OAK HILL (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.