Most People Safer in Big U.S. Cities But More
Seniors Murdered in Rural Areas
Cars, guns and drugs are the unholy trinity causing
the majority of injury deaths in the U.S.
July 23, 2013 A report released today reports the
surprising conclusion that in the U.S. cities are a safer place to live
than are the suburbs or rural communities. There is, however, a notable
exception although overall homicide rates are lower in rural areas
they are higher for senior citizens.
Researchers from the Perelman School of Medicine at
the University of Pennsylvania and the Children's Hospital of
Philadelphia (CHOP),analyzing 1,295,919 injury deaths that occurred between 1999 and 2006,
determined that the risk of injury death was 22 percent 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.
Though the risk of firearm-related death showed no
difference across the rural-urban spectrum in the entire population as a
whole, when age subgroups were studied, firearm-related deaths were
found to be significantly higher in rural areas for children and people
45 years and older; however, for people age 20 to 44, the risk of
firearm-related death was significantly lower in rural areas.
The new study overturning the common belief that
cities are the most dangerous communities in American appears online
ahead of print in the Annals of Emergency Medicine.
"Perceptions have long existed that cities were
innately more dangerous than areas outside of cities, but our study
shows this is not the case" said lead study author, Sage R. Myers, MD,
MSCE, assistant professor of Pediatrics, Perelman School of Medicine and
attending physician, Department of Emergency Medicine at CHOP.
guns and drugs are the unholy trinity causing the majority
of injury deaths in the U.S. Although the risk of homicide is
higher in big cities, the risk of unintentional injury death is
40 percent higher in the most rural areas than in the most
urban. 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.
"This has important implications about staffing of emergency
departments and trauma care systems in rural areas, which tend
to be underserved as it is." - lead study author Sage Myers, MD,
MSCE, University of Pennsylvania
"These findings may lead people who are considering
leaving cities for non-urban areas due to safety concerns to re-examine
their motivations for moving. And we hope the findings could also lead
us to re-evaluate our rural health care system and more appropriately
equip it to both prevent and treat the health threats that actually
The study examined county-level data on all injury
deaths across the U.S. from 1999-2006 (because of their unusual nature,
deaths from the 9-11 terrorist attacks were excluded).
Findings from the study support prior work showing
that overall homicide rates are lower in rural areas than urban areas.
This was found to be true in all age groups, except the oldest adults
(over 65 years old).
Suicide rates, on the other hand, showed an
increase with rurality, but the increased rate of suicide death in rural
areas only reached statistical significance for the two youngest age
groups: 0-14 years and 15-19 years.
However, the magnitude of homicide- and
suicide-related deaths, even in urban areas, is far outweighed by the
magnitude of unintentional-injury deaths such as those from car
crashes and falls in nonurban areas, especially in rural areas.
Specifically, the rate of unintentional-injury
death is over 15 times that of homicide for the entire population and
the risk of unintentional-injury death is 40 percent higher in the
nation's most rural counties compared to the most urban.
The research team found that the bulk of
unintentional injury deaths result from motor vehicle crashes, with
motor vehicle injury-related deaths occurring at a rate that is more
than 1.4 times higher than the next leading mechanism of injury death.
In rural areas, this difference is even more
pronounced, where motor vehicle injury-related death rates are twice
that of the next leading injury mechanism. Across the rural-urban
continuum, the risk of motor vehicle-related injury death is 2 times
more likely in rural areas as compared to the most urban.
"We think our work serves as a reminder that injury
is an important health issue for Americans, wherever they live. Our
findings can inform both targeted prevention efforts and strategic
efforts to improve trauma care in the U.S. This work provides a real
opportunity to build systems of medical care that are positioned to best
care for the populations that depend upon them for life and limb saving
treatment in their time of need," said senior study author, Brendan G.
Carr, MD, MSHP, assistant professor Emergency Medicine and Biostatistics
and Epidemiology at Penn.
Race was also a factor. Rural counties with large
black populations had significantly lower risk of injury death than
those with small black populations. The opposite was true for Latino
populations: Rural counties with large Latino populations had
significantly higher risk of injury death than rural counties with small
Surprisingly, rural counties with the highest
levels of college-educated inhabitants and median income had
significantly increased risk of injury death compared to rural counties
with the lowest levels of each.
The researchers note that next steps in this line
of research should focus on creating local injury priority scores a
relatively simple and objective tool that uses data available in trauma
center registries to rank injury causes according to both frequency and
severity and considering innovative ways to continue to develop the
U.S. emergency and trauma care system to assure that all Americans
receive the best emergency and trauma care possible.
"Trauma has been a leader in planning for care from
the population perspective," says Carr, referencing the interactive
trauma system mapping tool created at
"but we've still got work to do."
Additional Penn authors are Charles C. Branas, PhD;
Benjamin C. French, PhD; Michael L. Nance, MD; Michael J. Kallan, MS;
and Douglas J. Wiebe, PhD.
The research was funded by the Agency for
Healthcare Research & Quality, the Centers for Disease Control &
Prevention, the National Institutes of Health.
Annals of Emergency Medicine is the
peer-reviewed scientific journal for the American College of Emergency
Physicians, the national medical society representing emergency
Penn Medicine consists of the Raymond and Ruth
Perelman School of Medicine at the University of Pennsylvania (founded
in 1765 as the nation's first medical school) and the University of
Pennsylvania Health System, which together form a $4.3 billion
The Perelman School of Medicine has been ranked
among the top five medical schools in the United States for the past 16
years, according to U.S. News & World Report's survey of
research-oriented medical schools.
The University of Pennsylvania Health System's
patient care facilities include: The Hospital of the University of
Pennsylvania; Penn Presbyterian Medical Center; and Pennsylvania
Hospital - the nation's first hospital, founded in 1751.
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