How many people in the United States under 80 die of the five leading causes of death who would not have, if every state did as well as the best? A CDC analysis of death records from 2010 to 2022 puts a number on it for every kind of county — and finds that in every year, rural counties had a higher share of preventable early deaths than urban ones for all five causes.
Image from CDC's report
Measuring "preventable"
- Premature means before age 80 — close to average U.S. life expectancy in 2010, about 79.
- For each cause and age group, CDC took the death rates of the three states with the lowest rates in 2008–2010 as a benchmark. Every death above what those rates would predict counts as preventable (or "potentially excess").
- The benchmarks were held fixed so trends could be compared; a category that beat them was counted as zero, not negative.
- Deaths were sorted by the county the person lived in, using the National Center for Health Statistics' six-level scale from large central metropolitan (most urban) through large fringe, medium and small metropolitan, to micropolitan and noncore (most rural).
- COVID-19 deaths were excluded. 2022 figures cover January–June, scaled up to a full year.
The five causes: heart disease, cancer, unintentional injury (including drug overdose, traffic crashes, drowning and falls), chronic lower respiratory disease (CLRD) and stroke.
Nationally
| Cause | 2010 | 2019 | 2022 | Direction |
|---|---|---|---|---|
| Unintentional injury | 38.8% | 53.8% | 63.5% | ▲ steep rise, peaking in 2021 |
| Heart disease | 33.5% | 28.8% | 33.6% | fell, then jumped from 2020 |
| Stroke | 32.4% | 26.4% | 33.9% | fell, then jumped from 2020 |
| CLRD | 38.6% | 25.5% | ▼ | |
| Cancer | 21% | 0.3% | ▼ |
Share of deaths before 80 that were preventable, by the report's benchmark.
Image from CDC's report
By county type, 2010 → 2022
| Cause | Large central metro | Large fringe metro | Medium metro | Small metro | Micropolitan | Noncore |
|---|---|---|---|---|---|---|
| Heart disease | 33.5% → 30.1% | 24.1% → 22.0% | 31.7% → 33.7% | 36.9% → 39.5% | 42.0% → 45.8% | 45.1% → 49.4% |
| Cancer | 17.9% → 0% | 17.7% → 0% | 21.4% → 2.8% | 23.6% → 6.4% | 26.7% → 14.0% | 28.7% → 18.1% |
| Unintentional injury | 25.4% → 62.8% | 28.8% → 56.9% | 43.1% → 66.2% | 44.5% → 65.2% | 53.1% → 67.9% | 60.9% → 70.0% |
| CLRD | 23.4% → 0% | 29.4% → 6.5% | 41.1% → 29.9% | 47.1% → 42.1% | 53.1% → 50.7% | 54.3% → 54.8% |
| Stroke | 31.7% → 32.8% | 22.7% → 26.1% | 33.3% → 35.7% | 34.9% → 36.3% | 40.5% → 42.0% | 41.6% → 40.9% |
Image from CDC's report
Cause by cause
Cancer — the big success, mostly in cities. Preventable early cancer deaths fell in every kind of county, but most in the cities: large central and large fringe metro counties reached the benchmark in 2019 (a −100% change). The gap therefore widened — noncore counties in 2022 (18.1%) were where large central metro counties had been in 2010 (17.9%). Behind the fall: more screening (lung, colon, cervical and female breast cancer), which finds cancer earlier or, for colorectal cancer, before it starts; more vaccination against cancer-causing viruses; less smoking; Medicaid expansion; and new treatments, especially for lung cancer and melanoma. Overall cancer mortality fell 27% between 2001 and 2020. Lung cancer, the leading cancer killer, caused 23% of cancer deaths in 2020 — and rural counties have less access to lung cancer screening.
Unintentional injury — worse everywhere, fastest in cities. Driven by the overdose epidemic, rising traffic deaths and falls, the share rose in every category — by 147.5% in large central metro counties and 97.5% in large fringe ones — and in every state except Wyoming. The rises were statistically significant everywhere except micropolitan counties. The rural–urban gap narrowed, but only because cities got worse. Rural residents still have less access to medicines for opioid use disorder (low buprenorphine dispensing, less treatment capacity), a higher risk of dying in a crash, and lower seat belt use. Many fall risks can be changed.
Heart disease and stroke — the pandemic reversal. Both sharpened from 2020; from 2019 to mid-2022, 96% of states saw more preventable heart disease deaths and 88% more from stroke. The biggest heart disease rises over the whole period were in noncore (+9.5%) and micropolitan (+9.1%) counties; the biggest fall was in large central metro (−10.2%), which dropped back after 2020 (32.9%). Likely reasons tied to COVID-19:
- Blood pressure rose in every age group between 2019 and 2020, and control of hypertension became more unequal.
- People avoided emergency care: ED visits for heart attack and stroke fell 20% in the weeks after COVID-19 was declared a national emergency on March 13, 2020, and hospital admissions for both fell.
- COVID-19 itself raises the risk of heart disease and stroke.
For stroke, the highest shares in 2022 were in southern states; micropolitan (42.0%) and noncore (40.9%) counties led.
CLRD — cities improve, the countryside doesn't. Large central metro counties hit the benchmark (0%) in 2022; noncore counties were the one category not to improve (+0.8%). The sharpest urban drop, 2019–2021, may partly reflect people with CLRD such as chronic obstructive pulmonary disease dying of COVID-19 instead — they are at higher risk from it.
Why rural counties fare worse
- Rural death rates were 7% above urban ones in 1999 and 20% above by 2019; the national age-adjusted rate in 2021 was 841.6 per 100,000.
- Four of the five leading risk factors for early death are more common in rural areas: tobacco use, obesity, physical inactivity and drinking.
- Rural residents are older on average, but age alone doesn't explain it: income, social circumstances, behavior and access to care matter, and may account for about half of all preventable early deaths.
- Shrinking rural populations mean smaller tax bases and less money for health and social services.
- The highest early death rates are in rural counties where most people are Black or African American, or American Indian or Alaska Native; CDC plans follow-up reports by race and ethnicity.
Caveats
- One benchmark for all county types makes comparison easy but may not show what's achievable for each; fixed 2008–2010 benchmarks don't reflect later improvement.
- The five causes can't be added up — someone with cancer who dies of heart disease counts under heart disease.
- COVID-19 deaths misrecorded under other causes, and the pandemic's indirect effects, may have inflated 2020–2022.
- 2022 is provisional and covers half a year.
Sources
Based on Macarena C. García, Lauren M. Rossen, Kevin Matthews, Gery Guy, Katrina F. Trivers, Cheryll C. Thomas, Linda Schieb and Michael F. Iademarco, "Preventable Premature Deaths from the Five Leading Causes of Death in Nonmetropolitan and Metropolitan Counties, United States, 2010–2022," MMWR Surveillance Summaries, volume 73, Centers for Disease Control and Prevention, using National Vital Statistics System data; a work of the United States government in the public domain. Two statements in the report's text disagree with its own table and are left out: a 2021 heart disease figure for large central metro counties (the text gives 30.1%, the table 30.0%), and the claim that the rural–urban gap widened for stroke, which the table shows narrowing.
Licence: CC0 1.0 (public domain) · Adapted from www.cdc.gov
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