The 2020 China report of the Lancet Countdown on health and climate change

Abstract

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. Climate change threatens the health and wellbeing of populations in every country.1Watts N Adger WN Agnolucci P et al.Health and climate change: policy responses to protect public health.Lancet. 2015; 386: 1861-1914Summary Full Text Full Text PDF PubMed Scopus (775) Google Scholar China is particularly susceptible to these health effects, with large proportions of the population exposed to rising sea levels, climate-sensitive infectious diseases such as dengue fever, yellow fever, and chikungunya, and substantial increases in both wildfires and heatwaves.2Watts N Amann M Arnell N et al.The 2019 report of the Lancet Countdown on health and climate change: ensuring that the health of a child born today is not defined by a changing climate.Lancet. 2019; 394: 1836-1878Summary Full Text Full Text PDF PubMed Scopus (364) Google Scholar As the world's second largest economy, and the country with the largest population and total carbon dioxide (CO2) emissions, China is a key global stakeholder in the response to the health effects of climate change, with progress benefiting not only the health of the 1·4 billion people in China, but also the health of populations around the world. However, the interlinkage of public health and climate change has yet to receive full attention from the Chinese Government. For example, the recently adopted Healthy China Action Plan (2019–30), a public health agenda for the building of a comprehensive health system in China, contains no mention of climate change.3Promotion Committee for Healthy China ProgramHealthy China Program (2019–2030).http://www.gov.cn/xinwen/2019-07/15/content_5409694.htmDate: July 15, 2019Date accessed: May 8, 2020Google Scholar With the Paris Agreement due for implementation and the deadline for the achieving the Sustainable Development Goals (SDGs) just a decade away, interventions taken in 2020 will be pivotal.4UN Climate ChangeThe Paris Agreement.https://unfccc.int/process-and-meetings/the-paris-agreement/the-paris-agreementDate accessed: May 8, 2020Google Scholar, 5The Intergovernmental Panel on Climate ChangeGlobal warming of 1·5°C. An IPCC Special Report on the impacts of global warming of 1·5°C above pre-industrial levels and related global greenhouse gas emission pathways, in the context of strengthening the global response to the threat of climate change.https://www.ipcc.ch/site/assets/uploads/sites/2/2019/06/SR15_Full_Report_High_Res.pdfDate: 2019Date accessed: April 20, 2020Google Scholar, 6UN Sustainable Development Goals Knowledge PlatformTransforming our world: the 2030 agenda for sustainable development.https://sustainabledevelopment.un.org/post2015/transformingourworldDate: 2015Date accessed: April 20, 2020Google Scholar At the same time, the world has been disrupted by a global pandemic, from which the effects will be felt for years to come. Moving forward, the development of national and international COVID-19 stimulus packages should align with the goals and principles of both the Paris Agreement and the SDGs, to ensure a sustainable recovery. Tracking the progress on health and climate change at the national level in China will not only enhance understanding of these interlinkages, but also evaluate the adequacy of its response and highlight the benefit of aligning environmental and social policy. To deliver this, Tsinghua University has developed the inaugural Lancet Countdown report for China, in collaboration with University College London and 17 Chinese and international institutions. This paper serves as the first endeavour to track China's progress across all of the dimensions of health and climate change, mirroring the definition and grouping of indicators, and approaches and methods used by the global Lancet Countdown report. This work will be developed over time, with an iterative and adaptive approach that sees continual improvement in the indicators and methods considered. In its first year, the report presents 23 indicators across five domains: climate change effects, exposures, and vulnerability; adaptation planning and resilience for health; mitigation actions and health co-benefits; economics and finance; and public and political engagement (panel).PanelThe China Lancet Countdown indicatorsClimate change impacts, exposures, and vulnerability1.1:health and heat1.1.1:exposure of susceptible populations to heatwaves1.1.2:heatwave-related mortality1.1.3:change in labour capacity1.2:health and extreme weather events1.2.1:wildfires1.2.2:cyclones1.3:climate-sensitive infectious diseasesAdaptation, planning, and resilience for health2.1:adaptation planning and assessment2.2:adaptation delivery and implementation2.2.1:detection, preparedness, and response to health emergencies2.2.2:air-conditioning–benefits and harmsMitigation actions and health co-benefits3.1:energy system and health3.2:clean household energy3.3:air pollution, transport, and energy3.4:sustainable and healthy transportEconomics and finance4.1:health and economic costs of climate change and benefits from its mitigation4.1.1:costs of heat-related mortality4.1.2:economics cost of heat-related labour productivity loss4.1.3:economic costs of air pollution-related premature deaths4.2:the economics of the transition to zero-carbon economies4.2.1:healthy energy investments4.2.2:employment in low-carbon and high-carbon industries4.2.3:fossil fuel subsidies4.2.4:coverage and strength of carbon pricingPublic and political engagement5.1:media coverage of health and climate change5.2:individual engagement in health and climate change5.3:coverage of health and climate change in scientific journals Climate change impacts, exposures, and vulnerability 1.1:health and heat1.1.1:exposure of susceptible populations to heatwaves1.1.2:heatwave-related mortality1.1.3:change in labour capacity1.2:health and extreme weather events1.2.1:wildfires1.2.2:cyclones1.3:climate-sensitive infectious diseases Adaptation, planning, and resilience for health 2.1:adaptation planning and assessment2.2:adaptation delivery and implementation2.2.1:detection, preparedness, and response to health emergencies2.2.2:air-conditioning–benefits and harms Mitigation actions and health co-benefits 3.1:energy system and health3.2:clean household energy3.3:air pollution, transport, and energy3.4:sustainable and healthy transport Economics and finance 4.1:health and economic costs of climate change and benefits from its mitigation4.1.1:costs of heat-related mortality4.1.2:economics cost of heat-related labour productivity loss4.1.3:economic costs of air pollution-related premature deaths4.2:the economics of the transition to zero-carbon economies4.2.1:healthy energy investments4.2.2:employment in low-carbon and high-carbon industries4.2.3:fossil fuel subsidies4.2.4:coverage and strength of carbon pricing Public and political engagement 5.1:media coverage of health and climate change5.2:individual engagement in health and climate change5.3:coverage of health and climate change in scientific journals Where possible, the data sources and methods have been improved, to provide higher spatial resolution (including down to the provincial level) or information more relevant and appropriate within the context of China. This report presents the results for each of the 23 indicators, with a complete description of the methods, data, limitations, and future improvements provided for each indicator in the appendix 2. Climate change interacts with each of the social and environmental determinants of good health, affecting lives and livelihoods through a myriad of different pathways.1Watts N Adger WN Agnolucci P et al.Health and climate change: policy responses to protect public health.Lancet. 2015; 386: 1861-1914Summary Full Text Full Text PDF PubMed Scopus (775) Google Scholar This section attempts to understand the interactions between climate change and health, tracking the ways in which climate change has influenced the health of Chinese people, through heat and heatwave (indicators 1.1.1–1.1.3), extreme weather events (indicators 1.2.1 and 1.2.2), and the climate-sensitive infectious diseases (indicator 1.3). Given China's unique vulnerabilities and long coastline in the tropics, an additional indicator tracking exposure to cyclones (indicator 1.2.2) has been included in this report. Heat and heatwave exposure can often be fatal for older populations, owing to a range of factors, including a higher prevalence of chronic disease and medication use, and an impaired physiological and behavioural response.7Mayrhuber EA-S Dückers MLA Wallner P et al.Vulnerability to heatwaves and implications for public health interventions - a scoping review.Environ Res. 2018; 166: 42-54Crossref PubMed Scopus (26) Google Scholar Against a baseline of warm seasons in 1986–2005, this indicator tracks the number of days that people aged older than 65 were exposed to a heatwave from 2000 to 2019, with the use of gridded temperature and population data.8Copernicus Climate Change ServiceERA5.https://www.ecmwf.int/en/forecasts/datasets/reanalysis-datasets/era5Date accessed: April 23, 2020Google Scholar, 9Chambers J Hybrid gridded demographic data for the world, 1950–2020.https://zenodo.org/record/3768003#.X4spwZ5KiUkDate: April 27, 2020Date accessed: April 27, 2020Google Scholar For this indicator, a heatwave is defined as a period of 3 or more consecutive days where the daily maximum temperature was greater than the 92·5th percentile of the grid's distribution of the baseline daily maximum temperature in summer, a definition that best captures the health effects of heatwave events in China.10Yang J Yin P Sun J et al.Heatwave and mortality in 31 major Chinese cities: definition, vulnerability and implications.Sci Total Environ. 2019; 649: 695-702Crossref PubMed Scopus (60) Google Scholar A full description of the methods and data can be found in the appendix 2 (pp 3–5). Nationally, heatwave exposure has been rising steadily, from an increase of 71·8 million person-days from the baseline in 2000 to a record high of 2·20 billion person-days in 2019, which is second only to 2·24 billion in 2017. The increase is equivalent to a person aged over 65 years enduring 13 more days of heatwave in 2019 than in 2000 (figure 1). The total amount of heatwave exposure is affected by both climate change and population ageing, whereas the change of heatwave exposure per person is only affected by climate change. Looking closer at 2019, each older person in Yunnan had 39 more heatwave days, the highest among all provinces, followed by Hong Kong (22 days), and Hainan (18 days). (A) Country-level trend. (B) Provincial-level results in 2019. In their most extreme form, heatwaves result in excess mortality, usually seen in the exacerbation of cardiovascular and respiratory disease.11Xu Z FitzGerald G Guo Y Jalaludin B Tong S Impact of heatwave on mortality under different heatwave definitions: a systematic review and meta-analysis.Environ Int. 2016; 89-90: 193-203Crossref PubMed Scopus (128) Google Scholar This indicator evaluates heatwave-related mortality across all age groups, with the use of gridded population and temperature data, the heatwave definition as described in indicator 1.1.1, and location-specific exposure–response curves, with methods described in the appendix 2 (pp 5–6).8Copernicus Climate Change ServiceERA5.https://www.ecmwf.int/en/forecasts/datasets/reanalysis-datasets/era5Date accessed: April 23, 2020Google Scholar, 9Chambers J Hybrid gridded demographic data for the world, 1950–2020.https://zenodo.org/record/3768003#.X4spwZ5KiUkDate: April 27, 2020Date accessed: April 27, 2020Google Scholar, 10Yang J Yin P Sun J et al.Heatwave and mortality in 31 major Chinese cities: definition, vulnerability and implications.Sci Total Environ. 2019; 649: 695-702Crossref PubMed Scopus (60) Google Scholar, 12Ma W Chen R Kan H Temperature-related mortality in 17 large Chinese cities: how heat and cold affect mortality in China.Environ Res. 2014; 134: 127-133Crossref PubMed Scopus (107) Google Scholar There were around 26 800 heatwave-related deaths in China in 2019, with the rising trend becoming increas-ingly apparent over recent years (figure 2). Taking a 5-year moving average, it took 3·8 years for every in-crease of 1000 annual heatwave-related deaths from 1990 to 2009, but just 1·2 years for the same increase to occur from 2010 to 2019. Among the provinces, heatwave-related mortality was highest in Shandong, followed by Henan and Anhui, all of which are located in east and south-central China. (A) Trend of heatwave-related mortality in 1990–2019. (B) Heatwave-related mortality in different provinces in 2019. Considering broader heat-related mortality in the future, there would be 27 900 additional heat-related deaths in Chinese cities per year over 2060–99 in a 2·0°C increase in average annual temperature scenario compared with a 1·5°C increase scenario,13Wang Y Wang A Zhai J et al.Tens of thousands additional deaths annually in cities of China between 1.5 °C and 2.0 °C warming.Nat Commun. 2019; 103376Crossref PubMed Scopus (45) Google Scholar and in the 2080s, heat-related cardiovascular mortality in Beijing could increase by 69·0% in the Representative Concentration Pathway 4·5 scenario and 134·0% in the Representative Concentration Pathway 8·5 scenario.14Li T Ban J Horton RM et al.Heat-related mortality projections for cardiovascular and respiratory disease under the changing climate in Beijing, China.Sci Rep. 2015; 511441Crossref PubMed Scopus (39) Google Scholar There is a clear consensus from biometeorological studies that increased heat stress from climate change will reduce labour productivity, leading to an increased socioeconomic burden.2Watts N Amann M Arnell N et al.The 2019 report of the Lancet Countdown on health and climate change: ensuring that the health of a child born today is not defined by a changing climate.Lancet. 2019; 394: 1836-1878Summary Full Text Full Text PDF PubMed Scopus (364) Google Scholar, 15Kjellstrom T Freyberg C Lemke B Otto M Briggs D Estimating population heat exposure and impacts on working people in conjunction with climate change.Int J Biometeorol. 2018; 62: 291-306Crossref PubMed Scopus (57) Google Scholar, 16Dunne JP Stouffer RJ John JG Reductions in labour capacity from heat stress under climate warming.Nat Clim Chang. 2013; 3: 563-566Crossref Scopus (247) Google Scholar Indicator 1.1.3 focuses on this effect, calculating the work hour losses by the use of Wet Bulb Globe Temperature in primary industries (agriculture, forestry, animal husbandry, and fishery), secondary industries (manufacturing, construction, and mining), and tertiary industries (catering, finance, and other services), as described in the global Lancet Countdown report and in the appendix 2 (pp 6–9).17Watts N Amann M Arnell N et al.The 2018 report of the Lancet Countdown on health and climate change: shaping the health of nations for centuries to come.Lancet. 2018; 392: 2479-2514Summary Full Text Full Text PDF PubMed Scopus (313) Google Scholar In 2019, the potential total work hours lost in China were over 9·9 billion, 4·8% higher than in 2000 and representing 0·5% of the total national work hours. Labour capacity loss per worker in the primary industry worsened by 6·2% annually from 2000, reaching 36 hours (or 4·5 working days) in 2019. Nearly a quarter (2·4 billion h) of these potential losses occurred in Guangdong, the most populous and economically developed province, which accounts for 11% of China's gross domestic product (GDP). Each primary industry worker in Guandong potentially lost an average of 14·3 days and secondary industry workers potentially lost an average of 5·2 days, resulting in substantial losses to wages, productivity, and livelihoods. Wildfire causes direct thermal injuries and death, as well as excess morbidity and mortality from smoke-related exacerbations of acute and chronic respiratory symptoms.2Watts N Amann M Arnell N et al.The 2019 report of the Lancet Countdown on health and climate change: ensuring that the health of a child born today is not defined by a changing climate.Lancet. 2019; 394: 1836-1878Summary Full Text Full Text PDF PubMed Scopus (364) Google Scholar In this report, change in the population exposure to wildfire is estimated by overlaying satellite data with population data and counting the number of days in which wildfires occur per grid cell, with densely populated urban areas excluded.9Chambers J Hybrid gridded demographic data for the world, 1950–2020.https://zenodo.org/record/3768003#.X4spwZ5KiUkDate: April 27, 2020Date accessed: April 27, 2020Google Scholar, 18National Aeronautics and Space AdministrationActive Fire Data.https://earthdata.nasa.gov/active-fire-dataDate: 2020Date accessed: May 23, 2020Google Scholar The annual mean days of exposure were calculated for four time periods: 2001–05, 2006–10, 2011–15, and 2016–19. Nationally, total exposure increased in the first three periods, and decreased in the last period, probably owing to increased urbanisation. However, at the provincial level, 24 of 34 provinces had an increase in annual person-days exposed to wildfire in 2016–19 compared with 2001–05. The largest increase was observed in northern and northeastern provinces, including Heilongjiang, Jilin, and Tianjin provinces, implying a need for strengthened wildfire monitoring and control. China's extended eastern coastline is affected by tropical cyclones, which can cause injury and death, infectious diseases, and negative mental health effects.19Doocy S Dick A Daniels A Kirsch TD The human impact of tropical cyclones: a historical review of events 1980-2009 and systematic literature review.PLoS Curr. 2013; 5: 5Google Scholar, 20Zheng J Han W Jiang B Ma W Zhang Y Infectious diseases and tropical cyclones in southeast China.Int J Environ Res Public Health. 2017; 14: 494Crossref Scopus (11) Google Scholar, 21Jiao K Hu W Ren C Xu Z Ma W Impacts of tropical cyclones and accompanying precipitation and wind velocity on childhood hand, foot and mouth disease in Guangdong province, China.Environ Res. 2019; 173: 262-269Crossref PubMed Scopus (4) Google Scholar, 22Lowe SR Joshi S Pietrzak RH Galea S Cerdá M Mental health and general wellness in the aftermath of hurricane Ike.Soc Sci Med. 2015; 124: 162-170Crossref PubMed Scopus (31) Google Scholar, 23Scaramutti C Salas-Wright CP Vos SR Schwartz SJ The mental health impact of hurricane Maria on Puerto Ricans in Puerto Rico and Florida.Disaster Med Public Health Prep. 2019; 13: 24-27Crossref PubMed Scopus (16) Google Scholar, 24Taioli E Tuminello S Lieberman-Cribbin W et al.Mental health challenges and experiences in displaced populations following hurricane Sandy and hurricane Harvey: the need for more comprehensive interventions in temporary shelters.J Epidemiol Community Health. 2018; 72: 867-870Crossref PubMed Scopus (12) Google Scholar Unique to the Chinese Lancet Countdown report, this indicator tracks cyclone exposure and damage, with the use of national data.25Ying M Zhang W Yu H et al.An overview of the China meteorological administration tropical cyclone database.J Atmos Ocean Technol. 2014; 31: 287-301Crossref Scopus (360) Google Scholar, 26China Meteorological Administration Tropical Cyclone Data CentreIntroduction to tropical cyclone data of China meteorological administration.http://tcdata.typhoon.org.cn/Date: 2020Date accessed: May 23, 2020Google Scholar The tropical cyclones are described in terms of frequency, intensity, and spatial–temporal distribution at the provincial level. The trend in the occurrence of tropical cyclones for each intensity grading is calculated for 2000–19 compared with an extended 1980–99 baseline. Compared with the baseline, a statistically significant increase has been detected in the occurrence of severe and super typhoons from 2000 to 2019, whereas the occurrence of tropical depressions and tropical storms have decreased. Because of better adaptation interventions, the damages caused by tropical cyclones to hotspot provinces, such as Fujian and Zhejiang in east China, have significantly decreased over this period (appendix 2 pp 20–25). Dengue virus is a notable climate-sensitive infectious disease that is vector borne, with climate suitability for the transmission of this virus rising in every world region. This indicator focuses on the change in vectorial capacity of the A aegypti and A albopictus mosquitos to transmit dengue virus, which is expressed as the average number of daily cases resulting from one infected patient, and is influenced by daily temperature. The method for calculating vectorial capacity is the same as that described in the 2019 Lancet Countdown report and by Rocklöv and Tozan.27Rocklöv J Tozan Y Climate change and the rising infectiousness of dengue.Emerg Top Life Sci. 2019; 3: 133-142Crossref Scopus (11) Google Scholar Compared with 1961–65, the climate suitability for the transmission of dengue virus in 2014–18 has risen by 37% for A aegypti and 14% for A albopictus. In turn, there has been considerable and continuous national growth in both the incidence and disability-adjusted life-years lost in China. In 2017, the all-age incidence rate of dengue fever increased by 5·7 times and the disability-adjusted life-years rate of dengue fever increased by 4·7 times, compared with that of 1990, reaching 183·8 per 100 000 for the all-age incidence rate and 1·8 per 100 000 for the disability-adjusted life-years rate.28Institute for Health Metrics and EvaluationGlobal burden of disease study 2017 (GBD 2017) data resources.http://ghdx.healthdata.org/gbd-2017Date: April 23, 2020Google Scholar Several other infectious diseases in China are climate sensitive, placing further risk to Chinese populations now and in the future. For example, the transmission potential of malaria will increase by 39–140% in south China, with an air temperature increase of 1–2°C.29Yao-Dong D Xian-Wei W Xiao-Feng Y Wen-Jun M Hui A Xiao-Xuan W Impacts of climate change on human health and adaptation strategies in south China.Adv Clim Chang Res. 2013; 4: 208-214Crossref Google Scholar Overall, this section provides clear evidence that the health effects of climate change are rising rapidly and affect different parts of China in unique ways. Different regions have their unique health threats and need a targeted response, with figure 3 providing a composite assessment of this diversity across the country. In three provinces, Henan, Shandong, and Zhejiang, five of six indicators reported here have worsened by at least 10% between 2000 and 2019. These three provinces alone account for around 20% of China's population and national GDP.30National Bureau of Statistics of ChinaNational and provincial vehicle ownership.http://data.stats.gov.cn/english/Date: 2020Date accessed: May 5, 2020Google Scholar Most of the highly populated and economically developed provinces in eastern and northern China have more than three indicators that have risen by at least 10%, implying that a large proportion of Chinese people and the economy are at risk. These findings provide a strong justification for more ambitious adaptation and mitigation inter-ventions to protect health, for which the indicators are tracked in later sections in this Health Policy paper.