Like most coal miners' loved ones, Liz Williams has endured many days and nights of worry.
Throughout the four decades her husband, Michael, worked in underground Appalachian mines, Liz was aware of the risks: collapse, explosions, asphyxiation. But black lung — a chronic condition caused by breathing in coal dust — wasn't on her mind.
That's because the number of miners diagnosed with the often-deadly disease declined for decades, after federal officials introduced regulations more than 50 years ago.
But no more. The numbers have climbed precipitously as mining techniques have evolved to extract increasingly hard-to-reach coal reserves. After a career in the mines, Michael Williams, 62, now lives with an advanced stage of black lung.
Williams, a resident of the small town of McRoberts, is among a growing number of people diagnosed with the disease in central Appalachia, a region primarily comprising West Virginia, eastern Kentucky, and southwestern Virginia. The increase in the disease's most deadly form, progressive massive fibrosis, has been especially pronounced. Since 2005, black lung cases have tripled in the region and PMF has increased tenfold among long-term miners. A study published last fall identified the driving force behind the spike in severe black lung disease as silica dust.
"We were seeing much more severe disease," said Dr. Robert Cohen, director of the Mining Education and Research Center at the University of Illinois-Chicago and the study's lead author. "We were seeing disease in younger miners, with lesser exposures, so, therefore, more intense exposure."
Silica is the same toxic dust that has been pinpointed in recent years as the cause of deadly lung disease in workers in other industries, including those who make and install stone countertops. In mines, silica exposure comes from drilling into sandstone, which has become more common as thick coal seams peter out and miners move more rock to reach smaller veins. The dust turns to sharp particles that become trapped in lung tissue, causing inflammation and scarring and reducing the lungs' capacity to take in oxygen. The condition is debilitating and potentially fatal.
Regulations allow miners to be exposed to twice as much airborne silica as the Occupational Safety and Health Administration permits for workers in other industries. Five U.S. senators representing parts of central Appalachia believe the Mine Safety and Health Administration has been dangerously slow to fix the discrepancy. They sent a letter in November demanding a new standard for miners nationwide. An announcement of a more restrictive proposed standard is expected from MSHA soon.
The more intense exposure is attributed, at least in part, to new technology that allows coal companies to drill deeper into rock to reach thin seams of coal. The process involves removing the silica-laden rock strata that surround coal seams, generating dangerous levels of dust.
Miners, Cohen said in a 2018 interview for a documentary, are "essentially suffocating while alive."
Michael Williams said his most physically demanding stint in the mines was around Clinchco, Virginia, where he worked on his hands and knees, sandwiched between "sandstone, top and bottom."
"The two years I worked in that seam — that's what done the damage," Williams said.
Popular belief once held that miners developed black lung only after spending decades toiling underground, according to Dr. Drew Harris, medical director of the Black Lung Clinic at Stone Mountain Health Services in southwestern Virginia. "And I think that's not the case in central Appalachia anymore," Harris said, "though, certainly, the longer the tenure, the worse and the more likely you are to develop the disease."
Among the most susceptible mineworkers are roof bolters, who install supports to keep mine roofs from collapsing. It's a job Paul White, 61, of Harlan, Kentucky, began at age 18. He left the mines at 25 after a wall collapsed on him, injuring his head and back and causing seizures he still experiences today.
It's sometimes years before symptoms of black lung take hold. White, now a Baptist minister, said he began getting pneumonia he couldn't shake around 2011 or 2012, two decades after he left the mines.
From there, his breathing capacity incrementally worsened, and now shortness of breath hinders his ability to preach.
William McCool, 68, was born and raised in Letcher County, Kentucky, and went to work in the mines after high school.
"I loved coal mining," he said. "I mean, I loved it. I sure did." Among his jobs was roof bolting.
McCool said that as the purer coal seams were depleted, crews cut through more rock.
Research has shown silica exposure is an issue also among workers who cut stone countertops, especially those who work with synthetic stone composed of crushed quartz. That workforce is generally immigrant and nonunionized, Cohen said. There hasn't yet been a national surveillance program for any industry other than miners.
The resurgence of PMF in coal country startled those who advocate for miners. Wes Addington runs the Appalachian Citizens' Law Center, an organization that provides, among other services, free legal representation to black lung victims and their families. When he began working on black lung cases in the early 2000s, he said, his firm would occasionally see X-rays that showed lung damage that Addington and his colleagues believed might qualify as a complicated diagnosis, which includes PMF. Often doctors they consulted would report back that it was not complicated black lung.
Addington and his team came to view complicated black lung as having been "basically eradicated in the United States by the mid-’90s." Its apparent rarity led him to conclude "that it's just not going to be part of the way we practice these cases."
Then, around 2009, Addington said the firm began seeing a few more advanced cases. And in the following years, they "really started pouring in, to the point now, in the last decade or so, we've kind of been overwhelmed with just how many of these miners have progressive massive fibrosis."
The five Appalachia-region senators, all Democrats, who wrote to Mine Safety and Health Administration Assistant Secretary Chris Williamson in November — Sherrod Brown of Ohio, Bob Casey of Pennsylvania, Joe Manchin of West Virginia, and Tim Kaine and Mark Warner of Virginia — asked the agency to explain its delay in announcing a new silica standard for miners.
"The Department of Labor has indicated that we could see a proposed rule as early as April, so I'll be watching this closely and will continue to push for proper protections for coal miners," Warner said.
"It's cruel that this would happen in such a rich country," Addington said of the persistence of black lung. "We know how to prevent it," he said, "and never in my wildest dreams would I have imagined that we'd be in a situation where we're having that same conversation" about progressive massive fibrosis.
Michael Williams can't ignore the consequences of those long hours spent crawling under the earth. Over the past few months, he's been repairing the damage July's catastrophic flooding caused to his home. "I can go out there and shovel gravel for 15 minutes and I have to sit down; I'm losing my breath," he said. "My mind says I can, but my body says I can't."
He's troubled by the rattling in his chest: "You think it's a cat or something outside. You don't even know that you're doing it."
His wife, Liz, is proud of the many years of hard work Michael put in — that "he was willing to go into those dark mines to provide for his family."
"But if we had hindsight," she said, "and we could see what we know now, nothing is worth seeing him struggle to breathe. I would have encouraged him to do something different."
This article was reprinted from khn.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.