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Left unmitigated, climate change poses a catastrophic risk to human health, requiring an urgent and concerted response from every country. As the home to one fifth of the world's population and the largest emitter of carbon dioxide globally, China's interventions in climate change are of pivotal importance, both to human health and to the planet. Similar to other countries, climate change mitigation and adaptation would bring immense health benefits for China's 1·4 billion people, and building these considerations into any COVID-19 recovery strategy and the detailed pathway to fulfil the 2060 carbon neutrality pledge will ensure it improves human wellbeing, both now and in the future. Decisions made over the coming months and years will establish the course of climate change policy for decades to come. To meet this challenge, Tsinghua University (Beijing, China), partnering with University College London (London, UK) and 17 Chinese and international institutions, has produced the Lancet Countdown China report, focusing at the national level and building on the work of the global Lancet Countdown. Drawing on international methods and frameworks, this report aims to understand and track the links between public health and climate change at the national level. This paper is one part of the Lancet Countdown's broader efforts to develop regional expertise and understanding. Uniquely, the data and results in this report are presented at the provincial level where possible, to facilitate the targeted response strategies for local decision makers. Taken as a whole, the findings of the 23 indicators convey two key messages. The first message is that the health effects from climate change in China are accelerating, posing an unacceptably high amount of health risk if global temperatures continue to rise. Every province is affected, each with its unique health threats, and targeted response strategies should be made accordingly. The effects of climate change, manifested in rising temperatures, more extreme weather events, and shifting vector ecology, are being felt in China. Heatwave-related mortality has risen by a factor of four from 1990 to 2019, reaching 26 800 deaths in 2019. The monetised cost of the high number of deaths is equivalent to the average annual income of 1·4 million people in China. Older people (>65 years old), who face a 10·4% higher risk of dying during a heatwave, endured an average of 13 more heatwave days in 2019 compared with the 1986–2005 baseline. For outdoor workers, their potential heat-related labour productivity loss reached 0·5% of total national work hours, costing 1% of China's gross domestic product (GDP), equivalent to its annual fiscal expenditure on science and technology. Driven in part by rising temperatures and a changing climate, the advent of more extreme wildfires and the spread of dengue fever will in turn lead to profound health effects. Different regions have unique health threats, requiring a targeted response—19 provinces have had an at least 10% rise over the past two decades in three or more of the six health effect indicators reported. Importantly, many highly populated and economically advanced provinces, such as Henan, Shandong, and Zhejiang, are faced with health risks that are larger and more rapidly accelerating than others. The second message is that impressive and concerted improvements have been made across several sectors in China; however, the gap in the country's response to the health effects of climate change is large. In some sectors, China has taken large steps to address climate change. Solar power generation is growing at an unprecedented rate of 26·5% per year, rising to 26·8 gigawatts (GW) of newly installed capacity in 2019. Investments in low-carbon energy are now nine times greater than those in fossil fuels (rising from a 1:1 ratio in 2008); and, providing 4·1 million jobs in 2018, renewable energy now employs more people in China than fossil fuel extraction industries. As a result of strong policy measures, severe air pollution has also decreased, with a 28% reduction in annual average particulate matter of 2·5 μm or less (PM2·5) concentration in cities from 2015 to 2019, resulting in 90 000 fewer PM2·5-related premature deaths annually. These air pollution control policies also act to mitigate climate change and have resulted in a decline in China's coal share in total primary energy supply from 66% in 2014 to 59% in 2018. Showing leadership at the subnational level, three provinces already have a provincial health and climate change plan in place, with four more provinces underway. However, although these changes have been rapid, more shifts of a greater size are necessary to enact a response that is of the scale required to fulfil China's carbon neutrality by 2060 pledge and to minimise the rising health burdens of climate change, both in China and around the world. Although renewable energy use is rising, coal stills holds a 59% share of the total primary energy supply in China. Fossil fuel subsidies were US$41·9 billion in 2018, without considering the contribution of fossil fuels to the estimated $10·7 billion economic losses because of premature mortality from PM2·5 air pollution. Although there have been substantial reductions in air pollution, 42% of China's population still live in areas that do not meet the interim air quality guidelines from WHO, and almost all cities have PM2·5 concentrations more than the recommended annual average of 10 μg/m3. The health effects of climate change are not adequately recognised or addressed, as climate change is not referenced in the Healthy China Action Plan (2019–30), and China is yet to introduce a standalone national adaptation plan for health. Taking a broader perspective, media coverage and individual engagement in health and climate change are low, with little spread of knowledge and engagement. China will need to scale up progress in all sectors to counteract the rising curve of the health risks from climate change. Five recommendations are proposed to key stakeholders in health and climate change in China: (1)Enhance interdepartmental cooperation. Climate change is a challenge that requires an integrated response from all sectors. Although China commits to integrate health into all policies, substantial interdepartmental cooperation among health, environment, energy, economic, financial, and education authorities is urgently needed.(2)Strengthen health emergency preparedness. Although the amount of health emergency preparedness in China would be greatly enhanced after COVID-19, knowledge and findings on current and future climate-related health threats still do not have enough attention and should be fully integrated into the emergency preparedness and response system, so that future health service, medical supplies, and infrastructure needs could be planned ahead.(3)Support research and raise awareness. Additional financial support should be allocated to health and climate change research in China, to enhance the knowledge of health system adaptation, mitigation measures, and their resulting health benefits. At the same time, media and academia should be fully motivated to raise awareness on this topic for the public and for politicians. Additionally, the Government of China should update the Healthy China Action Plan (2019–30) to address the health risks of climate change as soon as possible.(4)Increase climate change mitigation. China's new pledges towards carbon neutrality by 2060 is a major step forward. Speeding up the coal phase-out process is therefore necessary to be consistent with the carbon neutrality pledges and continue China's progress on air pollution reduction. Fossil fuel subsidies should also be phased out to reflect the true cost of ongoing fossil fuel use and to avoid undermining the effect of China's emissions trading scheme, scheduled to take effect in 2021.(5)Ensure the country's recovery from the COVID-19 pandemic protects health both now and in the future. Decisions made as part of China's efforts to recover from COVID-19 will shape the public's health for years to come. The longer-term prospects for lives, livelihoods, and a sustainable economy will be put in jeopardy if these interventions do not prioritise climate change.

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Climate change is a public health emergency.1Solomon CG LaRocque RC Climate change–a health emergency.N Engl J Med. 2019; 380: 209-211Crossref PubMed Scopus (75) Google Scholar Clinicians worldwide now face the reality of caring for patients during wildfires, heat waves, floods, and shifting infectious disease patterns. Health-care workers need better preparation to care for communities facing the health effects of climate change.2Salas RN The climate crisis and clinical practice.N Engl J Med. 2020; 382: 589-591Crossref PubMed Scopus (22) Google Scholar Medical students have been key advocates in these efforts, driving research, community partnerships, and education.3Goshua A Gomez J Erny B et al.Addressing climate change and its effects on human health: a call to action for medical schools.Acad Med. 2021; 96: 324-328Crossref PubMed Scopus (44) Google Scholar, 4Fadadu RP Jayaraman T Teherani A Climate and health education for medical students.Clin Teach. 2021; 18: 362-364Crossref PubMed Scopus (7) Google Scholar, 5Baker N Bromley-Dulfano R Chan J et al.COVID-19 solutions are climate solutions: lessons from reusable gowns.Front Public Health. 2020; 8590275Crossref Scopus (20) Google Scholar When we began medical school during record-setting Californian wildfires and a global pandemic, our curriculum did not address the effect of climate change on human health, nor the disproportionate effects on communities made vulnerable by racism and poverty. Here, we detail how we integrated the effects of climate change on health into more than a dozen courses at our institution, starting with the preclinical curriculum and then progressing through all levels of training. In this Comment, we use the example of reproductive health and obstetrics and gynaecology education to describe this longitudinal approach. Our student team first addressed the preclinical curriculum, highlighting the effect of climate change on disease pathophysiology across human health. We began with a review of our required preclinical curriculum, identifying areas of opportunity for integration on the basis of peer-reviewed literature. We worked closely with course faculty leads to incorporate climate topics into pre-existing course materials using an equity lens, emphasising the disproportionate health effects of climate change on low-resourced communities.4Fadadu RP Jayaraman T Teherani A Climate and health education for medical students.Clin Teach. 2021; 18: 362-364Crossref PubMed Scopus (7) Google Scholar, 5Baker N Bromley-Dulfano R Chan J et al.COVID-19 solutions are climate solutions: lessons from reusable gowns.Front Public Health. 2020; 8590275Crossref Scopus (20) Google Scholar, 6Nardone A Casey JA Morello-Frosch R Mujahid M Balmes JR Thakur N Associations between historical residential redlining and current age-adjusted rates of emergency department visits due to asthma across eight cities in California: an ecological study.Lancet Planet Health. 2020; 4: e24-e31Summary Full Text Full Text PDF PubMed Scopus (164) Google Scholar For example, we supplemented our reproductive health course with lecture slides identifying air pollution and heat exposure as environmental teratogens that increased the risk of adverse birth outcomes, especially for Black women and people with asthma.7Bekkar B Pacheco S Basu R DeNicola N Association of air pollution and heat exposure with preterm birth, low birth weight, and stillbirth in the US: a systematic review.JAMA Netw Open. 2020; 3e208243Crossref PubMed Scopus (257) Google Scholar Transitioning to clinical integration, our team expanded on knowledge gained in the preclinical setting to teach students how to identify climate-related disease pathology. In the obstetrics and gynaecology clerkship, we integrated climate and health effects into relevant didactic sessions and case presentations. For example, we highlighted how wildfire smoke contributes to preterm birth in our home state of California, USA.8Heft-Neal S Driscoll A Yang W Shaw G Burke M Associations between wildfire smoke exposure during pregnancy and risk of preterm birth in California.Environ Res. 2022; 203111872Crossref PubMed Scopus (37) Google Scholar Students also learned how to discuss climate-related topics in patient encounters. Lastly, we extended our efforts into the education of junior doctors, aiming to equip junior doctors with tools to counteract climate change's impacts on patients. These efforts emphasised how climate and health presentations are rooted in upstream factors that contribute to health inequities. For example, we developed a didactic session for the obstetrics and gynaecology junior doctor programme focused on taking environmental histories, providing climate-related patient education, and connecting junior doctors with advocacy resources.9Program on Reproductive Health and the EnvironmentPrenatal exposure to toxic chemicals and climate change.https://prhe.ucsf.edu/figoDate: 2022Date accessed: January 21, 2022Google Scholar Given the vital role that junior doctors play in medical student education, these efforts will not only provide junior doctors with tools to care and advocate for patients affected by climate change, but will also be passed down to medical students during clinical rotations. Although we use the obstetrics and gynaecology curriculum as an example of our longitudinal approach to climate and health education, our work has spanned across more than a dozen courses to date. Five best practices were crucial to our success: setting tangible education objectives as defined by the School of Medicine administration and relevant national climate educational efforts allowed us to develop targeted, effective educational interventions;10Fadadu R Hampshire K Ndovu A Medical students as agents of change in the climate crisis.Acad Med. 2022; 97: 1104-1105Crossref PubMed Scopus (3) Google Scholar soliciting iterative feedback from faculty and trainees enabled us to benchmark the school's progress in planetary health education; aligning with the Deans of Curriculum and Scholarship gave us a platform to directly interact with course faculty leads and integrate our research systematically; grounding our work in local effects and health equity by collaborating with at-risk community members ensured our educational materials were relevant to our patient population and showed how climate change is one of many social determinants of health; and connecting with national student and physician groups such as Medical Students for a Sustainable Future and Physicians for Social Responsibility enabled us to share resources, knowledge, and best practices. As climate change forces the world to grapple with a new understanding of normal, it is crucial that clinicians are prepared for the novel health effects that climate change will have on the communities they serve. A longitudinal approach to climate and equity education throughout medical training aims to not only build competency and awareness on the effects of climate change on health, but also provide an equity frame (figure). This approach empowers clinicians to effectively counsel patients within hospitals in addition to advocating for resources and policies outside clinical walls to best protect the health of their communities, ultimately preparing trainees for a career rooted in social justice and health equity. We declare no competing interests. AJ and AL contributed equally.

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