By Mareike Kroll and Peter Rosenbluth
Background
Mercury is a highly toxic metal that persists in the environment. While the general population can be exposed to elemental mercury, for example in old mercury-containing thermometers, or to methylmercury in some fish, occupational exposure to toxic elemental mercury vapours in Artisanal and Small-scale Gold Mining (ASGM) is a much higher magnitude and very common among the estimated 10 million miners in the sector globally.
The artisanal gold mining sector is – due to its high use of mercury – a priority focus under the Minamata Convention on Mercury, an international legally binding agreement that protects human health and the environment from anthropogenic releases of mercury and its compounds. According to Article 7 of the Convention, parties with significant ASGM sectors are obligated to develop a National Action Plan (NAP) to reduce or eliminate the use of mercury in ASGM. The NAP should include strategies (e.g., the provision of information) to reduce the exposure of miners and their communities to mercury, especially of vulnerable populations such as children and women of child-bearing age. The NAP also includes requirements for the development of a Public Health Strategy (PHS). Suggested strategies include, inter alia, the gathering of health data for monitoring and evaluation, and training of health care workers to raise awareness through health facilities on the health risks associated with mercury, but also to improve their diagnostic and treatment capacity.
Existing guidance documents from United Nations Environment Programme (UNEP) and World Health Organization (WHO) on the NAP and PHS provide some information about how to design a PHS. This also includes the latest report published by WHO, a helpful step-by-step guide on how to conduct an assessment and how to translate findings into a PHS. While these guidelines will hopefully help countries to gather and sift through relevant baseline health data, countries still lack guidance on how to focus on the design of mercury-related health interventions where they will do the most good, at the least cost.
The Challenge
Though there is variability among the 80-plus ASGM producer nations, many of these countries have a rather weak, chronically underfunded public health sector. For example, the government spending on health per capita in 2018 in two countries with large ASGM sectors was US$40.25 in Burkina Faso (average in low-income countries: US$35.59) and US$111.68 in Indonesia (average in upper-middle income countries: US$486.43). In comparison, the average per capita spending of high-income countries in 2018 was US$5,562.34. While this comparison does not take into account the actual health care costs in those countries, it indicates that lack of health spending in many countries with an ASGM sector causes low access to public health care services, especially in remote areas where artisanal miners tend to operate. Burkina Faso had a national average of 0.9 nurses and midwives per 1,000 inhabitants in 2017, the number was slightly higher in Indonesia with 2.4 nurses and midwives per 1,000 inhabitants in 2018 (the average of high-income countries was around 10 times higher at 10.9 in 2018).
Many countries with ASGM sectors are struggling with public health challenges such as the control of malaria or tuberculosis, and the improvement of maternal and child health. Therefore, it is challenging for governments to dedicate scarce resources to the toxic effects of mercury exposure – a problem that usually does not manifest immediately in adults and children due to the slow onset of various, diffuse symptoms of chronic mercury intoxication. However, with an estimated one-third of active ASGM workers suffering from chronic elemental mercury intoxication as well as ongoing exposure of vulnerable groups, mercury intoxication in ASGM constitutes a silent epidemic that is depleting human health within an already marginalised population. Mercury exposure in the mother’s womb or during early childhood can have severe health implications including developmental delays, which can impede the possibility of a person to improve their socioeconomic position later in life.
Therefore, a national PHS for mercury in ASGM needs to carefully develop and prioritize strategies based on the magnitude of the public health concern, the feasibility and impact of each strategy as well as the co-benefits for other health concerns.
Through AGC’s direct work in the ASGM sector and our experience in guiding countries through the NAP process, it has become clear that many governments lack basic knowledge on the ASGM sector in general and its health problems in particular, especially regarding the impact of mercury on human health and the environment. It is more difficult for these governments to be motivated to find health solutions when they don’t have basic knowledge with which to frame the challenge. Furthermore, health policy actors have difficulty transmuting baseline data into prioritized public health actions. The result of these knowledge gaps is that public health strategies tend to be overambitious and not focused enough. In addition, inconsistent attention has been given to the PHS as part of the NAP, ranging from detailed action plans in some countries to minimal in others. One reason might be weak institutional relationships between the main ministries involved in the NAP, as a strong relationship is required to include public health strategies as a cross-cutting issue.
A Way Ahead
A new cohort of approximately 20 countries will be starting to develop their NAPs in the coming years. It is therefore a superb time to develop detailed guidance and practical tools to support countries in the complex task of developing realistic and effective PHSs that both maximize the benefits for ASGM communities and the co-benefits with other public health programs. The AGC has found that the consideration and emphasis of health and non-health related co-benefits in activities has multiple advantages including much stronger uptake by beneficiaries. Such practical guidance can include a review of existing PHSs to identify the strengths and weaknesses of the approaches adopted to date, keeping in mind it may yet be too early to evaluate the implementation and impact of many of these PHSs.
Another tool could be created by conducting a systematic literature review of different approaches to capacity building and public health surveillance that have been implemented for other public health challenges (e.g., HIV/AIDS, maternal and child health, malaria, etc.). Clear and actionable lessons learned could provide invaluable information to support governments in formulating an adequate and feasible mercury-focused PHS that doesn’t ‘reinvent the wheel’. For example, ASGM countries will need to collect pertinent health data to develop and monitor effective programming, however, should these countries do this by conducting human bio-monitoring, sentinel surveillance, population-based surveys or other methods? The right approach for gathering this data depends on existing National Health Information Systems, the laboratory capacity for case confirmations and other country-specific factors. Without guidance on how to choose a data collection approach, many countries may spend valuable resources chasing information that has little policy value.
Countries also need to have awareness that there have been many efforts to conduct health training with ASGM communities and a litany of lessons have been learned. One of the most important of these is that successful interventions need to go beyond simple knowledge transfer about the danger of mercury exposure. Just broadcasting that mercury is dangerous is not good enough. Instead, they need to also include adequate strategies for risk communication and behavioral change. This requires a trusting relationship between ASGM communities and the health care sector with improved health provider-patient relationships (patient-centered care) to improve the adequacy and delivery of medical advice and the compliance of artisanal miners with it, which will eventually lead to the adaption of healthier mining practices.
Good Minamata PHSs will have to take into account available funds, existing infrastructures (e.g. health care, education, data infrastructures), and the capacities of the key stakeholders involved in the NAP. With limited funds, the development of common resources such as training modules for health workers and ASGM
communities, or adaptable and simple systems for routine health data collection are essential. Therefore, concerted efforts to pilot and evaluate capacity-building modules and reporting formats should be supported. Once tools have been piloted, use of them should be upscaled with options to adjust to different public health care systems as well as sociocultural contexts. The provision of verified tools for implementing different aspects of the PHS would be an invaluable step to support countries in fulfilling their Minamata obligation to improve health in ASGM communities.
