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The death rate gap between urban and rural America is getting wider

The simple fact of where you live can have a huge impact on your health.

If you live in a city or a suburb, chances are you’ve seen the health of people around you improve over time — fewer deaths from cardiovascular disease, better cancer treatments, and fewer premature deaths.

But if you’re one of the 46 million Americans who live in a rural area, odds are you’ve watched the health of your neighbors stagnate and worsen.

New data from the Centers for Disease Control and Prevention shows that rates of the five leading causes of death — heart disease, cancer, unintentional injuries, chronic lower respiratory disease, and stroke — are higher among rural Americans. In other words, mortality rates in rural areas for these preventable deaths, which were going down, are now plateauing and even increasing.

Arguably, the decline of health in rural America isn’t new. Many studies have recently highlighted this growing divide between health outcomes in urban and rural America. But it’s increasingly true that more than income, more than the frequency with which you exercise, the simple fact of where you live can have a huge impact on your health.

More Americans in rural areas are dying, and the rural-urban health gap is worsening

In the past 15 years, the number of people who died from heart disease, cancer, and stroke in the US declined — but not equally across America. In rural areas, improvements are now slowing and even declining, widening the rural-urban health gap.

It’s not that rural America hasn’t seen any improvement in the number of preventable and premature deaths. What’s problematic is that after years of decline, the data now indicates that rural counties are experiencing a steady uptick in the number of premature deaths.

“The change in mortality rates over time was often slower [in rural areas], and over time the differences [with urban areas] were getting larger and not smaller,” said Ernest Moy, at the CDC’s National Center for Health Statistics, who analyzed data from 1999 to 2014 for the new report.

And as you can see in the chart below, the most pronounced rural-urban gaps are deaths from unintentional injuries — like suicide or drug overdose — and deaths from chronic lower respiratory disease (CLRD).

Charts showing that for the top 5 causes of death in the US, rural areas are harder hit.
Age-adjusted death rates for the five leading causes of death in rural and urban areas
National Vital Statistics System, 1999-2014

Most shockingly, rural Americans were 50 percent more likely to die from an unintentional injury than urban Americans during this 15-year period. Why? According to the CDC, part of it is that people in rural areas often don’t have access to health care facilities that can quickly treat severe trauma. The opioid epidemic is also overwhelmingly concentrated in rural pockets of the US, as are the related overdose deaths.

But it’s not just deaths from unintentional injuries that disproportionately affect rural Americans. Rural Americans are also far more likely to die from CLRD, which encompasses a wide range of lung diseases from occupational lung diseases to pulmonary hypertension. The CDC believes this discrepancy is largely due to cigarette smoking being far more prevalent among adults living in rural counties.

Many more deaths could be prevented with more rural health services

In addition to more rural Americans dying from the five leading causes of death in the US, a larger number of rural deaths are preventable, too.

“People that look at rural areas have known mortality rates are higher for a while,” said Moy. “But when we converted mortality rates into something more concrete, like the number of deaths that could be prevented, that was striking to me. When you add these things up and realize 25,000 deaths from cancer could be prevented, it made it much more real than looking at just the mortality rates.”

What the researchers found was that more than 70,000 deaths in rural areas could have been prevented with better public health resources and access to health care, including 25,000 deaths from heart disease and 19,000 from cancer.

Charts showing the percentage of potentially preventable death for the five leading causes of death in rural and urban areas
Percentage of potentially preventable death for the five leading causes of death in rural and urban areas
National Vital Statistics System, 2014

Rural health clinics are far more likely to be understaffed (only 11 percent of all physicians choose to practice in a rural area), and they often lack subspecialty care, which hurts people who need specialized treatment.

Additionally, a higher percentage of rural Americans are in poorer health. Generally speaking, rural Americans report higher incidences of preventable conditions like obesity, diabetes, cancer, and injury. They also face higher uninsured rates in addition to fewer health services.

The good news: Stroke deaths are going down in rural (and urban) areas

There is a sliver of good news in the CDC report: Fewer rural Americans died from stroke in 2014 than in 1999. (Urban communities also saw a significant decline in stroke deaths in this time period.)

Age-adjusted death rate for stroke-related deaths in rural and urban areas
National Vital Statistics System, 1999-2014

And the CDC also has a clear answer to why: The agency, along with the American Stroke Association, has targeted both urban and rural hospitals with resources for acute stroke care.

Similar strategies to reduce the number of deaths associated with cardiovascular disease or cancer have not been implemented, which might explain the disparity we see in the death rates for these diseases in rural communities.

Yuling Hong from the CDC’s Division for Heart Disease and Stroke Prevention told Vox he thinks some of the successes around stroke interventions could be applied to other health threats. The first step? Better identification of the areas where preventable deaths are greatest.

Hong also said that removing barriers to access in rural areas when dealing with time-sensitive events like strokes and heart attacks is crucial. And he emphasized building out the network of hospitals in rural areas able to provide emergency care related to strokes and other cardiovascular diseases.