Cause of Death: Follow-up

Guest News Brief by Kip Hansen – 18 December 2020

The New York Times and The Guardian are both reporting a “landmark ruling” from Britain.  “A 9-year-old girl who suffered a fatal asthma attack in 2013 became the first person in Britain to officially have air pollution listed as a cause of death, a British official said. . . . In the ruling on Wednesday, assistant coroner Philip Barlow in London said air pollution had significantly helped induce and exacerbate Ella’s asthma, adding that she had been exposed to levels of nitrogen dioxide and particulate matter in excess of World Health Organization guidelines.” [ source: NY Times ]   

In a recent essay here, I discussed he problems with the reporting of Cause of Death and some of the details on how this is done in the United States. For the details, read (or re-read)  Cause of Death: A Primer

The fact is that Cause of Death is not simple, not cut-and-dried,  not always obvious and often contentious.  It is important to know that deaths in the UK are handled differently than in the United States.

In the United States, a doctor or coroner simply fills out a Death Certificate listing the chain of events or chain of diseases that led to the death, including any contributing factors.  In England and Wales, there are a long list of cases in which a death must be subject to an inquest.   If you watch British TV shows, you may be familiar with the older version of an inquest, in which some coroner must rule a death a natural death, a suicide, a murder or “death by misadventure”. 

 The Guardian reports the case this way:

A coroner has made legal history by ruling that air pollution was a cause of the death of a nine-year-old girl.

Philip Barlow, the inner south London coroner, said Ella Kissi-Debrah’s death in February 2013 was caused by acute respiratory failure, severe asthma and air pollution exposure.

He said she was exposed to nitrogen dioxide and particulate matter (PM) pollution in excess of World Health Organization guidelines, the principal source of which were traffic emissions.

The coroner said the failure to reduce pollution levels to legal limits possibly contributed to her death, as did the failure to provide her mother with information about the potential for air pollution to exacerbate asthma.

“Ella died of asthma contributed to by exposure to excessive air pollution,” said the coroner on Wednesday.

This young girl’s death had been subject to an inquest in 2014, which found she had died of acute respiratory failure.   But, Cause of Death can be contentious and sometimes, political.  In this case:

Ella’s mother, Rosamund Kissi-Debrah, a former teacher, spent years fighting to have her daughter’s death examined by a second coroner. Her resilience was repaid on Wednesday when Barlow agreed with expert medical evidence provided by the family which said Ella’s particular form of acute asthma was exacerbated by air pollution.

Kissi-Debrah’s lawyers submitted that air pollution was a public health emergency and there was a pressing need for it to be recorded as a cause of death to ensure public health programmes to tackle toxic air were prioritised.

In evidence to the two-week inquest, Prof Stephen Holgate, an immunopharmacologist and consultant respiratory physician of the University of Southampton and Southampton general hospital, said a biological cause of Ella’s disease getting worse in the winter months was the seasonal worsening air pollution.

He said it was the cumulative effect of the toxic air Ella was breathing in living within 30 metres of the South Circular road that caused her final acute asthma attack.

The Guardian

For those not familiar with London, UK, the South Circular Road  is not a multi-lane major highway, but rather: “The South Circular is 20.5 miles (33.0 km) long. The majority of the road is single carriageway, one lane each way, aside from a small section of dual carriageway near the Woolwich Ferry. It is a primary road for its entire length” and “The South Circular has received sustained criticism for congestion and pollution and is one of the least popular roads in Britain.” [source:  Wiki ]  

In this case, we see the sad end of a young girl’s life.  A young girl that had suffered from severe asthma for years and had been repeatedly hospitalized for asthma attacks and seizures.  Somehow, the public health doctors had reportedly failed to inform her mother that asthma sufferers should not live where there are exacerbating circumstances, such as high ozone levels, high dust levels, high levels of roadway auto and truck exhaust.  Her mother, a school teacher, should have known this, with or without public health officials specifically informing her, as all medical web sites on asthma feature this information

In the end, it appears that a second coroners inquest has found, as should have been obvious from the beginning, that, as is common medical knowledge, roadway air pollutants can be a contributing trigger for asthma attacks.  The landmark ruling though is almost entirely political  — the shocking thing being that her family apparently remained ignorant of the basic facts that every parent of a child suffering from asthma would know. 

As for Cause of Death, we see once more that it is not always a matter of simple medical facts and that the medical facts can be confused and conflated with other considerations and popular social movements. 

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Author’s Comment:

The area in which I live, the Central Hudson Valley of New York State, is listed as #19 on the Allergy Capitals of America list – one of the worst paces for allergy and asthma sufferers to live.  Everyone with pollen allergies living here knows this and is rudely and painfully reminded of this twice a year (we are lucky enough to have two allergy seasons).  If any parent of a child suffering from severe allergies living here had tried to claim ignorance of this simple fact, they would be laughed out of court. 

As for science, in a greater sense, the concept of cause is a difficult issue, and, in my opinion, is most often mis-assigned based on vague association.

As many medical practitioners have begun to point out, Covid Deaths being reported in the media are more correctly characterized as “Deaths Involving Covid” and in many more cases, “Deaths with some vague association to Covid”.

Cause of Death is simply not simple.

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December 18, 2020 at 08:47AM

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