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Born less than 15 months apart, Irma and Marta were closer to one another than to any of their other six siblings. The family grew up poor in the state of Puebla, southeast of Mexico City, and they both dreamed of raising their children in the United States. When they were in their early 20s, they made their way north. Over the years, they would earn the solid, working-class life they'd aspired to.
For a while Irma lived in East Harlem with Claudialee's father, Napolean Gomez. They separated when Claudialee was a year old. Irma moved in with Marta and her husband in Flushing. She stayed for a year, waiting for an apartment to open up in the same building. She wanted to live near her sister, who stayed home to look after her three children. There was nobody Irma trusted more with the care of her daughter.
Irma took Claudialee's temperature. No fever. She offered food but the girl wasn't hungry. She was very thirsty, though. Irma placed Gatorade and ginger ale on the nightstand by her bed, but Claudialee only wanted water. She napped for a couple of hours, then gulped more water. She fell back to sleep at about 10 p.m., with her mother lying beside her.
Claudialee woke up drowsy. She always dressed herself, but on this day Irma had to do it for her.
They made the 10-minute walk and got to Dr. Cabatic's clinic at 9:30 a.m. It didn't open until 10, but Irma routinely arrived at doctors' appointments early. Then 9:30 became 10:30 and 10:30 became 11. The door remained locked. Irma called Cabatic's cell phone and office line seven times. No answer.
Claudialee kept saying her stomach ached, that she felt tired and really thirsty. She'd vomited three more times that morning.
She normally didn't complain about things—she was the type of girl who fell off a scooter, scraped her knee, and got right back on without hesitation. Irma called a cab and asked the driver to take them to New York Hospital.
Claudialee began to sway and stumble as they walked toward the emergency room. Before reaching the entrance, she nearly collapsed. Irma picked her up and carried her the rest of the way.
As hospital workers ran tests, a nurse asked Irma if Claudialee had been urinating more and drinking more than usual recently. Irma said she had noticed her daughter doing both since Christmas.
This suggested that Claudialee's blood sugar had been rising.
The test results—five times the normal level—supported that hypothesis.
"When the doctors came in and told me about blood-sugar levels—that was a surprise," Irma tells the Voice. "That was the last thing I expected to hear. That's when I knew something was really wrong."
There had been other signs. Months after Claudialee checked into New York Hospital's ER, pediatric endocrinologist Craig Alter reviewed her medical records. He was shocked, unable to understand why Dr. Mercado had so quickly ruled out type 1 diabetes.
"If you tell me there is a five-year-old with diabetes, the chance that they have type 1 is probably 99.99 percent," he would later testify. "If you tell me they are obese, I would say, okay, the chance is 99.7. It's almost definitely type 1."
Alter, a physician at the Children's Hospital of Philadelphia, is one of the world's top experts on diabetes in kids. He teaches a pediatric endocrinology class at the University of Pennsylvania's medical school. He is chairman of the Educational Committee for the Endocrine Society and gives lectures across the globe. In 2001, he founded Camp Freedom, a summer program in Pennsylvania that brings together diabetic youth for a week of swimming, hiking, and sharing insulin-injection stories around the bonfire. Last year, 140 kids registered; 139 of them had type 1.
Even though rates of type 2 are rising among minors, the condition remains rare in children under 10 years old. The National Institutes of Health report that one out of every 5,000 kids in that age group has type 1 diabetes, while one out of every 250,000 gets type 2. The reason is simple: Type 1 is a condition people are born with or acquire very early in life; type 2 develops over time—enough time for the body to build a resistance to insulin.
Not only is type 1 far more common in six-year-olds, it is also far more urgent.
"Type 2, you have a little more luxury of time. Type 1, you do not have the luxury of time," Alter testified. "Type 1, if we don't give them insulin, they will die."
Blood sugar is like temperature—it rises gradually. In the months since Claudialee's last tests, the girl's blood sugar level continued to rise, right under her doctors' noses.
Even as the puzzle pieces began to emerge, each showing a symptom of the disease, neither Mercado nor Cabatic saw the whole picture. Weight loss can indicate that the body is starving as a result of its failure to absorb glucose. Sudden heart palpitations can indicate that the body is dehydrated from losing the sugar-laden fluids via urination.
"In a child where there is a possibility of diabetes, any symptoms that develop that might be linked to diabetes have to be assumed diabetes until proven otherwise," Alter said. "You look for anything to tip you over the edge. The appropriate treatment would have been more-frequent monitoring to determine if diabetes was present then, or to catch it early within a few days, had it progressed."