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In the middle of a sentence, Gary Bone has to stop and gasp.

“I lose my breath,” he tells me through the phone.

Bone is 56 and suffers from asbestosis, chronic obstructive pulmonary disease (COPD), and black lung. These aren’t the only remnants of nearly 20 years working in the coal mines of West Virginia. A scar on his back marks the spot where three discs were removed from his spine after a rock fell on him.

“I can definitively say that there are higher levels of health problems in mining communities than others.”

“Any kind of injuries you can imagine, a coal mine’s going to have it,” Bone says. “I’ve seen people that’s got their eye put out, fingers mashed up, whole lot of cuts, whole lot of back injuries. Back injuries are one of the most visible things.”

Bone isn’t the only miner with stories like these. Junior Walk, an outreach coordinator with the anti-mining nonprofit organization Coal River Mountain Watch (CRMW), says his grandfather survived several injuries in the mines.

“He broke his back twice in two different rock falls underground, where the ceiling just collapsed in on him. Broke his legs once—both of his legs—getting run over by a man trip, which is how they transport you in and out of the coal mine,” Walk says. “He made me swear to him when I was a kid that I would never set foot in an underground mine.”

Today, Walk’s grandfather has black lung, and Bone’s mobility is severely limited. The biggest disasters of coal mining certainly make the news—like the Upper Big Branch Mine explosion in 2010, which killed 29 men and shook the ground beneath the house where Walk grew up. But a growing body of research suggests that the invisible threats that cause many miners to retire early—the respiratory problems, the cancer, the chronic disease—also debilitate and kill an untold number of West Virginians each year.

In recent years, research has drawn new links between coal mining and health problems in the areas where that mining takes place. In response, local groups are working to support further research and boost awareness of these problems. The chemical leak that left 300,000 West Virginians without water for more than a week in January, the 108,000-gallon slurry spill on Feb. 11, and another slurry spill just days ago have brought national attention to the issue. Local advocates hope that this attention, in combination with new research, will translate into a more open dialogue on the health dangers of coal mining.

Janet Keating, executive director at the nonprofit organization Ohio Valley Environmental Coalition, says that the spills should draw attention to the more chronic problems at hand.

“The day-to-day air and water pollution and associated health impacts from living with mountain removal and large-scale surface mining has been largely ignored by lawmakers and people in West Virginia living outside of the southern coal regions,” she wrote in an email.

Health impacts have been an everyday worry for Bone, whose wife has been by his side through all the doctor’s appointments and the difficult days. While we’re on phone, he stops to call out to her: “Peggy, put something on, it’s cold out!”

It’s one of the coldest Januaries in decades. Into the receiver, he says, “I should be doing that. I should be starting my wife’s vehicle.”

Chronic disease, birth defects, and coal

Mortality rates attributed to kidney, respiratory, and heart disease are significantly higher in Appalachian counties with high levels of coal mining, compared to non-mining areas, according to .

Cancer is a particular culprit. that compared two rural West Virginia communities, one with mining and one without, found that self-reported cancer rates were twice as high in the mining areas. In areas with mountaintop removal (or surface mining), rates of lung, bladder, kidney, and colon cancer, along with leukemia, are all higher than in non-mining areas. These findings control for other risk factors, like smoking and socioeconomic status. (Lung cancer and kidney disease hospitalization rates, though, were actually lower in areas with coal production. This may be because people aren’t necessarily hospitalized in the community where they live, the author of this study points out.)

COPD, which affects Gary Bone, to coal mining. The odds of COPD hospitalization increase 1 percent for every additional 1,462 tons of coal mined in an area during one particular year, according to . Odds of hospitalization for high blood pressure increase, too—1 percent for every 1,873 tons mined that year.

One of the most stunning findings of recent years: the risk for birth defects in areas where mountaintop-removal coal mining is prevalent is significantly higher than in non-mining areas, according to published in 2011. The study looked at two periods of time: 1996 to 1999, during which risk was 13 percent higher in areas with this type of mining; and 2000 to 2003, during which risk was 42 percent higher. Six of seven types of birth defects—including circulatory/respiratory, central nervous system, and gastrointestinal—were “significantly higher” in areas with mountaintop removal. This, again, is after controlling for other factors.

Dr. Michael Hendryx, a professor of applied health science at Indiana University, who co-authored the study, has been researching health issues in the coal mining areas of Appalachia since 2006. He says the research left him with little doubt about the impact of the mining industry.

“I can definitively say that there are higher levels of health problems in mining communities, especially mountaintop removal communities, than others,” he says. “To try to pretend that we don’t have enough information to try to act, that we don’t know what is happening, is unethical. It’s immoral.”

Not everyone agrees that the evidence is definitive. Nancy Gravatt, senior vice president of communications at the National Mining Association, points to several responses that she says refute the results of studies like Hendryx’s. One by Dr. Jonathan Borak, et al., concludes that coal mining isn’t an independent risk factor for increased mortality in the Appalachian region and points to other factors such as obesity and poverty. Borak’s paper was , though Borak has .

Representatives of coal company Alpha Natural Resources did not respond to interview requests for this article.

An environment built by coal

Another way that scientists have tried to assess the effect of coal on public health is to measure the air and water quality near both surface and underground mines.

“People in the state have been ‘done to’ and ‘done for’ long enough.”

Several recent studies indicate that when it comes to environmental pollutants, mining areas are often much worse off than areas where no mining is taking place. One collected particulate matter from the air within one mile of an active mountaintop removal site in southern West Virginia, and found it to be 38 percent sulfur and 24 percent silica. According to Hendryx, the silica (in this case, ) is a particular cause for concern.

“Crystalline silica is toxic. It’s highly carcinogenic, and I think it’s the silica in particular that’s driving the health problems we’ve seen,” he says.

Another paper, authored by Dr. Laura Kurth of the National Institute for Occupational Safety and Health and slated for release soon, has documented for the first time that there is more ultrafine particulate matter in areas with surface mining. Ultrafine particles are smaller than a tenth of a micron in size, and can penetrate through the lungs into the blood system, Hendryx explains.

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Water quality has also been affected by mining. A published in the Proceedings of the National Academy of Sciences in 2011 notes that waste rock from mountaintop removal mines is often disposed of in nearby valleys, where it comes into contact with streams. The study found that the amount of sulfate, magnesium, and selenium in the water increased in proportion to the amount of mining upstream, and in some areas, there was a “very high incidence” of selenium-linked developmental deformities in the larvae of two types of fish.

Large amounts of selenium , though it’s unclear whether there’s enough selenium in West Virginia waterways to harm humans. Still, selenium levels in West Virginia waters have been a topic of debate between community groups and politicians for years. In 2013, a bill to weaken current maximum selenium standards and conduct more research about whether selenium is actually impacting West Virginia streams passed almost .

One possible source of water pollution is the slurry that remains after the coal frothing process in coal prep plants, in which coal dust is separated from other materials so that the dust can be used. This slurry, and the chemicals in it, is pumped into huge reservoirs, called slurry impoundments, or into underground mines.

Gravatt confirmed in an email that, “On occasion, [slurry] can be disposed of in abandoned underground mines. To do so, operators need to get a permit from the state water authority (at least in the case of WV). It should be noted that disposing of such materials in abandoned, underground mines avoids placing the same materials on the surface in impoundments.”

Walk grew up with well water, and remembers that it would sometimes run red from the faucet.

“Anybody with half a brain wouldn’t drink it. But you still have to shower in it, you’ve got to wash your clothes, wash your dishes. Sometimes my parents would even cook with it because they boiled it and when you boiled it, it looked fine, smelled fine,” Walk said. He learned later that boiling the water doesn’t make the chemicals go away.

Science and community

Local groups have generally advocated for greater awareness about coal mining’s health impacts in three ways: community education, policy work, and direct action.

In 2013, OVEC partnered with the Southern Appalachian Labor School to host a series of public meetings in Fayette County, W.V., to educate people about the impacts of coal mining.

These meetings inspired a group of citizens to organize a study in their area with Hendryx’s help. About 45 people were surveyed for self-reported illnesses. Although the sample size was small, Keating said the most important result was empowering people to defend themselves.

“People in the state have been ‘done to’ and ‘done for’ long enough,” she said. “It’s time that people realize that they do have power.”

Many of OVEC’s efforts have centered around raising awareness in small communities. The organization provides water testing around the state upon request, and in the last two years, has hosted a conference to open up a dialogue between people affected by fracking and others affected by mountaintop removal. At least one faith group plans to help Hendryx conduct a survey this year, Keating said.

“There are a lot of people of faith here, and it’s more difficult for politicians or industry to marginalize us when we have solid backing from the faith community,” she said.

On the policy front, Coal Mountain River Watch in collaboration with OVEC and other groups that required Alpha Natural Resources, a coal company, to construct selenium treatment facilities at a cost of more than $50 million.

Today, CRMW is helping to spearhead the Appalachian Community Health Emergency Act in the U.S. Congress. The act, introduced in February 2013 by Rep. John Yarmuth, a Democrat from Kentucky, would require comprehensive studies on mountaintop removal’s impact on human health. It has 45 co-sponsors in the House.

Walk is a member of at least three local advocacy groups, and is a founding member of RAMPS (Radical Action for Mountain People’s Survival), which focuses on nonviolent direct action. He recalls one of those campaigns as we walk up a muddy path through Roberts Cemetery, a small island of public land at the center of the Hobet Mountain surface mining complex. Fallen leaves coat the hillside, but when we reach the top, the scene opens up: The mountains are mostly bare of trees. Ahead of us, a thin layer of grass sprouts from a huge pile of rubble that resembles a mountain, and in the distance, a few large machines groan dully. It’s a Saturday; the site is quieter than usual.

Walk describes an event that RAMPS put together called the Mountain Mobilization, which happened here at Hobet in July 2012. “It was pretty awesome,” he says. “We just had about 50 of our good friends go with us, climb up all over their equipment, and lock ourselves to things, and generally raise havoc that day on that mine site, and shut them down.”

The site was shut down for a day, and . Their total bail amounted to $500,000. But Walk’s goals were to raise awareness and cost the coal companies money, and RAMPS achieved those goals.

Home in the mountains

Walk and I stop the car off the side of Route 3, which runs for miles along the base of Coal River Mountain. We’re trying to get a good look at a valley fill, where rock and debris from a nearby mine piles up between the ridges to the south. It’s hard to see through the trees, but the sun is coming out on an otherwise gray December day, and flickering off the Big Coal River below. The branches sway in a gust of wind left over from the rainfall.

“I would never live anywhere else,” says Walk. He grew up just down the road, and as a kid, spent his free time riding four-wheelers in the mountains.

“My grandpa used to collect arrowheads a lot, … and there was this one place he used to take me on Coal River Mountain called Bear Wallow, and that place doesn’t exist any more,” he says. “It was on top of a ridge. They blew it up.”

After high school, Walk worked in a coal preparation plant for six months. Walk quit working there, but then took a job as a security guard at another plant.

“I felt like I had blood on my hands when I worked that job, and I just couldn’t do it,” he says. “I knew that the people who lived below that mine site I was making money off of were going through the same things I went through when I was a little kid, and I felt miserable about it. And that’s when I started coming around the local organizations around here and seeing what I could do to help out.”