The Emergence of an Urban Mortality Advantage in Brazil: An Assessment of Age and Causes-of-Death Contributions to the Urban-Rural Mortality Gap.

Brazil has historically seen higher mortality among urban residents compared to rural counterparts, despite better self-reported health among urban residents and better access to healthcare services. However, recent trends in these urban-rural mortality differentials and the specific causes of death contributing to them have not been well documented. We address this gap by analyzing trends in adult life expectancy in Brazil's five macro-regions from 2006 to 2023. We decompose changes in the life expectancy gap by age, sex, and cause of death. Our findings reveal an emerging urban advantage in male life expectancy in Brazil, beginning in the mid-2000s and continuing until the start of the COVID-19 pandemic. For females, a small initial urban survival penalty had shifted to an urban advantage by 2019. The North and Northeast regions showed larger urban penalties for both sexes than the southern regions. For males, the emerging urban life expectancy advantage was primarily driven by a more rapid decrease in mortality from external causes among urban residents aged 20-39. For females, the urban advantage was fueled by relative gains in mortality from neoplasms, respiratory diseases, and external causes. The COVID-19 pandemic initially widened the urban mortality penalty or narrowed the urban advantage in 2020 due to higher COVID-19 mortality in urban areas. However, this trend reversed from 2021 to 2023, as the urban penalty in COVID-19 mortality turned into an urban advantage, reversing the relative gains seen in rural areas.