Although homicides in cities far outpace those in rural areas, overall the risk of dying from some form of accident or injury is 20% greater in the most rural counties of the United States than in the nation's biggest cities.
The findings may give pause to people tempted to flee cities for the bucolic ideal of rural life, says Dr. Sage Myers, a pediatric emergency medicine specialist at the University of Pennsylvania and the Children's Hospital of Philadelphia.
"As you moved further and further away from cities you got less and less safe. Even going into the suburbs dropped your safety a little bit," said Myers, whose study was published in the Annals of Emergency Medicine. "It's a little counterintuitive."
More accidental deaths in countryside
Myers said when people think of their personal safety, they tend to think about intentionally inflicted injuries, such as being attacked or shot. But the researchers found that the risk of dying from an accidental injury is 40% higher in the nation's most rural counties than in its most urban.
"It turns out unintentional injuries dwarf intentional injuries," Myers said, and those types of injuries occur much more often in rural areas.
Part of the differences in the study may reflect reduced access to trauma centers, which are staffed with doctors who are trained to handle life-threatening injuries. Since most trauma centers are clustered near large cities, rural dwellers may be more at risk of dying from life-threatening injuries.
Myers and colleagues studied government data on all injury-related deaths from all 3 141 counties across the United States from 1999 to 2006. They excluded deaths caused by the September 11, 2001, attacks, which the researchers deemed too anomalous to be counted.
Of the nearly 1.3 million deaths during the study period, the overall rate of deaths caused by accidents was 37.5 per 100 000, compared with 17 per 100 000 for homicide and suicides.
The most common causes of injury-related deaths were motor vehicle crashes, which occurred at more than twice the rate in rural areas than in cities. Overall, car crashes caused 27.61 deaths per 100 000 people in most rural areas and 10.58 per 100 000 in most urban areas.
That may be because people in rural areas are more prone to drive on highways at high speeds and some studies have shown people in rural areas are less likely to comply with seatbelt and child restraint laws than are individuals in urban areas.
When the team looked at firearm-related deaths, they found no significant difference in the overall risk of death between urban counties and rural counties but there were significant differences in the trends by age.
In rural areas, for example, children aged up to 14 and adults over 45 had the highest risk of dying from a firearm injury, but among adults aged 20 to 44, the risk of a firearm-related death was much higher in urban areas. The risk was about the same for youths aged 15 to 19, regardless of where they lived.
The study did not look at the number of people who were injured but survived their car crashes or gunshot wounds, which might reflect whether people in urban areas simply have better access to trauma centers than people in rural areas.
Ian Weston, executive director of the American Trauma Society, a group that represents trauma centers and emergency experts, said when people sustain a life-threatening injury, there is "what we call the golden hour - that first hour post-injury is really the life or death hour."
That is where proximity to a trauma center makes a difference. "In rural areas, it's common that you are seeing transport times of over half hour to an hour to a trauma center," he said, noting that in South Dakota, there are just one or two trauma centers covering the whole state.
That contrasts with a state like New York, where there are nearly 50 trauma centers in the state, he said.
But Tom Smith of the University of Chicago's national opinion research group NORC said while the findings may accurately reflect access to trauma care in the United States, the notion of personal safety goes far beyond whether a person survives a life-threatening injury.
"There's a lot of other components to safety than deaths. What about crimes you weren't injured in?" said Smith, pointing to the two people in his own neighborhood in Chicago who were robbed at gunpoint the previous night. "There were no injuries, but I'm sure they don't feel very safe."
Smith said a survey his group did found many people in cities feel less safe taking a stroll around the block at night than do people in the suburbs, and much less safe than do rural residents.
Myers said more study is needed to tease out the differences in risks between urban and rural areas, but she said such studies should be taken into account as health policy experts consider the placement of new trauma centers.
The study was funded by the Agency for Healthcare Research & Quality, the Centers for Disease Control & Prevention and the National Institutes of Health.