<p>Artisanal and small-scale mining (ASM) has emerged as a vital economic lifeline for millions across Africa, Asia, and Latin America, driven by increasing gold prices, global demand, unemployment, and poverty. This sector accounts for approximately 28.9% of Ghana’s GDP and provides a livelihood for nearly 70% of Ghanaians, predominantly those residing in rural areas. However, this sector faces numerous environmental and health challenges, including uncontrolled mine waste disposal, contaminating water and soil with heavy metals. This review critically examines the environmental consequences of ASM waste management, focusing on informal underground tailings disposal. Using a dual-method strategy that combines systematic review and literature analysis, the study synthesizes 110 Scopus-indexed publications (2004–2024) to examine how ASM activities affect the safety, health, and ecosystems of Ghanaian ASM communities. Key findings reveal critical gaps in long-term waste management strategies, inadequate attention to health risks, and a lack of holistic socio-environmental assessments of ASM operations. The study underscores the urgent need for evidence-based interventions, including stricter regulatory enforcement, community-centered remediation, and sustainable livelihood alternatives. By addressing these gaps in Ghana, similar ASM-dependent economies can transform this sector into a force for equitable development without sacrificing environmental integrity or public health. Future research should prioritize cost-effective remediation technologies and policy frameworks that are tailored to the realities of informal mining communities.</p>