Poverty, war, HIV affect over 1 billion children, UNICEF says

PRETORIA -- More than 1 billion children suffer from poverty, war, and HIV/AIDS, a new UNICEF report says, indicating that gains in reducing child deaths in the 1980s and '90s have stalled in the past decade.

According to the report, being released today, one in three children in developing countries lives without adequate shelter, one in five has no access to clean water, and one in seven lacks access to health services.

It also left no doubt about the epicenter of the problem: 26 of the 27 countries with the highest child-mortality rates were in Africa. Only Afghanistan, the fourth-worst, was outside the region. The world's most deadly place for a child, Sierra Leone, recorded nearly three children in 10 dying before their 5th birthday.

The report is the UN agency's 10th annual overview of the world's children and the last produced under the 10-year leadership of executive director Carol Bellamy, who steps down next year. She acknowledged that the recent trends are disappointing.

''I'm not proud that the world is not a better place today than it was 10 years ago in regard to children," she said by telephone from Nairobi. ''But I also don't think it is all our fault."

She said the blame mostly rested with countries that failed to properly fight the AIDS pandemic and pervasive poverty and to prevent armed conflicts. Fifty-nine wars were fought around the globe between 1990 and 2003, and of the world's 20 poorest countries, 16 suffered a major conflict in the past 15 years.

But some critics of Bellamy's tenure said the latest report was full of evidence that she had failed to emphasize childhood survival. They cited a reduction by UNICEF in funding immunizations as well as Bellamy's focus on children's rights, which they said detracted from finding ways of reducing child deaths.

''The right to survival is the most critical right for a child," said Dr. Robert E. Black, chairman of international health at the School of Public Health at Johns Hopkins University. ''If we can't put our focus on that, how meaningful is the rest of the discussion on child rights?"

An estimated 10.5 million children under 5 die every year, equal to the number of children under 5 living today in France, Germany, Greece, and Italy. A group headed by Black found this year that half of the deaths occur in just six countries -- India, Nigeria, China, Pakistan, the Democratic Republic of Congo, and Ethiopia -- and said that more than 60 percent of the deaths were easily preventable.

The researchers, in findings published in the medical journal The Lancet, estimated that in the 42 countries accounting for the vast bulk of the deaths, about 80 percent of children did not receive oral rehydration therapy to fight life-threatening diarrhea; 61 percent were not exclusively breast-fed, weakening the infants' ability to fight off infections; and 60 percent did not receive simple antibiotic treatment for pneumonia, the single largest killer of young children.

Lancet editor Richard Horton, in a commentary published in the journal last week, echoed Black's criticism. ''It is widely, if regrettably, accepted that UNICEF has lost its way during Carol Bellamy's long term of office," he wrote.

The UNICEF report, titled ''Childhood Under Threat," compared child mortality figures in 1990 and 2003, the latest year for which estimates were available. In sub-Saharan Africa, it found that child deaths had declined at an annual rate of 0.6 percent -- from 188 deaths for children under 5 per 1,000 births to 175 deaths. In comparison, the under-5 mortality rate for children in industrialized countries fell from 10 deaths per 1,000 births in 1990, to six deaths in 2003 -- a 3.9 percent annual reduction.

Fifteen countries, according to UNICEF figures, registered increases in child deaths from 1990 to 2003, and 12 remained at high levels.

Bellamy defended her priorities over the past decade, saying she was ''proud we have embraced a child's rights approach, advocating that children not be seen as charitable instruments, if you will, but human beings that have rights. I'm also proud UNICEF has taken on sensitive issues such as child soldiers . . . and the trafficking of children."

She insisted that child survival is a top UNICEF priority.

''Child rights has not been a diversion from survival," she said. ''The rights of a child are not only to survive, but to thrive, not to become a victim of HIV/AIDS, not to be exploited, not to be abused. The world doesn't stop at simple survival."

Bellamy has supporters for that view. Mark L. Rosenberg, executive director of the Task Force for Child Survival and Development, created in the mid-1980s to coordinate efforts toward reducing child deaths, said there is not ''such a dichotomy between focusing on the rights of child and childhood survival."

But Rosenberg said by telephone from Atlanta that Bellamy's successor should develop closer relationships with other UN groups, especially the World Health Organization, as well as the US government and major philanthropic institutions, such as the Bill & Melinda Gates Foundation and the Rockefeller Foundation.

Rosenberg also said one big challenge ahead was tackling complex problems. In Bangladesh, he noted, drownings were the biggest childhood killer; one reaction, he said, should be to outlaw housing developments near irrigation ditches.

Injuries, especially from road accidents, also kill many children. Rosenberg said the responses should be to encourage wearing seat belts; to separate pedestrians from moving traffic; and to separate people on bicycles and ox-driven carts from cars, trucks, and buses.

Nils Daulaire, executive director of the independent Global Health Council, the world's largest consortium of health groups, said the new UNICEF director also could reduce deaths by doing a better job at expanding things that already work. Bellamy's successor has not been named.

''We're not talking about inventing new things," Daulaire said. ''We're talking about getting stuff we know out to the people who need them."

Benefits, he said, would extend to improving the health of hundreds of millions of children. ''The main impact will be the much larger number of children who enter school with their minds and bodies in good shape," he said.

John Donnelly can be reached at donnelly@globe.com