This article was first published in The National, UAE Edition.

Bangladesh – When a major upsurge in violence broke out in Myanmar’s northern Rakhine state on August 25, it started an exodus that sent almost half a million of the mainly stateless Rohingya Muslim minority fleeing over the border into Bangladesh in just two months. As the year comes to an end, the number of new arrivals is now more than 655,000.

Those who arrived may have escaped the widely-reported brutality they suffered in Myanmar, but that does not mean that they are free from danger.

Two weeks ago, the ground behind the primary health care clinic in Kutupalong, Cox’s Bazar, was an empty patch of mud – a spot where visitors would stop, stunned by the sweeping view it gave over what has been dubbed “the world’s biggest refugee camp”, a seemingly endless vista of black tarpaulin shelters stretching to the horizon.

That bare patch of earth is now the site of a new inpatient ward, rapidly constructed by the UN migration agency, IOM, as a deadly outbreak of diphtheria spreads through the overcrowded settlement – the latest tragedy to hit the estimated 866,000 Rohingya refugees who now live there.

According to the World Health Organisation, by December 19, more than 1,500 probable cases of diphtheria – 75 per cent of them children – had been reported since the disease was first identified on November 8. At least 21 people are thought to have died from the illness, which can cause the throat to swell so much that patients suffocate. And doctors fear that the true number of people affected could be much higher.

“When people are living in such close quarters, with poor sanitation and low rates of existing immunisation, the risk of disease spreading is extremely high. We are working to raise awareness of the disease and how to get treatment, but the early symptoms are easily confused with seasonal cold and flus,” said IOM emergency health officer Mariam Spijkerman-Abdelkerim, who is overseeing the organisation’s response.

This includes supporting a vaccination campaign, development of treatment centres and tracing those who have come into contact with infected people so they can be given prophylactic treatment.

That is no easy task in a population the size of Kutupalong. The scale of the medical needs in the camp is such that since August 25, IOM staff at the organisation’s 13 health facilities, and nine government clinics where it works, have carried out more than 125,000 consultations and are currently seeing more than 2,000 patients a day.

Some are suffering life-threatening illnesses. Sanura, 30, describes her vague memories of waking up in an IOM clinic after being carried there unconscious by her husband. A sudden onset of severe diarrhoea – which is rife in the camps – had caused her blood pressure to rapidly drop to levels where she was close to death.

“We thought she had only one to two hours left to live,” said Dr Raisal Islam, an IOM medic at the clinic who helped save her life.

It is hard not to focus on the immediate, individual human misery: the swollen bellies of malnourished children, the traumatised faces, and the desperation of people who have lost everything. But those working to improve conditions in the camps concentrate on the technical matters of construction, engineering and sanitation in an effort not just to make life better, but also to prevent disaster.

In the initial chaos of the early mass influx of people, families constructed shelters on steep muddy slopes and well-meaning but inexperienced organisations built latrines next to water sources. Even relatively small amounts of rain create rivers of mud in this area, stripped of vegetation to make room for shelters.

Aid agencies are working alongside the Bangladesh government and military to improve roads and drainage and identify new areas for shelter construction ahead of the rains.

In the New Year, supplies including more tarpaulins and sandbags will be distributed, which will enable 120,000 households to reinforce and upgrade their shelters ahead of the rainy season in May.

When the monsoon rains arrive, there is a strong likelihood of landslides, causing shelters, latrines and people to come crashing down on top of one another. It may be several months away, but site planners and shelter experts, who are working against the clock to improve conditions, predict it may be nearly impossible to prevent disasters.

“When we arrived [in early September] there was so much rain and mud. Our shelter is not too bad just now, but it is cold at night, and I am worried what will happen when it rains again,” said Arafa, who lives with her five children in a small tarpaulin shelter.

On top of vital shelter and health care, families who have fled Myanmar often need more than just physical support.

People who had mainly survived through small scale farming or as fishermen, living in village communities where their neighbours were friends and relations they had known all their lives, now find themselves dependent on aid and surrounded by hundreds of thousands of strangers.

For the men, frustration often arises from their inability to work and provide for their families.

“Before [in Myanmar] I had my farm. We didn’t have much, but I could feed my children. Now we have to rely on handouts. We don’t want to live like that. We don’t feel good about it,” says Muhammad, a father of five.

A number of schemes are getting underway to provide “cash-for-work.” These involve refugees being paid to help IOM and other organisations to implement various projects in the camps. But most families will continue to rely on aid to meet their most basic needs.

For Rohingya women in particular, many of whom traditionally remain in or close to the family home, the crowded camps are particularly difficult.

“It is our tradition that we don’t leave our homes. I can’t go without my husband,” explains 25-year-old Rajuma, torn between worry over her ill baby and anxiety about going out alone to get help.

A recent IOM survey into population needs found that 70 per cent of community leaders questioned did not consider latrines, washrooms and waterpoints to be safe for women.

In addition, embarrassment and feelings of shame mean many women wait all day until it is dark before going to the latrines – a practice that causes health problems and places them at additional risk when they leave their shelters at night.

IOM and partner agencies have distributed solar-powered lanterns for women to carry if they need to go to the latrines at night. They are also working to install better public lighting. But there are also other dangers faced by women that are more difficult to address.

The refugees are extremely vulnerable and human traffickers are already in operation, luring women, children and men with promises of good jobs that in fact often lead to prostitution, domestic slavery and forced labour in various industries.

In any refugee setting, women and girls are at increased risk of gender-based violence. But this is of particular concern among this population, where many have reported suffering rape and other forms of sexual assault in Myanmar. Many others are believed to be keeping silent about what happened to them, because of shame and social stigma. A large number of those arriving in Bangladesh describe having suffered years of persecution before losing family members in the recent violence. Many also recall seeing people killed.

“The extent of trauma we are witnessing here is immense. Providing counselling and support services to those in need is vital to help women develop positive coping methods and see a way forward after what they’ve experienced,” says mental health and psycho-social support coordinator Olga Rebolledo.

One place where women and girls can access counselling is at a newly-opened women’s safe space in Kutupalong camp.

There, behind a high bamboo fence sits a female guard in a little sentry box, beside a small garden of newly planted flowers. It is a tiny oasis of calm amid the chaos of the camps and a sense of immediate ease descends upon entering the space.

Inside the safe space building, female psycho-social support staff from IOM and a partner organisation, Pulse, offer individual counselling and group sessions for women and adolescent girls in need. Staff are intensely protective of the privacy of those they are supporting, but say they see some “extremely serious” cases.

Other services include lessons and information on issues from women’s health to how to avoid the risks posed by traffickers. Much needed supplies of sanitary products are also available. There are also spaces for relaxation, games, arts and crafts materials and facilities for watching informative or positive TV programmes.

“I can’t sleep at night for thinking about all the different ways we can try and support the women,” says Lutfa Bakshi, a psycho-social support officer who has spend decades working with Rohingya refugees.

Four months into the crisis that provoked so many to flee to Bangladesh, there are some signs of normality. It is not all misery.

Outside the Kutapalong health clinic, a group of teenage boys play Chinlone – a traditional Myanmar game played with a rattan ball. An old man with a gap-toothed grin proudly shows off the pink, furry-hooded jacket he’s acquired to keep out the cold on winter evenings. It might be second or even third hand, but it is new to him. A trail of women and children bustle past, each bearing several blankets and a fresh plucked chicken – welcome donations that will keep them warm and feed families who mostly survive on rations of rice.

But the reality is that life in the camps is hard and dangerous. Despite the ongoing efforts of aid agencies, and the local and national Bangladeshi authorities, there is so much more work to be done to give the Rohingya refugees the most basic support they need to ensure their safety, dignity and well-being.

Fiona MacGregor has reported on Rohingya issues since 2013. She is currently working as a communications consultant with IOM in Cox's Bazar in Bangladesh.