Gaziantep, Turkey – It was a tiring surgical operation, but for the nurses at the Damascus Specialist Hospital in Eastern Ghouta, the work was still not done.

After the procedure was over, workers came over to collect used tubes, syringes, gloves and sundry medical supplies from the operation theatre that would be considered medical waste in any other hospital.

On this day, they had already collected more waste from the hospital’s different wards.

Damascus Specialist Hospital, located in Eastern Ghouta’s Douma area, is one of the few medical centres still able to provide limited medical services to some of the 400,000 inhabitants of this suburb of Syria‘s capital, Damascus.

“We clean the single-use medical supplies because they’re not available here, and UN’s aid isn’t bringing it,” says Omar Mohammed, who is the manager of this facility. He says the hospital stopped some medical procedures because of a lack of anesthetics.

Doctors say the government of Syrian President Bashar al-Assad is blocking surgical equipment and supplies as part of a punitive siege of rebel-held Eastern Ghouta that has entered its fourth year.

Sick are dying

Doctors in Douma are angry and frustrated because they have been forced to decide who must live and who must die. They try to save the patients who have the maximum chances of survival.

Medicine is being rationed and people are dying of complications due to the limited availability of simple procedures like dialysis.

The doctors are also upset with the United Nations because the medical evacuation of 452 people from the besieged enclave has been held up by bureaucratic delays.

Since July, nine people on that list have died and medical workers fear many more will follow.

They have identified 29 patients with a 100 percent chance of survival, but they will die if they do not receive medical care soon.

The list does not include late-stage cancer patients, people with terminal illnesses, senior citizens and others who need urgent medical care but whose chances of recovery in the coming years are slim.

The selection process involves screening patients in Eastern Ghouta by specialists, who then identify those for whom no treatment is available. These patients are then referred to a Syrian Arab Red Crescent (SARC) sub-branch in Douma or Harasta.

The SARC then approves or rejects the case according to the evaluation and the availability of resources.

Syrians are facing their seventh winter since the 2011 uprising began [Bassam Khabieh/Reuters]

“The most painful are the cases involving patients with conditions that do not require advanced medical equipment or specialty treatment but simply specialised drugs” one aid worker told Al Jazeera on the condition of anonymity, citing kidney-transplant and haemophilia patients as examples.

“The doctors in Eastern Ghouta have the ability to provide the necessary medical care but the issue is one of a lack of medicines.”

No food

UN reports and Al Jazeera interviews in Eastern Ghouta confirmed reports that local residents are drinking large amounts of water to suppress hunger, with food intake reduced to one meal a day.

The Assad government has allowed in some aid but the UN says its current level of assistance covers just about 10 percent of the besieged population of Eastern Ghouta.

This year, the Syrian government has approved only 26 percent of UN requests to deliver assistance to besieged areas. From this amount, the ministry of foreign affairs has the authority to remove any item.

Local agriculture has been in decline, but it is still the only lifeline for the besieged population.

People in Eastern Ghouta are eating boiled corn, cabbage and cauliflower because of a lack of cooking fuel, cooking oil and other basic essentials.

War economy

Locals say Eastern Ghouta has not run out of all foodstuff.

Flour and several other food items are available, thanks to smuggling through tunnels and porous government checkpoints.

However, due to the large sums that have to be paid as bribes, prices have skyrocketed.

Petrol and diesel that costs half a cent a few miles away, is available for nothing less than $4 a litre. “My family can’t buy anything. Sugar, tea, a bag of bread – it’s all out of our reach,” Om Tahsin of Eastern Ghouta told Al Jazeera.

“A kilogram of tea costs nearly 60,000-65,000 Syrian pounds ($100), Sugar around 15.50.”

Predictably, smugglers from all sides of the conflict are getting richer.

One doctor who spoke to Al Jazeera on the condition of anonymity said, on some occasions when they have money, they buy medicine from regime-controlled areas.

“What would cost one dollar there, would cost us $4, sometimes as high as $5, in Ghouta,” he said.

UN blamed

Doctors and medics are frustrated with what they see as UN red tape, saying it is preventing the different agencies of the organisation from saving lives.

One source, who is privy to UN meetings where reports from the regional hubs in Damascus, Gaziantep and Geneva are discussed, told of the utter lack of urgency at a UN meeting in September, months after the list of people in need of medical evacuation was provided.

“The UN’s base of operations [the Four Seasons Hotel] is less than ten kilometres from an area where people are dying of hunger and preventable diseases. Yet all that the UN does is wait for permission from the Assad government,” the source told Al Jazeera.

Another senior member of one of the UN partner agencies described the situation in Eastern Ghouta as “shameful and disgraceful” on the part of the UN.

Starving children

Corn [maize] cobs are the most popular dish these days. Then there is boiled corn, which many cannot afford for individual family members. For larger families, there is corn broth, with a sprinkling of salt for those who can afford it.

Rahaf, 12, suffers from cerebral palsy, a condition that inhibits her brain’s growth. While her mother spoke to Al Jazeera, she played with her siblings in a dark room, power cuts being a feature of daily life in Eastern Ghouta.

Rahaf’s mother showed Al Jazeera photos of her daughter as a healthy girl before the siege began and when medicines were still available. When Rahaf’s diet used to have honey, milk and other nutritious food, she could go to school.

Um Rida became emotional as she described the pain of living below the subsistence level. “I don’t have enough because my husband cannot work, and due to high prices, we can’t afford much,” she said.

Power cuts are frequent in Eastern Ghouta, which is under a government siege [Bassam Khabieh/Reuters]

Zeid Ra’ad Al Hussein, the UN rights chief, has described the plight of civilians in Syria’s besieged areas as an outrage and says it could constitute a war crime.

A recent UN report quotes Salma, a schoolteacher in Kafr Batna, as saying: “I asked my students to draw their dreams and it broke my heart when I saw that the dream of children has become a falafel sandwich.”

Syria’s conflict, which started with peaceful anti-government demonstrations in March 2011, escalated into a full-blown war that has claimed more than 300,000 lives and driven about half of the country’s pre-war population of 22 million from their homes.

Forces loyal to Assad and those opposed to his rule continue to battle each other, as well as fighters from the Islamic State of Iraq and the Levant (ISIL) group.