President Donald Trump warned of a “big price to pay” in response to reports of a chemical attack outside Syria’s capital, days after he said he wanted to quickly end the U.S. military presence in the war-torn Middle East country.

Rescue workers and activists said dozens died in a chemical assault amid renewed fire by Bashar al-Assad’s government on a rebel stronghold near Damascus. The use of chemical weapons in April 2017 provoked a U.S. missile strike, the first direct American hit on Assad’s regime since the conflict in Syria began in March 2011.

While Trump has said he wants U.S. troops out of Syria “very soon,” he posted tweets Sunday condemning the attack and saying Russian President Vladimir Putin and Iran “are responsible for backing Animal Assad.” The episode thrust the U.S. and Russia into a new confrontation, with Moscow warning against any military strike and Washington calling for an immediate international response.

“Big price to pay,” Trump said on Twitter. “Another humanitarian disaster for no reason whatsoever. SICK!”

Syria’s official Sana news agency denied the reports, saying the rapidly advancing army “doesn’t need to use any chemical weapons as the media channels that support the terrorists are fabricating.” It cited an official it didn’t identify.

Russia, whose military backing of Assad helped turn the course of the war in his favor, denied that Syrian government forces deployed chemical weapons in Douma, according to the Tass news service, which cited Major General Yuri Yevtushenko. Russia plans to send specialists to analyze the scene once militants are expelled from the area, and said the data will refute claims of chemical use, Tass reported.

The Foreign Ministry in Moscow warned that any foreign military strike against Syria over “fabricated” reports of chemical warfare may lead to the “gravest consequences.”

More than 40 people suffocated due to exposure to an unknown chemical agent, the White Helmets, an opposition-linked civil defense force that operates in rebel areas, said on Twitter. Images of lifeless children and women foaming from their mouths were circulated on social media. Fatalities could exceed 100 people, according to the Syrian National Coalition, an opposition umbrella group.

“Reports from a number of contacts and medical personnel on the ground indicate a potentially high number of casualties, including among families hiding in shelters,” the U.S. State Department said in a statement. “These reports, if confirmed, are horrifying and demand an immediate response by the international community.”

France’s Foreign Minister Jean-Yves Le Drian said the attacks on Douma were a “flagrant violation of international humanitarian law.” Le Drian called for the UN Security Council to meet on the matter as soon as possible.

Last year’s U.S. Tomahawk missile strike increased tensions with Russia, which has backed Assad in his battle to suppress an uprising that morphed into a regional proxy war. The State Department said in its statement that Russia “ultimately bears responsibility for these brutal attacks” and has “breached its commitments to the United Nations as a framework guarantor” to a 2013 agreement to strip Syria of its chemical weapons stockpiles.

Internal rift

Internal divisions in the Trump administration over how to address Syria leave Russia, Iran and Turkey, not the U.S., “calling the shots in Syria,” said Andreas Krieg, assistant professor of defense studies at King’s College, London.

“Washington is in no position to take any action, and Russia knows that,” Krieg said. “The Trump administration’s rhetoric about pulling out of Syria hasn’t helped the U.S.’s bargaining position. The regime knows now that it will get away with murder.”

Senator Lindsey Graham, a Republican from South Carolina, said Sunday’s tweet had set up “a defining moment” in Trump’s presidency.

“If he doesn’t follow through and live up to that tweet, he’s going to look weak in the eyes of Russia and Iran,” Graham, a member of the Senate Armed Services Committee, said on ABC’s “This Week.”

More than seven years of war in Syria have killed half a million people and dispersed millions more as refugees. The fighting has also drawn in Iran, Russia, the U.S. and Turkey, and a postwar scenario could include a continuation of Syria’s de facto partition into spheres of foreign influence.

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