American Scientist

Snow often falls early in Inner Mongolia, a Mongolic autonomous province in northern China. Local people in my hometown are not afraid of the incoming cold weather because Inner Mongolia has more than a quarter of the world's coal reserves. Many local residents work in the coal industry, and we have plenty of coal for generating electricity and space heating. On Chinese New Year Eve, our communities often light a small coal pile like a bonfire party, and people gather together and walk around the fire, believing that the heat from coal will bring good luck for the new year.

Yet living in a region producing a large amount of coal turned out to be a misfortune. Before I went to college, many of my family members had developed respiratory diseases and suffered from similar symptoms. However, they could not afford regular formal health care and often practiced self-care if the symptoms were not severe. As a result, when my grandpa was diagnosed with lung cancer right before his 68th birthday, the doctor told us that he only had about three months to live. Family members decided to withhold the news of the diagnosis from him and prepare the best and last birthday party for him. (Editors’ Note: Withholding a fatal diagnosis from a family member is not uncommon in China, as shown in the documentary, The Farewell.) At that party, we had a toy candle that played the “Happy Birthday” song on repeat, but I wasn’t happy at all. Hearing it made me cry secretly in another room. I really hoped this tragedy would never happen again and set myself the goal of becoming a medical doctor who can save lives.

In China, the majors of undergraduate students are often determined by their scores in the National College Entrance Examination. I failed to reach the score threshold for a medical school and ended up studying public finance. Feeling disappointed, I thought I would work in a bank after graduation, as many alumni in my major did. But that changed when I took the class Urban Economics, taught by Lanlan Wang of the Central University of Finance and Economics. She asked junior students to briefly introduce themselves to classmates and share their dreams. Without a second thought, I said, “I want to be a doctor, but I know…” I stopped talking when a few students laughed. However, Dr. Wang smiled at me and told me that achieving this dream is still possible. She said, “Don't give up, Ruoding. You may consider applying for a graduate program in health economics, and your future work can help many people improve their health.“ She planted a seed of hope in my heart, and it eventually grew into a flower: I came to the United States and studied food and health economics at Virginia Tech.

For my dissertation, I have studied the health impacts of living in coal mining counties for local residents like my family. Using individual mortality record data from the Virginia Department of Health, I estimated the coal-county effect by comparing the likelihoods of dying from respiratory diseases between coal-mining counties and tobacco-producing counties in the state of Virginia. Tobacco counties were chosen as an economic comparison group because they share similar characteristics as coal-mining counties, such as low economic diversification and low educational attainment rates. Our results showed that living in a coal county significantly increased the mortality risk of respiratory diseases, especially for male and working-age populations. This coal-county effect might be driven by air pollution around mine sites as well as the occupational hazard of people working in coal mines.

A shortage of doctors and low health insurance coverage significantly increased the mortality risk related to coal exposure. For example, doctors were leaving Lee County, Virginia, because the only hospital there was closed in 2013. This lack of doctors significantly increased the adverse health impact of coal mining in Lee County. Our model predicted that an additional 80 people died from respiratory diseases related to coal mining because doctors left Lee County. Indeed, this phenomenon is widespread among Appalachian coal-mining counties, which are often located in mountain areas and have limited access to health services. A 2004 survey by Kathleen Huttlinger, who was at Kent State University at the time, and her coauthors showed that many respondents in Appalachia had to wait up to three months for a doctor’s appointment due to the lack of specialty care providers. Without easy access to health care providers, one may delay seeing a doctor or getting a screening test until the disease becomes too severe to prevent mortality, because many respiratory illnesses related to coal exposure are symptomless in the early stages. As the demand for coal has decreased in the United States, several coal companies have declared bankruptcy and stopped contributing to the health-care benefits for their retirees. This loss of benefits might further hurt health insurance coverage in coal counties and increase mortality risk.

Because the U.S. government is attempting to revive the coal industry, more research is needed to address the potential increase in adverse health impacts in coal regions. The take-home message of my study is that people who live in coal counties suffer from illness and die at higher rates than people who do not, and that improving health-care access in the Virginia coal region is crucial to preventing their deaths from respiratory diseases. Our health-care system and society can do much more to make sure that people who live in rural, coal-producing areas remain healthy, by protecting the environment, retaining doctors, and making affordable insurance available. If your family members are living in coal counties like mine, it is best to do everything you can to get them the screening tests annually and buy the right health insurance to protect them.