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Because Mercado had locked in on type 2, she did not monitor her patient's blood. She did not tell Irma to purchase a $20 blood sugar meter from the drugstore. She did not ask Irma about the frequency with which her daughter drank and urinated. And neither she nor Cabatic described to Irma the danger signs to look out for.
"Being that she has a family history of diabetes, I would be thinking that she would know the symptoms of diabetes," Cabatic later testified in court.
Even after it was clear that Claudialee suffered from type 1, Mercado stood by her diagnosis. When later questioned in court, she disagreed with the notion that type 2 diabetes is uncommon in young kids.
"How many type 2 infant diabetics have you treated?" a lawyer asked her.
"A lot," she replied. "Maybe it's geographical, because I work at Brooklyn as an assistant professor and also in wellness program where there are a lot of obese children, so we diagnose a lot of children with type 2 diabetes."
It's tempting to assume that Claudialee received substandard care because of her family's income status. Doctors don't make as much money treating Medicaid beneficiaries, explains Jim Sheehan, former New York State Medicaid inspector general. A specialist earns as little as $30 a visit. By contrast, a pediatric endocrinologist treating someone with private insurance gets nearly $100 an hour. So Medicaid providers often have trouble filling their networks with enough doctors who specialize in common issues like diabetes. Patients are sometimes left to the lesser skilled or lesser known—doctors who can't afford to turn away the business.
"Some specialties, they have a very tough time recruiting people to be Medicaid-based," says Sheehan. "And so you're not gonna say, 'We want board-certified.'"
Though she'd failed to earn certification, Arlene Mercado had established a respectable career. She graduated from the University of Santo Tomas's medical school in the Philippines in 1984 and spent much of the next decade treating poor people in rural villages. She came to the U.S. in the mid-1990s, interning at Harlem Hospital before beginning her residency at Pitt County Memorial Hospital in Greenville, North Carolina. Her transition reflected competence: Foreign doctors must complete a rigorous testing process to become licensed here.
After two years of endocrinology training at the National Institutes of Health, Mercado took a position as a senior fellow at Mt. Sinai Hospital in Manhattan. In 2006, SUNY Downstate hired her as an attending physician. Two years later, she was named associate medical director of the hospital's wellness program for obese and diabetic patients. (SUNY did not respond to interview requests for this story.)
By the time Mercado treated Claudialee, a good number of experienced doctors had vouched for her. She'd co-authored at least seven academic papers in peer-reviewed journals. Multiple private insurance companies added her to their networks. Over the course of her career in New York, she sustained a spotless record. Not once had the Office of Professional Medical Conduct, an investigatory division of the New York State Department of Health, taken disciplinary action against her.
Shortly after sunset on January 23, 2010, Irma and Napolean sat in the waiting room at New York Presbyterian Cornell Medical Center. Claudialee had been transferred there a few hours before. Family and friends surrounded the parents.
A doctor approached and explained what was happening to their daughter. Claudialee's blood sugar had been rising for months. Because she didn't have enough insulin, her body burned fatty acids as an alternative fuel source. As those acids accumulated, they poisoned her body, and its systems began to shut down. The resulting nerve damage allowed fluids to seep into her brain, causing it to swell and pushing her further from consciousness. Twice that evening, doctors had had to resuscitate Claudialee. Now only machines kept her alive.
There was almost no chance she would recover.
That reality was dawning on Irma. She'd tried to stay optimistic, to stay strong for her only child. She'd dedicated herself to building a life for her daughter. She thought she'd done everything right. Coming to America. Working the long hours that might pull them up the economic ladder. Signing the girl up for dance classes and after-school tutoring sessions. And all those doctor visits. She wondered what she should have done better.
She felt guilty and betrayed. She'd put her faith in the healthcare process and it failed her.
Irma asked about organ donation. The doctor told her that wouldn't be possible. Her daughter's organs were damaged beyond repair.
The family members entered Claudialee's room and said their goodbyes.
On a summer afternoon, the waiting room of Downstate Pediatrics Associates is filled with nearly two dozen people. There are babies in strollers, parents reading magazines, and grade-schoolers playing tag. There are giggles and stomps and adults saying things like "give that man his sunglasses back" and "take that sticker off your face."
A reporter approaches the front desk and asks to speak with Dr. Arlene Mercado. The receptionist goes to get her.
It has been a rough few weeks for Mercado. In July, a jury found her 100 percent liable for the death of Claudialee Gomez-Nicanor. (Cabatic, also a defendant, was cleared.) In her testimony, Mercado admitted to having thrown away her original notes from Claudialee's treatments after learning she had been subpoenaed. Before discarding them, she typed up copies for the court. The new version indicated that she had intended to administer a blood test at Claudialee's next appointment in January 2010, days before the girl's death.