Pakistan: In a valley marked by conflict, one clinic offers critical support to thousands returning to damaged homes
After more than a decade of being displaced from their homes by conflict, people have been returning to Tirah Valley, a mountainous area in the northwest of Pakistan’s Khyber Pakhtunkhwa province, near the Afghan border. Families have been returning to the valley since 2022, encountering their damaged homes, facing a lack of basic services, and seeing little sign of the support they had been promised for rebuilding their lives. A Médecins Sans Frontières (MSF) team has been caring for the returning communities, operating a clinic in Tirah since May 2022.
Until the early 2000s, Tirah, in the region formerly known as Federally Administered Tribal Areas (FATA), experienced relative stability. However, the situation shifted dramatically in the aftermath of the September 11 attacks and the subsequent US-led war in Afghanistan. The area soon became the scene of prolonged conflict from clashes between armed groups to conflict between state forces and various armed groups, including Tehrik-i-Taliban Pakistan, Lashkar-e-Islam, and Ansar-ul-Islam. From 2009 onwards, military operations by the Pakistan Armed Forces against the armed groups led to the mass displacement of thousands of people.
As security situation improved, families have been returning to Tirah since 2022, yet hardship persists: electricity, schools, transport, markets, health centres and communications remain scarce, with most areas still lacking mobile or landline coverage. Communities are steadily trying to rebuild, even as violence and clashes between security forces and armed groups continue to affect the region, and government services are still limited.
Dost Muhammad is nearly 80 years old, and starting over seems impossible to him. He now lives in a tent, not by choice, but because his home was lost during the conflict. “Our businesses were destroyed, and there is no real livelihood here,” he says. “Before our displacement, we had a booming trade with Afghanistan. Now, there is nothing left. Our homes were destroyed, and we don’t have the means to rebuild. We have no income, and we haven’t received the promised financial compensation [for damaged houses] yet.”
In May 2022, MSF opened a clinic for people who have returned to Tirah. The single-storey facility serves as the closest thing to a hospital for this remote community. It offers general healthcare, emergency care, referral services, as well as maternal and childcare.
In 2024, MSF staff provided 40,000 outpatient consultations at the clinic, an increase from 26,000 the year before. This surge shows three things: the steady return of displaced families, awareness of MSF services in the community, and improved access to the clinic after more roads were built. During a summer day, staff can treat up to 170 patients.
“The patterns are predictable,” says Yousaf Ali, MSF’s medical activity manager. “In winter, we see respiratory infections; in summer, it’s malaria, diarrhoea, and skin diseases, like scabies” -conditions commonly occurring in areas with inadequate living conditions.
“My child has scabies,” says a woman during a visit to the clinic. “This clinic gives us free tests and medicines. Elsewhere, even if you find a doctor, there’s nowhere to get medicines. I’ve seen mothers lose children to diarrhoea on the long journey to a city hospital. This clinic is a relief. We don’t want it to leave.”
The journey to the clinic can be treacherous for people from far-away villages, who need to travel along mountains. Most arrive on foot; others are carried on a relative’s shoulder or whatever transport is available.
“If we can’t carry them, we beg a donkey, these days even donkeys refuse to move,” says Dost Muhammad. Jan Akbar, a diabetic patient, puts it plainly: “Before this clinic, even for a minor treatment, we spent 9,000 rupees (Rs) just on travel [to reach a hospital]. It was unbearable for us.” In an area where it is difficult to make a living, Rs 9,000, which is equivalent to about US$30, is a huge sum.
While not equipped for advanced care, our clinic has seen people in need of emergency medical care. “We sometimes receive patients requiring emergency care, often in the middle of the night,” says Sajjad Khan, MSF’s project coordinator assistant. He recalls a recent case when a man with severe injury was losing blood rapidly. “We stabilised him and referred him to Peshawar’s tertiary care hospital in a ‘rescue 1122’ ambulance [state-run emergency ambulance service]. The odds were against him, but he survived.”
Women in Tirah face additional barriers, not least because of the lack of female healthcare staff in the area. “We just hope for more female doctors and a gynaecology unit around here,” says Hashmat, a woman patient.
“No one should have to walk for hours across mountain tracks just to see a doctor,” says Vangelis Orfanoudakis, MSF’s country representative in Pakistan. “A clinic may be basic, but this one has become a reliable anchor for thousands of people returning, showing the need for more health facilities to open in the region in the future.” “Here, a health facility is a lifeline in a hard place,” says Orfanoudakis.
Hannah Hoexter