BEIRUT — When hundreds of Islamic State militants muscled into the Yarmouk refugee camp last week and planted their black flags amid the charred, blown-out buildings, it was the latest trial for the remaining Palestinians who for two years have endured a suffocating government siege, starvation and disease.
The dire situation in the camp appears certain to deteriorate as the extremist group looks to consolidate its hold and establish a presence near the heart of the Syrian capital.
It is a high-stakes fight whose outcome may determine the direction of the civil war around Damascus, where President Bashar Assad has maintained a firm grip despite the presence of thousands of rebels in surrounding suburbs.
"The situation is catastrophic. There is barely food and water, and the only functioning hospital has long run out of medication," said a resident of the camp who communicated by writing on condition of anonymity Wednesday because of safety fears.
Heavy clashes continued in the camp, a week after extremists from the Islamic State group burst in from the Hajar Aswad district south of Damascus. They had settled in that area after being pushed out of regions east of the capital by Islamic rebels last year.
At least 18 civilians, including a humanitarian worker and a 12-year-old, have been killed in Yarmouk in the past week since IS attacked, Amnesty International said. One of Yarmouk's two surviving medical facilities, the Palestine Hospital, was struck April 1 by a missile, injuring six volunteers, it added.
"For civilians still trapped in Yarmouk, life is an agonizing struggle for survival. After enduring a crippling two-year-long government-imposed siege, now they are pinned down by sniper fire, fearing for their lives, as shelling and aerial attacks escalate," said Hassiba Hadj Sahraoui, Amnesty's deputy Middle East and North Africa director.
U.N. spokesman Stephane Dujarric told reporters the situation remains "extremely tense" for the 18,000 men, women and children trapped in the camp without safe access to water, food and basic health care. "In Yarmouk, where the fighting has been going on, it's a very urban setting, close-quarter fighting," he added.
The Islamic State group has created a fiefdom in areas straddling the Syria-Iraq border after declaring a self-styled caliphate last year. But prior to the assault on Yarmouk that began April 1, it did not have much of a presence in Damascus.
If it succeeds in maintaining its hold over Yarmouk and attracting more fighters to its cause, the group could use it as a gateway into central Damascus. It also gives the group a potential sanctuary where forces of the U.S.-led coalition were unlikely to strike because of the camp's proximity to the capital.
Cabinet minister Ali Haidar said Wednesday the Syrian government's "top priority" was to expel IS from the camp, indicating a large-scale military operation was looming.
"The Syrian state is not the party that chose the military solution, but rather those who had overrun the camp," he said. He spoke with reporters after a meeting with Palestinian Labor Minister Ahmad Majdalani, who was sent to Damascus this week to try to deal with the situation.
Salim Salameh, the Sweden-based head of the Palestinian League for Human Rights-Syria and a former Yarmouk resident, said he feared the military option will prevail, worsening an already catastrophic situation.
"There is collective starvation going on inside people's homes. Residents cannot go out to get food, which was already scarce before all this happened," he said.
Salameh, who fled Yarmouk in 2012, said the government has dropped 25 barrel bombs over the camp in recent days, causing unimaginable destruction.
"I fear Yarmouk will be another Kobani, minus the joy of liberation and the capacity for people to run from this hellhole to a safe area," he said, referring to the Kurdish town in northern Syria that was liberated from IS militants after five months of battles that reduced large parts of it to rubble.
Yarmouk was established in 1957 as a refuge for Palestinians forced from their homes with the 1948 creation of Israel. It has since expanded to include thousands of Syrians as well.
Once a lively community of about 160,000, it became an early victim of the Syrian conflict, which began in March 2011 amid Arab Spring-inspired uprisings. Some Palestinian factions based in the camp, including Hamas, sided with Sunni rebels fighting to topple the Syrian government, and it became a refuge for anti-Assad activities.
Most of its residents fled in late 2012 as rebels moved in amid fierce government attacks, with many heading to overcrowded Palestinian camps in neighboring Lebanon. The government blockaded Yarmouk, preventing the entry of basic supplies.
Since then, most of its residents have survived on food parcels that they call "Karateen," Arabic for "cartons," which the U.N. is allowed to bring in sporadically. Palestinian officials and Syrian activists say at least 200 people have died of hunger-related illnesses in the camp.
Located just minutes from the relative prosperity of Damascus, the camp's name became synonymous with death and starvation — a place where people brave sniper fire to forage for food, and where children die of malnutrition.
A photo released in March 2014 by UNRWA, the U.N. Relief and Works Agency that looks after Palestinian refugees, showed hundreds of gaunt camp residents lined up on a bomb-ravaged street, awaiting the distribution of food.
UNRWA spokesman Chris Gunness said the agency has been unable to deliver supplies since the fighting began April 1.
"That means that there is no food, there is no water and there is very little medicine. ... The situation in the camp is beyond inhumane," he said over the weekend.
The deteriorating situation prompted the U.N. Security Council to call an emergency meeting Monday to discuss Yarmouk, urging the safe evacuation for the Palestinians, protection for the refugees, and humanitarian access to the camp.
Mohammed, a resident of Yarmouk reached via Skype, said three Syrian rebel groups had joined the fight against IS in the camp, but that the militants controlled most of the neighborhoods. He said the militants occupied homes, arrested an unknown number of people, killed about 30, and beheaded some of them. Mohammed did not give his last name for fear of reprisals.
Other Syrian activists also have reported that militants carried out at least five public beheadings.
The fighting in the camp has largely pitted the Islamic State group against Aknaf Beit al-Maqdis, an anti-Assad Palestinian faction affiliated with Hamas. The group has reportedly been conducting indirect contacts with pro-Assad elements for a compromise that would result in lifting the siege of Yarmouk.
On March 30, Hamas official Yahya Hourani was gunned down in Yarmouk by two men on a motorcycle who then fled to Hajar Aswad neighborhood. That led to tensions and the arrest by Aknaf Beit al-Maqdis of several IS members suspected of involvement in the killing. Two days later, hundreds of IS fighters attacked.
Some have questioned how hundreds of fighters were able to storm a camp under a suffocating government siege, with some going as far as suggesting authorities facilitated their entry as an excuse to hit hard at the camp.
Palestinian officials and Syrian activists said the IS militants were aided by rivals from the al-Qaida affiliate in Syria, the Nusra Front, although the two groups have fought each other in other parts of Syria. Nusra maintains a presence in the camp.
Ali Baraka, the Hamas representative in Lebanon, said the attack was a joint IS-Nusra "pre-emptive" strike to foil any reconciliation taking place in the camp. He said he worried that the IS presence would give the government a pretext to destroy the camp.
Associated Press writer Bassem Mroue in Beirut, Albert Aji in Damascus, Mohammed Daraghmeh in Ramallah and Edith M. Lederer at the United Nations contributed to this report.