Civilians killed and forced to flee as fighting intensifies in northwestern Pakistan

The fighting between government forces and anti-government militants in the North West Frontier Province and the Federally Administered Tribal Areas of Pakistan has intensified throughout 2008.  Air strikes by United States military in the area have also increased insecurity. In August, thousands of Pakistanis were displaced within the country or fled to neighboring Afghanistan for safety. At the same time, the Pakistani army also began expelling Afghan refugees, specifically in Bajaur Agency, for alleged connections to militant groups.

Throughout the course of the year, hundreds of people in the Bajaur Agency and Swat and Mohmand regions were killed or injured in suicide bombings, air attacks, and shootings, with thousands more repeatedly uprooted from their homes.  MSF provided thousands of people with the basic materials they needed to survive: blankets, floor mats, shelter items, hygiene kits and food. MSF adapted its primary health-care programs to respond to the sharp increase in victims of violence by providing medical supplies to treat war wounded, assisting in referrals, and providing care for the treatment of watery diarrhea caused by the poor quality of water initially provided for the displaced.

As local health clinics began to close for fear of violence, MSF opened mobile clinics in partnership with local health providers, and established a clearly identifiable ambulance service to bring patients safely to hospitals. During the many curfews imposed by the military, the MSF ambulance became the only vehicle allowed to travel around, transporting 700 patients over a 5-month period - primarily women in labor and victims of violence.

In October, a spike in violence sent hundreds of thousands en masse into neighboring regions over the course of just a few days.  Fleeing air attacks and bombings, many found refuge in private homes, mosques, schools and makeshift camps.  As diarrhea broke out in camps, MSF assisted with water and sanitation while local health authorities provided basic medical care. 

In Kurram Agency, providing assistance is increasingly difficult due to ongoing sectarian violence and insecurity due to outside armed groups operating in the area. MSF's main activities have been the provision of mother and child health care, including emergency obstetric surgery and neonatal services.  Insecurity means only the most critical patients will risk traveling to reach medical services.

Security for MSF staff is a growing problem. Attacks on humanitarian aid workers are a real and increasing concern.  Already, MSF ambulances have been attacked and MSF teams have regularly sought refuge from the fighting.

In Balochistan, MSF assists Afghan refugees through support to mother and child health care near Quetta. In the border town of Chaman where health actors are struggling to provide care for the residents of the city, MSF also assists the local population and patients coming from Afghanistan by providing reproductive health care, including emergency obstetrics, neo-natal services, and nutritional support.

The eastern region of Balochistan is rich in gas reserves, but poor in health care, with an internal conflict that has been simmering for more than 30 years. An emergency feeding program for children has been started by MSF in the eastern districts of Jafarabad and Nasirabad, where in three months MSF treated more than 1,000 children for malnutrition. Besides the armed conflict, the mountainous region of northwestern Balochistan was hit by a magnitude 6.4 earthquake on October 29.  Most of the mud brick houses were destroyed with people forced to sleep out in the cold due to the damage and fear as aftershocks continued. The official death toll rose to approximately 300 people, with 35,000 injured and 40,000 left homeless. In addition to providing emergency medical support and relief supplies, MSF teams also provided mental health care for the affected communities.