BANI SAIFAN, Yemen — The family of Osama Hassan faced a wrenching choice as his tiny body wasted away. Should they use the little money they had, in a time of war, to take the 2-year-old to a hospital? Or should they buy food to feed their other children?
His family chose food.
Outside their hut, Ahmed Sadek grimly observed his frail grandson, who was lying on a wooden cot and staring blankly at the gray sky. His hair was sparse, his teeth decayed, his arms sticklike. He could no longer walk on his spindly legs.
With every raspy breath, Osama's ribs protruded through his dry skin.
"There's nothing we can do for him," Sadek said. "I know he's going to die."
Every day children are perishing in rural Yemen, where two-thirds of the nation's population lives. Parents are forced to decide between saving their sick children and preventing healthier ones from following the same perilous route. Cemeteries in this desperately poor and rugged stretch of villages in the northwest contain the bodies of children who have recently died of hunger and preventable diseases. Most are buried in unmarked graves, their deaths unreported to authorities.
The more fortunate are taken to a hospital, often hours away on broken roads. Survival, though, is bittersweet. Families are often bankrupt after paying for medical care, and the children return home to the same cycle of war-induced poverty and malnutrition.
Hunger has long gripped the Middle East's poorest country, its hold tightening as the nation collapsed after the 2011 Arab Spring uprising that toppled President Ali Abdullah Saleh. But Yemen's 20-month-old civil war has brought the country closer to famine.
The health system and other safety nets that caught many children before their bodies withered away are frayed or have disappeared. International aid agencies are facing a multitude of barriers, including airstrikes by a Saudi-led coalition helped by the United States and obstruction by the rebels who rule the capital, Sanaa, as well as the main northern sea port of Hodeidah.
The U.N. Children's Fund estimates that 370,000 Yemeni children are severely malnourished and facing death, and 2 million are in urgent need of help.
"This is an entire generation that's at risk here," said Erin Hutchinson, Yemen director for the aid agency Action Against Hunger. "We're seeing a worsening situation as the conflict continues, and it's not stabilizing. The needs are only deepening at the moment."
Osama was born prematurely six months before the war started. Underweight, his first view of the world was from inside an incubator. His father worked in Saudi Arabia as a laborer, like tens of thousands of others in Hajjah province, which borders the kingdom. His grandfather sold grain from the family's small farm at the base of a craggy mountain.
There was money, but not much, to take Osama to a hospital.
By March 2015, northern rebels known as Houthis had seized the capital and forced President Abed Rabbo Mansour Hadi into exile, fracturing the nation. Saudi Arabia and other Persian Gulf countries entered the conflict to restore him to power with the Pentagon providing weapons, intelligence and other forms of support.
The rebels, aligned with Saleh's loyalists, control the northwest, while portions of the south and east are held by forces backing Hadi's government. Radical Islamists, including al-Qaida's local branch and an emerging Islamic State affiliate, rule areas that aren't under government or rebel control.
Few aid agencies operate in Bani Saifan and other remote areas. Hospitals have been destroyed by airstrikes or depleted of medicine partly because of a Saudi air and naval blockade. Jobs have disappeared as the violence and siege have torn up Yemen's economy and displaced more than 3 million people, nearly half of whom are children.
With the border closed, Osama's father never returned from Saudi Arabia. Soon, his remittances stopped. The child's grandfather and uncle care for him, his mother and three siblings, as well as 20 other relatives.
"This year is more difficult than last year," said Sadek, a thin man with a white beard. "Many people can no longer afford to buy my grain. They are suffering like us."
Osama's body began to break down this year. Unable to afford fruit, vegetables and other nutritious foods, his family fed him a diet of goat's milk and biscuits. Unclean water and poor sanitation abetted his decline.
Three children have died of hunger in their village this year, Sadek said.
Other families in Bani Saifan face a similar situation. Four months ago, Faris al-Shamiri buried his 9-month-old daughter, Samah, in a cemetery near their home.
"A lot of children are buried there," Shamiri said. "Two months old, 6 months old, they are of different ages. Most of them have died of hunger."
Samah had stopped eating. But Shamiri delayed taking her to the hospital because he didn't have money, and prayed that she would improve. Samah died in the intensive care unit.
Help for the region is hardly on the way.
The Houthi administration is struggling financially as the war strangles the economy. And the United Nations has raised less than half of its appeal to international donors this year as Yemen remains in the shadow of Iraq, Syria and other crises.
"Yemen ultimately is a media blackout," said Jamie McGoldrick, the top U.N. humanitarian official in the country. "It's not getting the attention it deserves. It's not Aleppo. We don't have drones flying over it showing the destruction. We don't have a Mosul, which has BBC cameras 24-7 on it."
Osama's uncle took him to the nearest government clinic, a bumpy journey on a motorcycle taxi that lasted an hour.
There was no doctor to serve the district's population of 70,000. The staff hasn't been paid in three months. Medicine and supply cabinets were empty.
A nutritional supplement provided by UNICEF to treat severe malnutrition, a peanut-base paste known as Plumpy'Nut, had run out. The Houthi authorities have not cleared deliveries for weeks, said Bismarck Swangin, a UNICEF spokesman. He added that 240 health facilities in the north and coastal areas were facing the same predicament.
Vaccines and other essential supplies have also sat for months in neighboring countries, awaiting approval from the Houthis. The rebels, long suspicious of the West and running out of resources, seek to control and direct the flow of aid, Western aid officials say.
"You've got two levels of a blockade, really," said a senior U.N. official who spoke on the condition of anonymity to avoid jeopardizing relations with the rebel government. "The blockade which is the result of the [Saudi-led] coalition, an economic blockade of the country. Inside that blockade, you have some elements of the [Houthi] authorities who are making life so incredibly complicated. The medical response is not as effective as it could be.
"There's a malnutrition crisis in the country," the official added, "and yet the overall government approach seems to show no sense of urgency."
Mohammed Albukhaiti, a Houthi political official, denied the allegation. He blamed the crisis on the Saudi-led coalition, saying that it "has stopped many medicines from coming into the country and [is] selective in what they allow to enter." The coalition has publicly blamed the Houthis for Yemen's humanitarian woes.
At the government clinic, the need for urgency is unmistakable. Last month alone, 116 children under the age of 5 arrived with severe malnutrition, 17 of them from Bani Saifan.
"Can you help my child?" pleaded Zahra Meksha, who was carrying her malnourished 4-year-old daughter, Widad. She explained that her husband was unemployed and that they were surviving on milk and yogurt.
"We can't do anything for her," said Hassan Chailan, the clinic's malaria coordinator. "She needs to be admitted to a hospital for at least a week."
The clinic advised Osama's uncle to take the child to a therapeutic feeding center at the main government hospital in Hajjah city, the provincial capital. But the trip there, a three-hour drive from their village, costs $50, a princely sum in Bani Saifan.
Two weeks after his clinic visit, Osama was still at home, his face gaunt and taut like an old man.
By then, his grandfather had made a decision. There were too many mouths to feed in the family, including Osama's 4-year-old brother, who had also suffered from malnutrition but was improving.
"This is God's judgment," Sadek said, looking first at Osama, then at his other grandson. "What can I do?"
Even when a child is taken to the hospital, there are no guarantees.
Ali Humeit and his wife, who live less than a mile from Bani Saifan, took their 5-year-old son, Rayaan, to the malnutrition ward of Hajjah hospital.
It was a return visit.
In October, Rayaan was hooked up to an IV drip and given nutritional supplements and medicine. He recovered his appetite in 10 days. But when he returned home, he began to lose weight fast. His parents could only afford to feed him water, milk, tea and bread.
"Since the war began, I have not been working," said Humeit, who was a construction worker before the conflict.
For the first hospital visit, Humeit borrowed $150 from other villagers. This time, he was forced to beg on the street, he said. At night his wife sleeps with their child at the hospital, and he beds down free on the floor of a nearby mosque.
With four other children to feed, Humeit has prepared himself for the most agonizing decision of his life if Rayaan gets ill again.
"If I don't have money, I can't bring him back," he said, looking at his son, who was visibly irritated and crying. "I'll have to leave him at home, and let God handle it."
Abdul Fatah Baashami and his wife never got to see their only child, Nabil, walk or talk.
Eight months ago, the signs of hunger emerged: swollen stomach, loss of weight. Nabil refused to breast-feed. So his parents carried him to nearby private hospitals, then to the same clinic where Osama had been taken. But he still teetered between life and death.
Then last month, Baashami's father died. As the eldest son, he was suddenly responsible for 18 relatives. He earned $1 to $3 a day as a laborer - whenever he found work.
"I owe a lot of people money —$650," he said.
When Nabil's health deteriorated, the couple borrowed more money to take him to the hospital in Hajjah.
"My son was just skin and bones," recalled Najua Showken, 18, his mother.
In the morning, an hour before their trip, she tried to breast-feed Nabil. Too weak to respond, he began to fade away. Drifting in and out of consciousness until his "eyes were rolling up," he finally went silent, his mother said.
"He died in my arms," she said.
Nabil had lived for 14 months.
Three hours later, after Nabil's body was washed and wrapped in a white cloth in accordance with Muslim ritual, he was placed in a grave at a cemetery a short walk from their home, where eight other children were buried this year.