In the past decade, particulate matter with aerodynamic diameter less than 2.5 μm (PM) has reached unprecedented levels in China and posed a significant threat to public health. Exploring the long-term trajectory of the PM attributable health burden and corresponding disparities across populations in China yields insights for policymakers regarding the effectiveness of efforts to reduce air pollution exposure. Therefore, we examine how the magnitude and equity of the PM-related public health burden has changed nationally, and between provinces, as economic growth and pollution levels varied during 2005-2017. We derive long-term PM exposures in China from satellite-based observations and chemical transport models, and estimate attributable premature mortality using the Global Exposure Mortality Model (GEMM). We characterize national and interprovincial inequality in health outcomes using environmental Lorenz curves and Gini coefficients over the study period. PM exposure is linked to 1.8 (95% CI: 1.6, 2.0) million premature deaths over China in 2017, increasing by 31% from 2005. Approximately 70% of PM attributable deaths were caused by stroke and IHD (ischemic heart disease), though COPD (chronic obstructive pulmonary disease) and LRI (lower respiratory infection) disproportionately affected poorer provinces. While most economic gains and PM-related deaths were concentrated in a few provinces, both gains and deaths became more equitably distributed across provinces over time. As a nation, however, trends toward equality were more recent and less clear cut across causes of death. The rise in premature mortality is due primarily to population growth and baseline risks of stroke and IHD. This rising health burden could be alleviated through policies to prevent pollution, exposure, and disease. More targeted programs may be warranted for poorer provinces with a disproportionate share of PM-related premature deaths due to COPD and LRI.
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