In Eastern Ghouta, the scene of Syria's last major siege, residents are being slowly starved into submission.
Malnutrition cases among children are rife and shortages abound in everything from medicine to food. Even items that do make it through the tight blockade enforced by Syrian government forces are prohibitively expensive for most people living in the former breadbasket of Damascus.
A kilogram of sugar costs 12 times more in rebel-held Ghouta than a few kilometres away in the government-controlled capital, and cooking oil is nearly six times more expensive. A kilogram of rice, meanwhile, costs 2,900 Syrian pounds (Dh21) in the besieged suburb, compared to 225 pounds in Damascus.
“Malnutrition cases are so numerous,” said Hamza, a doctor who lives and works in Eastern Ghouta. “Many of the wounded here could have lived, but because we lack medications many have died. I have spoken to many of these patients, knowing that they would die.”
Doctors working with the Syrian American Medical Society (SAMS), which operates dozens of hospitals in opposition-held areas, say some 7,500 children in Eastern Ghouta are at risk of malnutrition or are already suffering from it.
But as the siege on the suburb continues and humanitarian organisations sound the alarms once again — the International Committee of the Red Cross saying earlier this week that the situation has reached a "critical point" — Syrian president Bashar Al Assad retains the military momentum in the wider war. The opposition is scattered and divided by infighting, and its weakened position on the ground has left it with little negotiating clout.
Last week, UN-brokered talks in Geneva collapsed due to the regime delegation's unwillingness to even broach the subject of a transition, with UN special envoy Staffan de Mistura lamenting the loss of what he described as a “golden opportunity.”
It now falls to the three powers with the most influence in Syria — regime allies Russia and Iran and rebel backer Turkey — to broker a peace settlement that builds on an earlier agreement that has greatly reduced violence across the country.
That deal, reached in the Kazakh capital of Astana, established several “de-escalation zones” around Syria. Despite occasional bursts of violence, and the ongoing siege in Eastern Ghouta, the de-escalation zones agreement has been largely successful, maintaining the military status quo and limiting the casualties that are a daily reality in Syria.
The challenge in the coming year for the three powers who brokered the Astana deal will be to see whether they are able to build on that agreement to reach a so far elusive peace.
“It has been proven that the Astana tripartite alliance is the only political initiative that has been able to deliver concrete results on the ground in Syria,” said Sinan Ulgen, a former Turkish diplomat. “The next step is much more difficult, to build the minimum common ground for a map to peace.”
Such a deal will be difficult to reach, however. The Assad government refuses to discuss the president's departure — the key demand of the opposition — while it maintains the military upper hand, and the agreement will need to address numerous controversial issues, including revising the constitution, future elections and how the different provinces, such as those with a Kurdish majority, will be governed.
Moscow, which is planning a national dialogue conference in the Russian city of Sochi next year, is eager to push on with talks in order to reduce the resources it is using in helping to Damascus to secure military gains. During a recent whirlwind tour of the region, Russian president Vladimir Putin announced that Moscow would begin a military withdrawal.
“Their message is to the Americans, that if we withdraw, how do you imagine things will remain stable in the de-escalation areas?” said one official in the Damascus-based opposition. “Who will fill the vacuum if we leave? It will be your rivals in the region, Iran.”
Ankara, which backs the Syrian opposition, has already conceded much. When asked about their stance on whether Mr Al Assad should remain in power, Turkish officials no longer outright demand his ouster, pointing to the fact that other powers have changed their positions.
“I see that it is not only Russia and Iran, now the US, even Saudi Arabia and France are more flexible on Assad,” said Turkish foreign minister Mevlut Cavusoglu at a recent briefing. “Assad might stay during the transition, this and that, different positions, different opinions. But here we should not be emotional, we should be very realistic. We need to unite all the different groups and it seems that it's not very easy to unite everybody around Assad after seven years of civil war.”
After years of being the opposition's stalwart supporter, Turkey is now primarily concerned with Kurdish expansionism in northern Syria along its border. Ankara considers the People's Protection Units (YPG), which led the campaign against ISIL in Raqqa, as indistinguishable from the Kurdistan Workers' Party (PKK), a separatist group fighting an insurgency against the Turkish state.
Those concerns prompted Turkey's military intervention in Syria last year, and its flexibility over Mr Al Assad's fate.
“Going forward, I think there is certainly going to be pressure on Turkey to concede on other points, including the potential role for Assad himself — namely the term limit and how long he will be allowed to stay,” said Mr Ulgen, who is also a visiting scholar at Carnegie Europe.
He said Turkey wanted to see "disconnected Kurdish cantons in Syria” rather than large connected areas under Kurdish control.
Militarily, the Syrian opposition never recovered from the loss of Syria's second city, Aleppo, the eastern half of which fell to a concerted assault by Russian airplanes, regime troops and allied militias from Lebanon and Iraq a year ago this month. Now, the opposition controls only Idlib province, parts of northern Aleppo's countryside, a portion of Hama province, and parts of northern Syria that are under Turkish tutelage.
“The choices in the field are few,” said one defected Syrian army officer who joined the ranks of the opposition. “But that does not mean the opposition forces are weak. It is impossible for the regime to take back Idlib, even with the Iranian and Russian armies, because of the immense number of opposition fighters and the large number of refugees who are all opposition.”
Despite the Astana deal, violence has continued sporadically. Meanwhile, Idlib is buckling under the weight of hundreds of thousands of refugees who were forcibly displaced there after ceasefire agreements with the government, and air strikes occasionally target the province. In April, the town of Khan Sheikhoun was subjected to a sarin gas attack that killed at least 80 people.
The opposition's cause has been harmed by infighting and the predominance of Hayat Tahrir Al Sham, an alliance led by Jabhat Fatah Al Sham, the extremist group known as Jabhat Al Nusra before its split with Al Qaeda.
Having now consolidated its hold on Syria's heavily populated eastern provinces and taken control of Deir Ezzor in the east by the Iraqi border, the Assad regime has little incentive to negotiate. Russia, meanwhile, has secured a foothold in the Middle East through its support of the Syrian government, signing an agreement with Damascus to continue using the Hmeimeem airbase in Latakia and the naval base in Tartus.
Moscow has found willing partners in Syria and the region partly due to US reticence about involvement in Syria beyond the narrow aim of defeating ISIL militarily, a goal that has now been largely accomplished with the group's loss of its main stronghold, Raqqa, and much of its territory in the east.
Russian and Turkish ambitions will run, however, against the competing interests of Iran, which is adamant that Mr Al Assad must stay and seeks an expanding role for its proxy militias like Hizbollah.
“The opposition, whether it is the broader opposition or those who are hand-picked to take part in conferences like Geneva, cannot ignore the question of Assad,” said the former Syrian army officer turned rebel military official. “The issue of Assad and a transition is not just a matter for these states to discuss, it is simply an irreplaceable demand if you want to begin resolving the crisis.”
As talks potentially lurch towards a settlement, the shape of a possible transition, a timetable for elections and even a system of governance will have to be decided.
“The Geneva process is dead, it no longer exists, and the narrowly defined opposition of Geneva has no popular legitimacy and no longer has international support,” said the opposition official in Damascus. “That definition needs to be expanded, and national dialogue and civil society dialogue are the way forward.”
But he said the talks need to go beyond simply revising the constitution and setting a date for elections. By themselves, changes in texts are not enough, and they must ensure broader participation by society in the political process and discussions over how the various provinces of the country that rebelled against the government will be managed.
“Looking into these issues I think can move us towards a more serious stability,” he added.