In Gaza, war kills not only with bombs but also with silence, the silence of empty pharmacies, broken refrigerators, and the absence of insulin.
As the Israeli onslaught continues to devastate the coastal enclave, thousands of diabetics are trapped in a cruel equation: survive without treatment or surrender to the disease.
For them, every day is a battle fought between two invisible enemies, war and the slow poison of untreated illness.
In a makeshift tent near Khan Younis in the southern Gaza Strip, 58-year-old Nofal al-Sharafi squints at his blood sugar meter, the small screen flashing an alarming number.
It has been a week since his last insulin dose. "We were displaced from Gaza City three weeks ago […] Since then, I haven't had a single dose," he told The New Arab.
"The medical centres in the south are overwhelmed. Doctors are doing their best, but they can't meet everyone's needs," he added.
Al-Sharafi carries in his worn bag a few spoiled insulin bottles. He tries to keep them cool by placing them in a bowl of water inside the tent.
"The heat ruins everything […] Sometimes I stop taking my medicine because I fear it will harm me more than help me," he said.
Last week, al-Sharafi fainted while helping his family cook over a wood fire.
"My neighbours took me to the medical point. They said the available insulin was reserved for critical cases. I never imagined my treatment would become a distant dream," he added.
A collapsing health system
In Gaza City, healthcare has come to a standstill. Israeli bombardment has destroyed several medical centres, including the Palestinian Medical Relief Society headquarters in al-Rimal and Tel al-Hawa neighbourhoods. This strike wiped out large stockpiles of essential medicines.
Doctors Without Borders (MSF) also suspended its operations and evacuated its staff after the Israeli invasion of the city, citing the danger of ongoing shelling near hospitals.
The result has been catastrophic for patients with chronic illnesses who rely on consistent care to survive.
In the bomb-scarred neighbourhood of al-Sheikh Rudwan, 70-year-old Abdul Karim Salim sits on a broken chair surrounded by his neighbours, listening to a battery-powered radio.
"Diabetes here is not an individual disease. It has become a collective suffering. Every home has one or more patients," he told TNA.
Abdul Karim lost his right foot last year due to complications from diabetes. Now, he fears losing the other. "The doctors told me I must clean the wound regularly, but the road to the hospital is too dangerous. And when I do get there, the corridors are full of patients sleeping on the floor," he said.
"Illness is no longer just pain; it's waiting between one explosion and the next. Sometimes I feel that patience itself has become our only medicine," he added.
In the overcrowded camp of Deir al-Balah, 46-year-old Randa Hamouda carefully places her insulin vials inside a clay pot filled with cold water, her only method to keep them from spoiling.
"The electricity has been out for two years. Refrigerators are just a memory now. I pray every day that the medicine doesn't go bad," she told TNA.
Randa was displaced after an Israeli airstrike destroyed her family's home, killing her daughter. Since then, she has been struggling to balance grief with survival.
"Some people in the camp bury their insulin in wet sand or near the sea. It's not safe, but we have no other choice," she said.
For 32-year-old Jamal Abed, who has lived with diabetes since childhood, the war has turned survival into a cruel gamble.
From his tent in al-Nuseirat refugee camp, he told TNA, "I had to cut my insulin dosage in half because there's simply not enough. I feel dizzy all the time and sometimes lose my balance. Every night I sleep not knowing if I'll wake up."
"Insulin has become like gold […] Whoever finds it lives. Whoever doesn't… faces their fate," he added.
According to Samer Badwan, an endocrinologist working at a field medical centre in southern Gaza, the crisis has reached catastrophic levels.
"There are over 60,000 diabetic patients in the Gaza Strip who are at risk of death or coma due to a lack of insulin and electricity," he told TNA.
Badwan said that some patients resort to expired or poorly stored medication, leading to severe complications.
"We receive patients every day suffering from acute infections and dangerously high or low blood sugar. It's like a slow death," he added.
"This didn't start with the war. Years of blockade crippled Gaza's health system, but now it has completely collapsed. There are no testing devices, no strips, and an insufficient number of medical staff. Even doctors are exhausted working around the clock with almost nothing," he explained.
Children on the brink
Among the most heartbreaking victims are children. In al-Buriej refugee camp in the central part of the Gaza Strip, 40-year-old Khaled Abu Zayed sits beside his 10-year-old son, Adam, who has Type 1 diabetes.
"Every night, I fear his blood sugar will drop while he's sleeping," Abu Zayed told TNA, saying, "We try to balance his insulin with food, but there isn’t enough food—and no devices to test his sugar levels."
"Under normal circumstances, this disease can be managed. But here in Gaza, it has become another weapon, one that kills silently," he added.
According to the Haifa Association for Diabetic Children, at least four children have died this year due to insulin shortages and malnutrition. Field clinics are struggling to cope with the daily influx of cases amid dwindling supplies.
Its director, Awni Shweikh, describes the situation as "beyond emergency."
"Families are forced to estimate insulin doses without proper testing. That leads to fatal comas. Hospitals cannot accommodate everyone, and staff shortages exacerbate the issue—some doctors work 20 hours straight. This is a humanitarian disaster in every sense," he said.