Black Lung Disease Surges in Appalachia as Federal Protections Stall and Coal Mining Expands

Justin Smarsh used to spend weekends kayaking on rivers near his home in Cherry Tree, Pennsylvania, and taught his two sons to hunt in the Appalachian Plateau woods northeast of Pittsburgh. Today, he struggles to breathe just walking across a room.

“I get suffocated just walking,” Smarsh said. “I have a constant dry cough, and I lose my breath if I bend down to tie my shoes.”

After graduating high school and getting married, Smarsh followed his father and grandfather into the coal mines of his home county. “It was the best-paying job around,” he said. “It still is.” Now, at 42, he has progressive massive fibrosis — the most severe form of coal workers’ pneumoconiosis, commonly known as black lung. There is no cure for his condition. Smarsh manages symptoms with “piles of meds,” but doctors say his disease will progress, potentially leading to heart failure. Patients with advanced black lung can drown from fluid filling their lungs after a flu or cold. His doctors say he won’t live to see 50.

“Most people think coal mining is a thing of the past,” said Deanna Istik, CEO of Lungs at Work, a black lung clinic in Washington County, Pennsylvania. “Meanwhile, we see more people being diagnosed with black lung disease than we ever have before.”

Silica Exposure: The New Threat in Modern Mining

Coal mining has always been dangerous, but today’s miners face a deadlier hazard: crystalline silica. As large coal seams in Appalachia dwindle, miners must cut through more rock containing high quartz levels. When pulverized, this quartz turns into microscopic shards that inflame and scar lung tissue, accelerating progressive massive fibrosis.

Researchers at the National Institute for Occupational Safety and Health (NIOSH) estimate that one in 10 miners with 25+ years of experience now has black lung. The disease is driving sharp increases in lung transplants and mortality. Between 2013 and 2017, clinics in Virginia identified hundreds of progressive massive fibrosis cases, prompting NIOSH to declare a renewed black lung epidemic.

Black-lung-associated deaths, which declined from 1999 to 2018, rose again between 2020 and 2023.

Federal Policy and Industry Expansion Fuel the Crisis

The resurgence of black lung coincides with federal efforts to expand coal production. Last fall, the U.S. Department of Energy announced a $625 million investment in coal projects. This month, President Trump signed an executive order reaffirming coal as an “essential” energy source.

Critics argue these policies ignore the human cost. “The government is prioritizing coal over the health of miners,” said Istik. “We’re seeing younger miners with severe disease because they’re inhaling silica-laced dust.”

What Is Black Lung Disease?

• Coal workers’ pneumoconiosis (CWP): Lung disease caused by inhaling coal dust, leading to scarring and nodules.
• Progressive massive fibrosis (PMF): The most severe form of CWP, characterized by large areas of lung tissue becoming scarred and functionless.
• Silica exposure: Crystalline silica from quartz in rock dust causes more aggressive lung damage than coal dust alone.

Key Statistics

• One in 10 miners with 25+ years of experience has black lung (NIOSH, 2023).
• Hundreds of PMF cases identified in Virginia clinics between 2013–2017 (NIOSH).
• Black-lung-associated deaths rose from 2020 to 2023 after decades of decline.
• $625 million invested in coal projects by the U.S. Department of Energy (2023).