SCARBRO — Sitting still and slightly slouched, his gaze fixed blankly ahead, Lester Burnette inhales as deeply as his lungs allow.

He stands up slowly and coughs loudly. He unwraps a menthol lozenge and pops it in his mouth.

"Cough drops," he explains. "They help."

The 62-year-old has just powered through 20 minutes on the arm ergometer — a two-handled machine used to improve cardiovascular strength.

Burnette pats his pocket full of cough drops as he makes his way to the next of four exercise machines he'll use at the Grace Anne Dorney Pulmonary Rehabilitation Center at New River Health.

Like the other half dozen men in the clinic, Burnette has black lung. Pneumoconiosis, as it is technically called, is a common disease in coal miners.

Burnette, a 27-year coal miner, has the most severe form of the condition — complicated black lung, or Progressive Massive Fibrosis (PMF), in which large masses form, usually in the upper lobes of the lungs.

Dr. Anna Allen, a federal black lung examiner and board certified in occupational medicine, said severe cases of black lung seemed to peak in the 1960s and 1970s.

"It drops off, then bottoms out around the mid-90s," Allen says. "Then it starts climbing again."

In eastern Kentucky, western Virginia and southern West Virginia, miners are working in low coal seams, Allen explains.

"It's shorter coal seams, only like 20- to 30-inches high. They're using equipment that cuts through a larger section. The newer machines are all set at a certain height. They're cutting through the rock around the coal seam, generating more silica (sandstone dust) in the air."

That, along with increased workload, has been causing more cases of black lung, especially PMF, in the Appalachian region.

Allen says between June 2016 and May 2017, 16 percent of the patients at Cabin Creek Health Center, located in Dawes in Kanawha County, had black lung, and 6 percent of them had PMF.

More PMF cases are also being identified at the New River Health Pulmonary Rehabilitation, where Burnette is treated.

Brenda Marion, RN and program director, says, "We would see maybe one or two a year over time. Now, it's monthly, and in some clinics, it's weekly."

She's seen the PMF diagnosis in miners from their 30s to their 80s. Most patients, though, are in their 50s.

In February, the Journal of the American Medical Association (JAMA) highlighted cases found at three federally funded black lung clinics in southwest Virginia. Of the 11,200 observed during the study, 416 coal miners were identified as having PMF.

"To our knowledge, this is the largest cluster of PMF reported in the scientific literature," the report said.

The miners in the study were all white men with an average age of 61.8. Nearly 23 percent of the miners had worked 20 years or less, and 12 percent of the miners were still working in the mines.

• • •

FAMILY TRADITION

Disabled due to his black lung diagnosis, Burnette retired in 2000 — the same year his dad died.

Both his father, Clarence Burnette Jr., and his grandfather, Clarence Burnette Sr., died in their 70s from black lung complications.

"I remember my dad telling me, 'I wish you wouldn't go into the mines,' " Burnette says. "I knew it was dangerous, but I was young. I was indestructible."

His original plan was to go to Florida. He wasn't a big fan of West Virginia winters. But he met a woman. They had a couple kids. And he had to take care of them. So he went underground.

"That's the only thing that paid anything."

Even today, coal mining jobs – those that are available – are some of the best paying in the region with an average starting salary of $60,000.

Burnette started his career in December 1973. For the first year and four months, Burnette manned conveyor belts, keeping them clear and unobstructed.

For the next 25 years, Burnette ran a continuous miner — a machine with a large rotating steel drum, equipped with tungsten carbide teeth that scrape coal from the seam. On a continuous miner, Burnette says, "If you don't have no air, which we never did, it starts getting real dusty real fast."

Burnette started having trouble breathing in the early 1980s, after less than a decade on the job. He was working 10-hour shifts, six days a week.

Dr. Allen says with work demands like that, "Your body doesn’t have a chance to heal and clear that dust out."

The development of black lung, Allen says, is largely dependent upon exposure.

As WebMD explains, coal dust accumulation in the lungs can sometimes cause the formation of coal "macules," a combination of coal dust and white blood cells. As the disease progresses, those macules can develop into nodules, which are abnormalities in lung tissue. A nodule wider than 1 centimeter is generally accepted as evidence of PMF.

Allen says, "If they're working somewhere well ventilated, in higher coal where you can walk through it, and not cutting through as much rock, you could work your whole life in coal mining and not get black lung."

Knowing the toll the mines took on his health, Burnette gave his sons the same advice his father gave him.

"I said, 'Guys, it ain't worth it.' "

They listened. Mostly.

They work with mining equipment, above ground, away from the hazardous conditions below.

• • •

SKIRTING REGULATIONS

Everywhere he worked, Burnette says he had to cut into rock seams, sometimes up to 12 inches of rock at a time.

"It's like opening a bag of flour and throwing it," he says. "It wasn't easy. You could try to hold your breath, but you couldn't hold it long, working the levers."

Within minutes, his nostrils would be completely filled with dust from rock and coal.

Federal and state regulations require underground coal mines to be well ventilated, not only to improve breathing conditions for the workers, but also to prevent methane explosions.

In a majority of the 17 mines he worked in McDowell, Raleigh and Wyoming counties, Burnette says miners were told to skirt regulations by placing their personal dust monitors in the clean air intake, giving an inaccurate reading of the air the miners were actually breathing.

"When the inspectors are gone, they're renegades."

Once, Burnette remembers a mine boss taking a 12-inch crescent wrench to the side of his continuous miner, smashing the dust pump on the machine.

"Now, they have motion sensors (on the personal dust monitors), but there are still ways to get around it," Burnette says.

He's heard that certain miners are assigned to take the monitors to the clean air intake and walk around, while the others continue working in the dust-filled spaces.

Falsifying safety reports is a well-known practice in some mines. It helps pass federal inspections. It helps keep mines open. It helps keep men at work.

A number of mine workers and operators have been charged throughout the years for the practice — a violation of the Mine Safety and Health Act.

The Upper Big Branch explosion, in which 29 men died April 5, 2010, at the Raleigh County mine, is one of the most well-known cases of the violation.

Don Blankenship, the CEO of UBB's parent company, Massey Energy, was convicted of conspiring to willfully violate mine safety and health standards. During his trial, prosecutors highlighted the culture at the mine, which, they argued, valued production over safety.

On a full day of production at UBB, where metallurgical, steel-making coal was mined, the same kind Burnette mined, the mine could generate $600,000 in revenue.

Multiple investigations, including one conducted by the Mine Safety and Health Administration (MSHA) and the Governor's Independent Investigation Panel, determined the disaster was caused by a long-time pattern of safety violations. The mine was issued hundreds of citations in the years and months leading up to the explosion. Documentation was found showing that low-level managers who made safety a priority were intimidated and, in some instances, dismissed.

Another account of violating the Mine Safety and Health Act took place last year in Kentucky. Daniel Couch Jr., former chief of maintenance at the Ken American Resources Paradise No. 9, was tasked with weekly inspections of electric equipment. When an MSHA inspector checked a 2016 record book, he saw there was no inspection May 1-7; however, upon his return days later, the book said Couch inspected the line on May 7 and saw no hazards.

While charges come less frequently for coal miners than for their superiors, some instances have occurred. In 2014, a 31-year-old miner, Sean Chase, was charged with falsifying safety records at an Ohio County mine.

• • •

SAFETY IMPROVEMENTS UNCERTAIN

Dr. Allen says one recent suggestion by safety experts has been to equip miners with respirators.

But miners still on the job tell Allen that the respirators don't seal properly because of body sweat.

"It gets real hot when you're already carrying 35 pounds of equipment," she says. "It's not the best option."

Even if it is a viable option, and miners actually wear the respirators, Allen says we won't know the benefits until 10 or 20 years down the road.

"Black lung can take 10, 15, 20 years to show up. It makes it harder to see in the short term whether we can help people or not."

The JAMA report pointed to new federal rules instituted in 2014, including decreased allowable dust concentrations, changes in dust monitoring, and expansion of the Coal Workers’ Health Surveillance Program.

During a three month check in 2016, 99 percent of more than 20,000 operator-provided samples were in compliance with the new dust standard. The report, too, acknowledged a need for continued surveillance.

Allen says she keeps at the men, trying to educate them and impress upon them the importance of their lung health.

But she thinks the answer is already in the mines, deep underground.

"Someone who's been in the mines longer, who's got the experience and maybe has the reputation — if you can get them to be advocating for safety and decreasing exposure, I think that might be how you have to do it."

Despite his condition, Burnette says he still loves the mining industry. But he's vocal about the need for adherence to safety regulations.

"We were young and macho," he says with a laugh – and a harsh cough. "If we only knew what it was doing to us."

• • •

DISEASE PROGRESSION

In some cases, Dr. Allen says, a black lung doesn't worsen. It stabilizes.

But other cases, for unknown reasons, progress even after exposure has ended.

"Some people develop PMF, and when it hits that stage, it's going to continue progressing," Allen says. "The biggest impact is on the heart."

Burnette is starting to experience heart complications.

"When your lungs don't work right, you can't get full strokes of air," he says. "Your heart goes, 'bom, bom, bom,' too fast."

Allen says PMF causes changes in the heart's structure, making the heart work harder and threatening heart failure. Technically, the condition is called cor pulmonale, an enlargement of the right side of the heart.

Some patients are referred to pulmonary rehabilitation, which can help improve lung capacity, blood oxygen levels and circulation. Pulmonary rehab centers also offer education about lifestyle choices and proper diet.

As Allen puts it, "It's not going to cure the disease. But it will help quality of life."

For nearly two years, Burnette has been going to rehab twice a week — Tuesdays and Thursdays. He says it's helped.

With his clear plastic nasal cannula in tow, Burnette plugs the far end of the tube into a square blue oxygen tank beside the next piece of exercise equipment, the NuStep.

With the aid of oxygen, he'll spend 20 minutes on this machine, which conditions the upper and lower body. Then he'll spend 20 minutes on a stationary bike. Then 20 minutes on the treadmill.

"When I started out, I could do maybe five minutes," he says. "If I'd have known about it sooner, I'd have gone sooner."

When Burnette's father and grandfather struggled with the disease, their only option was an oxygen tank. But medicine today is much better.

Medications, such as inhalers and nebulizers, can be used to alleviate constriction and inflammation in the airways. Burnette has three types of inhalers and does a nebulizer treatment twice daily.

• • •

THE LAST OPTION

Aside from medications, the only treatment for black lung is a lung transplant. Dr. Allen says a person must be in good health, aside from black lung, to qualify.

"There can be an age cap at some facilities," she says. "More cutting-edge facilities would push it a bit further. Each case is an individual case."

John Hopkins Medicine's website says the average age of lung transplant patients is in the 40s, but older patients have had successful transplants.

"Five years ago, we had a cut-off of about age 60-65 for a lung transplant, but that is no longer the case," the site says. "We’ve offered transplant to people in their 70s, and although their risks are higher, we’ve had terrific success in this age group."

Two or three years ago, Burnette was told he would be a good candidate for a transplant.

"It scared me to death," he says of the conversation with a doctor.

Under the Black Lung Benefits Act, miners disabled by black lung are eligible for medical coverage and treatment of the disease. Burnette's covered under the Federal Black Lung Program.

The National Foundation of Transplants says a double lung transplant costs roughly $1 million without insurance. A federal black lung patient in need of a lung transplant must go through mountains of red tape — pre-evaluation at an approved lung transplant center; determination of whether the patient's medical benefits are the responsibility of the coal mine operator, insurer or the Black Lung Disability Trust Fund; and approval from the responsible party.

"Pre-evaluation and transplant coverage is decided on a case-by-case basis," the U.S. Department of Labor site says. "We expect coal mine operators or insurers to provide the same coverage we do."

For now, Burnette's content with his own lungs, despite their deteriorating condition.

He sighs, coughs, and says, "I'll just keep going until there's no other option."

— Email: wholdren@register-herald.com and follow on Twitter @WendyHoldren

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