University of Ghana http://ugspace.ug.edu.gh SCHOOL OF PUBLIC HEALTH COLLEGE OF HEALTH SCIENCES UNIVERSITY OF GHANA EMERGING DISEASES ASSOCIATED WITH MINING: A STUDY OF SMALL SCALE MINING COMMUNITIES IN GHANA BY KWASI SAFO BOAKYE (10701690) THIS DISSERTATION IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON IN PARTIAL FULFILLMENT OF THE REQUIREMENT FOR THE AWARD OF MASTER OF PUBLIC HEALTH DEGREE. OCTOBER, 2019 University of Ghana http://ugspace.ug.edu.gh ~ i ~ University of Ghana http://ugspace.ug.edu.gh DEDICATION I dedicate this thesis to my lovely wife; Major Belinda Naa Amorkor Amarteifio-Boakye, daughters Efua and Ewurasi. For all your love, care, commitment and support throughout schooling period; I am extremely honored and owe you the world. Thank you ~ ii ~ University of Ghana http://ugspace.ug.edu.gh ACKNOWLEDGMENT First and foremost, my heartfelt gratitude goes to the Almighty God for His guidance and grace throughout my educational life. I say thank you Lord for bringing me this far. A sincere and hearty appreciation goes to my parents; Mr. & Mrs Boakye, for your support, love, sense of direction, messages of encouragement and motivation. To all siblings big thanks for your support and prayers. Special thanks goes to my whole-hearted supervisor, Dr. Samuel Oko Sackey, who really gave time to my work, and always at any time ready to assist. I really appreciate his time and effort giving me. Similar, profound gratitude goes to Mr. Charles Addo-Quaye (Lone Star Gas), who has been a truly dedicated mentor. I am particularly indebted to him for his constant care about my education, and for his support when so generously making sure I don’t lack during my studies. I am also hugely appreciative to Dr. David Makongo (Philanthropist), for being so dedicated and passionate about my education. Special mention goes to Brig Gen A.K. Adu, Justice Edward Asante, Justice Anthony Oppong, COP Alex Mensah, ACP Victor Adusah-Poku, Dr. Forster Gbagbo, Jerry Nyamekye (MTN), Eric Kwasi Yeboah (Konongo), for going far beyond the call of duty. Also Prof. Alex Duodu for nurturing my passion for Epidemiology. Finally, to all my course mates, especially Epidemiology department for your support, I say God bless you all. ~ iii ~ University of Ghana http://ugspace.ug.edu.gh ABSTRACT Background: Mining activities are a high prevalence of certain diseases compared to non- mining areas as a result of the environmental and social changes that create conditions that favor disease emergence over time. Over the years, most research on gold mining areas in Ghana have been from an economic perspective, with few looking into gold mining-related disease prevalence. This study is aimed to identify new diseases that emerge as a result of mining activities and exposures to hazardous chemicals. Methods: This study was a quantitative cross-sectional design and a total of 504 participants from selected mining areas in the Amansie Central, Asante-Akyem district and East Akim Municipal district in Ghana were sampled. Data was collected through interviewing using semi- structured questionnaire. A logistic regression model was fitted to determine the association between selected exposure variables and some mining diseases. Results: Mean age of the respondents was 33±9.1years and about 80% were males. The prevalence of mining related diseases were skin problems (39.2%), numbness in the palm and feet (34.2% and 33.8% respectively), respiratory problems (18.1%) and tremors (16.9%). About 68.8% of the miners worked with mercury and the majority burned amalgam or melted gold daily or at least once a week. Also 75.5% did not use hand gloves when working with mercury. Working with mercury was also associated with 3.72 times higher odds of numbness (AOR: 3.72; 95%CI: 2.21 -6.27) and skin diseases (AOR: 2.49; 95%CI: 1.51 -4.10). Handling mercury without gloves and handling mercury daily were also associated 1.99times higher odds of numbness and skin diseases. As compared to those who never burned amalgam, burning amalgam daily was associated with 2.01 times higher odds of numbness (AOR: 1.99; 95%CI: 1.14 -3.49) and skin diseases (AOR: 2.01; 95%CI: 1.12 -3.59) ~ iv ~ University of Ghana http://ugspace.ug.edu.gh Conclusion: This study found high prevalence of diseases related to mining activities including skin problems, numbness in the palm and feet, tremors and anxiety. It is urgent to adequately monitor and assess disease prevalence among small scale miners to adequately prepare the healthcare system for emerging health conditions. ~ v ~ University of Ghana http://ugspace.ug.edu.gh TABLE OF CONTENTS DECLARATION ........................................................................................................................................... i DEDICATION .............................................................................................................................................ii ACKNOWLEDGMENT ............................................................................................................................... iii Finally, to all my course mates, especially Epidemiology department for your support, I say God bless you all. ........................................................................................................................................ iii ABSTRACT ................................................................................................................................................ iv TABLE OF CONTENTS ............................................................................................................................... vi LIST OF ABBREVIATIONS .......................................................................................................................... ix AIDS………………….Acquired Immunodeficiency Syndrome ........................................................... ix ANOVA………………Analysis of Variance ......................................................................................... ix COPD…………………Chronic Pulmonary Obstructive Disease .......................................................... ix GFAA…………………Graphite Furnace Atomic Absorption Spectrometric Method .......................... ix HIV……………………Human Immunodeficiency Virus ..................................................................... ix ICP………………...…..Inductively Coupled Plasma Method ............................................................... ix PDMstyle………………Provider Decision Making Style ..................................................................... ix SES……………………Socio - Economic Status ................................................................................... ix SSM……………………Small Scale Mining ......................................................................................... ix STD……………………Sexually Transmitted Disease .......................................................................... ix XRF ……………....…. X – Ray Fluorescence ....................................................................................... ix LIST OF TABLES ......................................................................................................................................... x LIST OF FIGURES ...................................................................................................................................... xi CHAPTER ONE .......................................................................................................................................... 1 INTRODUCTION ....................................................................................................................................... 1 1.1 Background .................................................................................................................................... 1 1.2 Problem statement ........................................................................................................................ 2 1.3 Significance of the study................................................................................................................ 3 1.4 Conceptual framework .................................................................................................................. 3 1.5 Objectives of the study .................................................................................................................. 5 1.5.1 General objective ................................................................................................................... 5 1.5.2 Specific objectives: ................................................................................................................. 5 CHAPTER TWO ......................................................................................................................................... 6 ~ vi ~ University of Ghana http://ugspace.ug.edu.gh LITERATURE REVIEW ............................................................................................................................... 6 2.1 Overview of artisanal and small-scale mining in Ghana................................................................ 6 2.2 Diseases ass ociated with mining .................................................................................................. 9 2.3 Envir onmental impacts  of g old mining ........................................................................................ 9 2.4 Mercury use in artisanal and small-scale mining ........................................................................ 12 2.5 Hazard  of mercury use in artisanal and small-scale mining ....................................................... 13 2.6 Clinical signs and sympt oms  of mercury .................................................................................... 14 CHAPTER THREE .................................................................................................................................... 16 METH OD OL OGY ................................................................................................................................... 16 3.1 Study design ................................................................................................................................ 16 3.2 Study area .................................................................................................................................... 16 3.3 Study p opulati on and sampling .................................................................................................. 19 3.4 Study variables ............................................................................................................................ 21 3.5 Data analysis ................................................................................................................................ 25 3.6 Ethical c onsiderati ons ................................................................................................................ 26 CHAPTER F OUR ..................................................................................................................................... 27 RESULTS ................................................................................................................................................. 27 4.1 Backgr ound characteristics  of resp ondents............................................................................... 27 4.2 Habitat and w ork exp osure characteristics  of resp ondents ..................................................... 28 4.3 F o od and water c onsumpti on characteristics ........................................................................... 31 4.4 Lifestyle, health c onditi ons and past health pr oblems .............................................................. 32 4.5 Ass ociati on between w ork characteristics and w ork related diseases ..................................... 37 CHAPTER FIVE ........................................................................................................................................ 42 DISCUSSI ON........................................................................................................................................... 42 5.1 Key findings ................................................................................................................................. 42 5.2 Discussi on  of key findings ........................................................................................................... 42 5.2.1 Prevalence  of mining related diseases ................................................................................ 42 5.2.2 Ass ociati on between use  of mercury and mining related diseases .................................... 44 5.2.3 Ass ociati on between  other w ork related exp osures and mining related diseases ........... 46 5.2.4 Strength and limitations ....................................................................................................... 48 CHAPTER SIX .......................................................................................................................................... 49 C ONCLUSI ON AND REC OMMENDATI ONS ........................................................................................... 49 6.1 C onclusi on .................................................................................................................................. 49 6.2 Rec ommendati ons...................................................................................................................... 50 ~ vii ~ University of Ghana http://ugspace.ug.edu.gh REFERENCES .......................................................................................................................................... 51 APPENDIX A- STUDY QUESTI ONNAIRE .................................................................................................. 59 APPENDIX B - ETHICAL APPR OVAL ........................................................................................................ 65 ~ viii ~ University of Ghana http://ugspace.ug.edu.gh LIST OF ABBREVIATIONS AIDS………………….Acquired Immunodeficiency Syndrome ANOVA………………Analysis of Variance AOR……………………Adjusted Odds Ratio BMI……………………Body Mass Index COPD…………………Chronic Pulmonary Obstructive Disease GFAA…………………Graphite Furnace Atomic Absorption Spectrometric Method HIV……………………Human Immunodeficiency Virus ICP………………...…..Inductively Coupled Plasma Method PDMstyle………………Provider Decision Making Style SES……………………Socio - Economic Status SSM……………………Small Scale Mining STD……………………Sexually Transmitted Disease XRF ……………....…. X – Ray Fluorescence ~ ix ~ University of Ghana http://ugspace.ug.edu.gh LIST OF TABLES Table Page Table 3.1 Study variables 21 Table 4.1 Background characteristics of respondents 27 Table 4.2 Habitat and work exposure of study respondents 29 Table 4.3 Food and water consumption 31 Table 4.4 Lifestyle and health status of respondents 34 Table 4.5 Work characteristics and mining related diseases 38 Table 4.6 Logistic regression analysis of association between selected exposure 40 variables and mining related diseases ~ x ~ University of Ghana http://ugspace.ug.edu.gh LIST OF FIGURES Figure Page Figure 1.1 Conceptual framework 4 Figure 3.1 Amansie Central district 17 Figure 3.2 East Akim district 18 Figure 3.3 Asante Akim district 19 Figure 3.4 A dug pit at and artisanal small scale mining 23 Figure 3.5 Artisanal small scale miners at work 24 Figure 3.6a Artisanal small scale miners at work 25 Figure 3.6b Artisanal small scale miners at working without hand gloves 25 Figure 4.1 Prevalence of malaria 33 Figure 4.2 Prevalence of mining related diseases 34 ~ xi ~ University of Ghana http://ugspace.ug.edu.gh CHAPTER ONE INTRODUCTION 1.1 Background Mining, a human activity since pre-historic time, involves the extraction of valuable minerals or other geological materials or deposits from the earth. It is an important economic activity which has the potential of contributing to the development of areas endowed with the resource. In North America for instance, the mining industry employs approximately one million people (Mbendi Information Services, 2005) and in Ghana, the sector plays an essential role in the development of the economy. In 2000, minerals accounted for 38.96% of Ghana’s total export earnings, followed by cocoa (22.51%) and timber (9.03%) (ISSER, 2001). The mining sector now contributes 41% to the country’s foreign exchange and is the leading foreign exchange earner (Awudi, 2002). Mining operations, however, usually create negative environmental impacts, both during the mining activity and after the mine has closed. Pollution caused by quarrying and blasting in mines increases the dust particles in the air and the surrounding environment and promotes the spread of toxic chemicals such as cyanide and sulfur dioxide, which are all very harmful to the body (Martin, Dowling, Pearce, Sillitoe, and Florentine, 2014). In addition, arsenic, which is used in processing the crushed rock, flows into streams and rivers, the major source of drinking water for local residents. This emanates from the methods of operation by the mining companies, its effects on the natural environment as well as the people in the surrounding communities. In Ghana, activities of illegal miners have caused extensive damage to forest vegetation and water bodies that serve as sources of drinking water to millions of people (Boadi, Nsor, Antobre, and Acquah, 2016; Eshun, 2017). In Ghana, previous research in gold mining towns show that upper respiratory tract infections and skin rashes are exacerbated due to mining activities (Akabzaa and Darimani, 1 University of Ghana http://ugspace.ug.edu.gh 2001; Awudi, 2002). Conjunctivitis, respiratory tract diseases, vector borne diseases such as malaria, schistosomiasis and STDs such as HIV/AIDS may also be intensified in mining areas (Vora, 2008; Zhang et al., 2010). The environmental and social changes associated with mining also create conditions that favor disease emergence over time. For example, in 1995, an Ebola outbreak occurred in Mékouka and other gold-mining camps deep in the rain forest of Gabon with a mortality rate of 60 percent (Awudi, 2002). An outbreak of Lymphocutaneous Sporotrichosis, a tropical fungal disease, also occurred among mine workers employed at a gold mine close to the town of Barberton in the sub-tropical north- eastern Lowveld area of South Africa (Govender et al., 2015). The largest outbreak of Sporotrichosis also occurred between 1938 and 1947 in the gold mines of Witwatersrand in South Africa (Govender et al., 2015). 1.2 Problem statement The environmental and social changes associated with mining that create conditions that favor disease emergence over time. Mining areas there therefore characterized by a high prevalence of certain diseases compared to non-mining areas. High levels of arsenic have been found in ground water in mining areas in Ghana, the long-term exposure of which, may cause a wide range of health effects, including skin lesions, circulatory disorders, diabetes and cancers of the bladder, lung, kidney, and liver (Ahoulé, Lalanne, Mendret, Brosillon, and Maïga, 2015; Asante and Ntow, 2009). However, over the years, most research on gold mining areas in Ghana have been from an economic perspective, with few looking into gold mining-related disease prevalence. In Ghana studies are scares. examining the emergence of mining-related diseases in mining areas of Ghana. Monitoring the emergence of diseases in mining areas will ensure timely prevention and management of diseases to curtail possible disease outbreaks and epidemics in mining areas in Ghana. 2 University of Ghana http://ugspace.ug.edu.gh 1.3 Significance of the study This study is important for two reasons. First, it contribute to knowledge in the field of mining and health and provides insight into the emerging diseases that are attributed to mining activities and related exposures in Ghana. Second, it provides a basis for timely prevention and management of diseases by the health sector to curtail possible disease outbreaks and epidemics in mining areas in Ghana. 1.4 Conceptual framework Figure 1 is the conceptual model showing how the arsenic contamination leads to disease outcome among small scale miners in Ghana. As illustrated, arsenic contaminates water bodies when it flows into streams and rivers through the methods of operation by the mining companies. Ground water, contaminated with arsenic directly affects humans’ sources of drinking water, sources of proteins and also affects agro products. Through consumption of contaminated agro foods and protein from fishes and livestock, and or direct drinking of the contaminated water, arsenic gets transferred to humans. This leads to the development of diseases such as lymphoma, black-food disease, skin and lung diseases among humans. 3 University of Ghana http://ugspace.ug.edu.gh Figure 1.1: Conceptual framework SMALL SCALE MINING ACTIVITIES GROUND WATER ARSENIC CONTAMINATION AGR O PRODUCTS DRINKING WATER PROTEIN SOURCES HUMAN DISEASE OUTCOMES  Lung diseases ● Skin disease  Lymphoma ● Still births  Black-foot disease ● Post neonatal mortality  Developmental deficits ● Nephritis and Nephrosis 4 University of Ghana http://ugspace.ug.edu.gh 1.5 Objectives of the study 1.5.1 General objective This study aimed to identify new diseases that emerge as a result of mining activities and to assess the factors that are associated with these mining related diseases. 1.5.2 Specific objectives: 1. To determine the prevalence of diseases in mining areas in Ghana 2. To assess emerging diseases that are attributable to mining activities in Ghana 3. To assess factors that are associated with mining related diseases in Ghana 5 University of Ghana http://ugspace.ug.edu.gh CHAPTER TWO LITERATURE REVIEW 2.1 Overview of artisanal and small-scale mining in Ghana Artisanal  or small-scale mining is a makeshift pr ocess t o extract valuable minerals fr om primary and sec ondary  ore b odies. This is characterized instituted l ong-term mine planning/c ontr ol (Hint on et al, 2003a). It enc ompasses either f ormal  or inf ormal pr ocess and fr om individual g old panners t o large-scale  operati ons that empl oy th ousands  of pe ople. It is w orthy t o indicate that, artisanal and small-scale mining  operati ons f orm the backb one  of several livelih o ods  of devel oping rural c ommunities especially in Africa. It is estimated that there are 11 t o 13 milli on artisanal miners w orldwide, with 80 t o 100 milli on pe ople directly  or indirectly dependent  on artisanal miners f or their livelih o od (Jennings, 1999). Hazards ass ociated with artisanal small scale mining include: p o or gr ound c onditi ons leading t o undergr ound failure, methane  or c oal dust expl osi ons fr om c oal mines, fl o oding, machinery accidents, p o or lighting and ventilati on, expl osives accidents, and electr ocuti on (Priester et al, 1993). In artisanal and small scale mining, mercury, cyanide and  other hazard ous chemicals are used as reagents f or rec overing and purifying g old and  other preci ous metals. Fine dust fr om mineral pr ocessing, leading t o silic osis and n oise p olluti on are endemic pr oblems (Hint on et al, 2003a). Hist orically, the Ghanaian small-scale mining industry is well  over 2,000 years  old (Hils on, 2001). G old extracti on and winning activities begun as far back as the sixth century, and there is a wealth  of evidence indicating that preci ous metals rec overed fr om regi onal artisan activities were attracting Arab traders t o certain areas  of the c ountry as early as the 7th and 8th centuries AD (Hils on, 2001). Hist ory indicates that, it was the rich g old dep osits  of the western Sahara that were largely resp onsible f or the wealth and strength  of large ancient 6 University of Ghana http://ugspace.ug.edu.gh Ghanaian empires and cultures, and by the 15th and 16th centuries, at the peak  of Eur opean c ol onial expl orati on, Ghana was fittingly labelled the ‘G old C oast’. Small-scale mining in Ghana, was f or decades treated as an inf ormal industrial sect or. Up until the 1980s, small-scale mining activities in Ghana remained largely unregulated and received little, if any, supp ort fr om g overnmental b odies. This, h owever, changed with the implementati on  of the nati onal Ec on omic Rec overy Plan (ERP), which, f oll owing years  of careful planning, was finally launched in the mid-1980s. The Ghanaian minerals sect or was heavily targeted, which, between 1960 and 1980, had experienced mass declines in mineral  output: g old pr oducti on had declined fr om 900,000 oz in 1960 t o 232,000 oz in 1982; manganese  output had dr opped fr om 600,000t in 1960 t o 160,000t in 1982; bauxite pr oducti on declined fr om 407,000 in 1974 t o 64,700t in 1982; and diam ond  output had declined fr om 2,340,000 carats in 1975 t o 683,524 carats in 1982 (Hils on, 2001). The gr owing imp ortance  of artisanal and small mining in Ghana, cann ot be  overl o oked. The c ontributi on  of small scale mining t o wealth creati on, empl oyment and the ec on omy makes it  one  of the nati on’s m ost imp ortant livelih o od activities. It is kn own that small scale mining in Ghana empl oys an estimated  one milli on pe ople and supp orting appr oximately 4.5 milli on m ore pe ople (McQuilken and Hils on, 2016). Small scale mining acc ounted f or 35%  of Ghana’s t otal g old pr oducti on in 2014, c ontributing alm ost 1.5 milli on  ounces  of g old. Yet the maj ority  of miners in Ghana  operate inf ormally, with out the security  of a licence (McQuilken and Hils on, 2016). In Ghana, small scale mining empl oys a wide range  of individuals. These individuals undertake diverse r oles, fr om general lab ouring t o skilled machining, supervising and b o okkeeping. The maj ority are p overty-driven, fr om families and individuals trying t o earn en ough t o survive, y oung students funding their sch o ol and university educati on, and 7 University of Ghana http://ugspace.ug.edu.gh farmers supplementing their inc ome, t o larger lab our gr oups c omprising men, w omen and children. W omen c onstitute up t o 50%  of the lab our f orce and are engaged largely as haulers and washers, and service pr oviders. In additi on t o these p overty-driven livelih o ods, there is als o a burge oning number  of well-educated and well-c onnected ‘greedy industry players” wh o, due t o their unique p ositi on and access t o significant capital investment, are able t o navigate the c omplex s oci op olitical and bureaucratic landscape needed t o  obtain a license (Hils on, 2001; McQuilken and Hils on, 2016). By the end  of the 1980s, g overnment had fully regularized the small-scale mining sect or thr ough a series  of p olicies and regulati ons h owever maj ority  of miners in Ghana t oday  operate inf ormally usually with out license particularly due t o barriers ass ociated with  obtaining land and a license which are  often bureaucratic and  often times p olitical (McQuilken and Hils on, 2016). This has theref ore given rise t o a h ost  of envir onmental and s ocial pr oblems in Ghana, such as the p olluti on and destructi on  of water b odies, degradati on  of arable farmland, as well as the negative health impacts  of w orking in hazard ous c onditi ons; this has been the f ocus in the Ghanaian media, which tends t o depict the entire small scale mining sect or in a negative and damaging light. F ormalizing Ghana’s inf ormal mining sect or is theref ore a significant, timely and pressing devel opmental  opp ortunity that sh ould be realized. The m ost significant challenges facing Ghanaian small-scale miners and c ommunities are access t o equipment and f ormal finance, and, m ost pressingly, difficulties in  obtaining a license. These all stem largely fr om a sh ortage  of untitled land f or small scale mining activities and acc ompanying ge ol ogical rec ords, with out which it is difficult t o  obtain f ormal finance. Finance is needed t o c over the c ost  of acquiring land and t o meet the requirements  of  obtaining a license and an envir onmental permit. These issues b oth inhibit and disc ourage the maj ority  of pr ospective 8 University of Ghana http://ugspace.ug.edu.gh miners wh o are driven by p overty and lack sufficient s ocial capital and financial and technical res ources fr om f ormalizing their activities (McQuilken and Hils on, 2016). 2.2 Diseases ass ociated with mining Mining is an imp ortant ec on omic activity in b oth devel oped and devel oping c ountries. Despite the en orm ous ec on omic benefits ass ociated with g old mining, its detrimental effects  on the envir onment and health  of miners cann ot be  overl o oked. B oth surface and undergr ound mining activities, are ass ociated with numer ous health externalities and exp osure t o dust and chemicals fr om mining causes acute and chr onic respirat ory diseases (Ayaaba, Li, Yuan, and Ni, 2017). The situati on is m ore detrimental in limited res ource settings, where mining regulati ons are less enf orced and the safety  of miners is  of less c oncern. In 2017, a study was c onducted t o investigate respirat ory dis orders am ong g old miners in the Tarkwa an  Obuasi mines in Ghana using a cr oss-secti onal expl orat ory design am ong 1001 male w orkers (505 and 496 undergr ound and surface miners) (Ayaaba et al., 2017). The study rep orted high prevalence  of respirat ory dis orders. The prevalence  of asthma, pneum onia, br onchitis and emphysema were respectively 47.55%, 14.29%, 9.69% and 5.10%. The prevalence  of respirat ory sympt oms ranged fr om 35.4%  of c oughing t o 25.4%  of chest pain (Ayaaba et al., 2017). A literature review  of the prevalence  of Chr onic  Obstructive Pulm onary Disease (C OPD) including emphysema in Africa, rep orted a high variati on in prevalence, ranging fr om 5.3% t o 47% (Mehr otra,  Oluw ole, and G ord on, 2009). 2.3 Envir onmental impacts  of g old mining Mineral pr ocessing is als o ass ociated with the presence  of hazard ous chemicals which are detrimental t o human health. F or example, arsenic in dust, is a seri ous threat t o human p opulati ons thr ough out the w orld. Maj or s ources  of c ontaminati on include smelting 9 University of Ghana http://ugspace.ug.edu.gh  operati ons, c oal c ombusti on, hard r ock mining, as well as their ass ociated waste pr oducts, including fly ash, mine wastes and tailings (Martin et al., 2014). The number  of unc ontained arsenic-rich mine waste sites thr ough out the w orld is  of gr owing c oncern, as is the number  of pe ople at risk  of exp osure. Inhalati on exp osures t o arsenic-bearing dusts and aer os ol, in b oth  occupati onal and envir onmental settings, have been definitively linked t o increased systemic uptake, as well as carcin ogenic and n on-carcin ogenic health  outc omes (Martin et al., 2014). Arsenic and in organic arsenic c omp ounds are classified as Gr oup 1 carcin ogens and are ass ociated with cancers  of the lung, bladder, kidney, skin, liver and pr ostate (IARC, 2012). Exp osures t o arsenic c omp ounds are h owever increased with exp osure t o emissi on s ource. Emissi ons  of arsenic-bearing particulate matter are  of particular c oncern f or human p opulati ons living in pr oximity t o an emissi on s ource. Arsenic inhalati on is c onsidered a min or exp osure pathway f or in organic arsenic c omp ounds, whiles ingesti on is c onsidered the primary exp osure pathway (IARC, 2012). H owever, p opulati ons living in the vicinity  of an arsenic emissi on s ource have an increased risk  of additi onal exp osure thr ough inhalati on  of arsenic-c ontaminated particulates (Yang et al., 2012). A study was c onducted t o evaluate the effects  of an aband oned arsenic mine  on drinking water res ources quality and p ossible health effects  on the residents  of mining area in the N orth West  of Iran in 2011 (Hajalil ou et al., 2011). Water samples were c ollected and analyzed f or chemical parameters acc ording t o standard meth ods. F or determinati on  of arsenic in water samples, Graphite Furnace At omic Abs orpti on Spectr ometric Meth od (GFAAS) and f or wheat samples X – Ray Flu orescence (XRF) and Inductively C oupled Plasma Meth od (ICP) were used. Inf ormati on ab out p ossible health effects due t o exp osure t o arsenic was c ollected thr ough interviews in studied villages and health center. Arsenic c oncentrati on ranged fr om zer o in s ome villages up t o 2000 µg/L in mine  opening. The 10 University of Ghana http://ugspace.ug.edu.gh c oncentrati on  of arsenic in the water increased with increasing pr oximity t o the mine. The highest c oncentrati ons  of arsenic were inside and near the mine that with increasing distance fr om the mine, the c oncentrati ons were decreased (Hajalil ou et al., 2011). Previ ous research in Ghana f ound high levels  of mercy in the mining envir onment, which was rep orted t o be a result  of its use in g old rec overy pr ocess where the in organic f orm  of the metal is either washed int o rivers  or readily vap orized int o the atm osphere. The use  of mercury by illegal miners has been linked t o increased cases  of kidney diseases in Ghana (Kusi-Amp of o and B oachie-Yiad om, 2012). Mercury affects the renal system, nerv ous system, gastr ointestinal tract and respirat ory system ( Obiri et al., 2016).  One rep ort estimated that 5 t ons  of mercury is released fr om small-scale mining  operati ons in Ghana each year (Ragnar and Björn, 2005). A study  of five mining c ommunities in the  Obuasi Municipality  of Ghana als o f ound prevalence  of mining related diseases am ong the residents as a result  of exp osure arsenic in water b odies (JH Yeb oah, 2008). The study was c onducted t o assess the health impact  of Angl oG old Ashanti's mining  operati ons  on the residents in these areas. Skin diseases were rep orted principally by w orkers and residents fr om tw o  of the c ommunities studied; Anyimad okr om (26.6%) and Sans o (24.3%). The skin diseases were due t o chemical c ontaminati on  of water b odies which s ome residents are dependent  on f or water, f o od and  other d omestic purp oses. The high  occurrence  of skin diseases at Anyimad okr om is attributed t o its pr oximity t o Angl oG old Ashanti's P omp ola treatment plant where chemicals such as arsenic (sulfur di oxide) are used. In this study,  other c ommunities which were far fr om the mining site had l ow prevalence  of mining related diseases (JH Yeb oah, 2008). 11 University of Ghana http://ugspace.ug.edu.gh The endemic nature  of Buruli ulcer in Ghanaian c ommunities adjacent t o mining activities als o suggests that pr oximity t o artisanal and small-scale g old mining is a risk fact or f or this disease, as is the case  of the higher prevalence  of Buruli ulcer in the Amansie West District in the Ashanti Regi on  of Ghana (Duker, Stein, and Hale, 2006). The spread  of Buruli ulcer might n ot be linked with direct participati on in mining in this area, but it is rep orted t o be ass ociated with changes in land use that acc ompany small-scale mining activities such as stream bed (Merritt, Benb ow, and Small, 2005). 2.4 Mercury use in artisanal and small-scale mining The practice  of using mercury t o extract g old is an ancient practice that dates back t o the twentieth century. Even th ough it was  outm oded  over a peri od  of time in the late twentieth century, the g old rushes in Latin America began during the 1970s and 1980s led t  o its resurgence (Veiga, 1997). Due t o its simple effectiveness and practicality, mercury is virtually ubiquit ous with small-scale g old pr ocessing. The maj or pr ocess  of artisanal small scale g old mining that inv olve the use  of mercury is amalgamati on (Ntalikwa, 2015). Amalgamati on is an ancient pr ocess which inv olves the all oying  of the g old particles with metallic mercury t o f orm amalgam and then the separati on  of the g old fr om the mercury by heating in ret orts until the mercury is distilled  off. This pr ocess is str ongly  out  of fav or with the maj or mining c ompanies, due t o the extremely t oxic nature  of mercury and the pr ocesses inferi or perf ormance when c ompared t o the available alternatives. F oll owing this, gravity c oncentrati on is used t o create m ovement between the g old and h ost r ock particles in a manner t o separate the heavy pieces fr om the lighter pieces  of material. The material is then panned. Panning is a type  of gravity c oncentrati on used by artisanal g old miners f or the rec overy  of g old fr om river beds m ostly with their bare hand. It c oncentrates the heavy g old particles at the b ott om  of the pan while the light gangue is washed  off  on t op (Ragnar and Björn, 2005). 12 University of Ghana http://ugspace.ug.edu.gh 2.5 Hazard  of mercury use in artisanal and small-scale mining Even th ough the use  of mercury in small scale mining is a simple and inexpensive, there are several hazards ass ociate with the use  of mercury in small scale mining. In a typical artisanal g old mining, accidents are  often underrep orted, due t o the illegal  or semi-legal status  of m ost their  operati ons and the use  of mercury is  one  of these. While artisanal small scale mining  operati on may be relatively small, the practice is widespread especially in devel oping c ountries including Ghana. The  operati ons handle extra ordinary am ounts  of mercury directly by the miners and released int o the envir onment, leading a huge burden  on human (Ragnar and Björn, 2005). Mercury vap or inhaled by miners results in impaired c ognitive functi on, neur ol ogical damage, kidney damage and several  other health pr oblems (Esdaile and Chalker, 2018). In many cases, where mercury amalgams are pr ocessed near the h ome  or in g old sh ops in villages  or cities, s o the mercury vap or generated in the pr ocess affects n on-miners living in these areas. Exp osure t o mercury p olluti on is especially danger ous as it increases the likelih o od  of physical def ormities, neur ol ogical damage and l ower intelligence (Esdaile and Chalker, 2018). The high levels  of mercury that accumulate in fish and  other f o od supplies in artisanal and small scale mining c ommunities further increases the risks ass ociated with mercury exp osure. Mercury p ois oning is a tremend ous burden t o human health, especially in these mining c ommunities (Esdaile and Chalker, 2018). Mercury gas, such as that enc ountered in amalgam pr ocessing, is readily abs orbed in the lungs and then further transp orted t o  other  organs. Elemental mercury is able t o cr oss membranes including the bl o od–brain barrier and the bl o od-placenta barrier, p osing a threat t o neur ol ogical functi on and fetal devel opment, respectively (Mensah, 2012). Acute mercury exp osure can lead t o trem ors, mem ory l oss, respirat ory distress and even death (Erdiaw-kwasie, Mabunyewah, and Mabunyewah, 2012). Chr onic exp osure t o mercury gas may lead t o renal failure, trem ors, 13 University of Ghana http://ugspace.ug.edu.gh m ovement dis orders, and vari ous psych osis and mem ory impairment (Han, Chen, Harvey, Stemn, and Cliff, 2018). In organic mercury, f ormed thr ough  oxidati on  of mercury metal l ost during small scale mining c ontaminate water and als o lead t o kidney damage if c onsumed by rural f olks in mining areas (Esdaile and Chalker, 2018). C onversi on  of mercury p olluti on fr om small scale mining int o methyl mercury als o a lead t o highly t oxic f orm  of mercury accumulates in f o od supplies, such as fish, crustaceans and m ollusks. C onsumpti on  of methyl mercury is particularly harmful t o the central nerv ous system, causing nerve and brain damage. Kidneys are als o affected and methylmercury presents an extreme risk t o fetal devel opment (Erdiaw-kwasie et al., 2012; J oseph, 2008). 2.6 Clinical signs and sympt oms  of mercury In many devel oping c ountries, mercury p oising is underrep orted. What is  of great c oncern h owever is that, mercury p ois oning is frequently misdiagn osed because  of the gradual  onset and its ass ociated n onspecific signs and sympt oms (Mensah, 2012). The clinical presentati on  of an individual exp osed t o mercury depends up on the d ose, the length  of and f orm  of exp osure. Acute t oxicity is m ore c omm only ass ociated with the inhalati on  of elemental  or ingesti on  of in organic mercury. Chr onic t oxicity is m ore c omm on fr om exp osure t o  organic mercury. Irrespective  of the chemical f orm  of mercury present, the kidneys and the central nerv ous system are the tw o primary target  organs  of t oxicity. All mercury c omp ounds c oncentrate in the kidney t o s ome extent. Acute exp osure caused by inhaled elemental mercury can lead t o pulm onary sympt oms. Initial signs and sympt oms, such as fever, chills, metallic taste and pleuritic chest pain may  occur.  Other p ossible sympt oms c ould include st omatitis, lethargy, c onfusi on and v omiting. Chr onic exp osure usually results fr om pr ol onged  occupati onal exp osure t o elemental mercury that is 14 University of Ghana http://ugspace.ug.edu.gh c onverted int o the in organic f orm. Chr onic and high d ose acute mercury exp osure pr oduces a variety  of renal, neur ol ogical, psych ol ogical and cutane ous sympt oms. The exp osed individual may experience rather vague and n on-specific sympt oms, including weight l oss, fatigue, an orexia and muscular weakness that c ould be indicative  of a number  of diseases. 15 University of Ghana http://ugspace.ug.edu.gh CHAPTER THREE METH OD OL OGY 3.1 Study design This study was a quantitative cr oss-secti onal design and empl oy quantitative meth ods. Data f or this study was collected using structured questi onnaires. Data  on experiences  of mining- related diseases as well as the s oci o-dem ographic characteristics was c ollected  on a rand omly selected p opulati on. 3.2 Study area The selected mining areas were Jac obu in the Amansie Central district and K on ong o in the Asante-Akyem district b oth in the Ashanti regi on  of Ghana and Kibi in the East Akim Municipal district in the Eastern regi on  of Ghana. Amansie Central The population  of Amansie Central District is 90,741 representing 1.9 percent  of the regi on’s t otal p opulace (2010 P opulati on and H ousing Census). Males institute 49.9 percent and females 50.1 percent. Alm ost 89 percent  of the p opulati on is rural. The p opulati on  of the district is y outhful (42.9%) depicting a br oad base p opulati on pyramid which p oints  off with a small number  of elderly pers ons (5.7%). The t otal age dependency rati o f or the District is 94.9, the age dependency rati o f or males is higher (97.4) than that  of females (92.4).  Of the p opulace 11 years and ab ove, 73.9 percent are literate and 26.1 percent are n on-literate. The pr op orti on  of literate males is higher (92.4 %) than that  of females (81.7%). Ab out 70 percent  of the p opulati on (69.9%) can speak and write b oth English and Ghanaian languages. Ab out 76.6 percent  of the p opulace aged 15 years and  older are ec on omically active.  Of the ec on omically active p opulati on, 95.9 percent are empl oyed while 4.1 percent are unempl oyed. F or th ose wh o are ec on omically n ot active, a large percentage  of them are students (50.5%), 24.0% perf orm h ouseh old duties and 6.7 percent 16 University of Ghana http://ugspace.ug.edu.gh are disabled  or t o o sick t o w ork. Seven  out  of ten unempl oyed are seeking w ork f or the first time. The main w ork in this district is skilled agricultural, f orestry and fishery w orkers. Figure 3.1 : Amansie Central district East Akim The pe ople  of East Akim District, giving by the 2010 P opulati on and H ousing Census, is 167,896 representing 6.3%  of the regi on’s t otal p opulace. Males institute 49.7 % and females 51.3%. Alm ost 40%  of the p opulati on is rural. The district has a sex rati o  of 94.9%. The p opulati on  of the district is y outhful 35.9% depicting a br oad base p opulati on pyramid which p oints  off with a small number  of elderly pers ons 6.7%. The t otal age dependency rati o f or the District is 74.3  of the p opulace 11 years and ab ove, 71.0 percent are literate and 29.0 percent are n on-literate. The pr op orti on  of literate males is higher 50.4 % as c ompared t o females 49.6%. Ab out 71.1% c ould speak and write b oth English and Ghanaian languages. 67.9 Ec on omically  of the p opulace aged 15 years and ab ove are 17 University of Ghana http://ugspace.ug.edu.gh ec on omically active, The main w ork in this district is skilled agricultural, f orestry and fishery w orkers. Figure 3.2: East Akim district Asante Akim central Asante Akim Central is municipal in Ashanti Regi on with a p opulati on  of 71,508, 33,942 males 37,566 females. (2010 P opulati on and H ousing Census). The Municipality is surr ounded by Sekyere East District  on the n orth, Kwahu S outh District  on the east, Asante Akim S outh Municipal  on the s outh and Juaben Municipal  on the west. 78.0% are literate and 22.0% are n on-literate. The pr op orti on  of literate males is higher 51.4 % as c ompared t o females 48.6%. Ab out 70.1% c ould speak and write b oth English and Ghanaian languages. Its land is fertile f or Farming and als o rich in minerals like G old. Maj or activity is Farming. 18 University of Ghana http://ugspace.ug.edu.gh Figure 3.3: Asante Akim district 3.3 Study p opulati on and sampling This study was c onducted am ong Ghanaians (>18years) residing in mining areas in Ghana. The inclusi on criteria was:  Having lived in the c ommunity f or n ot less than  one year and v oluntarily c onsenting t o participate in the study. The exclusion criteria was:  Participants wh o had resided in the c ommunity f or less than  one year Sample size estimation A t otal  of 504 participants were inv olved in the study. This was estimated with rec ourse t o the f ormula by Kirkw o od and Sterne (2003); n =Z2𝝆𝒒 d2 19 University of Ghana http://ugspace.ug.edu.gh Where n = the desired sample size z = the standard n ormal deviati on 1.96 p = the prevalence  of mining related diseases in Ghana, assumed t o be 50% (0.50) based  on the scarcity of data on the prevalence of mining related diseasese q = 1.0-p d = degree  of accuracy desired at 0 .05 n = (1.96)2 (0.50) (0.50) (0.05)2 n = 384.16 20%  of n on-resp ondent effect w ould be used t o c omprehend the sample size, making a t otal  of appr oximately 461. The required resp ondents fr om each district was shared equally acr oss the three t owns due t o the fact that the number  of miners are n ot kn own. The distributi on  of resp ondents acc ording t o the study sites was Jac obu 154, K on ong o 154 and Kibi 154. H owever, the data c ollected slightly exceeded the minimum required sample size and all the 504 resp ondents were included. The final sample size f or the study sites 168 resp ondents per site. Sampling of participants A clustered rand om sampling technique was used t o select resp ondents f or this study. In the selected c ommunities, the required resp ondents were selected first by clustering the c ommunities, using the f our cardinal p oints. H ouseh olds were then selected using a sampling interval that was determined by the number  of h ouseh olds divided by the sample size. In the selected h ouseh olds, resp ondents were sampled using the l ottery meth od where pieces  of papers with inscripti ons “Yes” and “N o” was written f or picking. Resp ondents wh o picked “Yes” and c onsented t o participate in the study were enr olled. 20 University of Ghana http://ugspace.ug.edu.gh 3.4 Study variables The  outc ome variable was prevalence  of mining related diseases. The explanat ory variable will be the s oci o-ec on omic characteristics including  occupati on, inc ome, educati on, durati on  of exp osure t o mining envir onment and pr oximity t o the mining site. Table 3.1 Study variables Variables Descripti on Scale Dependent variables Mining related Self-rep ort assessment  of skin diseases, respirat ory Binary diseases pr oblems, hepatic diseases, maj or infecti ons like tubercul osis, anxiety, numbness in palm and feet, trem ors. Presence of disease=1; Absence of disease = 0. Exp osure /independent variables S oci o-dem ographic/backgr ound characteristics Age Age  of resp ondents in years Continuous Sex Sex  of resp ondents; male=1, female=2 Binary Educati on Educati onal level  of resp ondents; n o f ormal=1, basic=2, Ordinal Seni or High Sch o ol=3, p ost-sec ondary=4, tertiary=5 Marital Status Married=1, c ohabiting=2, single=3, div orce  or Nominal wid owed=4 Empl oyment status Resp ondents’ empl oyment status; empl oyed=1, Binary unempl oyed=2 Durati on  of stay in Length  of stay  of resp ondents in their respective Continuous c ommunity c ommunities M onthly inc ome T otal m onthly inc ome fr om all ec on omic activities Continous W ork-related characteristics J ob descripti on Descripti on  of j ob; e.g. Agriculture, small scale mining, Nominal clergy etc 21 University of Ghana http://ugspace.ug.edu.gh Descripti on  of small Pit w ork illegal mining=1, grinding=2, washing=3 and Nominal scale mining melting=4 activities Durati on  of w ork H ow l ong  one has w orked in small scale mining Continuous Mercury exp osure W orking with mercury, number  of times w ork with mercury, use  of hand pr otecti on, frequency  of melting amalgam, frequency  of melting g old F o od and c onsumpti on characteristics Fish c onsumpti on Frequency  of c onsuming fish; never=1,  occasi onally=2, Nominal  often=3 C onsumpti on  of C onsuming chicken, ducks, eggs, meat, fruit and Nomial f o ods pr oduced vegetables, milk; never=1,  occasi onally=2,  often=3 l ocally S ources  of water H ouseh old s ources  of water f or c o oking, drinking and Nominal  other h ouseh old ch ores: b oreh ole=1, rive/stream=2, pipe-b orne water=3, sachet water=4 Lifestyle and health status Perceived health Whether  one perceive him/herself t o be healthy (1)  or Binary status n ot (2) Sm oking status Whether  one sm oke cigarette (1)  or n ot (2); quantity  of Binary; cigarette sm oked continuous Drinking status Whether  one drink alc oh ol (1)  or n ot (2); type and Binary; quantity  of alc oh ol c onsumed continuous Sleeping pr oblems Whether  one has pr oblems with sleeping (yes=1; no=2) Binary and the perceived causes  of sleeplessness Descripti on  of mining activities Pit w ork: This pr ocedure  of mining is different fr om extractive techniques that require excavating int o the earth, such as l ong wall mining.  Open-pit mines are used when dep osits 22 University of Ghana http://ugspace.ug.edu.gh  of c ommercially useful  ore  or r ocks are f ound near the surface. It is applied t o  ore  or r ocks f ound at the surface because the  overburden is relatively thin  or the material  of interest is structurally unsuitable f or tunneling. In divergence, minerals that have been f ound undergr ound but are difficult t o salvage due t o hard r ock, can be reached using a f orm  of undergr ound mining. But f or illegal miners they dig tunnels  of ab out 40ft d own the earth and the dig m ore than 200ft acr oss it, in such  of r ocks that they believe t o be  of quality f or g old pr ocessing. M ost  often because  of lack  of experience these miners  often get trapped in their dug pits, resulting in death. Figure 3.4: A dug pit at and artisanal small scale mining Grinding: The r ocks that the pit w orkers bring, are br oken int o smaller pieces and grinded in a grinding machine, in a semi cl osed area. The grinders d o this with out any pr otected device, exp osing them t o all s ort  of inhalati ons causing ser ous chest infecti ons. 23 University of Ghana http://ugspace.ug.edu.gh Figure 3.5: Artisanal small scale miners at w ork Washing: Small-scale g old mining  operati ons m ostly use mercury t o separate the g old fr om  other materials. Mercury is mixed with the materials c ontaining g old. An amalgam is then f ormed, since g old will melt in the mercury while  other impurities will n ot. The small scale miner f or lack  of equipment’s  or machinery will used his hand f or trapping the g old with the mercury in the palm. This really exp oses them  of the t oxicity  of the mercury. They n ormally wash standing in stagnant water, and the still exp osing their feet t o the mercury that may fall int o the water, because the water is never changed, but t opped as and when it reduces. 24 University of Ghana http://ugspace.ug.edu.gh Figure 3.6a: Artisanal small scale miners at w ork Figure 3.6b: Artisanal small scale miners at w orking with out hand gl oves Melting: The refining  of the extracted g old is washed under a crude meth od, where c oncentrated tetra ox osulphate (IV) acid is used t o burn and get the shiny g old we see. 3.5 Data analysis Data was analyzed using STATA 15. The results are presented in tables and figures. Data was described using pr op orti ons for categorical variables and mean and median values for continuous variables. Univariable ass ociati ons was tested using t-test (c ontinu ous), chi- square (categ orical) and  one way analysis  of variance (AN OVA) where applicable. A l ogistic regressi on m odel was fitted t o determine the ass ociati on between exp osure variables (type of SSM, work duration with SSM, working with mercury, how mercury is handled, frequency of handling mercury, and burning amalgam) and mining related diseases (skin dieseases and numbness). All statistical tests were c onducted at a significance level  of p<0.05. 25 University of Ghana http://ugspace.ug.edu.gh 3.6 Ethical c onsiderati ons Ethical clearance f or this study was  obtained fr om Ghana Health Service Ethical Review C ommittee and permissi on was als o be s ought fr om the Direct orate  of Health Service fr om the vari ous districts. Inf ormed c onsent was s ought fr om all the resp ondents bef ore interviewing them. The purp ose and the  objectives  of the study, and any p otential risk  or benefits inherent in the study was explained t o the resp ondents. The resp ondents were given an  opp ortunity t o ask questi ons ab out the study. Privacy and c onfidentiality will was ensured by dealing with the resp ondents  on individual basis and c onducting interviews in c onfined l ocati ons. Participants were  offered the  opp ortunity t o decline t o take part in the study  or t o withdraw at any stage  of the research. 26 University of Ghana http://ugspace.ug.edu.gh CHAPTER F OUR RESULTS This chapter presents the results  of the study. The results are presented in tables and figures preceded by a narrati on. 4.1 Backgr ound characteristics  of resp ondents Table 4.1 presents results  of the backgr ound characteristics  of resp ondents inv olved in this study. The mean age  of the resp ondents was 33±9.1years and ab out 80% were males. Ab out 26%  of the resp ondents had Juni or Sec ondary Sch o ol educati on whereas 35.3% had Seni or Sec ondary Sch o ol educati on. Ab out 12% had n ot f ormal educati on. The maj ority  of the resp ondents earned up t o GHS 1000.00 m onthly with 42.7% earning less than GHS 500.00 as m onthly inc ome. Alm ost 45% were married and the median (range) number  of children b orn and alive 2 (0-10) and 1 (0-8) respectively. The age children died was given as <1year (n=1), 2years (n=2), 3years (n=1) and 4years (n=2). The cause  of death was sickness (3) and spiritual (1) and at birth (3). Ab out 8 resp ondents had ever given birth t o children with def ormities. The birth defects stated were blindness (n=2), eye pr oblem (n=1), hearing impairment (n=1) and sickle cell (n=1). Table 4.1 Backgr ound characteristics  of resp ondents Variables Frequency Percentage Age in years, mean±SD 33±9.1 Sex (n=476)  Male 383 80.5  Female 93 19.5 Educati on status (n=487)  N o f ormal educati on 59 12.1  Primary educati on 126 25.9  Juni or Sec ondary 172 35.3  Seni or Sec ondary 116 23.8 27 University of Ghana http://ugspace.ug.edu.gh  Tertiary educati on 14 2.9 M onthly inc ome, GHS (n=466)  <500 199 42.7  500-1000 182 39.1  1001-1500 52 11.2  >1500 33 7.1 Marital status (n=480)  Single 203 42.3  Married 215 44.8  Seperated 42 8.8  Div orced /Wid owed 20 4.1 Number  of children (n=375), median (range) 2 (0-10) Number  of children b orn alive (n=369), 2 (0-10) median (range) Number  of children died (n=25), median 1 (0-8) (range) Any children with birth defects (n=432)  Yes 8 1.9  N o 424 98.1 S ource: Field data, 2019 4.2 Habitat and w ork exp osure characteristics  of resp ondents Table 2 als o sh ows the results  of habitat and  other characteristics relating t o w ork exp osure am ong the resp ondents. The maj ority (59.7%) had resided in the area f or m ore than 5 years and were empl oyed (65.1%). M ost  of the resp ondents (66.9%) were inv olved in small scale mining and ab out 72%  of th ose inv olved in mining were int o washing, which inv olves trapping  of g old with mercury in the palm. F orty-seven percent and 29.4% had w orked in small scale mining f or 2.5years and 5-10years respectively whiles17.5% had w orked in small scale mining. M ost  of the resp ondents (68.8%) w orked with mercury and the maj ority burned amalgam  or melted g old daily  or at least  once a week. Ab out three f ourth  of the 28 University of Ghana http://ugspace.ug.edu.gh resp ondents put mercury in their palms with out gl oves during w ork and ab out 45% w ork with mercury daily. Table 4.2 Habitat and w ork exp osure  of study resp ondents Variables Frequency Percentage H ow l ong living in this area (n=494)  ≤1year 53 10.7  2-5years 146 29.6  >5years 295 59.7 Empl oyed (n=487)  Yes 317 65.1  N o 170 34.9  Occupati on (n=353) - Pr ofessi onal 7 2.0 - Clerical -  Sales and services 24 6.8  Small scale mining 236 66.9  Agriculture 38 10.8  Skilled manual 9 2.5   Other unskilled manual 39 11.0 If small scale w ork descripti on (n=406)  Washing 293 72.2  Grinding 25 6.2  Melting 20 4.9  Pit w ork 68 16.7 W ork durati on with SSM  ≤1 26 6.1  2-5 201 47.0  5-10 126 29.4  ≥10 75 17.5 D o y ou w ork with mercury (n=475)  Yes 327 68.8  N o 70 14.7 29 University of Ghana http://ugspace.ug.edu.gh  Uncertain 78 16.4 H ow many times d o y ou burn amalgam (n=381) -daily 122 32.0 -at least  once a week 86 22.6 -at least  once a m onth 36 9.4 -never 137 36.0 H ow many times d o y ou melt g old (n=409) -daily 107 26.2 -at least  once a week 123 30.1 -at least  once a m onth 45 11.0 -never 134 32.8 H ow d o y ou handle mercury? (n=432) -put in the palm with out gl oves 326 75.5 -put in palms with gl oves 106 24.5 H ow d o y ou handle amalgam? (n=320) -separating 22 6.9 -squeezing 192 60.0 -carrying 7 2.2 - opening 9 2.8 Any  other way 90 28.1 H ow many times w ork with mercy (n=460) -daily 207 45.0 -at least  once a week 116 25.2 -at least  once a m onth 36 7.8 -never 101 22.0 Return with w orking cl othes t o y our h ome (n=488) -yes 222 45.5 -n o 266 54.5 D o y ou keep w ork cl othes at h ome (n=492) -yes 223 45.3 -n o 269 54.7 S ource: Field data, 2019 30 University of Ghana http://ugspace.ug.edu.gh 4.3 F o od and water c onsumpti on characteristics M ost (68%)  of the resp ondents c onsumed fish daily and ab out 48% c onsumed l ocally pr oduced chicken  often. The maj ority als o c onsumed eggs (63.5%), meat (64.8%) and fruits and vegetables (73%)  often. The m ost cited s ource  of drinking water was sachet water (53.2%) whereas pipe-b orne water was the m ost cited s ource  of c o oking water (53.2). The s ources  of water f or  other h ouseh old ch ores included b oreh ole (45%) and pipe-b orne water (45%). Table 4.3 F o od and water c onsumpti on Variables Frequency Percentage H ow frequently d o y ou eat fish?  Daily 340 68.0  At least  once a week 107 21.4  At least  once in tw o weeks 24 4.8  At least  once a m onth 11 2.2  Never 18 3.6 D o y ou c onsume fr om l ocal pr oducti on: Chicken  Never 34 6.9   Occasi onally 224 45.3   Often 237 47.9 Ducks  Never 326 67.2   Occasi onally 136 28.0   Often 23 4.7 Eggs  Never 15 3.1   Occasi onally 164 33.5   Often 310 63.5 Meat (beef)  Never 24 5.0 31 University of Ghana http://ugspace.ug.edu.gh   Occasi onally 146 30.2   Often 313 64.8 Vegetables, fruits  Never 7 1.4   Occasi onally 124 25.6   Often 354 73.0 Milk  Never 57 11.6   Occasi onally 199 40.5   Often 235 47.9 H ouseh old s ources  of water: Drinking (n=496)  B ore h ole 88 17.7  River/stream 14 2.8  Pipe b orne water 131 26.3  Sachet water 256 53.2 C o oking  B ore h ole 194 39.1  River/stream 28 5.6  Pipe b orne water 264 53.2  Sachet water 10 2.0  Other h ouseh old ch ores  B ore h ole 223 45.0  River/stream 40 8.1  Pipe b orne water 223 45.0  Sachet water 10 2.0 S ource: Field data, 2019 4.4 Lifestyle, health c onditi ons and past health pr oblems Figures 4.1 and 4.2, and Table 4.4 presents results  of the lifestyle and disease prevalence am ong the resp ondents. The prevalence  of malaria was 77% (Figure 4.1). As sh own in 32 University of Ghana http://ugspace.ug.edu.gh Figure 4.2, skin pr oblems was the m ost rep orted health c onditi on am ong the resp ondents (39.2%). This was f oll owed by numbness in the palm and feet (34.2% and 33.8% respectively), respirat ory pr oblems (18.1%) and trem ors (16.9%). The prevalence  of anxiety and tubercul osis were 11.9% and 9.5% respectively whiles 11.1% stated that they had  other c onditi ons. S ome  of the  other c onditi ons named by resp ondents included Hypertensi on, eye pr oblems, chest pains, waist pains, typh oid and migraine. Figure 4.1: Prevalence  of malaria 111, (23%) Malaria 375, (77%) No Malaria 33 University of Ghana http://ugspace.ug.edu.gh Figure 4.2: Prevalence  of mining related diseases 50 39.2 40 34.2 33.8 30 18.1 20 16.9 11.9 9.5 11.1 10 0 Diseases As sh own in Table 4.4, m ost  of the participants discl osed that they were healthy (71%). Ab out 4.8%  of the resp ondents believed their health pr oblems has w orsened since their exp osure t o mercury. Seventy-six resp ondents c onstituting 15.3% were sm okers and maj ority (63.9%) sm oked 10-20 cigarettes per day. Ab out 28%  of the resp ondents drink alc oh ol with beer being the m ost c onsumed (70.5%). Ab out 43.6% drink daily and  out  of 89 resp ondents, 39.4% drank 1-3 b ottles  of beer per day. Ab out 27% suffered fr om excessive salivati on. Maj ority  of the resp ondents believed that with trem ors, they have p o or perf ormance than usual at w ork. Ab out 16%  of resp ondents had sleeping pr oblems at night and this was attributed t o tiredness fr om w ork  or unkn own causes. Table 4.4 Lifestyle and health status  of resp ondents Variable Frequency Percentage Are y ou healthy n ow? -Yes 358 71.0 -N o 146 29.0 34 Percentage University of Ghana http://ugspace.ug.edu.gh Actual  or f ormer health pr oblem w orsened since exp osure t o mercury -Yes 21 4.8 -N o 253 57.8 -Uncertain 117 26.7 -N o mercury exp osure 47 10.7 D o y ou sm oke cigarettes? -Yes 76 15.3 -N o 401 80.8 -Used t o 19 3.8 If yes, h ow many? -l ot( m ore than 20 cigarettes per day) 4 28.3 -medium( 10-20 cigarettes per day) 19 63.9 -rarely (0-10 cigarettes per day) 66 7.9 D o y ou drink alc oh ol? -Yes 139 28.2 -N o 315 63.9 -Used t o 39 7.9 If yes what type (n=139) -beer 98 70.5 -wine 37 26.6 -spirit/  other hard drink 18 12.9 -l ocal hard drink 62 44.6 H ow  often d o y ou drink? (n=149) -daily 65 43.6 -at least  once a week 56 37.6 -at least  once every tw o weeks 11 7.4 -at least  once a m onth 17 11.4 1-3 b ottles  of beer (n=89) -Per day 35 39.4 -per week 54 59.6 >3 b ottles  of beer (n=31) -per day 10 32.3 35 University of Ghana http://ugspace.ug.edu.gh -per week 21 67.7 1-3 glasses  of wine -per day 3 14.3 -per week 18 85.7 >3 b ottles  of wine -per day 2 33.3 -per week 4 66.7 1-3 glasses  of tuba -per day 24 46.2 -per week 28 53.8 >3 glasses  of tuba -per day 12 37.5 -per week 20 62.5 Usually feel a kind  of a metallic taste in y our m outh2 -Yes 79 16.3 -N o 405 83.7 D o y ou suffer fr om excessive salivati on? -Yes 131 27.0 -N o 354 73.0 D o y ou have any pr oblems with trem or (shaking) at w ork? -Yes 83 16.9 -N o 409 83.1 H ow d oes trem or interfere with y our w ork? -I have trem or  or trem or interfere with my j ob 38 24.5 -I am able t o d o everything, but with err ors; p o orer 111 71.6 than usual perf ormance because  of trem or -I am unable t o d o any  outside j ob; h ousew ork 6 3.9 very limited D o y ou have any pr oblems with sleeping at night? -Yes 81 16.3 36 University of Ghana http://ugspace.ug.edu.gh -N o 417 83.7 S ource: Field data, 2019 4.5 Ass ociati on between w ork characteristics and w ork related diseases Table 4.5 presents the ass ociati on between w orking characteristics and mining related diseases (skin diseases and numbness). The kind  of empl oyment was ass ociated with numbness (p=0.015) but n ot skin diseases (p=0.273). H owever, am ong small scale miners, the type  of w ork was significantly ass ociated with b oth skin diseases and numbness, with a higher prevalence am ong th ose inv olved in pit w ork and melting, p<0.001. The w ork durati on  of the small scale miners was als o ass ociated with skin diseases, with disease prevalence increasing with increasing durati on  of inv olvement in small scale mining (p<0.001). The prevalence  of skin disease was als o significantly higher am ong th ose wh o w ork with mercury (45%) as c ompared t o th ose wh o d o n ot w ork with mercury (31.4%), p<0.001. Similar ass ociati on was  observed between w orking with mercury and numbness. W orking  on mercury with out gl oves was als o ass ociated with higher prevalence  of skin diseases (p<0.001) and numbness (p<0.001) as c ompared t o th ose wh o wear gl oves. The frequencies  of melting g old (p<0.001) and handling mercury (p<0.001) were als o ass ociated with skin diseases, with higher prevalence  observed am ong th ose wh o perf ormed these tasks daily. 37 University of Ghana http://ugspace.ug.edu.gh Table 4.5 W ork characteristics and mining related diseases Skin diseases p- Numbness p-value Variables Present Absent value Present Absent N (%)% N (%)% N (%)% N (%)% Empl oyment 0.273 0.015  SSM 88 (38.1) 143 (61.9) 105 (44.5) 131 (55.5)  Agriculture 16 (42.1) 22 (57.9) 13 (34.2) 25 (65.8)   Other 42 (30.9) 94 (69.1) 41 (29.7 97 (70.3) If small scale w ork <0.001 <0.001 descripti on  Washing 43 (23.8) 138 (76.2) 62 (33.5) 123 (66.5)  Grinding 40 (42.6) 54 (57.4) 44 (46.3) 51 (53.7)  Melting 19 (51.4) 18 (48.6) 7 (18.9) 30 (81.1)  Pit w ork 68 (53.5) 59 (46.5) 66 (51.2) 63 (48.8) W ork durati on with <0.001 0.422 SSM  ≤1 10 (20.0) 40 (80.0) 17 (33.3) 32 (66.7)  2-5 61 (41.5) 66 (58.5) 62 (40.8) 90 (59.2)  5-10 60 (34.5) 114 (65.5) 63 (36.0) 112 (64.0)  ≥10 42 (56.0) 33 (44.0) 34 (45.3) 41 (54.7) D o y ou w ork with <0.001 <0.001 mercury  Yes 145 (45.0) 177 (55.0) 156 (47.7) 171 (52.3)  N o 22 (31.4) 48 (68.6) 24 (34.3) 56 (65.7)  Uncertain 16 (21.1) 60 (78.9) 8 (10.3) 70 (89.7) H ow many times d o y ou 0.022 0.003 burn amalgam  Daily 49 (48.8) 71 (59.2) 57 (46.7) 65 (53.3)  At least  once a week 31 (37.3) 52 (62.7) 43 (50.0) 43 (50.0)  At least  once a 7 (20.0) 28 (80.0) 19 (27.8) 26 (72.2) m onth  Never 36 (26.3) 101 (73.7) 41 (29.9) 96 (70.1) H ow many times d o y ou melt g old <0.001 0.019  Daily 56 (53.3) 49 (46.7) 55 (51.4) 52 (48.6)  At least  once a week 43 (36.1) 76 (63.9) 45 (36.6) 78 (63.4)  At least  once a 6 (13.6) 38 (84.6) 15 (33.3) 30 (66.7) m onth 38 University of Ghana http://ugspace.ug.edu.gh  Never 38 (28.4) 96 (71.6) 44 (32.8) 90 (67.2) H ow d o y ou handle mercury? <0.001 <0.001  Put in the palm 144 (44.9) 177 (55.1) 146 (44.8) 180 (55.2) with out gl oves  Put in palms with 24 (22.9) 81 (77.1) 25 (23.6) 81 (76.4) gl oves H ow many times <0.001 <0.001 handle mercury  Daily 97 (47.3) 108 (52.7) 87 (42.0) 120 (58.0)  At least  once a week 52 (46.0) 61 (54.0) 60 (51.7) 56 (48.3)  At least  once a 8 (22.2) 28 (77.8) 13 (36.1) 23 (63.9) m onth  Never 25 (25.3) 74 (74.7) 17 (16.8) 84 (83.2) Return with w orking 0.065 0.192 cl othes t o y our h ome  Yes 75 (34.6) 142 (85.4) 78 (35.1) 144 (64.9)  N o 113 (42.8) 151 (57.2) 109 (41.0) 157 (59.0) D o y ou keep w ork 0.303 0.040 cl othes at h ome  Yes 79 (36.2) 139 (63.8) 74 (33.2) 149 (66.8)  N o 109 (40.8) 158 (59.2) 114 (42.4) 155 (57.6) S ource: Field data, 2019; SSM=small scale mining Table 4.6 presents results  of the ass ociati on between selected exp osure variables and numbness and skin diseases. Being inv olved in pit w ork was ass ociated with higher  odds  of numbness as c ompared t o th ose wh o are engaged in melting, after adjusting for age, educati on, and durati on  of w ork (A OR: 3.93; 95%CI: 1.57 -9.86). A year increase in the durati on  of w orking in small scale mining was als o ass ociated with 1.09 higher  odds  of skin diseases (A OR: 1.09; 95%CI: 1.05 -1.14). W orking with mercury was als o ass ociated with 3.72 times higher  odds  of numbness (A OR: 3.72; 95%CI: 2.21 -6.27) and skin diseases (A OR: 2.49; 95%CI: 1.51 -4.10) as compared with those who did not work with mercury. Handling mercury with out gl oves and handling mercury daily are als o ass ociated with 39 University of Ghana http://ugspace.ug.edu.gh higher  odds  of numbness and skin diseases. The number  of times  one burns amalgam was als o significantly ass ociated with numbness and skin diseases. As c ompared t o th ose wh o never burned amalgam, burning amalgam daily was ass ociated with about two times higher  odds  of numbness (A OR: 1.99; 95%CI: 1.14 -3.49) and skin diseases (A OR: 2.01; 95%CI: 1.12 -3.59). Burning amalgam  once a week was als o ass ociated with higher  of numbness as c ompared t o th ose wh o never burned amalgam. Table 4.6 L ogistic regressi on analysis  of ass ociati on between selected exp osure variables and mining related diseases Numbness Skin diseases Variables A OR [95% CI] p-value A OR [95% CI] p-value Descripti on  of SSM (ref=melting)  Washing 2.05 [0.82-5.09] 0.124 0.48 [0.22-1.05] 0.068  Grinding 2.62 [1.01-6.78] 0.048 0.77 [0.34-1.76] 0.535  Pit w ork 3.93 [1.57-9.86] 0.003 1.36 [0.62-2.98] 0.441 W ork durati on with SSM 1.03 [0.99-6.27] 0.166 1.09 [1.05-1.14] <0.001 D o y ou w ork with mercury (ref=n o/uncertain) 3.72 [2.21-6.27] <0.001 2.49 [1.51-4.10] <0.001 H ow d o y ou handle mercury? (ref=with gl oves)  Put in the palm with out 2.18 [1.29-3.68] 0.004 2.40 [1.40-4.10] 0.001 gl oves H ow many times handle mercury (ref=never)  Daily 3.31 [1.72-6.36] <0.001 2.88 [1.56-5.30] 0.001  At least  once a week 5.41 [2.70- <0.001 2.74 [1.42-5.29] 0.003 10.86]  At least  once a m onth 2.35 [0.87-6.33] 0.092 0.88 [0.31-2.55] 0.818 H ow many times burn amalgam (ref=never)  Daily 1.99 [1.14-3.49] 0.016 2.01 [1.12-3.59] 0.019 40 University of Ghana http://ugspace.ug.edu.gh  At least  once a week 2.47 [1.35-4.51] 0.003 1.72 [0.91-3.23] 0.093  At least  once a m onth 0.82 [0.30 -2.27] 0.702 0.73 [0.25-2.16] 0.567 Regressi on analysis are adjusted f or age, educati on, and durati on  of w ork; A OR=adjusted  odds rati os; SSM=small scale mining 41 University of Ghana http://ugspace.ug.edu.gh CHAPTER FIVE DISCUSSI ON This chapter presents the discussi ons  of maj or findings  of the study. The discussi ons are  outlined in line with the  objectives  of the study and are discussed in relati on t o relevant published studies in this and  other settings. 5.1 Key findings This study was c onducted t o assess the prevalence  of mining related diseases in tw o mining c ommunities in the Ashanti regi on (Jac obu in the Amansie-Central district and K on ong o in the Asante-Akyem district) and  one c ommunity in the Eastern regi on  of Ghana (Kibi in the East Akim Municipal district). Findings  of this study sh ow a high prevalence  of mining related diseases; skin pr oblems 39.2%, numbness in the palm 34.2% and feet 33.8%, respirat ory pr oblems 18.1%, trem ors (16.9%) and anxiety 11.9%. The prevalence  of diseases am ong miners was significantly ass ociated with use  of activities related t o small scale mining and use  of mercury f or mining activities. 5.2 Discussi on  of key findings 5.2.1 Prevalence  of mining related diseases This study f ound a high prevalence  of mining related diseases in mining c ommunities in the Ashanti and Eastern regi on  of Ghana. This findings c orr ob orates previ ous studies that f ound high prevalence  of certain disease am ong miners and mining c ommunities in Ghana (Akabzaa and Darimani, 2001; Awudi, 2002). This include previ ous study by Ayaaba et al (2017) am ong surface and undergr ound miners in Tarkwa and  Obuasi mines in Ghana which f ound prevalence  of 47.6% f or respirat ory related c onditi ons. There is theref ore an urgent need t o prepare the health system t o handle these emerging c onditi ons, as m ost health w orkers are m ore likely t o diagn ose numbness in the as sympt om  of type 2 diabetes. 42 University of Ghana http://ugspace.ug.edu.gh The impact  of mining activities  on health and diseases, is h owever n ot limited t o miners but als o t o surr ounding c ommunities and p opulati ons. In Ghana, high prevalence  of mining certain disease c onditi ons are have been rep orted am ong c ommunities cl oser t o mining areas in Ghana. A study that l o oked at the health impact  of mining activities  of Angl oG old Ashanti  on five surr ounding c ommunities in the  Obuasi Municipality f or instance f ound that a 17.7% and 27% prevalence  of skin diseases and respirat ory infecti ons respectively (Yeb oah, 2008). Tw o c ommunities in that study, Anyimad okr om and Sans o rep orted prevalence  of 26.6% and 24.3%  of skin diseases respectively. The prevalence  of skin diseases in that study were attributed t o c ontaminati on  of water b odies with chemicals which s ome residents are dependent  on f or water, f o od and  other d omestic purp oses. The high  occurrence  of skin diseases at Anyimad okr om is due t o its pr oximity t o Angl oG old Ashanti's P omp ola treatment plant where chemicals such as arsenic (sulfur di oxide) are used (Yeb oah, 2008). The estimate  of prevalence  of mining related diseases in this study and  other related studies might h owever suffer fr om under/ over estimati on due t o the reliance  on self-rep ort. Ideally, a sensitive sympt om questi onnaire and a f oll ow-up medical examinati on is the best ch oice f or case finding am ong the w orker p opulati on (Lenderink et al., 2012). Undertaking a detailed eti ol ogical studies  of exp osed p opulati ons in which disease  outc omes can be studied in relati on t o risk fact ors at w ork and  other p otential causative fact  ors is a much r obust way t o estimate the incidence and prevalence  of w ork-related diseases. This type  of studies are h owever hardly perf  ormed  on such a scale that findings c  ould represent an estimate  of the prevalence  of several w ork-related diseases am  ong larger p opulati ons. Self-rep ort pr ovides an efficient and accepted means  of assessing p opulati on characteristics, risk fact  ors, and diseases. Self-rep orted diseases am ong w orkers is sh own t o pr ovide valuable inf  ormati on  on the presence  of diseases and diseases like 43 University of Ghana http://ugspace.ug.edu.gh muscul oskeletal and skin diseases are sh  own t o have m ore precise estimates which are generalizable (Lenderink et al., 2012). 5.2.2 Ass ociati on between use  of mercury and mining related diseases Findings  of this study sh ows a significant influence  of the use  of mercury  on skin diseases and trem ors. The maj ority (68.8%)  of the w orkers inv olved in this study used mercury in small scale mining activities. Use  of mercury was ass ociated with higher  odds  of trem ors and skin diseases the prevalence  of skin diseases increased with increasing frequency  of use  of mercury. S ome resp ondents in this study rep orted having excessive salivati on (27%) and  other resp ondents discl osed that they usually feel a kind  of metallic taste in their m outh (16.3%). The impact  of mercury exp osure  on health has been well established in previ ous studies. The ass ociati on between exp osure t o mercury and skin diseases f or instance has been rep orted in previ ous studies (Behnam and Al-Saleem, 1977; B oyd et al., 2000; Sun, Hu, Yuan, Zhang, and Lu, 2017). Findings  of this study als o c orr ob orates tw o studies in Ghana that have rep orted skin rashes, metallic taste and c omplaints  of numbness as pred ominant c omplicati ons suggestive  of mercury exp osure (Afrifa, Essien-Baid o o, Ephraim, Nkrumah, and Dankyira, 2017; Mensah et al., 2016). The study by Mensah et al f ound c omplaints  of numbness were significantly ass ociated with mercury exp osure am ong th ose wh o have previ ously w orked at  other small-scale g old mines (Mensah et al., 2016). Similarly, a p o oled analysis  on miners and c ommunity members fr om vari ous artisanal small-scale g old mining areas in Philippines, M ong olia, Tanzania, Zimbabwe and Ind onesia f ound trem ors as a typical sympt om  of chr onic metallic mercury int oxicati on (B ose- O’Reilly et al., 2017).  Other sympt oms  observed in that study were c o ordinati on pr oblems, excessive salivati on and metallic taste (B ose- O’Reilly et al., 2017). 44 University of Ghana http://ugspace.ug.edu.gh Inhaled mercury vap or can easily pass thr ough the walls  of alve oli and enter the bl o odstream resulting in the b ody abs orbing 80%  of the inhaled am ount, causing severe neur ol ogical, cardi ovascular,  or renal pr oblems (Díaz, Muñ oz-Guerrer o, Palma-Parra, Becerra-Arias, and Fernández-Niñ o, 2018). Acc ording t o the W orld Health  Organizati on, elemental and methylmercury are t oxic t o the central and peripheral nerv ous systems (W orld Health  Organizati on, 2017). The rep ort als o indicate that inhalati on  of mercury vap our can pr oduce harmful effects  on the nerv ous, digestive and immune systems, lungs and kidneys, and may be fatal. Further, the in organic salts  of mercury are c orr osive t o the eyes, skin, and may induce kidney t oxicity if ingested (W orld Health  Organizati on, 2017). Am ong w orkers exp osed t o elemental mercury in air  of 20 μg/m3  or m ore f or several years, mild, subclinical signs  of central nerv ous t oxicity are  observed (W orld Health  Organizati on, 2017). Mercury salts are generally irritants  on the skin that cause dermatitis, disc ol orati on  of the nails, and c orr osi on  of the muc ous membranes, and may als o cause c orr osive burns (Park and Zheng, 2012). It is estimated that appr oximately 7% t o 15%  of d oses  of in organic mercury c omp ounds are abs orbed in the gastr ointestinal tract after ingesti on (Xu, Suik o, Sakakibara, and Pai, 2002). The  occurrence  of mercury in the envir onment rep orted t o be as a result  of its use in g old rec overy pr ocess, where in organic f orm  of the metal is either washed int o rivers  or readily vap orized int o the atm osphere. Small-scale artisanal mining is the main s ource  of mercury emissi ons int o the envir onment, and releases 1400 t ons per year int o water, air, and s oil. In 2010, small scale mining c ontributed ab out 37%  of the t otal anthr op ogenic emissi ons, and 24% in 2011 (Gers on, Drisc oll, Hsu-Kim, and Bernhardt, 2018; Green, Lewis, W ozniak, Drevnick, and Thies, 2019). Another rep ort estimated that 5 t ons  of mercury is released fr om small-scale mining  operati ons each year in Ghana (Asklund and Eldvall, 2005). With 45 University of Ghana http://ugspace.ug.edu.gh the increasing exp osure mercury thr ough small scale mining, there is the need f or urgent attenti on t o c ontr ol mercury exp osure am ong artisanal miners. Acc ording t o previ ous rep orts, appr oximately 10 t o 15 milli on pe ople mainly in c ountries in Africa, Asia, and S outh America are inv olved in the extracti on  of g old thr ough artisanal small scale mining. Additi onally, acc ording t o calculati ons by the Gl obal Mercury Assessment, ar ound 3 milli on w omen and children w orked in the artisanal mining sect or in 2013 (Gers on et al., 2018; UNEP, 2013). 5.2.3 Ass ociati on between  other w ork related exp osures and mining related diseases The health effects  of mining and disease severity am ong pe ople exp osed t o mining activities might depend h owever  on the kind  of activities carried  out during mining and the durati on  of exp osure t o harmful chemical used in mining. The different pr ocesses  of small scale mining, such as washing, melting, pit w ork and grinding f or instance c onstitute difference exp osures t o mercury. Rep ort fr om the WH O f or instance implicated the inhalati on  of a vap orized f orm  of elemental mercury during amalgam smelting as the main r oute  of exp osure t o mercury am ong miners (W orld Health  Organizati on., 2008). Small scale mining in Ghana is ass ociated with life-threatening risks at the mine site, including dynamite blasts, c ollapsing pits and shafts and falls near excavati on sites. Small- scale g old mining  operati ons m ostly use mercury t o separate the g old fr om  other materials thr ough mixing mercury with g old-c ontaining materials and f orming an amalgam. The pr ocess  of trapping g old is h owever d one with the hand, which exp oses the miners t o the t oxicity  of mercury. Findings fr om this study sh owed higher  odds  of trem ors and skin diseases am ong miners wh o burn amalgam and handled g old daily and th ose wh o handled mercury with out gl oves. An increase durati on  of w ork in small scale mining was als o 46 University of Ghana http://ugspace.ug.edu.gh ass ociated with higher  odds  of skin diseases. These findings c ould be due t o the higher levels  of mercury exp osure related t o these activities  of small scale mining. This is supp orted by the  outc ome  of the p o oled analysis  on miners and c ommunity members fr om vari ous artisanal small-scale g old mining areas in Philippines, M ong olia, Tanzania, Zimbabwe and Ind onesia where mean mercury c oncentrati ons sh owed highest levels ab ove thresh old limits am ong amalgam burners as c ompared t o  other exp osed subgr oups (B ose-  O’Reilly et al., 2017). In that study, 54% the highly-exp osed gr oup (amalgam burners) were diagn osed as being mercury-int oxicated c ompared t o 0% within the c ontr ol gr oup. Despite the life threatening activities inv olved in small scale mining and the use  of hand in trapping g old, the use  of gl oves f or pr otecti on was limited in this study. M ore than three- f ourth  of the resp ondents in this study (75.5%) put mercury in their palms with  out gl oves. These p oses a huge health risk t o small scale miners in the study area in Ghana as a wh ole. It is suggested that in organic mercury may be abs orbed thr ough the skin by the transp ort  of mercury acr oss the epidermis and via the sweat glands, sebace ous glands, and hair f ollicles (Chan, 2011). This study c orr ob orates findings fr om  other studies in Ghana that rep orted very use gl oves and  other pers onal pr otective equipment am ong small scale miners, including the study am ong small-scale g old miners in the Talensi-Nabdam District  of Ghana’s Upper East regi on where 70% never used any f orm  of pers onal pr otective cl othing (Paruchuri et al., 2010). Similarly, study in Wassa West District als o rep orted that <13%  of miners used pers onal pr otective cl othing (D orgbet or, 2005) and in the study am ong small scale miners in Prestea, the use  of pers onal pr otecti on was rep ortedly l ow (Mensah et al., 2016). Findings  of this study sh owed that the miners wh o did n ot use gl oves had higher  odds  of trem ors and skin diseases. Use  of hand gl oves during mining activities c ould there  offer s ome pr otecti on against diseases related t o mercy exp osure am ong miners. 47 University of Ghana http://ugspace.ug.edu.gh 5.2.4 Strength and limitations The major strength of this study is the sampling from three mining disctrics in Ghana to ensure representativesness. The use of cross-sectional design in this study however made it impossible to make causal inferences. 48 University of Ghana http://ugspace.ug.edu.gh CHAPTER SIX C ONCLUSI ON AND REC OMMENDATI ONS This secti on presents the c onclusi on  of the study based  on the key findings and make rec ommendati ons f or impr oving the health  of small scale miners and surr ounding c ommunities in the c ountry f or impr oved public health. 6.1 C onclusi on In c onclusi on, this study f ound high prevalence  of diseases related t o mining activities including skin pr oblems, numbness in the palm and feet (peripheral neur opathy), respirat ory pr oblems, trem ors and anxiety. This c ould indicate an emergence  of certain diseases in mining areas in Ghana. H owever, the healthcare system in these areas might n ot be adequately prepared f or the emerging health pr oblems in mining areas. The use  of mercury is ass ociated with mining related diseases such as numbness and skin diseases am ong small scale miners, independent  of age, gender and the durati on  of exp osure. Peripheral neur opathy and skin diseases were significantly higher am ong th ose wh o use mercury in small scale miners in the Ashanti and Eastern regi ons  of Ghana and the use  of mercury resulted in higher  odds  of trem ors and skin diseases. Further more, the activities  of small scale mining such as the melting  of g old and use  of amalgam are ass ociated with mining related diseases. Increase durati on  of w ork in small scale mining is als o ass ociated with higher risk  of peripheral neur opathy and skin related diseases am ong small scale miners in the Ashanti and Eastern regi ons  of Ghana. Finally, the use  of pers onal gl oves f or pr otecti on is very limited am ong small scale miners. N ot using hand gl oves is ass ociated with higher  odds  of numbness and skin diseases am ong miners in the Ashanti and Eastern regi ons  of Ghana. 49 University of Ghana http://ugspace.ug.edu.gh 6.2 Rec ommendati ons Based  on the findings  of the study, the f oll owing rec ommendati ons are made t o impr ove the health  of small scale miners in Ghana and  other similar settings:  This study f ound high prevalence  of certain diseases am ong small scale miners in Ghana. The Ministry  of Health, Ghana Health Service and  other health stakeh olders sh ould c onduct regular health screening am ong this w orker p opulati on and surr ounding c ommunities t o identify the emergence  of diseases am ong these p opulati ons.  The Ministry  of Health, Ghana Health Service and  other health stakeh olders sh ould als o set up surveillance systems in mining areas in Ghana t o pr oper track the emergence  of certain diseases related t o mining t o avert p ossible healthcare hazards.  The g overnment agencies and  other stakeh olders resp onsible f or regulati on and c ontr ol  of mining in the c ountry sh ould embark  on training  of small scale miners  on the health c onsequences  of the use  of mercury f or mining activities.  Small scale miners in the study area and  other areas in Ghana sh ould be educated  on the health implicati ons  of the use  of bare hands in trapping g old and f or handling mercury in small scale mining activities.  The use  of eti ol ogical studies and f oll ow-up medical examinati ons is further rec ommended t o measure and assess disease prevalence and related risk fact  ors in mining areas in Ghana t o better inf orm preventive p olicies. 50 University of Ghana http://ugspace.ug.edu.gh REFERENCES Afrifa, J., Essien-Baid o o, S., Ephraim, R. 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Human Health Risk Assessment  of Artisanal Miners Exp osed t o T oxic Chemicals in Water and Sediments in the PresteaHuni Valley District  of Ghana. Internati onal J ournal  of Envir onmental Research and Public Health, 13(1), 139. https://d oi. org/10.3390/ijerph13010139 Park, J.-D., and Zheng, W. (2012). Human exp osure and health effects  of in organic and elemental mercury. J ournal  of Preventive Medicine and Public Health = Yebang Uihakh oe Chi, 45(6), 344–352. https://d oi. org/10.3961/jpmph.2012.45.6.344 Paruchuri, Y., Siuniak, A., J ohns on, N., Levin, E., Mitchell, K., G o odrich, J. M., … Basu, N. (2010).  Occupati onal and envir onmental mercury exp osure am ong small-scale g old miners in the Talensi-Nabdam District  of Ghana’s Upper East regi on. The Science  of the T otal Envir onment, 408(24), 6079–6085. https://d oi. org/10.1016/j.scit otenv.2010.08.022 Ragnar, A., and Björn, E. (2005). C ontaminati on  of water res ources in Tarkwa mining area  of Ghana. Lund. Sun, G.-F., Hu, W.-T., Yuan, Z.-H., Zhang, B.-A., and Lu, H. (2017). Characteristics  of Mercury Int oxicati on Induced by Skin-lightening Pr oducts. Chinese Medical J ournal, 130(24), 3003–3004. https://d oi. org/10.4103/0366-6999.220312 56 University of Ghana http://ugspace.ug.edu.gh UNEP. (2013). Gl obal Mercury Assessment 2013 S ources, Emissi ons, Releases and Envir onmental Transp ort. Geneva. V ora, N. (2008). Impact  of anthr op ogenic envir onmental alterati ons  on vect or-b orne diseases. Medscape J ournal  of Medicine, 10(10), 238. W orld Health  Organizati on. (2008). Guidance f or Identifying P opulati ons at Risk fr om Mercury Exp osure. Geneva. W orld Health  Organizati on. (2017). Mercury and health. Xu, F., Suik o, M., Sakakibara, Y., and Pai, T. (2002). Casarett and D oull’s T oxic ol ogy; The Basic Science  of P ois ons Casarett and D oull’s T oxic ol ogy; The Basic Science  of P ois ons, 1996. The J ournal  of Bi ochemistry. Yang, G., Ma, L., Xu, D., Li, J., He, T., Liu, L., … Chai, Z. (2012). Levels and speciati on  of arsenic in the atm osphere in Beijing, China. Chem osphere, 87(8), 845–850. https://d oi. org/10.1016/J.CHEM OSPHERE.2012.01.023 Yeb oah, JH. (2008). Envir onmental and health impact  of mining  on surr ounding c ommunities: a case study  of Angl og old Ashanti in  Obuasi. Kwame Nkrumah University  of Science and Techn ol ogy. Yeb oah, JY. (2008). Envir onmental and health impact  of mining  on surr ounding c ommunities: a case study  of Angl og old Ashanti in  Obuasi. Kwame Nkrumah University  of Science and Techn ol ogy. Zhang, G., W ong, M., Yi, P., Xu, J., Li, B., Ding, G., … Wang, N. (2010). HIV-1 and STIs prevalence and risk fact ors  of miners in mining districts  of Yunnan, China. J ournal  of Acquired Immune Deficiency Syndr omes (1999), 53 Suppl 1(Suppl 1), S54-60. 57 University of Ghana http://ugspace.ug.edu.gh https://d oi. org/10.1097/QAI.0b013e3181c7d8d2 58 University of Ghana http://ugspace.ug.edu.gh APPENDIX A- STUDY QUESTI ONNAIRE Title: Emerging diseases ass ociated with mining; a study  of mining c ommunities in Ghana I kindly ask y ou t o answer the f oll owing questi ons and statements. By d oing s o, y ou c ontribute t o a better scientific understanding  of the t opic ab ove. Inf ormati on pr ovided will be kept strictly c onfidential. Thank y ou. Interviewer Date  of interview: ……………………………………………………………… Name  of the interviewer: ..................................................................... 1 Pers onal Data ID Number__________ 1.1 Participant 1.1.1 Date  of Birth…………………………Age: …………………….. 1.1.2 Sex: Male [ ] Female [ ] 1.1.3 Educati onal Status N o f ormal educati on [ ] Primary educati on [ ] Juni or Sec ondary [ ] Seni or sec ondary [ ] Tertiary educati on [ ] 1.1.4 M onthly inc ome (GHC) Bel ow 500 [ ] 500-1000 [ ] 1001-1500 [ ] 1500 ab ove [ ] 1.1.5 Marital status Single [ ] Married [ ] Separated [ ] Div orced [ ] Wid owed [ ] 1.1.6 Number  of children _________ 1.1.7 H ow many children were b orn alive? _________ 1.1.8 H ow many children died in the meantime? _________ 1.1.9 At which age? Cause  of death (if kn own)? _________ 1.1.10 D o y ou have any children with birth defects? Yes [ ] N o [ ] 1.1.10a Which birth defects? ……………………………………………………… ……………………………………………………… 59 University of Ghana http://ugspace.ug.edu.gh 1.1.13 Address …………………………………………………........ 2 General Questi onnaire 2.1 Habitat 2.1.1 H ow l ong have y ou been living in this area? ______m onths ______ year(s) 2.1.2 Which c ommunity d o y ou live in? ..… 2.2 W ork Exp osure 2.2.1 Are y ou empl oyed? Yes [ ] N o [ ] 2.2.2 Descripti on  of  occupati on Pr ofessi onal/ technical/managerial [ ] Clerical [ ] Sales and services [ ] Small scale mining [ ] Agriculture [ ] Skilled manual [ ]  Other unskilled manual [ ] 2.2.3 If small scale mining, j ob descripti on Washing [ ] Grinding [ ] Melting [ ] Pit w ork [ ] 2.2.4 H ow many years have y ou w orked in Small scale mining? _________ 2.2.5 D o y ou w ork with mercury  or with mercury p olluted tailings? Yes [ ] N o [ ] Uncertain [ ] 2.2.6 H ow many times d o y ou burn amalgam in the  open (f or example in pans)? Daily [ ] At least  once a week [ ] At least  once a m onth [ ] Never [ ] 60 University of Ghana http://ugspace.ug.edu.gh 2.2.7 H ow many times d o y ou melt g old in the  open  or with inadequate ·fume h o ods? Daily [ ] At least  once a week [ ] At least  once a m onth [ ] Never [ ] 2.2.8 H ow d o y ou handle mercury? Put in palms with out gl oves [ ] Put in palms with gl oves [ ] 2.2.9. H ow d o handle the amalgam? Separating the amalgam fr om excess mercury by a washing  operati on [ ] Squeezing the amalgam thr ough a cl oth [ ] Carrying bags filled with tailings [ ]  Opening  or emptying bags with tailings [ ] Any  other way [ ] 2.2.9 H ow many times d o y ou handle mercury in the ab ove menti oned way? Daily [ ] At least  once a week [ ] At least  once a m onth [ ] Never [ ] 2.2.10 D o y ou return with w orking cl othes t o y our h ome? Yes [ ] N o [ ] 2.2.11 D o y ou keep w ork cl othes at h ome? Yes [ ] N o [ ] 2.3 Diet Issues and s ources  of water f or h ouseh old 2.3.1 H ow frequently d o y ou eat fish? Daily [ ] At least  once a week [ ] At least  once in tw o weeks [ ] At least  once a m onth [ ] Never [ ] 2.3.2 D o y ou c onsume fr om l ocal pr oducti on: Chicken Never [ ]  Occasi onally [ ]  Often [ ] 61 University of Ghana http://ugspace.ug.edu.gh Ducks Never [ ]  Occasi onally [ ]  Often [ ] Eggs Never [ ]  Occasi onally [ ]  Often [ ] Meat (beef etc.}? Never [ ]  Occasi onally [ ]  Often [ ] Vegetables, Fruits Never [ ]  Occasi onally [ ]  Often [ ] Milk  or milk pr oducts Never [ ]  Occasi onally [ ]  Often [ ] 2.3.3 What are y our h ouseh old s ources  of water? Drinking B ore h ole [ ] River/stream [ ] Pipe-b orne water [ ] Sachet water [ ] C o oking B ore h ole [ ] River/stream [ ] Pipe-b orne water [ ] Sachet water [ ]  Other h ouseh old ch ores B ore h ole [ ] River/stream [ ] Pipe-b orne water [ ] Sachet water [ ] 2.4 Health Pr oblems 2.4.1 Did y ou ever have malaria? Yes [ ] N o [ ] 2.4.3 Did y ou ever have any maj or acute  or chr onic health pr oblems in the past? Kidney diseases Yes [ ] N o [ ] Skin pr oblems (allergies, l oss  of hair, eczema's} Yes [ ] N o [ ] Pr oblems t o get pregnant, bec ome a father (fertility} Yes [ ] N o [ ] Respirat ory pr oblems (asthma, pneum onia) Yes [ ] N o [ ] Hepatic dis orders (hepatitis) Yes [ ] N o [ ] Maj or infecti ons, like tubercul osis Yes [ ] N o [ ] Neur ol ogical dis orders (epilepsy, Parkins on etc.} Yes [ ] N o [ ] Any mental/ nerv ous dis orders? Yes [ ] N o [ ] Anxiety pr oblems? Yes [ ] N o [ ] D o y ou feel Numb in palm? Yes [ ] N o [ ] D o y ou feel Numb in feet? Yes [ ] N o [ ]  Other diseases Yes [ ] N o [ ] If yes: .................................................................................................... 2.4.4 Are y ou healthy n ow? Yes [ ] N o [ ] If n o: Which health pr oblems, d o y ou have? 62 University of Ghana http://ugspace.ug.edu.gh ……………………………………………………………………… ……………………………………………………………………… ……………………………………………………………………… 2.4.5 Has the actual  or f ormer health pr oblem w orsened since exp osure t o mercury  occurred? Yes [ ] N o [ ] Uncertain [ ] N o mercury exp osure [ ] 2.4.6 D o y ou sm oke cigarettes? Yes [ ] N o [ ] Used t o [ ] 2.4.7 If yes, h ow many? L ots (m ore than 20 cigarettes per day) [ ] Medium (10-20 cigarettes per day) [ ] Rarely (0-10 cigarettes per day) [ ] 2.4.8 D o y ou drink alc oh ol? Yes [ ] N o [ ] Used t o [ ] (IF N O, M OVE T O QUESTI ON 2.4.12) 2.4.9 If yes, what type and h ow many time? Beer [ ] Wine [ ] Spirits/  other hard drink [ ] L ocal hard drink [ ] 2.4.10 H ow  often d o y ou drink? Daily [ ] At least  once a week [ ] At least  once every tw o weeks [ ] At least  once a m onth [ ] 63 University of Ghana http://ugspace.ug.edu.gh 2.4.11 Can y ou quantify h ow many glasses  or b ottles y ou drink per day/week? 1/2/3 b ottles  of beer Per day [ ] Per we ek [ ] > 3 b ottles  of beer Per day [ ] Per week [ ] 1/2/3 glasses  of wine Per day [ ] Per week [ ] > 3 glasses  of wine Per day [ ] Per week [ ] 1/2/3 glasses  of tuba-tuba  or hard drink Per day [ ] Per week [ ] > 3 glasses  of tuba-tuba  or hard drink Per day [ ] Per week [ ] 2.4.12 D o y ou usually feel a kind  of a metallic taste in y our m outh? Yes [ ] N o [ ] 2.4.13 D o y ou suffer fr om excessive salivati on? Yes [ ] N o [ ] 2.4.14 D o y ou have any pr oblems with trem or (shaking?) at w ork? Yes [ ] N o [ ] 2.4.15 H ow d oes trem or interfere with y our w ork? I have trem or  or trem or interfere with my j ob [ ] I am able t o d o everything, but with err ors; p o orer than usual perf ormance because  of trem or [ ] I am unable t o d o any  outside j ob; h ousew ork very limited [ ] 2.4.16 D o y ou have any pr oblems with sleeping at night? Yes [ ] N o [ ] If yes, what pr oblems d o y ou have? ………………………………………………… ………………………………………………………………………………………. 64 University of Ghana http://ugspace.ug.edu.gh APPENDIX B - ETHICAL APPR OVAL 65