Rural-Urban Gap in U.S. Death Rates Tripled Even Before Pandemic

The gap between the death rates of rural and urban U.S. residents tripled over the past two decades as city-dwellers enjoyed robust health improvement and drugs and disease pervaded the countryside.

A study in the journal JAMA published Monday compares mortality rates in 1999 and 2019. It finds that death rates dropped in all groups except middle-aged rural White and Native-American people, but fell most in cities.

“What we’re seeing is a ripple effect from the economic downturn in rural areas that’s now being manifested as a public-health crisis,” said senior author Haider Warraich, a physician and researcher at the Boston Veterans Administration.

Rural-Urban Gap in U.S. Death Rates Tripled Even Before Pandemic

The numbers add to disturbing findings in recent years that life expectancy has actually dropped among some Americans, particularly White people with less education, fueled largely by “deaths of despair” from substance use or suicide.

The new data and other studies show that “chronic disease is driving this trend as much as anything else,” Warraich said, including heart disease, lung disease, liver disease and even dementia. Factors in the rise include not just substance use or distress, he said, but also poor nutrition, lack of exercise, smoking, access to high-quality medical care and other systemic issues.

It doesn’t help that many rural hospitals have been closing, he said, more in 2020 than any previous year.

Black people had the highest mortality rates at both points in time, but between 1999 and 2019 the gap between Black and White people was halved, Warraich said. The disparity between urban and rural dwellers in 2019 was even bigger than the disparity between races, according to the data.

That could change when the pandemic’s disproportionate impact on people of color is considered, though Warraich said the pandemic will also exacerbate the urban-rural gap, because of hospital closings and lower vaccination rates in rural areas.

The study looks at age-adjusted mortality rates, meaning it corrects for the proportion of older people in different groups.

In 1999, the overall annual mortality rate was 875.6 per 100,000 people; In 2019 it was 715.2.

From 1999 to 2019 the gap between rural and urban death rates grew from 62 per 100,000 to 169.5.

In urban areas, the total rate went from 861.5 to 664.5. In rural areas it went from 923.8 to 834.

©2021 Bloomberg L.P.

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