Widening rural–urban gap in life expectancy in China since COVID-19

INTRODUCTION: Disparities in life expectancy between rural and urban populations are well established but how it varies with epidemics and pandemics remains poorly understood. We aimed to quantify the rural–urban differences in the mortality burden of COVID-19 and to contribute to understanding the disparity trends in life expectancy between 1987 and 2021 in China. METHODS: We used monthly death counts from death registration systems. Rural–urban gap estimation and decomposition were carried out using period life tables to calculate life expectancy, the Arriaga decomposition technique to break down into age-specific and cause-specific mortality, and the Lee-Carter forecasts to estimate the expected gap. RESULTS: The rural–urban gap increased to 22.7 months (95% credible interval (CI) 19.6 to 25.8) in 2020 and further to 23.7 months (95% CI 19.6 to 26.7) in 2021, and was larger than expected under the continuation of the prepandemic trends. Compared with that in the recent 2003 SARS-CoV-2 epidemic and the 2009 influenza epidemic, excess rural–urban gaps in the COVID-19 pandemic changed from urban disadvantage to rural disadvantage, and the contributions shifted toward old age groups and circulatory diseases. Variations in the rural–urban gap since 1987 were positively correlated with the rural–urban disparity in public health expenditures, especially among ages <60 (p values <0.005). CONCLUSIONS: Our findings identified a widening rural–urban gap in life expectancy since COVID-19, and a shifting trend towards old ages and circulatory diseases, disrupting the diminishing trend of the gap over 35 years. The findings highlight the unequal impact of the pandemic on different communities in terms of mortality burdens.