Forces loyal to Syrian President Bashar al-Assad pounded rebel-held areas of northern Aleppo on Saturday with almost 30 airstrikes, according to a monitoring group, bringing the total number of casualties after nine days of near constant bombing to 250.
At least five people were killed in Aleppo early on Saturday in the latest round of air strikes, which were believed to have been carried out by Syrian government warplanes, the Syrian Observatory for Human Rights said.
Since April 22, the death toll includes 140 people killed by pro-Assad airstrikes and shelling, including 19 children. Shelling carried out by rebels on the wartorn city killed 96, including 21 children, in the same period.
The United Nations condemned the recent surge in fighting across Aleppo, accusing both sides of displaying a "monstrous disregard" for civilian life.
"Wherever you are, you hear explosions of mortars, shelling and planes flying over," said Valter Gros, the head of the International Committee of the Red Cross (ICRC) in Aleppo, in a statement on Thursday. "There is no neighborhood of the city that hasn't been hit. People are living on the edge. Everyone here fears for their lives and nobody knows what is coming next."
The ICRC said the city is on the "brink of humanitarian disaster," and warned that "escalating violence is putting millions, many of whom are displaced and living close to frontlines, at grave risk and without a chance of getting much-needed aid."
While the northern Syrian city continues to be mired in violent exchanges of fire, the local truces declared by the Syrian army on Friday appeared to be holding in other areas recently blighted by fighting: The northwest coastal province Latakia and the outskirts of capital Damascus.
The exclusion of Aleppo from Friday's truces shows how pro-Assad forces are doggedly determined to gain full control over the northern city, which, before the war, was the largest in the country. Since 2012, Aleppo has been divided up into rebel and government-controlled zones.
The most recent uptick in fighting coincided with an announcement in a pro-government Syrian newspaper that said the country's military was preparing to recapture the city of 2 million. "Now is the time to launch the battle for the complete liberation of Aleppo," Syria's al-Watan paper said in an editorial on Thursday. "It's no secret that the Syrian army has prepared this decisive battle with its allies. It will not take long to begin, nor to finish."
On Wednesday night, an airstrike destroyed a Medicins sans Frontiers-supported hospital in a rebel-held area of northern Aleppo. Another two medical facilities were hit on Friday by government airstrikes — one in Bustan al-Qasr and the other in al-Marjeh.
Michael Van Rooyen, an emergency physician and the director of Harvard Humanitarian Initiative, told NPR that "targeted attacks on health care institutions that are clearly civilian facilities have escalated greatly" and that attacks on hospitals in Syria have been "the most notable and notorious example."
Van Rooyen added that its a clear violation of the Geneva Conventions to launch airstrikes on medical facilities, and that such attacks have made providing medical care in war zones an incredibly and increasingly dangerous undertaking.
"There are a range of symbolic and practical reasons why it's so important," Sharif Nashashibi, a London-based analyst of Middle Eastern politics told Al-Jazeera, explaining why Aleppo was excluded from the truce. "Aleppo is the biggest city, it's an economic hub, it's close to the border with Turkey. Since gaining support from Iran, Hezbollah and Russia, Nashashibi added, the Syrian regime finally feels that it is in a position to recapture Aleppo.
A Syrian military source told Reuters that Aleppo was excluded from the newly announced truces "because in Aleppo there are terrorists who have not stopped hitting the city and its residents… There are a large number of martyrs in Aleppo, which is why the situation is different there."
UN Special Syria Envoy Staffan de Mistura said on Thursday that the Syrian ceasefire, brokered by the US and Russia, was "still alive, but barely." He said fighters in some areas are still abiding by truce, but other places, like Aleppo, have seen a dramatic increase in casualties.
The quiet elsewhere in Syria on Saturday could make the ceasefire's chance of survival more promising.
"There aren't clashes in Latakia, there aren't clashes in Ghouta (Damascus suburbs)," Rami Abdulrahman, the director of the Syrian Observatory for Human Rights, said, adding that there were reports of scattered low-level violence between rival rebel groups outside Damascus.
A resident of Ghouta told Reuters that the government shelling ceased in the very early hours of Saturday morning.
"Until now there has been no military activity and no sound of bombardments in nearby areas, no sound of shelling or of warplanes," Maher Abu Jaafar said. "It's the opposite of last night, when there was a lot of bombing and the sounds of rockets and shells."
In a statement, the Syrian army did not clarify what military or non-military action constituted a "regime of calm" but did say that it would hold for 24 hours around Ghouta and Damascus, and for 72 hours in Latakia.
The UN has urged Moscow and Washington to press on with restoring the ceasefire and prevent the total collapse of talks aimed at ending the conflict in which more than 250,000 people have been killed and millions displaced.
Reuters contributed to this report