A national advisory committee finds that health disparities between rural and urban communities have widened. Similar disparities are found in North Carolina.

By Taylor Sisk

A recent report by the National Advisory Committee on Rural Health and Human Services indicates that life expectancy in rural American communities is consistently lower than in urban areas.

The NACRHHS, chaired by former Mississippi Gov. Ronnie Musgrove, provides recommendations on rural health issues to the secretary of the U.S. Department of Health and Human Services. A webinar was held Jan. 28 to discuss the results of its most recent report, “Mortality and Life Expectancy in Rural America: Connecting the Health and Human Service Safety Nets to Improve Health Outcomes over the Life Course.”

rural barns
Image courtesy Donald Lee Pardue, flickr creative commons

The report’s authors find that while life expectancy at birth for the nation’s population as a whole has been increasing for more than a century, in the past few decades the disparity between rural and urban communities has widened.

In fact, some rural counties have experienced declines in life expectancy during this period. The greatest disparities are found in Appalachia.

Data presented last year by NC Child (see interactive map below) indicates similar disparities in North Carolina.

“This rise in death rates is unique since the flu epidemic of 1918,” Wayne Myers, a committee member and former head of the federal Office of Rural Health Policy, told webinar participants. “There has not been such a large loss of life expectancy of such sustained duration in the industrial world.”

Myers called the rural/urban disparities “an equal opportunity tragedy,” in that they’re found in both majority-black as well as predominantly white communities.

Poverty bound

The committee found that almost all counties with the greatest declines in mortality are rural. From 2005 to 2009, the mortality rate in rural counties was 13 percent higher than in metro counties. (Mortality rate is the number of deaths that occur per 1,000 people in a given place and time.)

Rural/urban disparities in life expectancy also widened, and life expectancy worsened in the most rural areas.

According to NC Child’s data, life expectancy in Wake County in 2014 was 81.4 years; in the largely rural eastern county of Robeson, it was 74.2 years; and in rural Western North Carolina’s Swain County, it was 73.1.

Wake County men lived, on average, 79.3 years; Robeson County men, 71 years; and Swain County men, 70.5.

Wake County women had a life expectancy of 83.2; Robeson County women, 77.3 years; and Swain County women, 75.7.

The NACRHHS report also underscored that as poverty rates increase, life expectancy declines – and more so in rural than in urban communities.

Meanwhile, census data indicates that poverty is on the rise – again, in rural more than in urban communities. The U.S. Census Bureau’s 2013 American Community Survey found that nearly 2.6 million children in rural areas are in families with incomes below the federal poverty level ($24,250 for a family of four).

The child poverty rate of 26 percent in rural communities was up from the 1999 rate of 19 percent. The rate in urban areas rose in that same period from 16 percent to 21 percent.

In Wake County 14.3 percent of children live below the poverty level; in Robeson, the rate is as high as 46.6 percent; and in Swain, 28.8 percent.

[box style=”2″]This story was made possible by a grant from the Winston-Salem Foundation to examine issues in rural health in North Carolina. [/box]

‘Older, poorer, sicker’

In its report, the NACRHHS suggests several sources of the rural/urban disparity in life-expectancy rates:

“In general, rural America is older, poorer, and sicker than urban America, all of which contribute to the rural-urban mortality gap. Because rural Americans are on average older than their urban counterparts they are disproportionately represented in the Medicare population.”

In addition, a number of chronic diseases affect rural residents at higher rates. Cardiovascular disease is among them. Smoking is another primary issue.

The good news regarding smoking, said the NACRHHS’s Alana Knudson, co-director of the University of Chicago’s Walsh Center for Rural Health Analysis, is that there has been an overall decrease in the past decade in adolescents who smoke. The bad news is that kids in rural areas are smoking at about twice the rate of their urban counterparts.

Rates of obesity, heart disease and cancer are high in Robeson County relative to the state average and it has the highest smoking rate in the state.

Targeted funding

“By looking at national trends, which are not good, we have missed the fact that some parts of the country are not simply not gaining in life expectancy, they are actually seeing life expectancy decline,” said NACRHHS chair Musgrove.

Throughout the past 25 years, the committee states in its report, the Department of Health and Human Services has addressed access to health care in rural communities by such measures as financing community health centers and providing differential reimbursement for low-volume, rural health care providers.

“However, access to care alone is not enough to fully address complex health outcomes including mortality and life expectancy of populations,” they write. “Approaches must strengthen the health care delivery system while increasing integration of primary, specialty, substance abuse, and mental health services with human services including economic development, employment, housing, transportation, and education.”

Myers reiterated this, saying, “A lot of the issues, I would argue, underlying both the rural/urban disparity and the rising death rates in rural areas are not within the traditional purview of the [DHHS] secretary.”

Efforts to address these issues, he said, must include the secretaries of Commerce, Labor, Justice and Education.

Among the NACRHHS’s recommendations are calls to increase federal support of “research projects that examine behavioral health and primary care integration in rural communities to expand the evidence base for these efforts.” Another recommendation is for the DHHS secretary to direct the National Institute on Drug Abuse to conduct research into the rural/urban implications of opioid use and overdose, including heroin.

The committee also calls for an increase in funding for training primary care providers and emergency medical providers in the use of opioid overdose-treatment drugs, including naloxone.

The report states that while “rural communities face higher levels of health disparities, the funding to address this disparity is allocated on a population basis, leaving rural programs significantly underfunded. The Committee suggests that HHS consider need as a significant factor in future allocation of public health and prevention funding.”

[box style=”2″]This story was made possible by a grant from the Winston-Salem Foundation to examine issues in rural health in North Carolina. [/box]

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Taylor Sisk is a writer, editor, researcher, producer and documentary filmmaker who served as the rural health reporter from 2015 into 2016. He has served as a managing and contributing editor of The Carrboro...