WESTERN BALKANS REGULAR ECONOMIC REPORT No.17 | Spring 2020 The Economic and Social Impact of COVID-19 AIR POLLUTION CHALLENGES “You and me” by Tanja Burzanovic (Montenegro) The RER No. 17 is a collection of notes on the Economic and Social Impact of COVID-19 that will be pub- lished in three parts. The first part was launched on April 29 and focused on the macroeconomic impact of COVID-19. This second part shows how the macroeconomic impact affects the people in the region. It discusses the social impact of COVID-19 in the Western Balkans in six separate RER notes on poverty and welfare, labor, health, education, air pollution, and social protection. The third part, to be launched in early June, will focus on specific economic policy response areas—fiscal, external, and financial sector—and the crisis impact on the private sector as reported by firms. THE ECONOMIC AND SOCIAL IMPACT OF COVID-19 How COVID-19 Could Magnify Air Pollution Challenges in the Western Balkans1 • Emerging evidence suggests that Ambient Air Pollution plays a role in the spread and impact of the COVID-19 pandemic. • The Western Balkan countries are particularly vulnerable as many countries suffer from air pollution, especially during the winter months where extremely high, toxic peaks of air pollution from residential heating dominate. • The transition into the more polluted winter season could trigger outbreaks and higher peaks of COVID-19 infections in the Western Balkans. • Households that may experience economic hardship through the loss of direct and indirect income, may substitute higher-grade fuels for cheaper more polluting fuels, which could exacerbate air pollution. • Countries with high air pollution should enforce regulations and introduce measures that improve air quality to reduce the exposure of people in the upcoming winter. 1. Introduction made outside of the Western Balkan region, the combination of these effects could have Ambient air pollution (AAP) is the main very negative consequences for morbidity and environmental death and disability risk mortality in the region. Without an effective in the Western Balkan region, with cities vaccine or treatment, the COVID-19 pandemic as the key hotspots. As the COVID-19 may likely continue or recur next winter, once pandemic has emerged, several links between again drawing attention to links between air the pandemic and air pollution have been pollution and the socioeconomic effects of the observed. At first, strict government “stay-at- pandemic. home” orders improved air quality, though with notable differences depending on location This note discusses possible links between and air pollution sources. Then, the global air pollution and COVID-19 that could discourse of those links swiftly homed in on the emerge for the Western Balkans.2 It covers hypothesis that populations exposed to more how the expected economic effects of the polluted air and therefore with compromised pandemic could aggravate the already severe respiratory health are more vulnerable to the environmental degradation from air pollution virus, and heightened morbidity and mortality. and the associated morbidity and mortality Even though these early observations were impact of COVID-19, and proposes initial 1 This note was prepared by Klas Sander of the World Bank environment team in the Western Balkan, with contributions from Simon D. Ellis, Michael Toman, Urvashi Narain, Nagaraja Rao Harshadeep, Yewande Awe, Sameer Akbar, Juan Jose Miranda Montero, Camilla Erencin, Sasa Eichberger, and Hrishikesh Prakash Patel. Additional guidance was provided by Kseniya Lvovsky, Gallina Vincelette, Enrique Blanco Armas, Marc Schiffbauer, and Edith Kikoni. 2 This note builds on extensive World Bank analytical work on AAP and Air Quality Management published in 2019 for Bosnia and Herzegovina, Kosovo, and North Macedonia. Individual country reports and a regional summary note are available at https://www.worldbank.org/en/region/ eca/publication/air-quality-management-in-western-balkans; http://documents.worldbank.org/curated/en/330811585586168639/pdf/Regional- Note-on-Air-Quality-Management-in-the-Western-Balkans-Bosnia-and-Herzegovina-Kosovo-and-North-Macedonia.pdf Air Pollution Challenges  |  1 WESTERN BALKANS REGULAR ECONOMIC REPORT NO.17 HOW COVID-19 COULD MAGNIFY AIR POLLUTION CHALLENGES IN THE WESTERN BALKANS interventions to mitigate the most severe in cities like Beijing, Mumbai, and New Delhi. impacts. Because of the spread and containment In Skopje, North Macedonia, PM2.5 levels are of the virus, many links are also still uncertain, more than four times the levels the WHO especially for the Western Balkans. considers safe; in Tetovo, North Macedonia, eight times the safe level; and in Sarajevo, BiH, three times the safe level.4 Ambient Air Pollution in the Western 2.  Balkans Capacity constraints and governance issues Throughout Eastern Europe, including to implement comprehensive, cross-sectoral the Western Balkan region, air pollution is air quality management programs are the commonly the main environmental influence main underlying reasons high air pollution on death and disability, especially in cities persists in the region. Inadequate laws and and urban centers where concentrations of insufficient enforcement of the laws combined air pollution are very high.3 Although formal with shortages of technical capacity, such as air quality standards in Bosnia and Herzegovina incomplete emissions inventories and lack (BiH), Kosovo, and North Macedonia are fairly of proper air quality monitoring are typical well aligned with European Union (EU) air problems. Further, limited institutional quality standards, people in the region typically capacity, especially vertical and horizontal breathe air that is more polluted by toxic institutional coordination, makes it difficult particulates than their neighbors in Western for a country to respond appropriately when air Europe (Figure 1). PM2.5 concentrations pollution cuts across sectors. exceed World Health Organization (WHO) recommendations by a margin wide enough to make them comparable to those observed Figure 1. Air Pollution, Selected Western Balkan and European Cities Annual average ambient PM2.5 (µg /m3) 90 80 70 60 50 40 30 EU PM2.5 limit 20 WHO PM2.5 AQG value 10 0 Pljevlja Skopje Novi Sad Tetovo Tuzla Lukavac Tetove Ilidza Zenica Korce Podgorica Belgrade Tirana Ljubljana Warsaw Bucharest Sofia Zagreb Vilnius Athens Budapest Brussels Nicosia Prague Berlin Paris Riga Rome Bratislava Vienna Amsterdam Luxembourg Copenhagen Lisbon Iz-Zejtun London Madrid Dublin Helsinki Stockholm Tallinn Sarajevo Source: WHO Ambient Air Quality Database. 3 About 91 percent of the world’s population lives in areas where ambient air pollution is above the limit that WHO considers safe. Worldwide, every year, air pollution accounts for an estimated 4.2 million premature deaths, primarily from respiratory diseases or related illnesses like COVID-19; the estimated welfare cost us US$5.7 trillion, equivalent to 4.8 percent of global GDP (2016). Most of this health burden is attributed to fine particulate matter less than 2.5 micron in size (PM2.5), which comes from a variety of sources. Policy recommendation and mitigation investments need to be carefully tailored to the emission sources, which respond to very different measures. 4 Breathe Life, based on data from the WHO Global Platform on Air Quality and Health, https://breathelife2030.org. 2  |  Air Pollution Challenges THE ECONOMIC AND SOCIAL IMPACT OF COVID-19 2.1 Pollution Levels and Sources For the Western Balkans, residential heating is the largest source of pollution emissions As discussed later in this note, the spatial, nationally, with frequent extreme and highly temporal, and sectoral structure of air toxic pollution peaks during the winter pollution matters in evaluating the possible months. These emissions are not expected to links with and impacts of COVID-19. decline much as long as the main household Using the case study examples of Sarajevo and heating sources are solid fuels—mainly low- Skopje, Figure 2 illustrates how these three grade wood and (lignite) coal, but also solid characteristics combined can translate into waste and rubber pellets, which are illegal for highly toxic pollution peaks in the winter season heating homes—and as long as stoves and in Western Balkan urban centers. Transport- boilers are inefficient. linked nitrogen dioxide (NO2) pollution is more evenly distributed throughout the year The transport sector contributes relatively (see Figure 2), but heating-related air pollution little to total air pollution, especially is seasonal, with higher peaks as winter if measured at national level, but it is temperatures fall, depending on the location more important when exposure to AAP and localized weather patterns. The chemical is considered.6 Unlike heating-induced features of pollutants can also be a factor in how air pollution, transport pollution persists air pollution links to COVID-19 and those can throughout the year, especially in cities because vary between pollutants from different emission vehicle concentrations are magnified by traffic source (e.g. transport or heating)5. congestion, inefficient transport systems, and aging vehicle fleets. Figure 2.  Source Attributions to Modeled PM2.5 Pollution over an Annual Cycle in two Selected Western Balkan Cities Monthly average; 2018 Skopje, North Macedonia Sarajevo, Bosnia and Herzegovina 200 200 180 180 160 160 140 140 120 120 100 100 80 80 60 60 40 EU and WHO 40 EU and WHO 20 PM2.5 limit values 20 PM2.5 limit values 0 0 JUL AUG SEP OCT NOV DEC JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC JAN FEB MAR APR MAY JUN J Vehicle exhausts J Cook-light J Heating J Waste-burn J Dust J Industry J Boundary Source: Modeling by UrbanEmissions.info for World Bank, November 2019. 5 For example, The Clean Air Task Force states that “Diesel particles act like magnets for toxic organic chemicals, many carcinogenic. The smallest diesel particles (“ultrafine particles”) can penetrate deep into the lung and enter the bloodstream bringing with them an array of toxins. Diesel exhaust contains 40 hazardous air pollutants (HAPs) listed by EPA, 15 of which are listed by the International Agency for Research on Cancer (IARC) as known, probable, or possible carcinogens”. An Analysis of Diesel Air Pollution and Public Health in America; Clean Air Task Force, June 2005. 6 WHO estimates that, mostly due to diesel traffic, road transport is responsible for up to 30 percent of particulate matter (PM) in European cities and up to 50 percent emissions in OECD countries. Air Pollution Challenges  |  3 WESTERN BALKANS REGULAR ECONOMIC REPORT NO.17 HOW COVID-19 COULD MAGNIFY AIR POLLUTION CHALLENGES IN THE WESTERN BALKANS Figure 3. Population-Weighted Annual Mean Concentrations of PM2.5, Three Countries, 2015 PM2.5 [µg m-3] BiH North Macedonia Kosovo 30 30 30 25 25 25 20 20 20 15 15 15 10 10 10 5 5 5 0 0 0 Natural Transboundary National Natural Transboundary National Natural Transboundary National J Power plants J Industry J Land-based transport J Households J Waste J Agriculture J Other Source: GAINS model, 2018. A particular characteristic of the Western deaths and illnesses caused by air pollution can Balkan region is the high share of result in heighten health spending and cut into transboundary air pollution. As Figure 3 makes labor productivity; but also affects cognitive clear, while most PM2.5 pollution originates learning negatively, a serious threat to children within each of the three countries modeled and young adults. (BiH, Kosovo, and North Macedonia)7—which underscores the need for each government to Air pollution is the leading environmental commit to tackle air pollution, the share of risk factor, contributing most to death transboundary pollution also demonstrates the and disability in the Western Balkans. need for regional collaboration. Only when It is estimated that because of exposure to all countries improve simultaneously will the ambient PM2.5 air pollution, 3,300 people die situation for each improve. prematurely every year in BiH; 1,600 people in North Macedonia; and 760 people in Kosovo. Some 80–90 percent of these deaths are 2.2 Health Impacts and Economic Costs from cardiovascular (CV) disease (stroke and ischemic heart disease [IHD]). The majority The causal impact of air pollution, of air quality-related deaths are of people of especially PM2.5, on cardiovascular (CV) productive age, between 50 and 70.9 The annual and pulmonary disease is well-documented.8 economic cost associated with health damage Exposure to PM2.5 is particularly dangerous to from air pollution in BiH, Kosovo, and North human health because these particles find their Macedonia, the three Western Balkan countries way deep into the lungs and the bloodstream modeled, ranged between 3.6 and 8.2 percent resulting in disease and death. Premature 7 Although this note builds on World Bank analytics for some countries published in November 2019, it is currently being extended to Serbia, among other countries. 8 As recommended by the WHO, health risk factors are divided into three groups: metabolic, behavioral, and environmental (http://ghdx.healthdata. org/gbd-results-tool). Other risk factors for CV and pulmonary disease include tobacco smoking, alcohol and drug use, dietary risks, and high blood pressure. 9 Country reports, Regional Air Quality Management in the Western Balkans. 4  |  Air Pollution Challenges THE ECONOMIC AND SOCIAL IMPACT OF COVID-19 Fig 4.  Annual Health Burden of Air Pollution by Fig 5.  Economic Costs of AAP Damage to Country and Age Group Health, 2016 Number of deaths per year US$ billion and share of GDP (percent) 2,000 12 1,750 10 1,500 8 8.2 1,250 6.9 1,000 6 750 500 4 3.6 250 2 0 0–4 5–14 15–49 50–69 70+ 0–4 5–14 15–49 50–69 70+ 0–4 5–14 15–49 50–69 70+ 0 Kosovo North Macedonia Bosnia and Herzegovina Kosovo North Macedonia Bosnia and Herzegovina J Ischemic heart disease J Stroke J COPD J Lung cancer J Lower respiratory illness Source: World Bank Country Reports BiH, Kosovo, North Macedonia Source: World Bank Country Reports BiH, Kosovo, North Macedonia (2019); see also footnote 2 in this report. (2019); see also footnote 2 in this report. equivalent GDP—in 2016 an average of 3. Ambient Air Pollution and COVID-19 US$240 million and US$1.38 billion.10 Although how COVID-19 is spread and The higher prevalence of lung, acute contained remains uncertain, scientists respiratory, and chronic obstructive are discussing two principal connections pulmonary disease (COPD) resulting from between air quality and COVID-19: exposure to air pollution is the key link why COVID-19 pandemic worsens the 1. The reduced economic activity associated health impacts of air pollution. While there with early lockdown measures has curbed are nuances to the association, patients with air pollution by highly visible rates. The preconditions, especially chronic lung and results can be regarded as extreme “pilot heart conditions caused or worsened by long- testing” of policy reforms often proposed term exposure to air pollution, tend to be more to curb air pollution, especially transport- vulnerable to common diseases and secondary based emissions. illnesses like flu or infections. As it appears that COVID-19 predominantly affects lungs and 2. The more prevalent lung and acute other parts of the human respiratory system, respiratory diseases and COPD in people with air pollution-linked diseases are populations exposed to air pollution, the likely to be highly vulnerable to this new more vulnerable they are to COVID-19, disease. which is likely to amplify the pandemic. Another aspect being analyzed is the possibility that aerosols could enable the virus to be carried over longer distances, infecting more people. This type of “hitch- 10 This conservative estimated cost does not include the costs of hospital stays, cost of illness, and loss of workdays. For details of how the costs are calculated, see country reports for BiH, Kosovo, and North Macedonia all published November 2019 at www.worldbank.org. Air Pollution Challenges  |  5 WESTERN BALKANS REGULAR ECONOMIC REPORT NO.17 HOW COVID-19 COULD MAGNIFY AIR POLLUTION CHALLENGES IN THE WESTERN BALKANS hiking” between people was observed with air pollution. To contain the pandemic, previous SARS-type viruses, which were millions of people throughout the world were inhaled with pollution particles by individuals instructed to stay at home, which dramatically exposed to air pollution.11 Assessing whether reduced road transport,13 beginning in China, this also applies to COVID-19 is difficult at the where lockdown measures affected almost half present time; analysis is needed of, e.g. whether a billion people. Similar measures followed the quantity transmitted from one person to elsewhere, especially in Italy, Spain, France, another in this way is large enough to cause the and Germany in Western Europe and later in disease, and how deeply it could penetrate into the United States, India, and other parts of the the respiratory tract.12 world. This primarily reduced NO2 pollution over cities where pollution can mainly be At this point, health-related links between attributed to cars and smaller industry14,15. air pollution and COVID-19 have to be In northern Chinese cities like Beijing, for further substantiated once additional and example, where much wintertime pollution more refined data are available and can be comes from residential heating, pollution analyzed. Until then, analyses from other reduction was limited. A differentiated view16 locations provide a context for discussing showed, that transport-based NO2 emissions possible exposures in parts of the Western did decline, but heating-linked PM2.5 emission Balkan region with high air pollution to were unchanged or even increased slightly.17 strengthen the potential resilience of the region to future outbreaks of similar diseases. The differentiated impact of lockdown effects in China and Western Europe is important in discussing possible scenarios linking air 3.1 Air Quality and COVID-19 Lockdown pollution and COVID-19 in the Western Measures—Policy Lessons Balkans. Transport is the dominant pollution The measures put in place to contain source where COVID-19-related air quality COVID-19 represent a large-scale improvements were observed in Western experiment related to air pollution, especially Europe (see Figure 6b for northern Italy) understanding the effects of much discussed and the US.18 An analysis of NO2 emission policy measures to reduce transport-based reduction for March 15–April 30 in 2019 and 11 Previous SARS-type viruses have been found to “travel” with PM air pollution, but whether the amount transmitted is sufficient to cause an effective transmission has not been confirmed. See, for example, Setti et al. (April 2020). SARS-Cov-2 RNA Found on Particulate Matter of Bergamo in Northern Italy: First Preliminary Evidence. Letter to the Editor. https://www. medrxiv.org/content/10.1101/2020.04.15.20065995v2. 12 Frontera, A. et al. (2020). Regional air pollution persistence links to COVID-19 infection zoning. Journal of Infection. Letter to the Editor. March 2020. 13 These assessments have been mainly conducted by using remote sensing methodology and approaches. However, this technology has limitations in assessing AAP levels, especially with regard to exposure of people as the vertical differentiation of AAP can be an important factor and ground-level monitoring (GLM) is needed to provide more reliable data. See, for example, Alvaro et al;. (2019). Evaluating the use of satellite observations to supplement ground-level air. In: Atmospheric Environment 218. 14 https://www.theguardian.com/environment/2020/mar/23/coronavirus-pandemic-leading-to-huge-drop-in-air-pollution 15 https://www.dlr.de/content/de/artikel/news/2020/02/20200505_corona-effekt-auf-luftqualitaet-eindeutig.html 16 http://www.g-feed.com/2020/03/covid-19-reduces-economic-activity.html 17 Also note that the steel industry did not close and emissions continued from that source. 18 According to Web-based publication on March 27, 2020, by the European Space Agency (ESA), based on Royal Netherland Meteorological Institute (KNMI) data from the Copernicus Sentinel-5P satellite monitoring both weather and pollution over Europe, the new images show NO2 concentrations from March 13 to April 13 2020, compared to the March-April averaged concentrations in 2019. Madrid, Milan and Rome saw decreases of about 45 percent, Paris of 54 percent, coinciding with the strict quarantine measures implemented across Europe. For Washington DC, pollution levels were reportedly the lowest in at least 25 years and ground-based monitoring at a measurement point in DC showed NO2 levels 6  |  Air Pollution Challenges THE ECONOMIC AND SOCIAL IMPACT OF COVID-19 Figure 6. Air Pollution Reductions due to COVID-19 Lockdown Mobility Restrictions observed through remote sensing approaches 6a. Western Balkans March 15–April 30 2019 March 15–April 30 2020 Source: European Space Agency (ESA) data from Copernicus Sentinel-5P and World Bank analysis (May 2020). 6b. Northern Italy Week 3, January 2020 Week 3, February 2020 Week 3, March 2020 Source: Reuters visualizations based on data from NASA’s Global Modeling and Data Assimilation published by the World Economic Forum. 2020 confirms similar patterns for the Western meteorological factors and transboundary Balkans (see Figure 6a). In contrast, because air pollution—both extremely important toxic peaks of air pollution in the Western for the Western Balkans. Spring in the Balkans are mainly triggered by residential northern hemisphere resulted in the expected heating in winter, transport-focused policies air pollution reduction in many regions as may address only a very limited aspect of air seasonal heating activities abated, independent pollution, especially in winter (cf. Figure 2). of responses to the COVID-19 pandemic. Further, localized weather patterns are a factor Additional aspects that are important because, e.g., rain and wet weather can reduce for evaluating AAP‒COVID-19 links are AAP and dry weather increases it20,21. Similarly, about 33 percent lower than the 2010‒19 average for this time of year (Washington Post, April 22, 2020). 19 https://www.weforum.org/agenda/2020/04/coronavirus-covid19-air-pollution-enviroment-nature-lockdown 20 https://www.washingtonpost.com/weather/2020/04/22/washington-dc-air-quality-coronavirus/ 21 https://www.nature.com/articles/d41586-020-01049-6 Air Pollution Challenges  |  7 WESTERN BALKANS REGULAR ECONOMIC REPORT NO.17 HOW COVID-19 COULD MAGNIFY AIR POLLUTION CHALLENGES IN THE WESTERN BALKANS transboundary pollution can diffuse the impacts may trigger. Decision-makers must also be of local measures that reduce traffic-based air aware that local measures can be considerably pollution. In several Western European cities, counterbalanced—even if only for a few pollution in common AAP hotspots was seen days—by pollution originating beyond the to be as high as usual, or even higher, although immediate area where air pollution exposure is lockdown measures had significantly reduced concentrated. Public discourse about air quality road-based transport.22,23 The reasons vary, management needs to be informed by clear and but are largely due to transboundary pollution transparent communication about data and effects, such as spring-related agricultural analyses of pollution sources, health impacts, activities, but also because of larger weather and their economic costs, and what results can systems transporting pollutants across longer be expected from the efforts proposed. distances (e.g., bringing Sahara sand to Europe24).25 For the U.S., the situation is less clear; many researchers have seen no statistically 3.2 Air Pollution as a Parameter of significant changes in air pollution in most COVID-19 Vulnerability US cities.26 Thus, preliminary observations More and more people exposed to severe will have to be verified by longer-term data air pollution suffer from diseases identified analysis.27 as heightening vulnerability to COVID-19. There are several nuances to this association, These early insights from the COVID-19 patients with preconditions, especially chronic lockdowns and their impacts on air quality lung and heart conditions caused or worsened confirm the complexity decision-makers are by long-term exposure to air pollution, are confronted with in designing effective and generally more vulnerable to secondary efficient policy actions, targeting investments illnesses, such as the flu or infections. Two main to improving air quality, and moving to risk factors in relation to COVID-19 are (1) proactive management of air quality. It the risk of contracting the disease faster than demonstrates the need to have a thorough healthy people and (2) the risk of having a more understanding about both source attributions severe reaction when the disease is contracted. and the spatial and temporal distribution At this point, the first risk seems negligible, but of pollution emissions. Policy actions and the second seems to be confirmed. Therefore, investments must be tailored to specific lessening air pollution can help the severity of pollution sources, the socioeconomic context, the infection—and any disease with a similar and associated behavioral aspects—especially impact profile—for the most vulnerable. when targeting mitigation measures to the Scientists who analyzed the SARS coronavirus magnifying effect the COVID-19 pandemic outbreak in China in 2003 found that infected 22 h t t p s : / / w w w. s p i e g e l . d e / p o l i t i k / d e u t s c h l a n d / d e u t s c h l a n d - d u e n n e r - v e r k e h r - d i c k e - l u f t - d a s - f e i n s t a u b - r a e t s e l - k o l u m n e -a-00000000-0002-0001-0000-000170518549 23 https://www.tagesschau.de/investigativ/ndr/stickoxid-corona-101.html 24 https://europepmc.org/article/med/18854705 25 https://www.theguardian.com/environment/2016/apr/04/sahara-dust-only-partly-responsible-for-uks-worst-pollution-event-in-10-years 26 https://www.nature.com/articles/d41586-020-01049-6 27 For example, Los Angeles, the only city for which significant improvements in air quality were observed during the pandemic, also experienced unusually rainy weather and it is unclear how much of the air quality improvement is due to weather and how much to COVID-19 stay-at-home measures. The situation is similar for Washington, DC, which has a wet and windy spring. 8  |  Air Pollution Challenges THE ECONOMIC AND SOCIAL IMPACT OF COVID-19 people who lived in areas with more air chronic inflammatory stimulus, even in young pollution were twice as likely to die as those in and healthy persons—a possible co-factor for less polluted areas.28 COVID-19 lethality. This effect is of particular concern because it may imply that many people While it is reasonable to argue that may suffer long-term health damage. Long- exposure to AAP and related morbidity term effects of reduced lung and respiratory exposes populations to more severe capacity that affects performance and quality courses of COVID-19, the magnitude of of life are being seen in COVID-19 patients as this relationship is unknown. A recent well.33 study by Harvard University scientists29 claimed that people living in areas with only a slight increase in exposure to PM2.5 were Scenarios for the Link between Air 4.  15 percent more likely to die from COVID-19 Pollution and COVID-19 but was heavily criticized for its research approach and for findings that seemed to In many ways the current crisis is a unique grossly overestimate the risks of COVID-19 learning experiment. Given the still early mortality from air pollution.30 Yet a World research phase, existing scientific findings Bank working paper31 suggests that PM2.5 is have more the character of hypotheses than a highly significant predictor of confirmed confirmed results. Emerging data, analyses, and COVID-19 cases and hospital admissions. It knowledge about the COVID-19 will gradually found that the relationship is nonlinear and improve the understanding of possible scenarios accelerates in concentrations above the WHO and countermeasures in specific regions like the guideline of 10µg/m3, with the number of Western Balkans. expected cases doubling, all else constant, when pollution worsens by 20 percent. Projections about seasonal COVID-19 However, the study could not confirm any transmission dynamics through the post- causal mechanisms, perhaps because of data pandemic period are highly relevant for issues: air pollution concentrations provide the region.34 As with the flu, current winter only limited information. A study in northern outbreaks of the virus are expected, and it is Italy concludes that people living in areas with possible that though the virus can proliferate high and prolonged pollution are more likely any time of year, there will be lower peaks to have chronic respiratory conditions and during winter/spring transitions and higher are more susceptible to any infective agent.32 peaks during fall/winter transitions. Some Prolonged exposure was found to lead to a scenarios modeled also suggest the possibility of 28 Cui, Zhang, Froines, Zhao, Wang, Yu, and Detels (2003): “Air pollution and case fatality of SARS in the People’s Republic of China: an ecologic study”, Environmental Health, 2, 15.; Na, Feng, Fang, Richardus, Han, Cao and de Vlas (2009): “Case fatality of SARS in mainland China and associated risk factors”, Tropical Medicine and International Health, 14, 21-27. 29 Wu, X., Nethery, R.C., Sabath, B.M., Braun, D., Dominici, F. (2020). Exposure to air pollution and COVID-19 mortality in the United States. Harvard T.H. Chan School of Public Health. Harvard University. 30 https://theconversation.com/air-pollution-covid-19-and-death-the-perils-of-bypassing-peer-review-136376 31 Andree 2020. Particulate Matter and COVID-19 Incidence: Evidence from the Netherlands. World Bank, etc. 32 Conticini, E., Frediani, F., Caro, D. (2020). Can atmospheric pollution be considered a co-factor in extremely high level of SARS-CoV-2 lethality in Northern Italy? In: Environmental Pollution (accepted March 24, 2020). 33 https://www.wetnotes.eu/tauchen-nach-covid-19-erkrankung/ 34 Kissler, S. et al (2020). Projecting the transmission dynamics of SARS-CoV-2 through the post-pandemic period. Science 10.1126/science.abb5793. Air Pollution Challenges  |  9 WESTERN BALKANS REGULAR ECONOMIC REPORT NO.17 HOW COVID-19 COULD MAGNIFY AIR POLLUTION CHALLENGES IN THE WESTERN BALKANS resurgence after it may at first seem to have died worsen air pollution. Daily air pollution out.35 Therefore, the winter weather patterns, levels in winter often jump in the morning air pollution variations, source allocation and when people heat their homes before seasonality, and, indirectly, the household leaving for work and school; then, after socioeconomic situations will make a difference easing during the day, air pollution increase in the Western Balkan region. Without again in the early evening until they go to effective therapeutic measures or vaccine, the sleep. If people were at home for the entire next winter could be critical in determining the day, residential heating would continue as medium- to long-term development impacts of long as they were awake—and residential the pandemic in the region. How these factors heating is the main source of AAP. could interact may help policy-makers to formulate measures that reduce vulnerability. y Individual road transport could also trigger additional transport-based air What follows, using a stylized approach, pollution from private cars,  because outlines how these factors might interact and people may choose individual over lead to an elevated air pollution‒COVID-19 public transport due to crowding and impact scenario: social distancing. The result could be more vehicles on the road, more traffic y The biggest unknown is next winter’s congestion, more transport-based weather pattern—an important factor— pollution—people being more exposed to and the resultant AAP-COVID-19 air pollution. links: (1) A long, colder winter could lead to a fall/winter transition with a y The negative economic consequences of stronger resurgence of the virus. (2) A the pandemic are also likely to impact, colder and longer winter could mean that and even accelerate, air pollution in private households need more heating, the Western Balkans, with implications the principal source of emissions in many for COVID-19.36 Declining economic Western Balkan cities. Together, these opportunities mean higher unemployment two factors could heighten the already and fewer income opportunities for high number of people suffering from households. And remittances, an AAP-related respiratory and pulmonary important source of income in the region, diseases, making them more vulnerable to are also likely to decline. Faced with COVID-19. considerably reduced income to meet their needs, households are likely to limit y Policy measures to respond to a their spending on heating fuels, which resurgence of COVID-19, especially have a high price elasticity of demand. if there are stay-at-home orders, could Similar patterns have already been seen 35 Carleton, T., Cornetet, J., Huybers, P., Meng, K.C., Proctor, J. (2020): Ultraviolet radiation decreases COVID-19 growth rates: Global causal estimates and seasonal implications; working paper (in draft at time of citation). 36 Compare Regional Economic Report Background Notes 1, “Setting the stage: The state and vulnerabilities of Western Balkan economies as they face the COVID-19 crisis”, 2, “Country Notes with extended outlooks, including a discussion on short- and medium-term policies”, 7, “The private sector impacts in the Western Balkans”, 8, “The Poverty and Distributional impact”, and 9 “Managing the Employment impact.” 10  |  Air Pollution Challenges THE ECONOMIC AND SOCIAL IMPACT OF COVID-19 elsewhere when consumers have had to moisture standards. As the costs for quality suddenly adjust their spending.37 Usually, fuels is higher, governments may also need to consumers economize on heating costs adopt social protection measures to compensate by using, often illegal, fuels, like trash, households for the higher costs. rubber pellets, and low-quality wood— all of which will worsen air quality significantly—and even more so in a long, Reducing the Impact of Air Pollution 5.  cold winter and households have to stay at on Those Vulnerable to COVID-19 home in private, especially single-family, residences. Next winter, measures to avoid exposure to air pollution could constitute a short- In such a worst-case scenario, Western Balkan term intervention to reduce health countries may see a surge in COVID-19 cases vulnerability. For example, distributing high- with severe morbidity and mortality. More quality facemasks, enhancing access to air optimistically, a best-case scenario of a warmer purification filters; installing more such filters winter with less demand for residential heating in kindergartens, schools, and hospitals is one could mean a lighter AAP-COVID-19 impact. example of how this can be done. However, There are a few ways to mitigate possible surges given still limited understanding of the virus, in COVID-19 infections and fatalities next its impact, and its course in persons with winter; they only have to be in place for a few different pre-conditions (or none at all), it is months and could be directed to three goals: still uncertain how effective these measures (1) avoid aggravation of pollution by, e.g., could be in reducing the COVID-19 impact. strictly enforcing and not relaxing current air quality regulations; (2) effectively reduce air To avoid a heavy increase in personal vehicles pollution itself; and (3) minimize exposure to on the roads, municipalities could offer air pollution. additional bus transport. That would make social distancing possible on public transport Quality standards for heating fuels can and may also motivate more people to use effectively reduce air pollution in the short- buses. Such measures could be supplemented by term. More stringent enforcement of fuel- regulation of transport through, e.g., restricting quality standards would eliminate most dirty circulation of private vehicles in defined traffic fuels, especially rubber pellets, poor-quality zones, especially during air pollution peaks. wood, and burning of household trash and If municipalities invest in more buses, clean industrial waste. Because this would increase electric buses should be preferred. demand for better fuels, especially higher- quality wood, well before winter programs In the medium- to long-term, phased could be initiated to increase the domestic investment in air quality management is supply of these fuels. With only a few months recommended. Actions should be prioritized to prepare for winter, industrial drying of based on their cost-effectiveness, institutional fuelwood may be necessary to meet wood feasibility, and targeting of pollution hot 37 https://blogs.worldbank.org/energy/a-ladder-wood-theft-and-sustainability Air Pollution Challenges  |  11 WESTERN BALKANS REGULAR ECONOMIC REPORT NO.17 HOW COVID-19 COULD MAGNIFY AIR POLLUTION CHALLENGES IN THE WESTERN BALKANS spots. Considering annual air pollution in Western Balkan cities, reducing the highly toxic pollution peaks in winter should be a high priority. While this will not necessarily reduce COVID-19 infections, it will reduce the impact and course of the disease, especially for people with pre-conditions. This will also require investments in improving residential heating because that will have the most effect on air pollution in winter. Investment in more reliable and comprehensive data of air pollution is necessary to inform choice of the most effective measures. Though more advanced than countries in other world regions, air pollution data for the Western Balkans are far from optimal. In the longer term, countries need to invest more in their ability to manage air quality, from building technical and institutional capacity to policy and institutional reforms, and investments in infrastructure, especially to make residential and commercial heating systems more efficient. 12  |  Air Pollution Challenges Western Balkans Regular Economic Report No.17 | Spring 2020 Air Pollution Challenges View this report online: www.worldbank.org/eca/wbrer You and me by Tanja Burzanovic (Montenegro) Dr. Tatjana Burzanovic has a wide experience in the fields of graphic design, graphics in architecture, interior design. She has worked as an art editor, interior designer and graphic designer at various levels. Many of her art exhibitions have taken place at different places. She has received many awards for her arts and literary works. She has published a book with a title The Interrelation between Art Worlds, with the support from the Embassy of India for Austria and Montenegro in Vienna. Her artistic philosophy includes displaying of interrelationship between art worlds (spatial and temporal arts). The artist thus meditates between nature and the sprits and yet stems from the absolute idea and serves the goal of realization of absolute sprit. ‘Grasping the meaning through the form’ is a task of the art set by a contemporary thinker to demonstrate that building forms and creating sense are two simultaneous, intertwined, and absolutely inseparable processes in Arts. Without that recognition it is not possible to take any further step in investigating the nature of art and literature. She believes that art is a way to search the truth. Art is inseparable from searching the truth. People forge ideas, people mold dreams, and people create art. To connect local artists to a broader audience, the cover of this report and following editions will feature art from the Western Balkan countries.