Black Lung Disease Surges in Appalachia as Silica Exposure Rises and Protections Lag

Justin Smarsh used to spend hours kayaking on the rivers near his home in Cherry Tree, Pennsylvania, and taught his two sons to hunt in the Appalachian Plateau northeast of Pittsburgh. Today, he struggles to breathe even after simple tasks like tying his shoes. At 42, Smarsh has progressive massive fibrosis, the most severe form of coal workers’ pneumoconiosis, commonly known as black lung.

There is no cure for Smarsh’s condition. He manages symptoms with medication, but his doctors say he likely 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.”

Smarsh’s story reflects a disturbing trend: black lung clinics are treating more patients in their 30s and 40s, a generation that entered mining when the industry was already declining. Coal mining has long been hazardous, but today’s miners face a new, deadlier threat—crystalline silica.

Why Silica Is Making Black Lung Worse

As large coal seams in Appalachia dwindle, miners must cut through more rock to reach thinner seams. This rock often contains high levels of quartz, which gets pulverized into fine silica dust. When inhaled, silica particles act like tiny shards of glass, causing severe scarring, inflammation, and eventually progressive massive fibrosis.

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

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

Regulatory Failures Exacerbate the Crisis

The resurgence of black lung coincides with stalled regulatory efforts to protect miners. Despite the growing evidence of silica’s dangers, protections have been slow-walked under recent administrations. Randy Lawrence, president of the Kanawha County Black Lung Association, stands outside his home near Cabin Creek, West Virginia, on October 13, 2025. His organization continues to advocate for stricter silica exposure limits and better enforcement of safety regulations.

“It was the best-paying job around,” Smarsh said of coal mining. “It still is.” But the cost is increasingly paid in human lives. For miners like Smarsh, the choice between financial stability and health is no longer a hypothetical—it’s a death sentence.