The ability of people to move between government and Maoist areas - even medical patients - is restricted by the Maoist demand for written permission to move, and the ever-present army patrols.

The girl sitting opposite me had such a serious look on her face. Her forehead creased as she glanced quickly between me and my translator. She had been suspicious and hostile to the doctor and I when we had first walked into the village. She had made sure we saw the two homemade grenades strapped, bandolier-like across her chest and had tried to say she was busy with the administration of the village, but I had insisted we discuss the Maoist policy on health care and that was the catalyst the girl needed to launch into her diatribe.

For 45 minutes she droned on in Nepali. I caught words like "American Imperialists", "Comrade", "integrated plan" and again and again, "Mao". Pratiksha, the single name the party had given her, was the village commander of Litakot, a community four hours walk down the Tila River from the capital of Jumla district.

She looked to be 17 years old. The villagers stood around staring at her, elders in homespun woollen jackets and younger men in dirty jeans and polyester pullovers. Her words came in an unending flow, no one said anything while she talked; Pratiksha relaxed into the rhetoric.

This is the new face of control in rural Nepal, young, aggressive, unyielding and absolutely sure of their words.

Nepal; for tourists it's a paradise of trekking and climbing, but for Nepalis their country is now a war zone. Over the past decade, increasing political and economic instability have helped create the conditions for a Maoist insurgency, the roots of which lie in Nepal's centuries-old caste and regional inequalities. Support for the ideologies expressed by the Communist Party of Nepal-Maoist (CPN-M) have surfaced from the most economically and socially deprived areas of Nepal, notably the Mid-Western Region and it is there where the insurgency is most entrenched.

The People's War (as it is known to the Maoists) began in 1996. In the past two years over 6,000 people have been killed. Around 40% of the country is under control of the Maoists, population of between 5-7 million people.The conflict has moved from a regional skirmish to a civil war; it has consumed the nation and disrupted every facet of life. It is in this environment that MSF has launched missions in the Mid-West heartland of the war.

At first glance Nepal is not a typical MSF environment; there are literally thousands of development NGOs in the country, there are tourists in the streets of Kathmandu. The capital looks to be a city of the rich. But the Mid-west of the country is in the grip of an escalating war, and MSF's aid is needed. The majority of deaths in the war have taken place in the Mid-west and the bulk of those have occurred in the past two years . The ability of people to move between government and Maoist areas - even medical patients - is restricted by the Maoist demand for written permission to move, and the ever-present army patrols.

Tragically, health workers are often accused by the security forces of working for the Maoists, when in fact they have been compelled by the insurgents to treat their colleagues.

The import of medical supplies into the highly affected districts, and the distribution of them out to Health Posts is controlled, not by health officals, but by the Chief District Officer (CDO). The government's fear of the Maoists looting medical supplies is inhibiting the ability of the population to receive medicines. Health workers fear harassment from both sides, from the Maoists, who force them to treat their cadres anywhere, anytime, and from the security forces who, under draconian seize and interrogate laws, can hold anyone without trial for up to three months.

Tragically, health workers are often accused by the security forces of working for the Maoists, when in fact they have been compelled by the insurgents to treat their colleagues.

According to Amnesty International, Nepal has one of the highest rates of political disappearances in the world; officially over 250 have been registered since the start of the war, but unofficially people say over 500 people have disappeared for political reasons.

The Mid-west has the highest incidence of disappearances in the country. Life in the region has always been difficult, but the mounting intensity of the conflict has made it doubly so. The Mid-west is the antithesis to Kathmandu, it is an area on the edge of survival; a region where people eke an existence from a difficult land. It is a place of tension; district capitals sieged by insurgents, rural areas controlled by sometimes lawless local commanders.

The Mid-West suffers from the worst health statistics in the country and no-one seems to care. Following assessment visits to Nepal in 2002, the decision was made to start working in conflict-affected Mid-West area. In January MSF opened a primary health care project in Rukum, and my colleagues there are now providing hands-on medical support, drugs and other materials to the 20-bed district hospital as well as a network of clinics in the mountains. I arrived here six months ago to established a project in Jumla, with the aim of providing medical support to the whole district of 95,000 people.

MSF tried many times to contact higher level commanders in the Jumla district to negotiate access back into the area, but eventually this led to Dr Ricardo Aguilar, myself and two Nepali staff being held by the Maoists against our will.

However the Jumla project has been plagued with difficulties. The labyrinthine Nepali bureaucracy has stalled MSF's national registration process. The lack of legal status as an NGO has inhibited our ability to import drugs and medical equipment in the country. Logistics and human resources problems delayed the team setting up the base outside of the Jumla district capital. But most significantly the breakdown of the ceasefire between the Maoists and the government on 27 August 2003 led to the restriction by the insurgents of all NGOs working in their areas.

The primary health support structures that had initiated in the district were effectively out of touch to us. MSF tried many times to contact higher level commanders in the district to negotiate access back into the area, but eventually this led to Doctor Ricardo Aguilar, myself and two Nepali staff being held by the Maoists against our will. Threats were made - we were to be taken to the jungle for five years to treat Maoist soldiers - and eventually we were forced to sign a set of preconditions by which MSF could work in the area. We escaped by moonlight at 4am the next day.

The prerequisites we were required to acknowledge are unacceptable as they wholly limit MSF's ability to operate freely. Since the incident we have had to limit our activities to providing assistance to the health posts through a remote control system and assisting the district hospital which is in Jumla town itself. But no matter how many setbacks have occurred we continue our efforts to engage the Maoist command in discussions on the health needs of the population under their control.

In Litakot village Pratiksha's discourse came to an end. There had been little verbal space for me to lobby for MSF to improve health care in the village. Pratiksha repeated again and again how the Maoist insurgents are fighting for a People's Republic. Unfortunately to realize their goal they must destroy 3,000 years of Hindu convention and 400 years of monarchy. One of the slogans you see painted on mud-brick walls everywhere is, "Destruction before Construction."

Pratiksha stood up, grasped my hand and shook it vigorously. She looked at my translator and said something, letting slip the first smile of our meeting. He looked at me and said, "She says that when the destruction is complete, we will work hand in hand in rebuilding the new republic."

The war will continue, the health of the people will suffer, and a 17 year-old girl had closed the door to assistance yet again.