Dragan Gjorgjev wears the weary smile of a man who lives and works at the fractious intersection of air pollution science and air pollution politics. Earlier in the week, the Macedonian Ministry of Health had announced a plan to subsidize and distribute roughly 50,000 air-filtering face masks to vulnerable citizens, and on this cold December morning three days later, Gjorgjev, a professor of medicine at Saints Cyril and Methodius University in the capital of Skopje and policy adviser to the health ministry, had been asked to brief political leadership — and the public — on the serious impacts of air pollution.

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Generally speaking, the news for Macedonia is not good: According to Gjorgjev’s calculations, the deaths of roughly 2,000 Macedonians each year, most of them in Skopje, can be linked directly to a noxious mix of smoke arising from household fireplaces, exhaust from a vast fleet of loosely regulated vehicles, relentless emissions from coal-fired power plants, and a litany of smaller, often ad-hoc industries. In the winter months, when the winds slow and warm air high in the atmosphere presses colder, heavier air down into the Skopje valley, the haze settles over the city like a quilt — a persistent fog laced with the acrid scent of ash and chemistry.

Gjorgjev’s figures are conservative, and other estimates have put the death toll even higher. But whatever the precise metric, the Dickensian tableau has contributed to Macedonia’s reputation for having some of the worst annual average air pollution in Europe. The northwestern city of Tetovo has earned the top slot on some lists, though that distinction will likely fade following the closure — perhaps temporary — of the massively polluting Jugohrom Ferroalloys plant. Meanwhile, during the gray winters, Skopje’s air often ranks among the worst on the planet, and Gjorgjev knows that the masks are at best a half-measure.

“If we start to use the masks, then we lost the battle,” he says, noting that at times, government officials have asked him to downplay his numbers, or to otherwise soften his gloomy message. “It means there are no collective measures.”

Collective measures are elusive in this mountainous, land-locked region, despite years of recognition that air pollution was killing Macedonians — and despite emphatic promises by politicians that change was afoot. Indeed, after 11 years in power, the previous government was ousted in 2017 amid criticism of its environmental record. Its successors arrived with promises of green reform, and while some plans are in the works, the air pollution crisis continues, for the most part, unabated. Gjorgjev is among those who say that change cannot come overnight.

“I really see that this is not a problem of one government,” he says. “This is a problem coming from many decades. So, many governments did not cope with this problem properly.”

When the winds slow and warm air high in the atmosphere presses colder, heavier air down into the Skopje valley, the haze settles over the city like a quilt.

More than 40 percent of the air pollution problem in Skopje is attributable to household burning for heat and cooking. Many of these residents are poor, and even when connections to centralized gas heating are available, some families can’t afford them. Many households burn scrap wood, coal, and even textiles and trash in order to keep warm. Indoor air pollution can be even more dangerous.

Traffic, too, is adding to Macedonia’s air pollution, particularly in cities like Skopje. Lack of an official census since 2002, however, makes it hard to quantify the problem. The new government, formed in 2017, has promised to address runaway pollution, but it will take time and money. Many citizens, meanwhile, say they are growing impatient with the lack of progress and commitment by leaders.

In 1991, Macedonia emerged from the breakup of Yugoslavia with an economy dominated by mining and construction, among other industries, and the largely unregulated, communist-era infrastructure that came with it. Eager to join Europe, the country’s ambitions have been hampered by Greece, which for years has blocked Macedonia’s accession to both the European Union and NATO over its own claim to the regional name “Macedonia.” A deal struck in late 2018 would rechristen the country as “The Republic of North Macedonia,” though the pending change, approved by parliament, continues to divide the country. It also distracts, critics argue, from badly needed reforms to Macedonia’s infrastructure and environmental laws.

At the Elem coal-fired power plant outside of Bitola, roughly 100 miles south of Skopje and just 17 miles from the Greek border, Lupcho Stojanovski, the environmental manager of the plant, explained that the facility has operated without a proper environmental permit for decades. “No one cared,” he said.

That’s starting to change, albeit at what activists say is a snail’s pace. The plant, which provides roughly 70 percent of Macedonia’s electricity by burning a low-quality, highly polluting form of coal known as lignite, is in the process of applying for that environmental permit, which it hopes to secure in coming months, Stojanovski says. By 2026, a new, updated pollution filtration system should also be in place. That would help to avoid periods like those witnessed here earlier this month, when the aging electrostatic filtering system failed and thick clouds of brown smoke churned from one of the plant’s stacks.

The Elem coal-fired power plant outside of Bitola has operated without a proper environmental permit — and only an aging filtration system — for decades.

While household fireplaces and traffic are major contributors to the pollution problem, industry plays a role too. An ongoing battle with Greece over the name “Macedonia” has consumed political energy, and distracted from the need to address pollution.

Under earlier governments, Stojanovski said, the Elem facility would have been inaccessible to independent journalists. Today, while photographs inside the plant are highly restricted, the staff happily conducts tours for visitors, including university students and other young, would-be environmental engineers — a discipline that is sorely lacking in Macedonia, Stojanovski said. They even receive a free bus ride and a meal.

“The first step is to be open and face the problem,” he said of the plant’s reputation for polluting, “not push it away.”

The problems are many here. Alongside household burning and growing traffic, another coal plant in Oslomej municipality — while targeted for closure and operating at lowered capacity — still churns out pollution, as do other smaller industries, some of which burn refuse for fuel. In the southeastern village of Kosturino, a family-run operation burns hundreds of discarded tires in open-air kilns to extract calcium oxide, or quicklime, from limestone — later to be sold for making whitewash paint and other uses. Plumes of thick, black smoke rise up from these operations for days at a time, followed by a brief respite to collect more tires, and more limestone, and begin the process anew.

For all of the pollution sources, the country has been slow to quantify the problem. No official census has been done since 2002, which has made accurate assessments of population growth — and the attending rise in air pollution — hard to come by. Air quality monitoring in Macedonia is also a relatively new discipline. There are 18 official monitoring locations, each with varying instruments designed to take readings of different pollutants. This includes fine particulate matter 2.5 micrometers or smaller in diameter, or PM2.5, which is particularly deadly over long periods of exposure. (Skopje’s annual average PM2.5 concentrations often hover above 30 micrograms per cubic meter of air — nearly three times higher than current regulatory limits set by the U.S. Environmental Protection Agency.)

Mite Anginov, 61, takes a moment’s rest from firing the highly-polluting lime kilns in Kosturino.

These burning sites dot the hills, although no one could say exactly how many furnaces exist in the area. The smaller furnaces are capable of extracting 10 tons of calcium oxide from limestone, and are fueled by discarded tires. It takes 600 car tires to fuel a small furnace for a single production run. Workers make about $150 for four days of work. There are larger furnaces that produce 20 tons of product and are fueled by larger truck and heavy equipment tires. The end product is a common industrial compound. In this region, it is used to create a long-lasting whitewash. Workers are constantly exposed to the thick black smoke. Plumes are visible for miles and, depending on the winds, the pollution blows into nearby Kosturino and beyond.

Gorjan Jovanovski, a Macedonian software engineer, released a popular air quality monitoring app in 2014 called MojVozduh or MyAir, which draws directly from public data. Jovanovski says that roughly 25 percent of the monitoring stations have been malfunctioning or down for months — and he suggests that in some cases, this may be deliberate. “If they’re broken and not delivering data, then no one can say what the situation is,” Jovanovski says, “and they don’t have to take any actions.”

Government officials dismiss this as conspiracy-mongering, but few would argue that the winter air here is anything other than stifling. At a monitoring station in the western Skopje district of Karpos, for example, the European Environment Agency reported concentrations of PM2.5 that hovered for days in early December above 100 micrograms per cubic meter of air — a value more than eight times higher than what global health officials consider safe. Exposures to such particulate pollution over many days and weeks can take a real toll. Indeed, a 2015 World Bank report estimated that air pollution is robbing Macedonia, an upper middle-income country trying hard to grow its economy, of 3.2 percent of its annual GDP, or $290 million a year.

Those figures can be traced directly to human illnesses and lost productivity. At a protest in the city of Bitola on December 6, residents called the Elem plant “Macedonia’s Chernobyl.”

“We are here to raise our voice and say that we cannot do it any more like this,” Dragi Zmijanac, a representative of a children’s rights organization Megjashi, told a local television station covering the protest. Some studies have suggested that Macedonia’s reliance on coal power in particular is shaving years off of residents’ lives. “The seriousness of the number of sick children,” he added, “is too high, and not only the central government, but also the local self-government must take urgent measures — short-term and long-term — to save the children.”



VIDEOS: WINTERS OF DISCONTENT The steep mountains and deep valleys of Macedonia provide perfect conditions for trapping pollution during the cold winter months. In the top video: sources of air pollution up close. Below that, scenes of air pollution across the country, from the vantage of a drone.



▲ 360 VIDEO: Click and drag the video above to change your view.

▲ DRONE VIDEO: The big picture of air pollution in Macedonia.

December is the beginning of the busy season at the University Clinic of Pulmonology and Allergy in Skopje, according to Dr. Dejan Dokic, director of the facility. Much of the hospital — another bleak architectural remnant of the former Yugoslavia — is in varying states of disrepair: peeling paint, crumbling concrete stairs, and darkened hallways lined with patients or loved ones.

The pulmonary ward is among the more recently renovated parts of the facility, and beds here fill up so fast with patients suffering from various forms of respiratory distress — allergies, asthma, chronic obstructive pulmonary disease — that many will be left to languish on a waiting list. Ambulances available to rush acute cases of respiratory disease to emergency rooms are also in short supply during the winter months.

“I feel the pollution very much, it bothers me and I can’t breathe,” 55-year-old carpenter Izet Vasovic said as Dokic listened to his lungs. “I can’t walk outside, especially during evening when it is more polluted,” he adds. “I feel like I am isolated and forced to stay at home. This is a disaster.”

Dokic agrees — enough so that he also wears a high-efficiency particulate air, or HEPA mask, on Skopje’s worst days. “All medical staff here tells all the patients, and they warn them to be careful, to carry masks if they go out,” Dokic says — though he adds that nothing can offer full protection.

“They should then carry this mask with a HEPA filter, which protects, you know, from PM particles,” he added. “And that’s it. What else can you do?”

Dr. Dejan Dokic is the director of the University Clinic of Pulmonology and Allergy in Skopje. Here he demonstrates a HEPA mask, which he recommends to his patients — and sometimes uses himself when pollution is bad.

During the winter months, the pulmonary ward fills up, and patients are placed on a waiting list. Ambulances, too, are in short supply. “I feel the pollution very much, it bothers me and I can’t breathe,” said 55-year-old patient Izet Vasovic. “I can’t walk outside, especially during evening when it is more polluted.”

Local activists like Tatjana Cakulev have ready answers to that question. Last year, her organization, called O2, prepared a list of 39 air pollution reform demands and asked candidates running for leadership positions in local Skopje elections to agree to address them. The demands were designed to be specific, like insisting that 3.5 percent of a local district’s budget be allocated for air pollution abatement, so that activists — and the public — would have clear endpoints to track the performance of their elected officials. “That actually gave us something that we can push — we can put the pressure,” Cakulev says, “because we can ask, ‘Ok, how far you are? Where are you with this?’”

According to the app developed by Jovanovski, who incorporated the 39 demands into MyAir for easy tracking, the answer to that question is: Not very far. To date, few of the demands have been fulfilled. “The things I’ve seen them doing are ridiculous,” Jovanovski said of local leaders. “They’re making Winterland in the middle of Skopje, for fuck’s sake,” he added, referring to the installation of an expansive, $340,000, holiday-themed entertainment and shopping village in the city center. It includes an ice-skating rink and a snow machine. “You have all this pollution choking people, and you spend your money on Winterland?”



KILLING SEASONS Weather is fate in Skopje. In the winter months, warm air presses colder, polluted air closer to the ground — and when wind or rain don’t sweep it away, that pollution stays put, wafting through every corridor of the city. Below, a snapshot of PM2.5 data for Skopje, from spring 2017 to mid-summer 2018.



INTERACTIVE CHART Click, drag, or resize the box at the bottom of the chart above to zoom in or out on the data, and to change the timespan covered. Hover over individual data points to see the average one-hour PM2.5 levels at that date and time. (Note: Gaps in data indicate that no reading was taken.)

Data courtesy AirVisual

The perceived lack of action has prompted activists to take to the streets with hand-held pollution monitors. In early December, they reported PM2.5 readings higher than 500 micrograms per cubic meter in the Aerodrom district — one of the most polluted sections of Skopje and home to 200,000 inhabitants. They have also decried the central government’s pledge to devote $1.8 million of next year’s budget to fighting pollution as absurdly low.

The deputy environment minister for Macedonia, Jani Makraduli, acknowledges the criticisms, but says that turning things around will take much more money — and time. He pointed to several new measures that his ministry is planning to implement in 2019. The biggest target, he said, will be the half of Skopje households — most of them poor — that are not connected to the central heating system. Such households, which burn wood, coal, and even textiles and trash to generate heat through the cold winters, Makraduli said, account for more than 40 percent of the country’s pollution problem, particularly in fast-growing Skopje. Vehicle exhaust and industry are the second and third biggest polluters, Makraduli said, and he pointed to several studies that supported this breakdown. Contrary to the suspicions of many residents, he added, big industry, including the Titan cement works in the Kisela Voda district of the city, are not big polluters.

Many people in Skopje are skeptical of such assertions, though skepticism of the government is something of a national pastime here. Makraduli, meanwhile, says he welcomes the complaints of environmental groups and he appears genuine in wanting to tackle a problem that has mostly been ignored by past governments. But he was also, in turns, combative, characterizing Jovanovski’s MyAir app, for example, as both misleading and “illegal” in its use of government data; the claim that some monitoring stations are deliberately offline was untrue, he said; the hand-held monitors of activists are low-budget, made-in-China devices, not precise scientific instruments; and of the residents who swear that, in the dark of night, Skopje’s cement plant belches noxious smoke directly into the air? They are simply confused.

“There is also a story that the Earth is flat,” Makraduli said, adding later: “I can take measures only based on science.”

A cross atop Mt. Vodno looks down over hazy Skopje. Whether 2019 will bring clearer air is an open question, but many say they are hopeful.

For his part, Dragan Gjorgjev, the health policy adviser, longs for a Macedonia that keeps its eye on the big picture. Every polluting sector matters, he says, because people are dying. Somewhere between 60 to 80 percent of those Macedonians who die from air pollution-related illnesses could have an extended life if the country brought particulate levels down to within E.U. or WHO standards, he said. Of the people who have already died, Gjorgjev offered a preliminary statistic: They could have lived 20 to 30 years longer, he said, if they were not exposed to air pollution.

That’s sobering news, but not much will change, Gjorgjev adds, until every Macedonian decides that it matters. To make his point, Gjorgjev shares the experience of a recently departed colleague.

“She was a lady from Finland working with us here for seven years, and her daughter has asthmatic attacks very frequently in Skopje,” he recalls. Those attacks ended quickly after the family moved away, Gjorgjev says, adding that when that colleague returned to Skopje for a visit a few weeks ago, she had uplifting news: “My daughter,” she said, “is living a new life.”

Tom Zeller Jr., a former New York Times staff writer and editor, is the editor in chief of Undark magazine. Jasmina Mironski was a Balkans correspondent for Agence-France Presse from 1991 to 2018, and a long-time contributor to Macedonian National Radio. She is currently a media trainer in Skopje.

Additional reporting for this story was provided by Larry C. Price and Sasko Golov.

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