A general view for the besieged town of Madaya, in the countryside of Damascus, Syria, shown in January 2016. Before war came to Syria, Madaya was a weekend retreat for the wealthy. (Youssef Badawi/EPA)

When an 11-year-old boy was shot on his rooftop in the Syrian town of Madaya last week, there were no doctors at the makeshift hospital to treat his wounds. Nor were there painkillers to ease his death.

For Muhammad Darwish, a dentistry student on hand to help that day, the boy’s death was the final straw. His two remaining colleagues — one a trainee, the other a vet — felt the same. And so finally, after four years of struggle and siege, they did the unthinkable: They closed the hospital for good.

“We felt so ashamed. But we had nothing. We could do nothing,” Darwish said. “We’re closed.”

Before war came to Syria, Madaya was a weekend retreat for the wealthy. Tourists from nearby Damascus would stay in hotels near peach orchards, taking in the fresh air and lining their suitcases with the wares of a roaring local smuggling racket. Now, the only newcomers are displaced Syrians — by some estimates making up half of the population of 40,000 — and the only goods that pass the checkpoints come on aid trucks.

Blockaded by Syrian army and Hezbollah forces since 2015, this opposition-held town has instead become an embodiment of the suffering experienced by communities under siege across the country, as well as the fraught politics of aid that has failed to address those challenges.

To the untrained eye, Madaya’s makeshift hospital would not have looked like much. The basement room was rented, and the specialist who trained the students and the vet had long since departed. But for years, that small team had acted as a lifeline as the town’s three medical facilities were bombed, amputating limbs lost to land mines surrounding the town and removing the bullets from government-allied snipers.

The team will now stay at home, responding only to the most serious emergencies. “We can’t face staying open. If we can diagnose the problem, then we don’t have drugs to treat it. If a patient needs to be evacuated, we can’t make it happen,” Darwish said.

According to Siege Watch, an advocacy group monitoring conditions in blockaded areas, almost a million Syrians are living under siege across 39 locations, most of them blockaded by forces allied with President Bashar al-Assad’s forces. Monitoring groups say that more than 800 people have died from a lack of food or medicine since 2011.

The United Nations has described the government’s strategy as “surrender or starve.”

In August, civilians and rebel fighters were evacuated from the Damascus suburb of Darayya, one of the area’s most stubborn rebel holdouts, to end the longest-running blockade of the war. A similar evacuation, described by the government as a reconciliation deal, is underway in besieged al-Waer, the final rebel-held neighborhood in the central city of Homs.

In December, photographs of starving and skeletal civilians in Madaya prompted global outrage and forced Syrian authorities to permit more regular aid convoys to reach the area. But with only carbohydrates arriving on the food trucks, residents instead now show signs of malnutrition and kidney problems, health workers in Madaya said this week.

“It was never enough,” said Ammar Ghanem, a Syrian physician in Michigan who has advised Madaya’s health workers remotely. “The food keeps them alive, but it doesn’t bring real nutrition.”

Madaya is surrounded by nearly 6,000 land mines and 65 sniper-manned checkpoints to ensure residents cannot flee, local authorities say. Those who try are routinely injured, often killed.

When casualties arrived at Madaya’s hospital, Ghanem was among a group of U.S.-based doctors who would parse case details via WhatsApp, running through possible treatment options. In most cases these days, there isn’t a solution.

“Our colleagues in Madaya are doing the jobs of physicians, anesthetists and cardiologists,” Ghanem said. “They are heroes. But they just aren’t medical staff.”

Darwish still remembers his first operation, hovering at the specialist’s side and passing tools when needed. Within a year he had conducted C-sections and amputations alone. But as the siege wore on and drug supplies ran low, his team increasingly was unable to help even the most basic of medical cases.

According to aid workers and a U.N. interagency report from September, conditions in the town have deteriorated significantly. The price of sugar is 17 times higher than that found just 30 miles away in the markets of Damascus. A water crisis has left residents dependent on springs where government-allied snipers train their sights. Even salt is a luxury, mostly taken from stocks once used to cover icy roads.

But ending the blockade, or bringing in more supplies, will be a knotty process.

Under the “Four Towns” agreement, U.N. and Red Cross aid convoys to Madaya and nearby Zabadani are allowed through only if equivalent access is given to two government-held towns that are besieged by rebels, Foa and Kefraya, in northern Idlib province. When the supplies do arrive, the government decides what gets through.

“As long as the Syrian government retains the authority to deny aid deliveries and restrict the amount and type of aid that can enter towns it is besieging, it is unlikely that conditions will improve in Madaya and other besieged towns across the country,” said Elise Baker, a research coordinator at Physicians for Human Rights. “One-off aid deliveries are not enough to alleviate the suffering and save lives.”