How air pollution shows up in our bodies.

Built from publicly available health data in and around Skopje. We separate what’s documented from what’s assumed, and we don’t fill gaps with guesses.

Health impacts of air pollution in Skopje

Understanding AQI: what the categories actually mean

AQI (Air Quality Index) is a way to translate pollution measurements into health-relevant categories. Higher AQI means higher health risk.

Good (AQI 0–50)
Air pollution levels are low. Most people can go about daily activities without concern.
Moderate (AQI 51–100)
Air quality is acceptable for most people. However, some sensitive individuals may notice mild symptoms.
Unhealthy for sensitive groups (AQI 101–150)
This is where health effects begin to matter. Children, older adults, pregnant people, and those with heart or lung disease should limit long or intense outdoor activity.
Unhealthy (AQI 151–200)
Everyone may start to feel effects. Sensitive groups are at higher risk of symptoms such as coughing, breathing difficulty, chest tightness, or fatigue.
Very unhealthy (AQI 201–300)
This level represents a health alert. Outdoor activity should be minimized for everyone.
Hazardous (AQI 301+)
Serious health risk for the entire population. Avoid outdoor exposure as much as possible.

How air pollution affects human health

A summary of widely documented health effects, with linked sources.

Global context

Air pollution is a major health threat worldwide. The World Health Organization reports that about 99% of people breathe air that exceeds WHO guideline limits [1]. Because pollution is often invisible, it’s easy to underestimate it, but evidence links polluted air to a long list of serious outcomes affecting the lungs, heart, brain, pregnancy, and more.

One major reason: fine particles (PM2.5) are small enough to reach deep into the lungs and can contribute to inflammation and stress throughout the body. That’s why polluted air is not only a “lung problem.”

Heart and cardiovascular system

Air pollution is strongly linked with cardiovascular harm. Fine particle exposure (PM2.5) is associated with higher risks of heart attacks, strokes, high blood pressure, irregular heart rhythms, and inflammation [2].

What it means in plain language: pollution can act like an extra “pressure” on your heart and blood vessels. On bad-air days, people with existing heart disease (and many older adults) can be pushed closer to an emergency.

Research also suggests that long-term exposure can raise hospitalization risk in seniors, even at relatively low levels of PM2.5 [3].

Brain, cognition, and mental health

Evidence is growing that long-term air pollution exposure is linked to higher risk of cognitive decline and neurodegenerative conditions (including Alzheimer’s and Parkinson’s) [4].

What this means: over years, polluted air may contribute to processes that are bad for brain health. This is still an active research area, but the direction of evidence is consistent enough that major public health institutions treat it seriously.

Lungs and breathing

The lungs are the first line of exposure. Air pollution can irritate airways and is associated with more asthma symptoms, bronchitis, and worsening of chronic lung disease. It can also increase vulnerability to respiratory infections. (This is part of why smoggy periods often feel like “everyone is coughing.”)

What this means: even if pollution doesn’t “cause” the virus, it can make breathing problems worse, especially for children and people with asthma.

Pregnancy and infants

Research links pollution exposure during pregnancy with higher risks such as low birth weight and preterm birth. This matters because the earliest stages of life are particularly sensitive to environmental stress.

What this means: pregnancy is one of the times when reducing exposure is most worth it, because small changes may matter more.

Who is most at risk

  • Children: lungs and immune systems are still developing; they breathe more air per body weight.
  • Older adults: higher baseline risk for heart/lung events; pollution can add strain.
  • People with asthma, COPD, heart disease, diabetes: more likely to have symptoms or complications.
  • Outdoor workers: higher exposure time on high-pollution days.

Is there a “safe” level?

Many large studies find health risks even at low concentrations, which is why public health guidance increasingly treats air pollution as a risk that generally improves as levels go down, rather than a simple “safe vs unsafe” switch.

What this means: lower is better. Even modest improvements can matter, especially at the population level.

Why this is treated as a global emergency

Harvard researchers reported that air pollution from burning fossil fuels was responsible for about 1 in 5 deaths worldwide in 2018 [5].

What this means: this is not a niche environmental issue, it’s a large-scale public health issue.

Sources (5)
  1. WHO — “Billions of people still breathe unhealthy air: new WHO data” (99% statement). Open source
  2. Harvard T.H. Chan — “The dangers of air pollution for heart health.” Open source
  3. Harvard T.H. Chan — “Chronic exposure to air pollution may increase risk of cardiovascular hospitalization among seniors.” Open source
  4. Harvard T.H. Chan — “How air pollution impacts our brains.” Open source
  5. Harvard T.H. Chan — “Fossil fuel air pollution responsible for 1 in 5 deaths worldwide.” Open source

Key findings (what the numbers are telling us)

These are the clearest documented signals in the data. Each point below is grounded in a source, with uncertainty labeled when needed.

National premature deaths linked to PM2.5

An official national assessment links PM2.5 exposure to approximately 3,583 premature deaths per year, estimated as 16.1% of total mortality (exposure period 2020–2022). [1]

Documented national estimate; useful context for Skopje without claiming a Skopje-only percentage.

Skopje region baseline mortality (2022)

In 2022, the Skopje region recorded 6,959 deaths (all causes). Of these, 346 (4.97%) were from respiratory diseases (ICD-10 J00–J99), and 622 (8.94%) had COVID-19 (U07) as the underlying cause. [3]

Official statistics; note that COVID-19 deaths often include respiratory complications.

Children’s respiratory illness surged after 2020

Between 2020 and 2022, a sharp increase in respiratory illness among children in Skopje was reported: +67.4% among school-age children and +107.5% among preschool children. [2]

Documented in an official analysis; the trend is interpreted in context of post-2020 disruptions.

Respiratory disease became the top reason for GP visits (2022)

In 2022, respiratory system diseases were reported as the most frequent reason for primary care visits, accounting for 15.6% of all outpatient visits in general medicine. [2]

Documented shift compared to 2020, when circulatory system diseases were reported as the top category.

“Kozle” clinic shows the everyday pediatric burden

In 2023, the “Kozle” pediatric pulmonary institute reported 35,000+ outpatient examinations and around 4,000 hospitalizations for children with respiratory diseases. [4]

Reported by the institution via media; a concrete indicator of sustained system load.

Short-term spikes can overwhelm services in a single day

During a winter period in December 2025, a reported 24-hour surge included 200 children examined and 60 hospitalized at “Kozle,” with infants requiring oxygen support. [5]

A reported episode; it illustrates how combined stressors can produce acute demand spikes.

Attributable mortality linked to PM2.5 (national context)

National estimates help size the overall health burden, but they should not be automatically converted into Skopje-only claims without Skopje-specific studies.

Documented national estimate (2020–2022 exposure period)

An Institute of Public Health assessment links PM2.5 exposure to approximately 3,583 premature deaths per year in North Macedonia, estimated as 16.1% of total mortality for the exposure period 2020–2022. [1]

What this means
Air pollution behaves like a background risk that increases the likelihood of earlier death from cardiopulmonary causes.
What this does not mean
It does not mean deaths happen immediately or that each case can be individually assigned to pollution.
Why Skopje is mentioned
Skopje often experiences higher exposure than many areas; however, a separate Skopje-only attributable-mortality estimate is not provided here.

Skopje region mortality profile (what the baseline looks like)

This section provides the official baseline categories within which pollution-related risk operates (rather than creating a separate “pollution” category).

Skopje region deaths in 2022

In 2022, the Skopje region recorded 6,959 deaths (all causes). Respiratory diseases accounted for 346 deaths (4.97%), and 622 additional deaths (8.94%) were recorded with COVID-19 (U07) as the underlying cause. [3]

Interpretation: what this implies for pollution-linked risk
  • Pollution increases risk inside existing categories (heart disease, stroke, respiratory disease) rather than creating a separate category.
  • COVID-19 years complicate trend comparisons because some respiratory cases are classified within COVID-19 categories.

Skopje region mortality peak in 2021 (pandemic year)

In 2021, the overall mortality rate in the Skopje region reached 14.4 per 1,000 residents (14.4‰), higher than previous years. This is attributed mainly to COVID-19 waves, and official guidance notes that direct comparison with prior trends is more difficult due to the pandemic effect. [2]

Children’s respiratory burden (Skopje signals that are hard to ignore)

The pediatric signal is one of the clearest local indicators: sustained high volume, plus acute spikes during winter episodes.

Documented increases (2020–2022)

A reported analysis for Skopje indicates a dramatic post-2020 increase in respiratory illness among children: +67.4% among school-age children and +107.5% among preschool children (2020–2022). [2]

“Kozle” annual workload (2023)

In 2023, the pediatric pulmonary institute “Kozle” reported 35,000+ outpatient examinations and around 4,000 hospitalizations for children with respiratory diseases. [4]

Optional detail: transparent daily averages (derived from annual totals)
  • 35,000 visits per year ≈ 96 visits per day (35,000 ÷ 365).
  • 4,000 hospitalizations per year ≈ 11 admissions per day (4,000 ÷ 365).

These daily averages are simple arithmetic for scale. The primary claim remains the reported annual totals.

Episode example: December 2025 surge

In December 2025, a reported 24-hour surge included 200 children examined and 60 hospitalized at “Kozle,” with infants requiring oxygen support. The report described polluted air as a factor that worsens respiratory conditions alongside seasonal infection dynamics. [5]

Additional reporting on winter overcrowding (context)

Additional reporting referenced frequent overcrowding during winter seasons in recent years. [8]

Healthcare demand signals (primary care and hospital patterns)

These indicators show how respiratory illness manifests as routine system demand, not only as rare crises.

Primary care: respiratory diseases as the top visit category (2022)

In 2022, respiratory system diseases were reported as the most common reason for visits to a family doctor, accounting for 15.6% of all outpatient visits in general medicine. [2]

Hospital admissions: respiratory diseases as a dominant category (pre-2020 reference)

A Skopje-focused analysis reported that approximately 13.9% of hospital admissions in the Skopje region were due to respiratory diseases, making them a leading cause of inpatient treatment (followed by neoplasms at 13.5% and circulatory diseases at 13.4%). This finding is evidence-based but refers to a period before 2020, and post-2020 trends may be affected by COVID-19 classification. [2]

Cardiovascular impacts (pollution is not only a lung issue)

Documented national models link PM2.5 exposure to cardiovascular and cerebrovascular mortality shares.

Modelled shares of heart disease and stroke mortality linked to PM2.5

According to Institute of Public Health estimates using integrated epidemiological models, at current PM2.5 levels in North Macedonia, approximately 10.7% of ischemic heart disease deaths and about 12% of stroke deaths are attributed to air pollution. [1]

Chronic lower respiratory diseases (national mortality indicator)

Official statistics reported 301 deaths in 2022 from chronic lower respiratory tract diseases (ICD-10 J40–J47). The text notes that many such conditions are worsened by long-term exposure to smog. [1]

Claims that require careful handling

Some statements are expert assessments or media framing. They can be included, but only with explicit qualification and without presenting them as confirmed Skopje-only statistics.

Expert statement about Skopje and PM2.5 (presented as an expert assessment)

A media report quotes Prof. Dr. Dragan Gjorgiev (Institute of Public Health) stating that Skopje is a leading city in Europe for PM2.5 pollution and that “every third citizen” dies as a consequence of polluted air, and that life expectancy in the most polluted environments is reduced by at least four years (as presented in the report). [7]

“Carcinogenic air” framing (guidance for responsible wording)

Some media reporting uses “carcinogenic” framing for air pollution risk. On this page, this is treated as a communication framing and should be expressed as “long-term exposure increases risk,” not as an immediate certainty. [6]

Data integrity note

A short set of rules that protects trust on a public-interest, text-heavy page.

What we still cannot say publicly (because the data is not published)

These are not opinions. They are missing public datasets that would allow stronger, testable conclusions. Without these, public discussion is forced to rely on fragments, even when the harm is recurring.

  • Daily/weekly linkage: Public EMS/ER logs that show whether PM peaks produce measurable spikes in emergency admissions.
  • New diagnoses: Public annual counts of new asthma/COPD diagnoses for Skopje.
  • Municipality breakdown: Indicators at municipality level within Skopje (Centar, Karpoš, Aerodrom, etc.), not only at “Skopje region” level.
  • Primary care absolute counts: Respiratory visit totals by month/season (not only percentage shares).
Sources (8)
  1. Institute of Public Health (North Macedonia). Assessment of the impact of particulate air pollution on health and burden of disease (2024)
  2. University repository (UKIM). ZBORNIK-19-12-2024 (PDF)
  3. Institute of Public Health (North Macedonia). Mortality report for North Macedonia (2022)
  4. SDK.mk. “Kozle” institute becomes a clinic; reported 2023 workload totals
  5. Kanal 5. Reported 24-hour surge in pediatric examinations and hospitalizations (December 2025)
  6. NetPress. Media report using “carcinogenic” framing for air pollution risk
  7. Prizma. Expert quotes and discussion on health costs of air pollution
  8. Kanal 5. News segment referenced as additional context on pediatric seasonal pressure (6.8.2023)

What happened when the data became impossible to ignore

Once air pollution data became public, the issue in Skopje shifted from a “seasonal inconvenience” to a visible health and accountability problem. Below is what changed — and what still hasn’t.

Skopje became a symbol of extreme urban air pollution

During winter pollution episodes, Skopje repeatedly appears among the most polluted cities in Europe. Residents describe the air as acrid, chemical, and difficult to breathe. These episodes are intensified by the city’s valley geography, which traps polluted air.

Sources: 1, 2

Annual deaths linked to air pollution (national estimate)

Across multiple independent analyses, air pollution in North Macedonia is associated with approximately 3,400–4,200 premature deaths per year. Some assessments cite higher worst-case estimates, but most cluster within this range.

Sources: 3, 4

Share of total deaths attributed to polluted air

Air pollution is linked to roughly 16–18% of all deaths nationwide. In practical terms, this means about one in every five deaths is connected to long-term exposure.

Sources: 4, 10

Infant mortality shows the clearest signal

The most alarming figures concern infants. Around 1 in 9 infant deaths — approximately 11–12% — are linked to air pollution exposure. This includes increased risk of pneumonia, respiratory failure, and impaired lung development.

Source: 5

Life expectancy is shortened by polluted air

Long-term exposure to polluted air is associated with an average loss of 2–3 years of life expectancy. In the most polluted areas, residents effectively live shorter lives due to preventable exposure.

Sources: 1, 12

Public access to data changed the conversation

When real-time air quality apps became popular, pollution was no longer abstract. Citizens could see spikes as they happened. This visibility increased pressure — and exposed gaps in enforcement and accountability.

Sources: 6, 7

Protests followed recurring pollution seasons

As pollution episodes continued, public demonstrations became common. Protesters highlighted health impacts, especially on children, and demanded enforcement rather than plans.

Source: 8

Legal accountability reached the courts

In 2024–2025, courts affirmed that clean air is a constitutional right. This opened the possibility for citizens to sue the state for health damage caused by prolonged inaction.

Source: 9

Air pollution entered formal parliamentary oversight

Parliamentary hearings were initiated using health data as evidence. The issue moved from public outrage into formal accountability processes.

Source: 10

External pressure reinforced what citizens already knew

European institutions repeatedly flagged air quality as a major unresolved problem. Despite policies on paper, pollution levels in cities like Skopje remain dangerously high.

Source: 11

Why this matters

The pattern is consistent: health harm is measurable, but without enforcement, monitoring, and consequences for polluters, conditions do not improve. Transparency alone is not enough — action determines outcomes.

Sources: 1, 7

Sources (12)
  1. The Guardian — “The air tastes like burnt plastic”: Skopje’s chronic pollution problem Open source
  2. MIA — Skopje ranks as tenth most polluted city in the world, worst air quality in Europe Open source
  3. Euronews Albania — 3400 deaths per year in North Macedonia due to air pollution Open source
  4. European Environment Agency — Health impacts of air pollution (North Macedonia) | Europe’s environment 2025 Open source
  5. UNICEF North Macedonia — 1 in 9 infant deaths in North Macedonia linked to air pollution Open source
  6. Open Government Partnership — Macedonia Open Data case study (PDF) Open source
  7. VICE — This European Country Has Some of the World’s Worst Air, and “It’s Too Expensive” to Fix Open source
  8. Sloboden Pechat — A green humane city organizes a protest march in Skopje for clean air (English) Open source
  9. The Region — Supreme Court rules citizens can sue state over air pollution-related health issues Open source
  10. MIA — Opposition initiates oversight hearing in Parliament over air pollution Open source
  11. Meta.mk — EU criticism about air pollution in North Macedonia, no remarkable progress noted Open source
  12. PMC — Losing Years of Human Life in Heavy Polluted Cities in Macedonia Open source

Start with the day you’re in

In Skopje, the worst days tend to cluster in the cold months, when pollution is trapped near the ground.

Check the air before you plan your day

Use the Hotspots page to see what’s happening right now: where pollution is highest, and whether today is a “normal day” or a “limit exposure” day.

How to think about it: the biggest wins come from reducing exposure on the worst days, not from obsessing over average days.

Change intensity, not your whole life

On higher-pollution days, the most effective personal change is to reduce long or intense outdoor activity, especially heavy breathing (running, fast cycling, hard workouts). If you still go outside, keep it shorter, less intense, and take breaks.

Avoid hotspots when possible

Pollution is not evenly spread across the city. Some streets and zones can be significantly worse than others. If your route goes through a hotspot, even switching to a parallel side street or a greener area can reduce exposure.

  • Avoid busy roads and intersections during peak hours when pollution is elevated.
  • If you’re exercising outdoors, choose parks/quiet streets and avoid rush hour when possible.

Make your indoor air a “recovery zone”

Spending more time indoors can help during bad-air episodes, but only if indoor air is cleaner than outdoor air.

Masks: only the right type helps for PM₂.₅

If you must be outside during severe pollution, a well-fitted high-filtration respirator (FFP2 / N95 / KN95) can reduce particle exposure. Cloth/surgical masks do much less for fine particles.

Who should be extra careful on bad-air days

People who should be extra careful on bad-air days:

  • Children
  • Older adults
  • Pregnant people
  • People with asthma, COPD, heart disease, high blood pressure, diabetes

If symptoms show up or worsen (wheezing, chest tightness, unusual fatigue, palpitations), treat it seriously and seek medical advice, especially during pollution episodes.

“Lower is better” — what the WHO guideline means

WHO’s 2021 air quality guidelines recommend an annual mean PM₂.₅ level of 5 µg/m³. That number isn’t meant to scare you; it’s a health-based target that shows why repeated high winter exposure matters.

Health basics that reduce vulnerability

These don’t “cancel out” pollution, but they support your resilience: don’t smoke, manage chronic conditions, and keep cardiovascular health in good shape.