shot, said Dr. Denise Jamieson of the Centers for Disease Control and Prevention.


"The vaccine is safe," she said.


___


Online:


Medical journal: http://www.nejm.org


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Asian shares consolidate, caution ahead of Chinese data

TOKYO (Reuters) - Asian shares eked out modest gains Thursday, consolidating amid better-than-expected U.S. earnings but demand was capped by caution ahead of Chinese data on Friday.


The MSCI's broadest index of Asia-Pacific shares outside Japan <.miapj0000pus> added 0.1 percent, after falling in the past two sessions, pulled higher by a surge in Australian shares <.axjo>, which rose 1 percent to a 20-month high.


Australian employment surprisingly contracted by 5,500 in December, bolstering the odds for another interest rate cut. The prospect of further policy easing boosted local shares but sent the Australian dollar down to session lows of $1.0534 from $1.0560 before the data.


Analysts said the data came against a fairly positive global backdrop.


"There's a growing sentiment among investors that international risks have been significantly reduced, particularly after the U.S. made a start on its fiscal negotiations," said Ric Spooner, market strategist at CMC Markets in Sydney.


World stock markets ended flat on Wednesday with the banking sector rising as earnings from Goldman Sachs nearly tripled and JPMorgan Chase's fourth-quarter net income jumped 53 percent and earnings for 2012 set a record.


Investors will now turn to economic reports from China on Friday, including fourth-quarter GDP, December industrial output, retail sales and house price, which will offer clues on the health of Asia's biggest economy.


Data showing demand for new cars in recession-bound Europe fell to a 17-year low in 2012 reminded investors of the challenges facing the global economy, after the World Bank sharply cut its outlook for world growth this year to 2.4 percent from 3 percent, citing a slow recovery in developed nations.


YEN RESUMES WEAKNESS


The dollar and the euro regained ground against the yen, snapping two days of selling when investors took profits from these currencies' sharp and rapid rises against the Japanese currency since November.


Traders expect the yen to remain on a weakening trend amid expectations for bolder monetary easing measures from the Bank of Japan as part of the new government's push to drive Japan out of years of deflation and economic slump.


Japan's benchmark Nikkei average <.n225> inched up 0.2 percent, after tumbling 2.6 percent for its largest daily decline in eight months on Wednesday. The Nikkei hit a 32-month high on Tuesday as the yen's slump to multi-year lows against the dollar and the euro bolstered exporters on improving earnings outlook. <.t/>


The dollar was up 0.1 percent to 88.50 yen, off its peak since June 2010 of 89.67 touched on Monday, while the euro climbed 0.3 percent to 117.75 yen, after surging to its highest since May 2011 of 120.13 yen on Monday.


Anxiety about a possible protracted fight in Washington over raising the federal borrowing limit pushed the five-year cost to insure against a U.S. default up to 44 basis points on Wednesday, the highest since August 2011 during the first debt ceiling battle between U.S. President Barack Obama and Republican lawmakers.


The euro was up 0.1 percent to $1.3306 against the dollar, after reaching an 11-month high of $1.3404 on Monday.


COMMODITIES SEEN RISING


Reduced concerns over the euro zone debt problems, relatively more solid global economic fundamentals than last year and China's moderate recovery suggest there are buying opportunities for shares in cyclically dependant sectors and economies including Japan, Philip Poole, Head of Strategy at HSBC Global Asset Management, told a seminar in Tokyo this week.


"Recovery will feed through into 2013, but China won't go back to pre-crisis (of 2008) levels of growth of 10 percent," Poole said, adding that growth was likely to be 7-8 percent in 2013, a level investors now need to get used to.


"Cyclically sensitive sectors look relatively cheap in emerging countries and developed countries," while defensives were less attractive given their relative outperformance in 2012 under the more stressed financial environment, Poole said.


Another sector likely seen getting a boost from the reduced risk environment is commodities.


"Investment focus for 2013 is shifting to economically sensitive areas as global recovery takes place, boosting commodities prices," said Naohiro Niimura, a partner at research and consulting firm Market Risk Advisory.


The rally in platinum prices to 3-month highs this week, regaining its premium over gold for the first time since March 2012, is an indication of investors turning more proactive about taking risks, he said.


U.S. crude was down 0.2 percent at $94.05 a barrel while Brent was steady around $109.64.


(Additional reporting by Thuy Ong in Sydney; Editing by Shri Navaratnam)



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India Ink: A Hospital Network With a Vision

Fixes looks at solutions to social problems and why they work.

As the United States struggles to find new business models for health care, some innovators are looking to other industries, ones that provide high-quality services for low prices. In a recent article in The New Yorker, for example, Atul Gawande suggests that the Cheesecake Factory restaurant chain — with its size, central control and accountability for the customer experience — could be a model of sorts for health care. That’s not as outlandish as it seems. The world’s largest provider of eye care has found success by directly adapting the management practices of another big-box food brand, one that is not often associated with good health: McDonald’s.

Aravind can practice compassion successfully because it is run like a McDonald’s.

In 1976, Dr. Govindappa Venkataswamy — known as Dr. V — retired from performing eye surgery at the Government Medical College in Madurai, Tamil Nadu, a state in India’s south. He decided to devote his remaining years to eliminating needless blindness among India’s poor. Twelve million people are blind in India, the vast majority of them from cataracts, which tend to strike people in India before 60 — earlier than in the West. Blindness robs a poor person of his livelihood and with it, his sense of self-worth; it is often a fatal disease. A blind person, the Indian saying goes, is “a mouth with no hands.”

Dr. V started by establishing an 11-bed hospital with six beds reserved for patients who could not pay and five for those who would pay modest rates. He persuaded his siblings to join him in mortgaging their houses, pooling their savings and pawning their jewels to build it. Today, the Aravind Eye Care System is a network of hospitals, clinics, community outreach efforts, factories, and research and training institutes in south India that has treated more than 32 million patients and has performed 4 million surgeries. And it is still largely run by Dr V’s siblings and their spouses and children — he has at least 21 relatives who are eye surgeons. (Aravind’s story is well-told in depth in a new book, “Infinite Vision.”)

Aravind is not just a health success, it is a financial success. Many health nonprofits in developing countries rely on government help or donations, but Aravind’s core services are sustainable: patient care and the construction of new hospitals are funded by fees from paying patients. And at Aravind, patients pay only if they want to. The majority of Aravind’s patients pay only a symbolic amount, or nothing at all.

Dr V was guided by the teachings of the radical Indian nationalist and mystic Sri Aurobindo (Aravind is a southern Indian variation of Aurobindo), who located man’s search for his divine nature not in turning away from the world, but by engaging with it.

This philosophy, however, has produced a sustainable business model because of the other major influence on Dr. V: McDonald’s. Sri Aurobindo and McDonald’s are an unlikely pair. But Aravind can practice compassion successfully because it is run like a McDonald’s, with assembly-line efficiency, strict quality norms, brand recognition, standardization, consistency, ruthless cost control and above all, volume.

Aravind’s efficiency allows its paying patients to subsidize the free ones, while still paying far less than they would at other Indian hospitals. Each year, Aravind does 60 percent as many eye surgeries as the United Kingdom’s National Health System, at one one-thousandth of the cost.

Aravind’s ideas reach around the world. It runs hospitals in other parts of India with partners. It is also host to a parade of people who come to learn how it works, and it sends staff to work with other organizations. So far about 300 hospitals in India and in other countries are using the Aravind model. All are eye hospitals. But Aravind has also trained staff from maternity hospitals, cancer centers, and male circumcision clinics, among other places. Some share Aravind’s social mission. Others simply want to operate more efficiently.

The vast majority of people blind from cataracts in rural India have no idea why they are blind, nor that a surgery exists that can restore their sight in a few minutes. Aravind attracts these patients in two ways. First, it holds eye camps — 40 a week around the states of Tamil Nadu and Kerala. The camps visit villages every few months, offering eye exams, basic treatments, and fast, cheap glasses. Patients requiring surgery are invited with a family member to come to the nearest of Aravind’s nine hospitals; all transport and lodging, like the surgery, is free.

When Aravind surveyed the impact of its camps, it found to its dismay that they only attracted 7 percent of people in a village who needed care, mainly because they were infrequent. To provide a permanent presence in rural areas, Aravind established 36 storefront vision centers. They are staffed by rural women recruited and given two years’ training by Aravind. They have cameras, so doctors at Aravind’s hospitals can do examinations remotely. These centers increase Aravind’s market penetration to about 30 percent within one year of operation.

At Aravind’s hospitals, free patients lodge on a mat on the floor in a 30-person dormitory. Paying patients can choose various levels of luxury, including private, air-conditioned rooms. All patients get best-practice cataract surgeries, but paying patients can choose more sophisticated surgeries with faster recoveries (but not higher success rates). The doctors are identical, rotating between the free and paid wings.

Also standard for all patients is the Aravind assembly line. Dr. V spent a few days at McDonalds’ Hamburger University in Oak Brook,, Ill., but that visit was a product of his longstanding obsession with efficiency. “This man would go into an airport and walk around with the janitor and see how he cleans the toilet,” said Dr. S. Aravind, an eye surgeon with a masters degree in business who is Aravind’s director of projects. (He is Dr. V’s nephew, also named for Sri Aurobindo.) “He would go to a five star hotel and follow the catering people.”

Doctors are hard to find and expensive, so the surgical system is set up to get the most out of them. Patients are prepared before surgery and bandaged afterwards by Aravind-trained nurses. The operating room has two tables. The doctor performs a surgery — perhaps 5 minutes — on Table 1, sterilizes her hands and turns to Table 2. Meanwhile, a new patient is prepped on Table 1. Aravind doctors do more than 2,000 surgeries a year; the average at other Indian hospitals is around 300. As for quality, Aravind’s rate of surgical complications is half that of eye hospitals in Britain.

This volume is key to Aravind’s ability to offer free care. The building and staff costs are the same no matter how many surgeries each doctor performs. High volume means that these fixed costs are spread among vastly more people.

In the 1980s, Aravind faced a dilemma. A new surgery, which implanted a lens in the patient’s eye, had become the gold standard for treating cataracts. But these lenses were not made in India, and Aravind could persuade manufacturers to reduce their cost only from $100 to $70 per lens. Should Aravind begin providing first-class treatment for paying patients and second-class treatment for free ones? Or should it try to get enough money from paid patients to cover intraocular lenses for all? Neither was acceptable.

The solution was to get into manufacturing. In 1992, Aravind set up Aurolab, which now makes lenses (for $2 apiece), sutures and medicines. Aurolab is now a major global supplier of intraocular lenses and has driven down the price of lenses made by other manufacturers as well.

Aravind could not do its work without paying patients, of course — they subsidize free patients. They also improve service, by demanding high quality for their money. But it also works the other way around: the free patients improve service and price for patients who pay. “One of our big advantages is the scale of the work we do,” said Dr. Aravind. “You become a good resource center for training doctors, nurses, everybody. Because of high volume, doctors get better at what they do. They can develop subtle specialties.” And free patients make cost control a priority. “If 60 percent of your patients are paying very little or nothing, your cost structure is attuned towards that,” Dr. Aravind said.


Whenever there is an innovator like Aravind, the question arises: how replicable is this? Do you need a Dr. V? Or is there a system that ordinary mortals can adapt?

The answer is a little of both. Other hospitals can and do successfully use the model. Lions Clubs International, which has worked to prevent blindness for more than a century, finances and supports a training institute. Aravind also works with the Berkeley-based Seva Foundation to grow eye hospitals in other countries. “There are a lot of eye hospitals in the developing world. Almost every single one is considerably underproducing,” said Suzanne Gilbert, the director of Seva’s Center for Innovation in Eye Care. “Surgical programs so often focus on the technique being used. Often the same level of scrutiny not applied to management, human resources and other systems that make the surgery work.”

Seva has worked with Aravind to establish hospitals in other countries (the Lumbini Eye Institute in Nepal has been particularly successful).  But its campaign to turn those hospitals into training centers has gone slowly. It’s hard to build those hospitals to be able to reach out while keeping good quality,” said Gilbert.   Seva was aiming to have 100 hospitals in the network by 2015, but has scaled back that goal.

“Of the 300 hospitals (that use Aravind’s model), I’d say 20 percent get the whole thing,” said Dr. Aravind. “Another 50 percent pick up pieces — how to make your operating tables more efficient, for example.  And the rest struggle.”

Combining paid and free care in a self-sufficient hospital is not possible for most health specialties. “The essential ingredient is volume that straddles the socioeconomic spectrum,” said Jaspal Sandhu, a Berkeley engineer who has studied Aurolab, and who is co-founder of the Gobee Group, a design firm that works with organizations to increase their social impact. “If you’re focusing on rich diseases or poor diseases, this model in existing form can’t really play out. The nice thing about cataracts is that it doesn’t greatly discriminate. And a cataract is a one-time hit. There’s a cure for it. You can treat it in a couple of days and it won’t come back.”

Male circumcision — an AIDS prevention measure — fits this description, and the World Health Organization’s guidelines for scaling up male circumcision uses Aravind’s principles. “When I was a doctor in a government hospital we did between 8 and maybe 12 circumcisions in a day per doctor,” said Dino Rech, a South African physician who has overseen the expansion of circumcision in several countries.  “With this model, the slowest doctors are doing 40 in a day — up to 60 for the faster ones.”

The McDonald’s part is the easiest piece of the Aravind model to export. More difficult to replicate is Aravind’s commitment to serving the largest number of free patients possible — indeed, to aim to eventually serve all of them. What’s needed, said Dr. Aravind, “is not leadership in the sense of organizing and making it work. It’s leadership that comes from empathizing with the community.”

Aravind spends a lot of resources recruiting free patients. “Never restrict demand. Build your capacity to meet the demand,” Dr. Aravind said. This community outreach work is the easiest part to sacrifice, he said. “This is where mission and leadership come in. People try to justify it with many things — we’ll build a bigger organization, then we’ll go back to community. If you have a choice between your paying and your free patients — well, the team is watching how you prioritize. Here’s its been internalized that this is the way we deal with any issue.  If someone can embody that, they can be like our founder.”

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Tina Rosenberg won a Pulitzer Prize for her book “The Haunted Land: Facing Europe’s Ghosts After Communism.” She is a former editorial writer for The Times and the author of, most recently, “Join the Club: How Peer Pressure Can Transform the World” and the World War II spy story e-book “D for Deception.”

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