On Wednesday 16 December 2020, air pollution was recorded as a cause of death for the first time, following a second inquest into the death of 9-year-old Ella Kissi-Debrah in 2013. Ella’s death certificate now reads “acute respiratory failure, asthma, and air pollution exposure.” Expert analysis showed Ella’s multiple admissions to hospital with severe asthma—and her fatal exacerbation—correlated with spikes in air pollution near her Lewisham home, and that she was exposed to levels “constantly exceeding” EU limits in the three years prior to her death. Ella’s mother, Rosamund, has been campaigning for the last 7 years for Justice for Ella. As Rosamund powerfully reflected after the ruling, “this was about my daughter…but also it’s about other children…there are still illegal levels of air pollution now.” 

For Ella’s legacy to be a “turning point” for accelerated action on air pollution, the health community must use their voice to advocate for justice. Justice is one of the core principles within medical ethics, often concerned with the fair distribution of finite resources. A wider conception of this views justice in broader terms of societal fairness. People in working class communities and people from ethnic minorities are disproportionately exposed to polluted air. As such, our responsibility to improve air quality relates not only to reducing disease, but to tackling a stark health inequality. As Guppi Bola writes in Reimaging Public Health, we must “use health justice in the vision of a fair and inclusive society.”

In “Build Back Fairer“, Marmot and colleagues highlight a potential association between pollution in urban areas, more often inhabited by people from ethnic minorities, and excess covid-19 deaths. Air pollution follows a strong social gradient; more than 80% of London primary schools surrounded by nitrous oxide (NOx) levels exceeding EU limits are found in deprived areas. Excessive comorbidity in deprived areas may interact synergistically with air pollution to exert exaggerated health effects in these groups compared with advantaged counterparts. The injustice of air pollution exposure has worsened over the past decade as households least responsible for emissions of PM and NOx are the most exposed.

Rosamund described that prior to Ella’s death she knew little about air pollution, “I knew about car fumes, the phrase, but nothing else.” It was some time later, when somebody contacted her with information about the high pollution levels in the two days surrounding Ella’s death, that she started to consider a link. This failure to provide Ella’s family with information about the potential for air pollution to exacerbate asthma was also noted by the coroner as a possible contributor to her death. It is key that within the health community, we are learning about the health impacts of air pollution, to support and advocate with patients. Not addressing the issue unequally disadvantages people living in polluted areas who are likely to be more deprived and pay the highest health cost.

So, how do we bring this up with families? It’s not easy for individuals to change their air pollution exposure, as much relies on systemic societal change. A NICE guideline was developed to provide specific recommendations for clinicians on how to address air pollution in patient management. Rosamund said that, had she known that living within 30m of the South Circular road in Lewisham was making her daughter’s asthma worse, she would have moved house “straight away.” The NICE guidance recommends supporting families to access air quality information for their area such as through the DEFRA “UK Air” website. 

The health community has unique insight into the health impacts of air pollution. We have a responsibility to use this understanding to advocate for meaningful changes in government policy, to tackle the root causes of air pollution. In the same way that health professionals have advocated clear opposition to tobacco as a major contributor to morbidity and mortality, so profession-wide unity of the centrality of clean air is equally necessary.

Crucial steps forward include active participation in demanding a broad and timely Clean Air Act and pushing for low-carbon public transport—an essential component in changing inactive, private-vehicle dependent lifestyles. Above all, the health community must advocate for socially just solutions that address the root causes and the injustices associated with air pollution. The health community must use its voice to act in solidarity with affected communities through campaigns such as the Ella Roberta Foundation, Mums for Lungs and Choked Up. Legal confirmation of the link between Ella’s death and air pollution should now make action by the health community and wider society on this injustice impossible to ignore.

Aarash Saleh, Respiratory registrar at Barts’ Hospital and PhD student in Cystic Fibrosis Gene Therapy at Imperial College London @aarashsaleh

Elizabeth Hobbs, Paediatric registrar at Royal London Hospital @lizzieannahobbs

Victoria Stanford, junior doctor and MPH student at École des hautes études en santé publique (EHESP), France. @VictoriaI_Stan

Ben Eder, Climate & Health Campaigner, Medact. @beneder