Expert Commentary

Safety in numbers: Are major cities the safest places in the United States?

2013 study in Annals of Emergency Medicine analyzing 1.3 million injury deaths in 3,141 U.S. counties from 1999 to 2006 to understand rural and urban risk factors.

When it comes to the relative safety of city and rural life in the United States, well-worn preconceptions abound. For many leading U.S. metropolitan areas, including New York, Los Angeles, Chicago, San Francisco and Boston, the 1970s era of “white flight” and urban disinvestment are in the past. Such cities are enjoying a renaissance, with central-area population growth, higher-wage jobs, rising real-estate values and, according to some calculations, a superior quality of life.

But the sheer size of cities gives understandable weight to the troubles that persist: Income inequality has soared throughout the United States, pockets of concentrated poverty remain in many formerly industrial towns, and even a Sunbelt capital such as Atlanta can have profoundly low levels of income mobility. As a consequence, major metropolitan areas can still perceived as “dangerous” places, while rural areas and the suburbs are far safer, or so the thinking goes. But is that true?

A 2013 study published in Annals of Emergency Medicine, “Safety in Numbers: Are Major Cities the Safest Places in the United States?” examines this question. Seven researchers from Children’s Hospital of Philadelphia and the University of Pennsylvania looked at a cross-sectional time-series analysis of 1.3 million injury deaths in 3,141 U.S. counties from 1999 to 2006. Mortality figures were the primary data examined, but how deaths occurred and the victims’ ages were also explored.

The study’s findings include:

  • Overall, the more rural the area one lives in, the higher chance of dying by accident or intentionally (homicide or suicide): “Both unadjusted and adjusted injury death rate ratios were significantly elevated in the most rural counties compared with the most urban.” In urban areas, the rate was 24 deaths per 100,000 people, while in rural areas it was 31.6 deaths per 100,000 — 31.7% higher.
  • Car and truck crashes were the leading cause of injury death in both urban and rural areas, with the number of deaths rising sharply with increasing rurality: 10.58 per 100,000 in most urban areas, 27.61 per 100,000 in the most rural areas — 161% higher. (A related 2013 study in Research in Transportation Economics gives fatality rates over time as well as risk factors.)
  • The second most common cause was firearms, which resulted in 10.4 intentional and unintentional deaths per 100,000. The most rural and most urban counties had similar overall risk factors, but the patterns of death varied: “In the youngest age group (0 to 14 years), as well as in the older age groups (45 to 64 years and ≥65 years), the risk of firearm-related injury death was significantly higher in rural areas…. In the 20- to 44-year-old age group, the risk of firearm-related injury death was significantly lower in the most rural areas compared with the most urban.” (A related 2012 study found that the risk of accidental firearm death more than doubled as one moved from urban to highly rural areas.)
  • Rural residents were less likely to die from homicide than those in urbanized areas but more likely to commit suicide. The difference in suicide rates was not significant in the most rural and most urban counties, however.
  • Over the period studied, the overall injury death rate was 56.2 persons per 100,000. The rate for unintentional injuries was 37.5, while the intentional injury was 17 per 100,000.
  • In urban areas, deaths peaked for those aged 45 to 65, at 57.66 per 100,000 people. In rural areas, the rate peaked for those 20 to 44 years old, with 96.28 per 100,000.
  • Rural and urban areas with the highest relative percentages of black inhabitants showed no significant difference in the risk of injury-related death. For counties with the highest relative percentages of Latinos, the risk in rural counties was significantly higher than in urban counties.

The authors recognize that a key limitation to their study is that they look only at fatal injuries to evaluate “safety”; many injuries are nonfatal, but are not consistently recorded and thus not able to be examined. “Important variables that we are unable to adjust for are distance to a trauma center, injury severity, rates of alcohol and substance abuse, and estimates of motor vehicle use.”

Related research: A 2012 study for the National Bureau of Economic Research, “Are Big Cities Bad Places to Live? Estimating Quality of Life across Metropolitan Areas,” looks beyond measures of an area’s cost of living and wages to include a wider range of factors. The adjusted quality-of-life measures are found to correctly predict how housing costs rise with wages, and show a close correlation with livability rankings.

Keywords: cars, guns, violence, rural