Sociocultural Barriers Related to Late-Stage Presentation of Breast Cancer in Morocco.

Breast cancer is the most prevalent cancer affecting women globally and in Morocco, where more than one fourth of patients are diagnosed at advanced stages. This study aimed to investigate sociocultural barriers that contribute to delayed presentation and diagnosis of breast cancer among women in Marrakesh, Morocco. Qualitative interviews were conducted with 25 breast cancer patients who received care at the CHU Mohammed VI Hospital in Marrakesh to elicit barriers to diagnosis and treatment and ease of access to care. Interviews with breast cancer patients revealed several themes regarding structural and sociocultural barriers to initial diagnosis and treatment. Structural barriers included high treatment-associated costs for patients and their families, burden of transportation to central treatment centers, and limited access to appropriate health care resources. Sociocultural barriers included perceived attack on one's identity associated with breast cancer diagnosis and treatment, influence of the local community, and ideas of faith, spirituality, and conception of death. Findings from this study can help identify areas for improved access and education of patients in order to improve breast cancer diagnostic and treatment efforts and enhance opportunities for early detection.

Pulmonary function and respiratory health of rural farmers and artisanal and small scale gold miners in Ghana.

The recent increase in artisanal and small scale gold mining (ASGM) worldwide has elicited a number of public health concerns for miners and mining communities, including respiratory health. The two primary inhalational exposures of concern are crystalline silica expected to be present in gold ore and smoke from biomass fuels used in cooking. Here, measurements of pulmonary function and of respiratory symptoms were performed in an ASGM community, Kejetia, and a comparison agricultural community, Gorogo, in the Upper East Region of Ghana in May-July 2011. Of 172 participants, 159 performed spirometry, yielding 119 and 95 valid measurements for FEV1 and FVC, respectively. Percent predicted FEV1, FVC and FEV1/FVC, which were lower than predicted for a healthy population, were not significantly different between Kejetia and Gorogo or by mining status in Kejetia. Abnormal lung function was elevated for predicted FEV1 (15.0%) and FEV1/FVC (22.0%) beyond an expected five percent in healthy populations. This first examination of pulmonary function in an ASGM community in Ghana (and possibly worldwide) did not show an obvious relationship between mining involvement and lung function abnormality, but did show associations between the use of biomass fuels, adverse respiratory symptoms, and reduced pulmonary function in both populations. A number of factors including age differences between the populations and the required lag time after silica exposure for the onset of respiratory disease may have affected results. Additional research is needed with larger sample sizes and with more detailed questionnaires to further assess the impact of multiple stressors on respiratory health in ASGM communities.

Understanding the Social Context of the ASGM Sector in Ghana: A Qualitative Description of the Demographic, Health, and Nutritional Characteristics of a Small-Scale Gold Mining Community in Ghana.

This descriptive paper describes factors related to demographics and health in an artisanal and small-scale gold mining (ASGM) community in Ghana's Upper East Region. Participants (n = 114) were surveyed in 2010 and 2011, adapting questions from the established national Demographic Health Survey (DHS) on factors such as population characteristics, infrastructure, amenities, education, employment, maternal and child health, and diet. In the study community, some indicators of household wealth (e.g., radios, mobile phones, refrigerators) are more common than elsewhere in Ghana, yet basic infrastructure (e.g., cement flooring, sanitation systems) and access to safe water supplies are lacking. Risk factors for poor respiratory health, such as cooking with biomass fuel smoke and smoking tobacco, are common. Certain metrics of maternal and child health are comparable to other areas of Ghana (e.g., frequency of antenatal care), whereas others (e.g., antenatal care from a skilled provider) show deficiencies. Residents surveyed do not appear to lack key micronutrients, but report lower fruit and vegetable consumption than other rural areas. The results enable a better understanding of community demographics, health, and nutrition, and underscore the need for better demographic and health surveillance and data collection across ASGM communities to inform effective policies and programs for improving miner and community health.

Mercury Exposure Assessment and Spatial Distribution in A Ghanaian Small-Scale Gold Mining Community.

Mercury is utilized worldwide in artisanal and small-scale gold mining (ASGM) and may pose a risk for miners and mining communities. While a number of studies have characterized mercury in ASGM communities, most have focused on a single media and few have taken a holistic approach. Here, a multiple media exposure assessment and cross-sectional study of mercury was conducted in 2010 through 2012 in northeast Ghana with a small-scale gold mining community, Kejetia, a subsistence farming community, Gorogo, and an urban ASGM gold refinery in Bolgatanga. The objective was to assess mercury in a range of human (urine and hair) and ecological (household soil, sediment, fish, and ore) samples to increase understanding of mercury exposure pathways. All participants were interviewed on demographics, occupational and medical histories, and household characteristics. Participants included 90 women of childbearing age and 97 adults from Kejetia and 75 adults from Gorogo. Median total specific gravity-adjusted urinary, hair, and household soil mercury were significantly higher in Kejetia miners (5.18 µg/L, 0.967 µg/g, and 3.77 µg/g, respectively) than Kejetia non-miners (1.18 µg/L, 0.419 µg/g, and 2.00 µg/g, respectively) and Gorogo participants (0.154 µg/L, 0.181 µg/g, and 0.039 µg/g) in 2011. Sediment, fish, and ore Hg concentrations were below guideline values. Median soil mercury from the Bolgatanga refinery was very high (54.6 µg/g). Estimated mean mercury ingestion for Kejetia adults from soil and dust exceeded the U.S. Environmental Protection Agency reference dose (0.3 µg Hg/kg·day) for pica (0.409 µg Hg/kg·day) and geophagy (20.5 µg Hg/kg·day) scenarios. Most participants with elevated urinary and household soil mercury were miners, but some non-miners approached and exceeded guideline values, suggesting a health risk for non-mining residents living within these communities.

An Integrated Assessment Approach to Address Artisanal and Small-Scale Gold Mining in Ghana.

Artisanal and small-scale gold mining (ASGM) is growing in many regions of the world including Ghana. The problems in these communities are complex and multi-faceted. To help increase understanding of such problems, and to enable consensus-building and effective translation of scientific findings to stakeholders, help inform policies, and ultimately improve decision making, we utilized an Integrated Assessment approach to study artisanal and small-scale gold mining activities in Ghana. Though Integrated Assessments have been used in the fields of environmental science and sustainable development, their use in addressing specific matter in public health, and in particular, environmental and occupational health is quite limited despite their many benefits. The aim of the current paper was to describe specific activities undertaken and how they were organized, and the outputs and outcomes of our activity. In brief, three disciplinary workgroups (Natural Sciences, Human Health, Social Sciences and Economics) were formed, with 26 researchers from a range of Ghanaian institutions plus international experts. The workgroups conducted activities in order to address the following question: What are the causes, consequences and correctives of small-scale gold mining in Ghana? More specifically: What alternatives are available in resource-limited settings in Ghana that allow for gold-mining to occur in a manner that maintains ecological health and human health without hindering near- and long-term economic prosperity? Several response options were identified and evaluated, and are currently being disseminated to various stakeholders within Ghana and internationally.

An Investigation of Organic and Inorganic Mercury Exposure and Blood Pressure in a Small-Scale Gold Mining Community in Ghana.

There is increasing concern about the cardiovascular effects of mercury (Hg) exposure, and that organic methylmercury and inorganic Hg(2+) may affect the cardiovascular system and blood pressure differentially. In small-scale gold mining communities where inorganic, elemental Hg exposures are high, little is known about the effects of Hg on blood pressure. In 2011, we assessed the relationship between Hg exposure and blood pressure (BP) in a cross-sectional study of adults from a small-scale gold mining community, Kejetia, and subsistence farming community, Gorogo, in Ghana's Upper East Region. Participants' resting heart rate and BP were measured, and hair and urine samples were provided to serve as biomarkers of organic and inorganic Hg exposure, respectively. Participants included 70 miners and 26 non-miners from Kejetia and 75 non-miners from Gorogo. Total specific gravity-adjusted urinary and hair Hg was higher among Kejetia miners than Kejetia non-miners and Gorogo participants (median urinary Hg: 5.17, 1.18, and 0.154 µg/L, respectively; hair Hg: 0.945, 0.419, and 0.181 µg/g, respectively). Hypertension was prevalent in 17.7% of Kejetia and 21.3% of Gorogo participants. Urinary and hair Hg were not significantly associated with systolic or diastolic BP for Kejetia or Gorogo participants while adjusting for sex, age, and smoking status. Although our results follow trends seen in other studies, the associations were not of statistical significance. Given the unique study population and high exposures to inorganic Hg, the work contained here will help increase our understanding of the cardiovascular effects of Hg.

Integrated Assessment of Artisanal and Small-Scale Gold Mining in Ghana - Part 3: Social Sciences and Economics.

This article is one of three synthesis reports resulting from an integrated assessment (IA) of artisanal and small-scale gold mining (ASGM) in Ghana. Given the complexities that involve multiple drivers and diverse disciplines influencing ASGM, an IA framework was used to analyze economic, social, health, and environmental data and to co-develop evidence-based responses in collaboration with pertinent stakeholders. We look at both micro- and macro-economic processes surrounding ASGM, including causes, challenges, and consequences. At the micro-level, social and economic evidence suggests that the principal reasons whereby most people engage in ASGM involve "push" factors aimed at meeting livelihood goals. ASGM provides an important source of income for both proximate and distant communities, representing a means of survival for impoverished farmers as well as an engine for small business growth. However, miners and their families often end up in a "poverty trap" of low productivity and indebtedness, which reduce even further their economic options. At a macro level, Ghana's ASGM activities contribute significantly to the national economy even though they are sometimes operating illegally and at a disadvantage compared to large-scale industrial mining companies. Nevertheless, complex issues of land tenure, social stability, mining regulation and taxation, and environmental degradation undermine the viability and sustainability of ASGM as a livelihood strategy. Although more research is needed to understand these complex relationships, we point to key findings and insights from social science and economics research that can guide policies and actions aimed to address the unique challenges of ASGM in Ghana and elsewhere.

Multiple metals exposure in a small-scale artisanal gold mining community.

Urinary metals were characterized in 57 male residents of a small-scale gold mining community in Ghana. Chromium and arsenic exceeded health guideline values for 52% and 34%, respectively, of all participants. About 10-40% of the participants had urinary levels of aluminum, copper, manganese, nickel, selenium, and zinc that fell outside the U.S. reference range. Exposures appear ubiquitous across the community as none of the elements were associated with occupation, age, and diet.

Occupational and environmental mercury exposure among small-scale gold miners in the Talensi-Nabdam District of Ghana's Upper East region.

Mercury use in small-scale gold mining is ubiquitous across Ghana but little is known about the extent to which such activities have contaminated community residents and miners. Here, occupational exposures to elemental mercury (via urine sampling) and dietary exposures to methylmercury (via hair sampling) were assessed among 120 participants recruited from a mining community located in the Talensi-Nabdam District of Ghana's Upper East region during summer 2009. More than one-fifth of the participants had moderately high levels of urinary mercury (>10µg/L) and 5% had urine mercury levels that exceeded the WHO guideline value of 50µg/L. When participants were stratified according to occupation, those active in the mining industry had the highest mercury levels. Specifically, individuals that burned amalgam had urine mercury levels (median: 43.8µg/L; mean ± SD: 171.1±296.5µg/L; n=5) significantly higher than median values measured in mechanical operators (11.6µg/L, n=4), concession managers/owners (5.6µg/L, n=11), excavators that blast and chisel ore (4.9µg/L, n=33), individuals that sift and grind crushed ore (2.2µg/L, n=47), support workers (0.5µg/L, n=14), and those with no role in the mining sector (2.5µg/L, n=6). There was a significant positive Spearman correlation between fish consumption and hair mercury levels (r=0.30) but not with urine mercury (r=0.18) though further studies are needed to document which types of fish are consumed as well as portion sizes. Given that 200,000 people in Ghana are involved in the small-scale gold mining industry and that the numbers are expected to grow in Ghana and many other regions of the world, elucidating mercury exposure pathways in such communities is important to help shape policies and behaviors that may minimize health risks.

Sustainable control of water-related infectious diseases: a review and proposal for interdisciplinary health-based systems research.

OBJECTIVE: Even when initially successful, many interventions aimed at reducing the toll of water-related infectious disease have not been sustainable over longer periods of time. Here we review historical practices in water-related infectious disease research and propose an interdisciplinary public health oriented systems approach to research and intervention design. DATA SOURCES: On the basis of the literature and the authors' experiences, we summarize contributions from key disciplines and identify common problems and trends. Practices in developing countries, where the disease burden is the most severe, are emphasized. DATA EXTRACTION: We define waterborne and water-associated vectorborne diseases and identify disciplinary themes and conceptual needs by drawing from ecologic, anthropologic, engineering, political/economic, and public health fields. A case study examines one of the classes of water-related infectious disease. DATA SYNTHESIS: The limited success in designing sustainable interventions is attributable to factors that include the complexity and interactions among the social, ecologic, engineering, political/economic, and public health domains; incomplete data; a lack of relevant indicators; and most important, an inadequate understanding of the proximal and distal factors that cause water-related infectious disease. Fundamental change is needed for research on water-related infectious diseases, and we advocate a systems approach framework using an ongoing evidence-based health outcomes focus with an extended time horizon. The examples and case study in the review show many opportunities for interdisciplinary collaborations, data fusion techniques, and other advances. CONCLUSIONS: The proposed framework will facilitate research by addressing the complexity and divergent scales of problems and by engaging scientists in the disciplines needed to tackle these difficult problems. Such research can enhance the prevention and control of water-related infectious diseases in a manner that is sustainable and focused on public health outcomes.

Perspectives on polio and immunization in Northern Nigeria.

Through the efforts of the global campaign to eradicate poliomyelitis, polio cases have declined worldwide, from 35,251 cases in 1988, to 1449 cases as of 28 October 2005. However, confirmed cases of wild polio virus continue to be reported from Northern Nigeria. This paper examines the reasons for the difficulties in eradicating polio in Northern Nigeria from the perspective of residents of one town, Zaria, in northern Kaduna State. Research methods included participant observation, open-ended interviews and the collection of polio-related documents. While some people believed that the vaccine was contaminated by anti-fertility substances, others questioned the focus on polio when measles and malaria were considered more harmful. Some also distrusted claims about the safety of Western biomedicine. These concerns relate to questions about the appropriateness of vertical health interventions, where levels of routine immunization are low. While the Polio Eradication Initiative was considered to be cost-effective by Western donors, from the perspective of some people in Zaria it was seen as undermining primary health care, suggesting that a collaborative, community-based framework for primary health care, which includes routine immunization, would be a more acceptable approach.