For its work in Pakistan, Médecins Sans Frontières does not accept funding from any government or donor agency, and relies solely on donations from the general public.

As fighting continues in certain areas of Pakistan's North West Frontier Province (NWFP) and tribal zones, access to medical care for the war affected population is practically non-existent. In Swat, an estimated 80 percent of health facilities are not functioning due to lack of medical personnel and supplies, but also because health centres have been destroyed, according to reports coming from the region. Curfews and continued violence make it very difficult for patients to travel to the few functioning hospitals in Swat, or to hospitals outside the district.

However some war wounded civilians are managing to travel to Timurgara Hospital, the district referral hospital in Lower Dir. An MSF medical team has been treating patients in the emergency room and providing medicines and medical materials here since March.

"Last week, when I was in Timurgara, 10 war wounded patients from Swat, including four children, arrived at the emergency room on the same day," said Stefan Van Der Mussele, medical supervisor for the MSF programme in Lower Dir.

"The injuries were caused either by bullets or explosions. Two brothers aged five and six were both wounded, one of them was unconscious with a neck and head injury. They came with three women who were also wounded. In the resuscitation room, there was no hope for a man who was dying from a severe head injury and had lost part of his brain. In the same room, an eight year old boy received treatment for his wounds, while his father stood by his side, covered in the boy's blood, trying to be strong in order to help his son."

Since June, the MSF medical team working in the emergency room has been treating an average 700 patients each week for a variety of ailments. MSF has treated 159 war wounded patients since April 26. Patients needing surgery are stabilised and then transferred to the surgical department where Ministry of Health surgeons are working.

Relaxation of curfews is allowing more patients to arrive in Timurgara.

"Initially, the war wounded from Swat arriving in Timurgara were travelling through the hills in order to avoid the main roads during curfews. One patient arrived with his intestines hanging out. He had been brought like this by his family, and managed to survive," explained Stefan. "Patients are now arriving by the main roads, and are sometimes transported by ambulance."

Wounded are also arriving from the Maidan area of Lower Dir, around 30 km north of Timurgara. With few functional health structures in the area, and no hospital with surgical capacity, people must make it to the district hospital for proper treatment. Families fleeing the violence in Maidan have been settling in camps, unused buildings and with resident families in the southern areas of Lower Dir district. Widespread insecurity throughout the region is affecting MSF's ability to assist the population.

"Though families displaced by fighting are finding refuge in the area and some of the war wounded are arriving at the hospital, this zone remains highly unstable, situated only a few kilometres from the war zone," said Gael Hankenne, MSF head of mission in Pakistan. "This, coupled with general insecurity in the province, greatly limits the number of teams and programmes we are able to run to assist the population and strengthen local hospitals. It is vital that actors in the conflict facilitate the evacuation of wounded and sick to functioning medical facilities."

Since August 2008, MSF has been working in two camps hosting 6,000 displaced people in Lower Dir. Sammar Bagh camp and Sadbar Kallay camp were initially set up to accommodate families who fled fighting in Bajaur Agency. Since May this year, most of the displaced people from Bajaur have left the camps and have been replaced by families escaping violence in Maidan.

MSF has provided shelter, relief items and is managing the water supply and the sanitation system in the camps. Outpatient consultations are carried out by MSF in Sammar Bagh camp and by the local health authorities in Sadbar Kallay. However, for the past three months, MSF presence has been greatly reduced by insecurity.