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China, with its growing population and economic development, faces increasing risks to health from climate change, but also opportunities to address these risks and protect health for generations to come. Without a timely and adequate response, climate change will impact lives and livelihoods at an accelerated rate. In 2020, the Lancet Countdown Regional Centre in Asia, led by Tsinghua University, built on the work of the global Lancet Countdown and began its assessment of the health profile of climate change in China with the aim of triggering rapid and health-responsive actions. This 2021 report is the first annual update, presenting 25 indicators within five domains: 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. The report represents the contributions of 88 experts from 25 leading institutions in, and outside of, China. From 2020 to 2021, five new indicators have been added and methods have been improved for many indicators. Where possible, the indicator results are presented at national and provincial levels to facilitate local understanding and policy making. In a year marked by COVID-19, this report also endeavours to reflect on China's pathway for a green recovery, ensuring it aligns with the carbon neutrality goal, for the health of the current and future generations.

Left unmitigated, climate change poses a catastrophic risk to human health, demanding an urgent and concerted response from every country. The 2015 Lancet Commission on Health and Climate Change and The Lancet Countdown: Tracking Progress on Health and Climate Change have been initiated to map out the impacts of climate change and the necessary policy responses. To meet these challenges, Tsinghua University, partnering with the University College London and 17 Chinese and international institutions, has prepared the Chinese Lancet Countdown report, which has a national focus and builds on the work of the global Lancet Countdown: Tracking Progress on Health and Climate Change. Drawing on international methodologies and frameworks, this report aims to deepen the understanding of the links between public health and climate change at the national level and track them with 23 indicators. This work is part of the Lancet's Countdown broader efforts to develop regional expertise on this topic, and coincides with the launch of the Lancet Countdown Regional Centre in Asia, based at Tsinghua University. The data and results of this report are presented at the provincial level, where possible, to facilitate targeted response strategies for local decision-makers. Based on the data and findings of the 2020 Chinese Lancet Countdown report, five recommendations are proposed to key stakeholders in health and climate change in China: (1) Enhance inter-departmental cooperation. Climate change is a challenge that demands an integrated response from all sectors, urgently requiring substantial inter-departmental cooperation among health, environment, energy, economic, financial, and education authorities. (2) Strengthen health emergency preparedness. Knowledge and findings on current and future climate-related health threats still lack the required attention and should be fully integrated into the emergency preparedness and response system. (3) Support research and raise awareness. Additional financial support should be allocated to health and climate change research in China to enhance health system adaptation, mitigation measures, and their health benefits. At the same time, media and academia should be fully motivated to raise the public and politicians' awareness of this topic. (4) Increase climate change mitigation. Speeding up the phasing out of coal is necessary to be consistent with China's pledge to be carbon neutral by 2060 and to continue to reduce air pollution. Fossil fuel subsidies must also be phased out. (5) Ensure the recovery from COVID-19 to protect health now and in the future. China's efforts to recover from COVID-19 will shape public health for years to come. Climate change should be a priority in these interventions.

China's coal-fired power industry urgently needs deep decarbonization to meet the challenge of climate change. Regional air quality improvement and the health benefits can motivate efforts to achieve low-carbon goals. However, the health cobenefit per amount of carbon reduction may vary drastically across power plant units. The strategy of targeting more health cobenefits has been considered in designing an efficient carbon mitigation pathway, whereas this issue has not been analyzed at the unit level. In this study, an indicator called health benefit by carbon reduction (H/C) was constructed for each power unit to assess the relative potential of obtaining health cobenefits. The results reveal that the distribution of H/C values among units is extremely uneven: the first 1, 5, and 20% of the total carbon emission contributed to nearly 20, 40, and 70%, respectively, of the total health effects. The additional health benefits from H/C optimization were evaluated, and the decommissioning pathway of China's coal-fired power industry for achieving more health benefits was explored.

Given the threats that anthropogenic climate change would pose to human health, tackling climate change is identified to be the greatest global health opportunity of the 21st century by the 2015 Lancet Commission on Health and Climate Change. The Lancet Countdown was then initiated, as an international and multidisciplinary collaboration dedicated to monitoring the evolving health profile of climate change, and providing an independent assessment of the delivery of commitments made by governments worldwide under the Paris Agreement. The 2019 report of the Lancet Countdown on health and climate change presents an annual update of 41 indicators across five key domains: 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. The report represents the findings and consensus of 35 leading academic institutions and UN agencies from every continent. The report warns that current progress is inadequate, and warming is occurring faster than governments are able, or willing to respond. The report concludes that meeting the unprecedented challenge of climate change will require an unprecedented global response, with bold, new approaches to policy making, research, and business. China is the global hotspot in both climate change mitigation and human health protection. Therefore, in addition to the Lancet Countdown global reports, experts from Department of Earth System Science, Tsinghua University who have been involved in the series of global reports, have been invited to prepare the China policy brief annually to provide a unique national analysis and policy recommendations for health and climate change to the policymakers and the public in China since 2017. The 2019 edition of China policy brief, jointly prepared by experts from Tsinghua University and Sun Yat-sen University, reviewed three indicators mostly related to China’s national conditions, i.e. health impacts of heat, coal phase-out and media coverage of health and climate change, and proposed the following policy recommendations. (1) Conduct vulnerability mapping to understand which populations are most at risk, and implement interventions to safeguard against the acute effects of extreme heat on human health. Curb greenhouse gas emissions to avoid intensification of heatwaves in the longer term. (2) Incorporate the close linkages between climate change, current and future air quality and human health into coal phase-out policymaking. Further enhance the ambition of coal phase-out policy to prevent climate change-driven mete-orological conditions that might worsen air pollution. (3) Media outlets present a key channel for the communication of health risks associated with climate change, spread-ing knowledge of adaptation measures to these adverse impacts, and shaping public perceptions of necessary interven-tions. Health professionals are trusted by the public and should engage with media to further raise awareness of the link-ages between health and climate change and of actionable ways to bring about positive change. (4) With updated Nationally Determined Contributions under the Paris Agreement due to be submitted by 2020, health considerations should be integrated throughout proposed interventions, with particular consideration of heat adaptation measures, coal and energy policy, and health sector engagement where relevant.

Climate change would pose a range of threat to human health both directly and indirectly. The direct adverse effects of climate change to human health include increased frequency of heatwaves, storms, floods, forest fire and drought. The indirect effects usually mediate through impacts on environmental conditions and ecosystems (e.g., air pollution, food insecurity and under-nutrition, and changing patterns of disease), economies, and social structure (e.g., displacement, migration and conflict). To map out the impacts that climate change is having on human health, and the health consequences of the global policy response, the 2015 Lancet Commission on Health and Climate Change and the Lancet Countdown: tracking progress on health and climate change has been initiated, with strong collaboration of world-class expertise from multiple disciplines and leading academic institutions around the world. The 2018 report of the Lancet Countdown on health and climate change tracks 41 indicators across five domains: Climate change impacts, exposures, and vulnerability; adaptation, planning, and resilience for health; mitigation actions and health co-benefits; finance and economics; and public and political engagement. The report warns that a lack of progress in reducing emissions and building adaptive capacity threatens both human lives and the viability of the national health systems they depend on, with the potential to disrupt core public health infrastructure and overwhelm health services. Therefore, the nature and scale of the response to climate change will be the determining factor in shaping the health of nations for centuries to come. China is the global hotspot in both climate change mitigation and human health protection. Thus, in addition to the annual editions of the Lancet Countdown global report, scholars from Department of Earth System Science, Tsinghua University who have been involved in the series of global reports, are invited to prepare the China policy brief, to provide a unique national analysis and policy recommendations for health and climate change. The 2018 edition of China policy brief, prepared by experts from Tsinghua University and Chinese Center for Disease Control and Prevention, reviewed three indicators mostly related to China’s national conditions, i.e. change in labour capacity, exposure to ambient air pollution and coverage and strength of carbon pricing, and proposed the following policy recommendations: (1) Pay more attention to the labour capacity loss driven by climate change in the policymaking process. Curb greenhouse gas emissions and take effective adaptation measures to manage heat stress at work and avoided unaffordable heat-related economic loss. (2) Prioritize measures that both decrease greenhouse gas emissions and reduce air pollution and its related health costs, and incorporate analysis of those benefits into the climate and air pollution control policymaking process in order to fully realize short-term health co-benefits and prevent climate-change-related meteorological conditions that will worsen air pollution in the long run. (3) Ensure full operation of the national ETS and implement ambitious carbon pricing policy as soon as possible. Fully consider the health co-benefits of carbon pricing, speed up the capacity building process, apply carbon pricing broadly across China without delay, and enhance ambition gradually.

Water is a fundamental and essential resource for sustainable and healthy development of natural environment and human society. China boasts considerable water resources but is below world average on a per capita basis, and is challenged by the disparity in temporal and geographical distribution and poor utilization of water resources, severe water pollution, etc. As water is closely associated with climate change, change in water resources amid climate change in the future might affect China’s water security. Based on the reality and challenges of China’s water resources, this chapter shall discuss the evolution of China’s water management system and the current water demand, as well as the trend in future. Next, a study of water resources risk and its temporal and spatial distribution in China’s power industry are introduced, concluding with policy recommendations for China to address the challenges.