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In Depth: CDC Report: Trends in Death Rates in Urban and Rural Areas: United States, 1999–2019

The Center for Disease Control’s (CDC’s) National Center for Health Statistics published a report entitled Trends in Death Rates in Urban and Rural Areas: United States, 1999–2019.  The report was referenced in serval popular press articles, and I thought it best to examine and comment on the source material.

Yahoo News referenced the report this way:

Rural Americans are up to 20% more likely than their urban counterparts to die from illnesses such as cancer, heart disease and lower respiratory infections. Lack of access to health care, poverty, smoking and heavy drinking all play a role in driving up the disparity between rural and urban residents – a gap probably exacerbated by the COVID-19 pandemic and closure of rural hospitals.

The federal study examined the 10 leading causes of death nationally from 2009 through 2019. It found people in cities live longer than their rural counterparts, and the health disparities are increasing. 

The report includes a summary (Key Findings) section, that I have included here:

Data from the National Vital Statistics System

  • From 1999 through 2019, age-adjusted death rates in urban areas declined from 865.1 per 100,000 to 693.4, whereas rates in rural areas initially declined from 1999 (923.8) through 2010 (837.6) and then stabilized through 2019 (834.0).
  • Death rates for both males and females were higher in rural than in urban areas from 1999 through 2019, and the differences in rates widened over the period.
  • In 2019, rates for the 10 leading causes of death were higher in rural areas than in urban areas, with the greatest difference in rates for deaths due to heart disease (189.1 compared with 156.3), cancer (164.1 compared with 142.8), and chronic lower respiratory disease (CLRD) (52.5 compared with 35.4).
  • Differences between rural and urban death rates for heart disease, cancer, and CLRD widened from 1999 through 2019.
As we are in the midst of a pandemic, it is logical that some would place the (admittedly pre-COVID-19) data in that context by adding some additional pertinent statistics. 
The Yahoo article also mentioned a disparity in the rate of deaths from COVID-19:

Rural Americans die from COVID-19 infections at about twice the rate of urban Americans, based on data analyzed by the Center for Rural Health Policy Analysis at the University of Iowa. Public health experts said rural Americans are less likely to have gotten vaccinated, driving up their coronavirus death rates.

NBC has a similar interpretation:

Rural Americans are dying of Covid at more than twice the rate of their urban counterparts — a divide that health experts say is likely to widen as access to medical care shrinks for a population that tends to be older, sicker, heavier, poorer and less vaccinated.

While the initial surge of Covid-19 deaths skipped over much of rural America, where roughly 15 percent of Americans live, nonmetropolitan mortality rates quickly started to outpace those of metropolitan areas as the virus spread nationwide before vaccinations became available, according to data from the Rural Policy Research Institute.

Since the pandemic began, about 1 in 434 rural Americans have died from Covid, compared with roughly 1 in 513 urban Americans, the institute’s data shows. And though vaccines have reduced overall Covid death rates since the winter peak, rural mortality rates are now more than double that of urban ones — and accelerating quickly.

The USDA adds in some context with Rural death rates from COVID-19 surpassed urban death rates in early September 2020, which includes this excerpt:

During the initial COVID-19 surge between March and June 2020, large urban areas had the highest weekly death rates from the virus in the United States. Those numbers declined as medical professionals learned more about the virus, how to treat it, and how to prevent its spread. As the virus spread from major urban areas to rural areas, the second COVID-19 surge, from July to August 2020, brought more deaths to rural areas. The peak in deaths associated with this surge was smaller because testing was more widespread, the infected population was younger and less vulnerable, and treatments were more effective. However, in early September 2020, COVID-19 death rates in rural areas surpassed those in urban areas. This trend continued into a third, still ongoing, surge that spiked in rural areas during the holiday season and again shortly thereafter.

As to “why?”, US News has a cogent take on the possible rationale.

“We looked at all-cause death, and found that instead of the difference in this disparity getting better over time, as you might expect as our economy progresses and our health system improves, we’ve actually seen that differences really multiplied,” said lead researcher Dr. Haider Warraich, a cardiologist at Brigham and Women’s Hospital in Boston and the VA Boston Healthcare System.

This gap is partly due to access to care, but other factors also contribute, he said.

In terms of access, rural areas have seen a wave of hospital closures driven largely by economics, especially during the COVID-19 pandemic, Warraich said.

“But it’s hard to disconnect health from other factors in our societies,” he said. “I think it’s linked to the overall economic outlook of rural America as well, and also, health behaviors that contribute to poor health, such as poor nutrition, lack of exercise, smoking, substance use, etc.”

In rural areas, death from conditions like heart and lung diseases as well as so-called “deaths of despair” from drugs, alcohol and suicide have risen significantly, and are likely to continue doing so, Warraich said.

As ACUTE CARE, INC. primarily serves a rural population, we will continue to follow this issue closely, and we are proud to partner with rural hospitals and healthcare systems that are working to be part of the solution to this troubling problem.
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Paul Hudson, FACHE
Chief Operating Officer