Trends in U.S. Working-Age non-Hispanic White Mortality: Rural–Urban and Within-Rural Differences

Abstract

After decades of lower or comparable mortality rates in rural than in urban areas of the U.S., numerous studies have documented a rural mortality penalty that started in the 1990s and has grown since the mid-2000s. The widening of the gap appears to be especially pronounced among non-Hispanic (NH) whites. However, the rural U.S. is not monolithic, and some rural places have experienced much larger mortality rate increases than others over the past 30 years. Drawing on restricted mortality files from the National Vital Statistics System (NVSS), I examine metro versus nonmetro and intra-nonmetro (divisional and economic dependency) all-cause and cause-specific mortality trends among working-age (25-64) NH white males and females, 1990-2018. Results show that the nonmetro mortality penalty is wide and growing and is pervasive across multiple disease and injury categories. Trends for females are particularly concerning. Smaller nonmetro declines in mortality from cancers and cardiovascular disease (throughout the 1990s and 2000s) and larger increases in metabolic and respiratory diseases, suicide, alcohol-related, and mental/behavioral disorders (throughout the 2010s) collectively drove the growth in the nonmetro disadvantage. There are also large divisional disparities (which are growing for females), with particularly poor trends in New England, South Atlantic, ES Central, WS Central, and Appalachia and more favorable trends in the Mid-Atlantic, Mountain, and Pacific. Mining-dependent counties have diverged from the other economic dependency types since the mid-2000s due to multiple causes of death, whereas farming counties have comparatively lower mortality rates. High and rising mortality rates across a variety of causes and rural places, some of which have been occurring since the 1990s and others that emerged more recently, suggest that there is not one underlying explanation. Instead, systemic failures across a variety of institutions and policies have contributed to rural America's troubling mortality trends generally and within-rural disparities more specifically.

Rural-Urban and Within-Rural Differences in COVID-19 Mortality Rates

“…Their six mutually exclusive categories include farming, mining, manufacturing, government, recreation, and nonspecialized. Research on all-cause and cause-specific mortality trends finds substantially higher rates of most types of mortality in mining-dependent counties and comparatively lower rates in farming-dependent counties (Monnat 2020a).…”

“…Rural America has long faced a mortality disadvantage (Cosby et al 2008(Cosby et al , 2019Elo et al 2019;James 2014;James and Cossman 2017;James et al 2018;Singh and Siahpush 2014;Monnat 2020a;Vierboom et al 2019). The gap has grown over the past couple of decades and is pervasive across multiple disease and injury categories (Monnat 2020a).…”

“…Rural America has long faced a mortality disadvantage (Cosby et al 2008(Cosby et al , 2019Elo et al 2019;James 2014;James and Cossman 2017;James et al 2018;Singh and Siahpush 2014;Monnat 2020a;Vierboom et al 2019). The gap has grown over the past couple of decades and is pervasive across multiple disease and injury categories (Monnat 2020a). The rural mortality penality is grounded in the literarure on ecological determinants of population health, which include individual-level risk factors and behaviors, community contexts (e.g., economic and employment conditions, health care infrastructure), and macro-level conditions (e.g., state policies, industrial restructuing, population loss) that increase risk of or protect against adverse health outcomes and premature mortality.…”

“…However, rural areas are not homogenous. Just as the overall mortality penalty varies across rural areas (James 2014;Monnat 2020a), so too should we expect that COVID-19 mortality rates would vary across different types of rural communities. Existing research shows that COVID-19 mortality rates are higher in rural counties with larger shares of Black and Hispanic residents (Cheng, Sun, and Monnat 2020).…”

“…Mining-dependent rural counties might also be expected to have increased COVID-19 mortality risk given their higher rates of poverty and higher rates of chronic diseases and related-mortality including cancer and heart and respiratory diseases (Esch and Hendryx 2011;Hendryx, Fedorko, and Halverson 2010;Liu et al 2021;Monnat 2020a). Environmental byproducts of mining, such as dust and other hazardous waste, harm respiratory health -a critical disadvantage for fighting off an airborne respiratory disease like coronavirus.…”