High in the snow-covered foothills of the Himalayas, Perveen Anwar is waiting with her sister for help.

Three-year-old Madia has a bronchial infection that, according to a neighbour, is pneumonia. Other sick people from the village, 9,000ft above sea level, are also waiting for the bus to take them to the nearest hospital, a hellish four-hour drive down the valley to Bagh.

Around them, in the remote neighbouring villages, people are beginning to die from the cold. Young children and babies are particularly vulnerable. Almost three months after the earthquake that killed 73,000 people in Pakistan-administered Kashmir, half of them children, a second tragedy is unfolding in the mountains. The winter disaster that the relief agencies had feared is now a reality.

According to Ishfaq Ahmed of the Kashmir International Relief Fund, 100 children have died of the cold in the past month in the towns of Muzaffarabad and Bagh alone, and the death toll in more remote regions must be higher.

Three and a half million earthquake victims are still homeless, many of them surviving in makeshift tent cities. Relief workers, who are already speaking of a lost generation, fear the death toll from the winter - temperatures dip to minus 10C at night - could exceed that of the quake. "The winter will be a bigger killer," said Mr Ahmed.

The arrival of the snow has triggered a migration south by those fit enough. A few feet deep at present, the snow will soon be drifting up to 20ft. Very soon, the mountain roads will be impassable. Major snowfalls and even colder temperatures are forecast for this weekend.

Perveen, at 17, is now the head of her family after her mother was killed and her father badly injured in the earthquake. She was collecting water when the ground began shaking, she was frightened but her young sister was not. Perveen picked her up, covered her face, and returned home to find the house in ruins..

Perveen and the other villagers now face a terrible dilemma. To stay is to risk freezing or starving to death, while to leave is a leap into the unknown. Livestock left behind must be slaughtered. The lucky ones make it into overcrowded camps where, so far, no deaths have been reported but where children are suffering from acute respiratory infections because of the cold. Despite the health risks, in a camp there is a better chance of survival, and even a chance of schooling.

Perveen's neighbours must decide whether to stay and mourn the dead buried under their homes, or head for the camps over a treacherous terrain, once familiar but now littered with deep cracks and holes that cannot be seen under the deep snow.

Commander John Lane, a British aid worker who has been organising shelter in the Balakot region since the quake on 8 October, said: "Thousands of tents were distributed that are completely useless against the snow. Those that remain are no protection against this severe weather, and most will collapse under the weight of the drifts."

Cdr Lane, a disaster management co-ordinator with Voluntary Service Overseas, and his Peruvian wife, Baba, have been climbing on foot to the villages of Arban and Bangrian, perched on the mountain flank at 6,000ft, to see what practical help and pastoral care can be given.

Kamran Shariff, a retired army brigadier who, like many former Pakistani top brass, returned to service to help deal with the emergency, said shelter, health and education were the priorities. "We considered flights over the mountains with megaphones advising inhabitants to evacuate but they won't even follow instructions to refrain from lighting fires inside tents. Without heat, light and electricity, you understand the need, but hundreds of tents have already been set alight. Whole families that survived the quake are being burnt alive, the burns unit in the city can't cope."

Brigadier Shariff flew by helicopter to the stricken region but the army and aid agencies lack manpower and resources to reach the thousands trapped in the mountains around Balakot, or indeed the hundreds of thousands scattered over the 1,000 sq miles of the disaster zone. Those that cannot be reached stand little chance of surviving. What angers the local relief workers most is that the winter deaths should have been avoidable. "This is what we predicted," said Mr Ahmed, who said his charity had asked for winter-proof shelters, rather than tents, for the quake victims 10 days after the disaster. A UN humanitarian affairs spokeswoman Stephanie Bunker replied that the priority in the early days was in getting relief quickly to victims.

Aid agencies say they still need more help, particularly logistical support in the area which is shaken by earth tremors almost daily. Forty thousand stoves have been collected at Muzaffarabad, the main city of the quake zone, awaiting distribution.

The head of the World Food Programme, James Morris, said this week that the UN agency's appeal for $100m (£50m) to provide air support for UN relief operations in Pakistan was only about one-third funded.

Overall, the UN has received about 40 per cent of the $550m it requires for relief efforts. The UN needs $45m (£26m) immediately to provide 2.4 million blankets and to bolster the shelters of 1.9 million survivors who are living below 5,000ft. According to UN officials, governments have tended to give long-term aid directly to the Pakistani authorities, rather than providing much-needed emergency aid to the agencies on the ground.

Standing in the Balakot camp of blue bamboo-supported shelters, Cmdr Lane says the town "looks as if it has been carpet-bombed. Nothing safe is left standing, just agency shelters and new graves."

Ahmet, 16, grins from behind a barrow of tangerines, sitting on what was once the side of a Balakot street, now a pile of debris and dust. He is an amputee, he lost his left foot in the earthquake. His right hand looks like a claw, partly covered in a leather patch, the result of frostbite.

In the UK, the snow and minus 10C temperatures have brought some inconvenience and a happy diversion for children on holiday. In the Himalayan foothills, it inflicts greater suffering on those who have suffered enough.

Counting the cost

* The Kashmir earthquake on 8 October destroyed communities across some 12,000 sq miles, mainly in Pakistan's North West Frontier Province. About 73,300 people were killed in Pakistan and 3 million have been left homeless in some of the most treacherous conditions on earth. A further 1,400 people died in Indian-administered Kashmir.

* The UN High Commissioner for Refugees has delivered more than 2,730 tons of aid to the Kashmir area, including 2.4 million blankets, over 21,000 tents, close to 100,000 plastic sheets and 600 rolls of plastic to keep homes and floors dry.

* Thousands of stoves, lanterns and sleeping bags have been delivered along with 35,000 mats, 32,000 jerry cans and 28,000 kitchen sets.

* International donors have pledged more than £3bn so far, largely in the form of low-interest loans.

* Despite the huge international relief operation in Kashmir the UN warned this month that up to a million people do not even have adequate blankets to survive the winter.

* There is also a huge shortage of equipment to insulate tents for the winter - 170,000 high-quality plastic sheets are still needed for non-winterised tents and 200,000 tarpaulins are required to keep temporary homes dry; 1.9 million tents need to be winterised for those living below 5,000ft.

* The International Organisation for Migration has warned that up to three-quarters of donated tents are not suitable for winter conditions.

* For those who live above the snow line, the World Food Programme is developing pre-positioned food deliveries that will be able to feed a family for between 45 and 60 days. Many of those living 5,000 metres above sea level may not be reachable by helicopter.

* The Disasters Emergency Committee says a £15 donation will buy seven blankets; £90 will buy a winterised tent.

Jerome Taylor