Health and Environment Alliance (HEAL) [612354]

Health and Environment Alliance (HEAL)
THE UNPAID HEALTH BILL
How coal power plants make us sick
A report from the Health and Environment Alliance

The Health and Environment Alliance (HEAL) is
a leading European not-for-profit organisation
addressing how the environment affects
health in the European Union (EU). With the
support of more than 65 member organisations,
representing health professionals, not-for-
profit health insurers, patients, citizens, women,
youth and environmental experts, HEAL brings
independent expertise and evidence from the
health community to different decision-making
processes. Members include international and
Europe-wide organisations, as well as national and
local groups.
Responsible Editor: Génon K. Jensen, Executive Director,
Health and Environment Alliance (HEAL)
Lead Authors (writing and research): Julia Huscher, Coal
and Health Officer, HEAL; Diana Smith, Communications
Adviser, HEAL
Technical report: Mike Holland, Ecometrics Research and
Consulting (EMRC)
Technical review group: Prof Paul Wilkinson, London
School of Hygiene and Tropical Medicine (LSHTM); Dr Dorota
Jarosinska, European Environment Agency (EEA); Dr Juliet
Duff, Irish Doctors’ Environmental Association (IDEA); Roberta
Savli, European Federation of Allergy and Airways Diseases
Patients Associations (EFA); Lesley James, Friends of the Earth
UK (FoE); Pippa Gallop/Gordana Dragicevic/Nikola Biliskov,
Zelena akcija and CEE Bankwatch network; Lauri Myllyvirta,
Greenpeace International; Mona Bricke, Kliamaallianz
Germany; Matt Phillips, European Climate Foundation (ECF).
Research consultant: Madeleine Cobbing, Environmental
Consultant
Editorial advisory group: Anne Stauffer, Deputy Director,
HEAL; Lucy Mathieson, Communications and Campaigns
Officer, HEAL; Matt Phillips, European Climate Foundation
(ECF);
Preface: Professor Jean-Paul Sculier, European Respiratory
Society (ERS)
Testimonies: Birgit Beger, Standing Committee of European
Doctors (CPME); Monica Fletcher, European Lung Foundation
(ELF); Sascha Gabizon, Women in Europe for a Common
Future (WECF); Lidia Joanna Geringer de Oedenberg, MEP ,
Poland; Monika Kosinska, European Public Health Alliance (EPHA); Dr Peter Liese, MEP , Germany; Dr Antonyia Parvanova,
MEP , Bulgaria; Daciana Octavia Sarbu, MEP , Romania;
Roberta Savli, European Federation of Allergy and Airways
Diseases Patients Associations (EFA); Dr Philippe Swennen,
International Association Internationale de la Mutualité (AIM);
Professor Paul Wilkinson, London School of Hygiene and
Tropical Medicine (LSHTM).
Design: Lies Verheyen, www.mazout.nu
Printing : Mazout
Printed on 100% post consumer waste with vegetable based
inks
We warmly thank all the health, environmental and energy
experts who provided feedback on the text of the report.
Special thanks goes to the European Respiratory Society
(ERS) for providing the preface to this report, as well as to
the health advocates and health professionals, public health
experts and decision makers who provided their testimonies
for this publication.
HEAL would like to thank the Global Campaign for Climate
Action (GCCA) for their financial support for the production
of this report and the European Climate Foundation (ECF) for
our climate and coal campaign and advocacy work.
www.env-health.org/unpaidhealthbill
Published in March 2013 About HEAL
HEAL gratefully acknowledges the financial
support from the European Commission.
The views expressed in this document do not necessarily
reflect the official views of these institutions and
organisations.

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41Table of content
Preface
Executive Summary
Introduction: Chronic disease from
long-term exposure to air pollution
Health damage from coal power plant emissions
• Respiratory system
• Cardiovascular system
• Nervous system
• Health impacts from heavy metals and organic pollutants
• Climate change: The heat is on
Trans-boundary air pollution from coal power plants
The economics of health impacts from coal power
generation
Results of HEAL expert assessment of the impacts and
economic costs for Europe
Discussion
• Should coal power generation have a future in Europe?
• Can there be such a thing as ‘clean coal’?
Policy Recommendations
Annexes
• Annex 1 Technical Report: Methods for the impact assessment
• Annex 2 Health risks from various pollutants, pollutant guideline
values for ambient air and emission limit values for coal power plants
• Annex 3 Tool box: Relevant EU legislation and tools to achieve better
health protection
References

The European Respiratory Society (ERS) is the largest organisation in its field, bringing
together almost 12,000 respiratory specialists, scientists, researchers and other health
professionals. Our mission is to alleviate suffering from respiratory diseases and to
promote lung health through research, advocacy and medical and public education.
The environment is an important health determinant, and this is especially the case with
regard to lung health where exposures to pollutants in both indoor and outdoor air
damage the lung. For this reason, ERS aims to improve the prevention and management
of environment related respiratory disease and to contribute to an improvement in
respiratory health in Europe and elsewhere by the provision of information and evidence-based recommendations
to policy makers and the public. The scientific evidence on the link between air pollution and respiratory health,
both in terms of mortality and morbidity, is overwhelming, and so is the need to act.
ERS published its 10 Principles for Clean Air outlining what must change in order to achieve an adequate level of
health protection. At the core is the assertion that clean air is the right of every European citizen. This claim has
indeed been made since the early 1970’s in the Stockholm Declaration of the United Nations (UN) Conference on
the Human Environment which held that air must be safeguarded for the benefit of present and future generations
through careful planning or management.
European Union (EU) legislation needs to be revised to ensure that the air we breathe does not contain higher levels
of pollutants than recommended by the World Health Organization (WHO). Decision makers must act now and in
order to succeed all major sources for air pollution need to be addressed.
ERS warmly welcomes the current report on health implications of coal power plants in Europe by the Health and
Environment Alliance (HEAL) for showcasing how a single important source of air pollution in Europe contributes
to respiratory mortality and illness. Addressing air pollution from coal power plants alone has the potential to yield
significant savings to health budgets, especially given that an average coal power plant operates for at least forty
years. As 2013 is the European Year of Air where a review of EU air quality policy will take place, this is the right time
to act. Over the next few years there will be far-reaching investment decisions on existing coal power plants due
to the Industrial Emissions Directive (IED) coming into force. This is a significant opportunity to provide cleaner air
for European citizens.
Health professionals and especially respiratory experts can play an important role in highlighting the existing
evidence to decision makers. The current report provides an excellent source of information and points out why
the external costs of coal power must be taken into account. I welcome this report as it presents an opportunity to
highlight the urgent need for action on air pollution. I hope that it will serve to engage many respiratory experts in
policy debates on environmental health.
Prof Jean-Paul Sculier, Secretary for European Affairs, European Respiratory Society (ERS)Preface
Health and Environment Alliance (HEAL)THE UNPAID HEALTH BILL: HOW COAL POWER PLANTS MAKE US SICK
Page 4

THE UNPAID HEALTH BILL: HOW COAL POWER PLANTS MAKE US SICK
Having been on a downward trend for decades, the use of coal in power generation in Europe is on the rise again.
Coal is still a major energy source in Europe, accounting for approximately one fourth of electricity production.
Around 50 new coal power plants are currently in the pipeline. But the continued reliance on coal comes with a
price that decision makers are hardly aware of: the unpaid health bill. This health bill is paid by individuals, national
health care budgets, and by the economy at large due to productivity losses.
How is coal pollution making us sick? Coal power plants are an important contributor to air pollution in Europe,
which European respiratory experts have called an ‘invisible killer’ and one of today’s most important public health
threats. Exposure to outdoor air pollution is linked to a number of health impacts including higher rates of respiratory
and cardiovascular disease. This report developed by HEAL aims to provide:
• An overview of the scientific evidence on how air pollution impacts health and how
emissions from coal power plants are implicated in this;
• The first ever economic assessment of the health costs associated with air pollution from
coal power plants in Europe;
• Testimonies from leading health advocates, medical experts and policy makers on why
they are concerned about coal, and;
• Recommendations for policy-makers and the health community on how to address the
unpaid health bill.
The main findings
Emissions from coal power plants in Europe contribute significantly to the burden of disease from environmental
pollution. The brand-new figures published in this report show that European Union-wide impacts amount to more
than 18,200 premature deaths, about 8,500 new cases of chronic bronchitis, and over 4 million lost working days
each year. The economic costs of the health impacts from coal combustion in Europe are estimated at up to €42.8
billion per year. Adding emissions from coal power plants in Croatia, Serbia and Turkey, the figures for mortality
increase to 23,300 premature deaths, or 250,600 life years lost, while the total costs are up to €54.7 billion annually.
These costs are mainly associated with respiratory and cardiovascular conditions, which are two important groups
of leading chronic diseases in Europe. Together, coal power plants in Poland, Romania and Germany are responsible
for more than half of the total health impacts. Substantial impacts are further attributed to coal combustion in
Bulgaria, Czech Republic, France, Greece, Serbia, Turkey, and the United Kingdom.
Outdoor air pollution: a major risk factor to health
There is a large body of scientific evidence consolidating the various health effects of air pollution, both in terms of
premature mortality and acute as well as chronic ill-health. Although outdoor air quality in Europe has improved
over the years, outdoor air pollution is still a major public health threat. Executive summary
Health and Environment Alliance (HEAL) Page 5

THE UNPAID HEALTH BILL: HOW COAL POWER PLANTS MAKE US SICK
The European Environment Agency (EEA) estimates that 80-90% of the urban population in Europe is currently
exposed to levels of particulate matter and ozone that are higher than recommended by the World Health
Organization (WHO). Although coal power plants are only responsible for a small portion of total outdoor air
pollution, they are the most important source of industrial air pollution. A large coal power plant emits several
thousand tons of hazardous air pollutants every year and has an average lifetime of at least 40 years. Building new
coal power plants would mean that hazardous emissions and their effects on health would continue for many years.
It would also counterbalance short-term reductions in air pollutants achieved in other sectors.
The two-fold burden on human health: air pollution and climate change
Coal power generation is furthermore a major contributor to climate change, which was recognised by the
Director-General of the WHO as the major public health challenge of the 21st century. Coal is the most carbon-
intensive energy source in the EU, contributing approximately 20% of total greenhouse gas emissions. Evidence
is growing that Europe already experiences health impacts from climate change, and scientific models project
alarming increases in morbidity and mortality over the coming decades. While a phase out of coal in electricity and
heat generation in Europe is a prerequisite for preventing long term health impacts from climate change, it will also
benefit people’s health in the short term due to lower air pollution.
Top health concerns
Coal power generation adds to already poor outdoor air quality in Europe – caused mainly by the transport sector,
industrial processes, residential heating, and agriculture. Coal power plants release substantial amounts of particulate
matter, sulphur dioxide, and nitrogen oxides – the latter contributing indirectly to the formation of ozone. Of these,
the most worrying for health are fine particulate matter (PM2.5) and ozone. Because pollutants can travel over long
distances and across borders, the whole European population is affected by coal pollution, dispersed in outdoor air.
Significant evidence exists on how long-term exposure to these air pollutants affects the lungs and the heart. They
include chronic respiratory diseases, such as chronic bronchitis, emphysema and lung cancer, and cardiovascular
diseases, such as myocardial infarctions, congestive heart failure, ischemic heart disease and heart arrhythmias.
Acute effects include respiratory symptoms, such as chest tightness and coughing, as well as exacerbated asthma
attacks. Children, older people and patients with an underlying condition are more susceptible to these effects.
Recent research suggests that air pollution may also result in low birth weight and pre-term delivery as a result of
maternal exposure during pregnancy.
Other hazardous substances emitted from the smokestacks of coal power plants are heavy metals, such as mercury,
and persistent organic pollutants (POPs), such as dioxins and polycyclic aromatic chemicals (PAHs). These can either
be breathed in or taken up indirectly via food and water. Special concern arises from the large mercury emissions
from coal power plants as mercury can impair the cognitive development of children and cause irreversible damage
to vital organs of the foetus. Coal power plants are the most important source of mercury in Europe, and the EU is
addressing technical options to reduce these emissions within the framework of a new UN treaty.
Health and Environment Alliance (HEAL) Page 6

THE UNPAID HEALTH BILL: HOW COAL POWER PLANTS MAKE US SICK
A breath of fresh air: what needs to be done
From a health perspective, building new coal power plants would work against efforts to tackle chronic disease,
create substantial costs for public health and lock in hazardous emissions for decades. The external costs to health
from coal power generation have been missing from the debate on the future of Europe’s energy mix. These costs
should be taken into consideration in all future energy investment decisions. Conversely, claims that domestic coal
represents a cheap energy source need to be urgently revised.
Given the urgent need to tackle climate change and the substantial health risks related to air pollution, a phase
out of coal in power generation is imperative on health grounds, with a moratorium on new coal power plants as
a first step. Many EU Member States are struggling to meet air quality standards and plans to construct new coal
power plants would threaten their progress in curbing air pollution. Instead, investments in renewable energies and
energy savings should be prioritised. They have the potential to secure large health co-benefits, both in the short
and long term.
How medical professionals and public health experts can advocate for a phase out of
coal
Health and medical experts are becoming increasingly concerned about air pollution and the role of coal
combustion in it, and they have continuously highlighted the enormous health risks of climate change. In October
2011, over 500 health and security experts, including medical associations, leading medical research institutes and
public health organisations, called on governments to ban the building of new coal-fired power plants without
Carbon Capture and Storage (CCS) technology, and to phase out the operation of existing coal-fired plants, starting
with lignite plants due to their most harmful effects on health.
Public health experts and medical professionals can play a vital role, especially at the national and local level, in
making the phase out of coal a reality. They can draw on the scientific evidence presented in this report to highlight
the role of coal in air quality and climate change discussions. In addition, three annexes of this report contain specific
information that can be used to advocate for better health protection: a technical report, method for the impact
assessment; an overview of the most harmful pollutants originating from coal power plants and their associated
health risks; and a tool box on how to apply EU environmental laws to tackle coal pollution.
The engagement of public health experts will be crucial to ensure that the unpaid health bill is taken into account
in future energy decisions.
Health and Environment Alliance (HEAL) Page 7

Health and Environment Alliance (HEAL)THE UNPAID HEALTH BILL: HOW COAL POWER PLANTS MAKE US SICK
Page 8Chronic disease from long-term
exposure to air pollution
Coal power plants are an important source
of industrial air pollution in Europe. Their
substantial emissions have to be considered
against the backdrop of a multitude of
sectors contributing to outdoor air pollution,
especially transport, domestic heating, and
agriculture, as well as the complex dynamics
of air pollutants. Although overall air quality
has improved in Europe since 19901, outdoor
air pollution is still responsible for an average
reduction in life expectancy of 8.6 months2 or,
in other words, for 492,000 premature deaths
every year.3 Air pollution is the most important
environmental risk factor for the health of
Europeans. In a recent analysis on the Global
Burden of Disease commissioned by WHO, air
pollution ranked among the most important
risk factors for chronic disease in the European
region for the first time.4 More than 80-90% of
the urban population in Europe is exposed to
levels of particulate matter and ozone higher
than those recommended by WHO.5 Nearly every person is exposed to outdoor air pollution
throughout their life. This long-term exposure
significantly increases the risk of developing chronic
cardiovascular or respiratory diseases. Between 4% and
10% of the European population has been diagnosed
with chronic obstructive lung disease6, and about
30 million people in Europe suffer from asthma.7
Prevention of outdoor air pollution has to become a
priority given the large number of individuals affected
and the high levels of asthma, chronic bronchitis,
emphysema, and other chronic lung conditions.
Health damage occurs at lower levels of exposure than
previously thought.8 European respiratory doctors
have stated that the current EU limit value for fine
particulate matter in ambient air, which is well above
the guideline value recommended by WHO, offers
no health protection at all.9 The same is regarded to
be true, to a lesser extent, for the ozone.10 For both
pollutants, no absolute safe levels, at which no harm
to public health occurs, have been established.11 This
implies that exposure has to be kept as low as possible.
Coal power plants are responsible only for a part of
current outdoor air pollution; however, each coal
power plant emits huge amounts of hazardous air
pollutants every year and has an average lifetime of
at least 40 years. Allowing new coal power plants to
be built would thus lock-in hazardous emissions for
many years. It would also counterbalance short-term
reductions in air pollutants achieved in other sectors. Introduction
Older people, children and patients with chronic respiratory or
cardiovascular diseases experience the largest threat to their health and
well-being from air pollution, as they are more susceptible to the damage
done by the pollutants.
“The report provides the
first-ever calculation of
the human health costs
associated with coal-fired
power stations in Europe.
This important economic
assessment represents
an unpaid health bill that
should be taken into account when
determining energy policy.”
Génon K Jensen, Executive Director,
Health and Environment Alliance
© gettyimages

THE UNPAID HEALTH BILL: HOW COAL POWER PLANTS MAKE US SICK
Direct and indirect air pollution
from coal power plants
Chronic and irreversible harm to human
health is caused via direct and indirect
pathways by the air pollutants sulphur
dioxide, particulate matter and nitrogen
oxides (especially nitrogen dioxide),
which are emitted in large quantities by
coal power plants. Sulphur and nitrogen
oxides further react in ambient air, forming
secondary fine particulates, while nitrogen
oxides are also a precursor for ozone. Both
short and long-term exposure to particulate
matter and ozone are causing significant
damage to human health.
The main groups of diseases related
to these environmental risk factors are
cardiovascular, respiratory and nervous
system diseases.
“European doctors know
air pollution to be an
important risk factor for
health, and the CPME
has a long-standing
interest in this topic. Health professionals are
committed to bringing new evidence-based
information to the public as well as to decision
makers and using their voice to bring about
policy changes.”
Birgit Beger, Secretary General,
Standing Committee of European Doctors (CPME) THE UNPAID HEALTH BILL: HOW COAL POWER PLANTS MAKE US SICK
Health and Environment Alliance (HEAL) Page 9

Health and Environment Alliance (HEAL)THE UNPAID HEALTH BILL: HOW COAL POWER PLANTS MAKE US SICK
Page 10 10
Air pollutants released from smoke stacks
of coal-fired power stations constitute the
largest health risk for the general public in
comparison to emissions to the water or soil.
They cause both acute and chronic health
effects. Communities in the proximity of
coal power plants sometimes experience a
much higher exposure to certain airborne
pollutants.12 The major fraction of the air
pollution, however, is transported over
long distances and thus impacts a much
bigger proportion of the population, by
increasing the background levels of ambient
air pollution. The report focuses on the
health effects of air pollution for the general
population.
The diagram below details figures from an expert
assessment of the health impacts from coal power
plant emissions in the EU commissioned by HEAL and
detailed in the technical report in Annex 1. Health damage from coal power
plant emissions
Figure 1: Annual health impacts caused by coal power plants in the EU (27 countries)
(Source: HEAL expert assessment, see Annex 1, approximate figures)
18,200
premature deaths
2,100,000
days of medication
4,100,000
lost working days
28,600,000
cases of lower respiratory
symptoms15.5 – 42.8 billion per year Total health costs
Severity of
health impactProportion of
population affectedAssociated sick leave impacts productivity and causes
economic costs. The need to take medication or to
receive hospital treatment on the other hand is a
budgetary restraint for the people affected, as well as
for health care systems. But beyond economic costs it
is the personal well-being of individuals, families and
communities that should be protected from adverse
environmental effects.
“Concrete
opportunities for
preventing ill-health
are always good news
for health insurance
organisations. We intend to support all
advocacy efforts in favour of reducing
exposure to polluted air, including from
coal-powered electricity stations in Europe. ”
Dr Philippe Swennen, Project Manager,
Association Internationale de la Mutualité (AIM)

Health and Environment Alliance (HEAL)THE UNPAID HEALTH BILL: HOW COAL POWER PLANTS MAKE US SICK
Page 11 11Communities in the proximity of coal mines and coal
waste deposits, as well as coal miners and power
plant workers are often exposed to exceptionally high
concentrations of pollutants and thus have higher
overall health risks. These occupational or coal life cycle
related risks are not covered in this report.
Bearing in mind the beneficial public health effects
that a move away from coal will bring for the general
public, particular attention should be given to potential
socio-economic trade-offs for local communities
resulting from the closure of individual power plants.
Experience shows that a loss of workplaces and the
subsequent decline in household income have led to
significant health and social impacts in communities in
former industrial areas. Although a loss of workplaces
in the coal industry is likely to be offset by nationwide
job creation in the renewable energies and energy
efficiency sectors, adequate retraining systems and
employment initiatives for affected communities are
essential to overcome barriers to re-employment.
“As a Member of the
European Parliament,
I have been piloting the
Petition against a huge
open cast mine in the
area of Lower Silesia from the beginning, (that
is from 2010). I hope that the weight given by a
European Complaint as well as the national action
of many others struggling with similar problems –
governments, NGOs and private persons –
will give a chance for our local government to
arrange a dialogue with the national government
and through that work out a common position
that takes into account the needs of Polish energy
without forgetting about the rights and health of
local communities.”
Lidia Geringer de Oedenberg,
Member of the European Parliament, Poland© flickr creative commons

Health and Environment Alliance (HEAL)THE UNPAID HEALTH BILL: HOW COAL POWER PLANTS MAKE US SICK
Page 12 12
Health risks related to early life exposure
Children, even before birth, are particularly susceptible to air pollutants. Increasing
evidence shows how early-life exposure to air pollutants is contributing to higher risks
of developing chronic diseases later in life, including obesity, diabetes, and hormone
related cancers.16,17 Furthermore, recent studies found associations between exposure to
outdoor air pollution during pregnancy and lower birth weight,18 as well as higher rates
of preterm birth and pre-eclampsia.19
Air pollution from coal power plants is contributing to
higher rates of respiratory and cardiovascular disease as
well as mortality in Europe. With the exception of a few
countries, cardiovascular disease is the leading cause of
death in Europe and accounts for approximately 40%
of deaths or 2 million deaths per year.13 Public health
costs related to cardiovascular disease were estimated
at €196 billion a year for the EU,14 the respective
estimate for chronic respiratory diseases, coming from the European Lung Foundation (ELF) and the European
Respiratory Society (ERS), being €102 billion per year.15
It should be noted, however, that the figures above
are not intended for direct comparison with the
results of the expert assessment commissioned for this
report, as they are based on different methodological
approaches.
© Rainforest Action Network

Health and Environment Alliance (HEAL)THE UNPAID HEALTH BILL: HOW COAL POWER PLANTS MAKE US SICK
Page 13 13
How inhalation of particulate matter
may affect our health
Lungs
• Inflammation
• Oxidative stress
• Accelerated progression and exacerbation
of COPD
• Increased respiratory symptoms
• Effected pulmonary reflexes
• Reduced lung function
Blood
• Altered rheology
• Increased coagulability
• Translocated particles
• Peripheral thrombosis
• Reduced oxygen saturation
Vasculature
• Atherosclerosis, accelerated progression
and destabilisation of plaques
• Endothelial dysfunction
• Vasoconstriction and hypertensionHeart
• Altered cardiac autonomic function
• Oxidative stress
• Increased dysrhythmic susceptibility
• Altered cardiac repolarisaion
• Increased myocardial ischemiaBrain
• Increased cerebrovascular ischemia
Figure 2: Exposure to particulate matter (PM2.5) causes a multitude of health impacts
Adapted from source: Aphekom project  (2012): Summary report of the Aphekom project 2008-2011

Health and Environment Alliance (HEAL)THE UNPAID HEALTH BILL: HOW COAL POWER PLANTS MAKE US SICK
Page 14 14Respiratory system
Coal fumes contribute to polluting the air
with NOx, SO2, PM and secondary ozone,20
which can cause or exacerbate different
respiratory conditions. Ozone exposure
leads to acute breathing difficulties and
exacerbates conditions such as asthma and
chronic obstructive pulmonary disease.
Longer exposure to certain levels of fine
particulates can result in chronic obstructive
pulmonary disease (COPD)21, a group of
lung diseases including chronic bronchitis
and emphysema, which are characterised
by airways becoming narrowed, shortness
of breath, and continuing decline of lung
function. Fine particulates are even associated
with increased mortality rates for lung
cancer.22,23 In addition, diagnosed COPD is also
a risk factor for lung cancer mortality.24 Children are particularly susceptible to air pollutants,
because they breathe more air in relation to their
body weight and spend more time outside but also
due to the immaturity of their immune and enzyme
systems and their airways still being in the growth
process. Some air pollutants such as NO2 and PM2.5
adversely affect lung development in children which
often precedes the development of chronic pulmonary
diseases. Lung damage resulting from exposure in early
life reduces the maximal lung function level a child
can reach in adulthood.25 The clearest relationships
have been established for particulates and for nitrogen
oxides.
Asthma is a major respiratory disease and can be
triggered by air pollution. In particular, ozone exposure
can trigger or exacerbate asthma symptoms.26
Particulate matter is known to aggravate asthma
symptoms, too,27 but it is also suspected to contribute
to asthma development. There are 30 million asthma
patients in Europe and as many as 6 million of these
people suffer symptoms that are characterized as
severe.28 10% of European children suffer from asthma
symptoms. The European research project APHEKOM
found that 15-30% of new asthma cases in children
were explained by the child living close to busy roads
and thus being exposed to higher local levels of air
pollution.29 The economic consequences of this high
incidence are affecting public health budgets. The
total cost of asthma in Europe is estimated to be €17.7
billion per year, and productivity lost to patients’ poor
control of their asthma is estimated at €9.8 billion per
annum.30 Asthma and allergic disorders are one of the
major chronic diseases in children and one of the most
frequent reasons for a child to miss school, as well as
a leading cause of emergency department visits and
hospitalisations.31 In many cases the asthma will persist
throughout the person’s whole life.
Air pollutants also play a role in the development of
(COPD) a lung disease characterised by permanent
narrowing of the airways: Exposure to particulate
matter exacerbates the disease through the
development of inflammation.32 The development
of lung cancer as well as mortality from lung cancer,
which is the most frequent deadly cancer worldwide,33
is also correlated with long-term exposures to
particulates.34 “For patients with asthma,
allergies and other
respiratory diseases,
air pollution can have
severe consequences,
imposing limitations on
their daily lives, restricting
their activities outdoors
and even resulting in days off from work.
Policymakers should use every opportunity
to create an environment that is free from the
burden of air pollution, with looking at the
health implications of coal consumption being
one of them.”
Roberta Savli, EU Policy Officer,
European Federation of Allergy and Airways Diseases Patients
Associations (EFA)

THE UNPAID HEALTH BILL: HOW COAL POWER PLANTS MAKE US SICK
“We have estimated the costs of four
major respiratory diseases in Europe
at €47.3 billion per year. Improving
air quality will reduce these costs
already in the short term. Even daily
fluctuations have been shown to reflect
in the numbers of asthma attacks or
hospitalisation and in death rates. ”
Monica Fletcher, Chair,
European Lung Foundation
(ELF)
30 million
people
in Europe suffer from asthma
4% to 10%
of adults in Europe are
diagnosed with COPD
Health and Environment Alliance (HEAL) Page �5 �5
Health and Environment Alliance (HEAL) Page �5 �5
10%
of European children have
asthma
54,500
Europeans
die every year from lung cancers
attributed to air pollution3© flickr.com / Pulsetoday

Health and Environment Alliance (HEAL)THE UNPAID HEALTH BILL: HOW COAL POWER PLANTS MAKE US SICK
Page 16 16
Cardiovascular system
Air pollution’s negative impact on
cardiovascular health is increasingly
acknowledged in the peer reviewed
literature. Overall there is a clear positive
correlation between air pollution and
rates of major cardiovascular diseases,
as well as cardiovascular mortality. The
associations are the strongest for particulate
matter. A systematic review suggests that
cardiovascular mortality rises by 12% to 14%
per 10 microgram increase of fine particulate
concentrations.35
Even short-term exposure to fine particulate matter can
trigger myocardial infarctions, symptoms of ischemic
(= coronary) heart disease, stroke and heart
arrhythmias, and cause death. Increased hospital
admissions due to these conditions have been
documented for periods with elevated fine particulates
in ambient air.36,37,38 Long term PM exposure increases
the risk for developing a variety of cardiovascular
diseases, including hypertension and atherosclerosis.39
Fine particles with less than 2.5 microns diameter are
small enough to penetrate the lung tissue and enter
the blood stream. A recent literature review provides
evidence that these particles can cause inflammation
of cardiovascular tissue as well as coagulation of the
blood.40 Exposure to air pollution can thus be linked
to artery blockages, which lead to heart attacks.41 The
exact mechanisms through which air pollutants impact
cardiovascular health are not yet fully understood.
At least three main underlying mechanisms may be
involved42 with the different adverse effects changing
over time.43
Higher death rates from cardiovascular as well
as respiratory disease have been associated with
higher NO2 concentrations in Italian cities.44 Similarly,
decreases in cardiovascular mortality within a period
of a few years were associated with reductions in
particulate levels.45 “Air quality and its
impact on public health
have been overlooked
for too long and it is
now essential that we
identify and address
all health risks associated with air pollution.
We must link up our environmental objectives
with a concrete public health outcome on
chronic airways and cardiovascular diseases. All
Europeans have the right to breathe clean air!”
Antonyia Parvanova,
Member of the European Parliament, Bulgaria
© flickr / Oldonliner

THE UNPAID HEALTH BILL: HOW COAL POWER PLANTS MAKE US SICK
40% of deaths
in Europe are attributed to
cardiovascular diseases
2.5 microns
or less is the diameter of
the particles that affect
cardiovascular health
1.9 million
people die every year in the EU
from cardiovascular diseases�7 12-14%
higher mortality rates have been
associated with an increase of
�0 microgram particle mass per
cubic meter of air
Nervous system
Arteries that nourish the brain are affected by air
pollutants in the same way as coronary arteries by air
pollutants. Inflammation and oxidative stress due to
short or long-term exposure to air pollution can cause
ischemic stroke and other cerebrovascular disease.
An ischemic stroke is triggered by low blood supply
to parts of the brain. Enhanced exposure to PM2.5 has
been correlated with an increase in hospital admission
rates for ischemic stroke and other cerebrovascular
diseases.46,47 In particular, there is strong epidemiologic
evidence for a causal relationship between exposure
to particulate matter and the occurrence of
cerebrovascular disease (stroke and cerebral venous
thrombosis) among people with diabetes.48,49
Although a small proportion of all strokes appear to be
related to air pollutants, the large number of people
who suffer from a stroke means that even this small risk
leads to a large total health impact.50 Stroke events in
Europe were �.� million per year in 2000,5� projected to
rise to more than �.5 million per year in 2025.52
Health and Environment Alliance (HEAL) Page �7 �7

THE UNPAID HEALTH BILL: HOW COAL POWER PLANTS MAKE US SICK
Health impacts from heavy
metals and organic pollutants
New evidence shows that children exposed to
mercury or lead are three to five times more likely
to have problems associated with Attention Deficit
Hyperactivity Disorder (ADHD),57 even if the exposure
happens before birth.58
Estimates for current levels of mercury exposure, both
within and outside Europe, give rise for great concern.
A recent study estimated the burden of impaired
cognitive development in children based on exposure
estimates from a human bio-monitoring project in
17 European countries as well as literature data from
eight further countries. According to the study, about
200,000 children born in Europe each year have been
exposed to critical levels of methylmercury in the
womb. The associated costs resulting from lost IQ
benefits are estimated to exceed €9 billion per year for
the 27 Member States of the EU.59
Global as well as European efforts aim at phasing
out the use of mercury in different applications.60
Yet, this general aim is not recognised in energy
policy as there is no EU wide limit value for mercury
released to the air from coal power plants. Because
gaseous mercury can be transported over very
long distances, regulating mercury emissions from
coal power plants should be a common concern in
Europe. Mercury emitted to the air by coal power
plants is deposited through precipitation and enters
the water cycle, where it is then transformed to the
organic form of methylmercury by certain bacteria.
Methylmercury accumulates as it moves up the
food chain and reaches the highest concentrations
in long living fish species. Human exposure to the
neurotoxic methylmercury is mainly derived from the
consumption of contaminated fish. Increased levels
of methylmercury in fish have been shown in the
proximity of a coal power plant, although selenium
emissions from the same source partly masked the
effect in this study.61
Health and Environment Alliance (HEAL) Page 18 18MERCURY
COAL FIRED POWER
STATIONS…
are the biggest human source for mercury in
Europe in terms of total emissions.53 In the frame
of a new treaty under the UN aiming at the phase
out of man-made mercury emissions, the EU has
committed to implement technical measures
to decrease mercury emissions from coal power
plants.54 Organic mercury taken up through food
is notorious as a nervous system toxicant and
can cause birth defects. It greatly impacts the
brain development of children. This damage is
neurologically irreversible, and mostly arises from
exposure during early foetal development. Brain
injury happens at doses much lower than previously
recognised and there may be no safe level of
mercury in the body of pregnant women.55,56
© ResiGrass.com/Gazon_Synthétique

Page 19 19THE UNPAID HEALTH BILL: HOW COAL POWER PLANTS MAKE US SICK
Health and Environment Alliance (HEAL) Page 19 19
LEAD
THE HEAVY METAL
LEAD IS ALSO…
emitted by some coal power plants. Like
mercury, lead damages the developing nervous
system of children. In adults it can disturb
the functioning of the cardiovascular system,
which can lead to death, cause hypertension
or anaemia.62,63 It affects almost every system
of the body and is directly poisonous in high
concentrations. Other metals and semi-metals
(which are often included in the terminology
“heavy metals” in medicinal contexts) emitted
by coal fired power stations include the
carcinogens arsenic, beryllium and chromium. POP S
PERSISTENT ORGANIC
POLLUTANTS (POP S)
SUCH AS DIOXIN DO NOT…
break down and can remain in the environment for
many years. Dioxins are the most dangerous POP
and are created as unintentional by-products in
coal combustion, but they are only released in very
small quantities. Dioxins can be transported over
long distances and can cause significant harm even
at very low concentrations. Some dioxins can be
carcinogenic (they can cause cancer64), mutagenic
(alter genes), neurotoxic or reprotoxic (damage the
nervous system or the reproductive system),65 and
at least one is known as an endocrine disruptor (it
interferes with human hormone systems).66 Other
POPs originating from coal combustion are from the
group of polycyclic aromatic hydrocarbons (PAHs),
some of which are carcinogenic.67
“A pregnant woman’s
exposure to mercury
can cause irreversible
damage to the brain
development of her
unborn child. A recent
study has put a price tag on this in Europe to
the tune of some 9 billion a year. Stricter EU
regulation of mercury emissions, reducing to
a minimum use of coal in power production,
would represent an important step.”
Sascha Gabizon, Executive Director,
Women in Europe for a Common Future (WECF)© Troy Page / Truthout; Adapted: athos[hun], Takver

Health and Environment Alliance (HEAL)THE UNPAID HEALTH BILL: HOW COAL POWER PLANTS MAKE US SICK
Page 20 20Climate change: The heat is on
Coal combustion also has indirect health
effects as it is responsible for enormous
greenhouse gas emissions, which accelerates
climate change and thus contributes to a
number of present and future health risks,
also for the European region. Coal power
generation contributes to about 20% of
Europe’s total greenhouse gas emissions.68 It
is the most carbon-intensive energy source in
Europe.69
During heat waves hot temperatures and certain air
pollutants act in synergy and dramatically increase
the frequency of cardio-respiratory cases, leading to
an increase in hospital admissions on these days. For
example, it has been estimated that, for the UK alone,
there will be 1,500 more ozone-associated deaths
by 2020 due to climate change.72 According to ERS,
people with respiratory problems will be hit particularly
hard by temperature increases. For them, the risk of
premature death from heat stress is much higher, as
recent scientific evidence shows. For a 1°C higher mean
temperature in Europe overall mortality and hospital
admissions will increase two to three times more
among respiratory patients than on average.73,74
The heat waves of summer 2003
with more than 70,000 excess deaths
recorded in Europe can be regarded
as a foretaste of climate change health
impacts.70 Extreme events like heat
waves are becoming more likely as
global mean temperatures rise.71
Similar to the differences in susceptibility to air
pollution, the population groups that will be hit hardest
by climate change impacts are the elderly, children and
people with underlying medical conditions. Globally,
the impacts from unchecked climate change will affect
the health of billions of people.
“Emissions from
coal-fired power
plants pose a risk
to human health
and contribute to
climate change,
which in turn creates further threats to
health through the onset of more extreme
weather conditions.”
Daciana Octavia Sarbu,
Member of the European Parliament, Romania
© Flickr creative commons

Health and Environment Alliance (HEAL)THE UNPAID HEALTH BILL: HOW COAL POWER PLANTS MAKE US SICK
Page 21 21Of 10,000 industrial facilities in Europe, the
20 facilities causing the highest damage to
human health and the environment are all
coal power plants. For these 20 plants the
annual external costs are of the order of
several hundred million Euros each.75
Coarse particulate matter (PM10) is a component of the
ashes and soot created when burning coal, whereas
fine particles (PM2.5) with a smaller diameter are not
only emitted directly but are to a great extent created
by chemical reactions in the atmosphere between the
various air pollutants. The sheer quantity and number
of pollutants released from the combustion of coal
exceeds emissions from many other industrial sources,
such as the steel or chemical industry.76
Particulate matter can travel as far as a thousand
kilometres and precursors of ozone (so-called volatile
organic compounds or VOCs) even beyond that.
Nitrogen oxides remain in the atmosphere for about
four days, however, it has been demonstrated that nitrogen oxides originating from power plants in South
Africa can travel across the Indian Ocean to Australia.77
These facts make pollution from coal power plants
a European and not a national problem, as has long
been recognised in EU policy measures such as the
National Emission Ceilings Directive, designed to address
acidification and ground level ozone pollution across
the EU.Trans-boundary air pollution from
coal power plants
Figure 3: Likely scale of diffusion of direct and indirect pollutants from coal power stationsThe health damage caused
by coal combustion is not
limited to the proximity
of the power plant, as
the exhaust cloud from
the smokestack can be
transported up to several
hundred kilometres and
across borders, until
pollutants deposit in
ecosystems or in people’s
lungs. The height of
smokestacks and wind
conditions determine
where pollution is
transported.
LOCAL
(�0km)
Coarse particulates
(PM10), nitrogen oxides,
sulphur dioxide, acid
gases, persistent organic
pollutants, heavy metals,
dioxinsGLOBAL
(>�000km)
Fine particulate matter
(PM2.5), mercury,
dioxins TRANS-
BOUNDARY
Sulphur dioxide,
nitrogen oxides, VOCs,
heavy metals, dioxins,
fine particulates (PM2.5)
“Polluted air is a top risk
factor for ill-health in Europe.
Families with low income
are more likely to live near
industrial sites or busy roads
and are thus more likely to
be impacted. Addressing air
pollution can help to reduce
health inequalities.”
Monika Kosinska, Secretary General, European Public Health Alliance (EPHA)

Health and Environment Alliance (HEAL)THE UNPAID HEALTH BILL: HOW COAL POWER PLANTS MAKE US SICK
Page 22 22Table 1 shows the annual total emissions of 20 large
coal power plants in Europe. These plants are among
the largest coal power plants in terms of electrical
power and burn large amounts of coal. They cause an estimated €7.7 – 21 billion of health and environmental
damage annually.78 Only five of these plants are fired
by hard coal whereas 15 use lignite, also called brown
coal.
Facility name Country Village/
TownSO2 (t) NOx (t) PM�0 (t) Mercury
(kg)
Maritsa iztok 2 Bulgaria Kovachevo 138,000 11,800 : :
Turceni Romania Turceni 81,200 14,000 1,320 426
Bełchatów Poland Rogowiec 73,500 41,900 1,450 1,580
Megalopolis A Greece Megalopoli 47,900 2,510 1,540 169
Jänschwalde Germany Peitz 21,400 18,700 573 348
Rovinari Romania Rovinari 54,800 11,100 1,850 340
Drax UK Selby 28,100 40,600 586 222
Turów Poland Bogatynia 39,800 12,100 1,490 :
Kozienice Poland Świerże
Górne35,100 21,700 730 411
Romag Termo Romania Drobeta
Turnu
Severin34,500 2,230 604 98
Longannet UK Kincardine 45,200 15,200 587 110
Isalnita Romania Isalnita 21,300 1,270 529 :
Gorivna Bulgaria Galabovo 58,600 1,060 : :
Nováky Slovakia Zemianske
Kostoľany36,400 3,540 : :
Niederaußem Germany Bergheim 6,870 17,900 386 467
Lippendorf Germany Böhlen 13,800 8,570 108 1070
Bobov dol Bulgaria Golemo
selo41,400 3,540 2,700 :
Prunéřov Czech
RepublicKadaň 17,300 16,800 635 196
Deva Romania Mintia 17,900 7,400 2,460 :
Rybnik Poland Rybnik 18,600 15,100 498 :Table 1: 2009 air pollutant emissions of the 20 most health damaging coal fired power stations in Europe
Ranking according to “High VSL” estimate, EEA 2011b; Emissions data: European Pollutant Release and Transfer Register
: indicates no data reported or no emissionsLIGNITE
COMBUSTION:
more dangerous to
human health
Burning one tonne of lignite,
commonly known as brown
coal, will usually release less air
pollution in comparison to hard
coal. However, as lignite has a
lower energy content than hard
coal, up to three times as much
lignite needs to be burned in
order to generate the same
amount of energy. A lignite
plant with the same electrical
power output as a hard coal
fired plant will thus generally
have more hazardous air
pollution emissions, correlated
also to the lower efficiency of
the plant. These plants also
have to meet lower emission
standards than hard coal plants,
so if new lignite plants were
built they would be an even
larger source of health damage
than refurbished hard coal
plants.

Health and Environment Alliance (HEAL)THE UNPAID HEALTH BILL: HOW COAL POWER PLANTS MAKE US SICK
Page 23 23The external costs caused by coal power
plants in terms of harm to human health
and the environment are not included in the
price for electricity. However, power plants
are obliged to report their annual emissions
to the EU, namely the European Pollutant
Release and Transfer Register E-PRTR, which
makes these data publicly available. By
modelling the dispersion of the pollutants
in the atmosphere and taking into account
the size of the population that is exposed,
external costs to health can be quantified. The external costs to health for electricity produced
from lignite and coal are higher than for any other
energy source in Europe.79 According to an assessment
published in The Lancet in 2007, based on the results
of the European research project ExternE, one Terawatt
hour (TWh) of electricity produced from hard coal
implies on average 24.5 air pollution related deaths.
Lignite combustion was associated with an even
higher number of 32.6 premature deaths per TWh. In
addition, 298 cases of serious respiratory, cardiovascular
and cerebrovascular disease (225 for hard coal) were
part of the estimated health burden of electricity
generation from lignite, as well as 13,288 (hard coal:
17,676) cases of minor illnesses. In comparison, a large
coal power plant operating at full load throughout
the year usually produces several Terawatt hours of
electricity.80
A recent report by the European Environment Agency
(EEA 2011) found that the largest share of damage
to health and the environment from industrial air
pollution in Europe came from power plants.81 Two
thirds (between €66 and €112 billion) of the total
damage of €102 – 169 billion annually was caused
by thermal power plants.82 Excluding damage from
CO2, the external costs from the energy sector were
estimated at €26–71 billion. However, the EEA report
did not include reference to the type of fuel consumed
by the power plants, nor differentiate their efficiency
or size. The data base used for HEAL’s assessment are
data reported from facilities falling under the Large
Combustion Plants Directive (Directive 2001/80/EC),
which contains fuel details.The economics of health impacts from coal
power generation
“The external costs to health from coal
power generation are bigger than for any
other energy source. The costs of reducing
greenhouse gases are
partially paid back
because of lower health
costs.”
Professor Paul Wilkinson,
London School of Hygiene and
Tropical Medicine (LSHTM)
© flickr / ugod

Health and Environment Alliance (HEAL)THE UNPAID HEALTH BILL: HOW COAL POWER PLANTS MAKE US SICK
Page 24 24HEAL commissioned an expert assessment of the
health impacts and costs from coal-fired combustion
plants for 30 countries in Europe (EU27 plus Croatia,
Serbia and Turkey). The assessment is based on data
reported under the Large Combustion Plants Directive
(LCPD), while the calculation of health impacts and
related costs is based on the same methodology as
used by the Clean Air For Europe (CAFE) Programme.
Detailed information on the methodology and data
sources can be found in the technical report in Annex 1.
The main findings are:
• The total health impacts from coal combustion
plants in the EU amount to 196,218 life years lost, or
18,247 premature deaths per year. When including
Croatia, Serbia and Turkey in the analysis mortality
increases to 250,604 life years lost, corresponding to
23,289 premature deaths, annually.
• Chronic health effects were calculated with 8,580
new cases of chronic bronchitis every year, and
5,498 hospital admissions due to respiratory
or cardiovascular conditions were additionally
attributed to coal pollution in the EU.
• Acute impacts are for example about 28.6 million
incidents of lower respiratory symptoms. • Ill-health causes people to miss their work or at
least limit their active tasks on certain days. About
4.1 million lost working days out of a total of 18.2
million restricted activity days for the working age
population were associated with coal power plant
emissions in the EU.
The results of this expert assessment are well within the
range of the coarse factors for mortality and morbidity
established by the ExternE project and cited in a
study in The Lancet in 2007.83 To each of the adverse
health outcomes a theoretical price tag is proposed
in scientific literature. The total costs of ill-health and
mortality in the EU together amount to €15.5 to 42.8
billion annually (lower and upper bound due to two
different expressions of mortality). Premature deaths,
health care costs caused by additional cases of chronic
bronchitis and restricted activity days account for
the largest expenditures. These costs are paid from
different budgets, ranging from national health care
budgets, to those borne by the overall economy in
lost productivity, and ultimately individuals’ household
budgets and savings.
Table 2: Health impacts and attributed costs from coal power generation in the EU (2009)
Health impact Burden associated with coal power
generation in the EU (2009)Attributed costs
(€ million per year)
Chronic mortality (premature deaths, VSL) 18,247 37,954
Chronic mortality (life years lost, VOLY) 196,218 10,596
Chronic bronchitis 8,580 1,785
Hospital admissions (respiratory and
cardiovascular)5,498 13
Restricted activity days (working age
population)18,242,034 1,769
Lost working days 4,140,942
Respiratory medication use 2,066,720 2
Lower respiratory symptoms 28,587,351 1,201
TOTAL COSTS 15,453 – 42,811 RESULTS OF HEAL EXPERT ASSESSMENT OF THE HEALTH
IMPACTS AND COSTS FOR EUROPETHE UNPAID HEALTH BILL: HOW COAL POWER PLANTS MAKE US SICK

Health and Environment Alliance (HEAL)THE UNPAID HEALTH BILL: HOW COAL POWER PLANTS MAKE US SICK
Page 25 25
Country Health costs in million Euro, mortality upper and lower bound (VOLY and VSL)
Austria 74 27
Belgium 134 46
Bulgaria 4,629 1,678
Czech Republic 2,842 1,034
Denmark 63 23
Estonia 445 159
Finland 169 62
France 1,879 697
Germany 6,385 2,303
Greece 4,089 1,474
Hungary 268 101
Ireland 201 72
Italy 857 312
Latvia 3 1
Netherlands 386 129
Poland 8,219 2,979
Portugal 90 33
Romania 6,409 2,315
Slovenia 228 86
Slovakia 925 336
Spain 827 310
Sweden 7 3
UK 3,682 1,275
non EU countries
Croatia 243 88
Serbia 4,987 1,832
Turkey 6,689 2,448
Total 54,730 19,821
EU 27 42,811 15,453Table 3: Economic valuation of the health impacts by source countryTHE UNPAID HEALTH BILL: HOW COAL POWER PLANTS MAKE US SICK
European countries contribute different amounts to
these overall health costs. Table 3 details the costs
on a country level. Coal pollution from Bulgaria,
Czech Republic, France, Germany, Greece, Poland,
Romania, Serbia, Turkey and the United Kingdom, each
accounts for costs of more than €1 billion in annual health damage. Poland, Romania and Germany are
ranking highest in total health costs and together are
responsible for more than half of the price tag.84 It is
important to note that the attribution of health costs to
individual countries does not reflect where the health
impacts finally occur.
Costs to health excluded from the
assessment
The assessment excludes health impacts from emissions
to water, and focuses only on three main air pollutants.
It further excludes neurological damage related to
the release of mercury, which is significant. A recent
assessment showed that preventing environmental
exposure to methylmercury could save the EU €8-9
billion Euros per year.85
More importantly, the assessment does not consider
all health impacts during the life cycle of coal, for
example the impacts from coal mining, transport and
waste disposal. A study on US coal power published in
2011 estimated the full life-cycle costs of coal power
generation at up to US$500 billion (about €400 billion).86
More importantly, it concluded that coal prices would double or triple if external costs were included; the best
estimate for the almost full life cycle related costs was
US$0.178 cents (€0.14) per kilowatt hour of electricity.
Several EU Member States directly or indirectly subsidise
coal combustion and coal mining. For example, in 2005
taxpayers contributed €2.7 billion for coal subsidies in
Germany alone.87 Although coal is promoted as a cheap
fuel, new coal plants receive substantial state subsidies,
whether directly or through tax exemptions – financial
resources which are thus diverted from investment in
renewable energy. In the light of substantial external
costs to public health, claims that coal is a cheap fuel
need to be revised, and state and EU subsidies to coal
extraction or coal power plants should be abandoned
immediately.

THE UNPAID HEALTH BILL: HOW COAL POWER PLANTS MAKE US SICK
Coal is still one of the major sources of primary
energy in the European region: 25% or one in
four kilowatt hours of final electricity consumed is
generated by coal power plants,9� with �5% from
hard coal and the smaller fraction from burning
lignite (�0% of electricity consumed).92 Roughly 200
million tons of hard coal and 400 million tons of
lignite were burned in the EU in 20�0. The obvious
lack of correlation with the electrical output data is
due to the lower calorific value of lignite, requiring
more fuel to be burnt. Some EU Member states do
not use coal at all in their electricity mix (Cyprus,
Lithuania, Luxembourg and Malta). Air pollution
from coal power, however, is a joint concern for all
European countries, due to its transboundary nature.
On the other hand, a wave of ageing coal plants is
due to close before the end of 20�5 because of EU
legislation (the Large Combustion Plants Directive)
that requires them to have improved SOx, NOx and
dust controls in place by that date, or to close. More
than half of the European coal fired power plants are
already older than 25 years, and �0% are older than
40 years.93 Some utilities chose to invest in their old coal plants and refurbish them, while others chose
to close them before the end of 20�5, and in some
cases propose new coal plants to replace them.
During the last couple of years, if a proposed new
coal plant had not already been granted a permit,
its chances of moving from announcement to
construction in the EU were small. For example, since
2007, only seven new plants have been permitted in
the EU and 67 proposals for new plants have been
abandoned. Instead the EU is promoting safer and
healthier electricity generation capacity through
massive investments in renewable energy sources.
In 20�� for example, 7�% of newly installed capacity
in the EU was renewables-based. This demonstrates
that new coal is no longer necessary for electricity
supply anywhere in Europe as other options
become more viable. Not one of the new coal plants
proposed in Europe is needed to keep the lights on
and indeed phasing out coal in power generation by
2040 is a realistic goal.94Over the past decades, the use of coal for electricity generation in the EU has fallen, from
39% in �990 to 24% in 20�0.88 However, there are indications for a recent short term
rebound in coal electricity and heat generation89,90 due to high gas prices and a low carbon
price. The threat of continued investment in coal in the EU and some of its neighbouring
countries still looms. Some countries intend to further exploit their domestic resources
of lignite because they regard it as a cheap fuel contributing to national energy security,
although it is the dirtiest and least efficient form of coal. An increase in coal utilisation for
energy generation is not a safe option in view of current levels of air pollution and the
impacts on health.SHOULD COAL POWER
GENERATION HAVE A FUTURE
IN EUROPE?
Health and Environment Alliance (HEAL) Page 26 26THE UNPAID HEALTH BILL: HOW COAL POWER PLANTS MAKE US SICK

Health and Environment Alliance (HEAL)THE UNPAID HEALTH BILL: HOW COAL POWER PLANTS MAKE US SICK
Page 27 27How coal might jeopardise
reaching climate targets
Runaway climate change, which could already be
triggered by 2 degrees celsius of global temperature
rise and which would cause immeasurable impacts
on human health, must be avoided. Therefore global
greenhouse gas emissions have to decline steeply over
the next decades. The EU as well as other industrialised
countries of the G8 have pledged to reduce their
greenhouse gas emissions to 80% below the level of
1990, as a fair share of global efforts to stay below the 2
degrees threshold.95
Anything other than a substantial reduction in the
amount of coal consumed for power generation would
move this target out of reach, even if technology
was to be applied in all new and most of the existing
plants that would almost completely eliminate CO2
emissions.96 In particular Carbon Capture and Storage
(CCS) technologies have been discussed as a means
to burn coal with few greenhouse gas emissions.
However, the technology gives several reasons for
concern and poses substantial risks to human health
(see next chapter).The huge public health benefits that arise from
decreasing the burning of fossil fuels such as coal
can substantially mitigate costs of greenhouse gas
reductions. Putting it the other way around, mitigating
climate change saves enormous costs in air pollution
control. Importantly, the health benefits already occur
at a short and medium time scale.Around 50 new coal power plants are
currently in the pipeline in Europe
(excluding Turkey); about half of these
would burn locally mined lignite. The
average life span of a coal power plant
is at least 40 years. If any of the 50 new
coal power plants were built millions of
tons of hazardous air pollution, massive
health damage and greenhouse gas
emissions would be locked in for
decades. This unhealthy future has to
be avoided.
In October 2011 over 500 health and
security experts called on governments
to ban the building of unabated coal
power plants and to phase out the
operation of existing coal-fired plants,
starting with lignite plants, due to their
most harmful direct effects on health.
The British Medical Journal (BMJ)
conference statement calls for urgent
action on climate change and has been
signed by medical associations, leading
medical research institutes and as well
as public health organisations.97 “The EU has
committed to
protect public health
from air pollution as
well as from climate
change impacts.
As the use of coal
in Europe is currently increasing, there is a
significant threat to people’s health in the
short and long term.”
Dr. Peter Liese,
Member of the European Parliament, Germany

THE UNPAID HEALTH BILL: HOW COAL POWER PLANTS MAKE US SICK
CAN THERE BE SUCH A
THING AS ‘CLEAN COAL’?
Even maintaining the status quo of the current coal burning capacity will lead to immense
damage to public health. An increase in coal generating capacity would be detrimental to
health protection. Voices from the industry claim that new coal power plants would deploy
‘clean coal technology’ and thus replacing older coal power plants with new ones would
lead to improvements in air quality. The following paragraphs aim at shedding more light
on the myth of clean coal. An important consideration in any debate on clean coal should
be that there is no legal requirement in Europe to close down an old coal power plant
whenever a new one is constructed. The promise of clean coal thus implies the risk of an
increase in the overall number of coal power plants.
CLEANING UP
EXISTING COAL PLANTS
THROUGH IMPROVED
FILTER TECHNOLOGY
Existing coal power plants have to be
required to apply the best pollution
control technology available, in order
to minimise their impact on people’s
health. This includes electrostatic filters
or fabric filters for particulates and
desulphurisation appliances. Improved
pollution control would transfer part of CAN MORE
EFFICIENT COAL
POWER PLANTS
BE CLEAN AND
SAFE FOR HUMAN
HEALTH?
Technical advances mean more
efficient coal power plants, but
improvements are small. The
higher the efficiency of a coal
fired power plant the less coal it
consumes to produce � kilowatt
hour of electricity. The current
state-of-the-art thermal efficiency
of a coal power plant in Europe
is between 34% and 40%. The
new generation “high efficiency”
coal plants have a maximum
46% efficiency for hard coal and
43% for lignite. In other words,
more than half the coal burnt in a
“high efficiency” coal plant is not
converted to useful electricity.
In addition, there is a general trade-off between improvements
in efficiency and improvements
in air pollution control: current
filter technology decreases the
thermal efficiency by about �%.98
The better the different filters can
catch particulates, sulphur and
nitrogen oxides, the more energy
or steam they consume within the
power plant.
If a coal power plant not only
produces electricity but also
heat, (an option called combined
heat and power generation
(CHP) or co-generation), the
total efficiency is much larger,
although less electricity is
produced. However, selling the
heat requires a different business
model that many utilities are not
yet interested in taking on and
the plant needs to be close to a
suitable user for the heat; many
large plants are situated far away
from centres of population.
Another technological option
targets the CO2 in the air: Carbon
Capture and Storage (CCS) is
the most frequently discussed “clean coal technology” . Although
frequently promoted as such, CCS
cannot make coal carbon neutral,
nor will it make the exhaust fumes
free of hazardous air pollutants.
The technology carries a number
of important further health risks
and to date remains an empty
promise.
Health and Environment Alliance (HEAL) Page 28 28THE UNPAID HEALTH BILL: HOW COAL POWER PLANTS MAKE US SICK

Health and Environment Alliance (HEAL)THE UNPAID HEALTH BILL: HOW COAL POWER PLANTS MAKE US SICK
Page 29 29
CAN HAZARDOUS
AIR POLLUTANT
EMISSIONS BE
REDUCED BY
CARBON CAPTURE
AND STORAGE
TECHNOLOGIES?
CCS technologies are widely
discussed as a means to make coal
combustion a ‘clean’ technology
in terms of low greenhouse gas
emissions. Through direct and
indirect effects CCS would also
impact the rate of emissions of
hazardous air pollutants: NOx
emissions from a CCS coal power
plant would be higher, while SO2
emissions would decrease.99

The central principle of CCS is
to separate carbon dioxide from
a gas mixture, for example in a
coal power plant, compress and
transport it and then dispose of the CO2 underground.100 Some CCS
options for the capturing process
require a high reduction of sulphur
oxides or particulate matter in the
gas beforehand, so that the ultimate
emissions of SO2 and PM10 are
low. Those CCS technologies that
filter the flue gas after combustion
usually use organic solvents, which
may also capture some hazardous
air pollutants, while others will not
be filtered out.
The downside of every CCS
technology is that it is very
energy intensive and burns 20-
30% more coal, in other words, it
substantially reduces the efficiency
of the coal plant.101 This leads to
higher total emissions of NOx per
kWh electricity produced while it
may counterbalance the above
mentioned effect for particulate
matter emissions and reduce the
positive effect on SO2 emissions. The
oxy-fuel combustion technology
seems to be the only CCS option
currently under development that
may decrease both greenhouse gas
and air pollutant emissions from the
combustion plant.102Apart from the continued health
impact from air pollution, the
storage of captured CO2 below
ground poses additional significant
risks to human health and the
environment. At the storage site,
groundwater may be contaminated
by leaked chemicals used in the
injection process, or by the upwards
displacement of brine loaded
with toxic metals and organics.103
CO2 leaking during transport or
from the storage site could cause
headaches and unconsciousness
at concentrations of 7 to 10%104,
whereas an accidental release of
huge quantities of the gas could
even cause mass suffocation.
The risks emanating from different
stages in the CCS life cycle simply
make it a gamble with people’s
health. From the health perspective,
CCS should not be pursued as
an energy option in Europe. The
only proven way to decrease all air
pollution from coal power plants
is installing the best abatement
technology available.
the costs that would otherwise
be imposed on public health
back to the polluter.
The most recent EU legislation
with regard to pollution control
from coal power plants is the
Industrial Emissions Directive
(IED), which will come into
force in 20�6 and introduces
stricter emission limits for
existing as well as new coal
fired power plants. Some of the
neighbouring countries of the
EU, the signatories of the Energy
Community Treaty (including
Turkey, the Ukraine and the countries of the Western Balkans)
have also bound themselves to
IED pollution controls albeit on
a slightly slower timetable and
with no enforcement mechanism.
But the standards laid out in the
IED are already out of date – the
USA and China both introduced
far higher pollution controls
for all major air pollutants from
coal power plants in 20�2. For
example, the Chinese and USA
limit values for nitrous oxides
emissions are 100 and 117 mg/m3
respectively, whereas the EU limit
value is 200 mg/m3.�05 Unfortunately, the text of the
IED provides for a number of
loopholes and derogations
that could be granted to older
plants so that they can continue
operating with higher pollution
levels until 2020-2022 or even
longer.�06 These gaps in the IED
need to be closed immediately.
Furthermore, the Chinese and the
USA examples show that the EU
should even raise the standards
set in the IED in order to better
protect public health from
hazardous emissions. Better filter
technology is already available.

Health and Environment Alliance (HEAL)THE UNPAID HEALTH BILL: HOW COAL POWER PLANTS MAKE US SICK
Page 30 30
POLICY RECOMMENDATIONS
The time is right for advocacy on
the health damage from coal.
Based on the established scientific
evidence about the health risks
from coal combustion, doctors
and health organisations can add
a long neglected perspective to
the debate about Europe’s future
energy supply.
THEY SHOULD >>>>> Highlight to EU and national decision makers
that the health impacts and external costs of
coal have to be taken into account in energy
decisions. From a health perspective building
new coal power plants is detrimental to
efforts of tackling chronic disease and creates
unnecessary costs.
Become involved in the debates on higher air
quality standards and more ambitious climate
action at EU level as well as nationally.
Raise awareness on the health risks from coal
power in local consultation processes and
help to ensure the enforcement of better
pollution control for existing coal in order to
protect public health. The tool box in Annex 3
aims to support medical experts by showing
how they can get involved in relation to coal
power plants in their region.
TO MEDICAL PROFESSIONALS
AND PUBLIC HEALTH EXPERTS:
Health and Environment Alliance (HEAL) Page �� ��
THE UNPAID HEALTH BILL: HOW COAL POWER PLANTS MAKE US SICK

Health and Environment Alliance (HEAL)THE UNPAID HEALTH BILL: HOW COAL POWER PLANTS MAKE US SICK
Page 31 31
National authorities have to take the
gloves off and reduce outdoor air
pollution from coal power plants. In
the interest of their citizens’ health but
also of their neighbouring countries
THEY SHOULD >>>>> Introduce a moratorium on the
construction of new coal power plants.
Develop a national phase-out plan for
coal in power generation.
End all exemptions from the highest
pollution control standards for existing
coal plants.
End all direct and indirect subsidies and
tax exemptions for hard coal and lignite
mining as well as coal power generation
by 20�8, when direct hard coal mining
subsidies are already required to end.
TO NATIONAL AUTHORITIES:
The phase out of coal
power in Europe is possible
by 2040 and constitutes an
important step to improve
air quality, reduce chronic
disease and cut greenhouse
gas emissions at the same
time.
THEY SHOULD >> Ensure that the costs and benefits to health are
taken into account in any energy and climate
policy assessments and decisions.
Strengthen the IED which regulates air pollution
from coal power plants by removing all
exemptions for existing plants.
Adopt stricter emission limit values, comparable
to recent Chinese and USA standards, for the
whole of the EU by 2020 and introduce binding
mercury emission limit values.
Make sure that Croatia as an EU accession
country is required to meet EU pollution
control standards for coal power plants without
any derogation by 20�8, and encourage EU
candidate countries to do likewise.
Support a termination of all EU lending,
including by EU financial institutions, to coal
plants, coal mining and infrastructure projects
that would contribute to an increase in coal
capacity. Similarly, support an ending of EU
subsidies for CCS technologies.
TO THE EU:
Health and Environment Alliance (HEAL) Page �1 �1THE UNPAID HEALTH BILL: HOW COAL POWER PLANTS MAKE US SICK

Health and Environment Alliance (HEAL)THE UNPAID HEALTH BILL: HOW COAL POWER PLANTS MAKE US SICK
Page 32 32ANNEX 1
TECHNICAL REPORT, METHOD FOR
THE IMPACT ASSESSMENT
The approach used to quantify effects follows the impact pathway approach developed in the EC-funded ExternE
study107 and adopted for assessment of air quality regulation in the EU since the mid-1990s, including the Clean Air
For Europe Programme that underpinned the development of the EU’s Thematic Strategy on Air Pollution. Analysis
proceeds through the following stages:
1. Quantify emissions. For most of the countries featured in the analysis data on emissions, combined with information
on fuel used, are taken from the Large Combustion Plant Database held by the European Environment Agency.108
Emissions were taken for the year 2009. Emissions for some plant result from the use of more than one fuel, and
for the present purposes it is necessary to allocate emissions by fuel. The following relationships have been used,
drawing on plant-specific information from a large number of case studies under the ExternE Project series, covering
plant with a variety of abatement technologies in place. Application of these factors has made a difference in
total emissions attributed to coal of only 8% for SO2, 3% for NOx and 6% for dust compared to a simpler approach
where emissions were attributed to different fuels according to the thermal input of each fuel. This small difference
between the cases suggests that any uncertainty introduced by this scaling process is very small.
Table 4: Typical pollutant emission ratios relative to coal for large combustion plant
Emissions of dust are specified in the LCP Directive as applying to total suspended particulate (TSP). For the
purpose of the analysis presented here, TSP needs to be converted to PM2.5, the fraction of particulate matter that
is sufficiently fine to penetrate deep into the lung. A factor of 0.59 is applied to convert TSP to PM2.5 drawing on
information from ExternE109 (a factor of 0.9 to convert from TSP to PM10) and CAFE110 (a factor of 0.65 to convert from
PM10 to PM2.5).
Three countries, Czech Republic, France and the Netherlands, do not report the fuel used to the LCP database. Data
are also unavailable from the LCP Database for Croatia and Turkey. A second source111 has been used for data from
all five countries, reports to the European Environment Agency (EEA) under the UNECE Convention on Long Range
Transboundary Air Pollution, taking emissions for the sector ‘Public Electricity and Heat Production’, again for 2009.
This provides the following estimates for the sector:SO2NOXDUST
Coal and lignite 1.00 1.00 1.00
Oil 1.00 1.50 0.42
Natural gas 0.00 0.38 0.00
Biomass 0.36 0.61 1.00

Health and Environment Alliance (HEAL)THE UNPAID HEALTH BILL: HOW COAL POWER PLANTS MAKE US SICK
Page 33 33Table 5: Emissions from ‘Public Electricity and Heat Production’ in 2��9
Particle emissions are this time expressed as PM2.5 for the Czech Republic, France and the Netherlands, and so
there is no need to apply conversion factors for these countries. However, in all cases, results apply to total
emissions from power and heat production, rather than from coal fired facilities specifically. Data on fuel mix
are derived from the Eurostat energy database��2 (Table 6) except for Serbia��3 and the emissions from Table
5 allocated to coal generation using the factors shown in Table 4. The figures exclude the nuclear fraction of
generating capacity (on the grounds that it will not directly emit the pollutants of interest here) and the waste
fraction. The latter will cause some overestimation in attribution of the share of coal, though this is considered
likely to be small, and balanced by other biases in the analysis towards underestimation.
Table 6: Relative proportion of different fossil fuels and biomass used in power generation in each
country (excluding nuclear, hydro and waste)
Results are shown in Table 7. A separate assessment of emissions of SO2 and NOx from the Turkish power sector
developed by Greenpeace (L. Myllyvirta, personal communication) suggests that the CLRTAP data may be too
pessimistic for Turkey (PM emissions were not considered). Comparison of PM emissions for Turkey with those
of other countries with high emissions of the three pollutants suggests potential for error in the PM data also.
To account for this, an alternative PM emission estimate for Turkey has been generated by applying the ratio of
PM2.5 : NOx from Bulgaria, Greece, Poland, Romania and Serbia combined. An alternative set of emissions data
are therefore shown for Turkey in Table 7. Whilst the ends of the ranges shown may be questionable, there
is reasonable confidence that the true figure for emissions is within the range shown. Reflecting some other
conservative positions adopted here, the lower estimates have been used for the analysis in the main report.SO2NOXPM2.5TSP
Czech Republic 104,345 79,233 1,871
France 74,114 68,259 2,277
Netherlands 6,335 26,314 272
Croatia 25,830 7,455 1,226
Serbia 244,546 108,580 2,744
Turkey 946,689 380,292 142,591
COAL OIL NATURAL GAS BIOMASS
Czech Republic 95% 0% 2% 3%
France 41% 8% 45% 6%
Netherlands 25% 0% 70% 5%
Croatia 28% 34% 38% 0%
Serbia 99% 0% 1% 0%
Turkey 35% 3% 62% 0%

Health and Environment Alliance (HEAL)THE UNPAID HEALTH BILL: HOW COAL POWER PLANTS MAKE US SICK
Page 34 34Table 7: Estimated emissions from coal and lignite fired power generation for the countries for which
complete data were unavailable from the LCP database
2. Assess human exposure to pollutants. This is based on earlier analysis designed to derive damage figures per
tonne emission of various pollutants, using transfer matrices developed using the EMEP model114 to describe
atmospheric chemistry and transport. Since the model runs were originally undertaken the dispersion modelling
has been revised in relation to the formation of HNO3, effects of which are assessed here via the contribution of
NOx emissions to atmospheric particles. It is reported115 that:
The largest differences was found for nitrate aerosol, where changes up to around 40%
appear for countries with high NOx and NH3 emissions.
For the purposes of the present analysis this is accounted for by a 50% reduction in nitrate exposure in all
countries. Whilst this goes beyond the reported reduction it provides better transparency for the analysis than a
more complex, country by country, approach.
3. Apply response functions to quantify effects on health, using the functions, prevalence and other data reported
for use in the methodology of the Clean Air For Europe (CAFE) Programme116 and also by the EEA117.
4. Apply valuations to obtain the economic equivalent of impacts to health. The data used here are again taken
from the methodology of the CAFE Programme, which remains the recommended data set for application in
analysis for the European Commission. The values used are updated in line with the EEA’s assessment of damage
by facilities reporting via the E-PRTR. Mortality is valued using both the value of a life year (VOLY) and the
value of statistical life (VSL), reflecting alternative views of economists working in the field (the present author’s
preference is for the former). Taking the extreme positions on each gives a range of a factor of about 3 from low
to high.
5. No account is taken in this analysis of damage to receptors apart from health. Hence, results exclude damage
from acid deposition to buildings, including cultural heritage and from deposition of acidifying and eutrophying
pollutants to ecosystems.SO2NOXPM2.5
Czech Republic 103,172 77,736 1,814
France 59,396 49,393 1,854
Netherlands 5,910 23,453 227
Croatia 11,665 2,642 475
Serbia 244,546 108,580 2,745
Turkey 871,950 336,968 80,517
Turkey (lower estimate) 760,100 182,000 29,086

Health and Environment Alliance (HEAL)THE UNPAID HEALTH BILL: HOW COAL POWER PLANTS MAKE US SICK
Page 35 35Table 8: Health costs from coal power generation per country, per capita and per kilowatt hour electricity
COUNTRY TOTAL COSTS,
VSL UPPER BOUND
ESTIMATETOTAL COSTS,
VOLY LOWER
BOUND ESTIMATECOSTS PER CAPITA118
(VSL )RELATIVE COSTS,
EURO CENT PER
KWH ELECTRICITY119
PRODUCED FROM COAL
(VSL)
Austria 74 27 9 2.0
Belgium 134 46 12 2.6
Bulgaria 4,629 1,678 608 23.3
Czech Republic 2,842 1,034 271 6.2
Denmark 63 23 11 0.4
Estonia 445 159 332 5.8
Finland 169 62 32 1.5
France 1,879 697 29 8.7
Germany 6,385 2,303 78 2.6
Greece 4,089 1,474 363 12.0
Hungary 268 101 27 4.2
Ireland 201 72 45 5.0
Italy 857 312 14 2.2
Latvia 3 1 1 2.5
Netherlands 386 129 23 1.6
Poland 8,219 2,979 216 6.2
Portugal 90 33 8 0.7
Romania 6,409 2,315 298 29.5
Slovenia 228 86 112 4.5
Slovakia 925 336 171 24.0
Spain 827 310 18 2.3
Sweden 7 3 1 1.4
UK 3,682 1,275 60 3.6
EU27 42,811 15,453 87 5.3
Croatia 243 88 55 14.7
Turkey 6,689 2,448 94 12.3
Serbia 4,987 1,832 680 21.5
TOTAL 54,7�� 19,821 95 6.2

Health and Environment Alliance (HEAL)THE UNPAID HEALTH BILL: HOW COAL POWER PLANTS MAKE US SICK
Page 36 36ANNEX 2
HEALTH RISKS FROM VARIOUS POLLUTANTS, POLLUTANT
GUIDELINE VALUES FOR AMBIENT AIR AND EMISSION LIMIT
VALUES FOR COAL POWER PLANTS
a The guideline values listed here refer to ambient outdoor air and are derived from the WHO 2000 Air Quality Guidelines for Europe as well as the 2005 WHO Air quality Guidelines Global Update.
The WHO gives recommendations for concentration limits that should not be exceeded, based on a review of the scientific evidence on health effects. The limit values for SO2, NOx and PM are
in contrast set for the exhaust air from coal power stations and thus have a different order of magnitude. They were taken from the Large Combustion Plants Directive 2001/80/EC which will be
substituted by Directive 2010/75/EC from January 2016 on. Other limit or target values are concerning ambient air and have been taken from Directive 2008/50/EC and Directive 2004/107/EC
on ambient air. POLLUTANT RELATED HEAL TH RISKS12� GUIDELINE AND LIMIT VALUESa
Carbon dioxide (CO2) Indirect health impacts from climate
change
High volume hazardous air pollutants
Sulphur dioxide (SO2) Can affect respiratory system and lung
functions, aggravation of asthma and
chronic bronchitis, makes people more
prone to infections of the respiratory
tract; irritation of eyes; cardiac disease
aggravated ; ischemic stroke riskWHO AQ Guidelines121:
20 μg/m3 (day)
500 μg/m3 (10min)
Directive 2001/80/EC:
400 mg/m3 (old plants),
200 mg/m3 (new plants)
Nitrous oxides (NOx); Asthma development (suspected),
asthma exacerbation, chronic
obstructive pulmonary disease, stunted
lung development; cardiac arrhythmias,
ischemic stroke.
Reacts with VOCs in sunlight to form
ground- level ozoneWHO AQ Guidelines89:
NO2: 40 μg/m3 (year),
NO2: 200 μg/m3 (1h)
Directive 2001/80/EC:
NOx: 500 mg/m3 (old plants)
NOx: 200 mg/m3 (new plants)
Particulate matter:
coarse particulates (PM10),
fine particulates (PM2.5)Respiratory: asthma development
(suspected), asthma exacerbation,
chronic obstructive pulmonary disease,
stunted lung development (PM2.5), lung
cancer;
Cardiovascular: cardiac arrhythmias,
acute myocardial infarction, congestive
heart failure (PM2.5).
Nervous system: ischemic stroke.WHO AQ Guidelines:
PM2.5 10 μg/m3 (year),
PM10 20 μg/m3 (year)
Directive 2001/80/EC:
(monthly, total dust)
50 mg/m3 (old plants),
30 mg/m3 (new plants)
Directive 2008/50/EC:
25 μg/m3 target PM2.5 (year),
50 μg/m3 (day) limit PM10, not to
exceed on >35 days
Ammonia (NH3) Respiratory irritation, can cause skin
and eye burns. Precursor of secondary
particulates.WHO AQ Guidelines:
270 μg/m3 (day)
Hydrogen Chloride and Fluoride
(HCl, HF)Acute irritation to skin, eyes, nose,
throat, breathing passages.

Health and Environment Alliance (HEAL)THE UNPAID HEALTH BILL: HOW COAL POWER PLANTS MAKE US SICK
Page 37 37Organic pollutants
Dioxins and furans (e.g.,2,3,7,8-
tetrachlorodibenzo-dioxin , short TCDD)Probable carcinogen (stomach cancer);
affect reproductive, endocrine and
immune systems. Dioxins accumulate
in the food chain.WHO AQ Guidelines value:
TCDD 70 pg/kg weight/month
tolerable intake (provisional)
Polycyclic Aromatic Hydrocarbons
(PAHs): e.g., Benzo-a-anthracene,
Benzo-a-pyreneProbable carcinogens; may have
adverse effects on the liver, kidney,
and testes; may damage sperm cells
and impair reproduction. PAHs can be
attached to small particulate matter
and deposit in the lungs.No guideline value, to be kept as low as
possible
Directive 2004/107/EC:
benzo-a-pyrene: 1ng/m3 (air)
Non-Methane Volatile Organic Compounds (VOCs)
Aromatic hydrocarbons: e.g. benzene,
xylene, ethylbenzene, tolueneIrritation of the skin, eyes, nose, throat;
difficulty in breathing; impaired
function of the lungs; delayed response
to visual stimulus; impaired memory;
stomach discomfort; effects to the liver
and kidneys; may cause adverse effects
to the nervous system. Benzene is a
strong carcinogen.WHO AQ Guidelines values:
Benzene: no safe levels can be
determined;
toluene: 0.26 mg/m3;
formaldehydes:
0.1 mg/m3 (30min)
Directive 2008/50/EC:
Benzene:
5 μg/m3 (year)Aldehydes including formaldehyde Probable carcinogen (lung and
nasopharyngeal cancer); eye, nose,
throat irritation; respiratory symptoms
Heavy metals
Mercury (Hg), in food as Methylmercury Damage to brain, nervous system,
kidneys and liver; neurological and
developmental birth defects.WHO AQ Guidelines value:
3.2 μg/kg weight/week tolerable intake;
EU: no emission limit values
Lead (Pb) Damages nervous system of children;
may adversely affect learning, memory
and behaviour; may damage kidneys,
cause cardiovascular disease, anemia.WHO AQ Guidelines value:
0.5 μg/m3 (air)
Directive 2008/50/EC:
0,5 μg/m3 (ambient air)
Antimony (Sb), Arsenic (As), Beryllium
(Be), Cadmium (Cd), Chromium (Cr),
Nickel (Ni), Selenium (Se), Manganese
(Mn)Carcinogens (lung, bladder, kidney, skin
cancers); may adversely affect nervous,
cardiovascular, dermal, respiratory and
immune systems. The International
Agency for Research on Cancer
classifies arsenic and its compounds as
group 1 carcinogens.WHO AQ Guidelines:
As: no safe level established;
Cd 5 ng/m3 air;
Directive 2004/107/EC:
As 6ng/m3; Cd 5ng/m3;
Ni 20ng/m3 (ambient air)
Radioisotopes
Radium (Ra) Carcinogen (lung and bone cancers);
bronchopneumonia, anemia, brain
abscess
Uranium (Ur) Carcinogen (lungs and lymphatic
system); kidney disease

Health and Environment Alliance (HEAL)THE UNPAID HEALTH BILL: HOW COAL POWER PLANTS MAKE US SICK
Page 38 38ANNEX 3
TOOL BOX: EU LEGISLATION RELEVANT FOR COAL POWER
PLANTS AND TOOLS TO APPLY THEM FOR HEALTH PROTECTION
The EU has a long history of tackling air pollution. There are important laws and legal
requirements in place to regulate emissions from power plants, but also to ensure a good
overall level of air quality. Given below is a list of laws for reference, which can be used as a
tool to check if current coal power plants comply with EU standards, and which may inform
discussions about plans for new coal power plants.
Emissions from coal power plants
Coal power plants of at least 50MW thermal power currently fall under the
requirements of the Directives on Integrated Pollution Prevention and Control
(IPPCD) and Large Combustion Plants (LCPD). From January 2016 onwards, all
emissions from large industrial sources including coal combusting thermal power
stations (>50MW) will be regulated through the IED (which combines both IPPC
and LCPD).
Both laws set legally binding minimum emission limit values (ELVs) for sulphur
dioxide, nitrous oxides, and dust (under which particulate matter is subsumed).
The IED introduces stricter limits for all these pollutants for most classes of power
plants. In order for an operator to get a permit for operating or constructing a
combustion plant from the national authorities, it has to be shown that the plant
at least complies with those emission limit values that have been set and, for all
pollutants applies best available technology (BAT).
Lignite burning plants are a special case, along with any other high sulphur fuelled
plants: they fall under the requirement for desulphurisation rates (96 – 97% for
plants >300MW) which means that they don’t have to comply with the emission
limit values for sulphur dioxide.
Unfortunately the new Directive has many loopholes. Existing plants that would
otherwise have to be retrofit can evade the legally binding ELVs via several
derogations. For example, if the plant is not going to operate more than 17,500
hours of remaining life; if it is not going to operate more than 1,500 hours per
annum; if the whole or part of the national sector is not complying. However,
plants not only have to comply with these minimum standards.
Under IED the role of the BAT Reference Documents which set the benchmark EU
standards has been strengthened, such that these references have to be included
in permits. However, national authorities can grant exemptions if the application
of best available technologies results in disproportionately high costs compared to
the environmental benefits. The respective cost-benefit assessment lies with the
national authorities. Similarly, other local technical, environmental or geographical
factors can be used to justify not meeting the best available technology standards. TAKE ACTION:
Check the emissions of an
existing coal power plant in the
publicly accessible database of
the European Pollutant Release
and Transfer Register (E-PRTR).
Your national authority monitors
if the plant complies with
emission limit values and keeps
data from local monitoring sites.
Use this information to assess
how much the power plant
contributes to local air pollution.

Health and Environment Alliance (HEAL)THE UNPAID HEALTH BILL: HOW COAL POWER PLANTS MAKE US SICK
Page 39 39Mercury Emissions
Mercury emissions from coal power plants are the largest anthropogenic source
of mercury emissions worldwide.
For mercury emission reductions, better filter technologies and associated
performance levels are described in the so-called BAT Reference Documents
(BREFs), but there are no benchmark standards. Since 2011, the EU has been
reviewing the BREFs for large combustion plants. This review is still in progress
and the issue of establishing standards for emissions of mercury to air and water
is an on-going strongly contested issue.
As other emissions from coal combustion have to comply with binding emission
limit values, mercury emissions could be reduced as a side-effect. It is partially
removed by dust control devices, by wet flue gas desulphurisation, and indirectly
via catalytic systems (SCRs) that primarily remove nitrous oxides. However,
elemental mercury can still be emitted as this form is not removed by the
standard filters. It is thus often necessary to use a technique designed specifically
to remove mercury, e.g. activate carbon injection.
The Water Framework Directive 2008/105/EC sets a binding Environmental
Quality Standard (EQS) for mercury discharge in surface waters of 0.05 μg/l as
well as an EQS of 20 μg/l for sediments and biota. These limit values have to
be applied in permits for coal power plants. Mercury must be included into
legislation on emission limit values from power plants, since a large amount of
mercury is emitted as a constituent of particulates.Background air pollution
As air pollution comes from many sources and
is a local, national and international problem,
it is important to look at the overall levels of air
pollution, the so called ambient or background
concentration.
The 2008 EU Ambient Air Quality Directive merges
several previous EU laws on air quality, and sets
standards, i.e. concentration limits, for a number
of hazardous air pollutants. These standards
include both target and limit values. Currently
there are limit values in place for pollutants such
as sulphur dioxide (SO2), nitrogen oxide (NO2) and
coarse particulate matter (PM10). For the highly
problematic fine particulates PM2.5 there is a
target value in place. The limit values are legally
enforceable, meaning that EU member states have
to comply with them (even though they can ask
for time extensions). TAKE ACTION:
Check the air quality situation in your area with the data from
the local monitoring station for SO2, NO2 and PM10. Have a look
at Annex 2 to see about the health effects of air pollutants and
where the WHO recommends concentration limits should be.
Analyse the situation in your area over a longer time interval. Attract
the attention of media and authorities and inform the public if
thresholds are exceeded. Coal power plants in the region might
contribute to high concentrations. Obtain weather data (wind
directions) for the same period in order to determine potential
point sources.
TAKE ACTION:
Check if the permit application
for a planned coal power plant
is correctly applying the EQS for
mercury emissions from the power
plant to surrounding water bodies.
Technical experts may be able to
provide independent calculations.
Submit your concerns in the public
consultation process. Also legal
actions might be applicable.

Health and Environment Alliance (HEAL)THE UNPAID HEALTH BILL: HOW COAL POWER PLANTS MAKE US SICK
Page 40 40International commitments of EU and Non-EU European
countries
As air pollution is also a transboundary problem, there is an international process
in place to tackle it for the western world. The EU and its member states are part of
the UNECE Convention on Long-range Transboundary Air Pollution (CLRTAP) and
its protocols. The Gothenburg protocol set national emission ceilings for sulphur
dioxide, nitrous oxides, volatile organic carbons (VOCs) and ammonia for the year
2010 (i.e. reducing emissions by 63%, 41%, 40% and 17%, respectively, compared
to 1990 levels). Recently an amendment of the protocol set the reduction targets
for these pollutants until 2020 and introduced a new limit for fine particulate
matter (PM2.5) emissions.
Public access to information
Regulation (EC) No 166/2006 on the establishment of a
European Pollutant Release and Transfer Register (E-PRTR)
makes accessible to the public detailed information on the
emissions and the off-site transfers of pollutants and waste
from approximately 24 000 industrial facilities. For example,
in 2008 coal fired power plants emitted 21.2 tonnes of
mercury.
The EU Ambient Air quality Directive also includes
information requirements for the public. TAKE ACTION:
Check what your country has
committed to under the CLRTAP
Gothenburg Protocol, and if
building a new coal power plant
could endanger the reduction
commitments.
TAKE ACTION:
Check the E-PRTR to find out the emission information
on the coal power plant(s) near you. Please consider
that emissions can be transported over several hundred
kilometres.
Environmental Impact Assessment
New coal power plants with at least 300MW thermal power122 have to undergo
a mandatory Environmental Impact Assessment (EIA) before a building permit
can be issued, as foreseen by Directive 2011/92/EU. For smaller power plants,
Member States can subject the project to an EIA on a case-by-case basis or
by applying general criteria in a screening procedure. The project developers
have to document all foreseeable impacts on the environment which should
by complying with existing environmental regulation. Public consultation is an
important component of the EIA process, which has often been able to hold up
or completely stop a coal plant proposal.TAKE ACTION:
Check if an EIA has been carried out
and if a zero-intervention option
was included in the assessment.

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effect of fine particles in ambient air leads to an average loss of life per person of three months in Finland, 16 months in the
German Ruhr area, and 18 months in a region in Hungary. The wider equity gap in air quality in Europe should be closed
quickly. See: Brunekreef B, Annesi-Maesano I, Ayres JG, Forastiere F, Forsberg B, Künzli N, Pekkanen J and Sigsgaard T (2012):
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99 EEA (2011c): Air pollution impacts from carbon capture and storage (CCS). Technical report No. 14. European Environment
Agency, Copenhagen, Denmark. http://www.eea.europa.eu/publications/carbon-capture-and-storage [accessed 12
February 2013]
100 European Technology Platform for Zero Emission Fossil Fuel Power Plants http://www.zeroemissionsplatform.eu/carbon-
capture-and-storage.html [accessed 19 November 2012]
101 MVV Consulting and Ecofys (2008): op. cit.
102 EEA (2011b): op. cit.
103 Greenpeace (2008): False hope; Why carbon capture and storage won’t save the climate. Greenpeace International, May
2008. http://www.greenpeace.org/international/en/publications/reports/false-hope/ [accessed 12 February 2013]
104 United States Environmental Protection Agency (2000): Carbon Dioxide as a Fire Suppressant: Examining the Risks. http://
www.epa.gov/ozone/snap/fire/co2/co2report.pdf [accessed 12 February 2013]
105 World Resources Institute (2012): ChinaFAQs; China Adopts World-Class Pollutant Emissions Standards for Coal Power Plants.
http://www.chinafaqs.org/files/chinainfo/China%20FAQs%20Emission%20Standards%20v1.4_0.pdf [accessed 12 February
2013]
106 Longer derogation is possible if article 15.4 is applied: derogation due to local factors affecting the determination of BATs.
107 http://www.externe.info/externe_d7/
108 http://www.eea.europa.eu/data-and-maps/data/plant-by-plant-emissions-of-so2-nox-and-dust-and-energy-input-of-large-
combustion-plants-covered-by-directive-2001-80-ec-1
109 http://www.externe.info/externe_d7/?q=node/38, page 117
110 http://www.cafe-cba.org/assets/volume_2_methodology_overview_02-05.pdf, section 3.2.4.
111 http://www.eea.europa.eu/data-and-maps/data/national-emissions-reported-to-the-convention-on-long-range-
transboundary-air-pollution-lrtap-convention-6
112 http://epp.eurostat.ec.europa.eu/portal/page/portal/energy/data/database
113 http://energy-community.org/pls/portal/docs/1146177.pdf, http://www.tradingeconomics.com/serbia/electricity-
production-kwh-wb-data.html
114 http://emep.int/mscw/index_mscw.html
115 http://emep.int/publ/reports/2008/status_report_1_2008.pdf
116 http://www.cafe-cba.org/assets/volume_2_methodology_overview_02-05.pdf
117 http://www.eea.europa.eu/publications/cost-of-air-pollution
118 Calculated based on Eurostat database for indicator “Population on 1 January by age and sex” (2009)
119 Calculated based on Eurostat database for indicator “Supply, transformation, consumption – electricity – annual data” 2009;
for Latvia: IEA data 2009
http://www.iea.org/stats/electricitydata.asp?COUNTRY_CODE=LV
120 Sources for health risks: Lockwood et al. (2009), op. cit.; American Lung Association (2011), op. cit.; European Environment
Agency 2011a, op. cit.
121 WHO (2000): Air Quality Guidelines for Europe. Second Edition. World Health Organization Regional Office for Europe,
Copenhagen, Denmark http://www.euro.who.int/__data/assets/pdf_file/0005/74732/E71922.pd f [accessed 12 February
2013]; as well as WHO (2006): WHO Air quality guidelines for particulate matter, ozone, nitrogen dioxide and sulfur dioxide;
Global update 2005; Summary of risk assessment. World Health Organization, Geneva. http://whqlibdoc.who.int/hq/2006/
WHO_SDE_PHE_OEH_06.02_eng.pdf [accessed 12 February 2013]
122 European Commission (2010): Environmental Impact Assessment of Projects – Rulings of the Court of Justice. http://
ec.europa.eu/environment/eia/pdf/eia_case_law.pdf

Health and Environment Alliance (HEAL)THE UNPAID HEALTH BILL: HOW COAL POWER PLANTS MAKE US SICK
Page 47 47About the report
This report produced by the Health and Environment Alliance (HEAL) aims to provide an overview of the scientific
evidence of how air pollution impacts health and how emissions from coal power plants are implicated in this. It
presents the first-ever economic assessment of the health costs associated with air pollution from coal power plants
in Europe as well as testimonies from leading health advocates, medical experts and policy makers on why they
are concerned about coal. The report develops recommendations for policy-makers and the health community on
how to address the unpaid health bill and ensure that it is taken into account in future energy decisions.
HEAL’s work on coal, climate change and air quality
HEAL has a strong track record in bringing evidence and knowledge about climate change and health to the
forefront of deliberations at EU and international levels as well as engaging public health and health professional
communities, particularly in Europe. Information, resources and partnerships are developed in collaboration with
our expert member organisations, such as the European Respiratory Society (ERS), European Lung Federation (ELF),
European Federation of Allergy and Airway Diseases Patients Association (EFA) and the U.S.-based Collaborative on
Health and Environment (CHE).
In 2007, HEAL published a briefing which reviewed the latest scientific evidence on climate change and health from
the Intergovernmental Panel on Climate Change (IPCC). This laid the basis for building policy recommendations,
focusing on protecting the most vulnerable groups and considering win-win scenarios for public health through
climate mitigation measures.
Through its work with the World Health Organization (WHO) in facilitating World Health Day on climate change
in 2008, HEAL helped to share health concerns about climate change with major stakeholder groups around the
world, including via international organisations of medical professionals, patients, youth and specialist journalists.
Since then, many health and medical groups, citizens and policy-makers have joined us in advocating for health to
be at the centre of climate change mitigation and adaptation measures. Public awareness on the health benefits of
tackling climate change was further increased through the 2010 groundbreaking report on a 30% reduction target
for EU climate policy, which HEAL published jointly with Health Care Without Harm Europe. The report argues that
stepping up the EU’s climate ambition would bring health benefits of up to 30.5 billion EUR health benefits as a
result of cleaner air.
The Unpaid Health Bill: How coal power plants make us sick marks the beginning of a coal and health campaign in
which HEAL will work closely with medical, health and climate advocacy groups, especially in countries where coal
is a particular threat to health. Launched during the EU Year of Air, this report highlights important opportunities to
improve public health through cleaner air.
About HEAL
The Health and Environment Alliance (HEAL) is a leading European not-for-profit organisation addressing how the
environment affects health in the European Union (EU). We demonstrate how policy changes can help protect
health and enhance people’s quality of life.
With the support of more than 65 member organisations, representing health professionals, not-for-profit health
insurers, patients, citizens, women, youth and environmental experts, HEAL brings independent expertise and
evidence from the health community to different decision-making processes. Members include international and
Europe-wide organisations, as well as national and local groups.

A report from the Health and Environment AllianceHealth and Environment Alliance (HEAL)
28 Boulevard Charlemagne, B-1000 Brussels
Tel: +32 2 234 3640
Fax : +32 2 234 3649
E-mail: info@env-health.org
Main website: www.env-health.org
Report website: www.env-health.org/unpaidhealthbill