AIR QUALITY BRIEFING

Air Pollution and Health in Serbia

Facts, Figures and Recommendations

PUBLISHED December 2014

Air pollution is an important risk factor for health in Europe and worldwide. A recent review of the global burden of disease
showed that it is one of the top ten risk factors for health globally1. Worldwide an estimated 7 million people died
prematurely because of pollution; in the European Union (EU) 400,000 people suffer a premature death2. The Organisation
for Economic Cooperation and Development (OECD) predicts that in 2050 outdoor air pollution will be the top cause of
environmentally related deaths worldwide3. In addition, air pollution has also been classified as the leading environmental
cause of cancer4.

Impacts of air pollution in Serbia

In 2010, more than 10,000 people in Serbia died prematurely from particulate matter (PM) and ozone exposure. It is
the second highest rate of premature deaths due air pollution in Europe. Furthermore, there were 2.5 million lost
working days5.

WHY IS AIR POLLUTION A CONCERN FOR A recent report in Serbia on air quality in 20138 states that
during that year, the annual limit value for PM10, 40
HEALTH? μg/m3, was exceeded in most of locations. In 2013 the air
Exposure to outdoor air pollution is associated with a in the agglomerations of Belgrade, Bor, Uzice and
broad spectrum of acute and chronic health effects ranging Smederevo in 2013 was that of category III, over-polluted
from irritant effects to death6. While the impacts on air.
respiratory and cardiovascular disease are well
documented, new science also shows air pollution as an During 2013, 73 percent of the population in urban or
emerging risk factor for children’s health and even urban-industrial agglomerations was potentially exposed
diabetes7. Sensitive and vulnerable groups such as to the concentrations of pollutants above the reference
pregnant women, children, the elderly and those already level8.
suffering from respiratory and other serious illnesses or
from low income groups are particularly affected.

The health effects of air pollution are well documented,

even though the pollution mixtures in the air can be
complex. Air pollution exists as a mixture of liquid and solid
phases; a mixture of gaseous, volatile, semi-volatile and
particulate matter, and its exact composition varies widely.
The main pollutants for which numerous studies on health
effects exist are particulate matter, ozone, nitrogen
dioxide, sulphur dioxide, methane, mercury and black
carbon.

AIR POLLUTION IN SERBIA

Air quality in Serbia is a big concern: measurements show
that citizens all over the country breathe in air that is
considered harmful to health. For example, concentrations
of PM2.5 and PM10 are much higher than what the EU and
the World Health Organization (WHO) have set to protect
health.

Health and Environment Alliance (HEAL)

28, Boulevard Charlemagne - B-1000 Brussels – Belgium / Phone: +32 2 234 36 40 / E-mail: [email protected] / Web: www.env-health.org
IMPACTS OF AIR POLLUTANTS ON HEALTH pulmonary epithelium into the circulation, such as gases,
and possibly ultrafine particulate matter along with soluble
constituents of PM2.5 (e.g. transition metals). These direct
RESPIRATORY SYSTEM effects of air pollution represent a plausible explanation for
the occurrence of rapid cardiovascular responses (within a
Effects include: increased respiratory symptoms, few hours), such as increased myocardial infarctions. Less
infections; increased airway reactivity, irritation; lung acute and chronic indirect effects (from several hours to
inflammation; increased respiratory mortality and days) may occur via pulmonary oxidative
hospital visits, hospitalisation; decreased lung function, stress/inflammation induced by inhaled pollutants.
asthma exacerbations, exacerbation of chronic
obstructive pulmonary disease (COPD), increased lung Peaks in the concentration of other air pollutants –
cancer risk. especially the combination of fine particulate matter and
nitrogen oxides – correlate with increased hospital
The US American Thoracic Society identified a broad range admissions for potentially fatal disturbances of heart
of respiratory health effects associated with air pollution rhythm. Most often those hospital admissions are due to
that should be considered “adverse”, spanning outcomes ischemic heart diseases; and congestive heart failure.
from death from respiratory diseases to reduced quality of
life, and including some irreversible changes in physiologic NERVOUS AND CEREBROVASCULAR SYSTEM
function9.
Effects include: neurodevelopmental disorders, neuro-
Studies show that lung function growth in children is
inflammation, oxidative stress, alterations in the blood-
reduced in areas with high PM concentrations10; and this
brain barrier, headaches, anxiety, stroke, Alzheimer’s
function either improves when children are relocated to
disease, and Parkinson’s disease.
areas with lower air pollution, or deteriorates when
children move to areas with greater air pollution11. This
The mixture of components of air pollution also includes
effect on lung development is an additional risk factor for
heavy metals that are emitted into the atmosphere, for
developing lung diseases later in life.
example mercury or lead. They remain in the air until they
are transmitted back to the earth by rain. Many of heavy
Air pollution exposure can trigger new cases of asthma,
metals are particularly neurotoxic to the human body,
worsen a previously-existing respiratory illness, and
especially to children.
provoke development or progression of chronic illnesses
including, COPD, emphysema and lung cancer. Lead exposure in childhood can result in decreased
cognitive functioning, including assessments of reaction
COPD is a life-threatening lung disease that interferes with time, scanning and executive functioning in adults, that is,
normal breathing. The number of deaths from COPD has cognitive flexibility and abstract reasoning. Lead exposure
increased more than 60% over the last 20 years, and air can also affect subsequent verbal memory and verbal
pollution is an important risk factor through inflammation, fluency. Aggression, behavioural issues (such as depression
an immunological response. The inflammatory response is and sleep complaints) and increased antisocial and
referred to as chronic bronchitis. In the air cells it leads to delinquent behaviour have also been positively correlated
destruction of tissue, or emphysema. with lead exposure.
Mercury is a potent neurotoxin that can severely harm the
CARDIOVASCULAR SYSTEM brain and the developing nervous system. Exposure to
methyl mercury in the womb can adversely affect the
Effects include: altered cardiac autonomic function, developing brain and nervous system of a baby, resulting
myocardial infarction, angina pectoris, increased blood in eventual impacts on cognitive thinking, memory,
pressure, arteriosclerosis, hypertension, and increased attention, language, and fine motor and visual spatial skills.
cerebrovascular ischemia.
REPRODUCTIVE CAPACITIES AND CHILDREN’S
In recent years, a large body of scientific evidence has
emerged that has strengthened the link between exposure HEALTH
to different air pollutants and cardiovascular effects, for Effects include: compromised sperm quality, DNA
acute and/or chronic effects12. fragmentation, low birth weight, preterm birth, small
gestational age births.
The biological mechanisms linking air pollution to heart
disease involve direct effects of pollutants on the In developing embryos, the placenta serves as a barrier
cardiovascular system, blood, and lung receptors, but also against many environmentally hazardous substances, but it
indirect effects mediated through pulmonary oxidative might not be protective against all components of air
stress and inflammatory responses. pollution. Children, even before birth, are particularly
susceptible to air pollutants. Increasing evidence shows
Direct effects may occur via agents that readily cross the how early-life exposure to air pollutants is contributing to

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higher risks of developing chronic diseases later in life, Emissions from coal power plants in Europe contribute
including obesity, diabetes, and hormone related cancers significantly to the burden of disease from environmental
such as breast and prostate cancer. Furthermore, recent pollution. The brand-new figures published in HEAL’s
studies found associations between exposure to outdoor report show that EU-wide impacts amount to more than
air pollution during pregnancy and lower birth weight, as 18,200 premature deaths, about 8,500 new cases of
well as higher rates of preterm birth and pre-eclampsia. It chronic bronchitis, and over 4 million lost working days
has been shown that there is an association between each year. The economic costs of the health impacts from
exposure to PM2.5 and birth outcomes, including low birth coal combustion in Europe are estimated at up to €42.8
weight, preterm birth and small for gestational age births. billion per year13.

HOW DOES COAL CONTRIBUTE TO AIR PUBLIC HEALTH INTERVENTIONS PAY OFF!
POLLUTION IN SERBIA?
The largest health burden is attributable to the long-term
Coal power generation adds to already poor air quality in impacts of chronic exposure to PM2.5. In Europe and
Europe and in Serbia - caused mainly by the transport globally, measures have been taken that have
sector, industrial processes, residential heating, and demonstrated a swift benefit to public health.
agriculture.

Coal power plants release substantial amounts of The ban on coal burning in Dublin (Ireland) in
particulate matter, sulphur dioxide, and nitrogen –oxides, the 1990s resulted in the reduction of black
with the latter contributing indirectly to the formation of smoke dust by 71% and sulfur dioxide by 34%.
ozone. Of these, the most worrying for health are fine This reduced the total mortality rate in the city
particulate matter (PM2.5) and ozone. by 8%, including reduction in cardiovascular
14
diseases by 7% and respiratory by 13% .
Other hazardous substances emitted from the smokestacks
of coal power plants are heavy metals, such as mercury, In Launceston, Australia, a new regulation of
and persistent organic pollutants (POPs), such as dioxins 2001 improved the air quality by reducing PM10
and polycyclic aromatic chemicals (PAHs). Special concern dust by 38%. This lead to a decrease in total
for children’s health arise from the large mercury mortality by 11.4%, including reduction in
emissions from coal power plants. cardiovascular diseases by 17.9% and
respiratory by 22.8%. In winter period health
A large coal power plant emits several thousand tons of benefits were even higher, reduction in
hazardous air pollutants every year and has an average cardiovascular diseases by 19.6% and
lifetime of at least 40 years. Building new coal power 15
respiratory by 22.9% .
plants would mean that hazardous emissions and their
effects on health would continue for many years. It would
also counterbalance short-term reductions in air pollutants
achieved in other sectors. In addition, a research project involving 25 European cities
has demonstrated that the compliance with the WHO
guideline of 10 g/m3 for annual mean PM2.5
HEALTH DAMAGE AND FINANCIAL BURDEN concentrations, would increase the life expectancy of up to
FROM COAL POWER GENERATION IN SERBIA 22 months for people aged 30 years and older. Considering
PM10, the compliance with the WHO guideline of 20 g/m3
It is estimated that directly due to in annual mean could save each year 16,000 lives in Serbia
outdoor air pollution more than 1,000 through this improvement in air quality16.
Serbians suffer from chronic bronchitis
cases, 600 are hospitalised due to
respiratory or cardiovascular
WHAT CAN MEDICAL EXPERTS DO?
symptoms, and 2,000 die yearly Health and medical experts are becoming increasingly
because of polluted air in Serbia13. concerned about air pollution and the role of coal
combustion, and they have continuously highlighted the
enormous health risks of air quality. Medical experts in the
Costs to ill-health by only one source of
USA such as the Physicians for Social Responsibility (PSR),
pollution - coal power plants, are
Australian physicians, British medical journal, the Lancet,
estimated to be up to €4.98 billion per
European Respiratory Society (ERS) and many others are
year13.
vocal clean air advocates.

In the light of ongoing EU accession process of Serbia it is

very timely that Serbian doctors and health experts
communicate to their patients and to the public that

3
current air pollution is a cause of adverse health effects Engage in policy developments
and, that improvements of air quality do result in better
health. At the same time health professionals should Become involved in the debates on higher air quality
engage in policy processes with decision-makers to show standards at national level.
how pollution can successfully be reduced.
Highlight to national decision makers that the health
The time is right to advocate on the health damage from impacts and external costs of coal have to be taken into
coal. Based on the established scientific evidence about account in energy decisions. From a health perspective
the health risks from coal combustion, doctors and health building new coal power plants is detrimental to efforts of
organisations can add a long neglected health perspective tackling chronic disease and creates unnecessary costs.
to the debate about Serbian future energy supply. Existing regulations need to be enforces and updated,
stronger regulation needed
STEPS OF ACTION
Educate the public on health risks due to air pollution
Physicians Raise awareness on the health risks from coal power in
local consultation processes and help to ensure the
Consider environmental factors when diagnosing patient enforcement of better pollution control for existing coal in
illness order to protect public health. Also, use the opportunity to
organise events to promote the importance of clean air.
Assess and include environmental information into the
medical history of patients. Such information can be
invaluable in discovering underlying causes of disease and
FURTHER INFORMATION
contributing to the body of knowledge on environmental http://env-health.org
risks. http://www.who.int/topics/air_pollution/en
http://www.eea.europa.eu
Check the air quality situation http://www.sepa.gov.rs
http://www.knowyourairforhealth.eu/
Check the air quality situation in the area where your
patient lives with the data from the local monitoring REFERENCE:
1. Global Burden of Disease: http://www.thelancet.com/themed/global-burden-of-disease
station for SO2, NO2 and PM10. Also, analyse the situation
2. EU Commission 2013: http://ec.europa.eu/environment/air/index_en.htm
in your area over a longer time interval. 3. OECD Environmental Outlook to 2050. The consequences of inaction
4. International Agency for Research on Cancer (WHO): Outdoor air pollution a leading
environmental cause of cancer deaths:
5. EMRC (2014). Cost-benefit Analysis of Final Policy Scenarios for the EU Clean Air Package
Public health professionals 6. Committee of The Environmental and Occupational Health Assembly of the American
Thoratic Society (ATS). Health effects of outdoor air pollution, Part 1&2. American journal
of respiratory and critical care medicine, 153: 3–50 (1996).
Inform the public or flag up a health alert 7. WHO (2013). Review of evidence on health aspects of air pollution (REVIHAAP).
8. SEPA. Godišnji izveštaj o stanju kvaliteta vazduha u Republici Srbiji 2013. godine
http://www.sepa.gov.rs/download/VAZDUH2013.pdf
Highlight to local authorities, the media, and the public if 9. American Thoratic Society (ATS). What constitutes an adverse health effect of air
pollution? American journal of respiratory and critical care medicine, 161: 665–673 (2000).
thresholds for SO2, NO2 and PM10 are exceeded. Coal 10.GAUDERMAN, W. J. ET AL. Association between air pollution and lung function growth in
power plants in the region might contribute to high southern California children. Results from a second cohort. American journal of respiratory
and critical care medicine, 166: 76–84 (2002).
concentrations. Obtain weather data (e.g. wind directions) 11.AVOL, EL ET AL. Respiratory effects of relocating to areas of differing air pollution levels.
for the same period in order to determine potential point American journal of respiratory and critical care medicine, 164: 2067–2072 (2001).
12.WHO (2003). Health Aspects of Air Pollution with Particulate Matter, Ozone and Nitrogen
sources. Dioxide
13.HEAL (2013). The Unpaid Health Bill - How coal power plants make us sick?
14.CLANCY, L ET AL. (2002). Effect of air-pollution control on death rates in Dublin, Ireland: an
Depending on the air quality situation, you may advise intervention study. Lancet, 360: 1210–14
sensitive groups to stay indoors. 15.JOHNSTON, FH ET AL. (2013). Evaluation of interventions to reduce air pollution from
biomass smoke on mortality in Launceston, Australia: retrospective analysis of daily
mortality, 1994–2007. British Medical Journal.
CONTACT 16.Calculation developed by HEAL based on CAFE methodology

Vlatka Matković Puljić

Project Coordinator, Energy and Health,
South & Central East European countries Health and Environment Alliance
Tel: +32 2 234 36 42
(HEAL)
E-mail: [email protected]
28, Boulevard Charlemagne
The Health and Environment Alliance (HEAL) is a leading European not-for-profit organisation B-1000 Brussels – Belgium
addressing how the environment affects health in the European Union (EU). With the support of
more than 70 member organisations, HEAL brings independent expertise and evidence from the Tel.: +32 2 234 36 40
health community to different decision-making processes. Our broad alliance represents health E-mail: [email protected]
professionals, not-for-profit health insurers, doctors, nurses, cancer and asthma groups, citizens, Website: www.env-health.org
women’s groups, youth, environmental NGOs, scientists and public health research institutes.
Members include international and Europe-wide organisations as well as national and local groups.

Promoting environmental policy that contributes to good health