Can Europe curb climate-related respiratory disease without tackling inequality?
A warming world increases the incidence of asthma and COPD. Public health solutions that fail to account for the most vulnerable within society will not succeed
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When nine-year-old Ella Adoo-Kissi-Debrah died following an asthma attack in 2013, her doctors were at a loss to explain what had happened to an otherwise healthy child from Lewisham in south-east London. After a chest infection two years earlier, she had developed a persistent cough, endured multiple tests and had been admitted to hospital 27 times. Her death certificate listed the cause simply as “acute respiratory failure”.
Ella’s mother, Rosamund Adoo-Kissi-Debrah, suspected a deeper cause. With the help of a local respiratory physician, she uncovered the extent of the air pollution Ella had been exposed to from the constant traffic near their home. Seven years later, in 2020, a coroner’s inquest found that excessive levels of nitrogen dioxide, above both World Health Organisation (WHO) and EU guidelines, had directly contributed to her death.
The ruling was a landmark. It was the first time air pollution had been formally recognised as a cause of death in the UK. It also spurred debate about equity: Ella lived in a highly polluted neighbourhood where more than one in three children experience poverty.1 “I’m going to say it again and again. Ella isn’t the only one,” Ms Adoo-Kissi-Debrah told the BBC in 2024, also describing the continuing deaths of children from asthma as “not acceptable”.
As European health officials confront the challenge of lowering rates of asthma and chronic obstructive pulmonary disease (COPD)—a task made more difficult by air pollution and climate change—they are increasingly identifying links between poverty and poor respiratory health. Although European Environment Agency data show that air quality has improved over the past two decades, pollution remains the continent’s largest environmental health threat, responsible for 279,000 premature deaths within the EU in 2023, disproportionately harming lower-income communities.2 “Any major change usually ends up magnifying inequalities,” says Sir Michael Marmot, president of the Institute of Health Equity. “Whether it's a pandemic, a flood, a tsunami—it’s likely that climate change will have the same effect.”
“Any major change usually ends up magnifying inequalities”
— Sir Michael Marmot, president of the Institute of Health Equity.
In 2024, pharmaceutical company Chiesi commissioned a report on people living with chronic respiratory disease in five European countries and the United States. It found that non-physiological factors, such as socioeconomic status, occupation, education, access to care and local air quality, had the greatest influence on lung health. “Climate hazards do not affect everyone equally. Your job, your housing and your income determine whether you survive or succumb,” explains WHO special envoy José Luis Castro, discussing the report’s findings. “There's a perception that existing air quality standards and heat alert systems are sufficient, when in reality the most disadvantaged populations, the people in substandard housing, the workers exposed to dust and chemicals, and migrants and those in low-income communities experience higher levels of exposure and have far lower resilience.”
The report found that about 15% of COPD cases were linked to jobs, for example in construction and agriculture, in which workers inhaled vapour, dust, gas and fumes. It also explained the link between income levels and asthma: roughly half of sufferers have been exposed to allergens such as dust and mould in poorly maintained homes. Climate change compounds the problem—hotter summers lengthen allergy seasons; wetter winters allow dampness to proliferate in substandard housing. People in poorer communities were also found to be less likely to be offered routine spirometry (standard lung-capacity testing) in primary care, missing opportunities for early diagnosis and treatment.
“Climate hazards do not affect everyone equally. Your job, your housing and your income determine whether you survive or succumb.”
— José Luis Castro, WHO director-general special envoy for chronic respiratory diseases
Despite the alarming data, calls for policymakers to pay more attention to climate change come at a time when political momentum is fading. The 2025 UN global climate conference ended without an agreement to phase out fossil fuels—a main driver of global warming. But experts such as Mr Castro argue that the key to restoring urgency is to show that the issue affects everyone. “The challenge is making clear that climate-related respiratory disease is not a niche health issue. It's a fundamental equity issue and it's a labour issue,” he points out. “It's also an economic issue, and unless the policymakers understand that COPD and asthma are deeply shaped by social inequality, we will continue to miss the most vulnerable.”
Mr Castro hopes that the clear cost-benefit case will motivate action. COPD and asthma caused or exacerbated by air pollution hurt Europe’s economy through increased healthcare costs, hospitalisation, premature deaths and lost productivity. COPD alone accounts for 56% (€38.6bn) of all respiratory-related costs in the EU, according to the Respiratory Health Initiative’s COPD Index.3
The most effective solutions, explains Dr Marmot, prioritise “health equity” over “health” alone. Encouragingly, recognition of the influence of socioeconomic status on health outcomes is growing. The UK now has more than 60 “Marmot communities”: places committed to tackling health inequalities by addressing education, employment, housing and income through cross-sector collaboration. Italy has built its own network, with cities such as Rimini and Bologna making notable progress. Spain's health ministry is now in talks to adopt the approach, and Norway has sought similar advice.
Alongside measures such as investing in greener homes and cleaner transport, stronger workplace protections—including updated occupational air quality standards—are “achievable and have strong public support everywhere”, Mr Castro says. However, such interventions remain elusive partly because those most affected by chronic respiratory diseases often remain unheard, which translates into their absence from policy decisions. He has called for the introduction of universal spirometry testing in primary care practices, which could dramatically reduce hospitalisations, as well as providing local authorities with better tools to track how pollution, heat and indoor air quality affect at-risk groups.
Such progress is possible, says Mr Castro, although, like Dr Marmot, he emphasises that it will require a collaborative effort by local authorities, businesses, healthcare, housing providers, social services, voluntary groups and communities.
“If we take this issue seriously now, Europe could become a global leader again, pioneering clean-air cities, resilient health systems and workplaces that protect rather than endanger the health of workers,” Mr Castro adds. “We could see fewer children developing asthma, fewer workers developing COPD and fewer families suffering avoidable tragedy.”
“If we take this issue seriously now, Europe could become a global leader again, pioneering clean-air cities, resilient health systems and workplaces that protect rather than endanger the health of workers.”
— José Luis Castro, José Luis Castro, WHO director-general special envoy for chronic respiratory diseases
Produced by EI Studios.
This article was funded and developed in association with Chiesi Group. Chiesi has commissioned analysis of the environmental, socioeconomic and demographic factors influencing COPD and asthma to inform health equity strategies and local interventions. At the time of publication, the report is forthcoming. For more information, please contact [email protected].