Researchers warn there is a widening disparity in death rates between rural and urban America that goes beyond racial lines.
While mortality rates overall among both urban and rural residents declined over the past 20 years, the decline was much slower among rural Americans, which fell by 9% compared to 23% among urban residents.
The disparity in rural and urban deaths tripled between 1999 and 2019, according to the finding of a study published Tuesday in the Journal of the American Medical Association.
In contrast, the gap between mortality rates in Black and white Americans has been narrowing over the past two decades, according to study co-author Dr. Haider Warraich, an associate physician at Brigham and Women's Hospital in Boston.
The smallest reductions in mortality rates were found among white men, which fell from 900 deaths for every 100,000 in 1999 to 833 deaths in 2019. The slow decline was driven in part by increases in mortality among white rural residents between the ages of 25 and 64.
"Usually we like to think as medical innovation advances and technology gets better that such disparities would be reduced or minimized," Warraich said. "But what we're seeing here is actually quite the opposite."
Risky health behaviors like smoking, alcohol and drug use, and obesity have led to a steady rise in chronic disease among rural residents, Warraich said. A previous study co-authored by Warraich published in JAMA in May found cardiovascular disease incident rates between rural and urban areas nearly doubled from 1999 to 2017.
Rural communities have also been hard hit by the effects of the opioid crisis, where deaths from drug overdoses have spiked during the pandemic.
"Often times when we think of rural places you have this sunny, really optimistic view of what rural life looks like," Warraich said. "But a lot of the bad habits with regard to nutrition, smoking, and lack of exercise that we first associated with urban areas have all been exported to rural areas."
Rural areas have also lost many of hospitals over the past decade, which has contributed to chronic disease and death rates. Since 2010,more than 180 rural hospitals have permanently closed their doors due to financial pressures.
While hospital closures have played a part in limiting acute care options for rural residents, Warraich said it was only one piece of a puzzle that included an urgent need to bolster primary care and preventive care services.
The need to address rural healthcare has larger implications for the rest of the country in that the dearth of investment in such care services has played a part in those areas having lower rates of COVID-19 vaccinations than more urban areas, making the chances the U.S. will reach a threshold of vaccinating 70% of the population to achieve herd immunity from the virus less likely in over the next several months.
"The idea that this is a self-contained crisis is short-sighted," Warraich said.