Air strikes destroyed a hospital and killed dozens of people in rebel-held areas of Aleppo, including children and doctors, in an attack that a U.S. official said appeared to be solely the work of the Syrian government.

The city of Aleppo is at the center of a military escalation that has undermined peace talks in Geneva aimed at ending the five-year-old war.

U.N. envoy Staffan de Mistura appealed to the presidents of the United States and Russia to intervene to salvage a ceasefire that was “barely alive”. The truce is intended to allow an opportunity for peace talks and delivery of humanitarian relief.

Six days of air strikes and rebel shelling in Aleppo, which is split between government and rebel forces, have killed 200 people, two-thirds of them on the opposition side, the Syrian Observatory for Human Rights says.

The “catastrophic deterioration” in Aleppo over the last 24 to 48 hours has jeopardized the aid lifeline that supplies millions of Syrians, said Jan Egeland, chairman of the U.N. humanitarian task force. “I could not in any way express how high the stakes are for the next hours and days.”

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