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ISLAMABAD (AP) -- In Pakistan, a country where breast cancer kills more women than terrorist attacks, an awareness group couldn't even say the word "breast" while talking at a university about mammograms and how to check for lumps.
They had to use the euphemism "cancer of women" to discuss a disease often shrouded in social stigma in this majority Muslim nation.
One in nine women in Pakistan will face breast cancer during their life, with the country itself having the highest rate of the disease across Asia, according to the breast cancer awareness group PinkRibbon, oncologists and other aid groups.
Yet discussing it remains taboo in a conservative, Islamic culture where the word breast is associated with sexuality instead of health and many view it as immoral for women to go to the hospital for screenings or discuss it even within their family.
Now, women like breast cancer survivor and prominent Pakistani politician Fehmida Mirza and groups are trying to draw attention to the disease and break the silence surrounding it.
"There's nothing to be shy about it," Mirza told The Associated Press in a recent interview. "No woman, no woman should die of ignorance and negligence."
No national database tracks breast cancer statistics but people who combat the disease say it kills nearly 40,000 women every year in Pakistan. That's about the same number as in the U.S., though Pakistan only has 180 million residents to the U.S.' 313 million.
With a health care system in shambles and more young women getting the disease, breast cancer rates only are expected to get worse. World Health Organization official Shahzad Aalam in Pakistan said it was difficult to determine the exact magnitude, but that the disease is rampant.
"It is the leading cancer killer among women," Aalam said.
Among Pakistani women there is very little knowledge about the disease. A study done at Rawalpindi General Hospital about breast cancer awareness among 600 women found nearly 70 percent totally ignorant of the disease, while 88 percent did not know about breast self-exams and 68 percent did not understand the significance of finding a lump in the breast.
"If women are being diagnosed with breast cancer, they don't even share the news with their family members," said Omar Aftab, who heads PinkRibbon in Pakistan, which put on the university presentation where organizers couldn't even say "breast."
"So, we're trying to break these taboos," he said.
Those cultural taboos have been one of the biggest issues preventing women from seeking treatment or even knowing about the disease. During an awareness event in Pakistan's capital, Islamabad, female students attending a breast cancer lecture demanded the men leave.
"It will take very long for us to discuss these issues openly," said one female student who requested anonymity because she feared her family wouldn't like her speaking about the issue.
Another challenge is Pakistan's abysmal health care sector that is starved for money, the latest technology and drugs. Oncologist Saira Hasan at Shifa International Hospital in Islamabad said most major hospitals lack a screening center or mammogram facility. Many patients first go to a traditional healer and by the time they visit a reputable doctor, the disease is often too far advanced to treat, Hasan said.
Women in the developing world, like Pakistan, tend to die at greater rates than in more developed countries because the disease is generally detected later and health care options aren't as good.
Hasan said several factors have contributed to the rise in the disease - above all the cultural taboos. Breast cancer survivor Sameera Raja, who owns an art gallery in southern Karachi and supports women facing breast cancer, says that it has to be changed.
"You're surprised to hear how women actually sit on things," Raja said. Recalling how a woman would feel too embarrassed to talk about it even with her husband, she said: "Don't hide behind closed doors."
Unlike in the U.S. where celebrities like singer Sheryl Crow or actress Christina Applegate have freely discussed their fight with breast cancer, few such public figures have come forward in Pakistan. That's changed with Mirza, though she had to delay her treatment for three months after she was diagnosed in March 2012 to handle her work, which included how to rule on whether a criminal conviction against the serving prime minister should disqualify him from politics.
"There was lot of pressure on me, work pressure," she said. "Everybody (would) say it's an excuse I'm using to run away."
Mirza described her friends and family being shocked by the diagnosis, as the cancer is considered by many as a death sentence. But during her diagnosis and treatment, she attended international conferences, ruled on the then-prime minister's case and later ran for re-election and won while undergoing chemotherapy.
She now uses her position in parliament to advocate for women's health issues. She plans to propose a bill making it mandatory for women to have breast cancer screenings and mammograms yearly, as well as to teach girls in schools to do breast exams themselves. She also pushed the health ministry to explain why there is no national database on breast cancer deaths.
"I think the role models will have to come forward," Mirza said. "That is one reason I had to."
Associated Press writers Adil Jawad in Karachi, Pakistan, and Zaheer Babar in Lahore, Pakistan, contributed to this report.
WASHINGTON (AP) -- The chemical spill that contaminated water for hundreds of thousands in West Virginia was only the latest and most high-profile case of coal sullying the nation's waters.
For decades, chemicals and waste from the coal industry have tainted hundreds of waterways and groundwater supplies, spoiling private wells, shutting down fishing and rendering streams virtually lifeless, according to an Associated Press analysis of federal environmental data.
But because these contaminants are released gradually and in some cases not tracked or regulated, they attract much less attention than a massive spill such as the recent one in West Virginia.
"I've made a career of body counts of dead fish and wildlife made that way from coal," said Dennis Lemly, a U.S. Forest Service research biologist who has spent decades chronicling the deformities pollution from coal mining has caused in fish.
"How many years and how many cases does it take before somebody will step up to the plate and say, `Wait a minute, we need to change this'?"
The spill of a coal-cleaning chemical into a river in Charleston, W.Va., left 300,000 people without water. It exposed a potentially new and under-regulated risk to water from the coal industry when the federal government is still trying to close regulatory gaps that have contributed to coal's legacy of water pollution.
From coal mining to the waste created when coal is burned for electricity, pollutants associated with coal have contaminated waterways, wells and lakes with far more insidious and longer-lasting contaminants than the chemical that spilled out of a tank farm on the banks of the Elk River.
Chief among them are discharges from coal-fired power plants that alone are responsible for 50 percent to 60 percent of all toxic pollution entering the nation's water, according to the Environmental Protection Agency.
Thanks to even tougher air pollution regulations underway, more pollution from coal-fired power plants is expected to enter the nation's waterways, according to a recent EPA assessment.
"Clean coal means perhaps cleaner atmosphere, but dirtier water," said Avner Vengosh, a Duke University researcher who has monitored discharges from power plant waste ponds and landfills in North Carolina.
In that state, Vengosh and other researchers found contaminants from coal ash disposal sites threatening the drinking water for Charlotte, the nation's 17th-largest city, with cancer-causing arsenic.
"It is kind of a time bomb that can erupt in some kind of specific condition," Vengosh said. The water shows no signs of arsenic contamination now.
In southeastern Ohio, tainted water draining from abandoned coal mines shuttered a century ago still turns portions of the Raccoon Creek orange with iron and coats the half-submerged rocks along its path white with aluminum.
Public drinking water systems in 14 West Virginia counties where mining companies are blasting off mountaintops to get to coal seams exceeded state safe drinking water standards seven times more than in nonmining counties, according to a study published in a water quality journal in 2012. The systems provided water for more than a million people.
The water quality monitoring in mining areas is so inadequate that most health violations likely were not caught, said Michael Hendryx, the study's author and a professor of applied health at Indiana University.
The EPA, in an environmental assessment last year, identified 132 cases where coal-fired power plant waste has damaged rivers, streams and lakes, and 123 where it has tainted underground water sources, in many cases legally, officials said.
Among them is the massive failure of a waste pond at a Tennessee Valley Authority power plant in 2008. More than 5 million cubic yards of ash poured into a river and spoiled hundreds of acres in a community 35 miles west of Knoxville.
Overall, power plants contributed to the degradation of 399 bodies of water that are drinking water sources, according to the EPA.
There are no federal limits on the vast majority of chemicals that power plants pipe directly into rivers, streams and reservoirs. The EPA just last year proposed setting limits on a few of the compounds, the first update since 1982. More than five years after the Tennessee spill, the EPA has yet to issue federal regulations governing the disposal of coal ash.
Experts say the agency is playing catch-up to solve a problem that began when it required power plants in the 1990s to scrub their air pollution to remove sulfur dioxide. An unintended consequence was that the pollutants captured were dumped into landfills and ponds, many unlined, where they seeped into underground aquifers or were piped into adjacent rivers, reservoirs and lakes.
"As you are pushing air rules that are definitely needed, you need to think of the water. And they didn't," said Eric Schaeffer, a former EPA enforcement official. "Now they are running after the problem."
He now heads the Environmental Integrity Project, a group whose research has uncovered previously unknown sites of contamination from power plant waste pits.
The federal government has in recent years issued the first-ever regulations for mercury released from power plant smokestacks, the largest source of mercury entering waterways. The EPA has stepped up its review of mountaintop mining permits, to reduce pollution.
"Coal-related pollution remains a significant contributor to water quality pollution across the United States," said Alisha Johnson, an EPA spokeswoman. "The EPA's efforts have yielded significant improvements, but significant work still remains."
On the mining side, a review of federal environmental enforcement records shows that nearly three-quarters of the 1,727 coal mines listed haven't been inspected in the past five years to see if they are obeying water pollution laws. Also, 13 percent of the fossil-fuel fired power plants are not complying with the Clean Water Act.
Many mines don't even report their discharges of selenium, although researchers have found the chemical near mines at levels where it can cause deformities and reproductive failure in fish.
A study in the journal Science in 2010 found that 73 of 78 West Virginia streams in mountaintop mine removal areas had selenium levels higher than the official threshold for fish life. Higher levels of selenium - a natural component of coal that seeps from rock when water runs through it - often means fish don't reproduce or have deformed, even two-headed, offspring, Lemly said.
University of Maryland environmental sciences professor Margaret Palmer spent much of the weekend that Charleston was without water testing the Stillhouse Branch stream near Clay, W.Va., just below a mountaintop removal coal mine. She said her tests showed the water was too salty from the rocks from the mine.
"It's like a desert with a few water rats in it," Palmer said. "The organisms that do live in (these streams), you think of them like water rats. Only the really hearty ones survive."
Efforts by the EPA to ease the problem, by requiring mine permits to be judged by a measure of the saltiness in downstream water, have been vacated by a federal court. That decision is under appeal.
A spokesman for the National Mining Association said the industry operates in accord with extensive and rigorous permitting guidelines.
Pollution still enters the environment from coal mined decades ago.
The EPA estimates 12,000 river miles are tainted by acid mine drainage from long-shuttered coal mines. One of them is Raccoon Creek in southeastern Ohio.
"These mines have been abandoned for a hundred years," said Amy Mackey, Raccoon Creek's watershed coordinator. "There is no one to fall back on."
States take the lead on the water pollution front. But advocacy groups from at least three states in coal country - Kentucky, West Virginia and Indiana - have asked the EPA to step in, arguing that state officials aren't doing enough.
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