The children are the most painful to see.
Bright, energetic Zaskia preens and laughs for the camera, balancing on her good leg to accommodate a clubfoot, seemingly unaware at age 3 that her fingers, too, are deformed.
Tiny Nyimas is 8 years old but has the shrunken body of a very emaciated toddler; hydrocephalus has left her hopelessly brain damaged.
Seven-year-old Fikri has a malformed skull, muscle weakness and is profoundly developmentally delayed; his mother abandoned him shortly after his birth.
Iqubal's mother cradles him in her arms. Two years old, Iqubal is as helpless as a newborn infant with stiff muscles and clenched fists. Dita, 10, lies on a mat all day, her muscles permanently constricted and her limbs twisted.
And there are many more such children with birth defects, seizures and debilitating ailments.
In villages throughout the islands of Indonesia where gold is mined and processed, there are hot spots of what the locals call "uncommon diseases." Babies are born with twisted and shortened limbs, cleft palate and missing fingers and toes, microcephalus (abnormally small heads) and hydrocephalus (excess accumulation of cerebrospinal fluid). Some children, who seem normal at birth, have seizures when they are a few months old, develop high fevers, and over time, lose the ability to walk and talk. For others, the onset of symptoms is later.
Adults, too, are affected, though often their ailments are less obvious to the untrained eye. Some shake uncontrollably. Others move very slowly. The most severely afflicted lie dying on mats.
Investigators suspect that these so-called "uncommon diseases" have a common denominator: mercury poisoning.
"Our findings in the three hot spots revealed the significant severe impact of mercury use in gold processing in small-scale gold mining sites," said Yuyun Ismawati, senior advisor to BaliFokus Foundation, a nonprofit Indonesian NGO that researches environmental pollution and works to educate miners about the dangers of mercury.
Ismawati, who also is a coordinator of the Indonesian Toxics Free Network, notes that medical tests are needed to confirm mercury intoxication in the suspected cases. But she says that high levels of mercury found in air, water, soil and food samples, as well as the constellation of classic symptoms, suggest that "children are most likely suffering from mercury pollution in the village, that was used and is currently still being used by their parents, neighbors and other adults." Says Ismawati, "We suspected that the babies and children in these hot spots were exposed to mercury since they were in the womb."
The United Nations Environmental Programme has identified small-scale gold mining as "the single largest source of mercury emissions from intentional use" in the world, estimating that gold processing releases approximately 1,400 metric tons of mercury into the environment each year.
Small-scale or artisanal gold miners use mercury, which binds to gold, to separate the precious metal from ore at various steps in processing. Miners pan for gold with mercury, often spilling the silver element directly into the rivers and streams where they fish, bathe and draw their drinking water. The contaminated water irrigates rice plants, and they, in turn, absorb mercury.
Mercury is added to pulverized gold ore tumbled in ball mills, which constantly spew clouds of mercury-laded dust. Most dangerous of all, miners burn the mercury-gold amalgam over open fires (often with acetylene torches) in their homes and backyards. As the mercury burns away to leave pure gold, highly toxic vapors fill the air.
BaliFokus and the Medicuss Foundation, a group of Indonesian physicians who volunteer field time, documented numerous sites on the Indonesian islands of Sulawesi, Lombok and Cisitu where levels of mercury in air, soil, water, and rice are exceedingly high during extensive testing in February and March of 2015.
At gold processing sites where mercury is burned, BaliFokus found ambient air mercury concentrations greater than 51,000 nanograms per cubic meter, the highest level their meters could measure, or more than 50 times the safe level established by the World Health Organization. Soil and water samples also had high concentrations of mercury, ranging from 600 to 3,000 times the acceptable limits established by the WHO. Rice tested on Cisitu had mercury contamination that ranged 0.81 ppb to 241.90 ppb.
The Indonesian Ministry of Energy and Mineral Resources developed a National Action Plan in 2014 to eliminate mercury in small-scale gold mining. Ismawati said that a provision issued in October 2014 specifically prohibits the importation, trade and use of mercury in small scale-gold mining. However, she said, the regulation has not been widely distributed and in many instances is not enforced. Additionally, as BaliFokus found, because the law does not prohibit the exportation of mercury and waste containing mercury, some enterprising miners are deriving mercury from waste for resale and at even lower prices than imported mercury.
The Indonesian Ministry of Health did not respond to requests from the Pulitzer Center for comment about the BaliFokus reports. A representative of the Indonesian office of the World Health Organization declined to comment on the BaliFokus Report, referring questions to the Indonesian Ministry of Health.
Ismawati said that BaliFokus is working closely with health ministries in West Lombok and Bombana Regency, while the ministry in Lebak Regency has not responded to the report. BaliFokus and the Health Agency of West Lombok hosted a medical screening clinic together in June 2015 where, Ismawati said, they found that approximately 10 percent of the 270 residents showed severe symptoms of mercury intoxication. The West Lombok Health Agency attributes the top 10 diseases in Sekotong and Pelangan areas to mercury exposure, according to a BaliFokus report released in June.
In Bombana, authorities have visited children identified by BaliFokus and taken additional environmental samples, Ismawati said.
Local authorities did not respond to emailed questions for this article.
Mercury use in small-scale gold mining is a global problem in developing nations and is particularly widespread in Southeast Asia and the Philippines. In the Philippines, BAN Toxics, a non-governmental environmental organization, has been promoting the use of borax, a common laundry booster, to replace mercury in gold processing. As in Indonesia, accurate diagnosis of mercury intoxication is difficult. BAN Toxics also is working with the Philippine Department of Health to train workers to identify mercury-poisoning cases and provide care and medical referrals for victims.
"In all of the cases we've seen in the Philippines, health care workers and medical practitioners in the rural areas are not familiar with mercury poisoning. Misdiagnosis [results in] the patient not getting the needed care," said Richard Gutierrez, executive director of BAN Toxics.
Ending exposure to mercury, both Gutierrez and Ismawati stress, is the most important first step.
"It's counterproductive to provide treatment to patients when the affected individuals are simply re-exposed when they return home to their communities," said Gutierrez. "In this regard, there has to be more effort by government and stakeholders in eliminating mercury use in [gold mining] communities."
Mercury is a neurotoxin that accumulates in the body and causes damage to the brain and central nervous system, the kidneys and the cardiovascular system in adults and children. Developing fetuses are particularly vulnerable; for them, damage to the brain and nervous system, as well as the digestive, immune and reproductive systems can be catastrophic. Mercury poisoning also interferes with bone development and is associated with hydrocephalus and microcephalus. Studies reported by the U.S National Institutes of Health have documented hydrocephalus in mice exposed to high doses of mercury, as well as a single case of a 50-year-old man with chronic mercury exposure who developed hydrocephalus.
Poisoning from elemental mercury, which occurs when people inhale mercury particles or vapors, can cause tremors, neuro-muscular changes, kidney and respiratory damage and failure and ultimately death.
One of the most insidious aspects of methylmercury poisoning, that results from ingesting organic mercury compounds in fish and other food, is that the symptoms develop over time with repeated exposure and may not become apparent for several years, health experts say.
One of the most extensive examples of methylmercury poisoning occurred in Minamata, Japan, where authorities estimate that more than 50,000 people were affected between 1932 and 1968 by factory waste discharged into Minamata Bay, which contaminated fish and shellfish, a major food source. More than 2,000 cases of Minamata Disease ultimately were certified, according to the WHO.
Adults may work with mercury for years before exhibiting the signs of mercury intoxication. Pere, a former village chief who worked in mining most of his life, recently died. In February 2015, when BaliFokus examined him, the man in his 60s shook uncontrollably and was not able to pick up and place matches in their wooden box or touch his nose while his eyes were closed—simple tasks that doctors use to assess the extent of damage from mercury intoxication.
Without sophisticated medical tests, it is often difficult to ascertain that afflictions and birth defects were caused by mercury exposure in utero. Chromosomal conditions, such as Patau Syndrome (Trisomy 13) and Edwards Syndrome (Trisomy 18) also were present with many of the birth defects that BaliFokus found in the children its investigators examined.
Furthermore, unless the afflicted children and adults are still being exposed to mercury when tested, their hair, blood and urine samples likely will show only trace amounts of mercury.
During the February and March testing, BaliFokus and the Medicuss Foundation identified and assessed 28 children living in or near known small-scale gold mining hotspots in Bombana, Sekotong and Cisitu. Most of the children suffered from multiple problems, including neurological deficits, congenital bone deformities, seizures, vision loss, deafness and paralysis. Since the testing was completed, two of the children have died, Ismawati said.
Only five of the suspected mercury intoxication victims were currently living in areas where air quality tests indicated high levels of mercury—though the families of all 28 children had at one time worked or lived in gold-mining areas. The levels of mercury at the homes with current exposure were at least twice the acceptable limit and three cases were high enough to merit immediate evacuation. At the home of a 10-year-old boy with a cleft palate, the ambient air mercury level was 49,632 ng/m3—or 49 times the acceptable limit established by the World Health Organization.
The case for mercury poisoning for the other children is largely circumstantial.
Rini is 15 years old but looks much younger. Rini's mother said that she, like many of the other afflicted children, seemed normal as an infant but began suffering seizures when she was 2 months old. When she was 2 years old, she developed a high fever and shortly after that stopped walking, her parents told BaliFokus. Her family took her to a witch doctor who told them that she was sick because her uncle worked in the gold mines. Today, Rini's limbs are twisted and her muscles constricted. Her mother, who worked as a cook in a mining town while she was pregnant with Rini, carries her from room to room.
Seven-year-old Fikri's mother worked in the ball mills while she was pregnant with him; his father was a miner. BaliFokus found that the boy is developmentally delayed and suffers from muscle weakness and hypersalivation, among other problems.
Rifki, 2, has an abnormally shaped head and appears to be mentally and neurologically impaired. His mother lived in the gold processing center of Cisungsang, surrounded by ball mills, while she was pregnant. She told BaliFokus that he started experiencing seizures and high fevers when he was about a month old.
Dita, featured in a Pulitzer Center article in July 2015, was, according to her parents, a normal little girl who began having seizures when she was about 3 years old. Her symptoms worsened dramatically when she was 7. Now 10 years old, Dita is largely paralyzed and essentially mute. Although Dita is not currently exposed to mercury—ambient air readings showed little mercury—her parents were actively involved in gold processing about the time she became ill, her mother told BaliFokus.
Despite the number of cases of "uncommon diseases," some gold workers ignore the danger.
In Selogong, a 35-year-old woman lies on the floor of her hut, unable to get up. Her family says she has been sick for four months; they suspect a liver ailment. The ambient air mercury level inside the hut is 18,700 ng/m3—more than 18 times WHO's safe limit.
Outside the hut where the sick woman lies, a backyard ball mill runs day and night. Saleh, 28, tends the ball mill. She says she has worked twice a week for two years processing gold and no longer gets headaches, though the smoke from nearby mercury burning stings her eyes.
"I know it's dangerous, but it became my job, so I can't avoid it," Saleh says as her three children run and play nearby.
The children are the most painful to see.