Increasing violence in Pakistan's Northwest Frontier Province (NWFP) and in some of the Federally Administered Tribal Areas (FATA), where Médecins Sans Frontières (MSF) works, has made access to health care extremely difficult for residents while needs have risen dramatically.

MSF, which is one of the few international humanitarian medical organisations in these regions, reports that civilians are regularly the victims of violence but often cannot reach a hospital. When those who do arrive at the health facilities need to be referred to another hospital for more specialised care, the violence makes it difficult to do so.

"This is an undeclared war with civilians caught in the crossfire," said Fasil Tezera, MSF Head of Mission. "The conflict has caused a lot of suffering. We see many war wounded. The needs are obvious."

Fighting between the Pakistani Army and armed militant groups for control of the area has intensified over the last year and become even worse in recent months. United States military air strikes in the area have also increased insecurity.

Security for MSF staff is a growing problem. MSF ambulances have been attacked and MSF teams have regularly sought refuge from the fighting. There is an increasing concern that humanitarian workers will be targeted or attacked.

Despite the many challenges, MSF maintains a number of projects to provide desperately needed medical assistance in the region.

Surge in violence

Violence in Swat, a once peaceful district in the NWFP, has surged in the last year as the Pakistan military has been battling to regain the control of the mountainous region from the militants.

Regular bombardments, suicide attacks and long curfews have caused heavy civilian causalities, drastically reduced movement and severely disrupted daily life. Residents, many of whom have been subjected to violent trauma, are finding access to health centres very difficult.

MSF, working in the area since November 2007, is providing primary health care and ambulance services and distributing basic relief items such as food, hygiene kits and shelter material to the displaced.

MSF is continuing to work in the most affected areas in Swat - Kabal and Matta - but growing violence is making it increasingly difficult and dangerous to provide assistance in the region.

MSF continues to run an ambulance service, which works throughout the region and brings patients safely to the hospital; many are pregnant women. During the prolonged curfew hours imposed by the military, MSF ambulances are the only vehicles allowed to move, apart from a local charity ambulance.

When militants blew up a power station in Mingora in October 2008 and disrupted the water system - which spurred a serious cholera outbreak - MSF provided three mobile generators and a water treatment unit so clean water would be available. It also opened a cholera treatment centre and treated thousands of patients.

"These kinds of attacks show how vulnerable the people are," said Tezera.

Together with volunteer doctors from a local non-governmental organisation, the Swat Doctors Society, MSF is running mobile clinics in five different locations in Upper Swat. About 4,000 consultations are carried out each month.

"Partnerships with local doctors and organisations are vital to our work in Pakistan," said Tezera. "We could not have done this work without the help of the Swat Doctors Society and other local community-based organisations. We need more people to do this work."

MSF is working to train local doctors and medical staff so they can better assist victims of violence and disease.

"We are providing ongoing training, and building the capacity of local doctors to respond to emergencies," Tezera said. "They are in the best position to respond to the growing medical needs of the communities affected by violence. They are in places in areas that MSF cannot access."

MSF is training doctors on cholera treatment and the creation of trauma treatment centres, among other issues, and helping to improve the infrastructure of local hospitals.

"In the future, we hope that more surgeries can be performed locally so we don't have to refer too many patients to Peshawar. This would be good progress towards better local care," Tezera added.