Still Digging Our Own Graves: Coal Miners and the Struggle over Black Lung Disease

Preface

Digging Our Own Graves, first published in 1987, concluded with an ominous prediction: "Black lung disease awaits the younger generation of coal miners who are now at work underground." Would that I had been wrong! Today, not only do coal miners still suffer from this lethal but preventable lung disease, they do so at younger ages, some even in their thirties, and they are contracting the most advanced form of black lung at the highest rates ever recorded. More than fifty years after the US Coal Mine Health and Safety Act of 1969 imposed a respirable dust standard on the coal industry, designed to prevent black lung, why do such carnage and suffering persist? This updated version of the original book seeks answers to that question.

My own introduction to black lung began in the winter of 1971–1972, when I came to West Virginia to work for the Black Lung Association. I was barely twenty years old. Extraordinary political transformations were in the making: coal miners, miners' wives, and widows were challenging powerful institutions that had once commanded their acquiescence—the hierarchy of the United Mine Workers, the coal operators' association, county political machines, and the Social Security Administration.¹The language of "miners' wives and widows" implies that all miners are male. However, since at the least the 1970s, women have worked in the mines, including underground, albeit in small numbers. I use the language of "wives and widows" because most black lung activists use this language in their organizing and their discussion of black lung compensation (e.g., "widows' claims"). For a young college student from the Midwest, these developments in the mountains of West Virginia beckoned with a romantic excitement. Besides, the mountains were my ancestral homeplace; now I could return to them, not on a summer vacation in the backseat of the family car, but on my own.

Working with the older coal miners and impatient young organizers who made up the Black Lung Association at that time was a formative political experience for me. Coming from a long line of southern subsistence farmers and circuit-riding preachers, I was instilled with a righteous, if vague, sense of populism that made me eager to join the struggles of "working people." But neither my political heritage nor my exposure to campus radicals prepared me for what I found in the coalfields of West Virginia: above all, the stark boundaries and clear perceptions of class antagonism. Virtually every coal miner over the age of sixty-five proudly claimed to have "fought in the battle of Blair Mountain with a machine gun" in 1921 to bring the union into southern West Virginia. They were up against the combined forces of coal company guards, the state police, county sheriffs and their deputies, aerial bombers, and, ultimately, the US Army. I was dumbfounded.

Fortunately, it didn't occur to me to write about any of these experiences until my age and the changing times helped to deepen my understanding of what they might mean. In 1978, more than six years after I had first worked for the Black Lung Association, I began the research for a dissertation on the black lung movement. The political atmosphere was altogether different. A reform movement in the United Mine Workers of America (UMWA) had arisen, succeeded in a special election for leadership of the union, then disintegrated; the black lung movement had seemingly disappeared; and a storm of reaction was sweeping the Appalachian coalfields. The setbacks were frightening, but they made possible a more sober and critical perspective on the earlier period of upheaval.

I began this book as a labor history, asking obvious questions that seemed most important at the time: Why did the movement end this way? What did it accomplish? How did it fail? Who or what was to blame? As I dug deeper into the history of the black lung movement, however, these apparently clear-cut questions about victories and defeats began to seem ambiguous, even misleading. The assessment of whether the movement had succeeded or failed depended a great deal on whose goals were used as the standard of measurement—and goals varied considerably among different participants. Moreover, what the larger political culture defined as the movement's greatest accomplishments often turned out to be mainly symbolic; they represented the visible outcomes of formal processes of reform (the passage of legislation, for example), but in and of themselves did not necessarily signify substantial and lasting change. The simplicity of my original questions faded as the labels of victory and defeat, success and failure, appeared more and more ephemeral. The central analytical problems increasingly seemed to involve the maddening complexity of social change itself, which prevented any person or group from controlling the course or outcomes of this movement.

As I delved further into the reforms sought and controversies engendered by the black lung movement, it became apparent that the movement was more than an important episode of labor resistance. At issue in the struggles over black lung, which have reemerged today, is not only how to prevent the disease or compensate those affected by it but also the very definition of black lung. Frequently, the most ideologically powerful opponents that miners have faced in their successive surges of activism are not coal operators or conservative politicians but physicians. At the center of the black lung controversy has been a profound power struggle between miners and physicians over who will control the definition of this disease.²See Daniel M. Fox and Judith F. Stone, "Black Lung: Miners' Militancy and Medical Uncertainty, 1968–1972," Bulletin of the History of Medicine 54, no. 1 (1980): 43–63, for an early framing of the black lung struggle as between miners and physicians over the definition of disease. Their emphasis on medical uncertainty differs from the analysis in my own article, which came out during the same time period: Barbara Ellen Smith, "Black Lung: The Social Production of Disease," International Journal of Health Services 11, no. 3 (1981): 343–359.

As a result of these and other shifts in emphasis, this book is a hybrid. It draws on diverse theoretical traditions in order to analyze not only the organization and development of the black lung movement, but also the history and conflict that underlie the brutal fact of coal miners' diseased bodies. Beginning with how and why black lung originates in the workplace, this book also explores the medical history of the disease and the conflicting meanings that miners and certain physicians, lawyers, and government administrators invest in black lung.

After moving away to a self-imposed exile some twenty-five years ago, I live once again in West Virginia. Contrasts with the 1970s heyday of working-class activism are evident throughout the rural landscape of abandoned gas stations, rusted coal tipples, and boarded-up union halls. The differences are personal as well: when I interviewed black lung activists in the 1970s, I was the age of their daughters and granddaughters; today, I am eligible for Medicare. As I conducted additional interviews in 2019, mostly with retired coal miners close to my age, their bodies as well as their words spoke the story of black lung disease and the physical toll of hard-labor jobs. Conditioned as a white woman to thinking of my embodiment primarily in terms of gender, I was struck again and again by how the privileges of class have shielded me from harm and become subsumed into my body. This updated and revised book, which includes two new chapters and a moving, evocative photo gallery by Earl Dotter, thus entails not only additional research into medical, legal, and economic materials relevant to black lung, but also historical reckonings both political and personal.

Today, as I write this preface, the power relations that miners experience on the job are dangerously asymmetrical, and their outcomes grim. Coal miners in southern West Virginia, once the stronghold of the UMWA in central Appalachia, where those who crossed a picket line invited ostracism if not assault, now work nonunion. Coal companies, facing shrinking domestic markets and in many instances bankruptcy, force workers, coal communities, and American taxpayers to bear the costs of their decline. Black lung can only be fully understood as part of this historical moment, when resistance, remarkably, persists. Digging Our Own Graves analyzes the dreadful resurgence of black lung within the long history of efforts to legitimate this disease and make it visible, prevent black lung in the workplaces where it is produced, and extend dignity and a measure of justice to those for whom prevention comes too late.

Conclusion: Class Power, Scientific Authority, and State Regulation

Nearly two centuries have passed since Dr. James Gregory opened up the lifeless body of John Hogg and hypothesized a connection between the miner's blackened lungs, his respiratory disability in later life, his occupation, and his death. For a time, physicians in Britain and the United States continued to investigate the relationship between occupational exposures and miners' respiratory distress. Toward the end of the nineteenth century, however, during a period of tight corporate control in the Appalachian coalfields and an increasingly restrictive scientific understanding of disease, black lung began to disappear from the medical literature of both countries. In the United States, coal miners eventually precipitated renewed medical attention to black lung by winning a union-controlled health care plan for themselves and their families. Even so, coal workers' pneumoconiosis—much less the broader ensemble of illnesses called black lung—was not accepted as a legitimate, occupationally related disease by the medical profession as a whole.³Journalistic and some scientific accounts equate coal workers' pneumoconiosis (CWP) with black lung. However, an essential component of the black lung movement was miners' and their families' struggle to broaden the definition, beyond CWP, of miners' disabling, occupationally related lung disease. Research by physicians and other scientists familiar with and sympathetic to miners and their health has validated this broader definition. See, for example, Edward L. Petsonk, Cecile Rose, and Robert Cohen, "Coal Mine Dust Lung Disease: New Lessons from an Old Exposure," American Journal of Respiratory and Critical Care Medicine 187, no. 11 (2013): 1178–85. Formal recognition required collective political intervention by coal miners themselves.

Even as social and economic factors have impinged on the medical construction of black lung, so have they shaped the actual production of disease. Black lung originates not simply from the physical presence of dust in coal mines, but from the relative power and respective actions of miners and operators, which influence conditions in the workplace. Miners' eventual success in unionization enhanced their collective power in the workplace, but, depending on UMWA leaders' priorities, unionism at times paradoxically undermined miners' capacity to make that workplace healthy and safe. In the years after World War II, the pact between larger operators and the UMWA produced unimpeded mechanization of the production process, high levels of unemployment, forced migration, and occupational death and disability from black lung. However, that industrial collaboration also produced massive rank-and-file upheaval and a successful effort to reform the union. In the present moment, union weakness and miners' lack of bargaining leverage in the workplace, combined with certain operators' endgame maneuvers to extract coal from thinner seams even while pressing for high levels of labor productivity, once again intensify the extent and severity of the disease.

The virulence of black lung today—fifty years after it was supposedly destined for elimination—does not diminish what coal miners, their families, and their allies accomplished in the past. Rather, it attests to the enduring realities of labor exploitation that the black lung movement episodically managed to contest. For its constituents, the movement achieved a unique and unprecedented federal compensation program. Approximately half a million miners and widows have received compensation under the federal black lung program; especially for those ineligible for a pension or other benefits, the monthly payments can mean the difference between destitution and modest survival.⁴This estimate of the number of black lung beneficiaries is extrapolated from data on the number of claims filed each year, changing approval rates, the annual total cost of claims, and, for some years, reports from the administering federal agency. See, for example, Social Security Administration, Annual Statistical Supplement to the Social Security Bulletin, 2016 (Washington, DC, 2017), Table 9. Beneficiaries who are miners and those who are widows, added together, do not equal the total number of miners judged disabled by black lung, as a widow may receive her husband's benefits after his death. Further, the number of beneficiaries is reported each year as a rolling total, and thus cannot be summed. The coronavirus interrupted my efforts to obtain more precise data. As of December 2018, an individual beneficiary is entitled to receive $660/month, which increases up to a maximum of $1,320 for those with three or more dependents. US Department of Labor, Division of Coal Mine Workers' Compensation, "Benefit Rates Under Part C, 1973–2018," accessed August 16, 2019, https://www.dol.gov/owcp/dcmwc/statistics/PastPartCBenefitRates.htm. The respirable dust standard and other disease prevention measures in the US Coal Mine Health and Safety Act of 1969 are also attributable to the black lung movement. As one element in a larger upheaval throughout the coalfields, the movement contributed as well to the rank-and-file takeover of the United Mine Workers of America and renewal of union leaders' critical attention to occupational safety and health.

Originally and essentially, however, the black lung movement was a struggle over the recognition and, more implicitly, causation of an occupational disease. What seemed at first a straightforward task— achieving legal inclusion of a "new" dust disease under the workers' compensation system—turned out to be a far more complex undertaking. Miners and other activists learned early on that "black lung," as refracted through the lens of scientific medicine, was quite different from the disease for which they sought recognition, compensation, and prevention. In a struggle that has lasted more than fifty years, activists have persistently challenged physicians, lawyers, and policymakers over the meaning of this disease; at different times, they have been able to replace the restrictive scientific construction of a rarely disabling coal workers' pneumoconiosis with their own definition of "black lung." Although focused on arcane disputes over diagnostic methods, disability standards, legal presumptions, and other issues, this conflict over the definition and causation of black lung is intensely political: it involves the ideological content of medicine's view of disease, including the technical perspective that narrows causation to the inhalation of dust, and the powerful role of physicians in labeling work-related disability as legitimate. On the outcome of such conflict rests financial liability for the coal industry that potentially ranges into billions of dollars. The legacy of black lung activism thus entails unsettling questions about the relationship between scientific and technical knowledge, state regulation, and the exercise of class power.

It should be stressed at the outset that not all physicians subscribe to a narrow or purely technical understanding of black lung: recall the role of three doctors (Buff, Rasmussen, and Wells) in the first black lung mobilization during 1968 to 1969 in West Virginia. Dr. Donald Rasmussen continued to work with and advocate for coal miner patients out of his pulmonary lab in Beckley, West Virginia, for five decades, up until his death in 2015.⁵Sam Roberts, "Dr. Donald L. Rasmussen, Crusader for Miners' Health, Dies at 87," New York Times, August 2, 2015, accessed September 29, 2019, https://www.nytimes.com/2015/08/03/health/research/dr-donald-l-rasmussen-crusader-for-coal-miners-health-dies-at-87.html. Rasmussen's mantle now falls on Dr. Robert Cohen, a pulmonologist who directs the occupational lung disease unit at Northwestern University and frequently testifies before Congress on miners' behalf.⁶Dr. Cohen testified during the hearings on black lung, "Breathless and Betrayed." See "What is MHSA Doing to Protect Miners from the Resurgence of Black Lung Disease?" YouTube video, 2:58:39, June 20, 2019, House Committee on Education and Labor, https://www.youtube.com/watch?v=sJUDcTf0a_g. Other physicians in the coalfields, such as Drs. Gregory Wagner and Brandon Crum, have devoted much of their professional lives to caring for coal miners with lung disease. After practicing medicine at a clinic on Cabin Creek (West Virginia), Wagner eventually came to direct Respiratory Disease Studies at NIOSH when that agency issued the criteria document that legitimated a broad definition of black lung, inclusive of COPD (chronic obstructive pulmonary disease), and recommended much lower limits on miners' exposure to coal dust and silica.⁷NIOSH, Criteria for a Recommended Standard: Occupational Exposure to Respirable Coal Mine Dust, publication no. 95–106 (Washington, DC: US Government Printing Office, 1995), xxii, https:// www.cdc.gov/niosh/docs/95-106/default.html. Crum, a radiologist—and, not coincidentally, former coal miner—was first to sound the alarm over black lung's escalating severity, which in 2014 he began detecting among his patients in eastern Kentucky. Four years later, the coal-industry-beholden state legislature responded by disqualifying him from reading X-rays for miners' workers' compensation claims.⁸Austyn Gaffney, "As Black Lung Strikes Younger Coal Miners, Kentucky Restricts Medical Benefits," NRDC, September 24, 2018, accessed September 29, 2018, https://www.nrdc.org/stories/black-lung-strikes-younger-coal-miners-kentucky-restricts-medical-benefits.

Apart from such individual physicians' political and medical predispositions, however, there remain epistemological tendencies within scientific medicine that militate against the understanding of disease advanced by black lung activists.⁹This summary of miners' perspectives on the origins of black lung and the role of physicians in advocating a restrictive view of work-related, compensable disease is based on the author's interviews and observations in southern West Virginia at different moments during the past five decades. Within the restrictive medical viewpoint that requires conclusive, scientific proof of occupational causation, black lung is in fact coal workers' pneumoconiosis, a single clinical entity, disabling only in advanced and, even today, relatively rare stages. The disease acquires legitimacy—indeed, effectively comes into existence—only when visible to trained personnel viewing objective diagnostic evidence, that is, X-rays, of an individual miner's lungs. The thousands of miners who believe themselves disabled by black lung yet exhibit no X-ray evidence of advanced CWP might legitimately be considered "disabled"—if the quantitative results of certain tests confirm such a condition. However, the origin of their disability is nonoccupational, above all their own cigarette smoking, or, if nonsmokers, other sources outside the workplace. Although this scientific definition of disease is quite different from physicians' earlier construction of a benign "miners' asthma," the result, in the eyes of many victims, is the same: black lung is trivialized. What many miners view as a collective problem becomes, from the perspective of scientific medicine, individual, quantifiable cases. What they experience as part of the shared social world of coal mining becomes occasional, biological events. What they attribute to their class relationship with the coal operators becomes the product of a single physical agent, dust. In sum, what is collective becomes individual, what is social becomes biological, what is produced by human action becomes the outcome of inert material.

Certain tendencies intrinsic to clinical medical practice are also at stake in the seemingly incommensurable perspectives of miners and certain physicians. Scientific medicine situates disease spatially, within the individual body, and temporally, at the point when signs, symptoms, or other physical alterations develop. Disease is ahistorical as well as asocial; it has no history except a "natural," that is, physical, history. It is said to exist when experienced by the individual and diagnosed by the physician, not at the point when it is being produced. The possibilities for prevention are thus constrained within the very definition of disease.¹⁰Howard S. Berliner and J. Warren Salmon, "The Holistic Health Movement and Scientific Medicine: The Naked and the Dead," Socialist Review 9, no. 1 (January–February 1979): 31–52.

Clinical medicine reflects this understanding of disease on a practical level: individual patients present the physician with their distinctive symptoms and complaints; they appear as random, disconnected "cases," and they are granted therapeutic treatment as individuals. There is no social meaning to disease in the sense of an internal relationship between social relations and the individual experience of ill health; primarily individual behaviors, such as diet, exercise, and smoking habits, command attention. Yet, in quantifying disability and allocating it to occupational or nonoccupational sources, physicians implicitly assess the conditions in which miners have lived and worked all their lives. That most physicians have never been in a coal mine (much less worked in one), and that some have never even been in the coalfields, serves to intensify the conflict between physicians and coal miners, who experience the superior legitimacy automatically granted scientific medical knowledge as a complex and powerful form of social control.

The authority of physicians to pronounce miners "healthy" or "disabled" carries important financial consequences. In the context of federal black lung compensation, doctors' assessments of coal miners' health can be decisive in the award or denial of financial benefits that are allocated in large part according to medical eligibility criteria. Doctors act as gatekeepers in a more generic sense as well: they control access to the "sick role," the sole avenue by which adults may legitimately escape the daily responsibilities of their class, race, and gender.¹¹See Talcott Parsons, The Social System (New York: Free Press, 1951). Parsons's conceptualization of the sick role was neither class nor historically specific. For coal miners, as for other workers, the preeminent requirement of their class position is to perform wage labor. Medical criteria for assessing disability (and determining compensation eligibility) that take as the standard for health the functional capacity to work explicitly enforce this requirement. Even if damaged by work, coal miners still must provide medically sanctioned evidence of their "total disability"—i.e., complete inability to continue working—in order to receive financial compensation and legitimate relief from wage labor. In pushing against the limits of this compensation policy, miners and their families implicitly contest not only the ideological authority of physicians to define disease and assess disability; they ultimately threaten the economic power of coal operators by pressing for a broad definition of black lung and relaxed standard of disability that would provide unhealthy miners an alternative to labor in the mines.

This convergence between the restrictive scientific view of black lung and the economic interests of the coal industry is, for many miners and their families, an ultimate source of distrust and conflict with physicians. The narrow definition of disabling black lung as a relatively rare, complicated pneumoconiosis is highly functional to the industry: it circumscribes the scope of occupational lung disease and correspondingly diminishes both the cost of compensation benefits and the importance of prevention. In the context of policy formation, scientific medicine plays a mediating role between the interests of the coal industry and the actions of the state. It facilitates apparent distance between corporate power and public policy, and seems to ground political decision-making in the neutral, technical knowledge of a third party.

The lessons of the protracted struggle over black lung disease encompass both caution and inspiration, loss and hope. In an era of science denialism, when defense of factual truths and scientific knowledge seems obviously necessary, the case of black lung still stands as a warning about the presumed neutrality and appropriate scope of scientific and technical solutions: beware of technical fixes for problems that ultimately derive from economic exploitation and grossly unequal political power. Activists' original quest for redress through the workers' compensation system offers a related caution: the sprawling administrative machinery of the state, which presents the customary, sanctioned route for institutionalizing reform, entails embedded interests that can thwart activists' aims even as it seems to grant their demands. Finally, the long history of black lung suggests that effective prevention of occupational disease, injury, and death ultimately resides in the ever-changing power relations of the workplace and workers' collective, organized capacity to defend themselves. For these and many other reasons, victories are never secure, achieved once and for all; they must be defended, expanded, critiqued, and revised, as black lung activists have doggedly done for some five decades now.

Today, the industry that for more than a century has defined central Appalachia is dying. Those who would chart a post-coal future must grapple with the industry's legacy of incalculable human and environmental destruction, but they would do well to learn from the additional legacy of coal mining families' solidarity and resistance. Ever since the first investors laid claim to the coal of Appalachia, the people of this region have been revolting in various forms against the appropriation of their land, their labor, and even their lives. Those who fought in the black lung movement are both heirs and contributors to this long history of resistance. Today, many miners pay the cost of coal production in the currency of their very breath, but they also continue to resist. Danny Whitt: "We don't never give up. You know when I'll stop? When the last breath leaves my body."¹²Author's interview with Danny Whitt, Matewan, WV, September 4, 2019.

About the Author

Barbara Ellen Smith is professor emerita of women's and gender studies in the Department of Sociology at Virginia Tech. She has been active in and writing about movements for social and economic justice in Appalachia and the US South for more than 45 years. Her recent publications include a co-edited book with Stephen L. Fisher, Transforming Places: Lessons from Appalachia (University of Illinois, 2012) and Digging Our Own Graves: Coal Miners and the Struggle over Black Lung Disease (Haymarket Books, 2020).

• fHealth
• fAppalachian Studies
• fIndustry and Labor
• fRegional Studies
• fSocial Movements
• fShort Read
• fSocial Class
• fEnvironmental Studies
• fRural Studies