ISLAMABAD - By the time Tasneem Bibi brought her four-month-old baby to the clinic, the girl's lower body was blue with cold.
The family had walked two hours through snow-covered mountains along the Afghan border to reach a road, then paid almost $40 - nearly a month's income - for a lift to a clinic many miles away.
The baby was diagnosed with hypothermia. She died a few hours later.
Already enduring frequent attacks on militants by US drone aircraft, a Taliban insurgency, sectarian violence and poverty, Pakistanis in the remote northwest face a new enemy: an unusually bitter winter.
A growing number of cases of pneumonia, hypothermia and other winter illnesses are stretching the few health facilities, says medical charity Medecins Sans Frontieres (MSF), or Doctors Without Borders.
Tasneem Bibi's daughter died at Tehsil Headquarters Hospital in Sadda town, where Dr Rahman Sakhi says cases of hypothermia and pneumonia are up about 15 percent from last year.
The hospital treated 3,300 patients in January, 80 percent of them for winter-related illnesses.
"Drone attacks and Taliban violence get all the attention while people are struggling through this exceptionally harsh winter with little access to healthcare," said Dr Javed Ali, the country coordinator for MSF.
Some residents of the semi-autonomous region, known as the Federally Administered Tribal Areas, complain that they have been neglected by governments since Pakistan was created in 1947, making its poor residents ideal recruits for militants. "These are difficult areas, you have to understand," said Riaz Khan, the head of the political administration in Kurram agency, one of seven regions, known as agencies.
"We have our own hospitals and clinics and we also work closely with foreign groups and do what we can."
He said he did not have figures for deaths this winter.
Government reports on demographics, health and living standards ignore the tribal areas. Most statistics come from international donors.
Unicef says mortality rates for children under five are 104 per 1,000 in the tribal areas compared with 94 in Punjab, the most developed province. The figures are from 2009, the latest available.
Deaths are difficult to verify independently. Foreign journalists are banned from the areas without permits and the government controls access by international aid groups.
In the last week, Reuters gained rare insight into the state of healthcare in the area by interviewing several patients, doctors and nurses at MSF's facilities.
All said this winter had been exceptionally hard. In December and January, MSF reported 28 deaths of children under the age of five in the region - almost double the figure from last year. Most died of hypothermia and pneumonia.
Years of conflict and displacement have led to the near-collapse of healthcare. Few doctors and technical staff will work in the region.
Snow and landslides often block roads to hospitals. Most sick people see traditional healers or go to pharmacists for generic medicines. The desperate may travel miles on foot or scrape together the fare for a taxi to hospital.
Often, they are too late.
Sumaiya Bibi, 17, cries down the telephone speaking about her 17-day-old boy diagnosed with hypothermia.
"I am tired of hearing his anguished cries," the mother says from the northwestern town of Hangu. "I didn't have the money to rent a private car so I waited to find a cheap bus. I hope I'm not too late."
Things are particularly bad in Kurram agency, racked by sectarian violence between Sunni and Shi'ite tribes and a 2009 army offensive to flush out Taliban.
The offensive ended in 2011 but clashes are common and many people need medical care.
"This area is remote. The terrain is hard. There is a security crisis. If only there was one problem," said Dr Sakhi from Kurram. "We need emergency wards within a 20 km radius. We need pharmacies. We need a health policy."