Health Disparities Tied to Gap in Rural, Urban Death Rates

The gap between rural and urban death rates has tripled over the past 20 years, in part due to socioeconomic factors and rural health disparities, according to a recent study from Brigham and Women’s Hospital published in JAMA.

Researchers analyzed data from the US Centers for Disease Control and Prevention (CDC) Wide-Ranging Online Data for Epidemiologic Research database, spanning from 1999 to 2019. While age-adjusted mortality rates declined in rural and urban regions, the study found that Black individuals still had the highest age-adjusted mortality rates of all racial and ethnic groups in both rural and urban regions.

Meanwhile, there was a 12.1 percent increase in age-adjusted mortality rates for rural residents between 25 and 64 years of age, significantly widening the gap between rural and urban mortality rates. While the rural-urban gap widened, death-rate discrepancies between Black and White people halved between 1999 and 2019.

"One might think that with medical advancements over the course of two decades, differences in mortality rates became narrower, but what we've seen is quite the opposite," said study author Haider Warraich, MD, of Brigham and Women’s Heart and Vascular, in a press release. "Instead, we saw an unprecedented reversal in the mortality rates of middle-aged white people, both men and women."

Along with the CDC database, researchers used the National Center for Health Statistics Urban-Rural Classification Scheme to inform their analysis. They also used 2013 US Census data to determine rural and urban populations. Although the rural population decreased from 16 to 14 percent between the years studied, researchers stated that this still does not explain the death-rate gap.

"Traditionally, researchers focusing on rural populations have highlighted the effect of the opioid epidemic and what have been called 'diseases of despair,' including alcohol abuse and suicide, but our previous work has shown that chronic conditions may also be driving this gap," Warraich continued in the press release.

"Rural areas have a higher prevalence of risk factors for these conditions like smoking, poor diet, lack of exercise, and obesity. A parallel crisis is the record number of hospital closures in rural areas, which will make solving this problem even more difficult with limited accessibility to primary and emergency care."

Across urban and rural areas, researchers found that men had greater age-adjusted mortality rates than women. Among rural residents, age-adjusted mortality rates went down between 1999 and 2019 for non-Hispanic Black, Asian, and Hispanic people, but the rates increased for non-Hispanic White and Native American people.

"We are seeing a public health crisis unfolding before our very eyes," Warraich stated in the press release. "This is a problem that affects a very large portion of our population, and we need to lend more attention to the drivers of this crisis, which mirrors a larger economic downturn that's taken place in rural America."

It is important to note that this research was done prior to the pandemic, which revealed significant health disparities across the nation. A recent study analyzed age-adjusted state-level data and found that racial disparities in COVID-19 deaths are even broader than previously researched.

In May, the Health Resources and Services Administration (HRSA), a division of the HHS, announced that it would distribute $1 billion from President Biden’s American Rescue Plan to assist rural health providers with COVID-19 relief. Rural health clinics have faced significant financial strain during the pandemic, and a lack of vaccine confidence has worsened COVID-19’s impact on rural communities.

In sparsely populated areas where clinics are not easily accessible and social determinants of health cause a spike in death rates, rural residents are paying the price.