Persistence of death in the United States: The remarkably different mortality patterns between America’s Heartland and Dixieland

Abstract

BACKGROUNDGeographic disparities in mortality have been analyzed by place in myriad ways. Although the people who live in a place continuously change, the health characteristics of those places tend to stay the same; they are persistent. Our work analyzes persistence of mortality across various geographic designations and uncovers the wide-ranging disparities in death across the United States. METHODSUsing 48 years of county-level mortality data, we analyze trends over time and disparities across places using rural-urban distinctions and census-based region and division classifications. Trends in death rates, excess deaths, and rates of mortality improvement are provided. RESULTSFindings support the hypothesis that persistently high mortality places are disproportionately concentrated in the rural South, particularly the East South Central division of Kentucky, Tennessee, Mississippi, and Alabama. The disparity between this division and urban America is wide and getting wider, and the disparity between this area of the South and the Midwest is alarming. CONTRIBUTIONOur research moves forward the literature on place-based mortality disparities in two important areas by testing the notion of persistence of poor health in place, and by identifying geographic disparities based on classifications not previously tested.

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

“…These divisional trends were driven by multiple causes of death, including the deaths of despair, cardiometabolic diseases, respiratory disease, and liver cancer. The southern mortality penalty is consistent with recent research showing a persistent and growing mortality penalty for this region (James 2014 ; James and Cossman 2017 ; James et al 2018 ). Together, these findings suggest that the rural southern and Appalachian disadvantage may be generational and impervious to changes in population composition over time.…”

“…James and Cossman ( 2017 ) similarly found that both white and black mortality rates were comparatively higher in medium-sized nonmetro counties and lower in the smallest nonmetro counties. James et al ( 2018 ) combined RUCCs and the nine Census divisions, finding that persistently high mortality was most heavily concentrated in rural counties in the East South Central division. Murray et al ( 2006 ) divided the U.S. into eight Americas based on race, region, and population density, finding comparatively high life expectancy (LE) in the Great Plains and low LE in the Deep South.…”

“…Rural population composition has shifted over the past 30 years (Burton et al 2013 ; Lichter and Brown 2011 ). However, health outcomes persist in communities over multiple generations (James et al 2018 ). Cosby et al ( 2019 ) show that the rural mortality penalty is not the result of place-based differences in education, income, and poverty.…”

The persistent southern disadvantage in US early life mortality, 1965‒2014

“…In addition, our data do not have the detail to directly address concerns about urban-rural mortality gaps (Cossman et al 2010;James 2014). Future research could apply innovative data linkages to formally model variation in urban-rural early life mortality gaps across state contexts, extending prior descriptive research (James, Cossman, and Wolf 2018). Extant research on geographic variation in adult mortality has been increasingly moving in this direction, linking large-scale highquality survey data to diverse administrative and historical data sets to better understand how macro-level contexts and changes influence region and even statespecific health outcomes (Hayward et al 2018;Montez, Hayward, and Wolf 2017;, including mortality .…”

“…In subsequent work, Singh and colleagues (2013) find that much of this southern disadvantage is driven by sustained socioeconomic deprivation at the county level, which, combined with higher risks of death in both urban and rural settings, contributes to higher levels of mortality from homicide, suicide, unintentional injuries (primarily from motor vehicle accident deaths), and HIV/AIDS. Moreover, southern rural settings have been associated with some of the highest age-specific mortality rates in the country, contributing to a wider urban-rural mortality gap (Cossman et al 2010;James, Cossman, and Wolf 2018), which some studies suggest may be impacted by statelevel factors such as expenditures on public health (Cossman, James, and Wolf 2017; James 2014).…”