A surge in fighting and bombing has seen Syria's prospects of peace disintegrate
Syrian civilian deaths: 'As awful now as it's ever been'
The doctor in Eastern Ghouta listed the casualties of a bloody day. Five killed in one town, 12 in another, six, four, 11, and on and on. The numbers, in the region bordering the Syrian capital Damascus, would rise later as rescue workers dug the dead up from underneath the rubble of collapsed buildings.
His colleagues in the northern province of Idlib had treated more than a dozen cases of civilians falling ill due to a suspected chlorine attack on the city of Saraqeb.
But in Eastern Ghouta, 78 people would be counted among the dead before the night was over on Tuesday, another 36 perished on Wednesday and at least 38 on Thursday, according to activists. The orgy of killing signalled the brutal collapse of what had been fragile nationwide ceasefires. Also dead was yet another halting peace process for Syria.
"It is mass killing, and we demand the protection of civilians, and we want our voice to reach decision-makers, because this bombing, destruction and killing are systematic," the doctor said.
The unrelenting bombardment of Eastern Ghouta and Idlib, last strongholds of the Syrian opposition to President Bashar Al Assad, inaugurated a new phase of the nation's seven-year-long war. It also heralded the violent end of a "de-escalation" agreement, brokered by Russia, Iran and Turkey, to reduce violence in Syria and prepare the ground for peace talks.
Those talks are in tatters. A Moscow-sponsored national dialogue congress in the city of Sochi was a debacle, boycotted by key components of the opposition. Its only saving grace was the creation of a committee to write a constitution, one that is unlikely to achieve much without an actual end to violence.
"What's happening on the ground in Syria is really awful self-evidently, but feels as awful now perhaps as it's ever been before, and we're on the verge of potentially very significant humanitarian catastrophes," said a European diplomat.
All throughout Syria, except in areas firmly under the government's control, the violence has escalated precipitously. The United Nations decried the "extreme" suffering of civilians in a statement this week, urging a month-long ceasefire nationwide that would allow the urgent transfer of humanitarian aid.
In Idlib, more than 300,000 people have fled ongoing fighting towards major population centres and the Turkish border since mid-December last year. The figures represent one of the largest mass movements of people since the war began, prompted by a major ground offensive by the Syrian regime into the province, the first such campaign since it fled the area three years ago.
That campaign has escalated despite Idlib being a "de-escalation" zone, with days of relentless bombardment following the rebel downing of a Russian fighter jet over the weekend and the subsequent death of the pilot. The jihadist group, Hayat Tahrir Al Sham (HTS), the latest incarnation of the former Al Qaeda affiliate, militarily dominates the province.
Aid workers there say several hospitals have been bombed, some more than once in a largely successful effort to put them out of service and deter civilians from using them. Idlib is already home to hundreds of thousands of internal refugees who fled there after negotiating surrender deals with the government in other parts of Syria.
Elsewhere, proxy battles continue on Syrian territory. The US-led coalition against ISIL said it had repelled an assault on its allies on Wednesday night by militias loyal to Mr Al Assad in Deir Ezzor in eastern Syria. The US said it was in contact with Russia, the regime's ally, before, during and after the attack.
Turkey meanwhile has continued its campaign in the majority-Kurdish enclave of Afrin, a battle that has progressed slowly amid resistance from Syrian Kurdish militias there. Ankara considers the militias that dominate the area as wings of its own Kurdish insurgency, and has sought to displace them from the border. In the battle, Turkey is relying on Syrian rebel forces that have lost all their other international backers.
That campaign is likely to take months, along with the other myriad conflicts prosecuted by international powers on Syria, an overall war that has grown more complicated as it drags on and global actors settle their proxy conflicts.
In Eastern Ghouta, the surge in attacks has coincided with the sharp rise in violence in Idlib. The region, once a breadbasket for the capital Damascus, has been under siege for years, and a particularly strict blockade since April last year.
Recent aid deliveries have partially alleviated the suffering of civilians, where children had died of malnutrition. But the recent bombardment appears calculated to punish the opposition for the failure of the Sochi conference, and perhaps force them to surrender the region as the conflict heads into its eighth year.
"Whenever anything happens on the political or military level the revenge is extracted from the civilians," said the Eastern Ghouta doctor. "The result is more victims, children, women and the elderly, the destruction of homes, the killing of all reason to live."