Starvation is threatening the survivors of more than two months of fighting in Ethiopia’s Tigray region.

Authorities say more than 4.5 million people there need emergency food.

The first humanitarian workers to arrive after pleading with the Ethiopian government for access describe weakened children dying from diarrhea, empty shops and refugees begging for something to eat.

One new report says parts of Tigray are likely a step below famine.

Mari Carmen Vinoles, the head of the emergency unit for Doctors Without Borders said: “There is an extreme urgent need” to scale up the humanitarian response.

“The population is dying every day as we speak,” she said.

The spectre of hunger is sensitive in Ethiopia, which transformed into one of the world’s fastest-growing economies in the decades since images of starvation there in the 1980s led to a global outcry.

Drought, conflict and government denial contributed to the famine, which swept through Tigray and killed an estimated one million people.

The largely agricultural Tigray region of about five million people already had a food security problem amid a locust outbreak when prime minister Abiy Ahmed on November 4 announced fighting between his forces and those of the defiant regional government.

Tigray leaders dominated Ethiopia for almost three decades but were sidelined after Mr Abiy introduced reforms that won him the Nobel Peace Prize in 2019.

Thousands of people have been killed in the conflict.

More than 50,000 have fled into Sudan, where one doctor has said newer arrivals show signs of starvation.

Others shelter in rugged terrain.

A woman who recently left Tigray described sleeping in caves with people who brought cattle, goats and the grain they had managed to harvest.

“It is a daily reality to hear people dying with the fighting consequences, lack of food,” a letter by the Catholic bishop of Adigrat said this month.

Hospitals and other health centres, crucial in treating malnutrition, have been destroyed.

In markets, food is “not available or extremely limited”, the United Nations says.

Though Ethiopia’s prime minister declared victory in late November, its military and allied fighters remain active amid the presence of troops from neighbouring Eritrea, a bitter enemy of the now-fugitive officials who once led the region.

Meanwhile, new satellite images of a refugee camp in the Tigray region show more than 400 structures have been badly damaged in what a research group believes is the latest “intentional attack” by fighters.

The report by UK-based DX Open Network said “it is likely that the fire events of 16 January are yet another episode in a series of military incursions on the camp as reported by (the United Nations refugee agency)”.

The Shimelba camp is one of four that hosted 96,000 refugees from nearby Eritrea when fighting erupted in early November.

The fighting has swept through the camps and two of them, including Shimelba, remain inaccessible to aid workers. Many refugees have fled.

UN refugee chief Filippo Grandi cited recent satellite imagery of fires and other destruction at the two inaccessible camps as “concrete indications of major violations of international law”.

On Sunday, the UN refugee agency requested access to the camps.

The new report said the satellite images showed “smouldering ruins, blackening of structures and collapsed roofs”.

Neither the UN nor DX Open Network has blamed anyone for the attacks, but the presence of troops from Eritrea has caused alarm.

Mr Grandi noted “many reliable reports and firsthand accounts” of abuses including the forced return of refugees to Eritrea.

Eritrean information minister Yemane Gebremeskel said Eritrea rejects the “forced repatriation of ‘refugees'”.