OAK HILL, W.Va. (AP) — Lisa Emery loves to talk about her “boys.” With each word, the respiratory therapist’s face softens and shines with pride. But keep her talking, and it doesn’t take long for that passion to switch to hurt. She knows the names, ages, families and the intimate stories of each one’s scarred lungs. She worries about a whole community of West Virginia coal miners — including a growing number in their 30s and 40s — who come to her for help while getting sicker and sicker from what used to be considered an old-timer’s disease: black lung.

“I love these guys,” she said, wiping tears. “I tell them … ‘Every single one of y’all that sits down in that chair is why I feel like I was put on this earth.’”

As director of the New River Health Association Black Lung Clinic, Emery’s seen guys as young as 45 getting double lung transplants as disease rates soar among miners forced to dig through more rock filled with deadly silica to reach the remaining coal — far worse than the dust their grandfathers inhaled. A rule approved last year by the U.S. Mine Safety and Health Administration would cut the federal limit for allowable respirable crystalline silica dust exposure by half to help protect miners of all types nationwide from the current driving force of black lung and other illnesses.

But, now, it’s in jeopardy amid other Trump administration cutbacks and proposals targeting workers’ health and safety guardrails: Stuck in a politically charged environment that promotes industry, with lawmakers arguing to change it and the federal agency that wrote the rule not pushing to enforce it. Some angry retired miners with black lung are fighting back, demanding that President Donald Trump honor promises he made to the people who voted him in.

The opposition comes months after Trump signed executive orders to allow coal-fired plants to pollute more and to streamline the permitting process and open up new areas for mineral production, including oil and natural gas drilling and mining of “beautiful, clean coal.” He was celebrated at the White House by smiling miners in hard hats, including some with West Virginia stickers, as he promised to put more people to work underground.

“One thing I learned about the coal miners: That’s what they want to do,” Trump said. “You could give them a penthouse on Fifth Avenue in a different kind of a job, and they’d be unhappy. They want to mine coal.”

But since his inauguration in January, a volley of firings, department eliminations and proposed regulation rollbacks have targeted hard-won health and safety protections fought for over decades to safeguard coal miners and other working-class folks.

The silica rule was delayed in April after industry groups suing the government filed an emergency request in court to block it from taking effect, citing costs and difficulties implementing it. Around the same time, the Trump administration told nearly all employees at the National Institute for Occupational Safety and Health that their jobs were being cut. That included those running a congressionally mandated surveillance program that certifies black lung cases.

Loud public uproar and bipartisan criticism followed, and a fraction of the agency’s positions were reinstated. That came only after a West Virginia coal miner diagnosed with black lung sued. A federal judge in that case issued a preliminary injunction ordering the government to bring back respiratory health division workers at NIOSH.

But some jobs, including those focused on mine safety and research, have not been restored. And even employees who have been recalled say a lack of funding and loss of expertise in specialized positions, from chemists to engineers, have made it impossible for them to operate at the same level as before.

In addition, the Labor Department has proposed altering some mining regulations to weaken the authority of district mine health and safety managers that could impact ventilation, roof prevention and training programs.

The result of all these changes is that many blue-collar workers and first responders nationwide — from commercial fishermen and miners to firefighters and construction workers — will have fewer people working to help keep them safe and healthy while doing some of the country’s most dangerous jobs, many of them deep in Trump country.

In fact, the two reddest states in America — Wyoming and West Virginia — had the highest overall worker death rates in 2023, according to the latest government figures. Together they experienced more than a dozen fatalities in the mining, quarrying and oil and gas sector that year.

As a United Steelworkers union leader representing about 700 trona miners in Wyoming, Marshal Cummings worries the little-known white powdery rock he digs — used in everything from glass and detergents to paper — could be making workers sick. He helped push for the silica rule to cover miners like him, offering them the same free health screenings as coal miners, and was forced to wait for researchers from NIOSH to investigate air quality at his site after a request he filed was initially killed by the layoffs.

“We got promised that we were going to make America great again, make America healthy again,” Cummings said at the time.

“You should be making these cuts with the scalpel,” he added. “You shouldn’t be using a chainsaw and chunking out all these things because you’re impacting workers.”

On the other side of the country, Emery sits in her office off a busy highway nestled amid West Virginia’s breathtaking mountains and whitewater rivers that attract tourists from across the world. Data collected from her clinic along with more than two dozen others nationwide, spell out what she sees in real time every day: Of the 11,500 coal miners from central Appalachia with X-rays analyzed by NIOSH-certified readers from mid-2020 through mid-2025, 55% had some form of black lung with the highest annual rate — 62% — recorded among miners seen in the past year, according to researcher Kirsten Almberg at the University of Illinois Chicago. That compares to 41% elsewhere in the U.S. over the same five-year period.

Experts say that’s because much of the easy-to-reach coal has already been extracted in West Virginia and neighboring Virginia and Kentucky, forcing miners to use massive equipment to eat through walls of quartz-filled sandstone to reach the remaining thin coal seams. This creates excess dust laced with shards of silica, which also cause lung cancer and kidney disease. It’s 20 times more toxic than coal dust, the major culprit of the past that often sickened older workers. The silica crystals embed in miners’ lungs, causing chronic inflammation and eventually irreversible scarring that peppers X-rays with chalky spots. It leaves proud, once-strong men skinny and weak. They choke on their food and gasp after just a few steps, cradling shiny cylinders that provide a lifeline of oxygen through tubes snaking into their nostrils.

“If you’ve ever about drowned — or anybody’s about drowned — they know what I’m talking about because I go through that every morning,” said Mark F. Powell, a fourth-generation miner from southern West Virginia who’s upset with Trump’s policies. “By the end of the day, I’m so tired. Sometimes I don’t even eat supper. I’ll come home and sometimes I’m not even able to take a shower. I’m not ashamed to tell it. I’ll lay on the floor and go to sleep.”

He said he wore his protective respirator throughout his nearly 30-year career, but was still diagnosed with a progressive form of complicated black lung and silicosis when he was 45. NIOSH certified his X-ray, allowing him to move to a job on the surface with no pay cut. Now, just four years later, he said he doesn’t have the wind to mow his lawn.

He said he worries about younger miners. Some, no longer protected by unions, were afraid to speak to The Associated Press or question bosses who may be skirting health and safety regulations.

From 1970 to 2016, more than 75,000 miners’ deaths were connected to black lung, according to NIOSH. Disease rates dropped after Congress put the agency’s Coal Workers’ Health Surveillance Program in place, but have surged since the late 1990s. NIOSH and unions have highlighted the need for the silica rule for decades, which cuts permissible silica dust levels inside mines from 100 to 50 micrograms per cubic meter of air averaged over an eight-hour shift — the same levels already enforced by the Occupational Safety and Health Administration in other industries such as construction. In 2018, NIOSH published a report showing around one in five coal miners with at least 25 years’ experience in central Appalachia had black lung. Those findings were based largely off of working miners who may not have been sick when X-rayed. Researchers say the newer numbers collected from black lung clinics like Emery’s show a bleaker picture because they capture miners who are disabled or retired, many of whom were never screened by NIOSH.

In July, seven House Republicans, led by Rep. Tim Walberg of Michigan, who chairs the House Education and Workforce committee, wrote a letter to the Mine Safety and Health Administration opposing parts of the silica rule, saying it ignored commonsense controls such as job rotation and personal protective equipment. The letter did not mention black lung or other diseases caused by silica dust, but said the rule was an example of Biden administration red tape and “imposed hundreds of millions of dollars in costs” on the mining industry.

Walberg did not respond to questions from AP, but a committee spokesperson said in a statement that while the Republicans support ensuring miner safety, the current silica rule does not provide mine operators enough flexibility to apply the standards in an economically feasible way.

The White House and the Labor Department insisted the administration can maintain miners’ health and safety while rolling back regulations.

“President Trump cares about our miners more than any other president in modern history – which is why he has implemented his energy dominance agenda to protect their jobs and revive the mining industry,” said White House spokeswoman Taylor Rogers.

But sick miners say the cost, for them, is their lives. Even after removing all exposure to silica and coal dust, symptoms continue to worsen, typically resulting in only two options: A risky, expensive lung transplant or death.

“I feel like in our part of the country … we’re kinda forgotten about,” said John Robinson, a former miner from Nickelsville, Virginia, who uses a walking stick and oxygen after being diagnosed with the disease 12 years ago at age 47. “I don’t think it’s right.”

Emery said her youngest patient with the most complicated form of black lung, called progressive massive fibrosis, was just 31 when he was diagnosed after only 10 years underground. And he’s not alone: Rates in the region have jumped in recent years — hitting an all-time high for long-tenured miners in the mid-2000s, according to NIOSH data.

“What we’re seeing at the black lung clinics is just really alarming,” she said. “So truly, if the rule got put in place today, cutting the silica exposure level in half, you already have sick miners. It’s going to take a solid 15 to 20 years for us to start to see this taper off.”

The history of disease and sacrifice is everywhere in these mountains. Just a few miles from Emery’s office, silica created one of the worst occupational disasters in U.S. history when more than 750 miners — most of them Black — died from breathing the toxic dust while drilling the Hawks Nest tunnel in the early 1930s to divert water to power a metal plant. A small cemetery with rows of sunken, unmarked graves memorializes the tragedy in an area where rumbling coal trains and steep mining tipples remain the backdrop in tired rural towns blighted by unemployment and decaying houses.

But the region also has a proud legacy of using disasters to galvanize workers to fight for greater rights. And West Virginia coal miners have been at the center of it.

Joe Megna was just a teenager when his dad left for the No. 9 mine in Farmington on the day he was set to retire in November 1968.

“I said, ‘This is your last shift, don’t go to work, we’ll go trout fishing,’” Megna said, recalling his dad’s dutiful response to the company. “He said: ‘I owe them that much.’”

Megna said his father then told him he loved him — for the first time — and drove off.

“This was the last time we talked,” he said.

Early the next morning, the ground shook so hard, it was felt miles away. Roaring plumes of smoke billowed more than 100 feet into the sky from a raging fire. Megna’s dad was among 78 miners who did not escape the explosion. His body remains entombed there along with 18 other men who were sealed inside.

It was the first mining disaster broadcast on national television, shocking the public and enraging workers. A few months later, roughly 40,000 West Virginia coal miners walked off the job in an unauthorized wildcat strike, demanding better black lung protections and benefits when the state was a Democratic stronghold. Congress responded by passing the Federal Coal Mine Health and Safety Act of 1969, which required government oversight and enforcement at coal mines and established breathable dust standards — the same ones the 2024 silica rule would cut in half — and compensation for miners disabled by black lung.

The federal black lung surveillance program was created as part of that act, which also helped lay the framework for broader workplace safety legislation a year later that formed OSHA and NIOSH as agencies. While OSHA is charged with enforcing worker health and safety standards under the Department of Labor, including citing employers for violations, NIOSH is the quiet research and development arm. It focuses on making recommendations to avoid work-related illness and injury and is overseen by the U.S. Centers for Disease Control and Prevention.

NIOSH investigates and studies firefighter deaths, including cancers. It certifies N95 masks and reviews and verifies illnesses involving 9/11 first responders who could be eligible for benefits under the federal World Trade Center Health Program. Scientists in its Spokane, Washington, laboratory — which remains gutted — work to keep wildland firefighters, oil and gas workers and commercial fishermen safe. Some were also helping to develop real-time monitors to alert miners of silica dust overexposure.

The chaotic layoffs in April and May were made in the name of redundancy when Elon Musk was at the helm of the Department of Government Efficiency, or DOGE, but no other agency does what NIOSH does. Health Secretary Robert F. Kennedy Jr., admitted during a congressional budget hearing in May that “we made a couple of mistakes” while saying he restored 328 jobs at NIOSH, mostly in Cincinnati and Morgantown, West Virginia.

“Under Secretary Kennedy’s leadership, the nation’s critical public health functions remain intact and effective,” a Health and Human Services Department spokesperson said in a statement. “The Trump Administration is committed to protecting essential services like those that support coal miners through NIOSH.”

Unions estimate around 500 employees remain on administrative leave while their future is hashed out in court after lawsuits were filed to have the jobs reinstated. Others took buyouts or have accepted positions elsewhere. The Trump administration has attacked federal employee unions, including those representing the agency, attempting to strip collective bargaining rights. That too has prompted lawsuits.

NIOSH was slated to become part of the newly planned Administration for a Healthy America, and Kennedy proposed its budget for fiscal year 2026 be slashed to $73 million — an 80% decrease from the previous year. Meanwhile, in September, the Trump administration provided $625 million in funding to expand and improve coal-powered plants.

Prior to the government shutdown, the House and Senate appropriations committees recommended the agency’s funding either be slightly reduced or maintained near pre-Trump levels. Experts have argued NIOSH is a bargain, costing about $2.20 per working American annually. In 2023, the nonprofit National Safety Council found workplace injuries alone amount to about $177 billion each year.

“We like to say that NIOSH is the little agency that no one’s heard of that’s probably helped save your life,” said Micah Niemeier-Walsh, an industrial hygienist at the agency’s Cincinnati offices, who spoke as vice president of the AFGE Local 3840 union. “Every single workplace safety and health regulation is written in blood.”

The fight has not died for some aging former West Virginia coal miners with black lung who meet regularly in a building adjacent to Emery’s clinic in Oak Hill. Last month, dozens of them drove hours along with counterparts from elsewhere in Appalachia to protest on the steps of the shuttered Labor Department, some pushing walkers and stopping to catch their breath every few steps. They held up photographs of dead friends and loved ones with signs reading “Coal Miners Lives Matter.”

On the opposite side of the building, an enormous banner with Trump’s face read: “American Workers First.”

Former miner and coal truck driver Randy Lawrence said both Trump and Kennedy should do an eight-hour shift underground to see why NIOSH and the silica rule are essential. He said he hopes to send a loud message to the president he voted for, but no longer supports.

“They’re doing everything they can to hurt the working man,” he said, lugging his oxygen tank. “They ain’t worried about the miners or people in West Virginia or coal miners anywhere. All they’re worried about is the almighty dollar in D.C. They don’t care about the little people that put them there.”

Outgoing United Mine Workers of America union president Cecil Roberts went a step further, accusing those delaying the silica rule of holding a pillow over miners’ faces, suffocating workers. The UMWA has tried to intervene in the silica rule lawsuit to help push for its enforcement, but government lawyers have opposed it.

“Let’s stop the killing in Appalachia!” he yelled into the crowd. “This country owes coal miners so much. … We allowed those fat-ass people up on Wall Street to be millionaires and billionaires. It’s our turn!”

The silica rule lawsuit is backed by a number of industry groups that represent different types of mining nationwide.

“We are absolutely supportive of the new lower levels,” said Ashley Burke, a spokeswoman at the National Mining Association, which is part of the lawsuit. She said the problem is instead with how the new rule is regulated.

Industry wants it to match more closely with OSHA’s methods of compliance, including allowing personal protective equipment to be used more to help meet the standards. But the mining rule calls for company ventilation systems and dust suppression devices to be used as part of the primary means of control.

Miners say respirators clog up frequently, making it hard to breathe, and they often slip or don’t seal properly due to beards, sweat or coal dust. They can also make it difficult for them to hear, see or talk in the noisy environment underground.

Retired miners who attended the rally say they also are pushing to make sure the Mine Safety and Health Administration isn’t weakened. Wayne Palmer was recently confirmed to lead the agency, which has seen a dwindling number of inspectors. Palmer previously worked as an executive for an industrial minerals trade association that filed a legal brief opposing the silica rule. Protest organizers say they asked to meet with Palmer, but never got a reply. The Labor Department did not respond to specific questions about the silica rule or whether Palmer planned to address the group.

“That’s like having a fox in a chicken house,” said Gary Hairston, 71, president of the National Black Lung Association, who came out of the mines in southern West Virginia sick at 48 years old. He said coal companies cannot be trusted to police themselves, adding he used to put tape over his air monitor to make sure he didn’t get bad samples because he feared being fired. He said the company also alerted miners when inspectors arrived to make sure all the safety violations were hidden. “You ain’t got nobody to go to.”

The Mine Safety and Health Administration houses inspectors who would be responsible for enforcing the silica rule, which the agency agreed to pause in April, citing restructuring at NIOSH and technical issues. This administration did not push back against the industry lawsuit in federal appeals court and was granted another delay in October, due to the government shutdown. The Labor Department has also proposed changes that would limit district managers’ authority to force mines to comply with ventilation, roofing and training regulations to carry out Trump’s directive to eliminate bureaucracy.

But at Emery’s black lung clinic in southern West Virginia, far from the lawsuits and the policy changes, all she can think about is one gasping miner arriving after another. Many are still working with limited lung capacity just to keep their health insurance, and they come to her with questions, hoping she can help delay the inevitable. She sees the young ones struggling to throw a football in the yard or make it to school sporting events.

“These families, you know, they’re my families,” she said. “It’s miners whose kids go to school with my kids.”

The worst ones have the number to her cellphone, which is never turned off. Sometimes they call in a panic, desperate for help.

“‘Lisa, I can’t breathe! Lisa, what do I do?’”

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Contact AP’s global investigative team at Investigative@ap.org or https://www.ap.org/tips/.