Ambovombe, Madagascar - Despite the heat, Manovo Edson shivers on the bed with a blanket wrapped around his small body. He is 14 years old, but looks to be only six or seven.
The desperate screams of a mother who just lost her 17-month-old child in the next room echo off the walls. Manovo is being treated for tuberculosis, or TB, in a basic hospital in Ambovombe, capital of the Androy region in Madagascar's remote and deprived south.
While many people imagine the country as a wildlife mecca, it is one of the poorest in the world, with at least 80 percent of the population living in extreme poverty and half of all children under five years old suffering from chronic malnutrition.
The associated problems, particularly the struggle for food - as malnutrition increases susceptibility to the disease, according to the World Health Organization - have contributed to TB becoming the leading infectious killer in Madagascar.
The latest estimates of the World Health Organization place the incidence rate of TB at a very high 235 cases for every 100,000 people. However, accurate figures are impossible to come by due a lack of accurate data, as well as inflicted people delaying treatment for a multitude of reasons.
Chronic malnutritionBy the standards of the developed world, Manovo has not eaten a proper meal in nearly two years, and perhaps never in his lifetime. His sporadic diet has mainly consisted of rice and cassava, a starchy root.
His condition was grave when he arrived at the hospital 23 days ago. A weakened immune system due malnourishment made him more susceptible to the mainly airborne bacterial disease.
However, Manovo is now responding to treatment and getting stronger, according to the healthcare workers looking after him, but he will be kept under observation for at least another two months.
As the airborne disease spreads easily in cramped living conditions, TB is often associated with poverty.
"Deaths at the hospital from TB are relatively rare, but patients often arrive very sick and would die if they did not receive treatment," says Melodie Paupert, a local healthcare worker. "Patients need the medicine."
In order for the family to bear the exorbitant costs of caring for Manovo, which include transport, accommodation, food and lost income, etc, they have used up most of their meagre assets, even selling one of their Zebu cows - a prized possession among many rural Malagasy.
Manovo's family mostly works in farming, but long periods of drought have exacerbated the situation and increased hardships for them. Although, his illness has put an enormous strain on their income, family members have interrupted their lives as they take turns sitting by the boy's side.
|Tuberculosis medication is crushed to make it easier to consume for a patient who has difficulty swallowing|
Deficient fundingLike numerous health centres in Madagascar, the staff all work voluntarily. One worker, Odille Licie, has not been paid in 10 years of working at the hospital.
Funding the fight against TB in Madagascar is a significant problem. The country's entire dedicated budget for combating TB - which has been little over $10m (PDF) for the years 2014-2017 for a population of nearly 23 million people - is now only provided by the Global Fund, a financing system established to combat aids and malaria, as well as TB.
"Tuberculosis remains a big issue, despite the time we've given it," sighs Dr Martin Rakotonjanahary, deputy director of the national programme fighting TB.
A lack of funding for his department is an ongoing problem. It suffers from a 90 percent budget gap and is entirely reliant on insecure donor funding. This year, he has just $7m to fight TB in the whole country, and he doesn't know if this money will be renewed.
Widespread corruption also means money allocated to healthcare workers and facilities is skimmed little by little as it makes its way from the central administration, which, due to the size of Madagascar - the fourth biggest island in the world - is a long way.
Traditional healingInfrastructure issues and cultural practices, especially in the country's remote southern region, have resulted in difficulties fighting TB. Many people approach traditional healers before doctors, as they are often geographically closer and more trusted by the community.
Rakotonjanahary doesn't want to fight this practice, but admits any health strategies involving traditional healers are hard to implement and must be approached with caution.
Even if people do reach proper care, their problems do not end. Lack of access to drugs due to insufficient funding and infrastructure issues can mean that TB treatment courses can be sporadic and improperly administered.
Many patients also choose not to complete their long and gruelling treatment courses, which include several rounds of pills each day, and stop medicating when their symptoms have eased, only for them to return later on.
This sporadic treatment has led to another problem: multi-drug resistant TB (MDR-TB). Drug resistance, caused by mutated microbes which can fight off medicines, is a very troubling issue according to international health experts.
In Madagascar, knowledge of MDR-TB is extremely varied. While some specialist doctors are aware of its dangers, they have limited resources with which to fight it. In contrast, the Minister of Health Mamy Andriamanarivo told Al Jazeera that he was "not worried" about it.
But MDR-TB, and anti-microbial resistance (AMR) more generally, is of global concern. Already, 700,000 people a year across the world die because of AMR, according to the Review on Anti-Microbial Resistance, a United Kingdom government-appointed task force set up to analyse the potential global impact of drug resistance. Deaths are projected to reach 10 million each year by 2050 if action is not taken.
Drug-resistant TB already kills 200,000 people each year, and will account for more than 2.5 million AMR-related deaths by 2050, according to the Review. For this reason, tuberculosis was called the "cornerstone" of the fight against drug resistance in the Review's May 2016 report (PDF) on the issue.
And drug-resistant TB does exist in Madagascar, but due to poor data collection practices, the true number of cases is unknown. In the Befelatanana Hospital in the capital, Antananarivo, doctors say there have been at least 20 cases of MDR-TB since 2012.
|Hortence Modesstina, who has HIV and TB, in the hospital room in which she is quarantined with her mother, Bao. Both wear face masks to prevent visitors catching TB|
Poor quality of drugsTwelve-year-old Hortence Modesstina has been ill for six years and treated three different times for TB by local doctors in the southwestern region, where she is from.
After consistent failures, she was taken to the city and has now been under treatment for eight months. It was only when she was admitted to hospital that it became known that, in addition to having a drug-resistant form of TB, she is HIV-positive.
Her mother, Bao Modesstina, 43, is also HIV-positive. She has stayed with Hortence, the youngest of her five children, while she has been in quarantine. They share a room in a quite wing of the hospital and both wear face masks when they receive visitors.
"I felt very discouraged, but the doctors kept counselling me, and I felt stronger after," says Bao. "It's very hard to always be kept inside, but when I see my girl getting better, it's worth it."
In the next room, 28-year-old Eternal is also beginning to feel better.
I felt very discouraged, but the doctors kept counselling me, and I
felt stronger after. It's very hard to always be kept inside, but when I
see my girl getting better, it's worth it.
He has been sick since 2013 with what is now known to be MDR-TB, explaining why his other treatments did not have any lasting effect. Isolated in a bare, cell-sized room, he worries about finding work when he gets out.
However, these patients may be considered fortunate, despite the harsh medications that must be carefully monitored, administered and - most crucially - uninterrupted.
Besides its inherent complexities, treating drug-resistant TB is made more problematic by the general quality of the drugs available to treat the disease.
Most standard TB medicines are decades old, and there is little appetite among pharmaceutical companies to produce new ones due to the small market return on them. The most demand is from low-income countries.
Resistance to single drugs is common and doctors are forced to use more powerful combinations for many months at a time, taking a physical and mental toll on patients.
The vast distances, poor infrastructure and sporadic healthcare in Madagascar mean a proper diagnosis of MDR-TB, let alone its proper treatment, are still far off as funding is still weak and heavily reliant on external donors.
Back in the isolated room, still wrapped in his blanket, Manovo rests on the bed. It's his grandmother's turn to sit by him, but 66-year-old Celestine Kasay doesn't mind.
"He looks better now than when he arrived," she says. "He misses school. He wants to go back."