Rural Life Can Be Hazardous to Your Health

A study finds that the risk of injury deaths is 22% higher in the most rural counties than in the most urban areas. While the data reveals some surprising findings, the lead author says she can only speculate as to the reasons why.

Caution: Rural life may be hazardous to your health.

A study in the Annals of Emergency Medicine finds that the risk of injury death is about 20% higher in rural areas when compared with large cities.

"I was definitely surprised by the findings," says Sage Myers, MD, lead author of the study: Safety in Numbers: Are Major Cities the Safest Places in the U.S? [PDF]

"All of us have this maybe more emotional reaction when you talk about safety as it relates to cities and rural areas. When we think about safety, we think about things that we are scared of, people attacking us and shooting us," says Myers, an associate professor at the Perelman School of Medicine at the University of Pennsylvania, and a pediatric emergency physician at Children's Hospital of Philadelphia.

"So we have that emotional connection that cities are not safe. But when you think of safety as your overall risk of injury to your person with all kinds of injuries included, I was surprised to see that it turns out to be the opposite, that cities are the safest."

Myers and her colleagues analyzed 1,295,919 injury deaths that occurred between 1999 and 2006 and found that the risk was 22% higher in the most rural counties than in the most urban. The most common causes of injury death were motor vehicle crashes, leading to 27.61 deaths per 100,000 people in most rural areas and 10.58 per 100,000 in most urban areas.  

Firearm-related deaths statistics were not much different in rural and urban areas for the entire population. However, when age subgroups were examined, firearm-related deaths were significantly higher in rural areas for children and people 45 years and older. For people aged 20–44, the firearm-related death risk was significantly lower in rural areas.

Myers says the risk of homicide is higher in big cities, but the risk of unintentional death is 40% higher in most rural areas when compared with their urban counterparts. "And overall, the rate of unintentional injury dwarfs the risk of homicide, with the rate of unintentional injury more than 15 times that of homicide among the entire population," Myers says. "The unintentional injuries are what are driving the whole thing. The unintentional injuries are so much higher than homicides and suicides in the rural areas than in urban."

While the study uncovered surprising findings, Myers says she can only speculate as to the reasons why. We've all heard about that "golden hour" of access to medical care after a traumatic injury that can mean the difference between life and death. Was that a factor?

"There probably is some component to access to care, but when we tried to adjust it in the way that we could with the data we had and look at—'do you have a trauma center in your county or surrounding county and how many do you have?'—to give an overall sense of 'do you have access to care?' and put that back into our analysis, it didn't seem to change the overall, even though there was a mild attenuation," Myers says. "But the same overall difference between rural and urban areas was still there. So it seems like there is more to it than just that."

Injury death risk fell in rural areas with larger populations of African-Americans, and Myers says she can only guess as to why. "Suicides have been found to be higher in rural areas than in urban areas and the black populations tend to be somewhat protected from suicides. That may be part of it," she says.  

The opposite was true for rural counties with large Latino populations, which had significantly higher risk of injury death than rural counties with small Latino populations. And perhaps most surprisingly, the study found that risk of injury death increased in rural areas with higher income and education levels. Explaining the causes for this and other findings, Myers says, "was not our focus, but it was more hypothesis-generating. Let's have further studies that look into this and try to see some of the underlying reasons."  

Myers says she hopes the study will prompt people to reexamine assumptions about healthcare needs in rural and urban America.

"First, it is important to try to dispel the myth that cities are dangerous and this information shows that when you consider injury-related death, overall cities aren't more dangerous. In fact we found them to be safer," she says.  

"Second, we saw the predominance of injury-related death risk tended to be in areas of the country where we have the least access to emergency physicians and trauma care and maybe we should use this to do more of a population planning evaluation of how do we put the resources where the needs are as opposed to what is happening now, which is a little more organic."

For example, Myers' data showed that elderly falls represented a more significant injury death risk in urban areas than in rural areas. "So it may be more cost-effective and effective in general to tailor safety and injury prevention in urban areas around falls among the elderly, rather than what we are doing now, which is a bit of a global technique of 'here is something that is important in safety. Let's do something to prevent it across the country,'" she says. "There may be parts of the country where you don't need that same message with whatever it is you are trying to change."

As a practical tool, Myers says her study underscores the implications of proper staffing of emergency departments and trauma care systems in rural areas, which she says tend to be underserved as it is.

"It can only help in the quest to make sure rural hospitals have access to the resources that are needed to care for the population they're serving," she says. "There are lots of rural emergency departments that are staffed by people who may or may not have the full training they need to care for these patients who are severely injured or severely sick. This could help support them as they are trying to move forward."