They looked at everything: the damage to the climate, to people’s health, and to the plants and animals around the mines. In the end, they estimated that the sum total of coal’s externalities amounted to between 9.42 cents and 26.89 cents per kilowatt-hour. Their best guess put it at 17.84 cents. The United States’ dependence on coal cost the public “a third to over one-half of a trillion dollars annually,” they wrote.

Since the study was conducted, new information has shown the energy source’s impact to be even more grave. “If we were to go back to do what we did in this paper,” said Jonathan Buonocore, a research fellow at Harvard who worked on the study, “the numbers could go up.”

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When coal is mined today in some parts of Appalachia, it’s not by burly union men descending into black caves underground. The rock instead is obtained by a kind of landscape vampirism, a process with a simple and brutal name: mountaintop removal.

First, workers clear mountains of their vegetation, cutting down and burning trees near the summit. Then, topsoil and bedrock from the hills is blasted away, a procedure that sometimes lops 600 feet off a slope’s overall elevation. Finally, the seams of coal, exposed to the air for the first time in millions of years, are harvested by enormous cranes called drag lines.

When completed, a once vernal hill looks like this:

Matt Wasson / Appalachian Voices

Mountaintop removal harms communities in special ways. Towns near removal sites are more likely to suffer from mudslides, dislodged boulders, and flash floods. Rocks and other debris, which the blasts can send flying, damage buildings and homes. Where forest used to be, there are ponds of coal slurry. Carcinogens and heavy metals fall into headwater streams, poisoning the water supply. And the environmental damage harms tourism and other local businesses: In Kentucky alone, almost 4,000 miles of streams have been polluted, damaged, or destroyed by mountaintop mining.

Coal has high costs beyond the reach of mountaintop-removal sites. The people who live in Appalachia pay for their community’s resource curse with their bodies. After miners retire, they—and others who worked near coal—suffer black lung, lung cancer, and other terminal diseases at elevated rates.

Coal takes a toll on even those who never descend into a mine: “All-cause mortality rates, lung cancer mortality rates, and mortality with heart, respiratory, and kidney disease were highest in heavy coal mining areas of Appalachia, less so in light coal mining areas, lesser still in non-coal mining areas in Appalachia, and lowest in non-coal mining areas outside of Appalachia,” wrote the authors.

The study estimated the full public-health cost of coal, in Appalachia alone, at $74.6 billion.