For one thing, the industry has consolidated. More than half of private land in West Virginia’s top coal producing counties is owned by the state’s top 10 landowners, none of them based in West Virginia, according to an assessment (PDF) released jointly in December by the West Virginia Center on Budget and Policy and the American Friends Service Committee. Almost 18 percent of the state’s 13 million private acres are divided among just 25 owners.

Large-scale ownership can lead to large-scale consequences. Many of the mines in Raleigh County’s Coal River Valley region, for example, are owned by Alpha Natural Resources —formerly Massey Energy, the company that owned the mine that collapsed and killed 29 workers in 2010. In early March, the energy conglomerate was fined $27.5 million and ordered to spend $200 million on wastewater treatment systems as penalties for its illegal dumping of coal-processing discharge into waterways in five Appalachian states, including West Virginia. It was the largest settlement ever levied against an energy producer by the Environmental Protection Agency. Cynthia Giles, head of the EPA’s enforcement office, told the AP that the fine marked the biggest case for permit violations, numbers of violations and penalty size, “which reflects the seriousness of violations.”

Coal’s hold on the community strangles any potential opportunities with other industries, Price said.

“Who is going to move into a community where you cannot drink the water?” he asked. “Where you are constantly seeing blasting and all those impacts? Who is going to locate a factory or any business to any area that is not fit to live in?”

Living in coal communities comes with a steep price. In 2008 coal amounted to an annual $74 billion public health burden in Appalachian communities, according to a study by Harvard Medical School’s Center for Health and Global Environment (PDF). In coal mining regions, the health consequences lead to 11,000 excess deaths each year from industry-induced ailments, such as lung cancer and respiratory disease, the study reported.

The direct cause is in the air, according to an epidemiology study authored by two West Virginia University professors released last month, which reported that the increased concentration of atmospheric particles making their way into lungs directly correlated to the elevated disease rates in mining areas, particularly MTR regions, which often have higher rates of cancer, birth defects, mortality and cardiovascular disease.

Despite the overwhelming health implications, many communities resist calls for enhanced regulation that would protect them, for fear of losing work.

“The reactions that we’re getting from people in the communities in Appalachia are, ‘We know this is a bad thing, but these are some of the few jobs that we have,’” Price said. “The coal industry has created a small economy where some communities are totally reliant on the coal industry for jobs and economic activity.”