Beyond Rural vs. Urban: The Importance of Considering Heterogeneity in U.S. Rural Health

Beyond Rural vs. Urban: The Importance of Considering Heterogeneity in U.S. Rural Health

The health challenges facing rural people and places in the U.S. have historically been overlooked by national politicians and the media, and the study of rural health problems has traditionally been relegated to a small group of rural sociologists, demographers, and public health researchers. But now, due in large part to the unexpected outcome of the 2016 U.S. presidential election and the nation’s unprecedented opioid crisis, the economic and health challenges of rural America are in the national spotlight. Media reports like Despair and Death in Small-town America and Rural America is the New ‘Inner City’ present portraits of a rural America in dire straits. To be sure, on average, rural areas perform worse than urban areas on a variety of key health indicators, including lower rates of health insurance coverage and higher rates of disability and pain, food insecurity, chronic disease, mental illness, and premature mortality. Thanks to more deaths than births, many rural communities are facing depopulation.

The rural health disadvantage stems from a complex interplay of multiple demographic, economic, and social forces, including older age composition, lower socioeconomic status, higher rates of risky health behaviors (smoking, heavy alcohol use, physical inactivity), greater reliance on injury-prone and manual labor intensive occupations, and less access to health care (lower insurance rates, healthcare workforce shortages, greater distance to providers, and fewer specialized and high-intensity care providers). Over 80 rural hospitals have closed since 2010, nearly 700 more are at risk of closing, and more than half of rural counties lack access to hospital maternity wards. Moreover, decades of declines in secure and livable wage jobs, especially for those without a college degree in small cities and rural hinterlands, has led to community breakdown, resource disinvestment, and outmigration. The very deep despair, dysfunction, and poverty in some parts of small city and rural America are increasingly reflected in high rates of opioid addiction and overdose, alcohol abuse, suicide, and declining life expectancy.

Despite these overall trends however, there is substantial heterogeneity in rural population health. The map below presents an example of this from my own research on spatial differences in drug mortality. Although it is technically true that “addiction does not discriminate”, there is significant spatial variation in drug-related mortality rates across the rural U.S., with the highest rates through Appalachia and the rust belt, American Indian reservation counties, parts of the desert southwest, and the Pacific northwest, and the lowest rates throughout the southern black belt, upper Great Plains, and Texas.

Drug-Related Mortality Rates among U.S. Nonmetropolitan Counties, 2006-2015

Note: Rates are age-adjusted; Data Source: U.S. Centers for Disease Control and Prevention. CDC WONDER. Multiple Cause of Death Files, 1999-2015

The media’s current emphasis on rural people and places offers a timely opportunity for health researchers, especially those with a spatial orientation, to highlight heterogeneity in rural health and advance rural health research and policy. First, I encourage researchers to consider the role of growing demographic and economic diversity on health in rural areas. For example, rural does not automatically equate to white. Racial/ethnic minorities account for about 20% of the U.S. rural population, are often geographically isolated, and face significant health challenges. The rural Hispanic population increased by 43% between 2000 and 2010, is expected to continue growing, and is more geographically dispersed than ever before. Despite lower rates of mortality and chronic disease than whites, rural Hispanics have very high poverty rates and face significant health care access challenges, including lower health insurance rates. Rural blacks and American Indians have the lowest life expectancies in the U.S., the highest rates of chronic disease (cancer, diabetes, heart disease), and shamefully low access to health care. American Indians also have the highest death rates from drug overdose, suicide, and alcohol-related causes.

Rural also does not automatically equate to farming. Fewer than 20% of the U.S.’s 1,976 nonmetro counties are farming dependent. Like urban areas, service industries account for the largest share of employment in rural areas, but many rural areas are also heavily dependent on manufacturing, mining, the public sector, and recreation. Health outcomes vary drastically across these different types of counties. For example, while mining-dependent rural communities fare poorly on nearly all health measures, rural recreation and retirement destinations have better health services and health outcomes than other rural counties.

In addition to considering the tremendous racial and economic diversity in rural health outcomes, this is also an ideal time to consider the multiple important intersections and interdependencies between rural and urban areas. Big cities and rural communities are more economically and socially interconnected and interdependent than ever. Hence, examining health via a rural vs. urban dichotomy is not a particularly useful way to understand national health disparities or to inform strategies to improve health. Rural demographers have increasingly been recommending analyses that consider the rural-urban interface. Rather than a boundary separating rural from urban, the interface is characterized by increasingly intense flows of capital, labor, population, information and culture, food, and material goods between rural and urban America.

More than 46 million people live in the rural U.S. It represents 70% of the nation’s land area. Rural areas supply disproportionate shares of the nation’s food, energy, military personnel, natural amenity recreation, and retirement destinations. As such, the health of rural people and places is crucial for U.S. economic competitiveness. The highly variable and dynamic demographic, economic, and social characteristics of the rural U.S. should be better reflected in our research and policy agendas.


Shannon Monnat, PhD, is Associate Professor of Sociology and Lerner Chair of Public Health Promotion in the Maxwell School of Citizenship and Public Affairs at Syracuse University. Dr. Monnat’s research blends perspectives from demography, sociology, and public health to better understand the correlates and consequences of social disadvantage, particularly at the intersections of place, public policy, and health. Stemming from her upbringing in rural northern New York State, a common theme binding much of her work is a concern for rural people and places. Her current research (much of which involves collaborating with New Connections Network Member, Khary Rigg), focuses on spatial differences in opioid misuse and mortality and other diseases and deaths of despair. Dr. Monnat was a 2014-2016 New Connections Grantee. Follow Shannon on twitter at @smonnat.

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