Undercounting black lung incidence in the Navajo Nation due to structural inequities

Abstract Information: A key part of the Mine Safety and Health Administration’s mission is to protect coal miners and their communities from black lung disease. A preliminary analysis by the U.S. Department of Labor’s Chief Evaluation Office suggested that some areas of the United States―such as Appalachia and the Navajo Nation―may suffer disproportionally from the negative health impacts of coal dust exposure. In response to this concern, the authors examined the prevalence of black lung disease in the Navajo Nation due to coal mining, residential coal use, and coal-related air pollution from coal transportation and processing. The authors met with experts in the coal industry and Navajo Nation, conducted a literature review, and analyzed publicly available data to assess black lung prevalence across the United States. During this process, the team explored medical definitions for black lung, researched the links between coal communities and relevant respiratory diseases, and compared black lung prevalence in the Navajo Nation to other parts of the United States. The team then constructed a series of Least Absolute Shrinkage and Selection Operator (LASSO) regression models to estimate county-level black lung cases and deaths in the Navajo Nation. Comparing the data against literature and expert insights, the authors found that most instances of black lung within the Navajo Nation are not reported in healthcare databases from federal sources such as the Centers for Disease Control and Prevention. The authors used publicly available coal, employment, and black lung statistics to estimate the amount of underreporting within Navajo Nation borders and concluded that even if federal data do not support it, the Navajo Nation may be one of the most pervasive regions of black lung across the United States. Our findings show that the Navajo Nation likely has a high rate of coal dust exposure, the impacts of which are largely masked by data undercounts in federal reports. This highlights the need for future research to fill this data gap, informed by an understanding of the structural and cultural barriers that have led to this missingness in the data. We also suggest opportunities to conduct culturally appropriate research on this population. With such research, evidence-based policies can be developed to address undercounts and build toward an accurate understanding of black lung incidence in the Navajo Nation.