Plovdiv, Padova, and the Croatian region of Brodsko-posavska recorded the highest rates of air pollution deaths in the EU in 2023. What they share is not exceptional pollution. What they share is poverty. Researchers at Barcelona’s ISGlobal and the Barcelona Supercomputing Center analysed 88.8 million deaths across 653 regions in 31 countries, encompassing 521 million people, covering the period from 2003 to 2019.
They were looking for something specific: not whether poorer regions are more polluted, which is generally known, but whether poverty itself changes how lethal air pollution is, even when pollution levels are comparable. The answer is yes, and the scale of the difference is stark. In the poorest regions, excess relative risks from air pollution were nearly twice as high as in wealthier regions. Two people breathing the same air face meaningfully different chances of dying from it depending on their postcode.
That is not an environmental problem. It is a social one expressed through lungs.
Why Poverty Makes Pollution Deadlier
First author Zhaoyue Chen was precise about the mechanism: “It is not just that poorer regions are more polluted.” Wealthier regions, he explained, usually have better-equipped healthcare systems, more comprehensive public health programmes, greater social awareness of the effects of air pollution, and a higher capacity to implement environmental policies.
That infrastructure acts as a buffer. When pollution spikes, people in well-resourced regions are more likely to receive early treatment for respiratory or cardiovascular symptoms, live in housing that limits indoor exposure, and have working conditions that reduce prolonged outdoor exposure.
Regions that rely more heavily on fossil fuels tend to be exposed to a broader mix of harmful substances, including ultrafine particles and heavy metals, which can cause greater damage than the standard pollutants measured in official monitoring. In other words, the poorest regions often face both worse pollution and less capacity to absorb it. The multiplier works in both directions simultaneously.
The geographic pattern is consistent and largely maps onto economic geography. Regions with higher GDP per capita, lower poverty rates, and longer life expectancy, primarily in Western and Northern Europe, showed lower and declining risks in air pollution-related mortality across the study period. Regions with lower income or life expectancy saw only small improvements or, in some cases, even increases in mortality risks associated with fine particulate matter and nitrogen dioxide.
The EEA reported separately last December that the highest rates of attributable PM2.5 deaths in the EU in 2023 were concentrated in Plovdiv in Bulgaria, Padova in Italy, and Brodsko-posavska in Croatia. Premature deaths attributable to PM2.5 fell by 57 per cent between 2005 and 2023 across the EU, meeting the zero-pollution action plan target for 2023, yet 182,000 people still died from PM2.5 exposure alone that year, with a further 63,000 attributable to ozone and 34,000 to nitrogen dioxide.
The Energy Transition Gap
The ISGlobal study did not only document the inequality. It identified one of the main levers for closing it. Increased renewable energy adoption across Europe over the past two decades was associated with a 15 per cent reduction in PM2.5, a 54 per cent reduction in coarse particulate matter, and a 20 per cent reduction in nitrogen dioxide. These improvements in air quality translated into a 12 per cent reduction in pollution-attributable mortality. The political implication is uncomfortable. The energy transition reduces air pollution deaths, but it does so unevenly.
Wealthier regions invest faster in cleaner energy and stronger regulatory enforcement. Regions that depend on EU structural funds or external financing move more slowly. The result is that the transition itself is reproducing the inequality it should, in theory, be helping to close. Poorer regions still burning solid fuels for domestic heating, still operating older vehicle fleets, and still lacking the healthcare infrastructure to buffer pollution spikes are not simply behind on the transition. They are falling further behind the mortality curve at the same time.
What the Numbers Demand
Air pollution remains the top environmental risk to Europeans, above exposure to noise, chemicals, and climate-related heatwaves, according to the EEA. New evidence also suggests that air pollution may cause dementia. The revised Ambient Air Quality Directive, which came into force in December 2024, cuts the allowable annual limit for PM2.5 by more than half, aligning EU standards more closely with WHO recommendations.
Commissioner for Environment Jessika Roswall stated last year that air pollution causes approximately 250,000 premature deaths and costs the EU economy up to €850 billion per year.
The ISGlobal study adds a layer that emissions limits alone cannot address: a region can meet the new directive’s standards and still produce significantly higher mortality than a wealthier region with the same air quality, because the population’s vulnerability determines how much damage those pollution levels cause. The study’s authors call explicitly for environmental policies to integrate health equity as a central axis, not a secondary consideration, with targeted investment in public health infrastructure, healthcare access, and epidemiological surveillance in the most affected regions.
Clean air policy built on average emission concentrations will keep producing unequal death rates until it accounts for the inequality that turns the same air into a different risk.
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