W.H.O. Sees Low Health Risks From Fukushima Accident

TOKYO — A study published on Thursday by the World Health Organization on the health risks associated with the disaster at the Fukushima Daiichi Nuclear Power Plant suggested that the risk for certain types of cancers had increased slightly among children exposed to the highest doses of radioactivity, but that there would most likely be no observable increase in cancer rates in the wider Japanese population.

The study, which capped off a comprehensive, two-year analysis of the estimated doses of radioactivity from the 2011 Fukushima accident and their potential risks, also warned that the disaster’s psychological impact could have a consequence on health, and called for continued monitoring and health screenings for populations most exposed to the radiological fallout.

The study’s authors warned, however, that their assessment was based on limited scientific knowledge; much of the scientific data on health effects from radiation is based on acute exposures like those that followed the bombing of Hiroshima and Nagasaki and not chronic, low-level exposure. In Japan, some densely populated areas are expected to remain contaminated with relatively low levels of radioactive materials for decades.

“Because scientific understanding of the radiation effects, particularly at low doses, may increase in the future, it is possible that further investigation may change our understanding of the risks of this radiation accident,” the report said.

The Japanese government called the report overly cautious. “It overestimates the risks, and could lead to misunderstandings of the likelihoods of developing cancer,” Japan’s Environment Ministry said in a statement made to the public broadcaster, N.H.K. In particular, the ministry said the study failed to fully take into account government evacuations of residents closest to the plant, assuming many people were exposed for longer than they were.

According to the W.H.O. study, girls exposed as infants to radioactivity in the most contaminated regions of Fukushima Prefecture, where estimated doses ranged from 12 to 25 millisieverts for the first year, faced a 70 percent higher risk of developing thyroid cancer than what would normally be expected. The report pointed out, however, that the normal expected risk of thyroid cancer was just 0.75 percent, and that the additional lifetime risk would raise that to 1.25 percent.

Girls exposed to radioactivity as infants in the most heavily contaminated areas also had a 6 percent higher risk of developing breast cancer, and a 4 percent higher risk of developing cancers that cause tumors. Meanwhile, boys exposed as infants had a 7 percent higher chance of developing leukemia.

The study also said that about a third of the emergency workers who remained to try to stabilize the Fukushima Daiichi plant were estimated to have a slightly increased risk of developing leukemia, thyroid cancer and other types of cancer.

There would most likely be no observable increase in cancer rates for the general population in Fukushima Prefecture outside the most contaminated zones, in the rest of Japan and the world, the report said. It also said that the radiological fallout from the disaster was not expected to cause increases in miscarriages, stillbirths and other physical or mental disabilities.

Still, the study said that the psychological toll of the disaster, including the stresses of evacuation, were harmful to health and should color the Japanese government’s response.

The W.H.O. report “underlines the need for long-term health monitoring of those who are at high risk, along with the provision of necessary medical follow-up and support services,” Dr. Maria P. Neira, the Geneva-based organization’s director for public health and environment, said in a news release. “This will remain an important element in the public health response to the disaster for decades,” she said.

Dr. Angelika Tritscher, acting director for the food safety and zoonoses department at the health agency, said, “In addition to strengthening medical support and services, continued environmental monitoring, in particular of food and water supplies, backed by the enforcement of existing regulations, is required to reduce potential radiation exposure in the future.” .

Matthew L. Wald contributed reporting from Washington.

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Doctor and Patient: Why Failing Med Students Don’t Get Failing Grades

Tall and dark-haired, the third-year medical student always seemed to be the first to arrive at the hospital and the last to leave, her white coat perpetually weighed down by the books and notes she jammed into the pockets. She appeared totally absorbed by her work, even exhausted at times, and said little to anyone around her.

Except when she got frustrated.

I first noticed her when I overheard her quarreling with a nurse. A few months later I heard her accuse another student of sabotaging her work. And then one morning, I saw her storm off the wards after a senior doctor corrected a presentation she had just given. “The patient never told me that!” she cried. The nurses and I stood agape as we watched her stamp her foot and walk away.

“Why don’t you just fail her?” one of the nurses asked the doctor.

“I can’t,” she sighed, explaining that the student did extremely well on all her tests and worked harder than almost anyone in her class. “The problem,” she said, “is that we have no multiple choice exams when it comes to things like clinical intuition, communication skills and bedside manner.”

Medical educators have long understood that good doctoring, like ducks, elephants and obscenity, is easy to recognize but difficult to quantify. And nowhere is the need to catalog those qualities more explicit, and charged, than in the third year of medical school, when students leave the lecture halls and begin to work with patients and other clinicians in specialty-based courses referred to as “clerkships.” In these clerkships, students are evaluated by senior doctors and ranked on their nascent doctoring skills, with the highest-ranking students going on to the most competitive training programs and jobs.

A student’s performance at this early stage, the traditional thinking went, would be predictive of how good a doctor she or he would eventually become.

But in the mid-1990s, a group of researchers decided to examine grading criteria and asked directors of internal medicine clerkship courses across the country how accurate and consistent they believed their grading to be. Nearly half of the course directors believed that some form of grade inflation existed, even within their own courses. Many said they had increasing difficulty distinguishing students who could not achieve a “minimum standard,” whatever that might be. And over 40 percent admitted they had passed students who should have failed their course.

The study inspired a series of reforms aimed at improving how medical educators evaluated students at this critical juncture in their education. Some schools began instituting nifty mnemonics like RIME, or Reporter-Interpreter-Manager-Educator, for assessing progressive levels of student performance; others began to call regular meetings to discuss grades; still others compiled detailed evaluation forms that left little to the subjective imagination.

Now a new study published last month in the journal Teaching and Learning in Medicine looks at the effects of these many efforts on the grading process. And while the good news is that the rate of grade inflation in medical schools is slower than in colleges and universities, the not-so-good news is that little has changed. A majority of clerkship directors still believe that grade inflation is an issue even within their own courses; and over a third believe that students have passed their course who probably should have failed.

“Grades don’t have a lot of meaning,” said Dr. Sara B. Fazio, lead author of the paper and an associate professor of medicine at Harvard Medical School who leads the internal medicine clerkship at the Beth Israel Deaconess Medical Center in Boston. “‘Satisfactory’ is like the kiss of death.”

About a quarter of the course directors surveyed believed that grade inflation occurred because senior doctors were loath to deal with students who could become angry, upset or even turn litigious over grades. Some confessed to feeling pressure to help students get into more selective internships and training programs.

But for many of these educators, the real issue was not flunking the flagrantly unprofessional student, but rather evaluating and helping the student who only needed a little extra help in transitioning from classroom problem sets to real world patients. Most faculty received little or no training or support in evaluating students, few came from institutions that had remediation programs to which they could direct students, and all worked under grading systems that were subjective and not standardized.

Despite the disheartening findings, Dr. Fazio and her co-investigators believe that several continuing initiatives may address the evaluation issues. For example, residency training programs across the country will soon be assessing all doctors-in-training with a national standards list, a series of defined skills, or “competencies,” in areas like interpersonal communication, professional behavior and specialty-specific procedures. Over the next few years, medical schools will likely be adopting a similar system for medical students, creating a national standard for all institutions.

“There have to be unified, transparent and objective criteria,” Dr. Fazio said. “Everyone should know what it means when we talk about educating and training ‘good doctors.’”

“We will all be patients one day,” she added. “We have to think about what kind of doctors we want to have now and in the future.”

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High & Low Finance: Report Lays Out Plan to Reduce Government Role in Home Financing

Can the American mortgage market ever function again without Uncle Sam guaranteeing that lenders will be repaid?

It is amazing just how few people think it can.

“For the foreseeable future, there is simply not enough capacity on the balance sheets of U.S. banks to allow a reliance on depository institutions as the sole source of liquidity for the mortgage market,” stated a report on the American housing market this week, issued by a group that was filled with members of the housing establishment.

The panel, which included Frank Keating, the president of the American Bankers Association and a former governor of Oklahoma, does not see that as an indictment of the American banking system, which would much rather trade leveraged derivatives than keep a lot of mortgage loans on its books.

“Given the size of the market and capital constraints on lenders, the secondary market for mortgage-backed securities must continue to play a critical role in providing mortgage liquidity,” added the report, issued by a housing commission formed by the Bipartisan Policy Center, a group that was begun by former Senate majority leaders from both parties. The group thinks investors will not be willing to finance enough mortgages — particularly 30-year fixed-rate loans — without a government guarantee.

The report does an excellent job of analyzing the history of the American housing finance system, as well as looking at the government’s efforts over the years to promote and subsidize rental housing. It calls for changes in those policies as well, aimed at assuring that those with very low incomes “are assured access to housing assistance if they need it.”

But those rental proposals are unlikely to lead to legislation any time soon, said Mel Martinez, one of four co-chairmen of the housing panel. Mr. Martinez, a former Republican senator from Florida and housing secretary under President George W. Bush, said in an interview that any proposal calling for spending government money, as this one does, would face tough sledding in Congress.

But he said it was possible that changes in the housing finance system, which is widely criticized on both sides of the aisle, had a better chance of getting approval.

Certainly, one principle enunciated by the panel will get wide support: “The private sector must play a far greater role in bearing housing risk.” But the details show that the panel still thinks sufficient money can be found for housing only if Uncle Sam remains the ultimate guarantor for most home mortgages.

Currently, the government backs about 90 percent of newly issued mortgages, more than ever before. The proportion fell in the years leading up to 2007 as subprime loans proliferated and then soared after that market collapsed. Since then, the Federal Housing Administration has expanded its role in backing home loans on the low end of the scale. But most mortgages are purchased by either Fannie Mae or Freddie Mac, the government-sponsored enterprises that the government took over after the housing bubble burst.

So-called jumbo mortgages, that is mortgages too large to qualify for purchase by Fannie or Freddie, account for most of the rest. Some mortgages are put into securitizations that have no government guarantee, but many jumbo mortgages end up being owned by the banks for the long term.

The F.H.A. appears to be more cautious than it used to be. The report notes that last year the average FICO score for an F.H.A. or Department of Veterans Affairs loan was close to 720 on a range of 300 to 850. That is about what the average Fannie Mae and Freddie Mac borrower had in 2001.

The commission, whose other co-chairmen were George J. Mitchell, the former Senate Democratic leader; Christopher S. Bond, a former Republican senator; and Henry Cisneros, who served as housing secretary under President Bill Clinton, wants to preserve the F.H.A., but orient it more to those who need the most help. It would phase out Fannie and Freddie — something that is politically necessary — but replace them with something that sounds sort of similar.

The new organization would be called a “public guarantor.” It would guarantee that investors in mortgage-backed securitizations would not lose money, much as Fannie and Freddie now do. But its responsibility would come after that of a “private credit enhancer,” which sounds like a monoline insurer that would make payments to securitization holders if the underlying mortgages were performing badly. That organization would be regulated by the public guarantor, and only after it goes broke — something that should happen only if housing prices fall more than they did in the recent crisis — would the public guarantor be responsible for making investors whole.

Floyd Norris comments on finance and the economy at nytimes.com/economix.

This article has been revised to reflect the following correction:

Correction: February 28, 2013

An earlier version of this column misstated the potential proportion of new mortgages that Mr. Martinez said he believed would eventually be financed by private capital. It is 40 to 55 percent, not 40 to 50 percent.

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The Lede: Syrians Describes Apparent Missile Strikes on Aleppo

A Human Rights Watch video report on the aftermath of apparent missile strikes in Syria’s largest city, Aleppo.

Human Rights Watch investigators who visited Aleppo, Syria’s largest city, have concluded that the Syrian government fired at least four ballistic missiles into civilian neighborhoods there last week, killing more than 141 people, including 71 children. As my colleague Anne Barnard explained, the rights group released details of the four documented strikes, and a video report, on Tuesday.

On Wednesday, opposition activists added English subtitles to an emotional account of the devastation caused by one missile strike on Aleppo from a young boy who said he survived the bombing, but lost several family members and neighbors.

A video interview with a young boy who said that he had survived a missile attack on a civilian neighborhood in Aleppo, Syria’s largest city.

The original interview with the boy was posted on YouTube on Monday by Orient News, a private Syrian satellite channel that began broadcasting from Dubai before the anti-government uprising began. Within a week of the first protests in Syria, Ghassan Abboud, the Syrian businessman who owns the channel, told a Saudi broadcaster that senior government officials close to President Bashar al-Assad had threatened to kidnap his journalists if they did not stop covering the demonstrations.

The boy’s testimony was subtitled by the ANA New Media Association, a group of opposition video activists led by Rami Jarrah, who blogs as Alexander Page.

The new reports come weeks after experts told The Lede that video of a huge explosion at Aleppo University last month suggested that the campus had been hit by a ballistic missile.

When Liz Sly of the Washington Post visited Aleppo’s Ard al-Hamra neighborhood after two missile strikes, residents gave similarly graphic accounts of pulling the mangled bodies of victims from wrecked buildings. The scenes of devastation, she wrote, “more closely resembling those of an earthquake, with homes pulverized beyond recognition, people torn to shreds in an instant and what had once been thriving communities reduced to mountains of rubble.”

Ole Solvang, a Human Rights Watch researcher who helped document the damage in Aleppo, drew attention to video posted online by opposition activists, said to show the desperate search for survivors in the immediate aftermath of the strike on Ard al-Hamra.

Video said to show a neighborhood in Syria’s largest city, Aleppo, after a missile strike last week.

As Mr. Solvang assessed the wreckage in person on Thursday and Friday, he described the damage to Aleppo and a neighboring town in words and images posted on Twitter.

Visited a site of similar attack in Tel Rifat today. 25 houses destroyed and 3 killed last Monday. Unbelievable. http://t.co/FaFhNFiAsS

— Ole Solvang (@OleSolvang) 22 Feb 13

Today visited site of yesterday’s missile attack on Ard al Hamra in #Aleppo #Syria. Dozens houses destroyed. Unbelievable destruction. @hrw

— Ole Solvang (@OleSolvang) 23 Feb 13

Bodies are still under the rubble. 3 found during our 30 min visit. Casualty # still unclear. #Aleppo #Syria @hrw http://t.co/gaT7COpRT3

— Ole Solvang (@OleSolvang) 23 Feb 13

Late Tuesday, an Aleppo blogger who supported the uprising but has been critical of the armed rebellion on his @edwardedark Twitter feed, reported that another huge blast had shaken the city.

a massive blast shockwave shakes Aleppo city just now. no idea what it is yet #Syria

— edward dark (@edwardedark) 26 Feb 13

Ms. Sly reported on Twitter Wednesday night that two more missiles were fired at rural Aleppo. “They landed in fields,” she observed. “That’s how accurate they are. Seems a bit pointless.”

Late Wednesday, Mr. Solvang pointed to video posted on YouTube by opposition activists, showing what they said were distant images of a missile being launched from Damascus in the direction of Aleppo.

Video said to show a missile being fired by Syrian government forces outside the capital, Damascus, on Wednesday night.

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AP Source: 49ers to send Smith to KC

SAN FRANCISCO (AP) — Alex Smith quietly stayed behind the scenes after losing his job and watched from the sideline as San Francisco returned to the Super Bowl for the first time in 18 years. Yet the No. 1 overall draft pick from 2005 did make one thing known: The veteran quarterback still considers himself a starter.

And he hoped to get that chance again. Now, he appears to have it.

The Kansas City Chiefs have agreed to acquire Smith from the 49ers in the first major acquisition since Andy Reid took over as the team's new coach in early January, a person with knowledge of the trade told The Associated Press on Wednesday.

The person spoke on condition of anonymity because the deal cannot become official until March 12, when the NFL's new business year begins. Another person familiar with the swap said the 49ers will get a second-round pick in April's draft, No. 34 overall, and a conditional pick in the 2014 draft.

After spending his first eight up-and-down years with the 49ers, Smith will get a welcome new start. The Chiefs will get the proven play-caller they hope can help turn things around under a new coach much the way Smith did under Jim Harbaugh in San Francisco.

"You never know when your opportunity's going to come," Smith said late in the season. "The good ones are ready when they do come."

The Chiefs have gone this route before, acquiring Joe Montana from the 49ers nearly 20 years ago, in April 1993, after he won four Super Bowls but gave way to Steve Young — San Francisco's quarterback of the future.

Not so different from Smith's situation last season behind second-year QB Colin Kaepernick.

Moving Smith was hardly unexpected. He realized it once Kaepernick emerged as a capable starter over the season's final two months, and Smith all but said goodbye with his first pro team when he played briefly in the regular-season finale against Arizona to cheers of "Let's Go, Alex!" and "Alex! Alex!" from the Candlestick Park crowd.

With Smith now headed for Kansas City, Matt Cassel is likely headed out of town. And Reid will enter his first draft as Chiefs coach in April no longer needing to search for a quarterback.

The Chiefs' problems at quarterback are the single biggest reason they went 2-14 last season and secured the No. 1 pick in the draft for the first time in franchise history.

It's been a long-running problem for a franchise that has tried Steve Bono and Elvis Grbac (two more one-time 49ers), and more recently Damon Huard, Tyler Thigpen and Tyler Palko at quarterback. And then there's Cassel.

He was acquired by recently fired general manager Scott Pioli, and has two years left on a $63 million, six-year deal. He will likely be cut once Smith is acquired.

Cassel was benched last season in favor of Brady Quinn, who also is a free agent after going 1-7 as the starter.

If Smith can bring the steady form that defined his last two years, the Chiefs might be able to establish a much-needed consistency under center. They also found themselves a team-first player who led the 49ers through workouts during the 2011 lockout.

Under the three-year contract he signed last March, Smith is guaranteed $8.5 million in base salary for the 2013 season.

Smith thrived under 49ers coach and former NFL quarterback Harbaugh in one-plus season as the starter. Then, just like that, it all changed after he sustained a concussion.

Last week at the NFL combine, Harbaugh praised Smith and reiterated just how strong San Francisco was with Colin Kaepernick as the starter and someone with Smith's credentials at backup.

Yet everyone knew it was likely the 49ers would do their best to improve Smith's situation considering all he did for the franchise for nearly the past decade.

"Alex is really playing the best football of his career the last two years," Harbaugh said. "We think we got the best quarterback situation in the National Football League, feel strongly about that. Again, that'll be a process that plays out. Alex Smith continuing to be a 49er or if a trade occurs in the next weeks or months. Those are the two possibilities, most likely possibilities."

Smith acknowledged when he lost the job to Kaepernick back in November that he had done nothing wrong but get hurt. Not only had he completed 26 of his previous 28 passes — 18 of 19 for 232 yards and three touchdowns without an interception and a 157.1 passer rating in a Monday Night Football win at Arizona on Oct. 29 — Smith had just earned NFC Offensive Player of the Week honors after that victory in the desert.

He then sustained a concussion in the second quarter of a 24-24 tie against St. Louis on Nov. 11 — saying later he threw a touchdown pass with blurry vision. Smith sat out the next game as Kaepernick dazzled in his debut as an NFL starter, beating the Bears handily at home on Monday Night Football.

After that, Harbaugh vowed to stick with the "hot hand," as he regularly put it, while complicating matters by still referring to Smith as a starter.

Smith's most poignant response to the situation was, "I feel like the only thing I did to lose my job was get a concussion."

Kaepernick led the 49ers to the NFC championship and a 34-31 loss to Baltimore in the Super Bowl in his second season. Now the 49ers are looking for his backup.

The 28-year-old Smith struggled for most of his career in San Francisco, plagued as much by coaching and constant coordinator changes as by his own indecisiveness. But when Harbaugh became coach in January 2011, Smith blossomed under the former QB's guidance. He was among the league leaders in passer rating (104.1) with a 70.2 completion percentage when he got hurt last season.

Fox Sports first reported the deal Wednesday.

___

AP Pro Football Writer Barry Wilner and AP Sports Writer Dave Skretta contributed to this story.

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Global Health: After Measles Success, Rwanda to Get Rubella Vaccine

Rwanda has been so successful at fighting measles that next month it will be the first country to get donor support to move to the next stage — fighting rubella too.

On March 11, it will hold a nationwide three-day vaccination campaign with a combined measles-rubella vaccine, hoping to reach nearly five million children up to age 14. It will then integrate the dual vaccine into its national health service.

Rwanda can do so “because they’ve done such a good job on measles,” said Christine McNab, a spokeswoman for the Measles and Rubella Initiative. M.R.I. helped pay for previous vaccination campaigns in the country and the GAVI Alliance is helping to finance the upcoming one.

Rubella, also called German measles, causes a rash that is very similar to the measles rash, making it hard for health workers to tell the difference.

Rubella is generally mild, even in children, but in pregnant women, it can kill the fetus or cause serious birth defects, including blindness, deafness, mental retardation and chronic heart damage.

Ms. McNab said that Rwanda had proved that it can suppress measles and identify rubella, and it would benefit from the newer, more expensive vaccine.

The dual vaccine costs twice as much — 52 cents a dose at Unicef prices, compared with 24 cents for measles alone. (The MMR vaccine that American children get, which also contains a vaccine against mumps, costs Unicef $1.)

More than 90 percent of Rwandan children now are vaccinated twice against measles, and cases have been near zero since 2007.

The tiny country, which was convulsed by Hutu-Tutsi genocide in 1994, is now leading the way in Africa in delivering medical care to its citizens, Ms. McNab said. Three years ago, it was the first African country to introduce shots against human papilloma virus, or HPV, which causes cervical cancer.

In wealthy countries, measles kills a small number of children — usually those whose parents decline vaccination. But in poor countries, measles is a major killer of malnourished infants. Around the world, the initiative estimates, about 158,000 children die of it each year, or about 430 a day.

Every year, an estimated 112,000 children, mostly in Africa, South Asia and the Pacific islands, are born with handicaps caused by their mothers’ rubella infection.

Thanks in part to the initiative — which until last year was known just as the Measles Initiative — measles deaths among children have declined 71 percent since 2000. The initiative is a partnership of many health agencies, vaccine companies, donors and others, but is led by the American Red Cross, the United Nations Foundation, the Centers for Disease Control and Prevention, Unicef and the World Health Organization.

This article has been revised to reflect the following correction:

Correction: February 27, 2013

An earlier version of this article misstated the source of the vaccine and some financing for the campaign. The vaccine and financing is being provided by the GAVI Alliance, not the Measles and Rubella Initiative.

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DealBook: J.C. Penney’s Poor Showing Is Another Retail Miss for Ackman

With J.C. Penney‘s awful fourth-quarter results, William A. Ackman has found success in retail investments elusive once more.

It’s hard to call J.C. Penney’s latest quarterly report anything but breathtaking. The retailer lost $552 million for the quarter, which at $1.95 a share far exceeded the 17-cent loss that analysts had been expecting. Same-store sales tumbled nearly 32 percent from the same time a year ago.

Shares in the company were down nearly 9 percent in after-hours trading.

So far, J.C. Penney’s chief executive, Ron Johnson — whom Mr. Ackman recruited from Apple — has asked for patience, citing all the changes that he has rolled out at the formerly dowdy department store chain. (Indeed, he spent the first several minutes of an investor Webcast on Wednesday enumerating the many innovations at the store.)

One wonders whether Mr. Ackman, whose Pershing Square Capital Management owns a 17.8 percent stake in J.C. Penney, can wait that long.

It isn’t the first time that he has taken a bath betting on a retailer. Mr. Ackman’s most recent failure in the industry was a bet on the Borders Group, taking a 17 percent stake in the troubled bookseller by late 2007.

Despite efforts by the hedge fund manager to help prop up the company, including offering to finance a merger with the much larger Barnes & Noble, Borders filed for bankruptcy in late 2010. Mr. Ackman has acknowledged losing at least $125 million on the investment.

Perhaps his most notable troubled investment was in Target, a wager in which Mr. Ackman actually created a special fund dedicated to the discount retailer. He also embarked on a lengthy and expensive campaign to gain seats on the company’s board, to forcefully advocate for a complicated restructuring he said would generate better returns for shareholders.

That didn’t quite work out either. Mr. Ackman lost the proxy fight. He sold Pershing’s stake by early 2011, having lost about 90 percent of his firm’s $2 billion investment.

Last month, it appeared that Mr. Ackman was willing to give Mr. Johnson room to prove naysayers wrong. “We put Ron in charge, and we’re letting him run the company,” the hedge fund manager told CNBC in an interview.

But he added that he’ll run out of patience — in three year’s time.

“If three years from now, Ron Johnson is still struggling to turn around J.C. Penney,” Mr. Ackman said to CNBC, “he’s probably the wrong guy.”

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Rocket From Gaza Hits Israel, Breaking Cease-Fire

Tsafrir Abayov/Associated Press

Israeli explosives experts gathered near a rocket believed to have been fired from the Gaza Strip, landing near Ashkelon, on Tuesday.

JERUSALEM — A Grad rocket fired from the Gaza Strip struck in southern Israel early Tuesday, threatening to further escalate tensions that have been mounting since Saturday, when a 30-year-old Palestinian prisoner died in an Israeli jail.

The rocket, which came down on a road outside the city of Ashkelon and caused no injuries, was the first from Gaza to hit Israel in the three months since a cease-fire agreement ended eight days of cross-border violence. Israel has violated the cease-fire several times by firing on fishermen and farmers approaching newly relaxed security perimeters, but the agreement has otherwise held.

A subgroup of the Al Aksa Martyrs Brigade, the military wing of the Palestinians’ Fatah faction, said it fired the rocket in response to what it called the “assassination” of Arafat Jaradat, the prisoner who died on Saturday. Palestinian leaders have blamed Mr. Jaradat’s death on what they described as “severe torture” during interrogation, though Israeli officials say the bruising and broken ribs cited as evidence of torture could have been caused by resuscitation efforts.

Mushir al-Masri, a lawmaker from the militant Hamas faction that rules the Gaza Strip, said in an interview that Israel was “fully responsible for the consequences of the wave of the Palestinian public fury.”

After the rocket attack, Israel shut its border crossings with Gaza to goods and people, allowing only “medical, humanitarian and exceptional cases,” according to a statement from the military. President Shimon Peres, who was visiting southern Israel on a previously scheduled tour, said, “Quiet will be met with quiet; missiles will be met with a response.”

Giora Eiland, a senior research fellow at Israel’s Institute for National Security Studies, said renewed rocket fire could change the current delicate balance between Israel and the Palestinians, because international opinion is largely critical of Israel’s actions in the West Bank but is sympathetic when Israel comes under attack from Gaza.

“I believe that it is under control, it can be contained, and with some gestures from both sides and clear messages from Washington — which I understand are coming every few hours — it will be able to prevent an escalation and not to deteriorate ourselves to a third intifada,” Mr. Eiland said, using the Arabic word for uprising. “There is a very delicate line between two conflicting interests: to do something in order to preserve the Jihadiic identity, to preserve the spirit of resistance, to serve so many domestic interests, but not to do something that would bring some unproportional response.”

Fares Akram contributed reporting from Gaza City.

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Experts: Pistorius violated basic firearms rules

JOHANNESBURG (AP) — Even if Oscar Pistorius is acquitted of murder, firearms and legal experts in South Africa believe that, by his own account, the star athlete violated basic gun-handling regulations and exposed himself to a homicide charge by shooting into a closed door without knowing who was behind it.

Particularly jarring for firearms instructors and legal experts is that Pistorius testified that he shot at a closed toilet door, fearing but not knowing for certain that a nighttime intruder was on the other side. Instead of an intruder, Pistorius' girlfriend Reeva Steenkamp was in the toilet cubicle. Struck by three of four shots that Pistorius fired from a 9 mm pistol, she died within minutes. Prosecutors charged Pistorius with premeditated murder, saying the shooting followed an argument between the two. Pistorius said it was an accident.

South Africa has stringent laws regulating the use of lethal force for self-protection. In order to get a permit to own a firearm, applicants must not only know those rules but must demonstrate proficiency with the weapon and knowledge of its safe handling, making it far tougher to legally own a gun in South Africa than many other countries where a mere background check suffices.

Pistorius took such a competency test for his 9 mm pistol and passed it, according to the South African Police Service's National Firearms Center. Pistorius' license for the 9 mm pistol was issued in September 2010. The Olympic athlete and Paralympic medalist should have known that firing blindly, instead of at a clearly identified target, violates basic gun-handling rules, firearms and legal experts said.

"You can't shoot through a closed door," said Andre Pretorius, president of the Professional Firearm Trainers Council, a regulatory body for South African firearms instructors. "People who own guns and have been through the training, they know that shooting through a door is not going to go through South African law as an accident."

"There is no situation in South Africa that allows a person to shoot at a threat that is not identified," Pretorius added. "Firing multiple shots, it makes it that much worse. ...It could have been a minor — a 15-year-old kid, a 12-year-old kid — breaking in to get food."

The Pistorius family, through Arnold Pistorius, uncle of the runner, has said it is confident that the evidence will prove that Steenkamp's death in the predawn hours of Feb. 14 was "a terrible and tragic accident."

In an affidavit to the magistrate who last Friday freed him on bail, Pistorius said he believed an intruder or intruders had gotten into his US$560,000 (€430,000) two-story house, in a guarded and gated community with walls topped by electrified fencing east of the capital, Pretoria, and were inside the toilet cubicle in his bathroom. Believing he and Steenkamp "would be in grave danger" if they came out, "I fired shots at the toilet door" with the pistol that he slept with under his bed, he testified.

Criminal law experts said that even if the prosecution fails to prove premeditated murder, firing several shots through a closed door could bring a conviction for the lesser but still serious charge of culpable homicide, a South African equivalent of manslaughter covering unintentional deaths through negligence.

Johannesburg attorney Martin Hood, who specializes in firearm law, said South African legislation allows gun owners to use lethal force only if they believe they are facing an immediate, serious and direct attack or threat of attack that could either be deadly or cause grievous injury.

According to Pistorius' own sworn statement read in court, he "did not meet those criteria," said Hood, who is also the spokesman for the South African Gun Owners' Association.

"If he fired through a closed door, there was no threat to him. It's as simple as that," he added. "He can't prove an attack on his life ... In my opinion, at the very least, he is guilty of culpable homicide."

The Associated Press emailed a request for comment to Vuma, a South African reputation management firm hired by the Pistorius family to handle media questions about the shooting.

The firm replied: "Due to the legal sensitivities around the matter, we cannot at this stage answer any of your questions as it might have legal implications for a case that still has to be tried in a court of law." Vuma said on Monday it referred the AP's questions to Pistorius' legal team, which by Tuesday had not replied.

Culpable homicide covers unintentional deaths ranging from accidents with no negligence, like a motorist whose brakes fail, killing another road user, "to where it verges on murder or where it almost becomes intentional," said Hood. Sentences — ranging from fines to prison — are left to courts to determine and are not set by fixed guidelines.

The tough standards for legally acquiring a gun were instituted in part because of a wave of weapons purchases after the end of racist white rule in 1994, said Rick De Caris, a former legal director in the South African police. Under South Africa's white-minority apartheid regime, gun owners often learned how to handle firearms during military service. Many of the new gun owners had little or no firearms training, which brought tragic results, De Caris said.

"People were literally shooting themselves when cleaning a firearm," said De Caris, who helped draft the Firearms Control Act of 2000.

Prospective gun owners must now take written exams that include questions on the law, have to show they can safely handle and shoot a gun and are required to hit a target the size of a glossy magazine in 10 of 10 shots from seven meters (23 feet), said Pretorius of the Professional Firearm Trainers Council.

In his affidavit, Pistorius said he wasn't wearing his prosthetic limbs "and felt extremely vulnerable" after hearing noise from the toilet.

"I grabbed my 9 mm pistol from underneath my bed. On my way to the bathroom, I screamed words to the effect for him/them to get out of my house and for Reeva to phone the police. It was pitch-dark in the bedroom and I thought Reeva was in bed," he testified.

Legal experts said they are puzzled why Pistorius apparently didn't first fire a warning shot to show the supposed intruder he was armed. Also unanswered is why, after he heard noise in his bathroom that includes the toilet cubicle, Pistorius still went toward the bathroom — toward the perceived danger — rather than retreat back into his bedroom.

"He should have tried to get out of the situation," said Hood, the attorney.

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Advanced Breast Cancer May Be Rising Among Young Women, Study Finds

The incidence of advanced breast cancer among younger women, ages 25 to 39, may have increased slightly over the last three decades, according to a study released Tuesday.

But more research is needed to verify the finding, which was based on an analysis of statistics, the study’s authors said. They do not know what may have caused the apparent increase.

Some outside experts questioned whether the increase was real, and expressed concerns that the report would frighten women needlessly.

The study, published in The Journal of the American Medical Association, found that advanced cases climbed to 2.9 per 100,000 younger women in 2009, from 1.53 per 100,000 women in 1976 — an increase of 1.37 cases per 100,000 women in 34 years. The totals were about 250 such cases per year in the mid-1970s, and more than 800 per year in 2009.

Though small, the increase was statistically significant, and the researchers said it was worrisome because it involved cancer that had already spread to organs like the liver or lungs by the time it was diagnosed, which greatly diminishes the odds of survival.

For now, the only advice the researchers can offer to young women is to see a doctor quickly if they notice lumps, pain or other changes in the breast, and not to assume that they cannot have breast cancer because they are young and healthy, or have no family history of the disease.

“Breast cancer can and does occur in younger women,” said Dr. Rebecca H. Johnson, the first author of the study and medical director of the adolescent and young adult oncology program at Seattle Children’s Hospital.

But Dr. Johnson noted that there is no evidence that screening helps younger women who have an average risk for the disease and no symptoms. “We’re certainly not advocating that young women get mammography at an earlier age than is generally specified,” she said.

Expert groups differ about when screening should begin; some say at age 40, others 50.

Breast cancer is not common in younger women; only 1.8 percent of all cases are diagnosed in women from 20 to 34, and 10 percent in women from 35 to 44. However, when it does occur, the disease tends to be more deadly in younger women than in older ones. Researchers are not sure why.

The researchers analyzed data from SEER, a program run by the National Cancer Institute to collect cancer statistics on 28 percent of the population of the United States. The study also used data from the past when SEER was smaller.

The study is based on information from 936,497 women who had breast cancer from 1976 to 2009. Of those, 53,502 were 25 to 39 years old, including 3,438 who had advanced breast cancer, also called metastatic or distant disease.

Younger women were the only ones in whom metastatic disease seemed to have increased, the researchers found.

Dr. Archie Bleyer, a clinical research professor in radiation medicine at the Knight Cancer Institute at the Oregon Health and Science University in Portland who helped write the study, said scientists needed to verify the increase in advanced breast cancer in young women in the United States and find out whether it is occurring in other developed Western countries. “This is the first report of this kind,” he said, adding that researchers had already asked colleagues in Canada to analyze data there.

“We need this to be sure ourselves about this potentially concerning, almost alarming trend,” Dr. Bleyer said. “Then and only then are we really worried about what is the cause, because we’ve got to be sure it’s real.”

Dr. Johnson said her own experience led her to look into the statistics on the disease in young women. She had breast cancer when she was 27; she is now 44. Over the years, friends and colleagues often referred young women with the disease to her for advice.

“It just struck me how many of those people there were,” she said.

Dr. Donald A. Berry, an expert on breast cancer data and a professor of biostatistics at the University of Texas’ M. D. Anderson Cancer Center in Houston, said he was dubious about the finding, even though it was statistically significant, because the size of the apparent increase was so small — 1.37 cases per 100,000 women, over the course of 30 years.

More screening and more precise tests to identify the stage of cancer at the time of diagnosis might account for the increase, he said.

“Not many women aged 25 to 39 get screened, but some do, but it only takes a few to account for a notable increase from one in 100,000,” Dr. Berry said.

Dr. Silvia C. Formenti, a breast cancer expert and the chairwoman of radiation oncology at New York University Langone Medical Center, questioned the study in part because although it found an increased incidence of advanced disease, it did not find the accompanying increase in deaths that would be expected.

A spokeswoman for an advocacy group for young women with breast cancer, Young Survival Coalition, said the organization also wondered whether improved diagnostic and staging tests might explain all or part of the increase.

“We’re looking at this data with caution,” said the spokeswoman, Michelle Esser. “We don’t want to invite panic or alarm.”

She said it was important to note that the findings applied only to women who had metastatic disease at the time of diagnosis, and did not imply that women who already had early-stage cancer faced an increased risk of advanced disease.

Dr. J. Leonard Lichtenfeld
, deputy chief medical officer of the American Cancer Society, said he and an epidemiologist for the society thought the increase was real.

“We want to make sure this is not oversold or that people suddenly get very frightened that we have a huge problem,” Dr. Lichtenfeld said. “We don’t. But we are concerned that over time, we might have a more serious problem than we have today.”

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