Aamir Hussain stands on the roof of his home in southern Pakistan, his head encased in a whirlwind of mosquitoes, overlooking the stinking floods all around.

Four months after record-breaking monsoon rains linked to climate change began, the standing water has congealed into a plague-like soup that is spawning malaria, cholera and dengue fever.

The UN has warned of a “second wave” of the disaster, with the risk that deaths from waterborne diseases and malnutrition will surpass the 1,700 drowned and electrocuted in the first cascade.

As dusk falls in Hussain’s sunken village in the Dadu district of Sindh province, so do the bugs and the gamble that they will infect his wife and two children.

“The mosquitoes often bite and we get sick,” the 25-year-old said on brickwork framing a yard awash with putrid, sucking mud.

His brother, who shares this house, has already ventured off the roof to treat his sick children in the hospital with borrowed money.

“Some of our nets are broken now, so we’re worried,” said Hussain, whose young son has fallen ill.

Sindh was hit hardest by the catastrophic floods that flooded a third of Pakistan, displaced eight million, destroyed or damaged two million homes, shut down 1,500 hospitals and clinics and caused an estimated $28 billion in damage.

Climate Protection Minister Sherry Rehman said this week that more than 20 million people were still in need “with a future that is completely precarious”. Eight million of them require “urgent medical care,” she said.

Zahida Mallah has already been tipped over the edge.

In a desolate camp south of Dadu, outside the city of Hyderabad, the 35-year-old said she was mourning the loss of her two-month-old twin sons.

One died on the day of AFP’s visit, the other in a separate camp about two weeks ago.

They died of “colds,” she said, after sleeping outdoors. Only when it was too late was she offered a tent.

“We just keep fidgeting,” she complained.

The nearby town of Johi is surrounded by water and accessible via a rickety flotilla of canoes powered by greasy petrol engines.

Residents rallied to save the city as rain poured down, heaving sandbags into a twisting makeshift dike. But it cannot hold back the disease.

In a desperately run-down emergency clinic, a doctor treats an unresponsive seven-year-old Kashaf, a suspected malaria patient, who lies on dirty sheets with a pile of medicine at her feet.

“Maybe it’s a natural disaster or maybe we’re being tested by God, but whatever it is, we’re the victims,” ??said her father, 20-year-old Dildar Mastoi.

Beneath a black scarf, his daughter’s eyes are rolled back into her head. She no longer recognizes her parents – doctors say a fever has attacked her brain.

Her mother and father, barely of adulthood themselves, twice fled rising waters before settling in a camp where they drink from a well they suspect is polluted by floodwaters.

“From early evening to dawn, throughout the night, the mosquitoes are overwhelming,” said Kashaf’s mother, 19-year-old Bashiran Mastoi. “As night approaches, we begin to worry.”

“Life in the camp is infinitely miserable,” she said at a vigil at her child’s bedside.

Medic Manzoor Shahani said there has been a “surge” in malaria, gastrointestinal diseases and dengue fever, while “most of the patients are children and pregnant women.”

Even before the floods, southern Pakistan was plagued by crushing poverty. Now, aid only sporadically makes its way into the patchwork swampland, while the true number of those in need is not even known.

Doctors and officials offer conflicting numbers while struggling to understand the extent. In Dadu, the official death toll is only 23, but everyone privately agrees the real number must be much higher.

“This is devastation beyond the government’s approach,” said provincial health monitor Faheem Soomro, while young doctors at a boardroom tallied up the day’s fresh patients.

Half of malaria tests are positive and most households have suspected cases.

Sindh has registered 208,000 malaria cases so far this year, a dramatic increase from 2021 when cases were reported.

Left untreated – as is certainly the case in the stranded areas of Sindh – malaria can quickly become fatal. In a normal year, there are 50,000 deaths from malaria in Pakistan.

Soomro describes it as “the hidden fever”. It has vaguely flu-like symptoms – as the mosquito-borne parasite invades the liver and bloodstream and, in severe cases, causes the brain to swell.

The health disaster is easiest to monitor in camps – there are 19 in Dadu – where the happiest of the displaced live in a series of hundreds of simple A-frame tents.

In one of the “tent cities” of around 5,000, residents clamor for treatment in a blustery pavilion, where doctors test them for malnutrition and malaria while others offer vaccinations and health advice for women.

Soomro estimates that 60 percent of those displaced once stayed in camps like this one, but three-quarters of them have retreated to the sodden hinterlands to rebuild their lives, often beyond the reach of relief efforts.

Outside the camps, IDPs can be seen everywhere – in tents and on day beds, lined by highways and near spongy stagnant lakes.

The monsoon flow came after a spring heatwave hit Pakistan, with Sindh Islands experiencing sporadic temperatures of 50 °C (122 °F).

Extreme weather events are increasing in severity due to climate change, scientists say.

Pakistan — the world’s fifth-largest population — is responsible for just 0.8 percent of global greenhouse gas emissions, but it’s one of the countries most vulnerable to extreme weather conditions caused by global warming.

In Johi, community activist Ali Pervez laments that the worst-hit Pakistanis are unable to stand up for climate justice.

“You don’t know about it,” he said.

“There is no quality education [so] that we can easily make aware empower our people.”