Rural Americans are sicker than urban Americans, a CDC report says, and that’s true for Washington.

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For many city dwellers, the country evokes images of healthy living: Clean air, farm-fresh produce and lots of outdoor activities.

Data tell a different story.

Rural Americans are sicker than urban Americans, and their health is declining, according to a new report from the Centers for Disease Control and Prevention (CDC).

Researchers looked at the rates for the five leading causes of death in the United States: heart disease, cancer, chronic lower respiratory disease (CLRD), stroke and accidents.

They found that not only are mortality rates for these causes significantly higher in rural areas, but the gap between urban and rural rates has been growing.

After a decade of decline, the rates in rural areas have leveled off or even shot back up, while the trend of improvement has continued in urban areas.

I looked at the CDC data for Washington and found that the trend holds true here.

In 2015, the most recent year for which data is available, that gap in death rates between King County and rural Washington hit an all-time high.

In King County, the age-adjusted rate for the five leading causes of death was 342 per 100,000 population. For Washington’s rural counties, the rate was 457 per 100,000 — 34 percent higher.

“We know there are differences in health-care behaviors between King County and rural areas of Washington,” said Jennifer Sabel, an epidemiologist with the state Department of Health. Rates of smoking and obesity are higher in rural areas, for example, while physical activity is lower.

Another issue is access to care, Sabel notes. Primary health-care providers are scarcer in rural areas. There’s also lower access to specialty care. And people are less likely to have health insurance.

The state’s highest age-adjusted death rate in 2015 was in rural Pacific County, in the southwest corner of the state — 606 per 100,000 people for the five leading causes of death.

Eighteen of Washington’s 39 counties are classified as rural by the CDC, meaning they are not contained within one of the state’s eight metropolitan areas. They’re on both the eastern and western sides of the state and are home to more than one in 10 Washingtonians.

For all five leading causes of death, the rates are higher in rural Washington than they are in King County.

One of the most pronounced gaps is in deaths from CLRD. That’s likely due to cigarette smoking, which is far more prevalent in rural counties. King County has the lowest rate of tobacco use in the state.

Another large discrepancy is in deaths from accidents. While rates are much higher in rural areas, the numbers also are trending upward in King County. Sabel attributes this to drug overdoses, which are increasing across the state and not just in rural areas.

The smallest gap is in the death rate for strokes, and that’s not by chance — the state has made efforts to improve stroke treatment in both rural and urban hospitals. Even so, after years of declines in rural deaths from strokes, the rate has leveled off since 2010.

“We have rural health programs specifically that focus on the rural areas, so they are certainly aware of lot of these issue and working to combat those,” Sabel said.

But there are challenges.

“Primary-care physicians in general don’t want to work in rural areas,” she said. “We have several programs working on improving that, but it’s not an easy task.”