Sympathy over US school shooting stretches globe

BANGKOK (AP) — Shock and sympathy were the initial reactions from around the world to a shooting rampage in Connecticut that left 28 people dead, including 20 children at an elementary school. Australian Prime Minister Julia Gillard described the attack as a "senseless and incomprehensible act of evil."

"Like President Obama and his fellow Americans, our hearts too are broken," Gillard said in a statement.

The gunman killed his mother at home before opening fire Friday inside the school in Newtown, Connecticut, killing 26 people, including 20 children, police said. The killer, identified as 20-year-old Adam Lanza, then committed suicide.

"As parents and grandparents, as brothers and sisters, as friends of the American people, we mourn the loss of children, aged only 5 to 10 years, whose futures lay before them," Gillard said. "We mourn the loss of brave teachers who sought only to lead their students into that future but were brutally murdered in a place of refuge and learning."

Australia confronted a similar tragedy in 1996, when a man went on a shooting spree in the southern state of Tasmania, killing 35 people. The mass killing sparked outrage across the country and led the government to impose strict new gun laws, including a ban on semi-automatic rifles.

Gillard's sentiments echoed those of British Prime Minister David Cameron, who said he "was shocked and deeply saddened" to learn of the "horrific shooting."

"My thoughts are with the injured and those who have lost loved ones," he said. "It is heartbreaking to think of those who have had their children robbed from them at such a young age, when they had so much life ahead of them."

In Japan, where guns are severely restricted and there are extremely few gun-related crimes, public broadcaster NHK led the noon news Saturday with the shooting, putting it ahead of an update on the final day of campaigning before Sunday's nationwide parliamentary elections.

NHK, which had a reporter giving a live broadcast from the scene, said that five of the children at the school were Japanese, and that all five were safe. Its report could not immediately be independently confirmed.

Several Japanese broadcasters ran footage from Newtown, showing scenes of people singing outside churches Friday evening, as well as part of President Barack Obama's tearful press conference.

The attack in Connecticut quickly consumed public discussion in China, rocketing to the top of topic lists on social media and becoming the top story on state television's main noon newscast. China has seen several rampage attacks at schools in recent years, though the attackers there usually use knives. The most recent attack happened Friday, when a knife-wielding man injured 22 children and one adult outside a primary school in central China.

Much of the discussion after the Connecticut rampage centered on the easy access to guns in America, unlike in China, where even knives are sometimes banned from sale. But with more than 100,000 Chinese studying in U.S. schools, a sense of shared grief came through.

"Parents with children studying in the U.S. must be tense. School shootings happen often in the U.S. Really, can't politicians put away politics and prohibit gun sales?" Zhang Xin, a wealthy property developer, wrote on her feed on the Twitter-like Sina Weibo service, where she has 4.9 million followers. "There will always be mental patients among us. They should not be given guns."

In the Philippines, a spokeswoman for President Benigno Aquino III said, "What makes it more painful is that most of the victims were small children."

"Our deep condolences go out to the families, teachers and their loved ones. Our hearts and minds are with them and pray with them as they go through a very difficult time, especially with Christmas approaching," deputy presidential spokeswoman Abigail Valte told DZBB radio.

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Associated Press writers Cassandra Vinograd in London, Kristen Gelineau in Sydney, Malcolm Foster in Tokyo, Charles Hutzler in Beijing and Oliver Teves in Manila, Philippines, contributed to this report.

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Owner of Rivera plane being investigated by DEA

PHOENIX (AP) — The company that owns a luxury jet that crashed and killed Latin music star Jenni Rivera is under investigation by the U.S. Drug Enforcement Administration, and the agency seized two of its planes earlier this year as part of the ongoing probe.

DEA spokeswoman Lisa Webb Johnson confirmed Thursday the planes owned by Las Vegas-based Starwood Management were seized in Texas and Arizona, but she declined to discuss details of the case. The agency also has subpoenaed all the company's records, including any correspondence it has had with a former Tijuana mayor who U.S. law enforcement officials have long suspected has ties to organized crime.

The man widely believed to be behind the aviation company is an ex-convict named Christian Esquino, 50, who has a long and checkered legal past. Corporate records list his sister-in-law as the company's only officer, but insurance companies that cover some of the firm's planes say in court documents that the woman is merely a front and that Esquino is the one in charge.

Esquino's legal woes date back decades. He pleaded guilty to a fraud charge that stemmed from a major drug investigation in Florida in the early 1990s and most recently was sentenced to two years in federal prison in a California aviation fraud case. Esquino, a Mexican citizen, was deported upon his release. Esquino and various other companies he has either been involved with or owns have also been sued for failing to pay millions of dollars in loans, according to court records.

The 43-year-old California-born Rivera died at the peak of her career when the plane she was traveling in nose-dived into the ground while flying from the northern Mexican city of Monterrey to the central city of Toluca early Sunday morning. She was perhaps the most successful female singer in grupero, a male-dominated Mexico regional style, and had branched out into acting and reality television.

It remained unclear Thursday exactly what caused the crash and why Rivera was on Esquino's plane. The 78-year-old pilot and five other people were also killed. Esquino was not on the plane.

The late singer's brother, Pedro Rivera Jr., said that he didn't know anything about the owner or why or how she ended up in his plane.

Esquino told the Los Angeles Times in a telephone interview from Mexico City earlier this week that the singer was considering buying the aircraft from Starwood for $250,000 and the flight was offered as a test ride. He disputed reports that he owns Starwood, maintaining that he is merely the company's operations manager "with the expertise."

In response to an email from The Associated Press, Esquino said he did not want to comment. Calls to various phone numbers associated with him rang unanswered.

Esquino is no stranger to tangles with the law. He was indicted in the early 1990s along with 12 other defendants in a major federal drug investigation that claimed the suspects planned to sell more than 480 kilograms of cocaine, according to court records. He eventually pleaded guilty to conspiring to conceal money from the IRS and was sentenced to five years in prison, but much of the term was suspended for reasons that weren't immediately clear.

He served about five months in prison before being released.

Cynthia Hawkins, a former assistant U.S. attorney who handled the case and is now in private practice in Orlando, remembered the investigation well.

"It was huge," Hawkins said Thursday. "This was an international smuggling group."

She said the case began with the arrest of Robert Castoro, who was at the time considered one of the most prolific smugglers of marijuana and cocaine into Florida from direct ties to Colombian drug cartels in the 1980s. Castoro was convicted in 1988 and sentenced to life in prison, but he then began cooperating with authorities, leading to his sentence being reduced to just 10 years, Hawkins said.

"Castoro cooperated for years," she said. "We put hundreds of people in jail."

He eventually gave up another smuggler, Damian Tedone, who was indicted in the early 1990s along with Esquino and 11 others in a conspiracy involving drug smuggling in Florida in the 1980s at a time when the state was the epicenter of the nation's cocaine trade.

Tedone also cooperated with authorities and has since been released from prison. Telephone messages left Thursday for both Tedone and Castoro were not returned.

Esquino eventually pleaded guilty to the lesser offense of concealing money from the IRS.

Joseph Milchen, Esquino's attorney at the time, said Thursday the case eventually revolved around his client "bringing money into the United States without declaring it."

However, Milchen acknowledged that a plane purchased by Esquino was "used to smuggle drugs."

He denied his former client has ever had anything to do with illegal narcotics.

"The only thing he has ever done is with airplanes," Milchen said.

Court filings also indicate Esquino was sentenced to two years in federal prison after pleading guilty in 2004 to committing fraud involving aircraft he purchased in Mexico, then falsified the planes' log books and re-sold them in the United States.

Also in 2004, a federal judge ordered him and one of his companies to pay a creditor $6.2 million after being accused of failing to pay debts to a bank.

As the years passed, Esquino's troubles only grew.

In February this year, a Gulfstream G-1159A plane the government valued at $500,000 was seized by the U.S. Marshals Service on behalf of the DEA after landing in Tucson on a flight that originated in Mexico

Four months later, the DEA subpoenaed all of Starwood's records dating to Dec. 13, 2007, including federal and state income tax documents, bank deposit information, records on all company assets and sales, and the entity's relationship with Esquino and more than a dozen companies and individuals, including former Tijuana Mayor Jorge Hank-Rhon, a gambling mogul and a member of one of Mexico's most powerful families. U.S. law enforcement officials have long suspected Hank-Rhon is tied to organized crime but no allegations have been proven. He has consistently denied any criminal involvement.

He was arrested in Mexico last year on weapons charges and on suspicion of ordering the murder of his son's former girlfriend. He was later freed for lack of evidence.

The subpoena was obtained by the U-T San Diego newspaper.

A Starwood attorney listed on the subpoena, Jeremy Schuster, declined Thursday to provide details.

"We don't comment on matters involving clients," he said.

In September, the DEA seized another Starwood plane — a 1977 Hawker 700 with an insured value of $1 million — after it landed in McAllen, Texas, from a flight from Mexico.

Insurers of both aircraft have since filed complaints in federal court in Nevada seeking to have the Starwood policies nullified, in part, because they say Esquino lied in the application process when he noted he had never been indicted on drug-related criminal charges. Both companies said they would not have issued the policies had he been truthful.

Another attorney for Starwood has not responded to phone and email messages seeking comment, and no one was at the address listed at its Las Vegas headquarters. The address is a post office box in a shipping and mailing store located between a tuxedo rental shop and a supermarket in a shopping center several miles west of the Las Vegas Strip.

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Associated Press writers Elliot Spagat in San Diego and Ken Ritter in Las Vegas contributed to this report.

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Fewer health care options for illegal immigrants

ALAMO, Texas (AP) — For years, Sonia Limas would drag her daughters to the emergency room whenever they fell sick. As an illegal immigrant, she had no health insurance, and the only place she knew to seek treatment was the hospital — the most expensive setting for those covering the cost.

The family's options improved somewhat a decade ago with the expansion of community health clinics, which offered free or low-cost care with help from the federal government. But President Barack Obama's health care overhaul threatens to roll back some of those services if clinics and hospitals are overwhelmed with newly insured patients and can't afford to care for as many poor families.

To be clear, Obama's law was never intended to help Limas and an estimated 11 million illegal immigrants like her. Instead, it envisions that 32 million uninsured Americans will get access to coverage by 2019. Because that should mean fewer uninsured patients showing up at hospitals, the Obama program slashed the federal reimbursement for uncompensated care.

But in states with large illegal immigrant populations, the math may not work, especially if lawmakers don't expand Medicaid, the joint state-federal health program for the poor and disabled.

When the reform has been fully implemented, illegal immigrants will make up the nation's second-largest population of uninsured, or about 25 percent. The only larger group will be people who qualify for insurance but fail to enroll, according to a 2012 study by the Washington-based Urban Institute.

And since about two-thirds of illegal immigrants live in just eight states, those areas will have a disproportionate share of the uninsured to care for.

In communities "where the number of undocumented immigrants is greatest, the strain has reached the breaking point," Rich Umbdenstock, president of the American Hospital Association, wrote last year in a letter to Obama, asking him to keep in mind the uncompensated care hospitals gave to that group. "In response, many hospitals have had to curtail services, delay implementing services, or close beds."

The federal government has offered to expand Medicaid, but states must decide whether to take the deal. And in some of those eight states — including Texas, Florida and New Jersey — hospitals are scrambling to determine whether they will still have enough money to treat the remaining uninsured.

Without a Medicaid expansion, the influx of new patients and the looming cuts in federal funding could inflict "a double whammy" in Texas, said David Lopez, CEO of the Harris Health System in Houston, which spends 10 to 15 percent of its $1.2 billion annual budget to care for illegal immigrants.

Realistically, taxpayers are already paying for some of the treatment provided to illegal immigrants because hospitals are required by law to stabilize and treat any patients that arrive in an emergency room, regardless of their ability to pay. The money to cover the costs typically comes from federal, state and local taxes.

A solid accounting of money spent treating illegal immigrants is elusive because most hospitals do not ask for immigration status. But some states have tried.

California, which is home to the nation's largest population of illegal immigrants, spent an estimated $1.2 billion last year through Medicaid to care for 822,500 illegal immigrants.

The New Jersey Hospital Association in 2010 estimated that it cost between $600 million and $650 million annually to treat 550,000 illegal immigrants.

And in Texas, a 2010 analysis by the Health and Human Services Commission found that the agency had provided $96 million in benefits to illegal immigrants, up from $81 million two years earlier. The state's public hospital districts spent an additional $717 million in uncompensated care to treat that population.

If large states such as Florida and Texas make good on their intention to forgo federal money to expand Medicaid, the decision "basically eviscerates" the effects of the health care overhaul in those areas because of "who lives there and what they're eligible for," said Lisa Clemans-Cope, a senior researcher at the Urban Institute.

Seeking to curb expenses, hospitals might change what qualifies as an emergency or cap the number of uninsured patients they treat. And although it's believed states with the most illegal immigrants will face a smaller cut, they will still lose money.

The potential impacts of reform are a hot topic at MD Anderson Cancer Center in Houston. In addition to offering its own charity care, some MD Anderson oncologists volunteer at a county-funded clinic at Lyndon B. Johnson General Hospital that largely treats the uninsured.

"In a sense we've been in the worst-case scenario in Texas for a long time," said Lewis Foxhall, MD Anderson's vice president of health policy in Houston. "The large number of uninsured and the large low-income population creates a very difficult problem for us."

Community clinics are a key part of the reform plan and were supposed to take up some of the slack for hospitals. Clinics received $11 billion in new funding over five years so they could expand to help care for a swell of newly insured who might otherwise overwhelm doctors' offices. But in the first year, $600 million was cut from the centers' usual allocation, leaving many to use the money to fill gaps rather than expand.

There is concern that clinics could themselves be inundated with newly insured patients, forcing many illegal immigrants back to emergency rooms.

Limas, 44, moved to the border town of Alamo 13 years ago with her husband and three daughters. Now single, she supports the family by teaching a citizenship class in Spanish at the local community center and selling cookies and cakes she whips up in her trailer. Soon, she hopes to seek a work permit of her own.

For now, the clinic helps with basic health care needs. If necessary, Limas will return to the emergency room, where the attendants help her fill out paperwork to ensure the government covers the bills she cannot afford.

"They always attended to me," she said, "even though it's slow."

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Sherman can be followed on Twitter at https://twitter.com/chrisshermanAP .

Plushnick-Masti can be followed on Twitter at https://twitter.com/RamitMastiAP .

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'Evil visited this community today': 20 children killed in shooting

Twenty children died today when a heavily armed man invaded a Newtown,
Conn., elementary school and sprayed staff and students with bullets.

The gunman, identified as Adam Lanza, 20, was found dead in the school.

Lt. Paul Vance said 18 children died in the school and two more died
later in a hospital. Six adults were also slain, bringing the total to
26.

In addition to the casualties at the school, Lanza's mother Nancy Lanza
was killed in her home, federal and state sources told ABC News.

According to sources, Lanza shot his mother in the face, then left his
house armed with at least two semi automatic handguns, a Glock and a Sig
Sauer, and a semi automatic rifle. He was also wearing a bullet proof
vest.

Lanza drove to Sandy Hook Elementary School and continued his rampage,
killing 26 people, authorities said. He was found dead at the school. It
appears that he died from what is believed to be a self inflicted
gunshot wound. The rifle was found in his car.

In the early confusion surrounding the investigation, federal sources
initially identified the suspect as Adam's older brother Ryan Lanza, 24.
He is being questioned by police.

LIVE UPDATES: Newtown, Conn., School Shooting

"Evil visited this community today," Gov. Dan Malloy said at a news conference this evening.

First grade teacher Kaitlin Roig, 29, locked her 14 students in a class bathroom and listened to "tons of shooting" until police came to help.

"It was horrific," Roig said. "I thought we were going to die."

She said that the terrified kids were saying, "I just want Christmas…I don't want to die. I just want to have Christmas."

A tearful President Obama said there's "not a parent in America who doesn't feel the overwhelming grief that I do."

The president had to pause to compose himself after saying these were
"beautiful little kids between the ages of 5 and 10." As he continued
with his statement, Obama wiped away tears from each eye.

He has ordered flags flown as half staff.

CLICK HERE for more photos from the scene.

The alert at the school ended when Vance announced, "The shooter is deceased inside the building. The public is not in danger."

The massacre prompted the town of Newtown to lock down all its schools
and draw SWAT teams to the school, authorities said today. Authorities
initially believed that there were two gunmen and were searching cars
around the school, but authorities do not appear to be looking for
another gunman.

It is the second worst mass shooting in U.S. history, exceeded only by
the Virginia Tech shooting in 2007 when 32 were killed before the
shooter turned the gun on himself. Today's carnage exceeds the 1999
Columbine High School shooting in which 13 died and 24 were injured.

The Newtown shooting comes three days after masked gunman Jacob Roberts
opened fire in a busy Oregon mall, killing two before turning the gun
on himself.

Today's shooting occurred at the Sandy Hook Elementary School, which
includes 450 students in grades K-4. The town is located about 12 miles
east of Danbury.

State Police received the first 911 call at 9:41 a.m. and immediately
began sending emergency units from the western part of the state.
Initial 911 calls stated that multiple students were trapped in a
classroom, possibly with a gunman, according to a Connecticut State
Police source.

Lt. Paul Vance said that on-duty and off-duty officers swarmed to the
school and quickly checked "every door, every crack, every crevice" in
the building looking for the gunman and evacuating children.

A photo from the scene shows a line of distressed children being led out of the school.

Three patients have been taken to Danbury Hospital, which is also on lockdown, according to the hospital's Facebook page.

"Out of abundance of caution and not because of any direct threat
Danbury Hospital is under lockdown," the statement said. "This allows us
simply to focus on the important work at hand."

Newtown Public School District secretary of superintendent Kathy June
said in a statement that the district's schools were locked down because
of the report of a shooting. "The district is taking preventive
measures by putting all schools in lockdown until we ensure the safety
of all students and staff," she said.

State police sent SWAT team units to Newtown.

All public and private schools in the town were on lockdown.

"We have increased our police presence at all Danbury Public Schools due
to the events in Newtown. Pray for the victims," Newtown Mayor Boughton
tweeted.

State emergency management officials said ambulances and other units were also en route and staging near the school.

A message on the school district website says that all afternoon
kindergarten is cancelled today and there will be no midday bus runs.

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New parties pop up in Japan, confusing voters

TOKYO (AP) — The buzz over Japan's parliamentary elections this Sunday has been all about "the third force" — a clear sign of the prevailing disenchantment over both the party that ruled for decades after World War II and the rival party that took over in 2009.

But with more than a dozen parties vying for votes — many of them popping up over the past several months— talk in the media and on the streets about a "third" alternative has become a bit of an understatement.

The circus-like myriad of parties spans a spectrum of views from the super-patriotic, calling for a more hawkish Japan, to those linked to the grass-roots movement demanding an end to nuclear power, a call that has grown following the Fukushima Dai-ichi plant meltdowns last year.

Polls show the conservative, pro-big business Liberal Democrat Party that led Japan for decades is likely to win the most seats, as the rest of the vote gets split among the hodgepodge of parties. Still, voters don't seem terribly enthused about the LDP or their leader, Shinzo Abe, a nationalistic former prime minister who is the front-runner to get the top job again.

The ruling Democratic Party of Japan, which swept to power in 2009 amid high hopes for change, is expected to lose badly. The public is disgusted after the Democrats failed to carry out one promise after another, including government subsidies for children, eradication of wasteful public spending and getting U.S. military bases off Okinawa, the tiny southern island that holds the majority of American troops.

Add to the mix a host of smaller, new parties, and many voters find themselves confused. Surveys this week show that nearly half of would-be voters still can't make up their minds.

"I can't decide. It's hard to know exactly what we're voting for," said Hiroko Takahashi, a 51-year-old part-time worker from Machida, a city west of Tokyo, echoing the sentiments of many.

"All the candidates are speaking out ahead of the election, but I'm not so sure they'll carry out any of their promises. I'm hopeful about the new parties, but I also wonder if I should trust one of the older parties," she said.

If no single party wins the majority in the 480-seat lower house, the more powerful assembly in parliament, a coalition government would be formed. With so many fledgling parties, a few, no matter how tiny, may end up wielding considerable clout, getting wooed to join a coalition government.

"It's after the election that action is expected, with all the small parties, as though the dice will be rolled all over again," said Tetsuro Kato, professor of political science at Waseda University in Tokyo.

Kato and other experts say the convoluted state of politics reflects a Japan striving for direction as it comes to terms with the recognition that its go-go growth years are over, its future increasingly overshadowed by China.

The new party with the most momentum, and one that could be part of the coalition government, is the Japan Restoration Party, led by Tokyo Gov. Shintaro Ishihara and Osaka Mayor Toru Hashimoto, pushing for a more assertive Japan and capable of flexing its military muscle in territorial disputes with China.

Two of the country's most outspoken politicians, Ishihara and Hashimoto rail against the power of bureaucrats and embrace a forceful leadership style. Supporters praise their decisiveness and vision, while critics see them as dictatorial and dangerous.

Ishihara, 80, stirred up the latest dispute with China over a cluster of islands in the East China Sea both countries claim by proposing the Tokyo government buy the islands from their private Japanese owners.

The Tomorrow Party, formed just two weeks ago, wants to phase out nuclear power within 10 years. Leader Yukiko Kada, the governor of Shiga prefecture and an environmental expert, has a clean image. But that was tainted when she linked with Ichiro Ozawa, a veteran politician with a reputation as a power broker who bolted from the ruling DPJ earlier this year.

Another new party is called Alone Now. Its founder and so far only member, Taro Yamamoto, is a movie star who became an activist after the tsunami-triggered nuclear disaster.

With all the sprouting parties, the handful of pre-election debates has been characterized by a crowded stage with each party leader fighting to sneak in a coherent sentence. That kind of chaos may very well help the Liberal Democrats return to power, analysts say.

"All the candidates are just saying what they think we want to hear," said Risa Katsuta, 20, a university student who is still undecided how she will vote. "It was either the Democrats or the LDP all this time, and so I'm interested in the Restoration Party. But is it really any good?"

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Follow Yuri Kageyama on Twitter at www.twitter.com/yurikageyama

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L.A. Reid not returning to 'X Factor' next season

NEW YORK (AP) — L.A. Reid will soon be an ex-judge on "The X Factor."

The veteran music executive is not returning to the Fox singing competition series next season, a representative for Epic Records said Thursday. Reid is currently the chairman and CEO of Epic, a division of Sony Entertainment.

Reid joined the American version of the show last year along with creator Simon Cowell. This season also boasts Britney Spears and Demi Lovato as judges. Its finale is next week.

Last year Reid left his job as chairman and CEO of Island Def Jam Music Group, where he helped launch careers for acts like Rihanna and Justin Bieber. At Epic, his roster includes Sade, Fiona Apple, Karmin, Ciara and "X Factor" season one winner Melanie Amaro.

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Study: People worldwide living longer, but sicker

LONDON (AP) — Nearly everywhere around the world, people are living longer and fewer children are dying. But increasingly, people are grappling with the diseases and disabilities of modern life, according to the most expansive global look so far at life expectancy and the biggest health threats.

The last comprehensive study was in 1990 and the top health problem then was the death of children under 5 — more than 10 million each year. Since then, campaigns to vaccinate kids against diseases like polio and measles have reduced the number of children dying to about 7 million.

Malnutrition was once the main health threat for children. Now, everywhere except Africa, they are much more likely to overeat than to starve.

With more children surviving, chronic illnesses and disabilities that strike later in life are taking a bigger toll, the research said. High blood pressure has become the leading health risk worldwide, followed by smoking and alcohol.

"The biggest contributor to the global health burden isn't premature (deaths), but chronic diseases, injuries, mental health conditions and all the bone and joint diseases," said one of the study leaders, Christopher Murray, director of the Institute of Health Metrics and Evaluation at the University of Washington.

In developed countries, such conditions now account for more than half of the health problems, fueled by an aging population. While life expectancy is climbing nearly everywhere, so too are the number of years people will live with things like vision or hearing loss and mental health issues like depression.

The research appears in seven papers published online Thursday by the journal Lancet. More than 480 researchers in 50 countries gathered data up to 2010 from surveys, censuses and past studies. They used statistical modeling to fill in the gaps for countries with little information. The series was mainly paid for by the Bill & Melinda Gates Foundation.

As in 1990, Japan topped the life expectancy list in 2010, with 79 for men and 86 for women. In the U.S. that year, life expectancy for men was 76 and for women, 81.

The research found wide variations in what's killing people around the world. Some of the most striking findings highlighted by the researchers: — Homicide is the No. 3 killer of men in Latin America; it ranks 20th worldwide. In the U.S., it is the 21st cause of death in men, and in Western Europe, 57th.

— While suicide ranks globally as the 21st leading killer, it is as high as the ninth top cause of death in women across Asia's "suicide belt," from India to China. Suicide ranks 14th in North America and 15th in Western Europe.

— In people aged 15-49, diabetes is a bigger killer in Africa than in Western Europe (8.8 deaths versus 1 death per 100,000).

— Central and Southeast Asia have the highest rates of fatal stroke in young adults at about 15 cases per 100,000 deaths. In North America, the rate is about 3 per 100,000.

Globally, heart disease and stroke remain the top killers. Reflecting an older population, lung cancer moved to the 5th cause of death globally, while other cancers including those of the liver, stomach and colon are also in the top 20. AIDS jumped from the 35th cause of death in 1990 to the sixth leading cause two decades later.

While chronic diseases are killing more people nearly everywhere, the overall trend is the opposite in Africa, where illnesses like AIDS, malaria and tuberculosis are still major threats. And experts warn again shifting too much of the focus away from those ailments.

"It's the nature of infectious disease epidemics that if you turn away from them, they will crop right back up," said Jennifer Cohn, a medical coordinator at Doctors Without Borders.

Still, she acknowledged the need to address the surge of other health problems across Africa. Cohn said the agency was considering ways to treat things like heart disease and diabetes. "The way we treat HIV could be a good model for chronic care," she said.

Others said more concrete information is needed before making any big changes to public health policies.

"We have to take this data with some grains of salt," said Sandy Cairncross, an epidemiologist at the London School of Hygiene and Tropical Medicine.

He said the information in some of the Lancet research was too thin and didn't fully consider all the relevant health risk factors.

"We're getting a better picture, but it's still incomplete," he said.

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Online:

www.lancet.com

http://healthmetricsandevaluation.org

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With Rice withdrawing, Kerry may get call

WASHINGTON (AP) — Susan Rice, the embattled U.N. ambassador, abruptly withdrew from consideration to be the next secretary of state on Thursday after a bitter, weekslong standoff with Republican senators who declared they would fight to defeat her nomination.

The reluctant announcement makes Massachusetts Sen. John Kerry the likely choice to be the nation's next top diplomat when Hillary Rodham Clinton departs soon. Rice withdrew when it became clear her political troubles were not going away, and support inside the White House for her potential nomination had been waning in recent days, administration officials said.

In another major part of the upcoming Cabinet shake-up for President Barack Obama's second term, former Republican Sen. Chuck Hagel of Nebraska now is seen as the front-runner to be defense secretary, with official word expected as soon as next week.

For the newly re-elected president, Rice's withdrawal was a sharp political setback and a sign of the difficulties Obama faces in a time of divided and divisive government. Already, he had been privately weighing whether picking Rice would cost him political capital he would need on later votes.

When Rice ended the embarrassment by stepping aside, Obama used the occasion to criticize Republicans who were adamantly opposed to her possible nomination.

"While I deeply regret the unfair and misleading attacks on Susan Rice in recent weeks, her decision demonstrates the strength of her character," he said.

"I am saddened we have reached this point," Rice said.

Obama made clear she would remain in his inner circle, saying he was grateful she would stay as "our ambassador at the United Nations and a key member of my Cabinet and national security team." Rice, too, said in her letter she would be staying.

Clinton, in a brief statement, said that Rice had "been an indispensable partner over the past four years" and that she was confident "that she will continue to represent the United States with strength and skill."

Rice had become the face of the bungled administration account of what happened in Benghazi, Libya, on Sept. 11, 2012 when four Americans, including the U.S. ambassador to Libya, were killed in what is now known to have been a terrorist attack.

Obama had defiantly declared he would chose her for secretary of state regardless of the political criticism, if he wanted, but such a choice could have gotten his second term off to a turbulent start with Capitol Hill.

In a letter to Obama, Rice said she was convinced the confirmation process would be "lengthy, disruptive and costly." The letter was part of a media rollout aimed at upholding her reputation. It included an NBC News interview in which she said her withdrawal "was the best thing for our country."

"Those of you who know me know that I'm a fighter, but not at the cost of what's right for our country," she tweeted later.

Rice may end up close to Obama's side in another way, as his national security adviser should Tom Donilon move on to another position, though that is not expected imminently. The security adviser position would not require Senate confirmation.

Rice would have faced strong opposition from Senate Republicans who challenged her much-maligned televised comments about the cause of the deadly raid on the U.S. Consulate in Benghazi, Libya.

Her efforts to satisfy Sens. John McCain, Lindsey Graham, Kelly Ayotte and Susan Collins in unusual, private sessions on Capitol Hill fell short. The Republicans emerged from the meetings still expressing doubts about her qualifications.

"The position of secretary of state should never be politicized," Rice said. "As someone who grew up in an era of comparative bipartisanship and as a sitting U.S national security official who has served in two U.S. administrations, I am saddened that we have reached this point."

Attention now shifts to Kerry, who came close to winning the presidency in 2004 and has been seen as desiring the State job. In a statement, he made no mention of his own candidacy but praised Rice, who was an adviser to him his in his presidential bid.

Kerry was an early backer of Obama and was under consideration to become his first secretary of state. Obama has dispatched Kerry to foreign hot spots on his behalf. Kerry played the role of Republican Mitt Romney during Obama's presidential debate preparations this year.

The longtime senator would be almost certain to be easily confirmed by his colleagues on Capitol Hill.

If Obama taps Kerry for State, the president will create a potential problem for Democrats by opening a Senate seat — one that recently defeated Republican Sen. Scott Brown is eyeing. Brown had been elected as Massachusetts' other senator in January 2010 after Democrat Ted Kennedy died, stunning the political world as he took the seat held by Kennedy for decades. Brown lost that seat in the November election.

House Democratic women had cast the criticism of Rice as sexist and racist — she is African-American — and some expressed disappointment with the news.

"If judged fairly based solely on her qualifications for the job, she would've made an extraordinary secretary of state," said Rep. Karen Bass, D-Calif., a member of the House Foreign Affairs Committee.

Rice did not have a strong relationship with members of the Senate. Graham, who is the top Republican on the Appropriations subcommittee that handles foreign aid and the State Department, said he barely knew her.

In a brief statement, a spokesman for McCain said the senator "thanks Ambassador Rice for her service to the country and wishes her well. He will continue to seek all the facts surrounding the attack on our consulate in Benghazi."

Rice's decision comes ahead of the anticipated release next week of a report by an Accountability Review Board into the attack on the Benghazi mission. The report ordered by Clinton, focuses on the run-up to and the actual attack and is not expected to mention Rice's role in its aftermath.

Clinton is to testify about the report before Congress next Thursday.

At issue is the explanation Rice offered in a series of talk show appearances five days after the attack in Libya.

Rice has conceded in private meetings with lawmakers that her initial account — that a spontaneous demonstration over an anti-Muslim video produced in the U.S. triggered the attack — was wrong, but she has insisted she was not trying to mislead the American people. Information for her account was provided by intelligence officials.

She reasserted that position in an opinion piece published late Thursday on The Washington Post's website, adding, "In recent weeks, new lines of attack have been raised to malign my character and my career. Even before I was nominated for any new position, a steady drip of manufactured charges painted a wholly false picture of me. This has interfered increasingly with my work on behalf of the United States at the United Nations and with America's agenda."

Hagel, a former Republican senator from Nebraska, is a Vietnam veteran, served two terms in the Senate and was a senior member of the Foreign Relations Committee. Obama and Hagel became close while they served in the Senate and traveled overseas together. Hagel has been critical of his party since leaving the Senate in 2008, saying the GOP had moved too far right.

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Associated Press writers Donna Cassata, Ken Thomas, Matthew Lee and Matthew Daly contributed to this story.

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NKorea policy in Seoul to soften despite rocket

SEOUL, South Korea (AP) — It is not too early to predict one sure winner of South Korea's presidential election next week: North Korea. President Lee Myung-bak's hardline approach to Pyongyang is going away, no matter who replaces him.

The question is: Just how soft will Seoul go?

Not even Pyongyang's successful launch of a long-range rocket Wednesday has changed the determination of both the liberal and conservative candidates in South Korea to pursue policies of engagement, aid and reconciliation with the North.

This matters because whoever wins the presidential Blue House on Dec. 19 will set the initial tone for new North Korea policy not just in Seoul but in Washington, Beijing and Tokyo. Those countries are undergoing political changes and have been waiting for a new South Korean leader before making any big decisions on North Korea policy.

Washington, especially, is keen to see who will take over when Lee leaves in February. U.S. policy toughened after the embarrassing collapse of an aid-for-nuclear-freeze deal with Pyongyang following a failed April rocket launch attempt by North Korea. However, barring more rocket or nuclear tests from Pyongyang or other acts Washington considers provocative, a new thaw on the Korean Peninsula could eventually provide Barack Obama with a cover to pursue more talks meant to encourage North Korean nuclear disarmament.

The need for more dialogue and aid for Pyongyang is one of the few things the South Korean candidates — conservative Park Geun-hye and liberal Moon Jae-in — agree on.

Many South Koreans are frustrated with Lee's efforts on North Korea. His policy links large-scale government aid to North Korea making progress on past commitments to abandon its nuclear ambitions. Instead of disarmament progress, though, the last five years have seen nuclear and missile tests — including Wednesday's rocket launch — deadly skirmishes and all-around simmering nastiness between the rival Koreas.

Park and Lee are members of the same conservative political party, so her comments on greater engagement and aid have been striking. They also stand out because Park is the daughter of Park Chung-hee, South Korea's late anti-communist dictator.

While Park's rhetoric on North Korea has hardened after Wednesday's launch, there's no plan to change her underlying policy, her aides say: She still envisions aid shipments, talks meant to spur reconciliation and the restart of some large-scale economic initiatives as progress occurs on the nuclear issue. The aid would be goods that can't be used for military purposes.

Park has also held out the possibility of a meeting with North Korean leader Kim Jong Un, but only if it's "an honest dialogue on issues of mutual concern." She'll also push for progress on nuclear disarmament, human rights and other sensitive issues and says North Korea will pay the price for any provocations.

Her North Korea policy is seen as thin on specifics, however, and there could be limits to her outreach. Many in Park's political party and conservative base have strong anti-North Korea feelings that could be an impediment if she pushes ahead with serious talks.

Moon, on the other hand, intends to quickly resume shipments of government-level food aid to North Korea, though details of how much aid would be worked out if he wins, aides say. He also wants an early summit with North Korea's Kim. His policy isn't influenced by the latest rocket launch, his aides say.

Moon is a protege of the late liberal President Roh Moo-hyun, a champion of the so-called "sunshine policy" of no-strings-attached aid to Pyongyang. Lee replaced Roh in early 2008.

For Moon, aggressive engagement isn't a reward for North Korean nuclear movement; it's the means to transforming the relationship so that "North Korea has an economic stake in a more moderate foreign policy and eventually has even an economic stake in denuclearization," said John Delury, a North Korea analyst at Seoul's Yonsei University.

Moon's candidacy has some in Washington worried about the return of the tension and anti-U.S. feelings that marked Roh's term — that "the ghosts of the anti-Americanism of the South Korean left will rise again," according to Delury.

The North's rocket launch was magnified because of its timing. Obama will be inaugurated in January to his second term, Japan and South Korea both have national elections this month, and China has just formed a new leadership. But the test is probably not going to "blunt South Korea's desire for renewed inter-Korean dialogue as a necessary step toward stabilizing peninsular relations," Scott Snyder, a Koreas specialist for the Council on Foreign Relations, wrote recently.

The Obama administration has consistently emphasized its solidarity with Seoul, and that rhetoric is unlikely to change, whoever is elected.

A rocket launch could actually "solve any alliance split problems" between Washington and either of the South Korean candidates by forcing a more unified stance, said Victor Cha, a former senior Asia adviser in President George W. Bush's administration.

Washington could also be willing to give either Park or Moon some leeway in reaching out to North Korea if it leads to movement on nuclear disarmament, the issue the United States cares most about. During a November visit to Myanmar, Obama said a decision by North Korea to give up its nuclear aspirations would result in "an extended hand" from the United States.

"A more flexible policy from Seoul also gives the Obama administration more political cover to try another overture toward the North," said Ralph Cossa, president of Pacific Forum CSIS, a Hawaii-based think tank.

Much will come down to the way North Korea treats the new South Korean leader. Pyongyang may expect, for instance, Moon to deliver everything his liberal predecessors promised, something seen as impossible in the current political environment. Pyongyang could also dismiss Park's attempts at engagement, dooming talks before they begin. North Korean media routinely criticize Park's North Korea policy as insincere and confrontational.

North Korea considers the United States, against which it fought during the 1950-53 Korean War, a major enemy. Seoul, on the other hand, is labeled a puppet of Washington, which has more than 28,000 soldiers stationed in South Korea.

"At the end of the day," Cossa said, "it will be the North's willingness, or not, to treat the South as a sovereign equal that will make meaningful dialogue possible, regardless of who is elected."

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Associated Press writer Hyung-jin Kim contributed to this report.

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