As the air quality deteriorates over winter, we look at its impact on health and the economy.
How bad is the air pollution in Macedonia?
Air pollution in Macedonia far exceeds international safety levels. In 2016 The WHO (World Health Organization) ranked Skopje as the third worst city in Europe in terms of particulate matter air pollution (PM2.5). Skopje’s annual mean for 2016 was 40 µg/m3 (40 micrograms per cubic meter), which is 4 times higher than the annual WHO guideline (10 µg/m3), and 60 per cent greater than the official Macedonian target and European guideline (25 µg/m3). Graph 1 below shows the daily PM2.5 observations over the last year for Skopje (Centar), Bitola, Tetovo, and Kumanovo. All four cities regularly exceed the WHO daily guideline (25 µg/m3) with winter being the worst period.
 WHO, “WHO Global Ambient Air Quality Database (Update 2018).”
 Ministry of Environment and Physical Planning (Macedonia), “Macedonian Air Quality Assessment Report for The Period 2005–2015,” 21.
 European Commision, “Standards – Air Quality – Environment – European Commission.”
What is Particulate Matter Air Pollution?
There are several different types of air pollution, including carbon monoxide, ozone, sulfur dioxide, and nitrogen dioxide, but Particulate Matter (PM) is the worst for human health. It also has the worst record for exceeding guidelines in Macedonia. PM2.5 is the chief focus of this article.
PM are microscopic liquid or solid particles suspended in the air. Particulates are measured at two main levels: less than 10 micrometers (PM10) and less than 2.5 micrometers PM2.5. PM2.5 is particularly dangerous because of its size. It is smaller than most bacteria and can penetrate the lungs and bloodstream. Once in the bloodstream it can cause and exacerbate a range of diseases, these are discussed in more detail below.
How bad is air pollution for health?
PM air pollution kills around 4.2 million people globally each year, which is more people than AIDS, malaria, and tuberculosis combined. In Macedonia, PM air pollution was the eighth largest mortality risk factor in 2016, and was linked to 7.3 per cent of deaths that year. When its severity is weighted by the level of exposure faced by the whole population, PM air pollution is ranked higher than smoking in terms of risk to the general population (a summary exposure value of 42.5 versus 37).
In terms of life expectancy PM air pollution decreases life expectancy in Macedonia by 0.81 years. Figure 1 below shows the diseases linked to PM air pollution. Unsurprisingly the World Health Organization (WHO) says there is no safe level of particulate matter (PM) air pollution.
 Anttila et al., “Characterisation of Extreme Air Pollution Episodes in an Urban Valley in the Balkan Peninsula.”
 US EPA, “Particulate Matter (PM) Basics.”
 Landrigan et al., “The Lancet Commission on Pollution and Health,” 471.
 The Institute for Health Metrics and Evaluation, “Global Health Data: Global Burden of Disease (GBD) Compare Tool.”
 The Institute for Health Metrics and Evaluation.
 Apte et al., “Ambient PM2.5 Reduces Global and Regional Life Expectancy,” sec. Supporting Information: https://pubs.acs.org/doi/suppl/10.1021/acs.estlett.8b00360/suppl_file/ez8b00360_si_002.xlsx.
 WHO (2016) ‘Ambient Air Pollution – a global assessment of exposure and burden of disease’p21: http://apps.who.int/iris/bitstream/10665/250141/1/9789241511353-eng.pdf,
 Apte et al., “Ambient PM2.5 Reduces Global and Regional Life Expectancy,” 547.
 Landrigan et al., “The Lancet Commission on Pollution and Health,” 475.
How bad is air pollution for the economy?
Air pollution is not only bad for people but it also hurts economic growth. Air pollution impacts the economy through increased medical expenditure, decreased productivity, and premature death. Air pollution imposes an enormous cost on the current and future wealth of Macedonia.
Increased medical expenditure is a particular problem for most countries, like Macedonia, who are already facing greatly increased costs from a rapidly ageing population. For high income countries the extra health costs from air pollution is estimated to be around 3.5 per cent of GDP – this is likely to be higher for countries, like Macedonia, with lower income. 3.5 per cent of Macedonian’s GDP in 2017 was 397 million USD.
Air pollution decreases productivity through missed days of work, for the sick and their carers, and through impaired ability at work. The World Bank estimates that the productivity impact of air pollution for an upper-middle-income country, like Macedonia, is around 0.13 per cent of GDP. In 2017, this was 14.7 million USD for Macedonia.
Premature death has a direct cost through lost labor hours. For 2017, I calculate this to be foregone GDP of around 18.5 million USD or 0.16 per cent of actual GDP. The cost of premature death become much higher when you consider an individual’s willingness-to-pay (WTP) to avoid the premature death. A recent study estimated the cost of premature death in terms of WTP from PM in Skopje to be between 570 and 1470 million euros in 2012.. A global study estimated the WTP cost to be around 8.37 per cent of GDP for upper-middle-income countries like Macedonia. In 2017, this would be around 723.5 million USD.
What are the causes of PM air pollution in Macedonia?
According to a recent study by the Finnish Meteorological Institute and the Ministry of Environment and Physical Planning, the main sources of PM2.5 are the burning of biomass (i.e. wood) for domestic heating, dust from soil, industry, and traffic. Contrary to popular opinion in Skopje, the incineration of waste is not considered a major source of air pollution. Graph 2 shows the breakdown of these sources using results from the Karpos monitoring station in Skopje. Table 1 examines some of these sources in more detail.
 Landrigan et al., 482.
 Landrigan et al., 486.
 Landrigan et al., 484.
 My calculation is based on the change in the baseline life expectancy because of air pollution multiplied by GDP per capita for 2017 and the number of deaths in the working age population for 2017.
 Martinez et al., “Health Impacts and Economic Costs of Air Pollution in the Metropolitan Area of Skopje,” 1, 4.
 Landrigan et al., “The Lancet Commission on Pollution and Health,” 487.
 Ministry of Environment and Physical Planning (Macedonia), “Macedonian Air Quality Assessment Report for The Period 2005–2015,” 17.
 Ministry of Environment and Physical Planning (Macedonia), 26.
Table 1: Sources of PM2.5
|Domestic Heating||Burning of wood, coal, and oil. 62 per cent of Macedonian household used wood for heating in 2015. The quality of wood and stoves used are important. Older stoves with green wood produces much more particulates than modern stoves with properly prepared wood or pellets.|
|Industry||Steel (ferroalloy) production, cement production, and electricity production (lignite used in Bitola and Oslomej).|
|Traffic||Traffic emits a range of pollutants including PM, carbon monoxide, and nitrogen oxide. Older diesel vehicles are the worst polluters, particularly those with a Euro Emission rating of 0 to 2 (zero is the worst rating). Around half of registered vehicles in 2015 had a Euro Emission rating of 2 or less while 10 to 18 per cent had a rating of zero.|
 Ministry of Environment and Physical Planning (Macedonia), 17.
 Ministry of Environment and Physical Planning (Macedonia), 15–18.
What part does geography and weather play?
The mountainous geography of Macedonia exacerbates the already high level of PM air pollution by concentrating it at ground level, particularly in winter. Mountains generally reduce air flows in the surrounding valleys preventing PM from being dispersed. Further, in winter the valleys become sinks of cold air with a higher layer of warm air trapping in the colder air and pollution like a blanket (temperature inversion)(figure 2). It is important to note that while temperature inversion concentrates air pollution, the air pollution in Macedonia is generally above WHO and national guidelines even in summer.
Figure 2: Temperature inversion in winter
 Ministry of Environment and Physical Planning (Macedonia), 19.
What is to be done?
PM air pollution imposes an enormous health and economic cost on Macedonia. Citizens are paying the cost with their health and lives, while the economy suffers the consequences of lost productivity and increased medical expenditure. The government has recognized this and with international help has improved monitoring, and has developed national and local strategies to reduce air pollution.
In our next issue we will look at what is being done in Macedonia and what is being done around the world. Air pollution is a global problem with lessons to be learnt. Even cities in the developed world with their generally lower levels of PM2.5 (London 12 µg/m3, Paris 16 µg/m3, New York 9 µg/3, Berlin 16 µg/m3, and Toyko 17 µg/m3) still may have individual neighborhoods above the WHO guidelines. Reflecting the severity of the problem, the WHO is holding the first ever global conference on air pollution and health starting on 30 October.
Anttila, Pia, Aneta Stefanovska, Aleksandra Nestorovska-Krsteska, Ljupco Grozdanovski, Igor Atanasov, Nikola Golubov, Pece Ristevski, Martina Toceva, Sari Lappi, and Jari Walden. “Characterisation of Extreme Air Pollution Episodes in an Urban Valley in the Balkan Peninsula.” Air Quality, Atmosphere & Health 9, no. 2 (March 1, 2016): 129–41. https://doi.org/10.1007/s11869-015-0326-7.
Apte, Joshua S., Michael Brauer, Aaron J. Cohen, Majid Ezzati, and C. Arden Pope. “Ambient PM2.5 Reduces Global and Regional Life Expectancy.” Environmental Science & Technology Letters 5, no. 9 (September 11, 2018): 546–51. https://doi.org/10.1021/acs.estlett.8b00360.
European Commision. “Standards – Air Quality – Environment – European Commission.” Accessed October 23, 2018. http://ec.europa.eu/environment/air/quality/standards.htm.
Landrigan, Philip J, Richard Fuller, Nereus J R Acosta, Olusoji Adeyi, Robert Arnold, Niladri (Nil) Basu, Abdoulaye Bibi Baldé, et al. “The Lancet Commission on Pollution and Health.” The Lancet 391, no. 10119 (February 2018): 462–512. https://doi.org/10.1016/S0140-6736(17)32345-0.
Martinez, Gerardo, Joseph Spadaro, Dimitris Chapizanis, Vladimir Kendrovski, Mihail Kochubovski, and Pierpaolo Mudu. “Health Impacts and Economic Costs of Air Pollution in the Metropolitan Area of Skopje.” International Journal of Environmental Research and Public Health 15, no. 4 (March 29, 2018): 626. https://doi.org/10.3390/ijerph15040626.
Ministry of environment and physical planning. “Macedonian Air Quality Assessment Report for The Period 2005–2015,” 2017.
The Institute for Health Metrics and Evaluation. “Global Health Data: Global Burden of Disease (GBD) Compare Tool,” 2016. The Institute for Health Metrics and Evaluation.
US EPA, OAR. “Particulate Matter (PM) Basics.” Overviews and Factsheets. US EPA, April 19, 2016. https://www.epa.gov/pm-pollution/particulate-matter-pm-basics.
WHO. “WHO Global Ambient Air Quality Database (Update 2018),” 2018. http://www.who.int/airpollution/data/cities/en/.