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The Extractive Industries and Society xxx (2015) xxx–xxx

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The Extractive Industries and Society


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Review article

The public health impacts of surface coal mining


Michael Hendryx
Department of Applied Health Science, School of Public Health, Indiana University, Bloomington, IN 47405, USA

A R T I C L E I N F O A B S T R A C T

Article history: The current paper reviews published evidence on the public health impacts of surface coal mining.
Received 12 March 2015 Particular attention is paid to recent evidence for a form of surface mining practiced in the United States,
Received in revised form 17 August 2015 namely mountaintop removal mining. Studies from other parts of the world are also briefly described.
Evidence is presented that documents epidemiological disease patterns for populations living in
Available online xxx
proximity to surface mining. Environmental evidence has shown that surface waters and biota are
harmed by mountaintop removal, while other environmental studies have shown water and air pollution
Keywords:
exist in residential areas close to mining. Studies that are able to directly link environmental exposure,
Coal mining
Mountaintop removal mining
dose, and biological impact are urgently needed. Although direct mechanistic links are not well
Public health understood, the weight of the evidence reinforces previous science-based calls to discontinue
Air pollution mountaintop removal mining due to its environmental and public health risks.
Water pollution ã 2015 Elsevier Ltd. All rights reserved.

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
2. Mountaintop removal mining . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
3. Early health studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
4. Epidemiological evidence of public health disparities in Appalachian mining communities ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
5. Environmental conditions in mining communities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
6. Biological links between MTR exposures and health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
7. Conclusions and next steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00

1. Introduction environmental and economic costs of America’s reliance on coal


as an energy source. He also describes the public health harm
“Dr. Diane Shafer, a busy orthopedic surgeon in Williamson, the caused by burning coal in power plants, for which there is
Mingo County [WV] seat, noticed that a surprising number of her considerable research evidence. Scattered here and there in the
patients in their fifties were afflicted with early-onset dementia. In book’s pages are impressions of local mining community residents,
addition, she was hearing more and more complaints about kidney such as Dr. Shafer, that the mining of coal, not just its burning,
stones, thyroid problems, and gastrointestinal problems such as causes public health problems as well. But research evidence that
bellyaches and diarrhea. Incidents of cancer and birth defects could support or refute these impressions was lacking.
seemed to be rising, too. She had no formal studies to back her up, At that time the research evidence that was available on coal
but . . . she knew that many people who lived in the hills beyond mining’s health impacts seemed to be limited to studies on
the reach of the municipal water supply had problems with their occupational exposure, and to a few studies conducted in Great
water.” Jeff Goodell, Big Coal, pp. 40–41. Britain on mining’s possible larger public health impacts.
Regarding occupational exposures, underground coal mining is
Jeff Goodell, a highly regarded journalist, published the book
known to increase risk of pneumoconiosis, chronic obstructive
Big Coal in 2006 (Goodell, 2006). The book details the
pulmonary disease, lung cancer and perhaps other illnesses
(Castranova and Vallyathan, 2000; Coggon and Taylor, 1998;
Graber et al., 2014; Laney et al., 2012; Scott et al., 2004). These
E-mail address: hendryx@indiana.edu (M. Hendryx). occupational diseases are related to inhalation of coal and rock

http://dx.doi.org/10.1016/j.exis.2015.08.006
2214-790X/ ã 2015 Elsevier Ltd. All rights reserved.

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dust and other mining related chemicals, that is, to air quality conductivity and total dissolved solids are also observed as a
problems. The studies in Great Britain also focused on air quality, consequence of MTR (Palmer et al., 2010). Effluents from valley fills
and examined possible respiratory problems for people, usually continue for years after active mining at a site has ceased, and
children, who lived near open-cast or surface coal mining sites effects accumulate as streams pass through mining sites and
(Brabin et al., 1994; Temple and Sykes, 1992). Yet, as suggested receive water from multiple mines (Lindberg et al., 2011).
above by Dr. Shafer’s concern, the original focus in examining The impact of mining on surface waters raises questions of
possible public health consequences of surface mining in the impacts on biota in those waters. Mining disturbance causes a
United States emphasized water quality issues. decline in stream biodiversity with consequences that extend well
The issue is complicated by the fact that mining populations, beyond the limits of the mining permits (Bernhardt et al., 2012;
especially in Appalachia in the eastern United States, experience Hitt and Hendryx, 2010; Pond et al., 2008). Palmer et al. (2010)
high levels of poverty, and often engage in poor health behavior report declines in numbers of invertebrate genera as sulfate
reflected by high smoking and obesity rates. It is relatively easy to concentrations from mountaintop mining increase. The increases
show that mining populations have poor public health outcomes, in selenium noted above have been linked to teratogenic
but more challenging to identify whether or not environmental deformities in fish and reproductive failure in fish and in birds
conditions caused by mining contribute to those outcomes over that consume the fish (Lemly, 2007).
and above socioeconomic and behavioral risks. The current paper
reviews the literature on the public health consequences of coal 3. Early health studies
mining, focusing especially but not exclusively on evidence since
2006 and evidence from mining in Appalachia. Appalachia is a Research conducted prior to Mr. Goodell’s publication includes
focus because of the advent of mountaintop removal mining, a a large body of evidence on the occupational health risks of coal
form of large scale surface coal mining that has major environ- mining. A few of those studies were cited above. The current
mental impacts, occurs in close connection to human settlements review will not attempt to summarize that literature, but rather
and has been most clearly identified as a public health concern by points to it only to illustrate that harmful consequences of
local residents. The paper will review the evidence base and exposure to mining activity have long been known. Miners are
present questions that direct the next research and policy steps exposed to diesel particulates, dust, chemicals, fuels and elemental
that should be undertaken to understand, and where indicated to toxicants (Scott et al., 2004). Of course, exposures faced by
reduce, the negative environmental impacts of coal mining on underground miners working in confined spaces do not mean that
public health. Before beginning to review the health literature, the there are harmful exposures faced by community populations. But
paper provides a brief description of mountaintop removal mining we also cannot assume that community environments are benign if
and its ecological impacts. they are located in proximity to mining activity.
The first studies on public health effects from coal mining
2. Mountaintop removal mining appear to have been conducted in Great Britain. Temple and Sykes
(1992) published perhaps the earliest account in the scientific
Mountaintop removal mining (MTR) is an aggressive form of literature. They showed substantial increases in medical visits for
surface coal mining that occurs on ridges and mountaintops in asthma in conjunction with the opening of a surface mine. Brabin
steep terrain. The depth and size of the coal seams and the et al. (1994) reported significantly higher occurrence of respiratory
topography of the land sometimes make other forms of mining symptoms among children exposed to coal dust, and a few years
impractical. It occurs in areas of four states in Central Appalachia later, Pless-Mulloli et al. (2000) reported weak but significant
including Kentucky, West Virginia, Virginia, and Tennessee, and is associations between surface coal mining and children’s respira-
distributed over an area approximately equal in size to the states of tory health (Howel et al., 2001; Pless-Mulloli et al., 2000). Pless-
Vermont and New Hampshire combined. About three million Mulloli in other studies, however, has reported no relationship
people live in counties where mountaintop removal is practiced. between surface coal mining and children’s respiratory health
Most residents in these areas live in valley bottoms along rivers and (Moffatt and Pless-Mulloli 2003; Pless-Mulloli et al., 2001).
streams or in other relatively small, flat areas beneath the An additional, relatively early study of coal mining effects was
mountains. reported from Turkey. Yapici et al. (2006) measured blood levels of
As early as 1997, mountaintop removal was recognized as a cadmium and lead in children living near coal mining activity, and
growing hazard and was characterized as “strip mining on found levels substantially higher than in other urbanized areas of
steroids” (Galuszka, 1997). As the name implies, the practice Turkey, and in the case of cadmium the levels exceeded World
involves the removal of up to hundreds of feet of rock and soil to Health Organization risk limits. They speculated that children may
reach coal seams. Before beginning this removal, forests are clear have ingested contaminated dust and soil secondary to air
cut and often burned. The rock and soil overburden is loosened by deposition. However, they were not able to ascertain whether
explosives, scooped by draglines and dropped into large trucks, the exposures were due to mining or perhaps resulted from other
which typically cart the overburden short distances to the nearest industrial activities in the area.
valleys where it is dumped over the side. The overburden It is interesting to note that in all of these earlier health studies
permanently buries headwater streams and eventually entire the focus was on possible effects from mining-related air pollution
valleys may be filled. The newly uncovered rock and soil are exposures. Possible risks from water pollution it seems had not
exposed to oxygen and rain and begin to leach long-sequestered been investigated. As mountaintop removal emerged as a major
minerals, metals and other chemicals. The water that emerges mining technique in the mid-1990s in Appalachia, concerns for its
from the base of the valley fills is contaminated with these ecological impacts revolved primarily around water. The focus on
chemicals. water seemed to be reinforced by early public concerns of
Important work on the water chemistry impacts of mountain- contaminated private well supplies. But the use of explosives
top removal mining has been conducted by several groups of and heavy diesel equipment, and the necessity of removing
researchers. This research shows that effluents from valley fills overburden to reach coal seams all suggest possible air pollution
typically contain high salinity, selenium, and sulfate concentra- effects, and both air and water exposure routes should be
tions (Vengosh et al., 2013). Sulfates can increase levels of toxic considered.
hydrogen sulfide (Palmer et al., 2010). Increases in pH, electrical

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4. Epidemiological evidence of public health disparities in tube birth defects for infants born in coal mining environments in
Appalachian mining communities China (Liao et al., 2010).
All of the studies reviewed in this section so far consisted of
As a consequence of the anecdotal and other early evidence, a secondary data analyses. They used data on mortality rates from
series of epidemiological studies were conducted in Appalachia the Centers for Disease Control and Prevention (CDC), self-report
beginning with a study that showed significantly higher hospitali- morbidity data from the Behavioral Risk Factor Surveillance
zation rates for hypertension and chronic obstructive pulmonary System (BRFSS), birth records from the National Center for Health
disease as a function of tons of coal mined (Hendryx et al., 2007). Statistics, data from a state cancer incidence registry, state
This was followed by a study of self-reported health indicators in a educational performance data, or state data on birth records.
large representative telephone survey of over 16,000 people in The mortality studies were limited to county-level ecological
West Virginia (Hendryx and Ahern, 2008). There was evidence for a designs rather than person-level data. None were able to assess
dose response effect in that persons living in counties where coal exposure at a finer geographic scale than the county of residence
mining was heaviest, measured by tons of coal mined, had (with the exception that the US birth defects study conducted
significantly worse health indicators for hypertension, respiratory additional spatial analyses to allow cross-county effects and found
disease and kidney disease, controlling for other risks, compared to evidence that mining effects crossed county lines). None measured
persons in areas with lesser amounts of mining or no mining. environmental conditions directly but only showed associations
Additional epidemiological studies using secondary data between mining and health outcomes, although there was
sources documented that coal mining in Appalachia was associated evidence of possible dose response effects and effects specific to
with higher adjusted mortality rates for total mortality (Hendryx MTR. These earlier studies, especially those using county-level
and Ahern, 2009), lung cancer (Hendryx et al., 2008), and chronic ecological designs, are suggestive only of mining effects on public
forms of heart, respiratory and kidney disease (Hendryx, 2009). health, but were followed by others using alternative designs and
Disparities were present for both men and women, and again were additional measures, as described below.
highest in areas where mining was heaviest. One important study Community health surveys have been reported that used
examined not mortality but incidence, and found higher adjusted person level survey data and selected samples living within a few
rates of lung cancer incidence rates in counties in eastern Kentucky miles of MTR, providing for a finer scale than county of residence.
with high coal production (Christian et al., 2011). These were primary data collection efforts rather than analyses of
These initial studies generally operationalized exposure to secondary data. These studies have documented higher self-
mining measured by tons of coal, regardless of the form of mining. reported cancer rates (Hendryx et al., 2012b), higher rates of a
More recent studies focused specifically on places in Central range of disease symptoms but especially respiratory conditions
Appalachia where MTR is practiced. Disparities documented for (Hendryx, 2013; Hendryx and Luo, 2014), and higher occurrence of
mining communities appear to be concentrated in mountaintop household illness and household cancer mortality (Hendryx,
removal areas. Esch and Hendryx (2011) showed that, after 2013). Strengths of these community surveys include the targeting
covariate adjustment, chronic cardiovascular disease (CVD) of sampled communities to include both active MTR and non-
mortality rates were significantly higher in MTR counties relative mining controls with similar demographics, the direct assessment
to non-mining counties, whereas counties where other forms of and control of covariates such as smoking and obesity, and the use
mining were practiced did not show higher CVD mortality. Within of the same survey approaches in mining and control communities.
MTR counties, CVD mortality rates increased significantly as a Overall the three survey studies interviewed 2346 adults. One of
function of surface tons of coal mined. these studies (Hendryx and Luo, 2014) employed a propensity
Other studies that examined MTR effects have found higher scoring methodology that offered a strong control for smoking and
levels of depression (Hendryx and Innes-Wimsatt, 2013), and other covariates and still found highly significant (p < .0001) MTR
poorer health-related quality of life (Zullig and Hendryx, 2011). effects on respiratory disease. A weakness of the surveys includes
Higher mortality rates in MTR areas have been observed for some the fact that survey times were largely limited to daylight working
forms of cancer including lung, colon, bladder, and kidney cancer, day hours and may not represent all residents, although this
and leukemia (Ahern and Hendryx, 2012). The MTR effect was cannot account for the differentially higher illness in mining
stronger in a later time period (2003–2007) relative to an earlier communities.
period (1999–2002), which may reflect cumulative exposure A study which analyzed secondary data was able to weigh
effects over time as MTR activities expanded. population exposure to mining according to population size and
Appalachian studies specific to children’s health are limited. geographic distance from mining at the level of the census block
One study documented that school children in West Virginia group, which is a finer scale than county (Hendryx et al., 2010).
mining areas show evidence of poorer cognitive development as Results showed that the weighted measure of exposure that took
measured by higher failure rates on standardized tests, controlling into account population size and distance to mining was more
for other risk variables (Cain and Hendryx, 2010). A second paper strongly related to cancer mortality rates than the cruder exposure
showed that pregnant mothers who lived in mining counties in measure based on tons mined at the county, arguing that
West Virginia were at higher risk for a low birth weight delivery, population exposure to mining contributed to the cancer
controlling for other risks (Ahern et al., 2011b). A third paper disparities and not unmeasured confounds.
documented higher rates of birth defects for mothers who during In sum, these studies clearly demonstrate that people who live
their pregnancy lived in counties where mountaintop removal was near coal mining in Appalachia experience a wide range of health
practiced (Ahern et al., 2011a). This study analyzed person-level problems. These include forms of cancer, cardiovascular and
birth records of almost 2 million deliveries. The study showed, for respiratory disease, kidney disease, developmental problems,
example, that the adjusted prevalence ratio for a cardiovascular or depression, poorer health-related quality of life, and a wide variety
respiratory birth defect was 1.93 (95% confidence interval = 1.73, of illness symptoms. Effects persist after statistical control for age,
2.15) for mothers in MTR areas relative to mothers who lived in sex, smoking, obesity, poverty, education, and other covariates.
non-mining portions of the same states, and that birth defect Health effects are present for men, women and children, indicating
disparities became stronger in more recent versus earlier years. An that they extend beyond possible direct occupational exposure
additional study outside the US reported higher rates of neural effects (almost all coal miners are men.) Health effects become
worse in a dose response fashion as measured by tons of coal

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mined, and are pronounced in areas of Central Appalachia where occur at surface mine sites as a result of deforestation, the
the most aggressive form of surface mining, mountaintop removal, liberation of rock and soil to reach coal seams, chemicals in
is practiced. However, none of these studies included direct explosives, wind erosion, dust from haul roads, the movement and
assessments of environmental conditions or biological exposures processing of coal itself, and the heavy use of diesel-burning
in mining communities. equipment including draglines, trucks, and trains.
In MTR environments, there is a small but growing body of
5. Environmental conditions in mining communities evidence that air quality is poorer in residential communities near
the mine sites compared to control sites. An unexpected finding
We know that MTR has detrimental impacts on surface waters from the first of these studies showed that particulate matter in
(e.g. Palmer et al., 2010), but whether those impacts affect human MTR residential communities was especially pronounced in the
health through drinking water is more difficult to ascertain. ultrafine range (Kurth et al., 2014). Ultrafine counts were measured
Community residents have expressed concerns about water across seasons using aerodynamic and scanning mobility particle
quality in proximity to mining activity in a Kentucky study sizers placed outdoors in residential environments. Ultrafines
(Blakeney and Marshall, 2009). In addition to the mining itself, (diameter <0.1 m) are increasingly recognized by the scientific
there is concern that contamination of private wells may occur community as particularly important when it comes to human
through chemicals used in the coal cleaning process. After coal is health impacts (Delfino et al., 2005; Oberdorster 2001; Peters et al.,
extracted, it is processed at local facilities that use proprietary 1997; Sioutas et al., 2005) because their small size allows for
formulas to remove impurities and noncombustible material. This deeper penetration into lung tissues and for possible transmission
cleaning process contaminates billions of gallons of water across from the lungs to the vascular system, and because they offer
mining areas. The water is disposed of by holding it in surface greater surface area per unit mass and thus relatively greater
impoundments where it may be treated in settling ponds before exposure to biological tissue. Ultrafines contribute little to
being released back to surface waters, or the water may be injected conventional mass estimates such as PM2.5 and PM10 and instead
into abandoned underground mine sites where it is ultimate fate is are measured by counts per cubic foot or meter. In the Kurth study,
unknown. The chemical profile of this water is poorly understood ultrafine counts in the rural MTR communities approximated those
but from West Virginia samples appears to contain ammonium, that have been observed in some urban environments. The average
phosphate, PAHs, phenols and hydrogen sulfide (Orem et al., 2012). ultrafine count for mining communities was 6830 per cubic cm,
Other analyses of coal slurry indicate that it contains coal fines, versus 4770 per cubic cm in non-mining control communities.
hydrocarbons, sulfur, silica, iron oxide, sodium and trace metals Another study found significantly elevated indoor and outdoor
(Ducatman et al., 2010; McAuley and Kozar, 2006). Tests on particle counts in a respirable range (0.5 < m < 5.0) in communities
drinking water from private wells near a slurry impoundment near surface mining compared to non-mining control communi-
revealed elevated levels of metals including lead, arsenic, barium, ties, although this study included both MTR and non-MTR surface
beryllium, iron, aluminum, manganese, zinc and selenium (Stout coal mining sites (Hendryx and Entwhistle, 2015). For example,
and Papillo, 2004). average counts in the respirable range were about 592,000
Contaminated water from mine sites or processing facilities has particles per cubic foot in the mining communities versus
clearly impacted private drinking wells in some instances. It is 334,000 in the non-mining communities (p < .01).
unknown how common or widespread this contamination may be. In addition to particle counts, it is important to understand the
The studies cited above provide some insight into these questions. chemical composition of particulate matter in mining communi-
Another suggestive but incomplete piece of evidence comes from ties. The complex mix of anthropogenic and natural sources makes
an analysis of water quality violations in public water systems in this a difficult undertaking. In a study by Kurth et al. (2015),
West Virginia (Hendryx et al., 2012a). Using data from the particulate matter was collected using high-volume active
Environmental Protection Agency’s Safe Drinking Water Informa- samplers placed outdoors in private household yards within a
tion System, the study examined violations in public water systems few kilometers of active MTR in West Virginia. Samples were
for the period 2001–2009 comparing public systems in MTR versus collected during all seasons. Particulate matter samples proximate
other parts of the state. Results indicated that MTR areas had an to MTR revealed elevated levels of inorganics including silica,
average of 73 violations per system compared to 10 violations per aluminum, and other rare earth elements that are present in the
system in non-mining areas. However, the bulk of these violations rock and soil around coal and are likely liberated by MTR activities
were not because levels of a particular contaminate were (Kurth et al., 2015). For example, about 85% of particles from MTR
exceeded, but rather due to failure to conduct required tests in areas were found to contain silica when examined under scanning
the first place, particularly for sampling of organic compounds. The electron microscopes, compared to 62% of particles from control
authors estimated that the number of health-based violations sites. The conclusion that the material likely represented matter
would be five times greater in the MTR area if the level of reporting liberated by MTR is based on the presence of crustal-derived
had been equal in both groups. More work is urgently needed to elements consistent with local lithogenic sources. The presence of
determine the quality of drinking water from public and private these crustal elements was 5.8 times higher in the MTR versus
sources in relation to MTR. control sites. Analyses of additional samples in other studies
Moving from water to air quality, studies in mining environ- confirmed elevated levels of silica (Knuckles et al., 2013;
ments outside of Appalachia show that surface mining creates Luanpitpong et al., 2014), which is an established health hazard
localized air pollution. Ghose and others have conducted a number and carcinogen. Organic constituents included a number of low
of studies in India showing elevated levels of particulate matter at molecular weight polycyclic aromatic hydrocarbons (PAHs)
surface mines in that country (Ghose, 2007; Ghose and Banerjee, characteristic of un-combusted coal, but also the presence of
1995; Ghose and Majee, 2000, 2007; Pandey et al., 2014). Air PAHs that result from fossil fuel combustion (Kurth et al., 2015).
pollution has also been observed around coal mines in Great
Britain (Reynolds et al., 2003), Australia (Higginbotham et al., 6. Biological links between MTR exposures and health
2010), and Columbia (Huertas et al., 2012a, 2012b). Soil contami-
nation secondary to air deposition has been observed for coal There is strong epidemiological evidence for poor health
mining areas in China (Liu et al., 2012; Wang et al., 2010) and conditions in mining communities, especially in relationship to
Turkey (Yapici et al., 2006). Air pollution could be expected to MTR. There is increasing evidence for air, and to a lesser extent,

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water quality problems in relationship to human exposures in these outcomes are partially attributable to serious and persistent
these mining communities. Connecting these two lines of evidence behavioral and socioeconomic disadvantages that characterize
would be studies that link environmental exposure, dose, and mining-dependent economies, significant disparities persist after
biological impact. Research in this vein has only started to emerge. control for covariate risks across multiple studies. Smoking, for
The first study in this area was based on particulate matter example, has been measured by self-report directly from study
collected by the investigators in outdoor residential environments participants in multiple studies and then controlled for statistically
(e.g. backyards and porches) where people lived within 1 mile of an in analyses. The results cannot be attributed to higher smoking
MTR site using low volume pumps and filters. Filters were rates in mining populations, or to factors such as higher obesity
collected and returned to the lab where particulate matter was rates or poverty rates. Furthermore, the evidence is stronger than
extracted. Results showed significantly impaired microvascular simply demonstrating a covariate-adjusted correlation between
function in rats upon respiratory exposure to MTR particulate mining and poor health, rather, the pattern of studies shows that
matter compared to control exposures (Knuckles et al., 2013). health disparities:
As an early indicator of biological impact in human populations,
a small study of adults showed that persons living within three Become stronger as amounts of mining increase
miles of surface coal mining had significantly elevated blood Are more pronounced in MTR areas compared to other mining
inflammation, measured by C-reactive protein, compared to areas
persons from non-mining communities (Hendryx and Entwhistle, Are present for men, women, and children's health indicators
2015). All participants were non-miners, non-smokers, not Become stronger as populations live in closer proximity to
pregnant, and reported no acute illness. This study was limited mining
by its small size (N = 48) and convenience sampling methodology. Become stronger in more recent versus earlier years as the
The study included adults in Indiana and West Virginia so was not impact of MTR has expanded in time and space.
specific to MTR. Blood samples were collected by capillary finger
sticks and analyzed by a commercial lab. Despite the small sample Second, the environmental evidence for impaired air and water
and the screening criteria that limited participants to relatively quality in mining communities is growing. There is strong evidence
healthy adults, the mean adjusted C-reactive protein levels were for ecological and ecosystem harm to surface waters caused by
more than five times higher in the mining sample (mean = 4.9 mg/L MTR (e.g. Lindberg et al., 2011). Evidence from other countries
in the mining group vs. 0.9 mg/L in the non-mining group.) It is documents air pollution in surface coal mining environments, and
important to note that, even though all participants were non- there is no reason to expect that US mining sites should be exempt
smokers, the mean level of 4.9 mg/L exceeds the recognized cut- from this phenomenon. In fact increasing evidence from MTR sites
point of 3.0 mg/L (Ridker, 2003) indicative of higher cardiovascular shows elevations in particulate matter compared to control sites,
or other disease risk. and shows that particulate matter from MTR sites is biologically
A final, compelling study found that particulate matter harmful. The quality of ground and surface water is impaired by
collected from MTR communities, but not from control communi- MTR. Studies have collected air and water samples directly from
ties, promoted tumor development and progression in human lung residential communities where people live. Impacts to drinking
cells (Luanpitpong et al., 2014). Particulate matter for this study water have been observed but the extent of population exposure to
was collected in the same manner as the Knuckles et al. (2013) impaired drinking water as a consequence of MTR is unknown.
paper. Indicators of tumor development and progression included Third, the mechanistic evidence linking mining exposures to
neoplastic transformation, accelerated cell proliferation and biological impacts in humans is underdeveloped. We still have little
enhanced cell migration of exposed lung cells in vitro. The information on the specific chemical exposures faced by residents
particulate matter from mining communities also promoted tumor of mining communities, the dose experienced by residents, or the
growth of human lung carcinoma cells that had been transplanted ways in which dose translates to biological effects. Air pollution
in mice. In this study, the level of particulate matter exposure was exposures likely include silica, PAHs, and other organic and
non-cytotoxic and estimated to represent what a human might be inorganic constituents. Exposures to particulate matter in the
exposed to over an eight-year period. ultrafine range may be especially important. Water exposures may
include a variety of metals along with chemicals used in coal
7. Conclusions and next steps processing. Research to investigate exposure, dose and effect
within representative samples of community residents and
A summary of the evidence for the public health impacts of coal controls is urgently needed.
mining includes the following observations and recommendations. Finally, the weight of the evidence, although incomplete, indicates
First, the epidemiological evidence for poor health status in mining that appropriate action should be taken. The precautionary principle
communities is strong. Any single epidemiological paper reported in environmental science argues that prudent steps are required
here has limitations. Covariates were measured and used as when there is evidence of environmental harm and corresponding
statistical controls but some degree of residual confounding is public health problems, even if all causal links are not understood
possible. Some studies were based on county-level ecological data. (Kriebel et al., 2001). Such is certainly the case for surface mining of
Some report mining exposure at the county level without coal. Prudent steps include more effective regulatory control over
specifying MTR versus other mining. Some are based on secondary surface mining practices to protect air and water and to protect
data while others that are based on primary data have imperfect public health. In the case of MTR, the complete termination of the
sampling methodologies. Any one study by itself would not be practice altogether has been previously called for based on the
convincing. But considered as a whole the pattern and the strength compelling scientific evidence of its harm (Palmer et al., 2010). The
of evidence for coal mining effects on public health are Palmer et al. (2010) paper, published in Science, focused primarily
considerable. People who live in coal mining communities are at on evidence for environmental rather than public health impacts,
increased risk for a range of poor health outcomes. These outcomes but concluded by stating, “Considering environmental impacts of
include some forms of cancer including lung cancer, non-cancer [MTR], in combination with evidence that the health of people
respiratory disease including chronic obstructive pulmonary living in surface-mining regions of the Central Appalachians is
disease, cardiovascular disease, kidney disease, depression, poor compromised by mining activities, we conclude that [MTR]
birth outcomes, and poor health-related quality of life. Although permits should not be granted unless new methods can be

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subjected to rigorous peer review and shown to remedy these Community Health 37, 320–327. doi:http://dx.doi.org/10.1007/s10900-011-
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Higginbotham, N., Freeman, S., Conner, L., Albrecht, G., 2010. Environmental
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