Healthy People 2020 target mortality rates and actual rates in 2017, by age and residence Click the graphic to enlarge.(Graphic provided by the authors)

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In December 2018, research published in JAMA Pediatrics highlighted the improvements in child mortality rates in the United States. These improvements were substantial enough that the Healthy People 2020 objectives calling for a 10% reduction in child mortality rates had already been met among nearly all age groups by 2015.  The Department of Health and Human Services’ Healthy People Initiative develops a set of health objectives every 10 years on a range of health metrics, including mortality.

The overall improvement is wonderful news! However, mortality rates among rural children, specifically, were not presented. To tweak Peter Drucker’s famous statement, “you can’t change what you don’t measure.” If we do not examine rural and urban populations separately, we miss an opportunity to improve rural children’s health.

Our research found that improvements in in children’s health have not been equal across all geographies—particularly children of minority race/ethnicity in rural areas ( December issue, Health Affairs).  Using mortality data from the Centers for Disease Control and Prevention (CDC), we documented that Healthy People 2020 objectives for mortality had been met among urban children across all age groups by 2017, but rural mortality rates in every age group still exceeded Healthy People 2020 objectives (See graph at top of article).

We know that rural populations are not monolithic—20% of rural Americans are people of color.  In our study, we found that infant mortality rates were nearly twice as high among rural Black infants compared to rural White infants during the most recent 3-year period (11.2 vs. 6.1 per 1,000 in 2015-2017). Tragically, we found that rural Native American/Alaska Native children had the highest mortality rates of any population, across all age groups.

Injury deaths account for a large part of rural child disparities.  Deaths due to unintentional injury, like motor vehicle crashes, were consistently twice as high in rural as they were in urban children. To reduce rural child deaths in road crashes, we need multiple interventions, including safer road design, legislation to discourage unsafe driving behaviors, and improvements in EMS response. In addition, improving access to trauma care and halting the closure of rural hospitals may help mitigate the disparities in unintentional injury. Rural hospital closures represent a dual loss of trauma care—both as a provider and a destination for rural EMS.

Rural children ages 1 through 19 do fare better than their urban peers in one form of intentional injury, assault.  Rural children are markedly less likely to be killed by others, an advantage driven by assault death rates among rural Black youth that were only 49% of those among urban Black children.

Unfortunately, the rural advantage in deaths caused by others vanishes for youth suicide.  Rural children aged 10 – 19 were 41% more likely to die at their own hand than similar urban children.  This enduring rural disparity could be related to the persistent shortage of mental health professionals in rural (non-metropolitan) counties, highlighted in the map (see map below). Promoting safe firearm storage (unloaded firearm, locked storage, ammunition stored separately) could reduce youth suicide rates by inserting more time for thought between impulse and action.

Access to Mental Health Services by County. Click to enlarge.

While we want to draw attention to the sobering rural disparities in child mortality, we also do not want to overlook the progress in rural child mortality that has occurred in the last nearly twenty years. Mortality among rural children declined 19% between 1999 and 2017. Despite the persistent rural-urban disparities, notable improvements have been made for unintentional injury and other causes of death. In keeping with the “we can’t change what we don’t measure” mantra, we must keep tracking outcomes among rural children to continue to build upon these successes.  Better public health surveillance is needed to help us understand the unique challenges facing rural children, particularly minority race/ethnicity children.  Finally, continued research and advocacy are needed to ensure that children, no matter where they live or the color of their skin, are ensured a bright future.

Whitney Zahnd is a Research Assistant Professor at the Rural & Minority Health Research Center at the University of South Carolina. Janice Probst is Distinguished Professor Emerita in the Department of Health Services Policy and Management and is Director Emerita with the Rural & Minority Health Research Center at the University of South Carolina. Follow the Center on Twitter @RMHRC_UofSC.