Coal mining has always been a hazardous occupation. But today’s miners face a new danger because they’re inhaling something worse than the coal dust that settles in lungs, triggering immune cells to form nodules, masses, and scarified black tissue. Most of the large coal seams in the mountains of Appalachia are gone now. To reach smaller seams, miners must cut through much more rock with high levels of quartz, which gets pulverized into crystalline silica.

When tiny particles of silica are inhaled, they act like minute shards of glass, leading to severe tissue scarring and inflammation and eventually to progressive massive fibrosis. Researchers from the National Institute for Occupational Safety and Health (NIOSH) estimate the disease now afflicts one in 10 working miners who have worked in mines for at least 25 years. Rising rates of the disease have led to stark increases in lung transplants and mortality. Between 2013 and 2017, hundreds of cases of progressive massive fibrosis were identified at three Virginia clinics alone, leading NIOSH to declare a renewed black lung epidemic. Black-lung-associated deaths, which declined between 1999 and 2018, rose between 2020 and 2023.