Pakistan was convulsed by intense violence throughout 2009. Conflict between the Pakistani army and armed opposition groups in the North-West Frontier Province (NWFP) and in the Federally Administered Tribal Areas (FATA) displaced more than two million people, while numerous bombings in major Pakistani cities killed hundreds and injured thousands. In the province of Balochistan, a long-running conflict continued beyond the media’s glare. Across the country, people suffer from a general lack of health care, and Pakistan features one of the highest infant and maternal mortality rates in the region.
Difficult living conditions in Pakistan’s more remote regions were made even worse by the violence, which has escalated over the last two years. Insecurity and travel restrictions limit the provision of medical services to people most in need. MSF was unable to provide medical support during fighting in Kurram, Swat, and South Waziristan.
Intensifying violence in NWFP’s Swat Valley forced MSF to suspend emergency activities there in April. It had been the only international organization with a permanent international team supporting the hospital in the town of Mingora and providing ambulance services in the region. Earlier, in February, two MSF medical workers—Riaz Ahmad and Nasar Ali—were shot and killed while driving in a marked ambulance en route to retrieve civilians injured in fighting in the town of Charbagh. While more than one million people reportedly fled a government offensive in May against Swat-based militants, many others remained trapped, caught in crossfire, or immobilized by curfews. They were unable to access food, water, and medical care.
As civilians continued to flee Swat and Buner and pour into other parts of NWFP, most settled with resident families. Providing assistance was extremely challenging because of difficulties in accessing insecure areas and identifying those who sought refuge in the major cities, although MSF managed to assist many people who sought refuge in schools, community centers, and private homes. Some displaced were sheltered in over two dozen improvised camps set up by the Pakistani government. MSF set up camps for thousands of people in Mardan and Lower Dir. Many people suffered from heat exhaustion and cholera.
Before many people began returning home in late summer, thousands were treated by MSF in hospitals, health clinics, and in displacement camps in Mardan District, Malakand District, Peshawar, and Lower Dir. But hospitals were still overwhelmed. Many patients in Lower Dir suffered from serious war-related injuries, among them children with gunshot- and explosive-related wounds. By the end of October, the Pakistani army reopened a front against militants in Bajaur Agency, leading to renewed flight of most of the local population towards Lower Dir. MSF assists 1,500 of these families.
In mid-October, the Pakistani army attacked militants entrenched in South Waziristan, a vast mountainous district in FATA straddling the border with Afghanistan. Up to 300,000 people reportedly fled towards the neighboring district of Dera Ismael Khan. While MSF teams identified significant needs in the district’s main hospitals, authorities were still refusing to authorize the presence of international staff there by year’s end. Fighting in FATA’s Kurram Agency has led to the near-collapse of the health system there. Since 2004, MSF has been working in Kurram and since 2006 has offered outpatient pediatric and maternal healthcare services in Sadda and Alizai. Since December there has been an acute intensification of fighting, leading thousands to be displaced. A daily curfew only allows the population to reach the hospital in Saada a couple of hours a day, greatly reducing access to treatment. For the second time within six months, a rocket landed on Sadda hospital on December 9. MSF called all parties involved in the conflict to respect the safety of the hospital in order to guarantee access to safe treatment to the patients in need of medical care.
Conflict and suffering also continued in Balochistan, where residents have long been neglected and marginalized. The eastern region’s health-care capacity is minimal at best; infant and maternal mortality rates are very high. Up to end of November 2009, MSF treated more than 3,509 malnourished children in its emergency feeding program. On the western side of Balochistan, MSF provided health care to Afghan refugees and many Baloch people near Quetta and the Afghan border, and supported mother and child healthcare, with between 100 and 150 babies delivered each month.
In a region where western powers involved in counterinsurgency operations are also major donors, the provision of humanitarian aid has largely been linked with political objectives. As in all conflict zones, MSF, an international, private medical organization independent of political, religious, and economic objectives, disassociates itself from these policies. In Pakistan, MSF does not accept funding from any government, relying solely on private donations from the general public.