On a dust-covered runway in rural Madagascar, a group of men carry a patient towards a waiting Cessna light aircraft.

As he grimaces, blood runs down Moussa Ibrahim’s legs from infected diabetic ulcers that have spread across his skin.

For a moment, there is hope: the plane is here, the pilot is here, help is within reach.

But Moussa is not able to board the plane.

There is no medical team waiting in the next town, and no ambulance ready to care for him at the other end. It’s an impossible situation.

The only alternative is a day-long journey over roads that only a 4x4 can traverse, through punishing heat, across terrain that has no mercy for the sick.

Later that night, somewhere on that journey, Moussa died as he lay in the back seat.

In Madagascar, there is a thin line between death and survival. A relatively common medical condition can rapidly become a death sentence.

And now, the fragile network of planes, supply chains, and volunteer medics – the only thing standing between Madagascar's remote communities and no care at all – is under threat from a war being fought 6,000 miles away.

When the United States and Israel launched strikes on Iran in late February, the closure of the Strait of Hormuz, through which a fifth of the world's oil passes, sent fuel prices surging across the globe.

The world's poorest countries, from Bangladesh to Vietnam, Pakistan to the Philippines – those with the least fuel storage, the weakest infrastructure and the thinnest margins – have been hit hardest.

On June 17, the United States and Iran signed a memorandum of understanding to extend their ceasefire for 60 days and reopen the Strait.

But with progress slow and dozens of ships still stuck in the strait, the world's poorest countries are still waiting to feel the difference.

There are an estimated 118 tankers stranded in the Persian Gulf, and experts believe it could take a year for global supply chains to return to pre-war levels.

The aviation charity keeping Madagascar's most remote communities afloat has seen its jet fuel costs rise by 74 per cent since the war began.

For Mission Aviation Fellowship (MAF), whose pilots are often the only link between rural communities and medical care, that figure is impossible to reckon with.

“Each flight is about saving a life,” said Andry Rajaobelison, the Country Director for MAF in Madagascar, which uses its three Cessna planes to help various charitable projects in the country.

Madagascar, which has a poverty rate of 80 per cent, was already on its knees before the shock of the Iran war arrived.

It is the world’s fifth-poorest country, with 1.57 million people food insecure, including 84,000 facing emergency levels of hunger.

Nearly 4,500 Malagasy women die in pregnancy or childbirth each year, while one in fifteen children does not survive to the age of five and 38 per cent of under-fives are stunted from chronic malnutrition.

In October 2025, a youth-led uprising, fuelled by anger at chronic power cuts and water shortages, ousted President Andry Rajoelina, who fled the country.

A military-backed transitional government took power, the African Union suspended the island from its activities, and the international community began the arduous and uncertain work of pushing Madagascar back towards democratic elections.

Against the backdrop of political chaos, the Iran war has hit hard in a country with extreme poverty rates, crumbling infrastructure, and no buffer against a global energy crisis.

As fuel prices increase, the cost of living has skyrocketed for the Malagasy people.

In April, the government declared a national state of energy emergency, and its impact is clear across the country.

In Anatihazo, a dense slum in the capital Antananarivo, a 22-year-old woman named Hasina runs the neighbourhood's main water pump.

She is a widow, supporting her own child, her late sister's child, and her mother on a single income of around £70 a month.

Before the Iran war, a gas cylinder for cooking cost 4,000 ariary.

According to Hasina, it now costs 10,000, or around £1.80 – a sum that, in a country where most of the population lives on less than £2 a day, can mean the difference between eating and going without food.

“It doesn't stop getting more expensive,” she said, hauling tanks of water for locals in the midday heat. “We have nothing we can do. We are helpless, and we are not being heard.”

Nearby, Noro, 28, and Tsilavina, 27, push around 300 kilograms of water on a wooden cart through the slum's narrow streets every day, delivering 20-litre bottles to customers who cannot access the mains supply.

They charge between 200 and 250 ariary per bottle, but before the crisis, the same amount cost 150 ariary.

The generators that pump the water run on fuel. When fuel prices rise, everything downstream rises with them.

Eight hundred miles to the south, in the sun-baked village of Ejeda, the crisis looks different, but the pattern is similar: when fuel becomes a luxury, the people with the least lose the most.

MAF flies supplies of fortified food to Ejeda for school feeding programmes that have more than doubled school attendance rates in one of Madagascar’s most isolated areas.

Many children walk hours across the bush to reach the two-room school where the food is distributed. For many, it is the only guaranteed meal they will eat in a day.

Benoet, 32, works for Convoy of Hope, a charity that runs feeding programmes in ten schools across the region.

Every day, he drives between three of them, checking food stocks and ensuring supplies reach the children who need them. It is a journey vulnerable to changes in fuel prices.

“We are having to have fuel subsidies so I can continue working,” he says. “But I am ready to do whatever it takes, even by bicycle or walking.”

If it came to that, a single school visit would take five hours each way. Instead of reaching three schools a day, he would reach one.

At one of the local schools, 146 children sat down to a midday meal of fortified rice, beans and salt, almost double the 80 who attended before the programme began.

Volclaire, 47, who helps run the kitchen, has watched the transformation.

“Before, kids would come in the heat having not eaten anything,” she said. “More children have started coming to school since they started being able to eat.”

The fear that runs through every adult here is the same: what happens if the fuel subsidies stop, the supply runs can't be made, and the food doesn't arrive?

“I can't even imagine what would happen if the programme had to be cut,” said Benoet. “All the hard work would be for nothing.”

The same vulnerabilities play out in the makeshift operating theatre in the town of Belo.

A volunteer medical team, flown in by MAF, is working 12-hour days out of the town’s only clinic, treating hundreds of patients who have often waited months to receive medical care.

There is no reliable electricity in the building, so the surgeons work until the light fades, and, with no oxygen, they use a specialised system that extracts it from the air.

There is no sterile environment, so they improvise with what they have.

“We do what we can,” said Norbert, an ENT surgeon who travelled to Belo with the Medical Safari team.

“Even if we want to continue into the evening, we cannot. When it starts to get dark, we stop the surgery and ask people to come back.”

The patients at the facility have often made hostile journeys to receive medical care, some by foot, others by canoe along the nearby river.

Zilisoa, 34, walked six hours to have a cyst in her nose removed, a problem she has lived with for more than two years. Her husband Fanovoana made the same journey.

“She has been in pain since then,” he said. “When she works at home, her head is very heavy. She cannot hear well. She cannot work properly. We are farmers. She cannot work, so we have lost crops.”

They came to the clinic last year, too, but the crowds of people ahead of them in the line meant Zilisoa was not seen by a doctor. They had walked six hours only to be turned away.

On the bed next to Zilisoa lay a seven-year-old boy named Arilahi, who arrived after a two-hour-long canoe journey with his father and grandmother.

He had been ill from complications relating to Yellow Fever for over three months.

Arilahi’s father pulled back the boy's eyelids to reveal the yellowed whites of his eyes, then pointed to the lesions spreading across his legs.

“I cannot sit still when my child is this ill,” he said, as Arilahi cried out in pain.

Outside, under the shade of a tree, lay Tsiketraki, 80, his nephew Simon crouched beside him. He had not been able to urinate for a week.

The journey to reach the clinic had taken six hours by a wooden cart across bumpy roads that were agony for Tsiketraki.

“Thank God the team came,” said Simon, 54, who had lost half his income caring for his uncle and could not afford the alternative, a two-day journey by car to Morondava, the nearest town with anything resembling a hospital.

“Without them, it would have been impossible.”

In the recovery ward, Ravao, 42, sat beside a cot where her one-year-old son Benito lay sleeping off anaesthesia.

He had been born with a hernia, and for twelve months, she had watched him cry with pain.

The surgery he had just received was free. Without the Medical Safari team, it would have remained out of reach indefinitely.

“We would have had to gather money,” she said. “It would have taken years.”

Nearby, Anjara, 46, had just come out of a hysterectomy operation. She had just given birth via C-section to her sixth child, a baby girl named Raelisoary.

“We will have to give the baby water from the rice as we cannot afford formula,” said Raelinirina, 59, Anjara's older sister. “Sometimes I just find a banana and give it to them, or anything else I can find.”

As jet fuel prices rise, the feasibility of programmes like this medical safari is at risk.

“It is beautiful to see that my work is making this possible,” said Rutger Bakker, MAF’s pilot in Madagascar, who flew in the fortified food and medical team. “But the future is not certain.”

Meanwhile, across the country, a world of suffering exists behind bars, where prisoners as young as 13 are crammed into rooms built for half their number, enduring chronic hunger as food supplies run scarce.

At one prison in Toliara, Pastor Bintsoa counsels inmates who, in some weeks, eat a handful of times.

The government provides cassava or corn, while rice, a relative luxury, comes once a week at best.

Prisoners are meant to receive 700 calories a day, but in reality, they are often fed around 200 calories.

“Often they get sick as they get weaker and weaker,” said Pastor Bintsoa. “Some of them even die because of this.”

“It is my duty to care for them,” he added. “But I can't.”

Inside the prison, there is a single cell for children who live alongside the adult population, usually convicted of petty crimes, including pickpocketing, but handed heavy sentences.

One 13-year-old had been given a four-year sentence for stealing a phone to feed himself after struggling to survive following the death of his mother.

Across Madagascar, lives are shaped by hardships like these: a child in a cell, a baby fed rice water, and a man dying on a dirt road.

Today, hundreds of ships remain backed up at the Strait of Hormuz, and shipping experts warn it could be months before global supply chains recover.

For wealthier countries, that means higher prices and economic uncertainty.

But for Madagascar, it means something more immediate.

It means flights that may not fly, food that may not arrive, operations that may not happen, and lives that may not be saved.

For people like Moussa, the margin between survival and death was already measured in hours.

Now, it is shrinking further still.

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