In some regions of India, a married woman will return to her mother’s house for the last trimester of pregnancy and the birth of her child. But in Mettur, pregnant women are advised by their doctors to stay away.

“Black wind” from a coal yard wafts constantly across poor neighborhoods, settling on rooftops, walking paths and even indoor furniture. People complain of asthma, wheezing and frequent colds.

In its bid to industrialize, India relies heavily on energy from coal. Accounting for 71 percent of India’s electricity, coal will remain a key player over the next decade, with 455 new plants proposed, according to energy experts.

The poor pay the highest cost of India’s dependence on coal, said Jennifer Wang of the nonprofit group Health Care Without Harm. Already burdened by chronic disease, poor nutrition and inadequate health care, they also are highly exposed to air and water pollution, she said.

Mettur and other industrial cities throughout India are now mobilizing to document coal’s health impacts on their own residents in an effort to wring environmental protections from local politicians and world leaders.

Coal poses health risks in India at all stages – mining, transportation, storage and use:

**In Jharia, famous for its rich coal resources, 700,000 people are exposed to toxic smoke that seeps from the ground as fires from opencast coalmines burn around the clock. Residents suffer from asthma, chronic bronchitis and skin problems.

**In Gujarat, on the west coast, fish catches plummeted after the construction of a massive 4,800-megawatt coal plant destroyed mangrove and creek ecosystems by discharging polluted water in the sensitive ecosystem.

**Mercury-laced ash from five mega power plants in the Singrauli district in central India is stored in piles five feet thick, polluting air, water and soil.

**In Mettur, in southern India, a coal yard where fuel is shipped in by rail and stored for a power plant and factories stands just 100 feet from some homes. Coal dust blows from the yard into neighboring communities. Air pollution levels are high.

Women in Mettur, a city of about 50,000 with a variety of heavy industries, are hit particularly hard. Doctors often recommend that pregnant women leave.

About 1,500 mostly low-income households are within reach of the coal yard dust, said Shweta Narayan of Community Environmental Monitoring, an environmental justice group in India.

“Women are told not to have their babies here. The pollution affects not only their daily lives, but their culture,” Narayan said.

A 2010 analysis by Narayan’s group found that airborne particles in Mettur were three to four times higher than the World Health Organization’s pollution guidelines. Worldwide, these tiny particles have been linked to increased deaths from lung and cardiovascular disease. Air quality measurements also suggest that Mettur’s air contains metal particles, such as manganese and nickel, which could harm child brain development.

Parents complain that their children are always sick. Kids often miss school due to wheezing. But complaints about sickness are largely anecdotal. Scientific analysis of the health impacts of coal pollution is lacking in Mettur and other communities.

“The health aspect has been largely ignored in India’s energy policy framing,” Narayan said.

Much of the evidence of health effects from coal pollution comes from the United States or Western Europe, which are much cleaner.

“There’s a lack of research regarding long-term exposure to air pollution in some of the world’s most polluted places, including India,” said Aaron Cohen, an epidemiologist at the Health Effects Institute in Boston.

An estimated 627,000 Indians die prematurely each year from outdoor air pollution, according to the World Health Organization’s Global Burden of Disease project. A 2012 Greenpeace India report estimated that about 20 percent of premature deaths and more than 20 million asthma cases each year could be attributed to coal pollution.

Next year, the nonprofit Community Environmental Monitoring will begin to screen people near the coal yard for asthma and other lung problems. They’ll also look for other effects in the women because “pollution manifests itself in different forms, including stress and anxiety,” Narayan said.

“Do we need more research to act? No. We know the immediate health effects from generating energy this way and the long-term effects from climate change,” said Dr. Peter Orris, director of the Global Toxics Policy Program at the University of Illinois School of Public Health. “But how do you convince local policy makers to take action? People need to feel a connection.”

Many of India’s coal plants and mines are government-run.

In some ways, energy regulations to curtail fossil fuel burning may be an easier sell in developing countries than in the United States, said Rachel Cleetus, senior economist with the Climate and Energy Program at the Union of Concerned Scientists. Carbon reduction efforts, such the landmark deal struck this week between the United States and China, are viewed largely as climate-change policies.

Growing concern over polluted air and water in China and India is more immediate. “Air and water pollution may be of concern to us, but to them it’s becoming a public health crisis,” Cleetus said.

The health costs associated with coal-fired power stations cost the European Union about 53 billion U.S. dollars each year, according to a report by the Health and Environment Alliance. No such economic analysis exists for India.

“Coal tends to look cheap when health and environmental costs aren’t taken into account. There is a huge need for monetizing the public health costs, especially in developing countries,” Cleetus said.

Looking to China, Cohen said, “it’s hard to argue that economic development there, in which coal has certainly played a role, hasn’t had significant beneficial effects on poverty reduction and population health. But it’s becoming evident that high levels of air pollution from coal burning and other sources is having an adverse effect on population health and life expectancy and is now an obstacle to continued development.”

Nevertheless, the energy landscape is beginning to change. China and India are the fastest growing markets in the world for wind and solar, Cleetus said.

“It’s not that old static picture anymore that coal is king,” she said. “We see that being challenged both in the U.S. and abroad.”