Bashar al-Assad’s regime is carrying out yet another massacre in full view of the world. The bombardment of Eastern Ghouta, an agricultural area of 400,000 people that is one of the last pockets of rebel-held territory near the Syrian capital, has killed at least 426 people, including at least 98 children, since Sunday, according to the Syrian Observatory for Human Rights.

The Assad government and its ally, Russia, claim to be targeting only military positions, and they blame the violence on rebels firing mortars into Damascus. But aid workers say army helicopters have been dropping barrel bombs—crude, indiscriminate weapons useful only for killing civilians—on marketplaces and medical facilities. Local insurgents also claim that Russian warplanes have been involved in the bombing, which Moscow denies.

Ghouta, under siege since 2013 and facing acute shortages of food and medicine, has already seen some of the worst suffering of the Syrian war, including the infamous 2013 chemical weapons attack that killed hundreds. With most residents now living in shelters with little access to food or medicine, conditions have become truly dire. U.N. Secretary-General António Guterres* described it as “hell on earth” in a speech to the Security Council.

The international response to the attacks is following a well-established script. The U.N. Security Council is working on a resolution calling for a nationwide cease-fire to allow medical evacuations and aid deliveries. Russia wants changes to the resolution: While the cease-fire in the draft agreement would not apply to strikes against ISIS and the formerly al-Qaida–linked Nusra Front, the Russians also want exceptions for other groups that have cooperated with them .

This could include the two main rebel groups in control of Eastern Ghouta, which have fought alongside Nusra in the past, meaning that the bombing could continue. Western governments accuse Russia of stalling for time to allow Assad to wipe out the resistance in Eastern Ghouta, possibly wiping out Eastern Ghouta itself in the process.

While the recent reports and photographs coming out of Eastern Ghouta have been as heart-wrenching and disturbing as anything seen so far in this very brutal war, the response from the Western media and governments seems muted compared with reactions to the 2016 siege of Aleppo or other Syrian atrocities. Last year, President Trump was so moved by the pictures of the “beautiful babies” killed by a chemical attack in Syria that he launched a missile barrage against Assad’s air force. Why no similar concern for babies like 35-day-old Samar Dofdaa, pictures of whom sparked brief international outrage when he died of malnutrition a day after being photographed at a clinic in Eastern Ghouta? (For what it’s worth, if the distinction comes down to death via chemical vs. conventional weapons, there have also been unconfirmed reports of chlorine gas being used in Eastern Ghouta.)

Part of the answer is no doubt simply atrocity fatigue. After almost seven years of fighting, the world has become hardened to images of suffering coming out of Syria.

It’s also likely that the increasing complexity of the situation in Syria works to Assad’s advantage. The conflict may have begun as a fight between Assad and the rebels, each backed by various outside powers, but now there are at least three other major conflicts in the country. First, while it’s been winding down this year, the U.S.-backed war against ISIS in Eastern Syria is still ongoing. Second, Israel and Iran are inching ever closer to outright armed conflict on Syrian soil. Third, there’s the recent Turkish incursion targeting Kurdish fighters along the Syrian-Turkish border.

In addition to the Eastern Ghouta campaign, Assad’s major initiative of the past week has been sending pro-government militias to fight alongside the Kurdish YPG against Turkey in the contested enclave of Afrin. Kurds have long been marginalized under Assad’s rule, and the YPG, which seeks an autonomous Kurdish region within Syria, is technically opposed to the government. But the two have mostly avoided confrontation while each fights against other enemies, and it’s not a huge shock to see them team up against their mutual enemy: Turkey.

Kurdish fighters also make up a significant component of the Syrian Democratic Forces, the main force working with the U.S. to fight ISIS. This means that at the same time the U.S. is condemning Assad’s actions in Eastern Ghouta and remains committed to his ouster, the main U.S. allies in Syria are cooperating with Assad to fight against America’s NATO ally, Turkey.

These dizzying dynamics undermine everyone’s leverage to put pressure on Assad to step aside—or at least halt his massacres—and can only benefit the Syrian leader’s efforts to cling to power at all costs.

The battle lines, alliances, and rivalries may be shifting rapidly as the war enters a new and unpredictable phase, but the one constant is that Syria’s civilians are bearing the brunt of the violence.