US city-country mortality gap widens | Hacker News Reader

US city-country mortality gap widens

kffhealthnews.org

95 pointsBrajeshwar176 comments

My experience for years living in several very rural areas of the US leads me to believe that one big factor is "positive peer pressure" and quality food availability.

"Southern" people's rural lives may be calmer and richer in nature, but their hobbies and lifestyle are quite unhealthy.

In big cities there is more social pressure for being good-looking, mainly a healthy BMI and muscles, both which are protective against cancer.

They're also "food deserts" where supermarkets and restaurants with healthy food are extremely scarce. I've been to towns where you'd be hard-pressed to find any vegetables in their menu besides tomato sauce and a pickle. Health literacy is also abysmal. I don't see how they can avoid a heart attack with such food menus.

It's quite ironic that rural living is devolved to processed food garbage in America. I come from rural Poland, vegetables were very much on the table every day be it fresh or pickled. Rural regions are the ones that should be more capable of being self-sufficient compared to say a city because you actually have fucking land.

Yes but the push towards expansion and financial leverage means that you and your family are out working all day every day. So you have land but you don’t have any fucking time. Beef jerky and Red Bull it is then.

Much of rural America grows corn or soybeans. You can drive for literally hundreds of miles and only see these two crops. And it’s not even a corn that is edible, it’s grown to be processed or fed to other animals. Vegetable production is isolated to a few areas. Even then they are often limited to a few crops with narrow seasonality. You can grow vegetables in these areas but it’s not profitable.

> Much of rural America grows corn or soybeans.

Not in the parts of rural America this article is focusing on.

In Iowa, Illinois, Indiana, etc, where they grow ridiculous amounts of corn and soybeans, the land is way too valuable to allow widespread poverty to occupy it. I’m not saying it doesn’t exist, but it’s nothing like the scale of the rural south.

Not sure what you mean by the is. Indiana, Illinois both have higher population densities than Arkansas, Louisiana, and Missouri. (Although I bet Chicago distorts Illinois' population). Only Iowa's is lower and not by much.

There are tons of small towns in these states with a few hundred in population that used to support some industrial center that has since been sent overseas or a farming economy that required more people. They also often have crippling poverty, high drug use rates, and low standards of living. Indiana literally had an HIV outbreak a few years ago. https://pubmed.ncbi.nlm.nih.gov/27468059/

I don't want to compare levels of misery, but these states aren't much better off.

FTA:

> The researchers found the expanding gap was driven by rapid growth in the number of women living in rural places who succumb young to treatable or preventable diseases. [...] Pregnancy-related deaths also played a role, accounting for the highest rate of natural-cause mortality growth for women ages 25 to 54 in rural areas.

If I read Figure 1 correctly, overall mortality has actually declined (minus Covid). Even in rural areas mortality has continued to decline while this statistic was tracked. What appears to be the case is its declined _faster_ in urban areas.

Figure 2 shows BOTH metro and non-metro increases in mortality for age groups 25-29 and 30-34.

Actually looking at other figures, its flat-to-worsening in rural areas since late 90s.

I think this somewhat makes intuitive sense. I think most people caught Covid. Covid was most risky for people who had other illnesses. In the universe without Covid, many of those people would have died anyway.

The people who survived Covid were on average healthier than the people it killed... so the life expectancy should go up post-peak-Covid.

USDA Report: https://www.ers.usda.gov/webdocs/publications/108702/eib-265...

US Rural Hospital Closures Since 2005 - https://news.ycombinator.com/item?id=36302937 - June 2023 (153 comments)

UNC Rural Hospital Closures - https://www.shepscenter.unc.edu/programs-projects/rural-heal...

If you live an hour from an emergency room, all kinds of urgent things will become more fatal statistically and lower life expectancy. Stroke, heart attack, trauma. EMS pays careful attention to the "golden hour" of receiving definitive care being a survival factor. If you have to wait longer for transport (because you're rural) and then wait longer to arrive at the ER, then your hour may be up before you're even seen.

One mitigating factor is rural EMS sometimes has more advanced care options (allowed by their medical director) than urban BLS because they know it's a long ride.

Lol, the joke here is depending on rural areas. You may wait a few hours just for an ambulance to show up in the first place.

A huge factor in my personal experience is the quality of care at the hospital. Many hospitals in more remote locations have poor care. Sometimes it's that doctors who can't get the higher paying jobs at the big hospitals go there, and the facilities have lower budgets for many things. I've had family in the medical field who have worked all over the world and have stated that a few specific hospitals serving rural areas are only slightly better than some of the 3rd world hospitals they've seen. They might be bigger or fancier, but the quality of care is poor and the rate of mistakes are high.

Many times these hospitals also lack specialists. Some of my relatives will drive an extra hour to a bigger city, even though they live 10minutes from a hospital, because the doctors there don’t have the same specialities.

Ironically physicians earn slightly more in rural areas. Cash is used to balance out the disadvantages of moving to the middle of nowhere.

https://resources.nejmcareercenter.org/article/demystifying-...

I shouldn't have said higher paying. I should have said more sought after. The rural hospitals are paying more to attract people (where they're able to). They're more willing to lower their standards to fill positions. But they're also less likely to have some of the higher paying specialties that you'll find in the bigger cities.

https://www.chartis.com/sites/default/files/documents/charti... ("Unrelenting Pressure Pushes Rural Safety Net Crisis into Uncharted Territory")

> America’s rural health safety net has been in crisis mode for nearly 15 years. Rural hospital closures, decreasing reimbursements, declining operating margins, and staffing shortages have all coalesced to undermine the delivery of care in communities whose populations are older, less healthy, and less affluent. The mission of the safety net to serve under-resourced communities is unraveling. The latest research conducted by the Chartis Center for Rural Health points to a startling new phase of this crisis as rural hospitals fall deeper into the red, “care deserts” widen throughout rural communities, and the increasing penetration of Medicare Advantage could further disrupt rural hospital revenue.

I wonder what effect the proliferation of rural dollar stores has had. More junk food and fewer health care facilities is probably not a good combo... And has smoking become more common?

Exercise through everyday walking likely plays a key role. Rural Americans drive everywhere and their most significant walking typically will take place only within stores while shopping.

It seems to me that they lost their good habits (manual labour and walking a lot) but kept their bad habits (diet and smoking).

Having lived in rural areas, suburban areas, and urban areas, I don't see there being much difference in walking between rural and suburban.

My guess is that it's a combination of rural areas being poorer (less access to healthy food and extra curricular activities) and the lack of societal pressure to be healthy that comes from living in a more isolated environment.

I suspect if you closely examined activity levels by distance from city center, you'd see something like a log curve with moderate activity for city dwellers, decreasing as you get farther from the core, to the point where suburban/exurban/rural dwellers have very similar activity levels.

I saw a huge difference when I moved from a tiny rural town to a city. I grew up comparatively close to a decent-sized town, in that it was a 20 minute bicycle ride or more than one hour walk to the nearest supermarket, but in the city I found that there was usually a supermarket within a 15 minute walk. In the country my parents had to drive to everything except the pub and playground, and deliberate effort was required to get more exercise.

This depends on how walkable your cities are, of course.

I think one would have to adjust for occupations. I would assume certain types of jobs are more prevalent in one are or the other. For example, you're not likely to find many office workers in a location without large office buildings.

You can exercise all you want (not saying its not good for health, in contrary!), if you eat consistently crap unhealthy food and too much of it it doesn't matter long term (both consistent problems in US population as viewed from literally anywhere else in the world, for past few decades).

Who eat more healthy? More intelligent (since they grok how important it is long term, despite less initial appeal compared to more stronger basic fat&salty&sugary taste), more wealthy (so they can afford it compared to processed junkfood prices pushed to absolute minimum).

Who cooks for themselves from raw ingredients (which ends up being healthier food in general due to many factors)? Again same as above, you need to either have it hardcore baked in your culture like say Italians or French have, or just realize facts, and have some money to afford the extra time (and not juggle 2-3 shitty jobs trying to stay afloat and hovering just above burnout).

Even in major cities in the US, the vast majority of people still drive most places. Sure, downtown office workers can usually walk to get lunch, but that's about the extent of it. Also, exercise is much harder in urban areas, cities have crowded gyms making it harder to work out at peak times, crowded roads making it harder to bike, and constant crosswalks making it hard to get in a consistently-paced run. Rural/suburban people just run on their land/around their neighborhood.

Good point but I would describe it as the death of proper grocery stores. This reflects a reduction in the standard of living.

These particular numbers do not include suicide, but those numbers are very bad too. This Time article was written about our county a couple of years ago. I know a few of the people quoted.

https://time.com/6218385/suicide-rate-new-mexico/

White men in particular are checking out at an alarming rate.

So while this is an "external" cause not counted in the stats of the article, I can't help but assume common causes. The kind of depression that makes you want to die also makes you not want to take care of yourself.

It isn't difficult to get state paid medical care here, except for the distance. Appointments at the two small clinics are not far in the future and the medical staff is competent. I doubt doubling or tripling spending there would have much if any effect.

I think it's more about people who have chosen to live a more traditional lifestyle and discovering that it's an increasingly poor fit for the modern world. A plague of psychiatrists could descend on our county like locusts and bury every depressed person in talk therapy, and I doubt it would help.

There's only ~3500 people that live in the county.

Due to random noise, there's bound to be some small county with shockingly high suicide rates.

This would be a better, less alarmist, way to look at suicide rates: https://www.cdc.gov/nchs/data/hestat/suicide/rates_1999_2017...

Men used to commit suicide at about ~4x the rate of women, now it's closer to ~3.6x.

White people commit suicide at high rates - and have for a long time (compared to other races) - and the growth in suicide in white people is outpacing other groups - but the growth rate is actually higher for white women (~68% vs ~41%).

Not because the male suicide rate is declining, but because the female suicide rate is rising faster than the male suicide rate is rising.

"There's only ~3500 people that live in the county."

The trend follows even when evaluated nationally for the urban vs rural rate.

https://www.cdc.gov/ruralhealth/Suicide.html

Yeah, but it's 22 per 100,000 nationally, not 63.2 per 100,000 like in the small outlier county.

That's about 1/3rd the rate in the time article - that seems alarmist and cherry-picking a small county to make a big story out of a smaller story.

Eh, the article acknowledges that it's the highest rate nationally and provides the national rate (better disclosure than most articles). Their intent was to interview people affected by it. It's not a study but a news story. It makes sense they'd go to a more afflicted area to make their job easier and get some better ratings. It doesn't make the stories any less insightful to some of the issues faced by similar people. It's just like how the vast majority of gun crime doesn't involve schools, but school shootings get the bulk of the air time while the day to day problems aren't covered in detail, if they're covered at all. They're looking for the most impactful and easy story.

I don't understand the focus on relative growth rates of very differently-sized groups. If the country had only these two groups and we had seen 100 additional deaths, that would mean ~70 additional male deaths and ~30 additional female deaths. While it is significant on its own that women made up an even smaller portion historically, it doesn't seem to me that that is a better description of the problem at large.

Not that I think this is a gendered issue; suicide attempt rates are about equal between men and women, and the fact that men more often succeed doesn't really have any bearing on their relative mental health.

> It isn't difficult to get state paid medical care here, except for the distance.

The distance can matter a ton, especially if you're already sick.

Free rides are available on request. The clinics are in the only places with any population density, and it wouldn't be practical to add more, which would be in the middle of nowhere. It does contribute to the problem, but there's not much to be done about it.

I'm only pointing out that I think you're minimizing the effects lack of close accessibility to healthcare is on, well, healthcare.

I'd guess it has less effect than the difficulty in getting fresh food. Most of the population here has to drive for long distances to get to a mini market filled with ultra processed food-like substances.

If we could deliver a doctor or groceries to their front door the later would probably do more good.

Why?

I think that the bulk of medical care goes to chronic diseases that have, in my case, been treated more effectively by a better diet. My diabetes, etc. got worse while I was taking medication, and better when I stopped the meds and switched to a better diet.

I'd say the primary problem is the attitude that there's nothing you or anyone can do about it.

I'm not sure they're saying that nothing can be done, just that increased healthcare and therapy is unlikely to make a large impact. Addressing the actual problems driving them to suicide could reduce the numbers. They have some programs about USDA aid, lawyers, accountants, etc that farmers can use to address some of the issues.

https://www.opb.org/article/2021/08/03/farmers-are-at-risk-o...

> increased healthcare and therapy is unlikely to make a large impact

In places where there is a lack of healthcare and therapy, increasing it seems very likely to make a significant impact. If they are against increasing it, then don't complain about the lack of healthcare.

"increasing it seems very likely to make a significant impact."

Have you been reading the same information here? There are other factors specific to rural areas that would need to be overcome for healthcare and therapy to have an impact on suicide.

I'm a bit skeptical of the age grouping. 25-54 is a very wide range, and I would assume cities have more 25-year-olds, whereas the countryside will have more 54-year-olds.

I think that's part of the point: US agricultural policy since at least the 1970s has been "get big or get out", so you'd expect remaining rural populations to be more marginal.

https://en.wikipedia.org/wiki/Earl_Butz#Secretary_of_Agricul...

(It's possible to still have viable family farms in 2024, but it requires a willingness to have both (a) economic inefficiencies, and (b) legislative restrictions; although the Home of the Brave might be willing to implement a similar program, the Land of the Free is certainly not)

>I would assume cities have more 25-year-olds, whereas the countryside will have more 54-year-olds.

Would that be true?

For the same total population on each (say, 1M in cities vs 1M in the countryside) I'd expect the countryside to have higher birth rates and younger marrying couples, so younger demographics. Whereas cities have more career focused people, who marry later (if ever), have less kids, and have them at a greater age.

Regardless of where you're born, high-paying jobs and the promise of professional growth are in the city.

So 18+ (heading-to-college-and-after) leave their rural homes and rarely go back. Even if they manage to go to a local university, schooling leads to a niche job in some /other/ city far away from home.

Not only that, but agricultural jobs have been dwindling for decades.

Anecdotally, (before my time) my high school used to shut down in the middle of spring so all the teenagers could harvest tobacco. These days that's just grandpa on a giant harvester.

>So 18+ (heading-to-college-and-after) leave their rural homes and rarely go back.

One would think so, but then you read things like:

"Do Americans live where they grew up? At 68%, the majority polled answered yes, they live in or near the city where they grew up. People most often stay in the same town to be with their family, while those who move typically move for work. The data shows that these two reasons are the biggest factors in moving. It’s interesting to compare the current data to the U.S. Census Bureau’s 2016 study results. A few years ago, 75% of women stayed in their hometowns, compared to 68% of men. Those numbers have flipped, according to our 2022 survey."

I'd also guess rural areas have higher birth rates and younger marriages. By the time those kids reach 25, though, a lot of them will have moved to cities. That could still mean HPsquared is correct. I'd need to look up stats to be sure.

> I'd also guess rural areas have higher birth rates and younger marriages. By the time those kids reach 25, though, a lot of them will have moved to cities.

Is that statistically true? Most small and rural towns I know of a lot of people feel or are stuck when they're young.

It’s pretty common in my rural area for people to move to a city after college and then come back (or go somewhere else rural) in their 30s or 40s.

People often want to raise kids in the type of environment they grew up in.

Yes, city people rarely enjoy quiet simpler life near/in the nature and wonder WTF folks actually do there, and rural folks struggle to find cities appealing enough due to all the missing bits, noise, pollution, crowds.

Work or studies overcome this, but as you write, especially with kids, getting a bit older folks somehow remember positives of their childhood and revert, if work allows it. WFH gained wider acceptance due to covid helped massively, I still hope self-driving cars/pooled ai taxis will cover the rest in few years.

Thats literally a continuous trillion dollar business, and compared to many big name corps popular here this would tremendously positively help so many people.

IIRC some psychological research found out we humans can adapt to almost any situation, positive or negative, and over time revert to our original selves and level of happiness coming from our own existence (that's why joy from ie new toy fizzles away so quickly not only in kids). But folks seem to not do that for 2 items even after time passes - pets you actually enjoy (consistent positive energy) and long daily commutes where life tickles away and you are stuck doing nothing worthwhile for your life (the opposite).

Huh? Most of the city people I've known go out on weekends to parks or other rural areas to go hiking, or go hiking in convenient city parks. Some go more often than others of course, but it's pretty common, since being fit and healthy is a part of urban culture. My rural extended family doesn't even know what "hiking" is. I've never seen rural Southerners who actually go hiking anywhere.

That is the range of ages for which they found an increase but the biggest increase is in the 30-34 age subgroup. The report is not hard to skim, the overall picture is rural populations particularly in southern states are dying much more of "natural" causes like heart disease and cancer, and that divergence from urban populations started in the mid 80s. There's some speculation in the report as to why.

Mortality is strongly correlated with wealth and physical activity.

Wealth is a proxy for better healthcare, diet and education.

City people are generally richer and walk more.

Rural residents are poorer and drive everywhere.

> Within the prime working-age group, cancer and heart disease were the leading natural causes of death

I have a lot of extended family and in-laws who live in rural locations.

The lifestyle differences between what I see in the city and what I see in their rural locations are stark. The norms around diet, exercise, drinking, and smoking are completely different.

Even norms around personal safety and protective gear are completely different. Most of my rural extended family will do things like casually spray pesticides or paint without a mask. I was mocked for pulling out safety glasses and hearing protection for power tools when we worked on a project together once.

The study classifies things like heart disease and cancer as “natural causes” and blames lack of healthcare, but my anecdotal experience is that the lifestyle differences could easily explain the difference in heart disease and probably a significant number of the cancer diagnoses as well.

Even when healthcare is available, many of them don’t trust it. Statins are still a common debate when I visit, with many of the people in mid-life telling me that they don’t work and it’s just a big pharma cash grab conspiracy (even though statins are dirt cheap now). Refusing to take doctor-directed medication is a point of pride for some, though they tend to reverse course in older life when they see their peers start dying young. Many refuse vaccines for themselves and children due to things they heard on podcasts or social media. And mental health? Don’t dare even suggest that one.

I can’t even get my parents to care about mold after their basement floods for the 10th time in 10 years. They will worry about superstitions about eclipses, but not any long term health consequence from any source that could be labeled “science”.

It's a machismo built up around preventative behaviors that cost short-term money.

If you're a farmer trying to compete in the last 50 years, your concern isn't with the possibility that you might get cancer in 20 years from the neonicotinoids you're spraying; it's making enough money to cover expenses now.

But your friend who helps you do all sorts of farm chores, he wants to wear protection when he sprays. He's spent money on this protective gear, money that could have been put towards new machinery or the mortgage. He spends five minutes "dickin' 'round" putting it on. Five minutes that could be spent spraying. Since the span of five minutes is easier for the human mind to comprehend than the possibility of health problems months, years, or decades away, you choose to value the five minutes and tell him to get a move on. When he insists, you call him a wimp. He's now been shamed out of the preventative behavior.

Yeah, but its still outright stupid behavior, no matter how you wrap it. And stupidity will always be punished eventually in this world (which is the only way to 'fight' it, since as we know its endless and unlimited in mankind).

'I saved 5 minutes (or half an hour, who cares) so I can die 30 years younger than I had to, yeeehaaa'. Lack of good education, or intelligence, or both.

> Lack of good education, or intelligence, or both.

Is it? You can sum up most of a Wharton MBA with "gamble until it bites you in the ass".

The only difference is, the guy with the Wharton MBA gets to pawn his mistakes off on the guy who's actually doing the work, thus evading your punishment for stupidity.

If you are an alcoholic, there is no gamble, you will ruin your life and lives of people around you and die early and most probably miserably, period. Same with say smoking cigarettes, still a popular addiction of poorer folks all around the world.

It goes much deeper - children of drug abusers, be it legal or illegal, tend to very closely repeat their parent's mistakes also in this aspect, vicious circle that takes a strong personality and probably some luck to step out of. I consider it an utter failure as a parent, no nicer way around this.

I think a lot of these studies must either not be considering social factors, or maybe their authors aren't familiar with the worldview of rural America. I grew up in a place where some of those ideas are more popular, and the people around me regularly derided (what I now understand to be) healthy habits as things that 'sissy liberals' did. It was not socially acceptable to be on a diet, go to the gym, wear protective equipment, etc.

My friend (urbanite) was offered statins but declined and instead went on a "P90x" home gym program. Six months later, his doctor agreed that statins weren't needed provided he stayed in shape. Of course, you have to actually do the exercise :)

I think a lot of medications like that are basically a substitute for a healthier lifestyle. Not everyone can pull off the healthier lifestyle, so the drugs are good for them, but for others, they wouldn't be getting prescribed these drugs if they lived healthier to begin with.

These same social norms exist in city areas as well. Get a job in a factory and try to get your hands on adequate personal protective gear. You will not last long.

This brain dead machoism is rampant, half the population is promoting a know-nothing facsist pig for president so that they can hammer the last nail in their own coffin.

"Statins are still a common debate"

Even among some doctors, researchers, and former users there is debate. Not debate about their effectiveness in general, but about which situations should warrant them. There are several common side effects that can significantly impact quality of life.

It's understandable that some people are skeptical of statins based on the history of pharma and their current proposals. For example, I heard a year or two ago that they were looking into recommending statins for everyone over 70. The cholesterol level for when statins are recommended dropped about 50-100 points just a few years ago too.

"The lifestyle differences between what I see in the city and what I see in their rural locations are stark."

Are you comparing neighborhoods of similar socioeconomic characteristics? I've seen plenty of your types of example in urban and rural areas. The big difference is money. The more well-off people in either location tend to be more conscience - diet, exercise, PPE use - than the poorer people.

Edit: why disagree?

There is debate, because while statins effectively lower cholesterol, the results don't correlate that people on statins live longer or better - though they often are less likely to die of heart disease.

The effect on mobility, muscle health, and skin health are all downsides of statins.

> The big difference is money. The more well-off people in either location tend to be more conscience - diet, exercise, PPE use - than the poorer people.

I don't think that's because of the money. I think their lifestyle choices, natural abilities, worldviews, and other personal factors are the cause of both their limited income, and their attitude towards the health choices they make.

I don't think I said it was causative, just that it's correlated. So comparing areas with different economic statuses is not really a fair comparison.

Its is a conspiracy to keep them alive, so the live longer, and need more services as the age. Muahahahahah

> Even when healthcare is available, many of them don’t trust it.

Right, due to bad healthcare. The industry is riddled with bad actors, bad ideology, and patient hostile practices.

From what I've seen of the system it doesn't surprise me that people die instead of getting medical treatment. There's a lot of propaganda and need for reforms.

Article title is “City-Country Mortality Gap Widens Amid Persistent Holes in Rural Health Care Access”

> The study does not address causes for the increase in mortality rates… differences in health care resources could compromise the accessibility, quality, and affordability of care in rural areas. Hospitals in small and remote communities have long struggled, and continued closures or conversions limit health care services in many places. [perhaps also] persistently higher rates of poverty, disability, and chronic disease in rural areas, compounded by fewer physicians per capita and the closure of hospitals, affect community health.

Avoid syndicated content.

Actual article: https://www.cbsnews.com/news/city-country-mortality-gap-wide...

Am I wrong in thinking it's the opposite? CBS notes and links back to KFF, and the reporter, Jazmin Orozco Rodriguez, works for KFF.

Ahh fairplay, my mistake. Misunderstood what "also ran on CBS News" meant. Weird for them to post where else things were syndicated if they're the source.

The main thrust of the article appears to be that it's Republicans killing these people by opposing Medicaid Expansion.

What is the policy position that explains this decision?

Think about putting people into a spreadsheet (and remember that you probably exist in a few yourself, starting with an employer). Presumably your life has some value in expected economic output, and some cost associated with providing medical care. If the second number is greater than the first, then what is society to do?

I say this as someone who lives with some physical disability (who fortunately at least has a bit of enough wits to do non-physical work) - it's a rather uncaring country for those with medical needs; particularly those parts of the country governed by the right (I live in South Texas, but not the rural part).

Even a 1 person = 1 spreadsheet cell analysis takes into account that economic output can vary with human capital investment. Low income countries struggle to break out of poverty traps by draining swamps, vaccinating, and offering universal public education. You can't work productively if you've got malaria or can't read. Otto Von Bismarck instituted sickness funds to deflate support for socialism.

TANSTAAFL.

E.G., https://thefga.org/research/medicaid-expansion-is-closing-ho...

Makes total sense; the rural areas have been manipulated by the shareholder class into selling out most of their quality-of-life-enabling institutions for scrap.

I live in a relatively large Lower Midwestern city. The general attitude of capital and policymakers in the United States after the 1960s became one of confusion about the purpose of the area between the Appalachian Range and Rockies. California was booming, the cities on the East Coast were moving into a service economic model as their factories had been packed up. Why were these people still here? That applies to cities that used to participate in mercantile capitalism (St. Louis is a wonderful example of this) as well as small towns of 150 people. There's a lack of investment that would simply be unacceptable to people in the other parts of the country. Imagine if Amtrak's Northeast Corridor had the reliability of the various Midwestern routes.

This brings up an interesting partial explanation that we might be able to explore with data. A portion of the healthier and more successful rural population will migrate to urban areas, while a portion of the least healthy and less successful will be stuck and unable to leave rural areas. Urbanization as selection.

To a point; there's still widespread poverty in the cities these people eventually move to.

if they're healthy and successful why would they leave? the families with college kids of send their chilluns to school, but plenty return. and with high COL exploding in many cities, all the more reason to come home, esp. if their people are already successful in such areas

> if they're healthy and successful why would they leave?

Because they could be even more healthy and even more successful, or simply just happier, elsewhere. People who can leave will always leave more often than people who can't.

> the families with college kids of send their chilluns to school, but plenty return.

And plenty don't. Again, those that never leave stay at a higher rate.

> and with high COL exploding in many cities, all the more reason to come home, esp. if their people are already successful in such areas

The more wealth you have, the less you are deterred by high COL. And COL only goes up in cities because people are willing to pay a premium to live there, often for the economic opportunities.

Why do people do this? It's an observed fact that The United States is still going through the process of urbanization as a lower percentage of the population lives in rural areas compared to urban/suburban [0]. In the rural areas I am personally familiar with the population is decreasing while nearby metropolitan areas have increasing populations.

Since the 18th century humanity has experienced a large concentration inside cities. Who am I to say hundreds of millions of humans made the wrong choice.

[0] https://en.wikipedia.org/wiki/Urbanization_by_sovereign_stat...

Poverty and low labor mobility feed into each other. You have to be able to afford a security deposit and first and last month's rent. And land a job that makes the move worth it.

If you are providing child care, elder care, or disability care you cannot bolt to a city.

it would be more interesting to see the health differences by profession. It's a lot easier on your body to sit in front of a computer than be a lineman working for the county.

I think you have to work very hard before it's worse for your body than extended sitting. I make my living in front of a screen so try to mitigate it by going out in the yard and simulating someone who physically works for a living.

News for you, sitting on your ass is way harder on the body than actually working for a living.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7700832/

This is gonna sound silly but, I never sit in chairs normally unless I'm being watched.

I've presently got one leg folded under me, and the other tucked up, so I'm not sitting on my ass, I'm sitting on a shin and a foot. And I will probably move in a couple minutes.

Is that the same as "Sitting on one's ass", or..?

That's not what the article says.

The article is about the health risks of a sedentary lifestyle, which means a lot of sitting with limited physical activity. But even as little activity as 60-75 minutes of brisk walking per day seems to be enough to compensate.

It also mentions that watching TV is worse than more active forms of sitting, such as office work.

i grew up in rural areas around West and North Texas, every single person and relatives i knew that worked in those hard, labor intensive jobs, had bad knees and backs by the age of 55 and were basically crippled by retirement age.

Yep. Now if you had to choose between bad joints or an inactivity-induced coronary a couple decades early, which way would you go?

Lifestyle differences in rural areas are much more sedentary now that broadband internet is more available. In urban areas you have social factors and other reasons to walk around or stand up for longer periods.

Couple that with the mentioned shrinking of hospital and healthcare access and yeah you’ve got a double whammy.

I think this is right. For counterpoint though, there will of course be variance, but an opposite hypothesis is a larger proportion have labor jobs (men moreso than women).

Grew up in rural PA (mostly farming, some factory work). They exact a significant toll (part of the reason opioid dependence grew IMO).

But most of the metrics I have been seeing in terms of death rates show it is both for men and women, so I don't think labor jobs can explain it.

Hold up a sec, are you proposing that life in the country is more sedentary than in urban areas? I'm guessing you've never bailed hay.

> I'm guessing you've never bailed hay

Never had my boat fill up with hay so...no. I'd also guess most country people don't bale hay every day.

Neither have most people living in rural areas.

As someone who grew up and lived in a very rural area, most rural people don’t bale hay.

Most rural people live like those in the suburbs but are just physically farther away from other people.

A cursory search indicates that the giant marshmallow looking haybales that modern farming produces are formed by a machine which you tow behind a tractor. I'm just a city gal, but how much of a workout is that, really?

Edit: also, why are we speculating on stereotypes and not consulting actual data collected on exactly this question? https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7182355/

It seems that people living in rural areas are, on average, more sedentary than their urban counterparts, despite the overwhelmingly popular stereotype that rural folk are svelte and outdoorsy.

It's a pretty significant workout. Hooking up, detaching, cleaning and maintaining a bailer is a lot more effort than even a good distance walk. The statistics you're quoting are more so due to the fact that most people in rural areas don't operate a bailer or really any farm machinery. Which showcases one of the problems with relying on "actual data" without having a good understanding of the situation.

Yes "actual data " is the problem. You even point out yourself

>most people in rural areas don't operate...really any farm machinery"

Which would be consistent with that damn actual data showing that rural folk are more sedentary than urban folk, in aggregate or on average.

Except it really wouldn't, because it doesn't take into account any of the bog standard daily lived realities of being rural that include hunting and fishing, managing livestock, working in the trades, dealing with equipment, or hell even just keeping several acres mowed and maintained, all of which are dirt common activities for rural Americans. What, you think you get outside the city and everyone's sitting on their ass in a trailer park collecting welfare and working on their diabetes or something?

> What, you think you get outside the city and everyone's sitting on their ass in a trailer park collecting welfare and working on their diabetes or something?

You're the one slinging data-defying stereotypes around. Believe it or not, "working in the trades" is something lotsa urban folk get up to, as with hunting and fishing, and boy howdy do urbanites love some huge lawns in their green spaces. Do you think urban grass just mows itself? No, cities hire urbanites for such jobs.

And, real talk. You made haybaling sound tough; I'll grant you that for lack of experience, but I've ridden a damn lawnmower and it's no great workout. And if my rural family is at all typical, mowing a lawn is a net positive in calories because riding a mower is occasion for a beer or six.

But the data says y'all are more sedentary and more obese on average than city dwellers. Now, I'm inclined to blame DDT exposure for the latter statistic, and reliance on cars for the former, but if you want to make some weird judgements about how folks are spending their time, that's on you.

> most people in rural areas don't operate a bailer or really any farm machinery.

This was effectively the claim made in the top-level comment; I responded to somebody countering that with weird claims about baling as if that's a typical activity for rural residents to engage in. But it's not, according to you and according to the data. What problem do you think this is showcasing?

The comment you made questions how much excersise operating a bailer involves, which is what I responded to. I don't see anything in your comment or the parent talking about how common that excersise is, which is why I offered it as an explanation of the incongruence between your dataset and your implication that bailing is effortless because it involves a machine.

Well, I'll agree on one thing, weighing in

> without having a good understanding of the situation

does seem problematic.

And yet here you are.

>The statistics you're quoting are more so due to the fact that most people in rural areas don't operate a bailer or really any farm machinery.

This is exactly the problem with some of these rural vs. urban debates. The pro-rural people will make claims about how important farmers are, etc., and seem to have some kind of romantic idea about what rural life is like, but the reality is that the vast majority of rural dwellers are not farmers, do not live any kind of "outdoorsy" life, and basically are people who are too poor or too anti-city to live in or closer to a city, and generally have a very sedentary and car-based lifestyle.

If by "romantic idea" you mean actual lived experience then ok.

No, it's not actual lived experience. I came from the rural South, I know what it's like there. The people there are NOT farmers.

I'll be sure to tell my three uncles who raise pigs, tobacco, corn, soybeans, and peanuts the next time I see them that they aren't farmers. I should probably ask my cousins how they manage to find time to sit on their asses given their employment in the timber industry, ask my father what a sedentary ironworker even looks like, and then there's the minor issue of all the time I've spent working in the trades during the week and on heavy equipment on the weekends...

So by your logic, because a handful of people are farmers, then everyone in rural areas is a farmer? Brilliant.

Clearly you've also never seen bailed straw, pine straw, or any of a number of other square baled products. Hell, you had to google round bales and still don't know what they're called. And yeah, not everyone has livestock, that was just tossed off the cuff as an example that the utterly uninitiated would maybe kinda grasp based on experience with lawn care. So anyway, tell us more about how folks in the country are living based on your obvious deep personal experience...

it's crazy how something seemingly minor, the necessity to walk some real distance for meeting daily needs, has such a wide range of benefits. Unconsciously, it makes you eat better and less, otherwise the walking would be very uncomfortable. It also makes you care about your immediate environment more, because you experience it a lot more directly.

When you don't have that, it's an uphill battle. You have to carve out dedicated time to exercise, and you have to be very conscious of your diet.

Walking makes for a healthier life, it really does, rather than only the healthy opting in for walking.

Every time I’m in Europe I’m just delighted at how much I walk without having to use any other form of transport. Virtually impossible at home (LA).

I miss it after moving back here (midwest).

The social politics of public health and medical schools is heavily slanted against focusing on rural Americans.

This isn’t an armchair statement.

Reduced institutional emphasis and engagement isn’t the cause of these trends, but it isn’t helpful.

Rural places would benefit from targeted loosening of healthcare regulations. More local experimentation. Clear eyed view of the road to recovery.

Groups like the Cicero Institute have put effort here. Their approach is pragmatic and appears to be effective.

Breakthroughs will not come from traditional institutions.

Can you clarify what you mean by "social politics?"

I ask because rural health is effectively its own subspecialty in family medicine. There doesn't seem to be a locality equivalent for other geographic subgroups. This implies, to me, an extra level of focus on the needs of a population.

The claimed support for this (Cicero Institute) is a right-wing libertarian policy group that is rather notorious for is attempts to criminalize homelessness at the state and municipal level. I would take any policy suggestions they make with a giant grain of salt. In almost all cases "loosening of <X> regulations" involves screwing the poor and disenfranchised as much as possible with regards to X.

Too much of this far right libertarian nonesense on HN, has really been grinding my gears.

Surprised not to also see someone bring up lab leak theories and anti-covid nonsense, somehow.

I've been saying for ages that HN is full of far-right extremists. It's long been a problem in the tech industry.

There's no shortage of it and there's a highly visible few ... but I wouldn't go so far as to say that HN is "full of" either far-right extremists or (US) libertarians.

Just in this little sub thread run there's clear push back on "far right libertarian nonesense" which is more the norm, there's always a few trying to run particular flags up some pole or another and there's generally many more pointing out issues in idealogical positions.

Various topics do devolve into attracting a small cluster of actively vocal shared bubble comments but these tend to disappear from ranking quickly as the comment noise outweighs the post vote and it sinks.

Much noise, less substance.

>but I wouldn't go so far as to say that HN is "full of" either far-right extremists or (US) libertarians.

"full of" can be interpreted many ways. I don't mean to say that the vast majority of people here are like that, but there are some very vocal members here, and I don't see them being down-modded to oblivion as I would in more moderate venues. In a forum full of college-educated Europeans, for instance, I would not see any of that nonsense.

It's a predominately US site, that brings a high tolerance for peculiarly US PoVs.

Many political comments on HN carry an implicit belief that only "free market" (for some variation of) capitalism OR extreme authoritarian "communism" exist as systems, many of the older coders grew up with Heinlein as teenagers which carried forward as influencing their thought, etc. Gun control and free speech are other topics that centre on a primarily US PoV, and so on down the line.

I'm neither North American nor European and always find it amusing | fascinating picking out the various implicit positions that comments carry.

I'm from the US myself, so I'm familiar with this kind of thinking, but it's just frustrating and annoying to me because it's really so juvenile. But it's basically the national religion for a significant (but minority) fraction of the American population.

And yeah, the gun control thing is really annoying too. Whenever a discussion thread here gets into guns, the Americans jump in and then it's always the same BS arguments about "gun control only keeps honest people from having guns". Americans are extremely myopic and have absolutely no idea what life is like outside their country, and can't even imagine what it's like in a developed country where gun ownership is extremely uncommon, among many other things. Despite the internet promising to bring the world closer together, it really hasn't, and as I've gotten older and more worldly, it just annoys me that Americans are so unable to see past their own borders.

I sometimes recommend Faul, "The Xenophobe's Guide to the Americans"

Can't afford to see a doctor. Last Doctor I did see told me they would not do a sweat salinity test because I couldn't afford a diagnosis.

Can't buy Sudafed; pharmacies treat the request like you asked them for their virgin daughter.

Can't buy anitbiotics at the feed stores no more; FDA took care of that.

I've got my own individual reasons to doubt the medical industry; I see my neighbors finding many of their own. We're going to need witch doctors and other unlicensed caregivers before long.

Of course, it could be a question of metrics vs incentives, too. Who gets promoted when they juke the stats to say there isn't a problem? "Rural Healthcare" is one of those lovely nebulous goals that can soak up nearly infinite amounts of grant money without ever having to show real results.

I’m sure you’ve run down a lot of options already but in case you haven’t come across these (or to anyone else with similar issues):

> Can't buy Sudafed; pharmacies treat the request like you asked them for their virgin daughter.

If you have a Costco when you go into town, you can get 24 generic for about $3 and can buy 3 boxes at a time from the pharmacy. 6 if you are there with someone else on the card. I’ve never been given a funny look about it and stock up whenever our family seems like they might be getting sick. I’m not sure what the limit is beyond single visit, but for a family of 6 we’ve never had an issue having enough on hand.

> Can't buy anitbiotics at the feed stores no more; FDA took care of that.

JASE seems expensive, but then and others will give you prescriptions via telemedicine.

I used a teledoc during COVID to get the verboten prescription and it wasn’t any more expensive than a pharmacy clinic or urgent care.

> Costco

Even when the nearest Costco is an hour away at best?

Having grown up and lived in the country, something being only an hour away is not unusual or a big deal. Our grocery store was 45 mins away, it isn’t a big deal when that has been your life.

Presumably buying 3 boxes of sudafed isn't something you do frequently.

Anyone will allergies will disagree :D

> Can't buy Sudafed; pharmacies treat the request like you asked them for their virgin daughter.

Do they really make it that hard in rural counties to buy that stuff? Here in the city you just need to ask for it at the pharmacy counter and they scan your ID and you're good.

Depends on where you live. I live in Indiana, and you can buy Sudafed in limited quantites, but you are reported to law enforcement. Most people don't want law enforcement even knowing they bought Sudafed, so they go without. I had a chance to sit in a policy briefing where they shed a little light on what's going on in rural Indiana with mortality rates:

* Opioid epidemic really hit rural communities hard and high suicide rates are pretty common among addicts. This led to an increase in suicide in older people.

* Meth epidemic was fueled by cooking meth in the country, and it hit younger people.

There's a lot that has to go wrong before those two things become a major risk, though. Happy people don't generally decide that doing meth is a great idea. So what's driving the high rates?

Is it high rates of bad overall health? Bad economic prospects and high expenses leading to hopelessness? Something else?

> Bad economic prospects and high expenses leading to hopelessness?

Debt + Meth is a bitch..

my wife wont even ask anymore. our state law is one box per adult, per month, with ID. you dare not mention "family", they can't sell to anyone who says they're buying for others.

When i ask, its a wait while thy call the other pharmacies to see if ive bought there, and then they copy my info down and post it on a bulletin board. That's assuming they've got the time to deal with me: if they're rushed they just say no.

> Who gets promoted when they juke the stats to say there isn't a problem?

Who says there isn't a problem? IME many people says there is a major one, that the US needs to revamp its healthcare system, and rural voters vote against it.

Why is sudafed still behind the counter when now it's not even necessary and it may improve the health of the community if they started making meth with it again?

Some people have been able to map increased glyphosate usage to the rise of chronic disease. I was surprised to learn that glyphosate ("Roundup") was patented as an antibiotic. I was not terribly surprised to learn that it is found throughout our environment. In rural areas you are basically doused in it. Supposedly the effect is to disrupt the gut microbiome, ultimately resulting in persistent inflammation which of course leads to chronic disease and cancer.

I don't want to live anywhere where I can see my neighbor. These people are choosing this lifestyle. These same people are a massive tax on society because we have to subsidize this lifestyle because it's very expensive to provide services to places where nobody lives. Why would you build a hospital where only 10,000 live? Why spend $5000 to drag fibre to someone's house so that they can pay $50/month for internet access? How can you afford to pave a road where one person has 800ft of frontage and pays $1500 a year in SALT?

Again, at the end of day this is a choice and their choice costs everyone. I can't really feel sorry for these people, it's what you get when you want to go it alone.

Shouldn't you use "we" instead of "these people"?

Yes, his first sentence is incongruent with the rest. I think he meant to add quotes around it, as it's a stereotypical thing that rural dwellers would say. The rest is an accurate argument, complete with dollar amounts, about why their lifestyle is unsustainable and needs subsidization to continue.

We need places where nobody lives to produce things. You cannot farm acres of land where everybody lives, it has to be done where nobody lives. You can’t raise cattle where people live because the cattle has to live there.

I suppose the converse view is that city dwellers are externalizing the cost of their existence and so we should see huge increases in prices for staple goods until rural dwellers are paid appropriately and we have equitable outcomes with respect to mortality between rural and urban populations.

Oh please, not this dumb argument again. Have you actually ever visited or lived in rural American areas? These people are not farmers. Building a road to a farm is fine, but there's a huge network of roads out there just to service non-farmers who choose to live rural lifestyles and expect everyone else to subsidize this lifestyle for them.

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