Bridging The Gap: Clinical Realities And The Case For Air Quality Governance

A conversation with Dr. Ciara Steele on public health, indoor environmental quality and the drive for mandated monitoring

For too long, the narrative surrounding building envelopes and heating, ventilation and air conditioning (HVAC) infrastructure has been heavily skewed toward energy efficiency, often at the expense of human health. As research continues to show that air pollution affects more than respiratory health, strong air quality governance remains essential to protecting public health. True sustainability cannot exist without prioritizing the well-being of building occupants, which demands a critical shift from treating ventilation as a fit-and-forget afterthought to adopting a rigorous, hardware-first approach to engineered filtration.

IFN’s Dr. Iyad Al-Attar recently interviewed Dr. Ciara Steele, an Ireland-based general practitioner (GP), GP trainer and co-founder of Clean Air Advocacy Ireland (CAAI), to talk about the gap between engineering infrastructure and medical outcomes.

Dr. Steele’s work represents a powerful blueprint for localized, grassroots action driving global mandates. From championing the transformative whole-school high-efficiency particulate air (HEPA) pilot at Scoil Naomh Bríd to representing CAAI at a conference on healthy indoor air at the United Nations, her advocacy emphasizes making the invisible visible through mandated monitoring. With a clinical focus on the intersection of indoor air quality (IAQ) and holistic health, Dr. Steele provides an essential medical perspective on why optimizing existing mechanical systems is a non-negotiable requirement for protecting our communities. She is a regular contributor to health-related radio segments on Highland Radio and is active in promoting clean air initiatives in her community.

The following conversation navigates the challenges of indoor environmental quality (IEQ), the insidious nature of airborne pathogens and particulate matter, and the collaborative policies required to elevate public health metrics to the forefront of global building standards.

Dr. Iyad Al-Attar: As a clinical practitioner and co-founder of CAAI, you witness the daily health impacts of poor indoor environments. How can we reframe global air quality governance so that public health and well-being metrics truly drive policy change, rather than continuing to let energy efficiency dictate building standards?

Dr. Ciara Steele: The answer to this question is simple — by mandating, monitoring and IAQ. If we make visible the air quality within our schools, classrooms, hospitals and offices, we will see the link between poor air quality and health outcomes.
Are there more students with asthma attacks in one classroom than another? Are there more people off sick with respiratory illness in one office or another? Are there higher rates of health care acquired infection in one ward more than another? The reasons can become immediately correlated with air quality when air quality is visible.

This can be enhanced with technology such as the Boston public schools’ live dashboard,1 where real-time data sensor information and hundreds of thousands of data points revealed the urgent remediation of air quality. The program has enabled translation of this data into action and health impact through teamwork science, awareness and funding. The result is better health outcomes, saving costs over time and improving health for decades.

The importance of establishing this link is that the problem of poor air quality and its related health impacts can often be remediated with immediate effect by introducing ventilation and air purification such as portable HEPA filters known to reduce indoor particulate matter 2.5 (PM2.5) by up to 68 percent.

If we make visible the air quality within our schools, classrooms, offices and hospitals, we will see the link between poor air quality and health outcomes.
— Dr. Ciara Steele

In contrast to sealing buildings for energy efficiency, we must establish health as a primary driver for generating global IAQ standards. Promoting health in all policies acknowledges that public health is determined by policies that guide actions beyond the health sector. Both are important. Patients intuitively understand that which affects their breathing. We can all sense a stuffy afternoon meeting room and if you ask someone with asthma, Where do you notice your symptoms are worse?” they commonly will tell you either at home, in school or in traffic. Visibly quantifying these risks allows us to take individual action by increasing mechanical and natural ventilation rates, reducing humidity, exercising indoors when pollen is high and planning travel routes among some examples.

With the INQUIRE2 project, further study and recommendations progress in Europe. Establishing a clear road map for mandating air quality monitoring is essential; global application demands we start somewhere, and if some countries lead, others will follow.

Dr. Al-Attar: The whole-school HEPA pilot you championed at Scoil Naomh Bríd is a tremendous milestone for reducing illness-related absences. When assessing our educational and community buildings, how critical is it to adopt a hardware-first mindset by optimizing the mechanical integrity and filtration capabilities of existing HVAC systems before overlaying newer technologies?

Dr. Steele: The first point here is to understand the heterogeneity in classroom occupancy, activity and building quality. Ventilation systems may be old, poorly maintained and fitted with an attitude of “fit and forget” or not even fitted at all. Buildings may be old, moldy and have faulty windows that don’t open, and climates in different countries lead to differing design requirements.

Again, regulation is imperative to include delivered air quality as the important metric, and this requires adaptability and monitoring over time with a maintenance program built in at the design stage. Live monitoring can lead to time-sensitive remediation with any issue in building infrastructure that may impact health. So, assessment and monitoring of what is already present is an essential first step in developing bespoke solutions for individual buildings.

In real terms, a holistic approach was taken by Principal Derek Foster and Scoil Naomh Bríd where awareness of air quality through assessment and monitoring has led to the removal of old and dusty soft furnishings, curtains and carpets, and the removal of old equipment and clutter piles that can accumulate dust and house dust mites. The removal of carpets in the main hall and installation of low volatile organic compound (VOC) flooring has led to increased light, space and immediate well-being.

An old, unused rostrum was also removed to open up space, make cleaning easier and give children a better indoor space to exercise when outdoor weather is poor. In addition, monitors in classrooms tell children when to open windows and there are “clean air champions” in every classroom leading calls to respond to air quality measurements.

Environmental health and awareness of outdoor air as well as indoor air have become a key science, technology, engineering and mathematics (STEM) topic for the children, which one hopes will foster increased community awareness as children bring ideas home. Understanding indoor and outdoor air as a continuum and the benefits of improving air quality in and around classrooms has generated excitement for STEM subjects.

Retrofit is important for medium- and long-term estate planning, but sometimes simple assessment can lead to quality, low-cost interventions like fixing windows and lifting carpets, encouraging walking to school and a no-car-idling policy. Green barriers can also protect and are easy to install.

Intervention streams can be done synergistically and simultaneously.

Dr. Al-Attar: To move beyond the initial construction phase and ensure long-term health outcomes, what specific policies and practices do you believe are urgently required to elevate IEQ and maintain the integrity of building envelopes against airborne pathogens?

Dr. Steele: Firstly, there must be recognition that aerosol transmission is problematic and secondly that it can be addressed. Is it really still acceptable to allow high levels of respiratory disease transmission in schools when respiratory illness is known to adversely affect long-term respiratory health?

Respiratory infections can lead to a higher risk of asthma3 and asthma exacerbations. Some 21 percent of children have ever had a diagnosis of asthma in Ireland, and globally, respiratory illnesses like chronic obstructive pulmonary disease (COPD) are rising, affecting 80 million people. Tragically, death occurs in children each season due to respiratory syncytial virus (RSV), influenza and COVID. Indoor environments in an inclusive modern society need to be safe for all.

Those with respiratory infections in childhood had twice the likelihood of dying from respiratory disease in adulthood4, and the Children’s Health in London and Luton (CHILL) study found children living in the highest areas of traffic-related air pollution (TRAP) had the smallest lung volumes. Long COVID occurs in children.5 And attenuating child respiratory function earlier in life impacts the trajectory of respiratory health for the rest of their lives. This leaves easily applicable public health interventions underused, despite their potential to prevent acute and chronic disease.

Government awareness and embedding health in policy to liaise with architecture, engineering and estate planning will prevent value-engineering exercises deprioritizing ventilation. Embedding air quality as a public health intervention in all policies and across departments is urgently necessary and this may demand a dedicated government department for indoor air quality assessment, monitoring, regulation, standards review and funding.

A “Scores on the Doors” type healthy air building standard can offer us the choice of when and whether to enter a building. If the air quality is not acceptable or does not meet standards this system is transparent, offers choice and ultimately will benefit businesses for building managers taking it on in terms of productivity and improved cognitive function as well as learning for occupants of healthier buildings. This is something that we call for at Clean Air Advocacy Ireland.

Dr. Al-Attar: The discourse around air pollution often focuses broadly on surface-level respiratory issues, occasionally obscuring the more insidious crises tied to how the physicochemical properties of airborne pollutants compromise human health. From your clinical perspective, how vital is engineered, optimized filtration in addressing these deeper, often overlooked physiological impacts in our daily environments?

Dr. Steele: The average person spends 90 percent of their time indoors and we breathe 20,000 times per day on average. The assumption is that the air we breathe is wholesome, especially in our places of refuge like our home. But we cannot know what is in our food and water without quality standards otherwise the water we drink and the food we eat might potentially be hazardous. So, we must apply the same rigor to the quality of the air we breathe. We breathe up to 11,000 liters of air per day on average and 438 million liters in a lifetime. Molecules inhaled and absorbed can be larger than those absorbed through the gut — the premise for inhaled medication. The lungs are a fantastic delivery system.

Our lungs have the surface area of a tennis court. To think that we have overlooked the physiological impacts of our environment on our lungs and bodies is astounding really. Particulate matter less than 2.5 microns is known to cross the alveolar-capillary barrier, travel around our bodies attached to blood cells, and deposit in heart, kidneys and brain. Ultrafine particles and PM2.5 are risk factors for all-cause mortality and cardiovascular disease including stroke, ischemic heart disease and cancer. Air pollutants are accepted risk factors for dementia, although identifying and ranking the specific pollutants involved requires further study. Even short exposures can impact cognition.6, 7 The Partnership for Evidence and Action on Clean Air (PEACE-Air)8, a Special EU Programmes Body (SEUPB) funded PEACEPLUS project, is looking at speciation of particulate matter and studying health impacts.

Dr. Al-Attar: You have successfully empowered local school communities to actively monitor and clean their air. As we rethink air filtration for sustainable buildings, how can these localized, grassroots victories in Ireland serve as a blueprint to enforce stricter, health-centric air filtration mandates on a global scale?

Dr. Steele: Teamwork is key. Bringing science, industry, concerned parents, school leaders, and political and medical advocates together is the recipe for success. In unison, the common goal of healthier indoor spaces is achievable on small or large scales. We can only ever occupy one classroom at a time, so every classroom counts and every positive change counts.

The ripple from a small pebble can travel far. I quote a teacher from Scoil Naomh Bríd, Ms. McNally, and thank her for her dedication. McNally said: “We hope that the knowledge and awareness gained through this project will extend beyond the classroom, with pupils bringing their learning home and into the wider community. By encouraging conversations around the quality of the air we breathe and the small changes that can help improve it, we hope this initiative will have a lasting and wider-reaching impact.”

Europe’s Energy Performance of Buildings Directive (EPBD) has been updated to integrate indoor environmental guidance for the first time. Harmonizing guidance across member states may offer the framework sought to bridge the gap between energy efficiency and health.

However, we must start somewhere and why not today? Every oak tree starts life as an acorn. We are becoming aware as parents, family members, health care workers, office workers, students and businesses that we no longer want constant sick days, taking leave to care for unwell children. Neither do we want to continue dealing with the personal and global costs of illnesses such as long COVID, leading to loss of productivity and personal tragedy, all while knowing that prevention is possible.

We are now in a position to reflect and learn from our justified and enforced focus on indoor air and environmental quality through the pandemic9 with a positive and progressive lens that action can and must be taken to address what we now understand as fundamentally detrimental to our health.

It is time to act and address poor IAQ.

Author’s Thoughts

The interview with Dr. Steele was eye-opening and highlighted the necessity of addressing air pollution directly through a clinical lens. With public health and well-being emerging as the core pillars of any sustainable urban development, embedding robust air quality governance must become a non-negotiable priority from day one of city planning. The historical trajectory of IAQ has traditionally revolved around filter performance, routine HVAC maintenance practices and technological integration. However, Dr. Steele illustrates that viewing air quality through a combined governance and clinical lens — alongside mechanical engineering and city design perspectives — will prove invaluable in rendering our modern built environments healthier for generations to come.

References:
1 https://drive.google.com/file/d/1QDhHGZp3p0GnGPkiD5lxLrNgDFRVycN5/view
2 https://inquire-he.eu/ideal-cluster/
3 https://publications.ersnet.org/content/erj/58/suppl65/pa2168
4 https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(23)00131-9/fulltext
5 https://www.unicef.org/parenting/health/long-COVID-children
6 https://www.mdpi.com/1660-4601/21/3/284
7 https://www.who.int/teams/environment-climate-change-and-health/air-quality-energy-and-health/health-impacts
8 https://peace-air.eu/
9 https://ephemerajournal.org/sites/default/files/2026-05/25%282%29%20Booker%2C%20Walker%20and%20Young.pdf