Even though cities have higher rates of crime and murder, a new study finds that overall, urban areas are safer than the sticks.
However, that counterintuitive conclusion doesn't fit Philadelphia. The City of Brotherly Love turns out to be about as risky as rural areas, largely because of car accidents.
"Philadelphia does tend to be on the worse end" of the safety spectrum for big cities, said lead researcher Sage Myers, an emergency medicine physician at Children's Hospital of Philadelphia.
The study, by researchers at Children's and the University of Pennsylvania, is the first to look at overall death rates for all sorts of injuries - crashes, gunshots, drownings, falls, poisonings, even animal attacks - across the nation, rather than for selected areas or specific injuries.
The analysis, published online Tuesday in the Annals of Emergency Medicine, also separated intentional injury deaths, namely suicide and homicide, from accidental ones.
Like previous studies, the new one found that homicide rates are higher in cities than the boonies. (Suicide rates were not significantly different.)
But the new analysis defied the prevailing perception that cities are innately more dangerous than remote areas. The most rural counties had the highest rate of fatal injuries - 74 deaths per 100,000 residents - compared with 50 deaths per 100,000 in the most urbanized counties.
People who are considering moving out of cities because of safety concerns may want to "reexamine their motivations," Sage said.
The study also raised - but could not answer - questions about the adequacy and accessibility of trauma care in rural America. Even when the researchers made mathematical adjustments to offset the fact that most counties lack hospitals with trauma centers, injuries in rural counties were deadlier than in urban counties.
Senior author Brendan G. Carr, an emergency medicine physician at Penn, said the findings provide a springboard for examining and better targeting rural trauma care.
For their analysis, the researchers used a federal database of 1.3 million injury deaths from 1999 to 2006 in all 3,141 U.S. counties. Then, using population data and other measures, the researchers classified the counties based on how urban, suburban or rural they were.
"Previous studies have looked at homicides or gun violence or motor vehicle deaths in some areas. What we wanted to do is take all those together and look nationally," Myers said. "We found the safest place overall is the most urban and the least safe is the most rural."
This pattern, however, was mostly due to motor vehicle accidents, the leading cause of accidental death everywhere. Crashes caused 28 deaths per 100,000 residents in the most rural counties, compared with 11 deaths per 100,000 in the biggest cities.
Previous studies, Myers noted, have found that rural crashes are more likely to involve no seat-belt use, poor road signage, and high speeds.
Other causes of fatal injuries did not vary much between rural and urban areas, or varied only in some age groups. For example, suffocation and drowning death rates were about the same nationwide. So were poisoning death rates, except among ages 45 to 64: Rural residents actually were at lower risk.
Firearm death rates were not much higher in rural than urban counties, but again, age mattered. Among ages 45 to 64, the chance of fatal gunshot injuries steadily rose with the degree of remoteness.
"I do think cities get a bad rap," Myers said. "When you think about safety, you think about somebody attacking you, but that is far outweighed by the chance of death in a car accident."
She speculated that crash injuries may be why Philadelphia fared badly when researchers divided selected cities into 10 groups based on their injury death rates. New York, Los Angeles, and even Detroit appeared safer than Philadelphia.
"Here, large highways run through the city, whereas in other cities, the highways may skirt the city," she said.