ISTANBUL // It was spring when the remaining people in Moadamiya, a besieged suburb of Damascus, started eating the leaves of trees because there was little else in the way of fruits or vegetables to put in their stomachs.
Four months later a serious shortage of food, fuel and medical supplies in the rebel-held neighbourhood has become even more acute.
Moadamiya is just six kilometres south-west of Damascus, where food is still freely available, if more expensive than ever. But an increasingly strict blockade put in place by regime military and militia units has left Moadamiya a world away from the malls and markets in Maliki, Kafa Susa and Abu Rumaneh still used by Syria's wealthy elites.
Grape vine leaves, stuffed with rice and meat and soaked in oil, are a traditional, much-loved meal in Syria. In Moadamiya, the vine leaves are being eaten without any filling, while the leaves from other trees, not usually considered food, are also being boiled and eaten.
"It's a terrible situation, people are eating whatever they can grow, they eat any leaves off the trees," said Abu Jafa, a leading opposition figure from Moadamiya, and one of a few hundred people still living in the district. "It's getting worse, we are under an intensive attack from all sides and the regime isn't letting anything in or out."
An unremarkable, sprawling suburb of cement block buildings, Moadamiya was home to some 50,000 people in the days before Syria's uprising began in March 2011.
There is no independent assessment of conditions inside the suburb and the activists' accounts cannot be confirmed. Journalists and aid agencies have been unable to enter for the past 10 months because of restrictions imposed by the Syrian authorities.
The World Food Programme, the UN's food agency, has made repeated efforts to deliver food to Moadamiya, all of them unsuccessful. Last week a WFP spokesperson said eight convoys had attempted to enter the district since October but were "either turned back, did not get approval or came under fire".
Fighting has been intense around the capital since rebels launched an assault last summer, with Moadamiya and neighbouring Daraya both coming under fire for taking an early stance in support of the uprising against President Bashar Al Assad.
The subsequent security crackdown, with peaceful protesters shot and arrested, has developed into an all-out war for control over these strategically important areas at the entrance to Damascus, with lightly armed rebels holding out against Mr Al Assad's large conventional army, reinforced by militia units loyal to the Syrian president.
Moadamiya has been routinely hit by artillery fire and air strikes since last year.
But in recent months, regime forces have sought to reassert control over areas of the capital and surrounding countryside in rebel hands and, as a part of that effort activists say, the siege on Moadamiya has been tightened,
Offensives by regime troops in other towns and villages that formed part of a tenuously held swathe of rebel territory have cut supply routes that once served as a lifeline.
"The situation has been very bad for some time in Moadamiya but it has worsened since the beginning of Ramadan as places held by the Free Syrian Army that used to send in assistance have come under attack and cannot help any more," said an opposition activist in Damascus who meets regularly with rebel fighters.
Meanwhile, international aid agencies working inside areas controlled by the Syrian authorities are dependent on special approvals from government departments in order to access neighbourhoods.
Humanitarian workers familiar with the process said those permissions had not been issued for Moadamiya.
"We have been in regular contact with the international aid organisations working in Syria and they are saying they cannot do anything about this without permission from the authorities and they are not getting them," said a Syrian involved in coordinating aid efforts in suburbs of Damascus.
Speaking over Skype from inside Moadamiya, Abu Jafa, a member of the local Islamic justice committee, which since its establishment last month has organised all relief efforts in the district, said even smuggled supplies were drying up.
"We used to be able to get some medicine and food through the checkpoints by paying bribes to militias but even that has almost stopped, and the regime troops shoot at anything that moves without their permission. Even the [pro-regime] militias are frightened of getting shot by their own side," he said.
Residents and refugees from Moadamiya say that every week to 10 days, a trickle of civilians do manage to pass through security checkpoints, either leaving or returning to the district, sometimes bringing several kilograms of bread, flour, powdered baby milk or medical supplies for those with chronic illnesses.
A bribe of US$200 (Dh735) might have to be paid to security forces in order to bring in $20 worth food and medicine, according to activists, with arrest a threat for those willing to risk passing through a checkpoint.
"Sometimes the older women will bring in bundles of bread - enough to feed three people for a day or two - but it is very expensive and they risk being killed for doing that," said a resident who fled from Moadamiya to Turkey with his family earlier this year.
In June hundreds of young men from Moadamiya, identifiable from their identity cards, were arrested at checkpoints in and around Damascus, according to opposition activists.
Most have since been freed, they said, but the detentions prompted another exodus of remaining civilians, and pushed others to join the ranks of rebel forces.
"Most of the young men have now left or are now in the Free Syrian Army. There are a few civilians left; those without any money to leave, or with no place to go if they do," the former resident said.
He described it as a "disaster area", recounting deaths from untreated illnesses and spreading malnutrition. A field hospital, staffed by two doctors, is unable to meet demands for even basic health care, activists said.
The main water supply has been out for months, so water is drawn from illegally dug wells sunk deep into the ground by locals during previous years of drought. Pumps needed to bring the water to the surface only work when there is enough fuel to run them.
"People are not starving to death at the moment, but that time is coming closer," said Abu Jafa, of the Islamic justice committee. "We urgently need everything but are getting almost nothing from outside, no help is coming."