Ella Kissi-Debrah, a nine-year-old who died in February 2013 after suffering an asthma attack, is the first person in the UK to have air pollution cited on their death certificate. Two weeks ago, Ella’s mother finally settled her legal action against the government, which said it was ‘truly sorry’ for Rosamund Adoo-Kissi-Debrah’s loss and that it was committed to delivering an ‘ambitious clean air strategy’. Ella’s death has become a cause celebre among anti-car and anti-pollution activists. There is no doubt that Ella’s death was a terrible tragedy. But to blame air pollution alone – as some campaigners have done – for what happened risks ignoring the complexities of this case.
Living just 25 metres from the South Circular Road, in Lewisham, south London, Ella’s short life was blighted by exhaust fumes from road traffic. It is this pollution that is now cited as the culprit of her death. It has long been known that filthy air is bad for you, but the inquest ruling seemed to confirm the worst: that pollution kills. It stated that ‘there is no safe level for particulate matter’. With declarations like this, it seems that nowhere is safe from the miasma of urban life.
Eliminating vehicles entirely – even if that were possible – would not mean that asthma no longer existed
But focusing on pollution alone cannot adequately explain what happened to Ella. She was a child with a severe, hypersecretory asthmatic condition, causing episodes of respiratory and cardiac arrest. Ella’s illness meant that she required frequent emergency hospital admissions. Her asthmatic attacks had already caused seizures resulting in 28 hospital admissions over three years. In 2009, she was placed in a medically-induced coma for three days when she was six years old. Her short life was difficult. Yet in much of the reporting of Ella’s death, these tragic details get lost.
So what did cause Ella’s death? The original death certificate stated that Ella’s death had been caused by asthma. Yet the deputy coroner, Phillip Barlow, who re-opened an investigation six years later which concluded in 2020, added that pollution in the form of air quality was a ‘material contribution to Ella’s death’.
Barlow’s report – which documented that ‘failure to reduce the level of nitrogen dioxide to within the limits set by EU and domestic law which possibly contributed’ to Ella’s demise – has been seized upon by campaigners. But during Ella’s childhood – between 2005 and 2013 – emissions of nitrogen oxides in the UK actually fell by 36 per cent and particulate matter reduced by more than 20 per cent.
Ella’s case represented a shift from assuming that a death might be caused by asthma, to a suggestion that asthma itself was triggered by a prior issue that was external to the child’s condition. Barlow’s report was published at the height of the Covid pandemic, when medical briefings regularly documented patients ‘dying with Covid’ as opposed to ‘dying from Covid’, for example. This debate shifted the dial in the discussion of death. It was no longer sufficient to say that someone had ‘died from complications arising from asthma’; instead it became ‘dying with asthma from a polluted environment’.
In fact, asthma is a condition that is hard to define. The NHS currently states that ‘the exact cause of asthma is unknown. Genetics, pollution and modern hygiene standards have been suggested as causes, but there's not currently enough evidence to know if any of these do cause asthma'.
We find it difficult to accept the reality of accidents. We are desperate to avoid the existence of tragedy
Whether car drivers can be blamed is up for discussion. Clearly pollution-free air might help those like Ella. But eliminating vehicles entirely – even if that were possible – would not mean that asthma no longer existed. The one group with the highest incidence of asthma and other breathing difficulties is cross-country skiers. These are fit, healthy people who spend their time in the cleanest of air. Clearly cold, dry air has a significant impact on asthma too. Indeed, there are other factors that often dare not speak their name, like the quality of healthcare. The Royal College of Physicians has written that ‘46 per cent of the children who died from asthma had received an inadequate standard of asthma care'.
The yo-yo effect in childhood asthma fatalities also suggests that pollution alone cannot be blamed. In 2019, the Office for National Statistics’s mortality statistics showed that – somewhat arbitrarily – the number of childhood asthma fatalities in 2009 was half that of the previous year. Admittedly, this could possibly demonstrate a link with traffic levels in that congestion on Britain's main roads and motorways fell by 12 per cent due to the 2008-9 recession. As the cost of fuel skyrocketed, fewer journeys were made. But the reduction in drivers on the road at that time is nowhere near representative of the percentage decline in deaths. Similarly, by 2013 (the year of Ella’s death) asthma fatality rates had returned to 2008 levels (30 per year), then declining by a third again in the following four years. These significant shifts are not explained – convincingly – by driving habits or even air quality mandates.
It seems likely that pollution played a part in Ella’s tragic death. But her severe asthmatic respiratory problems – admittedly exacerbated by her surroundings – must also have contributed. This doesn’t merely mean that car pollution is to blame; hay fever is also known to exacerbate symptoms for asthma sufferers. The 2014 National Review of Asthma Deaths for the UK says that 15 per cent of that year’s asthma deaths were exacerbated, in some way, by hay fever.
There is, it seems, an increasing tendency to examine forensically the minutiae of a case in order to find a way to apportion liability. But perhaps sometimes there are cases where blame is not always helpful. We find it difficult to accept the reality of accidents. We are desperate to avoid the existence of tragedy. We increasingly find it difficult to cope with bad things happening and seem to need the catharsis of culpability.
As it happens, in the past 30 years, we are living longer. In 1995, the average life expectancy in the UK was 76 years; today it is 81. These improvements in the UK’s ageing demographic have been caused by better medical care at both ends of life. Better elderly care has been supplemented by better survival rates for infants. In other words, the reduction in child mortality has boosted the mathematical average lifespan.
Mortality rates for under-fives in the UK have also improved greatly, from 142 deaths per 1,000 a century ago, to 20 deaths 50 years ago, to just four deaths per 1,000 today. That is still a figure of around 14,000 five-year-olds dying this year (Ella Kissi-Debrah died when she was nine years old), but the improvements in child mortality are similarly impressive for later years. It is a rare event for a child to die in this country. A 2009 research paper on asthma deaths in the British Journal of Medical Practice (the year that Ella first showed signs of respiratory ill-health) states that ‘the standardised childhood death rate in the UK is 2.5 per 1000. An average-sized [medical] practice with 10,000 patients including 1,500 children will have a child death about every two years'.
These statistics will bring no comfort to Ella’s family. But we must remember that the death of a nine-year-old is rare – and blaming air pollution alone for what happened means ignoring the truth about the circumstances that led to her tragic death.
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