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Rescuers in Turkey and war-ravaged Syria searched through the frigid night into Tuesday, hoping to pull more survivors from the rubble after a 7.8 magnitude earthquake killed more than 4,000 people and toppled thousands of buildings across a wide region.

Authorities feared the death toll from Monday’s pre-dawn earthquake and aftershocks would keep climbing as rescuers looked for survivors among tangles of metal and concrete spread across the region beset by Syria’s 12-year civil war and refugee crisis.

On both sides of the border, residents jolted out of sleep by the pre-dawn quake rushed outside on a cold, rainy and snowy night. Buildings were reduced to piles of pancaked floors, and major aftershocks or new quakes, including one nearly as strong as the first, continued to rattle the region.

Rescue workers and residents in multiple cities searched for survivors, working through tangles of metal and concrete. A hospital in Turkey collapsed, and patients, including newborns, were evacuated from facilities in Syria.

In the Turkish city of Adana, one resident said three buildings near his home were toppled. “I don’t have the strength anymore,” one survivor could be heard calling out from beneath the rubble as rescue workers tried to reach him, said the resident, journalism student Muhammet Fatih Yavuz.

“Because the debris removal efforts are continuing in many buildings in the earthquake zone, we do not know how high the number of dead and injured will rise,” Turkish President Recep Tayyip Erdogan said. “Hopefully, we will leave these disastrous days behind us in unity and solidarity as a country and a nation.”

The quake, which was centered on Turkey’s southeastern province of Kahramanmaras, was felt as far away as Cairo. It sent residents of Damascus rushing into the street, and jolted awake people in their beds in Beirut.

It struck a region that has been shaped on both sides of the border by more than a decade of civil war in Syria. On the Syrian side, the swath affected is divided between government-held territory and the country’s last opposition-held enclave, which is surrounded by Russian-backed government forces. Turkey, meanwhile, is home to millions of refugees from that conflict.

The opposition-held regions in Syria are packed with some 4 million people displaced from other parts of the country by the fighting. Many of them live in buildings that are already wrecked from past bombardments. Hundreds of families remained trapped in rubble, the opposition emergency organization, called the White Helmets, said in a statement.

Strained health facilities and hospitals were quickly filled with injured, rescue workers said. Others had to be emptied, including a maternity hospital, according to the SAMS medical organization.

The region sits on top of major fault lines and is frequently shaken by earthquakes. Some 18,000 were killed in a similarly powerful earthquakes that hit northwest Turkey in 1999.

The U.S. Geological Survey measured Monday’s quake at 7.8. Hours later, a 7.5 magnitude one struck more than 60 miles away. An official from Turkey’s disaster management agency said it was a new earthquake, not an aftershock, though its effects were not immediately clear. Hundreds of aftershocks were expected after the two temblors, Orhan Tatar told reporters.

Thousands of buildings were reported collapsed in a wide area extending from Syria’s cities of Aleppo and Hama to Turkey’s Diyarbakir, more than 200 miles to the northeast. A hospital collapsed in the Mediterranean coastal city of Iskenderun, but casualties were not immediately known, Turkey’s vice president, Fuat Oktay, said.

Televisions stations in Turkey aired screens split into four or five, showing live coverage from rescue efforts in the worst-hit provinces. In the city of Kahramanmaras, rescuers pulled two children alive from the rubble, and one could be seen lying on a stretcher on the snowy ground.

Offers of help — from search-and-rescue teams to medical supplies and money — poured in from dozens of countries, as well as the European Union and NATO.

In a tweet Monday, President Joe Biden said he is “deeply saddened by the loss of life and devastation caused by the earthquake” and has directed his administration to “provide any and all needed assistance.”

In a statement, the president wrote that he “authorized an immediate U.S. response” to the crisis, directing members of his administration to offer aid to their counterparts in Turkey.

“Our teams are deploying quickly to begin to support Turkish search and rescue efforts and address the needs of those injured and displaced by the earthquake. U.S.-supported humanitarian partners are also responding to the destruction in Syria,” he wrote. “Today, our hearts and our deepest condolences are with all those who have lost precious loved ones, those who are injured, and those who saw their homes and businesses destroyed.”

State Department Spokesperson Ned Price similarly offered condolences during a Monday afternoon press briefing, joining Biden in “expressing our deepest condolences to the people of Turkey and Syria” in the aftermath. 

“We are determined to provide any and all assistance to help those affected by these earthquakes,” Price added, saying U.S. secretary of state Antony Blinken “just got off the phone with his counterpart Foreign Minister Çavuşoğlu of Turkey to reiterate the same message.”

On continued efforts to help in the wake of the devastation, Price said the secretary and senior staff met Monday morning to examine “various accounts to see what funding the might have available, what other resources we might have available to help our Turkish allies, to help through NGO partners on the ground, the people of Syria.”

“This is very early hours, but we’re going to be focused on this,” he said. 

The damage evident from photos of the affected areas is typically associated with a significant loss of life — while bitterly cold temperatures and the difficulty of working in areas beset by civil war will only complicate rescue efforts, said Dr. Steven Godby, an expert in natural hazards at Nottingham Trent University.

In Turkey, people trying to leave the quake-stricken regions caused traffic jams, hampering efforts of emergency teams trying to reach the affected areas. Authorities urged residents not to take to the roads. Mosques around the region were opened to provide shelter for people unable to return to damaged homes amid temperatures that hovered around freezing.

In Diyarbakir, hundreds of rescue workers and civilians formed lines across a mountain of wreckage, passing down broken concrete pieces, household belongings and other debris as they searched for trapped survivors while excavators dug through the rubble below.

In northwest Syria, the quake added new woes to the opposition-held enclave centered on the province of Idlib, which has been under siege for years, with frequent Russian and government airstrikes. The territory depends on a flow of aid from nearby Turkey for everything from food to medical supplies.

The opposition’s Syrian Civil Defense described the situation there as “disastrous.”

In a hospital in Darkush in Idlib, Osama Abdelhamid said most of his neighbors died. He said their shared four-story building collapsed just as he, his wife and three children ran toward the exit. A wooden door fell on them and acted as a shield.

“God gave me a new lease on life,” he said.

In the small Syrian rebel-held town of Azmarin in the mountains by the Turkish border, the bodies of several dead children, wrapped in blankets, were brought to a hospital.

The Directorate-General of Antiquities and Museums in Syria said the earthquake has caused some damage to the Crusader-built Marqab, or Watchtower Castle, on a hill overlooking the Mediterranean. Part of a tower and parts of some walls collapsed.

In Turkey, meanwhile, the quake damaged a historic castle perched atop a hill in the center of the provincial capital of Gaziantep, about 20 miles from the epicenter. Parts of the fortresses’ walls and watch towers were leveled and other parts heavily damaged, images from the city showed.

The USGS said the quake was 18 kilometers 11 miles deep.

At least 2,921 people were killed in 10 Turkish provinces, with nearly 16,000 injured, according to Turkish authorities. The death toll in government-held areas of Syria climbed to 656 people, with some 1,400 injured, according to the Health Ministry. In the country’s rebel-held northwest, groups that operate there said at least 450 people died, with many hundreds injured.

Huseyin Yayman, a legislator from Turkey’s Hatay province, said several of his family members were stuck under the rubble of their collapsed homes.

“There are so many other people who are also trapped,” he told HaberTurk television by phone. “There are so many buildings that have been damaged. People are on the streets. It’s raining, it’s winter.”