Dr. Brandon Crum explains chest X-rays to former coal miner Wade Pauley, who has black lung disease after working 33 years underground in mines, at the United Medical Group in Pikeville, Kentucky, May 2018. Brian Snyder/Reuters

Brandon Crum was a fourth-generation coal miner. As a teenager, he spent his summers, holidays, and weekends working in the coal fields of eastern Kentucky. “I was raised with it,” says Crum. “My grandfather and my father were mine operators. From the time I was six I’ve been riding in bulldozers and cutting machines and scoops.”

He left mining at 21, but Crum didn’t stray too far from his roots. For the past 16 years, he’s been a radiologist and “B reader,” which means he is certified to evaluate chest X-rays for pneumoconiosis, or black lung, a debilitating respiratory disease. Caused by long-term exposure to coal mine dust, black lung is fairly common in coal miners in their sixties and seventies. Crum’s grandfather died from it, and his father has it, too. But in 2014, Crum began noticing a spike in severe black lung cases—and he was seeing them in younger and younger coal workers.

He contacted the National Institute for Occupational Safety and Health (NIOSH), which studied the X-rays of Crum’s patients. After multiple B readers in the region confirmed the diagnoses, Crum and NIOSH published their findings in December 2016. Continued research led NIOSH to conclude that one in five coal miners in central Appalachia has black lung. Even more shocking, one in twenty suffers from progressive massive fibrosis, the most severe form of the disease. Together, Crum and NIOSH uncovered the story of a fatal epidemic in Appalachia’s coal country.

“If one in five people who worked as nurses ended up with an incurable, chronic disease, people would lose their minds. In any other work this would be completely unacceptable,” says Evan Smith, an attorney for the Appalachian Citizens Law Center in Whitesburg, Kentucky. “It’s scary. It’s an incurable disease that will eventually lead to these people suffocating to death.”

Not Your Grandfather’s Coal Dust

The uptick of a coal-mining disease during a time when coal production and employment rates are in sharp decline may seem strange—until you consider how the industry must now get that coal out of the ground.

“A lot of the big, thick coal seams in Appalachia have been mined out. What’s left are center seams bounded by rock, usually sandstone,” says David Blackley, an epidemiologist for the respiratory health division of West Virginia’s NIOSH. The rock contains silica, which is many times more toxic than coal dust. Blackley says that the miners’ machines are cutting into almost as much rock as coal, and that while many factors may be contributing to the rise in black lung cases, the increased amount of fine silica inhaled by the miners is playing a part.

Smith agrees. “The dust that coal miners, especially in Appalachia, have been mining in recent history is, pound for pound, worse than what my grandfather was mining in the 1940s. And that has to do with thinner seams,” he says.

A section of coal is exposed in the rock face lining a road in Partridge, Kentucky, May 2018. Brian Snyder/Reuters

On the basis of the NIOSH data, the Mine Safety and Health Administration (MSHA) passed the “Dust Rule” in 2014, which lowered coal dust exposure limits and required continuous personal dust monitors. But, according to Smith and former miners, the monitor samples are often inaccurate. In order to get cleaner samples, miners may wear the pumps under their shirts, store them in lunch pails, or hang them in a part of the shaft with better airflow.

“Coal miners have been breathing more dust than health experts have recommended for decades,” says Smith.

Further, the Dust Rule doesn’t go far enough to reduce silica exposure. In 2016 the Occupational Safety and Health Administration (OSHA), MSHA’s counterpart for non-mining industries, lowered its allowable exposure levels on respirable crystalline silica. The administrator for MSHA announced in February that his agency, which has weaker limits than OSHA, had no plans to change its silica standards.

Former coal miner Wade Pauley stands for a chest X-ray at United Medical Services in Pikeville, Kentucky, May 2018. Brian Snyder/Reuters

When the Prognosis Is Dire (and Political)

For miners to receive benefits for black lung, they first have to see their doctor, then their company’s doctor, and finally a state examiner. When the individual’s doctor and the coal company doctor dispute the diagnosis, the state examiner, who is supposed to be an independent B reader, steps in and settles the case. Until recently, teams of physicians contracted with the state to perform black lung exams. Two such teams included pulmonologists who worked with B reader radiologists, one being Brandon Crum.

Currently, fewer than one in ten black lung claims receive compensation. And yet, after learning that huge swaths of their constituents have been diagnosed with black lung, Kentucky lawmakers decided to make it even harder for them to receive the medical benefits they need. In March, Governor Matt Bevin signed House Bill 2 (HB2), a workers compensation bill that prevents radiologists with B reader certifications from analyzing black lung claims. There are ten certified B readers in Kentucky; six are radiologists and four are pulmonologists. HB2 shrinks the pool of state examiners to only the pulmonologists, at least some of whom have previously worked for coal companies.

“It doesn’t seem reasonable no matter how you look at it,” says Crum, who since July has not been allowed to evaluate X-rays for black lung claims. “If it was another disease, like malaria or influenza, you would not want to limit the number of physicians who could diagnose it. Especially the most qualified ones.”

Blackley says, “There’s no evidence that pulmonologists and radiologists see things differently.”

“Crum was a more favorable B reader to miners,” says Phillip Wheeler, a workers’ compensation attorney in Pikeville. “The coal industry didn’t like it, so when they started talking about changing the workers’ compensation law, they came up with what I would call the Brandon Crum Exclusion Bill.”

Don't let the Trump administration destroy the Clean Power Plan Take Action

Wheeler fears the “enormous backlog” the new restrictions will create. Actually, it already exists. According to Roland Case, a workers’ compensation judge in Pike County, there are currently 75 to 100 black lung cases awaiting the attention of a state examiner. Of those qualified, only a single pulmonologist has agreed to do state exams.

The American College of Radiology is calling on the Kentucky legislature to rescind HB2 and instead “work with medical providers to save more lives,” and some state legislators have shown interest in overturning the law. But Wheeler is doubtful such an effort would succeed—and if it did, he says Governor Bevin would likely veto it.

“Big coal is pretty powerful in Frankfort—far beyond what I think they contribute to the economy,” Wheeler says, referring to the state capital. “I’m not anti-coal by any means, but I think if people are doing dangerous work that causes injury, we as a society have an obligation to take care of them.”

The financial outlook for sick miners is about to get even worse. The Black Lung Disability Trust Fund, which provided living and medical expenses to more than 25,000 miners and their families last year, is facing a 55 percent loss of revenue when a scheduled tax rate reduction goes into effect at the end of the year. According to a new report out of the U.S. Government Accountability Office, if Congress does not extend the tax, the 50-year-old fund would acquire a $15 billion deficit over 30 years—the same period in which, experts say, more miners will need it.

In the meantime, Crum says he will still see his patients—even though his care cannot currently help get them the financial support they need for the rest of their lives. Three of his former black lung patients are now on a waiting list for lung transplants. One is in his forties. Two are in their early thirties.