A United Nations resolution calling for a 30-day ceasefire in Syria appears "to be ink on paper," according to doctors working inside the besieged Damascus suburb of Eastern Ghouta, which suffered intense bombardment Sunday.
"Nothing has changed," Dr. Hamza Hassan said Sunday morning from Arbeen Hospital in Eastern Ghouta, hours after the UN unanimously adopted the resolution.
"The airstrikes are continuing. A maternity hospital has just been hit in Saqba (a town in Eastern Ghouta) and is out of service," he said of the offensive from the Russian-backed Syrian regime on the rebel-held enclave.
At least seven people are believed to have been killed since the resolution was passed, UN Humanitarian coordinator Panos Moumtzis told CNN on Sunday.
The airstrikes and artillery fire have concentrated on the outskirts of Eastern Ghouta, according to activists inside the city. Sunday's hostilities also included ground attacks for the first time in this offensive, they said.
More than 520 people have been killed and 2,500 wounded since the relentless bombardment of Eastern Ghouta began last Sunday.
The Syrian regime says it is targeting terrorists inside the enclave.
Meanwhile, rebel groups in the area have fired mortars into Damascus last week, causing dozens of deaths and injuries, Syrian state-run media SANA reported.
Who has agreed to the ceasefire?
A ceasefire in Eastern Ghouta would allow for the delivery of much needed medical supplies and evacuation of the wounded.
But after the ceasefire vote, Syrian UN Ambassador Bashar Ja'afari said the regime would continue to go after what it deemed terrorist groups.
"We practice a sovereign right of self-defense, and we will continue to fight terrorism wherever it is found on Syrian soil," he said, according to SANA.
Russia, a key ally of Syria, was accused by the United States of using its position on the UN Security Council to stall ceasefire talks, before eventually agreeing to the resolution Saturday.
Moscow has sought to lay the blame for the crisis at the door of the rebel groups, saying they have derailed talks to resolve the conflict and are preventing civilians from leaving the enclave.
Likewise, Iran, also an ally of Syrian President Bashar al-Assad's regime, sees the area as under "terrorist" control -- and therefore not applicable to the ceasefire.
"Parts of the Syrian outskirts that are under the control of terrorists are not under the ceasefire, and clearing operations will continue there," said Mohammad Bagheri, chief of staff of the Iranian Armed Forces, speaking at a defense gathering in Tehran Sunday, according to the semi-official Tasnim news agency.
Is this the next Aleppo?
As the death toll soars, analysts have raised fears the rebel-held enclave could face a similar fate to eastern Aleppo, which was all but destroyed in a government offensive in December 2016.
"It is highly frustrating that the resolution was adopted but we haven't seen a cessation in hostilities," said UN official Moumtzis on Sunday.
"We hope it will not be another Aleppo, with entire parts of the city destroyed."
Many in Eastern Ghouta, where close to 400,000 people are living under siege, have taken refuge in makeshift underground shelters.
And Dr. Hassan expressed concern the ceasefire agreement would fail to translate to real action on the ground.
"The people are waiting for translating the ceasefire and its content to actual implementation on the ground, that will stop the killing and bring in humanitarian goods to Eastern Ghouta," he said.
"Enough blood shed, there is not one person in a Syria who hasn't lost a family member, or dear person, or a friend. Everyone has been affected by this civil war in the past seven years."
The main rebel units actively holding territory in Eastern Ghouta are Islamist groups Jaish Al Islam and Faylaq Al Rahman, who have taken part in negotiations in the past, with small pockets of Hayat Tahrir Al Sham, a former al Qaeda affiliate, according to activists.