Economic Gaps Drive Nutrition Inequality

Income inequality is affecting our nation’s health ūüė® Let me illustrate: During my sub-internship on the gynecological oncology service as a 4th year med student, we managed the care of a patient with vulvular necrotizing fasciitis, which is essentially flesh-eating bacteria of the vulva. The vulva is one of the most intimate parts for a woman, and as a woman, I had a visceral reaction as we debrided and irrigated her skin in the operating. The vulvular skin was ruddy, swollen and crackled to the touch. We removed about 2 lbs of her left vulva, leaving a large unsutured gash to allow for frequent washings and reassessment (what we called delayed primary closure in medical-speak). After the debridement, we infused powerful IV antibiotics to prevent sepsis and ensured that the patient received good pain control for her open wound.¬†

The main risk factors for vulvular necrotizing fasciitis are smoking, hypertension, diabetes and obesity – mockingly called the¬†“American cocktail” of preventable chronic diseases in the United States. ¬†Our patient had all the risk factors – she was a current smoker, suffered from chronic hypertension, was an insulin-dependent diabetic and was obese. Obesity and type II diabetes are directly related to nutrition. On my third week on service, I found myself in the operating room once again assisting on a procedure on our patient. I was working with the plastic surgeon who agreed to a closure of her vulvular wound only if she promised to quit smoking because (in addition to ¬†being a risk factor for vulvular necrotizing fasciitis) smoking impairs the healing process after surgery. As we sutured the pink edges of the wound into tight neat planes, the attending sighed, “If we spent more money on nutritional education on patients, maybe we would have less of this happening…”

There’s an economic component to this story as well. Our patient was uninsured. She worked a minimum wage job and supported two children as a single mother. She did not have the financial and social resources available to her wealthier counterparts. She did her best, like we all do, but she struggled. She’s been on food stamps and found it financially-challenging to buy “that whole grainy bread” for her children. I empathized¬†with her plight, and appreciated the social and economic context that contributed to her hypertension, obesity and diabetes.

We need to change our culture and economy so that nutrition is prioritized ūüĆŅThe AMA (American Medical Association) recently announced that the American diet is improving unevenly based on socioeconomic class, prompting STAT to report that “changes in diet are very much a class affair”. It’s true in my experience in clinic. Patients with lower socioeconomic status tend to eat unhealthier than their wealthier peers. It’s sad that this is a reality in a developed country that technically has both resources and the means to build and sustain a healthier nation.


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