Justin Smarsh and his family used to kayak a few times a year on the rivers and creeks near their home in Cherry Tree, Pennsylvania. High on the Appalachian Plateau, northeast of Pittsburgh, he spent hours in the woods and taught his two sons to hunt. Today, Smarsh said, he gets “suffocated just walking.” He has a constant dry cough, and he loses his breath if he bends down to tie his shoes. 

A few years after he graduated from high school and got married, Smarsh went to work in a coal mine in his home county, just as his father and grandfather had. “It was the best-paying job around,” he said. “It still is.” Now Smarsh, 42, has progressive massive fibrosis — the most severe form of coal workers’ pneumoconiosis, or black lung.

There is no cure for Smarsh’s condition. He tries to slow the progression with “piles of meds,” he said, but things will eventually worsen, potentially to the point of heart failure. In patients with advanced disease, a flu or common cold can lead to a kind of drowning as the lungs fill with fluid. Smarsh’s 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.” 

Between 2013 and 2017, hundreds of cases of severe black lung disease were identified at just three Virginia clinics.

The disease is on the uptick at a time when the Trump administration is calling for the expansion of coal production. Last fall, the U.S. Department of Energy announced it was investing $625 million in coal projects, and this month, President Trump signed an executive order reaffirming coal as essential to national security, a move that will direct billions of dollars in federal funding to the industry. But while the administration is calling for more coal, it is simultaneously delaying implementation of new regulations that would protect miners from deadly silica. 

In the United States, black lung was officially acknowledged as a workplace-related illness only in the late 1960s, after a highly publicized disaster at a West Virginia mine killed 78 coal miners. Subsequent strikes and protests led to the passage of the 1969 Coal Mine Health and Safety Act, which mandated federal safety inspections of mines, set fines for violations, and established a benefits program to compensate miners with black lung. 

Rates of the disease dropped almost immediately, and by the end of the 20th century, thanks to the implementation of those standards and a strong union presence in mines in Pennsylvania and across Appalachia, black lung was nearly eradicated. 

Black lung clinics are seeing more and more patients who’ve gotten sick in their 30s and 40s.

But in Pennsylvania, says Istik, “this is not a dead industry. We’re still cutting coal.” A 2024 report by the Pennsylvania Coal Alliance counted more than 5,000 mining jobs generating some $2.2 billion in economic output. Nationwide, there are still close to 40,000 coal workers. 

Black lung diagnoses continue to mount. Doctors and miner advocates say the condition is underdiagnosed, as many miners are reluctant to undergo testing for fear of losing their jobs should their employer find out. “I think there’s always going to be that fear of retribution,” said Istik. But eventually, she added, the symptoms become debilitating. Smarsh, a patient of Lungs at Work, didn’t see a doctor about his labored breathing until his wife, Alicia, insisted he had no choice. 

Black lung clinics are seeing more and more patients like Smarsh, who’ve gotten sick in their 30s and 40s. In earlier generations, miners might have needed decades of coal dust exposure to develop serious disease, if they got sick at all. “My dad and my pap were both miners, and they didn’t get it,” Smarsh said. “So, I thought, ‘Who says I’m going to?’” But today’s workers, who are breathing a much higher proportion of silica, can develop a disabling illness in much less time. 

Smarsh worked mostly as a roof bolter — the person responsible for installing supports to prevent cave-ins — drilling up into rock. He spent eight years underground before his lung condition made it impossible for him to work, or to walk across his own backyard without using an inhaler. 

Experts have understood the dangers of silica dust for decades. In the 1970s, NIOSH suggested regulations that would limit exposure to 50 micrograms per cubic meter of air, averaged over a 10-hour workday in the mine. In 2016, the Occupational Safety and Health Administration (OSHA) adopted the 50-microgram silica standard for other occupations, like construction and manufacturing. But in 2017, the Mine Safety and Health Administration (MSHA) — which is mandated to conduct quarterly inspections of underground mines and enforce safety standards — responded to industry pressure and set the limit for mining at 100 micrograms over an eight-hour workday. 

After a negotiation process that spanned years and multiple administrations and involved mining industry lobbyists, legal groups, and scientists from NIOSH and other agencies, MSHA announced in 2024 that it would issue a new rule reducing the silica exposure limit in mines to 50 micrograms, with enforcement to begin in April 2025. 

It should not be the coal miner’s responsibility not to get black lung, says a union spokesperson.

The new rule would require operators to use “engineering controls,” such as improved ventilation systems, as the primary means of meeting the standard. Those tools could be supplemented, when necessary, by “administrative controls,” such as clothing decontamination and avoidance of especially dusty areas, to keep miners from breathing unacceptable amounts of silica.

The National Mining Association and other industry groups mounted a legal challenge, arguing that when ventilation systems aren’t enough to bring respirable silica levels below the 50-microgram standard, operators should be able to require miners to use respirators to achieve compliance.

But “respirators are really the last line of defense because they aren’t foolproof,” Istik said. “Silica is such a small particle; it still comes through.” 

Smarsh wore a respirator some of the time when he was underground. But there were other times, he said, when it was too difficult to see or breathe through it. “Anytime you’re underground, you see dust,” he said. “But it’s not the dust you see that gets you. It’s the little stuff you don’t see.” 

While respirators are important safety equipment, it should not be the coal miner’s responsibility not to get black lung, said Erin Bates, communications director of the United Mine Workers of America. It is the company, she added, that must ensure a safe work environment for its employees.

When the Trump administration came into office, it cut MSHA’s budget and staff. The agency had already been operating at a disadvantage: According to data from the Appalachian Citizens’ Law Center, MSHA’s coal mine enforcement staff has been cut in half over the last decade. The American Federation of Government Employees (AFGE) reported that another 7 percent of the agency’s full-time workforce accepted the Trump administration’s “Fork in the Road” buyout last year, and 90 newly hired mine inspectors had their job offers rescinded. There were concerns among black lung experts and advocates about the diminished agency’s ability to implement the new silica exposure rule. The loss included people “we desperately needed,” Carey Clarkson, who represents Labor Department workers for the AFGE, told NPR at the time. “I can’t image how many years of experience we lost.” 

A few days before the April 2025 enforcement date, the rule hit two different roadblocks: the 8th U.S. Circuit Court of Appeals granted an emergency stay of the rule in response to a petition led by another industry group, the National Stone, Sand & Gravel Association, and MSHA itself announced it would delay implementation to give operators more time to “come into compliance.” 

The litigation has remained in limbo. Last November, MSHA moved to have the legal proceedings paused as it “reconsiders” parts of the rule, and earlier this month it announced the delay would continue “indefinitely” pending judicial review. The agency did not respond to a request for comment. 

“All the good coal that was around here is gone. Now there’s nothing but rock and silica,” says a Pennsylvania miner.

Bates said the union is disheartened. The agency “was literally created for the health and safety of coal miners, but they don’t want to take that into consideration,” she said.

Rebecca Shelton, director of policy for the Appalachian Citizen’s Law Center, which has been advocating for a new silica rule since the late 2000s, said her organization had hoped to see the rule implemented under the Biden Administration “because we were concerned about challenges it might face.” The process was slowed by intense lobbying, she said, and MSHA’s need to study the rule’s impact across diverse mining industries. 

“If the Trump administration actually cared about protecting coal miners from black lung, we’d have a strong silica rule in place right now,” she said in a statement issued by the center after MSHA announced the indefinite delay. “Instead, they are hiding behind a ridiculous legal process to delay action while miners get sick and die.” 

Smarsh said his 19-year-old son wants to work in the coal mines. “Me and my wife tell him all the time, you see what I’m going through? All the good coal that was around here is gone. Now there’s nothing but rock and silica.” Gone too, Smarsh said, is any trust he once had in a coal company to keep miners safe. 

“All they’re worried about is ‘you better have that black gold,’” he said. “They say they care about miners, but you go underground, you’re taking the risk, for you to get nothing but sick, and to fill their pockets full.”