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Background Both air pollution and green space have been shown to independently affect mortality. We aimed to study whether greenness might interact with air pollution-related mortality among Chinese adults aged 65 years and older. Methods We used the 2008 wave of the Chinese Longitudinal Healthy Longevity Survey, with participants surveyed in 2012 and 2014. We used satellite remote sensing around participants' residential addresses to calculate our exposure variables. Normalized Difference Vegetation Index (NDVI) within a 500 m radius around their residence was used to measure contemporaneous NDVI (value at the time closest to the outcome event). Concentrations of particulate matter (PM2·5) were calculated using the 3-year average in a 1 km × 1 km grid. Cox proportional hazards models were used to estimate the effects of NDVI, PM2·5, and their interaction on all-cause mortality. We controlled for age, sex, ethnicity, marital status, geographic region, urban or rural residence, education, occupation, financial support, social and leisure activity, smoking status, alcohol consumption, and physical activity. We also stratified analysis by sex, urban or rural regions, smoking status, and exercise status. Findings We followed up 12 873 participants, totalling 47 884 person-years. There were 7426 mortality events from 2008 to 2014. At baseline, the mean age was 87 years (SD 11·34) and 84·62% lived in a rural area. The mean contemporaneous NDVIs were 0·42 (SD 0·21); the mean PM2·5 concentration was 49·63 μg/m3 (SD 13·72). In the fully adjusted model, the mortality hazard ratios (HRs) for each 0·1-unit decrease in contemporaneous NDVI was 1·08 (95% CI 1·03–1·13), each 10 μg/m3 increase in PM2·5 was 1·13 (1·09–1·18), interaction term 1·01 (1·00–1·02) with statistical significance (p=0·027). In our stratified analysis, people in urban areas were more likely to benefit from greenness, and people in rural areas were more likely to be harmed by air pollution. There was no effect modification by sex. Interpretation Our study showed that there is a synergistic effect of greenness and air pollution, which has important implications for urban planning and air pollution control to improve public health. Funding None.

Background Our study aimed to test whether the effects of residential greenness on cognitive function and mortality differ by APOE genotypes among Chinese adults aged 65 years and older. Methods We used Chinese Longitudinal Healthy Longevity Survey data, a longitudinal cohort of individuals aged 65 years and older. We calculated the normalised difference vegetation index (NDVI) using a 500 m radius around each participant's residence to reflect residential greenness. We used the Mini-Mental State Examination (MMSE) to measure cognitive function, and monitored survival status between 2000 and 2014. We categorised participants as APOE ɛ2 carriers, ɛ3/ɛ3 carriers, and ɛ4 carriers. We applied logistic regression to examine the association between baseline annual average NDVI, APOE genotypes, and cognitive impairment (reference group MMSE ≥24), and the Cox proportional hazard regression to assess the relationship between contemporaneous NDVI, APOE genotypes, and mortality. We adjusted for age, sex, ethnicity, marital status, urban or rural residence, education, occupation, financial status, social and leisure activity, smoking status, drinking status, physical activity, and geographic regions. Findings We included 9156 participants with a mean age of 82·6 years (SD 11·8). 1302 (14·2%) participants were APOE ɛ2 carriers, 6254 (68·3%) were ɛ3/ɛ3 carriers, and 1600 (17·5%) were ɛ4 carriers. We observed a significant interaction between NDVI and APOE genotypes both for cognitive impairment (pinteraction=0·0025) and mortality (pinteraction Interpretation Our finding elucidates possible gene-environment interaction mechanisms in which residential greenness might protect against cognitive impairment and mortality among older adults. Our study provides evidence of possible gene-environment interaction. Funding None.

Reiner RC Jr, Hay SI. Mapping geographical inequalities in childhood diarrhoeal morbidity and mortality in low-income and middle-income countries, 2000–17: analysis for the Global Burden of Disease Study 2017. Lancet 2020; 395: 1779–801—In this Article, the author byline has been amended to Local Burden of Disease Diarrhoea Collaborators. This correction has been made to the online version as of June 4, 2020, and the printed version is correct. © 2020 Elsevier Ltd

Background Exposure to nature, or greenness, may affect health through several pathways, including health-promoting activities and influencing psychological wellbeing. How greenness affects vulnerabilities due to old-age health has not been assessed. We assessed the relationship between residential greenness and mortality in an elderly cohort representative of China. Methods We used the prospective China Longitudinal Healthy Longevity Survey (CLHLS), a cohort representative of general elderly population in China. Our exposure was assessed by satellite-derived Normalised Difference Vegetation Index (NDVI) in 250 m and 1250 m radius around each participant's residential addresses between 2000 to 2014. We calculated cumulative NDVI, contemporaneous NDVI, and changes in NDVI values over time. We used all-cause mortality, excluding accidental death, as our outcome. The CLHLS was granted ethical approval from Research Ethics Committees of Peking University and Duke University. All subjects signed written informed consent before interview. Findings We followed up 3839 people at least 80 years of age between 2000 and 2014 totalling 13 253 person-years. The mean age at baseline was 92 years (SD 7·6). During 14 years of follow up, we recorded 3244 deaths. We used cox-proportional hazard models, adjusted for age, gender, ethnicity, urban/rural residence, geographical region, education years, occupation before age 60 years, marital status, smoking status, alcohol consumption, exercise, financial support, co-residence status, and annual average PM2·5. Compared with the lowest quartile of contemporaneous NDVI values, the highest quartile had a decreased risk of mortality (hazard ratio [HR] 0·78, 95% CI 0·70–0·87, for the 250 m radius; HR 0·77, 0·69–0·85, for the 1250 m radius). No significant effects on mortality were found for cumulative NDVI measurement (HR 1·12, 95% CI 0·99–1·27, for the 250 m radius; HR 1·09, 0·96–1·23, for the 1250 m radius). Compared with people living in regions with a significant decrease in NDVI from 2000 to 2014 (p Interpretation Our research suggests that more green space might promote healthy longevity, which has policy implications for eco-civilisation and preparing for ageing societies in China. Funding None.

Background Activities of daily living (ADL) is a measurement of the ability to care for one's self and body, including personal care, mobility, and eating. Greenness in the built environment has been shown to improve physical health and mental wellbeing. We hypothesise that greenness could delay declines in activities of daily living. Methods Using the prospective cohort of the China Longitudinal Healthy Longevity Survey (CLHLS) between 2000 and 2014, we explored the association between ADL and greenness in the oldest-old (people aged ≥80 years). We assessed exposure using satellite-derived Normalized Difference Vegetation Index (NDVI) in the 250 m radius around each participant's residential address and then categorised them into quartiles. Our study outcome was self-care capacity, measured by a six-item ADL survey (eating, bathing, dressing, toileting, transferring, and continence). We stratified our analysis of participants with complete independence at baseline (ADL score 0 out of 6). Both NDVI values and ADL scores were repeatedly measured in 2000, 2002, 2005, 2008, 2011, and 2014. We used mixed-effects logistic regression, adjusted for age, sex, ethnicity, marital status, childhood and adult socioeconomic status, smoking status, alcohol consumption, exercise, Mini-Mental State Examination scores, and time since study entry. Findings Among 3044 elderly participants at baseline, the mean age was 91 years (SD 7·1). 837 (27·5%) became dependent and needed assistance in performing any one of the ADL functions during follow-up. Participants who became dependent in ADL were more likely to be older, female, Han Chinese, and poor cognitive function at baseline. Participants in the highest quartile of greenness had an odds ratio of 0·54 (95% CI 0·43–0·68) of becoming dependent in ADL, compared with the lowest quartile. Interpretation The ageing of China's population is an irreversible trend, and poses a challenge to the care givers who care for the elderly. Our findings suggest that increasing green space, if properly introduced into city planning, might reduce the burden of long-term care for the Chinese elderly. Funding None

Background Despite relative affluence, Jiangsu, China, faces challenges brought by disease burdens, regional disparities, ageing, and migrant workforce, in achieving the health-related Sustainable Development Goals (SDGs) and Healthy Jiangsu 2030 goals. Therefore, we aimed to assess the current situation, gaps, and projection of Jiangsu attaining these goals. Methods We did a systematic analysis using a combination of quantitative and qualitative methods. We collected quantitative data from national and provincial health-related government agencies and the Global Burden of Diseases, Injuries, and Risk Factors Study 2016 (GBD 2016). We did semi-structured interviews with key stakeholders at provincial and sub-provincial levels. We also included other policy documents and grey literatures. On the basis of the model developed by the SDG Collaborators of GBD 2016, we did projections to assess the attainment of the quantitative health targets in Jiangsu. We also explored the gender disparities. Our study protocol was reviewed and approved by the Institutional Review Board of Duke University. Findings At baseline in 2015, Jiangsu performed well in indicators related to child under-nutrition and maternal and child health, meeting targets of the SDGs early. By 2030, Jiangsu is expected to meet targets in mental health, environmental health, and universal health coverage. However, our projections indicate that Jiangsu will not achieve the targets in exclusive breastfeeding, child overweight, infectious diseases, and non-communicable diseases, according to current trajectories. 7–28 day exclusive breastfeeding rate is expected to increase to 25·6%, a huge gap compared with the 6-month 50% target. Child overweight rate (1–4 years) was projected to increase by 2·6% compared with the zero increase target. The incidence of HIV/AIDS were projected to decrease to 0·9 per 100 000 population and tuberculosis to 15·3 per 100 000 population in 2030, suggesting that ending these epidemics would be highly improbable. New cases of hepatitis B virus and hepatitis C virus infections were projected to decrease by 45·3%, which is far from the 90% target. Large gender disparity was seen in non-communicable diseases, such as premature mortality and smoking rates. Interpretation The provincial Government of Jiangsu needs to take immediate and concerted actions to meet the SDGs and the Healthy Jiangsu 2030 goals. Funding Bill & Melinda Gates Foundation (grant number OOP1148464 )

Background There is evolving evidence about the effect of greenness on health, with findings from several studies showing a relationship with mortality. How greenness can affect mental and neurological systems has not been clearly elucidated. Currently, there are no prospective studies of how greenness can prevent the decline of cognitive function in the elderly in China. Methods We used the 1998 wave of the China Longitudinal Healthy Longevity Survey (CLHLS), a prospective cohort representative of the general elderly population (age ≥80 years) in China. We assessed residential greenness using satellite-derived Normalized Difference Vegetation Index (NDVI) in a 250 m radius around each participant's residential address from 2000 to 2014, and categorised them into quartiles. We assessed cognitive function using an adapted Chinese version of the Mini-Mental State Examination (MMSE). We defined participants with scores less than 24 as having abnormal cognition. We excluded participants with abnormal cognition at baseline in 2000. We used mixed-effects logistic regression to estimate odds ratios (OR) and their corresponding 95% CIs for MMSE scores, adjusted for age, sex, ethnicity, marital status, childhood and adult socioeconomic status, smoking status, alcohol consumption, exercise status, activity of daily living, and time since study entry. Findings There were 2345 participants without cognitive impairment at baseline. The mean cohort age was 90 years (SD 6·6). Participants who developed cognitive impairment over time were more likely to be older, female, not married, have low childhood and adult socioeconomic status, smoke, do not exercise, and had poor physical function at baseline. One quartile increase in NDVI values was associated with an odds ratio (OR) of 0·92 of developing cognitive impairment during follow-up (95% CI 0·86–0·99). Age, sex, marital status, socioeconomic status, smoking, exercise, and activities of daily living were significant predictors of cognitive impairment; 1 year of age was associated with an OR of 1·05 (95% CI 1·03–1·06) of developing cognitive impairment. Interpretation Our findings suggest that an increase in exposure to greenness might be an effective strategy to prevent cognitive decline in the oldest-old (aged ≥80 years), which could have implications for dementia and Alzheimer's disease (now the fifth leading cause of death in China). Funding None

Background The health of the Chinese people witnessed spectacular gains in the past half century. Life expectancy improved from 60 years in 1964 to 75 years in 2014. Infant and maternal mortality decreased substantially from 48 per 1000 children born in 1980 to 11 per 1000 children born in 2014, achieving benchmarks beyond those of Millennium Development Goals. The aim of this analysis is to examine three areas in China's development of its health workforce: improvements of the balance in the skill-mix amongst nurses and doctors, modernisation of medical education through reform of instructional content and purpose, and standardisation of post-graduate and continuing clinical education. Findings China has the largest production system of health professionals in the world. In 2012, China had 1·3 billion (18%) of 7 billion people in the world, 1·9 million (22%) of about 8·4 million doctors worldwide, and 1·9 million (11%) of 17·7 million nurses worldwide. However, the consequent doctor-nu rse ratio of 1:1 is highly imbalanced. Very rapid expansion of medical school student enrolment without corresponding expansion of faculty and infrastructure has compromised the quality of competence of graduating health professionals. Postgraduate education in China is currently ad hoc, fragmented, and suffering from the absence of quality standardisation. Currently, each institution is able to determine the content, duration, and quality of training of young physicians. There is inconsistency in the quality of physicians and specialists across all medical service institutions and between primary, secondary, and tertiary hospitals. Interpretation Although many people marvel at China's economic miracle, it has undergone slower progress in development of various social sectors such as health care. Continued progress and reform will require reform of undergraduate and postgraduate education, which are essential for cultivating health professionals who are trusted by patients to treat and prevent the growing burden of non-communicable diseases. Funding None.