More than 6600 coal-fired power plants serve an estimated five billion people globally and contribute 46% of annual CO2 emissions. Gases and particulate matter from coal combustion are harmful to humans and often contain toxic trace metals. The decades-old Kosovo power stations, Europe’s largest point source of air pollution, generate 98% of Kosovo’s electricity and are due for replacement. Kosovo will rely on investment from external donors to replace these plants. Here, we examine non-CO2 emissions and health impacts by using inductively coupled plasma mass spectrometry (ICP-MS) to analyze trace metal content in lignite coal from Obilic, Kosovo. We find significant trace metal content normalized per kWh of final electricity delivered (As (22.3 ± 1.7), Cr (44.1 ± 3.5), Hg (0.08 ± 0.010), and Ni (19.7 ± 1.7) mg/kWhe). These metals pose health hazards that persist even with improved grid efficiency. We explore the air-pollution-related risk associated with several alternative energy development pathways. Our analysis estimates that Kosovo could avoid 2300 premature deaths by 2030 with investments in energy efficiency and solar PV backed up by natural gas. Energy policy decisions should account for all associated health risks, as should multilateral development banks before guaranteeing loans on new electricity projects.