A landmark study from 1842 found that even low-income country dwellers in the U.K. lived longer than their more-affluent urban neighbors; 175 years later, the story hasn’t changed much.
The motto of Rutland, England is multum in parvo: Much in little. Rutland is England’s smallest county, 16.3 miles from north to south, home to quaint cottages, green hills, and the World Championship of Nurdling (competitors throw pennies into a narrow hole in a wooden bench).
As befits its motto, tiny Rutland has played an outsized role in two significant medical studies, both of which focus on life expectancy. The newest, from the University of Liverpool, compared lifespans in rural Rutland to those in four cities: Liverpool, Manchester, Bolton, and Leeds. Rutlandites live longer than their urban counterparts, the study found. The study is a sequel—175 years later—of a pioneering bit of public health research from the Victorian era: In 1842, social reformer Edwin Chadwick found that laborers in Rutland lived longer than tradesmen in the same quartet of cities.
“Chadwick’s study was groundbreaking—it provided one of the first pieces of evidence that locality mattered for your health,” says University of Liverpool study leader Mark Green, a lecturer in health geography. Green wanted to see how much had changed (or hadn’t changed) since the original report.
In Chadwick’s era, cities were plagued by poor sanitation, air pollution from coal- and wood-fired heating, contaminated drinking water, and waste. Today’s Western cities are generally a lot cleaner—and life expectancy has nearly doubled—but place still matters, Green found.
“What Chadwick showed 175 years ago was this: Location was so important that people in the lowest occupations in Rutland lived longer than those in the highest occupations in cities,” says Green. That striking gap has narrowed somewhat: Today’s low-income Rutland residents no longer outlive the most affluent urbanites. But Rutland’s middle class still lives longer than high-income individuals in cities like Liverpool. As the report concludes:
Given that we used different measure of mortality, different definitions of social classes, different geographical boundaries and that 175 years have passed, it is remarkable that the rank correlations between the two sets of results remain relatively high.
Because longevity isn’t limited to Rutland’s elite, Green believes that environmental factors play a key role in the U.K.’s longer rural lifespans. Air pollution, for example, still bedevils urban dwellers of all classes: A stockbroker or a brain surgeon in Glasgow—which has more severe air pollution than even smoggy London, a 2017 World Health Organization report showed—is breathing in the same carcinogenic particles as less-affluent neighbors. That affects more than just cardiovascular and respiratory health: In a study led by researchers at the University of Southern California, people living in areas with high levels of fine particulate matter—typically associated with vehicle emissions in urban areas—were more likely to develop dementia, including Alzheimer’s disease.
Urban air pollution can also counter the effects of exercise, a recent study in The Lancet found. Researchers in London sent two groups of adults age 60+ on a two-hour walk: One in Hyde Park, the other along busy Oxford Street. The walkers all benefitted from the exercise, but the benefits were lower for those who strolled on the exhaust-heavy street. Traffic-related air pollution was responsible for six percent of deaths in another Lancet study on public health in Austria, France, and Switzerland.
The modern city resembles its Victorian predecessors in other ways, too. “Many features of urban life are not conducive to health and well-being,” says Green. “Factors such as noise pollution, access to green space and natural environments, density of fast-food outlets—they are all much higher in urban areas.” On this last point, Rutland offers proof: It’s the only English county without a McDonald’s, Burger King, or KFC.
So if fresher air and a pastoral environment help boost life expectancy in the U.K., why isn’t the same true in the United States? In the U.K., rural residents live about two years longer than city dwellers; in the U.S., it’s the opposite: Urbanites live two years longer than their rural counterparts. And the gap is growing—in 1969, just four months separated the two.
In some U.S. counties, life expectancy has even declined—dropping by 13 months since the early 1990s for women in rural Kentucky, according to a 2016 National Rural Health Association (NRHA) report. And rural Americans are also more likely to die from five leading causes—heart disease, cancer, unintentional injuries, chronic lower respiratory disease, and stroke—than those living in urban areas, a 2017 Centers for Disease Control and Prevention study found.
One reason for the trans-Atlantic distinction is simple geography: At 94,060 square miles, the U.K. is roughly half the size of California, and quite densely settled. “We don’t have extreme rural areas, just because the distances aren’t as big,” says Andy Jones, professor of environmental sciences at the University of East Anglia’s Centre for Diet and Activity Research. “In the U.K., you’re never a long way away from civilization.” Rural Brits have access to similar healthcare infrastructure, compared to their city kin (not to mention a national health insurance program). In the U.S., the ratio of primary care physicians to patients is 39.8 physicians per 100,000 people in rural areas, compared to 53.3 per 100,000 in urban areas, the NRHA notes. And non-elderly rural individuals are 3 percent less likely to have private health insurance than urban residents, according to a 2017 report from The Henry J. Kaiser Family Foundation, with Medicaid filling the gaps.
The urban-rural income gap between the two nations is another difference. The English countryside tends to attract a more affluent crowd—the average cost of a home in Rutland is £297,807, compared to £226,071 in the U.K. as a whole. And while rural U.K. poverty rates have increased slightly in recent years, 16 percent of rural U.K. households are considered low income (meaning their income is 60 percent below median levels), compared to 23 percent of urban households, U.K. government statistics show. Conversely, a quarter of rural children in the United States live in poverty, and per capita income is $9,242 lower in rural America than the national average, the NRHA reports.
The other benefits of country life may still exist in the U.S.—the peaceful sounds of nature are helpful for stress reduction, researchers at the Bright and Sussex Medical School found in 2017. The problem, at least in the rural United States, is that those babbling-brook upsides are more than outweighed by other burdens, from higher rates of smoking, obesity, diabetes, and heart disease to insufficient access to health care and the rampant opioid epidemic. Opioid death rates quadrupled among those age 18 to 25 and tripled among females from 1999 to 2015 in rural areas, the CDC reports.
In the U.K., location is more important for longevity than economic status, Green and Chadwick found. But in America, money matters more. Consider this staggering statistic: The difference in life expectancy between the richest one percent of Americans and the poorest one percent is 14.6 years for men and 10.1 years for women, according a study in the Journal of the American Medical Association. Acute poverty and poor health seem inextricable, whether you’re living in Appalachia or Detroit. And it’s a trap that can grip populations for centuries.
“Our results are evidence that health inequalities haven’t changed much over 175 years,” says Green. “One reason is that the same kinds of people tend to live in the same kinds of places over time. We need to tackle these inequalities so they don’t persist for another 175 years.”