ED 310 890
RC 016 823
Work Disability in Appalachia.
West Virginia Univ., Morgantown. School of
Information Analyses (070) — Viewpoints (120)
MF01/PC01 Plus Postage.
*Coal; Labor Legislation; *Mining; Occupational
Diseases; ^Occupational Safety and Health; ^Physical
Disabilities; Social History; *Sociocultural
Patterns; Socioeconomic Influences; Work
* Appalachia; ^Disability Payments; Labor Studies
This paper begins by examining the history of
disability payments to disabled workers, specifically disability
payments to coal workers. Efforts by the United Mine Workers of
America made mine health and safety an issue in the 1960s, and
continuing liberalization of the law continued through the 1970s. The
identification of coal miners with disability is compounded by
geographical and cultural barriers. Currently underscoring disability
as a social construct among underground miners is the declining
regional economy and rising unemployment, brought on by technological
improvements in mining. The paper examines research about the effects
of early health intervention among underground coal miners and
describes other studies of physical disability in Appalachia. All
cited research supports the same general finding: disability is part
of an Appalachian life pattern, a natural consequence of work
occurring before old age. It is common for work to be punctuated with
periods of temporary disability and to end m disability retirement.
The uncertainty of mining as long-term employment makes benefits such
as Social Security and Workers 1 Compensation a necessary station in
the career course. There can be no solution to disability if
disability itself is a solution to narrow socioeconomic choices. Only
long-term improvements in basic education and the economy would
reduce work disability patterns. (TES)
* Reproductions supplied by EDRS are the best that can be made
from the original document.
WORK DISABILITY IN APPAIACHIA
— J. U S DEPARTMENT Or EDUCATION
Office N Educational Research and Improvement
EDUCATIONAL RESOURCES INFORMATION
j CENTER (ERIC)
Jo This <1ocumeni h,-»s been reproduced as
'ece'ved from the oerson or organization
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"PERMISSION TO REPRODUCE THIS
MATERIAL HAS BEEN GRANTED BY
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men! oo -»nt necessarily represent official
OERi poiitio.i or policy
TO THE EDUCATIONAL RESOURCES
INFORMATION CENTER (ERIC)."
WORK DISABILITY IN APPAIACHIA
WORK DISABILITY IN APPALACHIA
Judith Greenwood, Ph. D., M.P.H.
Director of Research and Development
West Virginia Workers 1 Compensation Fund
Clinical Associate Professor, Department
of Comunity Medicine, Department of
Behavioral Medicine and Psychiatry
West Virginia University, Morgantown
Coypright C 1986 by Judith G. Greenwood
I would like to thank Dr. R. John C. Pearson, Chairman of the Department
of Ccmnunity Medicine of West Virginia University, and Dr. Peter S. Barth,
Professor of Economics, at the University of Connecticut for their reviews.
As noted in an earlier article:
The term disability is relative and elastic, molded in
usage by cultural, social/ economic, and political cir-
cumstances. . . . Disability is fa] relativistic concept,
refering to nothing sui generis.
Yet, since the late 19th century, definitions of disability have been sought
as Western governmental bodies have adopted social insurance programs to
address the needs of disabled persons over and beyond poverty alone.
Beginning in Prussia under Bismark, the concept of disability became
linked to monetary compensation for persons unable to work because of acci-
dents and sickness or old age. This "model 11 compensation scheme spread across
Europe. In the United States, federal and state governments moved more slow-
ly and irregularly in addressing disability. Until 1911, practices in caring
for the disabled differed from cxrinunity to comnunity with no semblance of any
In 1911, the first state workers' compensation laws were passed in Wis-
consin and New York, marking the first step in the emergence of a uniquely
American disability system blending private, state, and federal obligations
and responsibilities. The first component of the workers 1 compensation sys-
tem rested on the philosophy that the government's role was limited to the
states individually legislating minimum industrial standards, overseeing the
obligation of employers paying injured workers some portion of pre-injury
wages , and seeing to it that the worker received seme medical attention .
There was a great deal of discretion left, up to employers as how to meet this
obligation. By 1920, all but three states had workers' compensation in seme
With the Social Security Act of 1935, states received federal funds for
the relief of indigent dependent children whose parents were unable to work,
often because of disability; also elderly adults, and blind persons. The
concept of disability was thus linked to public welfare. Unemployment in-
surance also began to meet seme temporary disability needs by paying benefits
to workers unable to work for specified time periods. Then after two decades
of federal planning and Congressional debate, in 1956 Social Security Disa-
bility Insurance wc.s added to the Social Security system to allow a disabled
worker to receive a pension before reaching retirement age. Entirely fed-
erally administered, Social Security was built on both enployer and employee
contributions. Unlike workers 1 compensation, coverage of disability under
Social Security did not differentiate between whether or not disability arose
out of a proveable v*ork-related injury or disease, but it did require the test
of an impairment preventing "substantial gainful activity."
Established in between the times of the first state workers 1 compensation
programs and the later federal Social Security disability program was the
federal-state vocational rehabilitation program. VSnile originally intended to
relate closely to workers ' compensation programs and later intended to relieve
any untoward financial inpact of long-term disability costs on Social Secur-
ity, it, of all disability programs, has been subjected to interest group
politics both internally - e.g. state agencies creaming the less severely
disabled to shew program success and thus gaining more federal dollars - and
externally - e.g. forceful lobby efforts of the United Mine Workers of America
(described later), the blind, and other disabled groups, most recently those
with severe neuromuscular disabilities seeking independent living. The fed-
eral state vocational rehabilitation program most clearly demonstrates hew
"public policy runs counter to the intentions of the policy maker, be-
cause the program did not develop in close relationship to either workers 1
compensation or Social Security.
Beyond the humanitarian intentions of policy makers, utilitarian goals
have become welded to disability in any context: (i) benefit entitlement for
individuals who can meet disability criteria, according to regulations, es-
pecially When a local, regional, or national economy is poor and (ii) politi-
cal clout for groups invested in the resource management for persons who are
disabled or deemed to have disabilities. Beyond its origin in the western
world as a legal and bureaucratic construct related to inability to work
either on a tanporary or a permanent basis, disability has become an important
social construct involving politics, economy, labor relations, and family
Underground Goal Mining and Work Related Disability
Underground coal mining has always been an inherently dangerous occupa-
tion from its early pick and shovel days to the automated mining of today.
Contributing to fatalities and injuries have been roof falls, cave-ins, gases,
dust, lew seams requiring tortuous body positioning; new machine noise and
machinery that can - and does - sever body parts. While underground coal-
miners are not a disabled group per se , they have become politically identi-
fied as at high risk for disability.
In the mid-20th century, the United Mine Workers of America (UMV™) pushed
for miners 1 entitlement to rehabilitation. John L. Lewis, president of
the UMWA worked closely with primary officials in the Social Security Admin-
istration to set up the UMWA's Welfare and Retirement Fund in 1946/ and fed-
eral officials worked for the Fund after that. One of the Fund's major goals
was to provide medical and rehabilitation services to injured miners, services
that prior to the Fund's establishment had been left up to mine owners and
company doctors since mines were remote frcm centers of medical care.
One of Lewis's first dramatic uses of the Fund was for the rehabilitation
of paralyzed miners.^ Fund officials sent doctors and public health nurses
into the hills, and they found miners who had lain bed-ridden for years. On
stretchers they were brought out of the hollcws to roads then taken by ambu-
lances to local hospitals, then taken on cots to train stations to wait for
trains taking them to rehabilitation hospitals - Henry Kessler's ir A New Jersy,
Hcward Rusk's in New York, Kabat-Kaiser in California.
The continued focus of the UMWA on its most disabled miners brought it in
conflict with the federal-state vocational rehabilitation program that wanted
to focus on "better material.' The Fund officials lobbied and pressured
federal agents to provide more dollars to state vocational rehabilitation
agencies for union miners. Rehabilitation was not the cnly coal, hcwever;
once the miners were accepted into the public program, the financial burden of
caring for the miners was shifted frcm the private sector UMWA Rind. The
pressure worked, and during the 1950 's it is reported that the "coal mining
states developed larger and more advanced rehabilitation programs than other
states." This link between rehabilitation and disability promoted by the
UMWA influence^ Congress in the 1950' s when it debated and then passed the
Social Security Disability Insurance. As one researcher has pointed out,
however, the much lobbied for UMWA rehabilitation program probably was not as
dynamic and efficient as portrayed publicly, or the union would not have had
to lobby as hard as it did. J
The UMWA did not immediately lobby with any vigor for coal mine health
and safety, hcwever, when that became an issue in the 1960's. Ralph Nader
having achieved victory over the auto industry and unsafe cars, turned to the
coal industry. To the industry's poor safety record, Nader added a new
charge: dust exposure leading to occupational disease in miners . Nader's
charge was based on a Public Health Service Report containing estimates that
10 percent of active miners and 20 percent of inactive miners had lung di-
sease. At the grass roots level the charge was supported by an outspoken West
Virginia physician I.E. Buff who unremittingly attacked the coal industry and
the dangers of dust exposure in the mines. It was Dr. Buff who coined the
term "Black Lung." The UMWA, hcwever, was unmoved, by either Nader's or
Then on November 20, 1968, a Consolodation Coal Conpany mine exploded in
Farmington, West Virginia, entombing 78 miners. The Farmington disaster
brought the issue of coal mine safety to the floor of Congress. Subsequent
Congressional debate and action are well documented. ' J Nearly one year
after the mine explosion, both the Senate and House had bills on the floor for
coal mine health and safety, each containing provisions for the canpensation
of "coal workers 1 pneumoconiosis," each, havever, restricting carpensatlon to
"complicated pneumoconiosis" based on medical testimony. The bill that energ-
ed frcm the conference camiittee ignored this area of agreement, deleting
references to "ccrrplicated" frcm the legislation, thus allowing for far broad-
er coverage. After sane sharp disagreement in the Houre regarding the integ-
rity of the conference process, the bill passed and then passed in the Senate,
and Title IV of the 1969 Coal Mine Health and Safety Act became a federalized
workers' compensation program for miners who were or would beccme totally
disabled because of pneumoconiosis and to dependent survivors of miners who
died frcm the disease.
The 1970' s saw a liberalization of the law. Union lobby new joined an
active grass roots lobby and coupled with powerful and well-placed Congres-
sional support gained amendments to the original legislation allowing for
presumptive respiratory disability based on number of years spent in coal-
mining; a positive X-ray was no longer necessary. Then came the most liberal
version of the program with amendments passed in 1978. The new amendments
mandated a review or reprocessing of all claims previously denied. "Miner"
was redefined to include any worker in or around a coal mine. Continuing
work, even continuing work in a coal mine, could not be used to refute a
Regarding the outcome of the liberalization of the Black Lung Program
during the 1970' s, one writer has observed that "...the hundreds of thousands
of successful beneficiaries actually exceeded the wildest possible goals set
by the program's supporters in 1969. , ^ 10 -' Another writer observes: "Through a
classic confluence of interest group politics and public relations, the Black
Lung Program mushroomed into a billion dollar a year permanent federal pro-
gram." 1 " Both writers note that in many ways the Black Lung Program re-
sembled a pension program responsive to social need . During the decade fol-
lowing the Coal Mine Health and Safety Act, automation of the mines produced
significant reductions in manpower requirements . Unemployment in mining
counties was increasing; seme mine owners were moving toward operating non-
union mines. To qualify for black lung benefits became the goal of many
Qiaract eristics of Appalachia
The sociopolitical identification of coal miners with disability is
compounded by geography and culture* In the United States much of the under-
ground coal mining is located in Appalachia, a mountainous region running from
northeast Alabama and northwest Georgia up through southwest South Carolina/
eastern Tennessee, eastern Kentucky, West Virginia, and southwestern Pennsyl-
vania. Within that area, the bulk of the coal mining is in Kentucky and West
The mountainous nature of the region naturally restricts mobility and
social interactions. Clay roads are common, and beccms mud roads in the
winter and spring. Original settlers sold off the wealth of timber and miner-
al rights, thus only the tof clay soil and rocks remained for any ownership .
Then mining companies came in and bought up much of the land. The company
towns have now gone, except for rews of identical small houses in some places,
and trailers in Which many miners live are now often placed on rented land,
Intellectual and cultural resource within the population is comparatively
diminished , and educational opportunities and resources are circumscribed .
Deprivation is a way of life in many of the hollows along the creek branches
of Appalachia and has been sensitively described in detail by a nurse anthro-
pologist^ 12 ^
If one who has been born and bred and worked in Appalachia becomes dis-
abled by injury or disease, function Which has always been limited anyway is
sinply further limited ♦ Within this geographical, cultural, and social con-
text, disability does not controvert a pattern of life as it does in more
mainstream middle-class America, but seems to magnify all the restrictions
Currently underscoring disability as a social construct among underground
coal miners is the declining economy of the region in terms of unemployment
brought about by mechanization of mining . In 1976. there were 9,050 mining
jobs in the leading coal producing county in West Virginia; in 1986 there were
2,760, Unemployment in that county is over 25 percent* Weekly workers 1
compensation disability benefits are almost $100 nore than unemployment
benefits • Thus the awarding of disability benefits following injury or dust
or noise exposure in the mines has become a matter of increasing controversy
between workers and their employers . Despite the rich coal seams and the
efficiency of machine mining, seme coal employers are finding the costs of
disability impeding their ability to do business . Among enlightened coal
employers, there is increased interest in intervening in what has been de-
scribed elsewhere as "the disability process" 1 * following injury,
Studies on Disability in Appalachia
A controlled demonstration project was undertaken by of the West Virginia
Workers 1 Compensation Fund to assess the cost-effectiveness of early inter-
vention among underground coal miners having back injuries resulting in time
lost frcm work. The intervention consisted of a rehabilitation nurse making a
health and psychosocial evaluation of injured workers within a week or two
after injury followed by a nurse and a counselor providing guidance to workers
deemed at risk for extended disability and coordinating primary care, spec-
ialty, and physical therapy services. Unexpectedly, the findings from the
study are not statistically significant and do not support this early inter-
vention approach. These findings counter other research and policy sup-
porting early intervention and raise questions regarding why this ap-
proach failed to reduce the length and cost of workers 1 disability. Certain
factors external to the intervention itself may help to explain the findings.
First is the depressed socioeconomic condition in the geographical area
from which the study sample came. Several small mining companies operating at
the time of the study have closed, and two of the larger companies have closed
mines and reduced personnel. There are few alternative employments in region.
Second is the intimidation of health care providers by union officials
and attorneys who are hostile toward overt return-to-work treatment inter-
ventions. When confronted by staff involved in the early intervention study,
a local hospital administrator responded, "We can't be known as an organi-
zation supporting a group that gets people back to work.'
Third, 47% of miners whose back injury had resulted in their entering the
study had had previous injuries, and 30% had previous partial disability
awards as a result of injury meaning that according to medical judgement, they
had permanently lost a certain percentage of normal body function. These
injury rates can be interpreted at two levels: first, to verify that coal
mining is a high risk occupation; second, to shew that for an individual miner
injuries and aggravations of previous injuries can make disability part of the
pattern of life.
Other studies have addressed disability in Appalachia. In 1952, Wiesel
and Arny described "miners 1 syndrome" after studing 100 coal miners in Harlan
County Kentucky. The syndrome was characterized by numerous somatic
complaints, a passive dependent attitude, a lack of anxiety with rationaliza-
tions of being exposed to "bad air," hard work, and "nerves being run down."
The researchers found both advantages and disadvantages to the then extant
UMWA Welfare and Retirement Fund and noted that it fostered dependency and a
chronic invalid reaction.
Cock in assessing psychosocial barriers to rehabilitation in Appalachia
in 1967 concluded that many individuals Who live in the restricted geograph-
ical and social environments, the hollows and valleys and small rural mining
tewns, have adapted to restriction and confinement, both of which are also
elements of disability. J Cock noted dependency as a significant factor
"that inhibits restoration to productivity," and that dependency is particu-
larly evident among coal miners in Appalachia who have over decades had two
major authority figures: the cenpany and the union. First, the ccmpany
provided not only work for the miner/ but his house and the script for food
and clothes at the company store. With the development of the UMWA, the miner
transferred much dependency to the union for advocacy. In both cases, how-
ever, autonomy and self-direction have been inhibited.
Ludwig in 1982 described the conrrcn affliction of "nerves" and resulting
disability among individuals, both men and vvomen, in Appalachia. "Nerves"
appears to be
. . .a conglomerate term to encompass chronic anxiety
without panic, mild depression without despair, neu-
rasthenia without malaise, a smattering of hypochond-
riasis, and a surfeit of illness behavior, all
superimposed on passive, dependent individuals with bor-
derline normal intelligence and exposed to profound socio-
cultural deprivation. ^ ^
Horton looked at patterns of illness in an Appalachian ocmmunity in 1984
In this area of Appalachia [Lincoln County, West Virginia],
disability is not experienced as it would be in the gen-
eral middle-class United States, as a sharp insulting
surprise . Dibability is not only inevitable, but it
inevitably acocntpanies age. As one informant explained,
that it is not a matter of 'if you'll be crippled, only
Human bodies, 'poor flesh at best,' are not presumed to
function well, especially s they grew older. An invading
set of ailments - 'arthuritis' (arthritis), 'sugar' (dia-
betes), 'highblood* (hypertension) - are expected by the
age of forty. As with injuries, these disorders are
judged to be irremediable and irreversible. Even fit,
healthy, hardvvorking young males are resigned to being
'past it' by their thirtieth birthday.
Horton further speculates that back pain among men and headaches among women
may be somatoform disorders, with belief in their inevitable occurrence as
These separate studies, unrelated to cne another, all support the same
general finding: disability is part of an Appalachian life pattern before old
In light of the studies just cited and the politics of disability rela-
tive to underground coal mining, one can conclude that in central Appalachia
work and disability are related concepts with disability perceived as a natur-
al consequence of work. It is common for work to be punctuated with periods
of temporary disability and to end in disability retirement.
At a systems level, disability is well supported. The Black Lung Pro-
gram, while modified by amendment in 1981 to limit a number of the liberal
provisions of the 1970' s amendments, was by no means "completely reform-
ed." It remains a quasi-pension program retaining essentially lenient
definitions and procedures. In the broader system of workers ' compensation,
when permanent total disability occurs as the result of the combined effects
of a work-related injury and a pre-existing impairment frcm injury or di-
sease, benefits to cover the pre-existing impairment portion of total dis-
ability may be paid out of special set-aside funds. This method of disability
coverage is prcminant in the two Appalachian coal mining states of West Virginia
and Kentucky. The employer is held responsible only for benefits related to
the subsequent work-related injury* Thus an employer can use pre-existing
impairment as a way to dismiss any protracted litigation over a claim and to
contain any future disability loss for one worker, and a worker can gain an
honorable retirement. The question of whether the worker is truly totally
disabled frcm work is relatively unirrportant.
In other cases , Social Security benefits can be the next step after
Workers 1 Compensation. And for many persons deemed unable to be gainfully
employed for 12 months or longer, because of physical impairment, but who
cannot claim a work-related injury, Social Security benefits may be the only
recourse. West Virginia according to the most recent data available has 74
disabled worker beneficiaries per 1,000 insured workers, the highest rate in
the ration and quite significantly higher than the rational average of 35
disabled workers per 1,000 insured workers. Kentucky's rate of 48 dis-
abled vorker beneficiaries per 1,000 workers, vtfiile considerably below West
Virginia's rate, is still higher than the national average.
What possibilities are there for change? First, it is clear that in West
Virginia geography, high risk occupations (timbering and glass manufacturing
in addition to mining), politics, and economy together with disability benefit
administration systems backed by liberal court decisions can make disability a
station in the career course, rather than an adverse interruption or an ad-
versity to be mounted. In a region where the economy is limited and educa-
tional levels are lew, vocational rehabilitation is generally not a premising
alternative for disabled workers vho have worked in heavy labor* Early inter-
vention in the course of disability may be more premising, but the lack of
cost-effectiveness in one research project leaves sane doubt . It would seen
that only long term improvements in basic education and the economy would
reduce work disability in Appalachian Lucwig frcm a study of Social Security
Disability recipients in Kentucky, has observed:
Any long-range remedy will have to be directed toward
prevention both in the very young and future generations.
In the education arena, special programs would have to be
constructed for predisposed children at the pre-school and
elementary school levels to make learning a more exciting
process and to broaden their intellectual horizons . ...
The presumed end product of this educational process will
be psychologically minded individuals who can recognize
the contributions of interpersonal and personal problems
and their frustrations in resolving them to the distress-
ing symptoms they experience. . . . Instead of a fatalistic
world view of accepting their lot in life, social activism
must beccme a credible alternative*
Ludwig's solution through an improved educational process, however, cannot be
realized without an economy that offers individuals job and career alterna-
tives, that gives them a sense of control over their circumstances. Without
economic options, disability _is a solution to unavailable or dissatisfactory
jobs with both legal and bureaucratic accomodation of compensation. The Black
Lung Program is the quintessential realization of such a solution. There can
be no solution to disability if disability is itself a solution to a limited
1. Greenv*xx3, J. G. Disability Dilemmas and Rehabilitation Tensions: A
Twentieth Century Inheritance. Social Science and Medicine, 20 (12), p.
2. The "poor law" in England in 1601 first established secular and legal
obligations beyond religious and moral to help individuals in unfortunate
3. Berkcwitz, E. D. The American Disability System in Historical Perspec-
tive. In Disability Policies and Government Programs, E. D. Berkowitz,
ed. p. 17, Praeger, New York, 1979.
4. ibid. p. 67
5. Berkcwitz, E. D. Growth of the U. S. Social Welfare System in the Post-
World War II Era: The UMW, Rehabilitation, and the Federal Government.
Research in Economic History, 5, p. 238, 1980.
6. ibid. p. 242
7. ibid. p. 244
8. Barth, P. The Tragedy of Black Lung : Federal Compensation for Occupa-
tional Disease . W. E. Upjohn Institute for Employment Research, Kala-
mazoo, MI, 1987.
9. Nelson, J. R. Black Lung: A Study of Disability Ccrrpensation Policy
Formation. The School of Social Service Administration, University of
10. Barth, op. cit. p. 284.
11. Nelson, op. cit. p. 155.
12. Gazaway, R. The Longest Mile . Doubleday and Co., Garden City, N. Y.
13. Baker, N. Vanishing Coal Economy: McDowell Hopes fo r Repl acement .
Sunday Gazette-Mail. Section D, p.l, Charleston, WV, Nov., 11-23, 1986.
14. Weinstein, M. R. The Concept of the Disability Process. Psychosomatics,
19 (2), 94-97, 1978.
15. West Virginia Workers 1 Compensation Fund. Very Early Intervention Pro-
ject: Management Report II. Charleston, WV, January, 1988.
16. Hood, L. E. and Downs, J. D. Return to Work: A Literature Review. The
Menninger Rehabilitation Research and Training Center. Preventing Disa-
bility Dependence. The Menninger Foundaton. Topeka, KA, 1985 .
17. Administrator, rural hospital in West Virginia, 1985 .
18. Wiesel, C. and Amy, M. Psychiatric Study of Coal Miners in Eastern
Kentucky Area. American Journal of Psychiatry, 108:617-624, 1952.
19. Cook, T. D. Psychosocial Barriers to Rehabilitation in Appalachia.
Rehabilitation Counseling Bulletin XL, 98-105, 1967.
20. Ludwig, A,M. "Nerves": A Sociomedical Diagnosis . ..of Sorts. American
Journal of Psychotherapy, 36(3) :350-357, 1982.
21. Horton, C. F. Women Have Headaches, Men Have Backaches: Patterns of
Illness in an Appalachian Community. Social Science and Medicine, 19(6)
22. ibid . p. 653
23. Barth, op.cit. p. 258.
24. Social Security Administration. Notes and Brief Reports. Social Secur-
ity Bulletin, 42(5), 1979 .
25. Ludwig, op.cit. p. 354.