When Robert Cohen learned about black lung disease as a medical student, he assumed it was a relic of the past. 

“I thought it was something that happened in the times of Émile Zola” — whose 1885 book “Germinal” chronicled the horrors of France’s coal industry. “I didn’t think I’d see it in my practice.” 

Almost four decades later, he still treats miners from downstate Illinois, their lungs scarred from breathing coal dust. They trek up to Chicago, sometimes looking out of place in the sleek hospital waiting room on Chicago’s ritzy Gold Coast, where Cohen sees patients. 

“The nurses love them, they are so down to earth,” said Cohen, who also founded a black lung clinic at Chicago’s public county hospital, serving miners from around the region, including many who had migrated to Chicago from Appalachia after mines there closed. 

Coal mining has become exponentially safer in recent decades, with far fewer miners dying on the job than at any point in history. However, an ancient and fatal scourge continues to take a toll beyond the workplace. 

Black lung cases have steadily increased and even spiked in recent years in Appalachia, as documented by researchers including Cohen and his colleagues at the University of Illinois at Chicago, where he is a clinical professor of environmental and occupational health sciences and director of the Mining Education and Research Center.

Cases are lower in Illinois than Appalachia, but still troubling, experts including Cohen say. According to data from the Centers for Disease Control and Prevention’s Coal Workers’ Health Surveillance Program, between 2010 and 2014, the latest data available online, Illinois led the country in the number of miners examined for black lung under the federal program, with 1,143 miners. Twelve of them were found to have cases eligible for benefits. During that time, 148 cases nationwide were diagnosed, 62 of them in West Virginia. 

Data from the National Institute for Occupational Safety and Health shows that in 2018, there were 120 hospital discharges in Illinois for coal mine-related pneumoconiosis, or black lung. In 2001 there were 265 hospital discharges for black lung in Illinois, perhaps reflecting higher coal mine employment in years past. 

Mining operation in progress at the MC-1 mine in Macedonia, IIlinois in late 2018.
Mining operation in progress at the MC-1 mine in Macedonia, IIlinois in late 2018. Credit: © Neeta Satam

Bias in the system

Working and retired coal miners in Illinois, as in other coal areas, have long faced a lengthy and often torturous process in trying to access the federal benefits meant to compensate them and their families for inability to work, premature death and reduced quality of life. 

In order to seek benefits, miners’ lung scans are examined by experts hired both by the Department of Labor and the coal company. Miners can also hire their own experts, though many cannot afford to. 

Doctors hired by mining companies to evaluate black lung benefits claims are significantly biased against diagnosing the disease, according to a study released in March by Cohen and colleagues including Lee S. Friedman, a University of Illinois at Chicago associate professor of environmental and occupational health sciences. 

Their research found that of 63,780 radiograph classifications made by 264 physicians in Black Lung Program claims filed from 2000 to 2013, experts who were identified as having ever been hired by a coal company read the images as negative for black lung in 85% of the records. In contrast, experts hired by the federal government and by miners themselves found negative diagnoses 63% and 51% of the time, respectively.

Cohen’s and Friedman’s research even showed that the same doctors were significantly less likely to diagnose black lung if they were hired by a company than if they were hired by the government for that particular case. They also found that there were 64 experts who made negative diagnoses in 95% of their cases, with the vast majority (93%) of them being primarily hired by coal companies. Across all evaluations for black lung, evaluators found the disease in 31% of cases. (The University of Illinois at Chicago’s Sudeshna De and Kirsten Almberg were co-authors of the study.)

“While there is evidence of bias on both sides, it is clear that the degree of bias is much heavier on the employer side, and this is twofold,” Cohen said in a statement. “Not only are those hired by an employer much more likely to classify a chest X-ray as negative for black lung disease, but it is also much more likely that an employer will have the resources to hire its own expert — at a much higher fee — in the first place. It is clear from this data that this bias is a systemic problem and the most significant offenders are identifiable.”

The recent study was the first time bias in the claims process was quantified, but Cohen said it only proves what he’s been seeing firsthand for more than 30 years. 

“I’ve been in the trenches examining miners, seeing miners with very serious disease going to a coal company doctor who will read the X-ray as not black lung, not related to their coal mining and saying things that are just not true,” Cohen said. “It’s a very disturbing thing about this adversarial process.” 

One of Cohen’s patients, an Illinois miner who retired in 2014 after 25 years working underground, has extreme shortness of breath and fears he has black lung disease. But he expects getting compensation to be a struggle.

“The companies that will be contesting [the claim] are the same companies that did away with the pensions and tried to do away with health care and everything else,” said the retired miner, who asked his name not be used because he still has family working in the industry and fears retaliation. 

MC-1 mine in Macedonia, IIlinois
The MC-1 mine in Macedonia, IIlinois Credit: © Neeta Satam

Inadequate oversight 

Bias in the black lung claims process is just one more way, Cohen and Friedman said, that mining companies make it harder for miners to do their work in the safest and healthiest way possible, in an industry that even under the best circumstances can be unhealthy and dangerous.

“Fundamentally our judicial system and democracy is based on the premise that every defendant has the right to a vigorous defense,” Friedman said. “The defendants in these cases — the companies — have a disproportionate amount of resources compared to the miners. There’s an inherent imbalance.” 

Cohen notes that there are various measures mines can take to reduce levels of coal dust that cause black lung. But since these measures cost money and can slow production, companies may be reluctant to do so. Cohen and other experts and labor union officials have also long complained about the federal inspection process for coal dust. Mines are notified as to when an inspection will occur and can reduce production during inspections to 80% of normal levels. Before reforms were instituted, they could cut their production to half of normal during dust inspections.

“That’s always going to give you a lower sample than what’s really happening,” Friedman said.  

After an outcry from miners and health advocates about the black lung crisis, in 2016 the Department of Labor reduced the amount of coal dust allowed in underground mines from 2.0 to 1.5 milligrams per cubic meter of air. 

Over the past five years, the Mine Safety and Health Administration found dust concentrations above the legal limit 100 times in MC-1, or “Sugar Camp,” Illinois’s largest mine. One reading in 2012 was 22 micrograms per cubic meter, 15 times the legal limit, and nine readings were more than double the legal limit. 

Meanwhile, the increasing presence of silica dust in coal mines may also be contributing to black lung disease, experts say. Silica dust comes from hard rock that is mined along with coal, and the increasing ability of mine processing equipment to efficiently separate coal from rock means that more rock is being hacked out of mines — and more dust potentially created, Cohen explained. 

Silica dust is regulated as a percentage of total allowable dust levels, so it is not regulated as specifically as coal dust, even as it poses an increasing risk to coal miners. During the Obama administration, a new rule on silica limits for mines was proposed and a docket was underway, but the process stalled under the Trump administration. The Biden administration is working on writing and instituting a new rule, according to an expert familiar with the process. 

During testimony before Congress in 2019, Cohen said his research showed that silica exposure was an important factor in the resurgence of black lung disease, including among younger miners. He advised the government to require that miners wear personal monitors specifically tracking exposure to silica dust. Silica is a particular risk in Appalachia because of the geology there, Cohen said, but he believes it is also a factor in Illinois. 

“Those of us who care for these young miners in our black lung clinics see them fighting for breath,” Cohen told the U.S. House of Representatives Subcommittee on Workforce Protections. “They suffer from loss of ability to do simple daily tasks, like walking to the mailbox, playing with their children and grandchildren; not to mention a loss of their careers, hobbies, and ability to support their families. They suffer from early mortality in spite of our heroic attempts to treat them, including referrals for lung transplantation. Let me remind you, there is no cure for this disease, it confers an early death sentence.”

Healing ‘sick’ mines, supporting survivors   

Health advocates and experts would like to see both coal dust and silica dust in mines regulated more stringently. And Cohen and Friedman have proposed reforms that could reduce bias in the black lung benefits process, helping miners access benefits more easily if they have black lung disease and potentially creating more incentive for companies to operate the healthiest possible mines. 

During the black lung claims process, doctors’ evaluations are presented to a judge, who ultimately decides whether a miner or retired miner gets benefits. The Department of Labor has instituted reforms limiting the number of doctors’ opinions a company can submit, but researchers have also found that companies are likely to seek multiple opinions and submit only those favorable to their position. Federal reforms have also tried to curb this phenomenon, but Cohen and Friedman would like to see safeguards go further. 

They propose that all doctors being hired to evaluate claimants be contacted through the Department of Labor, so that they don’t know who is ultimately paying them.

“That would eliminate that coordination between the employer’s legal team and the doctor,” Friedman said. 

They also recommended expanding and diversifying the pool of experts regularly called upon to evaluate black lung claims, making evaluators annually report any payments related to black lung claims, standardizing the rate that can be paid for evaluations (so companies don’t pay exorbitant amounts to gain favor with an evaluator), and making sure the best technology is available for evaluations, including tapping artificial intelligence to aid in the evaluations. 

Improved standardization and use of the best technology could go far in reducing bias in the black lung claims system, since diagnosing black lung is an inherently subjective pursuit. “You’re looking at shadows in a dark room, it’s not like a blood test where you inject a sample into a machine and it spits out an objective measurement,” Cohen said. 

Ideally, a more fair and transparent black lung claims process, along with more stringent dust-related regulations and testing, would help motivate companies to do everything possible to avoid exposing miners to dangerous dust. 

Meanwhile, Cohen and Friedman are studying correlations between coal dust exposure and injuries in coal mines, with preliminary work indicating the two are correlated. 

“The hypothesis being that a sick mine is a sick mine, with higher dust exposure and higher injury rates,” Friedman said. “Those mines tend to have management that isn’t emphasizing safety.”

Kari has written for the Energy News Network since January 2011. She is an author and journalist who worked for the Washington Post's Midwest bureau from 1997 through 2009. Her work has also appeared in the New York Times, Chicago News Cooperative, Chicago Reader and other publications. Based in Chicago, Kari covers Illinois, Wisconsin and Indiana as well as environmental justice topics.