More than 50 people have been killed in heavy fighting close to the Afghan border.
Hundreds of people fled from North Waziristan, Pakistan, yesterday, clutching clothes and possessions in their arms, after battles between Pakistani security forces and Islamic militants in the streets of Miran Shah, the main town.
The dead in the new fighting included at least 46 militants, five Pakistani troops, and two civilians, according to Pakistani authorities and reports from the local hospital.
The fighting broke out yesterday - even as President George Bush was meeting President Pervez Musharraf in Islamabad - when militants attacked several government buildings in Miran Shah and tried to storm the army's base in the town, the authorities said.
It was the heaviest fighting in the area for years.
A Pakistani military spokesman, Major-General Shaukat Sultan, said the attack appeared to be a retaliation after 45 militants were killed in a military operation in the area last Thursday.
But the timing of the latest violence is suspicious: it fits a pattern in which every time Pakistan comes under pressure from the US to do more about militants on the border with Afghanistan, it has responded with high-profile military operations in the area.
General Musharraf came under more pressure from the US than he has for years when Mr Bush made his first visit to Pakistan yesterday.
"Part of my mission today was to determine whether or not the president is as committed as he has been in the past to bringing these terrorists to justice," Mr Bush said at a joint press conference, while General Musharraf stood awkwardly beside him.
"And he is," Mr Bush added, almost as an afterthought.
It was an uncomfortable situation for General Musharraf, one of whose biggest successes as Pakistan's leader has been the alliance he forged with the US in the aftermath of the 11 September terrorist attacks on America.
US-Pakistani relations are probably at their coolest since 2001, as Pakistan has had to watch its arch-rival, India, being courted as a strategic ally by the US and granted a civilian nuclear technology sharing deal.
North Waziristan is one of the tribal agencies - a holdover from British colonial rule - where tribal law applies instead of Pakistani law.
Until the past few years, Pakistan's military rarely ventured into the tribal areas, which are known for the extreme ferocity of the Pashtun tribes who live there.
But in recent years, Pakistan has tried to extend its authority as it hunts down al Qaeda and other foreign militants.
In the past few months, a new local movement has emerged in North Waziristan that calls itself the Taleban and has tried to enforce strict, Taleban-style Islamic law in the area.
A video disc has circulated that showed criminals being beheaded and their bodies hung from lamp posts in the area.
Local reporters say this new "Taleban" is made up of local students and is not directly connected to the Afghan Taleban - though they are natural allies.
Pakistan's army said that the militants killed on Thursday included Chechens, Uzbeks and Tajiks, as well as Afghans and Pakistanis.
In January, 18 people, including several children, were killed in a US air strike on another tribal agency, Bajaur.
The intended target was believed to be the al Qaeda deputy leader.
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