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By Anne Barnard | BEIRUT, Lebanon — In the hills near the Lebanese border, an hour’s drive from downtown Damascus, much of a Syrian town is starving, according to residents and international humanitarian workers.

The town, Madaya, is controlled by rebels and encircled by pro-government forces with barbed wire, land mines and snipers. People there make soups of grass, spices and olive leaves. They eat donkeys and cats. They arrive, collapsing, at a clinic that offers little but rehydration salts. Neighbors fail to recognize neighbors in the streets because their faces are so sunken.

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Syria, once classified as a middle-income country, now reports periodic malnutrition deaths. At least 28 people, including six babies, have died from hunger-related causes at a clinic in Madaya aided by Doctors Without Borders, medics there say. And the 42,000 people that the United Nationscounts as trapped in Madaya are about a tenth of those stranded in besieged or hard-to-reach areas as conditions grow steadily worse.

Their plight represents a stark failure of international powers that has worsened even as they intensify military and diplomatic activities, all in the name of resolving the conflict.

This is happening as the United Nations plans a new round of peace talks for Jan. 25. It is happening amid escalating military interventions by Russia and the United States. And in some ways, according to diplomats and humanitarian workers, it is happening not just despite those efforts, but also because of them, as the warring parties flout international law while being courted for negotiations.

Yet in Madaya and neighboring Zabadani, once popular mountain resorts, thoughts of political change have receded in the face of hunger. Hamoudi, 27, a business-school graduate who took up arms after the government’s crackdown on protests in 2011, said many people would surrender in order to eat, even though they expected arrests and retribution to follow.

“In the revolution I was dreaming of democracy, freedom,” Hamoudi said slowly in an interview via Skype, exhaustion evident in his voice. “Today all my dreams are food. I want to eat. I don’t want to die from starvation.”

Five more people, a 9-year-old boy and four men older than 45, died on Sunday of suspected malnutrition, according to the medics working withDoctors Without Borders, who said that 10 more people needed immediate hospitalization to survive, and that 200 more could reach that state in a week. “Madaya is now effectively an open-air prison,” the medical charity’s operations director, Brice de le Vingne, said in a statement.

About 400,000 Syrians are trapped behind front lines, denied access to food and medicine. That United Nations count has risen from 240,000 since 2014, when the United Nations Security Council unanimously adopted a binding resolution ordering the warring parties to allow aid delivery.

Both Russia, the Syrian government’s most powerful ally, and the United States have been carrying out airstrikes that they say are aimed at Islamic State militants. But the airstrikes have complicated the relief efforts. Since last fall, when Russia joined the fray, at least 16 health centers have been hit, and six aid groups have pulled out of Idlib Province, where the Islamic State has little presence but Syrian and Russian forces regularly bomb other groups that oppose President Bashar al-Assad.

As they seek to maximize gains before the talks, all sides are inflicting new pain on civilians.

Even now, as the Syrian government promises to allow United Nations aid into Madaya as soon as Monday — as international outrage over reports of starvation mounts — government forces are tightening a new siege on another rebel-held town, Moadhamiyeh, a suburb of Damascus.

“Surrender or you will be annihilated,” was the message residents say Mr. Assad’s negotiators delivered to Moadhamiyeh — which endured a chemical weapons attack in 2013 and a two-year siege that ended with a deal favoring the government.

Using hunger as a weapon flies in the face of international law. Yet global and regional powers — like Russia, Iran, the United States and Saudi Arabia — are unable or unwilling to pressure their battlefield allies. The United Nations says that just 10 percent of its requests last year to deliver aid to besieged and hard to reach areas in Syria were approved.

The Security Council resolutions have made “little difference to the Syrian civilians,” said Andy Baker, of the aid group Oxfam.

That puts the United Nations in an awkward position: helping to carry out local cease-fires that may permit aid for a time but also reward commanders’ siege tactics.

The United Nations has repeatedly found itself in the middle of deals that made bargaining chips of access to food and medicine that should be unconditional. Some deals have required civilians to leave their homes for aid and protection, going against basic principles of humanitarian relief.

While the United Nations emphasizes that it is not a party to the agreements, its officials are intimately involved in carrying them out — aid delivery and evacuations cannot take place without them. In several cases, they have helped facilitate the talks as go-betweens.

And with the United Nations special envoy, Staffan de Mistura, pressing for a national cease-fire, the local truces are often perceived and portrayed as United Nations-approved and as steps toward a broader accord.

Many diplomats and aid workers — who requested anonymity in order to continue working on or in Syria — say that Mr. Assad has played on the divide between the United Nations’ political and humanitarian branches. Political officials can deplore terms of starve-or-surrender, but once a deal like that is struck, humanitarian agencies can hardly refuse to deliver aid, especially if the alternative is zero relief for trapped civilians.

Critics say the United Nations, eager to keep the Syrian government on board for peace talks with opposition groups, is either selling out or getting played.

“The regime will continue to use its submit or starve policy because it’s working,” Bissan Fakih of the Syria Campaign, a group pushing for a no-fly zone over Syria, declared on Facebook, “with a big happy stamp of approval by the United Nations” and global powers.

Officials like Mr. de Mistura, who visited Damascus over the weekend, should be pressing loudly and publicly for unconditional aid access, said Bassam Barabandi, a former Syrian diplomat. Instead, he said, they privately tell opposition groups that they do

(Mr. de Mistura, visiting Iran, said in a statement issued Sunday that Saudi Arabia and Iran had pledged to participate in the Geneva talks despite their entanglement in a tense standoff after Saudi Arabia executed a Shiite cleric this month.)

Sieges are nothing new in Syria. Nearly half of the 400,000 Syrians the United Nations counts as besieged are surrounded by government forces, who have used the tactic systematically around Damascus and Homs. The largest group is encircled by the Islamic State, which is blockading 200,000 people in Deir al-Zour, in the east. Other insurgents, mainly the Islamist group Ahrar al-Sham, have also encircled more than 12,000 people in isolated pro-government towns in northern Syria, like Foua and Kfarya.

But things were supposed to change in Madaya. It was part of a pact thatwas hailed last month as the most complex local cease-fire yet, involving Foua and Kfarya on one hand, and Madaya and neighboring Zabadani on the other.

Wounded fighters and their families were evacuated simultaneously on both sides, and plans were made for more aid and evacuations. But those plans have stalled as people continue to become sick and die in Madaya — subject to one of the tightest sieges of the war, including what the United Nations calls “credible reports” of people being shot as they try to escape.

Civilians also suffer in rebel-encircled northern towns, though government helicopters make occasional airdrops.

The talks are complex and sensitive, involving discussions between Iran and rebel groups because Zabadani and Madaya are encircled mainly by Hezbollah, the Iran-backed Lebanese militia that supports Mr. Assad. There are divisions within the towns, too, with some accusing fighters of hoarding food and many debating what terms to accept.

In the meantime, dozens of people come daily to the Doctors Without Borders-affiliated clinic, said Khaled Mohammad, a nurse anesthetist there who shared photographs of a skeletal man, Suleiman Fares, 63, who was found dead by activists who brought food to his house.

Such images have galvanized alarm about the siege. Some of the photographs circulating are from other places in Syria and elsewhere. But the ones shared by Mr. Mohammad were new and corresponded with other witnesses’ accounts.

Samar Hussein, a nurse, was one of a dozen residents interviewed. She said she had spent $40 last month for a few spoonfuls of sugar for her 19-year-old daughter, who had passed out, and the baby her daughter was trying to breast-feed. She and several families recently shared a soup made with one cup of bulgur wheat, gathering together to cook it because there was little wood. On the street, she said, she saw a woman picking grass to eat and did not realize at first that it was her neighbor.

“She looks so different,” she said. “So skinny.”

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Starving Syrians in Madaya Are Denied Aid Amid Political Jockeying

© 2016. The New York Times.