In the past ten years, drug supplies have been sporadic, Moscow-based expertise lost, and financial support has ground to a resounding halt. Home to a population of 5.2 million, inhabiting the fertile oases of the vast Karakum desert, Turkmenistan is in the grip of an economic downturn. Levels of education and health status are declining, with women increasingly worse off. Many say life was better under the Soviets.

Women and children in one room, men in another; these people have been lying here like this for weeks.

At the end of the corridor, in semi darkness and facing the wall, lies Meret. He's 26 years old, painfully thin, and lies contorted on a dirty mattress, wrapped up in a torn mosquito net. He's too weak now to even cough properly, and the pus from his lungs is being drained by tube into a dirty red bucket sticking out from under the bed. Two loaves of bread are tied to the bedpost—supplies from his family until they can next afford the bus trip to this remote corner—since the hospital provides no food for its patients.

"I escaped from the other clinic", Meret tells us in a hoarse whisper, via the translator.

"They wanted to operate on my lungs and I got scared. I went back to my family in the country." The doctor here seems at a loss as to what to do with many of these patients. "We don't have the drugs to treat them when they are at this stage", he says. "And even if we did, no laboratory facilities to do the tests. What more can we do but send them home?"

We drive to another clinic in which Médecins Sans Frontières (MSF) have set up a DOTS treatment programme. We've come to see the laboratory, which comprises a blue-stained sink, a box of masks, three bottles of reagents, and a shiny new donated microscope.

"When we first arrived", says Roy Male, head of the MSF project, "all diagnosis was done by x-ray, so left vast numbers of cases undetected.

We have spent the last three years training laboratory staff, updating laboratories, and ensuring that at the primary care level microscopic diagnosis of sputum smears can be carried out according to international standards." According to Yulduz, the laboratory technician, "we used to send patients an hour away to the regional laboratory.

Often the results would be negative, even when the patient was clearly ill with tuberculosis."

However, he feels frustrated that they can only go this far. Increasing evidence is showing rates of multidrug resistant tuberculosis in all of the Newly Independent States to be alarmingly high, an inevitable product of the slow deterioration of health services witnessed here since independence from Moscow in 1991.

In the past ten years, drug supplies have been sporadic, Moscow-based expertise lost, and financial support has ground to a resounding halt. Home to a population of 5.2 million, inhabiting the fertile oases of the vast Karakum desert, Turkmenistan is in the grip of an economic downturn. Levels of education and health status are declining, with women increasingly worse off. Many say life was better under the Soviets.

"Our survey has shown MDR-TB [multidrug resistant tuberculosis] rates of up to 40% among retreatment cases", says Male. "But this country faces an uphill struggle. Not only does the drug supply here rely solely on support from outside donors, but there is no functional laboratory in the entire country that can carry out the basics in MDR-TB treatment—quality-assured culture and drug-sensitivity testing".

MSF relies on a laboratory in Borstel, Germany, to process samples from suspected multidrug resistant tuberculosis patients free of charge, and goes through considerable logistical hoops on a weekly basis to transport such biohazardous specimens from this rural outpost, over the desert to Ashgabat, then on to Germany.

Indeed, finding a laboratory willing to do this work took three years of negotiations.

Tuberculosis is one of the biggest global burdens on human health—not because the total number of cases is particularly large, but because about a quarter of sufferers die, most of them young adults. The international debate on how to tackle multidrug resistant tuberculosis is underway, but when you visit such regions it is hard to not feel utterly despondent as to the feasibility of taking the next step.

Struggling so with basic tuberculosis care in Turkmenistan, a country in which tuberculosis services are increasingly being sidelined, how do we begin with drug resistance? Expensive second-line drugs, strong laboratory support, monitoring, training, and long-term donor commitment appear but a distant dream to many health-care workers, and "cost-effectiveness" is a well worn term in these remote corners of the world.

But for addressing uncomplicated tuberculosis, the DOTS nurse remains optimistic. "Implementation of DOTS here is helping us find and treat more cases", she says flicking through a pile of treatment cards in a dimly lit room at the back of the clinic.

In this so-called DOTS corner, patients who are no longer sputum positive come three times a week to take their drugs under direct observation, and she has a high rate of compliance.

"People did not used to like us going into their villages, and they would say to us, 'We are afraid of you, you are working with tuberculosis.' Even health-care workers were reluctant to be associated with us. But now they know they will be fully cured after 6 months of DOTS, everything is changing."

One hopes such optimism will last.