The 2022 China report of the Lancet Countdown on health and climate change: leveraging climate actions for healthy ageing

Business Intelligence Lab, Baidu Research, Beijing, China (J Zhou PhD); School of Economics and Management, Beihang University, Beijing, China (Y Xie PhD, S Zhang PhD); School of Airport Economics and Management, Beijing Institute of Economics and Management, Beijing, China (Z Liu PhD); School of Management and Economics, Beijing Institute of Technology, Beijing, China (C Zhang PhD); School of Environment, Beijing Normal University, Beijing, China (B Chen PhD); Research Center of Practical Meteorology, Chinese Academy of Meteorological Sciences, Beijing, China (X Fang PhD); State Key Laboratory of Infectious Disease Prevention and Control, National Institute for Communicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China (Q Liu PhD, X Liu PhD, L Zhang BM); Department of Atmospheric and Oceanic Sciences & Institute of Atmospheric Sciences (H Jin BS, X Tang PhD, J Yuan PhD) and Integrated The 2022 China report of the Lancet Countdown on health and climate change: leveraging climate actions for healthy ageing


Executive summary
A health-friendly, climate resilient, and carbon-neutral pathway would deliver major benefits to people's health and wellbeing in China, especially for older populations, while simultaneously promoting high-quality development in the long run.
This report is the third China Lancet Countdown report, led by the Lancet Countdown Regional Centre based in Tsinghua University. With the contributions of 73 experts from 23 leading institutions, both within China and globally, this report tracks progress through 27 indicators in the following five domains: (1) climate change impacts, exposure, and vulnerability; (2) adaptation, planning, and resilience for health; (3) mitigation actions and health co-benefits; (4) economics and finance; and (5) public and political engagement. From 2021 to 2022, two new indicators have been added, and methods have been improved for many indicators. Specifically, one of the new indicators measures how heat affects the hours that are safe for outdoor exercise, an indicator of particular relevance given the boom in national sports triggered by the summer and winter Olympics. Findings in this report, which coincide with the UN Framework Convention on Climate Change 27th Conference of the Parties (COP27) hosted in Egypt (where much attention is being focused on adaptation for clinically vulnerable populations), expose the urgency for accelerated adaptation and mitigation efforts to minimise the health impacts of the increasing climate change hazards in China.

Another worsening year of health threats from climate change in China
With record-high national average temperatures and increasing frequencies of extreme weather events, people in China are increasingly threatened by the health risks imposed by a changing climate. In 2021, compared with the 1986-2005 average, people in China had an average of 7·85 more heatwave days (which led to an extra of 13 185 heatwave-related deaths; indicator 1.1.1), and a loss of 0·67 more hours of safe outdoor physical exercise per day (indicator 1.1.3). The loss of 33 billion heat-related potential working hours resulted in a loss of 1·68% of gross domestic product (GDP) in 2021, which reversed the declining trend in lost working hours since 2018 (indicator 4.1.2). The rising temperature also caused the annual average exposure to wildfire to increase by 60·0% between 2017-21 compared with the 2001-05 average. Despite yearly downward fluctuations from 2019 to 2020, extreme rainfalls (indi cator 1.2.2) and the disease burden of dengue (indicator 1.3) showed an increasing trend since the year 2000, compared with historical baseline periods.

Growing recognition and uneven progress in actions
The recognition of the association between climate and health continues to increase in academic and political communities. Notably, climate-related content was explicitly included in the annual work priorities in the Healthy China Action report in 2022, echoing the policy recommendations given in the 2021 China Lancet Countdown report. The National Climate Change Adaptation Strategy 2035 also included more concrete and comprehensive provisions related to the health risks of climate change, representing a major step forward compared with the previous strategy issued in 2013. From 2020 to 2021, the coverage of climate and health in Chinese scholar websites grew by 14·2% (indicator 5.3) and, for government websites, grew by 2·8 times (indicator 5.4).
However, there has been mixed progress in the actions on climate adaptation and mitigation. From 2021 to 2021, driven by the response to the repeated waves of COVID-19, most provinces' capacity to detect, prepare, and respond to health emergencies increased (indicator 2.2.1). The collaborations between health and meteorological sectors were also deepened (indicator 2.3). In 2021, compared with levels measured in 2020, the capacity for low-carbon electricity increased by 13% and the capacity for renewable electricity increased by 17·6% (indicator 3.1). Employment in China's renewable sector has accounted for 40% of worldwide renewable energy employment since 2012, reaching 4·7 million people in 2020, already exceeding levels of employment in fossil fuel extraction industries by more than 1·5 million. Nevertheless, the absence of a stand-alone health adaptation plan at the national level, and the lack of a comprehensive assessment of the health impacts of climate change, indicate that progress is still scattered rather than organised. The ongoing investment in new coal (indicator 4.2.1), the record-breaking coal consumption (indicator 3.1), the remaining large amount of fossil-fuel subsidies, as well as the weak carbon market (indicator 4.2.3) in 2021 all point to the necessity for cleaner air and a healthier future in China, where over 41% of people are still exposed to annual average particular matter (PM 2·5 ) concentrations of over 35 ug/m³ in 2021 (indicator 3.3). Meanwhile, along with the crisis in Ukraine and the related energy crisis, which is causing more countries to reverse their promises to cut fossil fuel use, these situations also pose serious concerns on billions of fossil-fuel-related assets during the transition to a zero-carbon economy.
Despite being more clinically vulnerability and facing greater risks, older populations are marginally represented in the media's coverage of health and climate change (indicator 5.1.1 and 5.1.2), and they are seldom mentioned in the growing coverage of climate and health from government websites (indicator 5.4). In the 14th Five-Year Plan For Healthy Ageing report published in March, 2022, climate change was absent from the policy document. Moreover, older age groups showed less individual engage ment in climate change and health than other age groups (indicator 5.2).
Tailored measures can substantially improve the health and wellbeing of older populations. For example, as older populations are more likely to choose solid fuels as their indoor energy source, providing them with intelligible and tailored information can help reduce millions of deaths related to indoor air pollution in China (indicator 3.2). Without timely and targeted mitigation and adaptation actions, the ageing of China's population might offset the progress already made (indicator 3.3).
In 2020, older people represented 13·5% of the total population in China; a proportion that is expected to increase to 26·1% in 2050. Given their susceptibility to climate-related risks, as well as their higher dependency on health-care systems, it is important to better protect older age groups from the health risks associated with climate change both by incorporating health concerns into climate actions and by addressing climate risks in health strategies.

Accelerated and more ambitious actions are urgently needed
Despite growing awareness of the link between climate change and health from different actors in Chinese society, current progress is not sufficient for China to achieve green recovery and protect its citizens from the growing health threats of climate change. Therefore, we propose five policy recommendations to achieve this goal:

Increase adaptation across governmental departments and accelerate investment in climate resilience
With near-term increases in multiple climate hazards now unavoidable, adaptation across governmental departments and investment in climate resilience must be substantially increased to protect the health of Chinese populations. These changes will require strengthening the leadership of the Ministry of Ecology and Environment to facilitate faster climate adaptation, as well as enhancing cross-departmental coordination (such as the cooperation between the Ministry of Ecology and Environment, the National Health Commission, the National Bureau of Disease Control and Prevention, the China Meteorological Agency, and the Ministry of Housing and Urban-Rural Development). Chinese leaders need to invest more in climate resiliency from the early stage of urban planning to urban renewal and take climate risks into account when constructing healthy cities.

Develop a stand-alone Health National Adaptation Plan for climate change
With the guidance from a more robust, multisectoral, and coherent National Climate Adaptation Strategy (ie, the National Climate Change Adaptation Strategy 2035), a stand-alone, Health National Adaptation Plan for climate change to better protect public health must be developed. Leaders must strengthen the response of local efforts to national plans, for example, by establishing a nation-wide heat and cold and health early warning system with regional characteristics. Leaders must also include quantitative goals and define clear responsibilities for different departments and divisions to ensure that the climate adaptation strategies can be translated into detailed implementation plans. Moreover, leaders must establish stringent and periodic evaluation mechanisms to track the progress and performance of the National Climate Change Adaptation Strategy 2035, as well as the Health National Adaptation Plan, to help ensure the success of building a climate-resilient society.

Prioritise climate change in health policies, with a focus on the wellbeing of vulnerable populations
Leaders must increase awareness within the health-care sector of the threats to health that climate change will bring, particularly in people who are most clinically vulnerable, such as older populations, people with disabilities, people with underlying diseases, and people who might need help at the community level. Leaders should include climate change health impact prevention and treatment as one of the key responsibilities of the new National Bureau of Disease Control and Prevention. Leaders should also include climate change as a major health threat in the specific work plan of the 14th Five-Year Plan For Healthy Ageing report in China. Specifically, leaders should (1) provide clinically vulnerable populations with targeted meteorological and early warning information services; (2) issue guidelines or standards for safe outdoor physical activity under heat stress for different groups of people as soon as possible; (3) provide community-based health education for older populations; (4) establish a regional health and ageing dataset for intervention purposes; and (5) build a joint prevention and treatment initiative between Centers for Disease Control and Prevention (CDC), Red Cross Society of China, community hospitals, and local hospitals.

Accelerate coal reduction and integrate health considerations into China's pathway to carbon neutrality
Leaders must strictly control the capacity of coal-fired power generation and accelerate the pace of coal reduction (especially in the household sector). These actions are imperative for China to achieve a carbon neutral pathway that maximises the health benefits to the population, including through cleaner air, energy security, and social stability. Leaders should also integrate health considerations into climate actions, which are essential for delivering health benefits and cobenefits, avoiding unintended harms, and improving the wellbeing of the population.

Promote a low-carbon economy
Leaders should keep encouraging renewable energy generation and consumption. Fossil fuel subsidies must be redirected as funds to promote the development of China's low-carbon economy. With the continuous declining marginal cost of renewable energy, this form of energy represents a favourable opportunity for China's investment layout in a low-carbon economy. Leaders should further increase employment in renewable sectors by providing skill training and stimulate enterprises' awareness of emission reduction with national emission trading, which are essential for assuring a smooth energy transition and for strengthening the green economy.
China faces several challenges, including pandemic control, economic recovery, and addressing climate change, all of which potentially threaten people's health and livelihoods. Pursuing a climate-resilient and carbonneutral transition will help to tackle these intertwined challenges. At a time of rapid population ageing, climate actions could be leveraged for healthy ageing, but this will require a fast and coordinated transition from all stakeholders.

Introduction
In 2021, climate change continued to threaten the health and wellbeing of Chinese people, with record-high national average temperatures and an increased frequency of extreme weather events. 1 Health risks were exacerbated by an ageing population and by the impact of COVID-19 on the health-care system. Older people (people aged 65 years and older) are more clinically vulnerable to the health threats from climate change and are more dependent on a functioning health-care system than younger age groups. In 2021, older people comprised 14·2% of the total population in China. 2 This share is expected to grow to 26·1% in 2050, 3 leading to an even greater proportion of older people than in most countries. Therefore, timely and effective actions for health adaptation that are tailored for these clinically vulnerable people, as well as actions towards climate change mitigation, are paramount for China to reduce the health impacts from climate change and to build a climate-resilient and low-carbon society.
Positive policy actions are starting to emerge. For the first time, the Healthy China Action Promotion Committee added "promoting actions to address health impacts of climate change" in its annual work priorities in 2022, 4 as had been suggested in the 2021 China Lancet Countdown report. 5 China's National Climate Change Adaptation Strategy 2035 was announced in 2022, with more comprehensive and practicable action plans laid out in the public health subsection. However, climate change and health considerations were absent from the Healthy Ageing Strategy announced in March 2022. This omission exposes a concerning lack of understanding within the health sector of the extent to which climate change is becoming the defining factor of China's public health profile. Around the world, academic and policy-making communities are increasingly advocating the integration of climate concerns into health policies.
The 2022 China Report of the Lancet Countdown is the third annual report led by Lancet Regional Centre in Asia, 5,6 presenting progress in climate change and health interlinkages through 27 indicators across five sections: climate change impacts, exposures, and vulnerability; adaptation, planning, and resilience for health; mitigation actions and health co-benefits; economics and finance; and public and political engagement (panel 1). Two new indicators (indicator 1.1.3: heat and physical activity and indicator 1.4: population exposure to sea level rise) have been added into this report, while most of the pre-existing indicators have undergone methodological improvements. When possible, indicators explore the particular climate-change-related health risks posed to people aged 65 years and older, the health co-benefits of climate actions to this vulnerable group through reduced air pollution, and their engage ment in the climate-health issue. Exposure to consecutive days of heat beyond a particular threshold can lead to a notable increase in the risk of death. 7 This indicator tracks non-accidental heatwaverelated deaths, with particular consideration of the impacts on older populations, by using age-specific dose-response relationships (appendix p 1). In 2021, heatwave exposure was 113% (or 7·85 days) higher than the baseline (1986-2005) average, and the related deaths increased by 13 185 (115%), leading to an estimated 24 966 deaths. With China's population rapidly ageing, the proportion of deaths in people aged 65 years and older continues to increase from 61·1% (in 1986-2005) to 78·4% (in 2017-21). Among all 31 provinces, heatwaverelated deaths in older people were highest in Guangdong (which accounted for 14·9% of total deaths in 2021), followed by Henan (13·9%), and Shandong (10·7%).

.3: heat and physical activity
Physical activity can benefit mental health and reduce the burden of non-communicable diseases, such as cardio vascular diseases, diabetes, and cancer. 9,10 The participation of Chinese people in sports has continued to rise since the Beijing 2008 Summer Olympics, and the 2022 Winter Olympics is also likely to increase physical activity. 11,12 However, physical activity in high heat and humidity can pose risks of exertional heat stress and potentially lethal heat stroke. 13-16 Rising temperatures can also reduce the hours available for safe outdoor physical activity. 17 This new indicator evaluates heat stress with a heat index, 18 which combines temperature and humidity, and estimates the number of hours per day (activity hours lost [AHL]) when the heat index exceeds a preassigned threshold. The threshold is set as 33°C, above which experts in China, the USA, and Australia advise against outdoor physical activities because of the high risk of heat illness, 14,19,20 and above which deaths from hyperthermia are likely to increase. 21 In 2021, AHL reached 2·04 hours in all age groups, and 1·99 hours in people older than 65 years, representing an increase of 48·2% (0·7 hours) for all age groups, and 41·2% (0·6 hours) in people older than 65 years, compared with the baseline period (1986-2005; figure 1). People in south central China were affected the most, with 3·94 hours lost in 2021, and had the highest annual average growth rate (2·1%) during 2000-21. Within this region, Guangdong, Hunan, and Guangxi were the most affected, accounting for 40·5% (total population) and 36·8% (older population) of total AHL in China. If this trend continues, the AHL per person per day in south central China is estimated to rise to 7·1 hours in 2050 (appendix pp 6-9).

Indicator 1.2: health and extreme weather events Indicator 1.2.1: wildfires
Climate change is increasing wildfire-related health risks. 22 This indicator monitors the annual average number of days that people are exposed to wildfire using satellite observations and population data and, new to this report, providing a breakdown of age-group specific exposure. In 2017-21, in the all-age group, the national annual average wildfire exposure increased by 60·0% compared with the average recorded for 2001-05, while the growth was 142·3% (compared with 2001-05) for people aged over 65 years. This increase was mainly due to the increased proportion of older populations. Mean while, exposure to wildfires increased in 25 provinces, with particularly large increases in Jilin, Qinghai, and Chongqing. In 19 provinces, exposure to wildfires in older people in 2017-21 increased by more than 100% compared with levels of exposure measured in the same group for 2001-05.

A B
Year Safe physical activity hours lost per day per person

Indicator 1.3: climate-sensitive infectious diseases
Dengue fever is one of the most rapidly spreading climate-sensitive diseases in the world, and older populations are at an increased risk of developing severe dengue. 26,27 This indicator tracks the vectorial capacity for its transmission by Aedes aegypti and Aedes albopictus, the population's susceptibility to dengue, and the disease burden of dengue in China. The vectorial capacity for dengue transmission has substantially increased in 19 provinces in China during 2004-20 because of changing climatic conditions (appendix p 27). In the three provinces with both A aegypti and A albopictus distribution (Guangdong, Yunnan, and Hainan), the average susceptibility to dengue fever in 2016-2020 increased slightly compared with that in 2011-15. Moreover, the disability-adjusted life years of dengue declined sharply from 883 person-years in 2019 to 31 person-years in 2020. This change is believed to be due to the strict border restrictions and quarantine policies that were in place during COVID-19. 28 Dengue fever is one of the most serious mosquito-borne diseases in China, 29 whereby the highest number of severe symptoms and deaths occur in older populations. In addition, as a representative of other important climate-sensitive vectorborne diseases, the incidence and epidemic area of severe fever with thrombocytopenia syndrome, which most commonly affects older people who are farmers, 30 is increasing 31 and needs further exploration.
Indicator 1.4: population exposure to regional sea level rise The average regional sea level (RSL) in Chinese coastlines has risen about 0·12 m between 1980 and 2020. 32 Rises in sea level due to global warming could threaten the health and wellbeing of people living in coastal areas through increased flooding, saltwater intrusion, and increased risk of infectious disease transmission. 33 This new indicator tracks population exposure to risk of RSL rise in China using sea level projections, 34 coastal elevation data, 35 and gridded population data. 36 It is predicted that more than 156 000 (95% CI 59 800-339 000) people who are currently (as of 2022) living in coastal areas will be below average RSLs under high-emission scenarios (Shared Socioeconomic Pathway 5 and Representative Concentration Pathway [SSP5]-8·5) by the year 2060 (RSL forecasted at 0·31m [0·1-0·5]) and 855 000 (287 000-1 873 000) people are currently living in areas that will be below average RSL by the year 2100 under this same scenario (RSL forecasted at 0·8m [0·5-1·2]). Considering a low-warming scenario (SSP1-1·9), over 207 000 (25 800-712 000) people are currently settled in areas that would be below average RSL (forecasted at 0·4 [0·1-0·7] m) by the year 2100. Guangdong and Jiangsu provinces have the largest populations settled in low-lying areas and account for over 64% of the total population settled in areas that will be under RSLs in China under all scenarios (appendix pp 32-33).
Unless rapid adaptation or relocation of coastal population occurs, under all scenarios, about 12% of the population that will be living in areas below future RSLs will be people aged 65 years and older. Considering their lower capacity and willingness to migrate, 37 older populations living in coastal areas might be more susceptible than younger groups to the increased risk of RSL rises, and tailored adaptation strategies will be needed even with stringent mitigation measures.
To conclude, the findings in this section reaffirm that climate change continues to threaten the health and wellbeing of Chinese populations, with different regions facing unique health threats (figure 2). At the national level, and compared with the historical average, in 2021, the rising temperatures resulted in an increase in heatwave-related mortality of 115%, the potential hours of labour decreased by 7·1%, and wildfire exposure increased by 62·7%, while the number of hours available for safe physical activity fell by 48·2%. The health risk of climate change on physical activity in all age populations should be carefully considered, as rising temperatures increase the risk of heat-related illnesses from outdoor physical activity, and could substitute outdoor activity into indoor sedentary lifestyles. Older people are more exposed to climate change-related health hazards than the all-age population in most provinces (figure 2) and account for over 70% of the heatwave-related mortalities. Given that near-term increases in multiple climate hazards are unavoidable, timely responses to adapt to and mitigate these health risks are urgently needed.

Section 2: adaptation, planning, and resilience for health
In 2021, the increased frequency of extreme weather events across China caused unignorable health impacts, which were compounded by the simul taneous shock of COVID-19, stressing the importance and urgency of implementing adaptation measures across the whole population. There are encouraging signs of emerging health adaptation measures in China. For example, in 2022, for the first time, the Healthy China Action Promotion Committee explicitly mentioned "promoting actions to address health impacts of climate change" in its annual work priorities, reflecting the increasing awareness of the climate-health linkages in the healthcare sector. Panel 2 distinctly compares the latest National Strategy on Climate Adaptation with the previous one, making further recommendations to better protect public health from climate change in China.
This section explores progress towards health adaptation across three domains: adaptation planning and assessment (indicator 2.1), adaptation delivery and implementation ( [33][34][35][36][37][38][39][40][41][42][43][44][45][46]. Follow-up calls were made to ensure the credibility and accuracy of the findings. A comprehensive assessment of the health effects, clinical vulnerability, and adaptation to climate change was conducted in the whole province of Guangdong, and in a few cities in Jiangsu, Shandong, Xinjiang, and Zhejiang provinces. A lack of government funding support (70%) was still identified as the most important constraint to developing an adaptation plan. Although most provinces stated they have established climate-sensitive disease surveillance systems and early warning systems for extreme   Countdown weather events, they still lack response plans or programmes to address extreme-weather-related health risks. Addressing health risks from climate change has been added to the annual work priorities in the Healthy China Action Promotion report in 2022, reflecting a growing emphasis on climate change of some policy makers from health sectors. However, the significance of climate change has not been recognised by all health policy makers. For example, there is no mention of climate change in the 14th Five-Year Plan On Healthy Ageing report proposed in March, 2022, reflecting a lack of awareness of the impact of climate change on the health of older populations.

Indicator 2.2: adaptation delivery and implementation Indicator 2.2.1: detection, preparedness, and response to health emergencies
This indicator created a multi-level index to track the capacity of provinces to respond to public health emergencies, combining 20 indicators covering risk exposure and preparedness, health emergency detection and early warnings, and medical resources (appendix pp [51][52][53][54][55][56][57][58][59][60]. From 2019 to 2020, the capacity scores improved in all provinces, and the national average score increased from 56·2 to 73·0, partly as a result of the strengthening of the health system following the outbreak of COVID-19. Provinces in east and southwest China made the fastest progress, mainly because of their efforts to develop more stringent standards in hygiene, disinfection, and infectious disease control practices, as well as increasing medical and hygiene expenditure, strengthening disease risk control measures, and promoting medical informatisation, all measures that can better prepare health systems to respond to climatechange-related health emergencies.

Indicator 2.2.2: air conditioning-benefits and harms
Although household air conditioning is very effective at preventing heat-related health impacts, it also drives an increase in electricity demand and additional carbon and particulate matter emissions. 38  Similarly to the first adaptation strategy, public health is covered as a subsection in the second adaptation strategy.
Despite the absence of a stand-alone national adaptation plan for health, the National Strategy on Climate Adaptation 2035 represents notable progress in protecting public health in three ways: First, more comprehensive work priorities with performance evaluation mechanisms are mandated. Two work priorities (advancing health risk assessment and improving the monitoring and early-warning system of climate-sensitive diseases) that were already mentioned in the 2013 strategy were again included in this update. In addition, two new work priorities were added to the 2022 strategy: increasing the climate resilience of health-care systems and promoting health adaptation actions across society. The 2022 strategy also requires setting up a new performance evaluation mechanism to track the progress of these work priorities. The more comprehensive mandates facilitate translating the results of the health impact assessment into adaptation actions, and to make sure that their progress aligns with the goals.
Second, in the 2022 strategy, timelines and progressive goals are set for the first time. The strategy mandates establishing a campaign to advance health impact assessment research and to promote health adaptation actions. For the first time, the campaign is associated with clear timelines and progressive goals, which makes the implementation path clearer than in the previous strategy.
Third, region-specific health risk assessment guidelines and location-specific adaptation action advice are now required. The strategy mandates the production of guidelines to assess the health impact of different climate hazards, to carry out regionspecific health risk assessments, and to provide the recommended adaptation actions for different locations (eg, urban and rural areas, schools, hospitals, and nursing homes for older people). These mandates will improve local capacity to carry out climatechange-related health risk assessments and will accelerate the progress of assessment across the country. They will also increase the feasibility of the suggested adaptation actions.
Despite progress, most of the key goals in the public health subsection are qualitative (although progressive), which will make the evaluation of progress and performance challenging. Therefore, the National Bureau of Disease Control and Prevention in China should formulate a stand-alone national adaptation plan for health with quantitative goals that are based on these national-level strategies and work priorities so that progress can be monitored effectively.
older. However, this use of air conditioning also contributed to an estimated 300 million tons of CO 2 emissions, which was approximately six times higher than in 2000. To achieve the carbon neutrality goal, the energy efficiency of air conditioning units must be rapidly improved, and other climate-friendly heat adaptation measures (eg, personal cooling strategies and increased urban green spaces) prioritised and rapidly rolled out. 35 Green energy generation and thermal energy storage technology (eg, ice thermal energy storage) must be also considered in the future development. 39

Indicator 2.2.3: urban green space
Urban green spaces can provide benefits to physical and mental health through direct and indirect pathways, 40,41 and have been associated with reducing overall mortality. 42 Most of the Chinese population now live in cities or in places experiencing peri-urbanisation. Green spaces can lower local temperatures 43 and reduce air pollution. 44 This indicator monitors urban green space cover using the normalised difference vegetation index (NDVI; 45 appendix pp 62-66) and gridded population data to calculate population-weighted NDVI as a proxy for green space exposure. Changes in mortality attributable to changes in urban green space exposure were calculated while taking into account the relative risk reduction associated with it, as previously published. 42 In 2021, three provinces had very high levels of urban greenness, seven had high levels of urban greenness, and nine had moderate levels of urban greenness. 12 provinces or municipalities (Guizhou, Yunnan, Shaanxi, Shandong, Beijing, Tianjin, Hebei, Gansu, Shanxi, Inner Mongolia, Ningxia, and Tibet) saw an increase in urban green space over the past decade, while the area of urban green space decreased in one province (Zhejiang in southeast China). The overall green space change during 2011 to 2021 is estimated to have averted 22 893 (95% CI 16 691-36 330) deaths in China.

Indicator 2.3: climate information services for health
This indicator tracks the interdepartmental collab orations between meteorological and health departments through data sharing and collaboration using data collected through an annual survey conducted by the Lancet Countdown Asia group, as well as through a search for official news releases. Among the 29 provincial meteorological departments that responded to the survey, 27 claimed to have provided meteorological data to the public health sector, up from 21 in 2020. According to the survey, only one meteorological department indicated that climate information that was tailored to older populations was provided. According to the news releases, different local meteorological bureaus (including province-level, city-level, or county-level) in 21 out of 31 provinces reported the existence of a collaboration (or indicated to have signed collaboration agreements) with local health-related departments or organisations to provide them with climate information services (appendix p 67).
To conclude, according to the indicators tracked in this section, there has been positive progress in health adaptation measures in China in 2021, including the more comprehensive climate-health work priorities in the newly launched national adaptation strategy (panel 2), enhanced cross-sector collaborations, and growing health emergency management across China. These trends reflect the increased priority of climate and health issues in the policy agenda from both health and climate sectors, and echo the policy recommendations made in the previous two reports of the Lancet Countdown in China. However, more resources and attention need to be directed to adaptation efforts from all sides of society, especially from the perspectives of investment and risk-reducing effects, as well as mitigation measures, which could have complicated benefit-cost relations with climate adaptation measures. Current adaptation efforts are not targeting clinically vulnerable groups, such as older populations, which could jeopardise their effectiveness to protect the health of Chinese populations. 46 Therefore, rapid acceleration for adap tation efforts and enhanced support for vulnerable groups are urgently needed.

Section 3: mitigation actions and health co-benefits
After making the carbon neutrality pledges in 2020, the Chinese Government announced a so-called 1 + N policy framework in 2021 to help achieve these pledges. 47 If the potential health co-benefits of mitigation actions are prioritised in the implementation of this framework, it will further benefit the low-carbon transition, and substantially improve the life expectancy and welfare of Chinese people. 48 This section tracks China's progress on transitioning towards low carbon energy systems, climate change mitigation (indicators 3.1-3.2), and pollution abatement, together with its associated health implications (indicator 3.3).

Indicator 3.1: energy systems and health
This indicator shows progress in, and challenges associated with, renewable electricity development, coal phase-down, and carbon intensity in China. In 2021, the capacity of low-carbon energy (ie, solar, hydro, wind, and nuclear energy) continued to grow, reaching 1·08 terawatts (representing 13% more than that recorded for 2020 and 45·4% of the national power capacity). Similarly, renewable electricity (ie, solar, hydro, and wind) also continued to grow, reaching 1·02 terawatts (representing 13·3% more than that recorded in 2020 and 43·2% of the national power capacity). 49 Meanwhile, low-carbon electricity (ie, solar, hydro, wind, and nuclear) generation increased by 288·2 terawatt hours in China in 2021, which was equivalent to 2 times the low-carbon electricity generated in the UK in 2020. 50 However, driven by the fast e1082 www.thelancet.com/public-health Vol 7 December 2022 Countdown economic reactivation that followed the peak of the COVID-19 pandemic, coal consumption in China rose by 3·7% from 2020 to 2021, reaching a new peak. China's CO 2 emissions from fossil fuel use and cement production increased by 5·7% in the same period, reaching 11·1 billion tons in 2021. With gross domestic product (GDP) increasing by 8·1% in 2021, carbon intensity per unit of GDP reduced by 2·3% compared with 2020.

Indicator 3.2: clean household energy
In 2019, using data from the global burden of diseases study, 51 the consumption of solid fuels in the household sector is estimated to have caused over 2·3 million deaths worldwide, and 36 300 deaths in China. At 258 deaths per million people, mortality was 48 times higher in China than in other high-income countries. Therefore, increasing the use of clean energy in the household sector in China will have substantial health implications. Although coal is still reported as the preferred energy source as the substitution of biomass for residents in rural areas, 52 there are positive signs of progress as coal use in the household sector continues to decrease, with a 14·5% decline in use (per capita) during 2018-19. Similarly, between 2018 and 2019, per capita use of natural gas increased by 6·3% and per capita use of electricity increased by 4·7%. However, using raw data collected from CHARLS, 53 it is estimated that 47·5% of older people chose solid fuels as their energy sources for cooking in rural areas, which was 11·4% higher than people younger than 65 years and 20·6% higher than people younger than 50 years. This difference is mainly because of the lower price of these fuels, which makes it difficult for older people to stop using these fuels for heating and cooking. [54][55][56] In addition, because of their tendency to spend more time indoors than younger people, mortality related to household air pollution of solid fuels in people older than 65 years was 5·7 times higher than in the whole population, and 13·4 times higher in people older than 65 years. Promoting knowledge and disseminating information on the risks of the use of fuels in the home among older populations can help to reduce mortality related to indoor air pollution. Policy and publicity are key to promoting clean energy use among older populations, particularly those in rural areas. 57,58 Indicator 3.3: air pollution, transport, and energy From 2020 to 2021, efforts to improve air quality in China led to a reduction of 4·7% in ambient PM 2·5 concentrations, and a 1·9% decrease in ozone concentrations in Chinese cities. The improvement of emission standards for major vehicle categories strongly contributed to this progress. As a result, the emission intensity of nitrogen oxide, PM 2·5 , hydrocarbon, and CO from passenger cars and trucks declined sub stantially from 2020 to 2021. However, the corresponding emission intensity of passenger transport (emission per passenger kilometre travelled) increased in this period because transport demand reduced faster than emissions during COVID-19. The contribution of vehicle emissions to ambient ozone concen trations remained at 30% in 2018, 59 exposing the need for further efforts to reduce emissions in the transport sector (eg, by promoting truck-to-rail policies; 60 appendix pp [86][87]. During 2015-20, the number of older people who were exposed to annual average PM 2·5 concentrations over 35 μg/m³ decreased by 22%. However, the size of the older populations exposed to average annual PM 2·5 concentrations above 5 μg/m³ increased by 33%. Meanwhile, the number of older people exposed to ozone concentration above 100 μg/m³ increased by more than 38% (appendix p 81). The rising proportion of older people in China was partly responsible for this increase, which rose from 10% in 2015 to 13·5% in 2020.
Between 2019 and 2020, a policy called the Three-Year Action Plan for Winning the Blue Sky Defense Battle (2018-20) 61 led to 14 600 fewer premature deaths. 30% of the reduction in premature deaths occurred in south central China, 28% occurred in east China, and 16% occurred in north China (as estimated using the greenhouse gas-air pollution interactions and synergies model, appendix pp 83-85). 1,2 Premature deaths that were attributable to air pollution from the household, industry, and agriculture sectors had the largest reductions, mainly as a result of the implementation of ultra-low air pollution emission standards and of a chemical fertiliser and pesticide use policy. 62 However, the emissions from the waste sector caused more premature deaths in 2020 than in 2019. Despite the notable health benefits of cleaner air, progress towards improving air quality in China has been insufficient so far, with over 41% of people being exposed to annual average concentrations of PM 2·5 of over 35 µg/m³ in 2021.
To conclude, the indicators in this section track China's progress on climate change mitigation and the health benefits that are associated with a reduction in air pollution. The CO 2 emissions from fossil fuel use and cement production increased rapidly after COVID-19, to a level 5·7% higher than in 2020. The delay in decarbonisation threatens China's carbon neutrality goals and contributes to exacerbated health risks from climate change. In addition, despite the notable health co-benefits from the air pollution control policy in China, progress towards cleaner ambient air quality and household energy use have been insufficient. With populations ageing, there is an urgent need to rapidly reduce exposure to air pollution for all age groups to reduce adverse health outcomes during old age and to promote healthy ageing. 63 Achieving these goals demands more ambitious climate policies and more stringent clean-air policies that are closely coupled in China to help achieve the air quality target set by WHO. Specifically, more efforts need to be done to ensure that coal consumption in China peaks as soon as possible, and that short-term investments align with the long-term carbon neutrality goal. This green recovery pathway will help carbon neutrality, air quality improvements, and healthy ageing goals to be achieved in a synergistic manner.

Section 4: economics and finance
Transitioning to a zero-carbon economy requires large financial investments. 64,65 However, having a zero-carbon economy would offer net economic benefits by reducing near-term and long-term climate impacts, creating green jobs, and contributing to healthy ageing. 65,66 In this section, seven indicators have been designed to track the progress of the health-related economic costs of climate change (indicators 4.1.1-4.1.4) and progress towards the transition to zero-carbon economies (indicators 4.2.1-4.2.3) in China. The data in this section are all presented in the 2020 value of US$.

Indicator 4.1: health and economic costs of climate change and its mitigation Indicator 4.1.1: economic costs of heat-related mortality
This indicator estimates the economic costs of heatwaverelated mortality of working-age people (aged 15-64 years) using the same methods used in the 2021 report (appendix p 88). 67 The overall economic costs of heatwaverelated mortality of working-age people in 2021 were $109·4 million, about five times higher than the costs in 2002, and 14·4% higher than those in 2020. About 74% of the overall costs were due to indirect impacts; the largest indirect costs were found in the manufacturing industry (52%), followed by the service industry (38%). Using provincial-level data up to 2017, the three provinces with the greatest costs were Gansu ($8·0 million), followed by Henan ($7·6 million) and Inner Mongolia ($6·7 million; diff erences with results from the 2021 report 6 are explained in the appendix [pp [89][90]).

Indicator 4.1.2: economic costs of heat-related labour productivity loss
Based on the potential heat-related labour productivity losses estimated in indicator 1.1.2, this indicator quantifies the economic costs of heat-related labour productivity losses at the national and provincial level. It is a measure of the reduction in national or provincial GDP due to the work hours lost and the consequent business interruption cascading through the interdependencies between sectors and regions. The economic costs of heat-related labour productivity losses were found to rebound slightly to $285·8 billion (representing 1·68% of GDP) in 2021 after 2 years of declines since 2018. The three provinces that had the greatest economic costs in 2021, relative to their GDPs, were Hainan (4·75%), Guangxi (3·86%), and Jiangxi (3·33%).

Indicator 4.1.3: economic costs of air pollution-related premature deaths
This indicator monitors the economic costs associated with PM 2·5 -related premature deaths, using the same method as in indictor 4.1.2 (appendix pp 97-98). Although the absolute national economic costs increased slightly by 3% (from $9·00 billion to $9·24 billion during 2015-20), the relative costs as a percentage of China's GDP declined from 0·07% to 0·06% in the same period. Progress towards air pollution control seen since the year 2015 continued during 2020. 6 The manufacturing and service industries still accounted for most (an increase from 90% in 2015 to 92% in 2020) of total costs. The three provinces that had the greatest economic costs in 2020, relative to their GDPs, were Xinjiang (0·27%), Heilongjiang (0·26%), and Hebei (0·12%). Although not included in this indicator, which only focuses on the premature deaths of workingage people, extra economic costs are expected to occur because of the increasing needs for health-care services from the ageing population, as acute impacts of air pollution could be more felt by clinically vulnerable populations, and the symptomatology of chronic exposure to air pollution becomes more pronounced in older age. [68][69][70] Indicator 4.1.4: economic costs due to climate-related extreme events This indicator updates the economic losses due to climaterelated disasters that occurred from 2019 to 2021. The national economic losses due to climate-related extreme events declined to $59·8 billion (0·35%) in 2021 after a peak in 2020 ($66·4 billion; 0·45%). The three provinces that had the greatest economic losses in 2019, relative to their GDPs, were Jiangxi (2·61%), Heilongjiang (2·04%), and Zhejiang (1·19%). In 2021, the compound events of extreme flooding and the coronavirus epidemic in Zhengzhou city (Henan province) caused $19·6 billion of direct and indirect economic losses nationwide, equivalent to nearly a third of the national total losses (panel 3).

Indicator 4.2: the economics of the transition to zerocarbon economies Indicator 4.2.1: investment in new coal and low-carbon energy and energy efficiency
This indicator monitors investments in new thermal power generation and low-carbon energy in China, following the same methods used in the 2021 report. 5 Although the new capacity of thermal power generation continued declining, reaching 46·3 gigawatts in 2021 (18% less than 2020 [56·6 GW]), the investment in new thermal power generation in China reversed the previous declining trend, increasing from $8·86 billion in 2020 to $10·68 billion in 2021, 75 resulting in a 4% rise of installed capacity of coal-fired power units. If the construction of all planned coal-fired power units that were commissioned from 2020 to 2030 in China went ahead, the stranded asset losses would be $451 billion during 2020 to 2045. 76 Investment in low-carbon energy (including biomass) reached new heights of $123 billion in 2021, 3·8% higher than that in 2020. The ratio between investment in low-carbon energy (including hydro, wind, solar, biomass, and nuclear power) and new thermal power kept growing in 2021, from 1:1 in 2008 to 9·5:1 in 2020, and further to 11·5:1 in 2021. The top three investors in low-carbon energy in 2021 were Sichuan ($7·48 billion), Shandong ($6·99 billion), and Hebei ($6·02 billion).

Indicator 4.2.2 employment in low-carbon and high-carbon industries
This indicator monitors employment in renewable energy sectors and fossil fuel industries using data from the International Renewable Energy Agency (IRENA), Global Economic Data, Indicators, Charts & Forecasts (CEIC) Data, and the Chinese National Bureau of Statistics, 77-79 as in the 2021 report. 6 In contrast to the decreasing trend in the total number of people employed in China (from 754·5 million people in 2019 to 750·6 million people in 2020), the number of people employed in the renewable energy sector increased (from 4·4 million in 2019 to 4·7 million in 2020). With employment in the hydropower industry increasing by 45% in 2020, the number of people employed in renewable energy was 1·5 million more than the number of people employed in fossil fuel extraction industries (appendix p 113). If the world followed the 1·5°C pathway by the year 2050, employment in the global renewable energy sector would grow to 43·3 million jobs over the next three decades. 78 China has occupied around 40% of total renewable energy employment worldwide since 2012, 78   Between 2019 and 2020, fossil fuel subsidies in China declined by 25% to $25·5 billion. Subsidies to fossil fuel electricity reduced substantially, from $15·2 billion to $3·8 billion, while subsidies to oil products slightly increased, from $18·8 billion to $21·7 billion. In the global ranking of fossil fuel subsidies per capita, China moved from 87th to 88th position in 2020 (from $24·2 per capita to $18·1). And in the global ranking of fossil fuel subsidies per unit of GDP, China dropped from 97th to 100th position in 2020 (from 0·24% to 0·17%, appendix p 116). Despite this progress, further accelerating phasing down the rest of fossil fuel subsidies is highly recommended because it could help China to transition towards a low-carbon energy system, improve air quality through less fossil fuel use, and avoid a substantial share of air-pollution-related premature deaths. 81 The national carbon emission trading market in China launched in July, 2021. More than 2000 power generation enterprises, covering 4·6 billion tons of CO 2 (or 41% of China's carbon emissions in 2021) participate in this carbon market, which is the largest in the world. By the end of 2021, the cumulative carbon trading volume reached 178·6 million tons. However, the average carbon price in China was $6·93, 82 which was much lower than the average carbon price of the EU Emissions Trading System in 2021 ($63·47). This price implies that From July 17 to July 23, 2021, Henan province (central China) was hit by unprecedented levels of heavy rainfalls and floods, and its capital city Zhengzhou had extensive casualties and property damage. 71 The event was listed as the deadliest natural disaster in 2021 in China. 72 The situation was further worsened in Zhengzhou by a local coronavirus epidemic a week later, 73 which affected the progress of the post-flood recovery and compounded climate risks. Using similar methods as indicator 4.1.4, the total economic losses of these events were estimated to be US$19·6 billion, equivalent to 0·12% of China's gross domestic product in 2021, 74 excluding health costs. Although the flood-induced direct damage only occurred in Zhengzhou, the indirect losses occurred across other regions due to supply chain disruptions (appendix p 107). Although almost a third (29%) of direct losses happened in Zhengzhou's real estate industry, the indirect losses were bigger in Zhengzhou's non-metallic mineral product (13%), food and tobacco (10%), and transportation services (10%). In regions outside Zhengzhou, the agriculture, mining, petroleum and coking, chemical products, accommodation and restaurants, and financial services were the most heavily affected sectors by these events. Among them, the agriculture in Henan (except Zhengzhou) had the greatest indirect loss, at $0·4 billion. This case study shows how devastating an extreme climate event can be, both to lives and economies, and how the confluence of different risks, such as the collision between an epidemic and extreme weather, can further aggravate socioeconomic consequences. The huge economic costs of these events show the value of risk assessment, planning, and the implementation of early and adequate adaptation and mitigation actions towards climate change.
www.thelancet.com/public-health Vol 7 December 2022 e1085 Countdown the current emission cap is not stringent enough and the carbon market is still in too early a phase to have an important role in China's pathway to carbon neutrality.
To conclude, despite the downward trend of economic losses due to climate-related extreme events in 2021, with accelerated climate warming and climate-related extreme events, the health and economic costs of climate change as a whole are highly likely to increase in the near future. [83][84][85] China is at a critical period of heated discussions and designs towards the path to carbon neutrality. Compounded by the continued investment in new coal, the cuts in fossil fuel subsidies are not sufficient enough to protect Chinese people from the health risks related to the use of fossil fuels, and might lead to large amount of fossil fuel-related assets becoming stranded during the transition to a zerocarbon economy. 86 Meanwhile, the market could miss the long-term objectives with short-term policy volatility. The missteps would further increase the future financial and economic risks. Economic markets cannot solve climate change alone. Authorities must continue to provide direction. Accelerating the pace of fossil-fuel subsidy reduction and redirecting these funds to promote the development of China's low-carbon economy could protect present and future economic prosperity, and a healthy future. China's low-carbon green transition is a process that involves balancing energy security risks, financial and economic risks, and the co-benefits of reducing climate-associated harms to public health as a whole. 87

Section 5: public and political engagement
An awareness of the links between climate and health is essential for driving accelerated climate action that protects the health of Chinese populations. In a year marked by carbon neutrality commitments, extreme weather events, and COVID-19 in China, this section tracks engagement in climate change and health across varying parts of society, including the media (indicator 5.1), individuals (indicator 5.2), academia (indicator 5.3), and the public sector (indicator 5.4). Seven media Weibo accounts (@People's Daily, @Xinhuanet, @The Beijing News, @The Paper, @HealthTimes, @China Science Daily, and @China Meteorological News) were selected for this report, covering government media, commercial media, and professional media in China. From 2010 to 2021, there was an average of 1131 posts per year discussing climate change across all seven accounts, of which 132 (11·7%) were related to health. From 2021 to 2022, the number of posts covering climate change increased by 8%, reaching 1733 posts. This increase was mainly driven by the coverage of extreme weather events that occurred during the summer. Among them, only 138 (8·0%) posts were healthrelated, representing a 68% reduction from 2020. Only nine posts covering health and climate mentioned older populations, and all of them provided reminders of the health risks to these populations of extreme heat and cold during summer and winter, but only three provided specific guidance on how they could protect themselves from the risks.

Indicator 5.1.2: newspaper coverage of health and climate change
As the most widely-used source of information, the mainstream media can influence the social media agenda, shape public perceptions, and facilitate public engagement. [88][89][90][91] This indicator tracks media coverage of health and climate change in Chinese provincial newspapers from 2008 to 2021, using 34 high-circulation and influential newspapers (appendix pp 122-127). During 2008-21, an average of 24 312 articles per year were published discussing climate change, of which about 1375 (6%) articles per year were related to human health. Continuing an upward trend, newspaper coverage of climate change spiked in 2021, with 36 477 articles, representing a 37% increase nationwide from 2020. Meanwhile, health and climate change coverage remained high, although the number of articles covering these topics in 2021 (2335 articles) was slightly lower than its peak in 2020, which coincided with the outbreak of the COVID-19 pandemic. Older age groups were marginally represented in news articles on health and climate change, with only 30 (less than 1%) of the 2335 articles mentioning older age groups in 2021.

Indicator 5.2: individual engagement in health and climate change
This indicator uses search queries in Baidu, the most popular Chinese search engine, which accounted for 83·97% of the market share in China in 2021, to track individual engagement in health and climate change. The indicator was improved in 2022, whereby Baidu is now able to stratify search queries by age groups and incorporate keywords related to extreme weather events and population ageing (appendix pp 127-135). In 2021, queries related to climate change rose by 77·5% compared with 2020. Although the share of climate and health co-queries remains low (only 4·71 out of 1000 climate change queries), the total number of coqueries grew by 48·2% from 2020. This trend could be driven by governmental climate and health policies, COVID-19, and extreme weather events. Henan province and its nearby provinces Shaanxi and Shanxi, which had extreme rainfall events in 2021, had a higher proportion of climate change queries than other areas in China. Although ageing was a topic of increasing interest from 2018 to 2021, people seldom searched population ageing with climate change, reflecting little engagement with Countdown the compounding links between ageing and climate change. Compared with other age groups, older people were less prone to co-search climate and health, suggesting that this age group had less awareness and knowledge of climate-health risks.

Indicator 5.3: coverage of health and climate change in scientific journals
This indicator tracks the engagement of Chinese scholars in climate and health research in journals published in English (with data from Scopus, MEDLINE, and Web of Science Core Collection databases) 92   From 2020 to 2021, the number of climate-related articles and documents grew by 1·83 times, and the number of climate-and-health-related articles and documents grew by 3·7 times. These increases were mainly driven by the articles related to carbon peaking and carbon neutrality policies. Issues around ageing were seldom mentioned in the content related to climate and health, with only six articles and documents on average per year doing so.
To conclude, compared with 2020, the engagement on health and climate issues from the individuals, scholars, and public sectors continue to grow rapidly. However, coverage decreased in social media and remained stable in newspapers. Therefore, it is important to break barriers between the general public and professionals by communicating academic knowledge and policy attempts to the public through multiple channels including popular media. Additionally, older populations received marginal attention on this issue in media coverage, although they are more vulnerable to the health threats of climate change than younger populations. 93

Conclusion of the 2022 China report of the Lancet Countdown on health and climate change
In this report we found that, across every indicator within section 1, the health impacts of climate change in 2021 were above historical baseline levels (figure 3), and most exceeded levels measured in 2020. Due to rising temperatures, heat-related health impacts increased from 2020 to 2021, increasing heat-related mortality, reducing labour capacity, and undermining the capacity to partake in physical activity. In addition, exposure to wildfire, extreme drought, and extreme rainfall also increased in different regions across China. Economic losses from heat-related labour losses reached 1·68% of GDP in 2021, the first increase since 2018. The vectorial capacity of dengue transmission also increased as a result of changing climatic conditions and showed an increasing trend since 2004 compared with historical baseline periods.
Since 2020, progress has been made towards increasing climate change adaptation for health. This progress was particularly evident in the areas of adaptation planning, cross-sectorial collab orations, and health emergency management, which reflected the increased priority of climate and health issues in the governmental agenda and echoed policy suggestions made in the previous two Lancet Countdown China reports. However, the inputs and attention to adaptation are still insufficient compared with the increasing health risks posed by climate change.
By contrast to the stagnant trend of low-carbon employment around the world in recent years, China's employment in renewable energy has continued to grow since 2012, accounting for 40% of the global share. In 2020, the employment in renewable energy reached 4·7 million people, rep resenting 1·5 million more people than those employed in the fossil fuel extraction industry.
Conversely, the continued increase in the installed capacity of coal-fired generation and the insufficient reduction in fossil-fuel subsidies is a misstep on the road towards low-carbon development. This negative trend could endanger public health and increase future financial and economic risks.
In most provinces, people aged 65 years and older are facing higher health risks of climate change than the general population. However, older people are marginally represented in media coverage and policy design, and show less engagement with climate and health issues than younger age groups. Without timely mitigation and adaptation actions, the ageing of China's population might offset the benefits of China's clean energy transition and reverse the declining trend of air-pollutionrelated deaths in the coming years.
In a year marked by climate extremes, carbon neutrality commitments, and repeated waves of COVID-19, public health and climate change are receiving growing attention from key actors in society. However, the absence of rapid responses, especially those tailored to clinically vulnerable populations such as older people, jeopardises efforts towards delivering green COVID-19 recovery and sustainable development. Drawing from the evidence in this report, we call for a greater emphasis on accelerated adaptation and mitigation efforts to minimise the health impacts of the increasing climate change hazards, with particular focus on vulnerable groups such as the elderly. Protecting the Chinese populations from a rapidly changing climate will require a faster and more coordinated transition towards low-carbon, resilient societies from all stakeholders.

Contributors
The work for this paper was conducted by five working groups, which were responsible for the design, drafting, and review of their individual indicators and sections. All authors contributed to the structure and concepts of the overall paper and provided input and expertise to the relevant sections. Authors contributing to working group 1 were: CH (who was the lead for working group 1), YB, NC, HC, LC, HJ, QL, XiaL, ZhaL, SL, XT, YY, FY, JY, LZ, RZ, and QZ. Authors contributing to working group 2 were: CR (who was the lead for working group 2), WD, WF, XF, YG, JHua, HH, LL, BL, HM, and QW. Authors contributing to working group 3 were: ShaoZ (who was the lead for working group 3), BC, XC, TG, GK, HLin, HLiu, ZhuL, CL, ZLuo, WM, WS, LW, WW, DZ, and HZ. Authors contributing to working group 4 were: HD (who was the lead for working group 4), DG, YH, XinL, YX, YZ, and ShanZ. Authors contributing to working group 5 were: JS (who was the lead for working group 5), MC, BD, LJ, Q J, SW, JZha, and JZho. WC, CZ, ShiZ, JHuang, XJ, TL, MR, CW, BX, XY, LY, MF-CCF, YL, and PG contributed to coordination, strategic direction, and editorial support. WC had full access to all the data included in the paper. All authors had access to all data reported. WC, CZ, and SZ (ShiZ), accessed and verified the data.

Declaration of interests
We declare no competing interests.