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JAAPA Podcast
Human Trafficking
00:28:51
In this episode, PA Angela Meredith speaks with Clay, Kim, and Martine about how clinicians, particularly PAs, can be prepared to handle the issue of human trafficking. Learn valuable information you can use to help patients who may be at risk,...
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- [00:00]
A
Foreign.
- [00:07]
B
Welcome back to the Joppa Podcast, where today we have an excellent guest and author to discuss an appropriately timed topic. With January being National Slavery and Human Trafficking Prevention Month, in this episode we'll dive in with PA author Dr. Angela Meredith on her newly published article identifying victims of labor and where we aim to explore the complex world of human trafficking, specifically focusing on labor trafficking. Now, when I think about this topic in clinical medicine and my own practice, some initial definitions that I always find helpful when discussing would be human trafficking, labor trafficking and sex trafficking, and noting that they are interrelated concepts, but they do indeed have distinct definitions and focus areas. So when we look at these three things here. First, human trafficking is an overarching term that refers to the act of recruitment, transporting, transferring, harboring or receiving individuals through force, fraud, coercion or deception for the purpose of exploitation. When we look in contrast to labor trafficking, this specifically refers to the exploitation of individuals for labor or services through force fraud or coercion. And then when we look at sex trafficking, this is going to be a form of human trafficking that specifically involves the exploitation of individuals for commercial sex acts through forced fraud or coercion. Without further ado, Angela, thank you so much for taking the time to come onto the podcast with us today. Would you take a moment to introduce yourself and what inspired you to focus your research on labor trafficking?
- [01:44]
A
Ah, yes. Thank you for having me here today, Clay. Thank you again. I'm Dr. Angela Meredith and I've been a PA for 18 years, with most of my career spent in outpatient primary care and internal medicine. So what inspired me to focus on labor trafficking was the gut wrenching realization that I likely had a patient who was a victim, but I failed to recognize it. When I was fresh out of PA school, I had no real working knowledge about human trafficking. It wasn't until several years later when I went back to grad school to get a master's in security studies, that I really learned what human trafficking was. It was an eye opening education and prompted me to reflect back on a particular patient I had early in my career. And so in reassessing that patient through the lens of that education, I recognized that my patient and that patient encounter had exhibited several key signs of being trafficked, signs that in the moment I had just chalked up to a language barrier and gender and cultural differences. Later, when I was getting my doctorate, I wanted to focus on the intersection of human trafficking and health care and specifically that of recognizing victims of adult labor trafficking in the healthcare setting.
- [03:15]
B
Excellent, Angela. That is you know, certainly a very intriguing story and a, you know, a fantastic way that you've been able to seek interest in this topic but also be able to share it with the masses of PAs and healthcare clinicians as well there, which is certainly a very important topic. And one of the big things that I would say, Angela, when I was reading your article and going through this, is that in the literature, in your article you published, you shared the rate of labor trafficking is increasing. And we wanted to share firstly some of these statistics with the audience that were in your article. First, the United Nations Office on Drug and Crime indicates the ratio of labor trafficked victims accounting for almost 40% of all detected trafficking cases. Second, between 2014 and 2019, the Polaris project reported that a national hotline experienced a 100% gain in the number of calls related to labor trafficking, which represented 36% of all cases by the year 2019. These are pretty alarming numbers. Angela, can you describe and dive in more into the types of labor trafficking specifically?
- [04:22]
A
Oh, certainly. There have been some scholars that have made the argument and it makes sense to me that we are seeing this kind of increase more because it represents that people are becoming aware of what this is and are reporting it more so than it's just reflecting a true increase in prevalence, if that makes sense. Just because typically sex trafficking has been the big focus of human trafficking and people, including law enforcement, have been focused on sex trafficking. So as we've become more aware of labor trafficking, people are able to identify it, report tips. And so we're seeing an increase in the reporting and they're arguing that it could be reflective of just an increase of awareness, which I'm very happy to hear. But here it's the state. The labor trafficking is so insidious, and it's this insidiousness that allows it to be embedded across a wide swath of legitimate businesses and industries. So victims, they're found everywhere, from landscaping and housekeeping, busboys, cooks, nail technicians, workers in agriculture and on construction sites, daycare centers, textile and garment manufacturing, huddling and begging, and even forced criminal activities such as moving drugs. But it's through this veil of legitimacy that enables traffickers to operate all around us with few people really aware of what is going on.
- [05:52]
C
Angela, thinking about the numbers that Clay just mentioned in your personal experience, it makes me start to wonder as a healthcare provider, what I should be looking for. 87% of survivors interacted with a healthcare provider at one point in their captivity. The most common healthcare settings they go to include emergency departments, primary care providers, gynecologists and child advocacy and teen clinics. What signs or red flags should we be looking out for?
- [06:16]
A
Thank you for asking Kim, because these victims are not just going to come out and tell you I am being trafficked. So there are some things that could raise suspicion for us and they include like right when you get into the exam room, is your patient sharing a scripted or inconsistent history? This history can seem out of context to the injury or disease that you are there to assess. Is your patient unwilling or reluctant to answer your questions when you ask for further details? And this is a big one, Is your patient accompanied by someone who does all of the talking for them or refuses to let them have any privacy? Is your patient displaying fearful behavior or avoiding eye contact? And do you see evidence of a controlling relationship, like excessive concern about pleasing a family member or romantic partner or employer? You know? And then as you start to examine your patient, there are also physical indicators you may come across. These include signs of physical abuse or other unexplained injuries like burns, bruising, cuts or wounds, broken teeth. Patients will also often present with evidence of untreated or poorly treated comorbidities like uncontrolled hypertension or diabetes, poor detention, malnutrition. And you may also see signs and symptoms of prolonged exposure to extreme temperatures like heat exhaustion and dehydration, or effects of prolonged exposure to industrial or agricultural chemicals like organophosphate poisoning or repetitive yeast injuries. Additionally, and this can be a very sensitive subject for your patient. But given the extent of sexual exploitation, assault and violence involved in all forms of human trafficking, many of the health problems experienced by victims will involve reproductive issues and these include sexually transmitted diseases, unintended pregnancy, complications from unsafe termination of pregnancy, chronic pelvic pain and traumatic genitourinary injuries. Now all of this information and more can be found at the National Human Trafficking Resource center. So on their website and their website is humantraffickinghotline.org, they have a printable one page decision flowchart called the Framework for a Human Trafficking Protocol in Healthcare Settings. This flowchart outlines the red flags to look for and next steps to take. It also lists the national hotline number you can call should you suspect your patient is being trafficked. And I would encourage everyone to visit that website and print off that page to have on hand in your office. And again, the website is humantraffickinghotline.org thank.
- [09:21]
D
You Angela for all these great information. I have to say myself, I was not familiar with human trafficking at all until 2019 when I went to a national medical leadership conference with my form A company and one of our hospital system, the ER providers had experienced that and they were able actually to track down a whole group of people in their state. Thanks their quick response. They had one of the victims coming through the ER and thankfully the staff, I think it was the ED physician and a nurse practitioner. They were informed enough to be able to identify it and they took care of it and they decided to present it as a case study and to more inform us. And then I think Florida now it's a requirement to do that as a cn. It's a CME requirement for license renewal.
- [10:18]
A
So wonderful.
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D
So you write in your article about an issue also that now that I find that I was not familiar with, I never heard that term even though I've done some of the CME on human trafficking CME education sessions and you talk about animal husbandry. So for our listeners, could you define what that means and the problems that it can create?
- [10:43]
A
Certainly. So I think we're all familiar with agriculture as being the growing, maintaining and harvesting of crops. Animal husbandry involves the growing, maintaining and harvesting, if you will, of animals either as a food source or for their byproducts. So animals such as cows, pigs, chickens, goats, sheep and so on, they're cultivated for their meat, milk, eggs, wool, those kinds of things. And it's a large scale business. And the day to day care of these animals is often strenuous and conducted in harsh environmental conditions. So trafficked victims are likely to be forced to work prolonged hours in these conditions with few if any breaks or adequate access to shade or hydration.
- [11:37]
C
This is all very eye opening. Given that labor trafficking often occurs in plain sight and yet remains under recognized. What are the biggest challenges healthcare providers face in identifying victims and how can these challenges be addressed effectively?
- [11:51]
A
Kim, you have put your finger right on the crux of the problem. We can't see what we haven't been taught to recognize. Additionally, most victims themselves fail to recognize their situation for what it is, or they are reluctant to self identify because they fear violent repercussions or deportation. So it's incumbent upon us as clinicians to educate ourselves about both the issue and the signs and symptoms to look for during the patient encounter. And the challenges to doing this are significant, and I think they include foremost a lack of robust research that guides our understanding for how to effectively recognize these victims. We still do not have one single validated tool that can be used across all clinical settings to effectively identify these victims and Additionally, PACME educational requirements vary from state to state, and it's often not ever included in PA school. So meeting these challenges is going to require continued research so we can develop effective screening tools as well as implementing educational requirements.
- [13:08]
D
With that said, so I have some more questions. Therefore, what do you think are the most common misconceptions about labor trafficking? From the top of my head, I'm thinking, especially when they do not want help, some people who are not well informed might think these people are crazy. How can they accept their situations? Or how did they fall into that trap? That would never be me. Sometimes we might think that way. So can you enlighten us more about some of the common misconceptions?
- [13:39]
A
Yes, good question, Martine. I think one of those most common misconception is that human trafficking and labor trafficking specifically is not happening where you live and where you practice. The United States serves as both a source and a destination for traffic victims, and victims have been found in every state. Another common misconception is that most victims are undocumented immigrants. Now, most labor traffic victims are immigrants, but they're not undocumented. In fact, a study by the National Institute of justice found that 71% of those experiencing forced labor entered the United states on lawful H2A and H2B visas. But yeah, it's easy for us to look back and say, well, I would never find myself in that situation. But we see patients from across the socioeconomic spectrum and traffickers prey on the vulnerable in our society.
- [14:35]
B
That is excellent information for us to be aware of there, Angela, and you mentioned there in the last question about the undocumented immigrants being affected. But how does labor trafficking affect other different demographics, whether that be children, ethnicity, women, men, et cetera? Is there any different aspect or how each of those individual categories may be affected?
- [14:57]
A
They're affected mainly in the way the traffickers will exert force, fraud, or coercion in order to maintain their control. You know, again, traffickers, they prey on the vulnerable and the disadvantaged in our society. And so it includes those people with few resources at their disposal, you know, including women, children, immigrants, disabled, those with substance abuse issues. You know, so the tactics, again, that traffickers will use, they are geared toward the specific vulnerabilities of that person. For instance, traffickers will confiscate the identification and documentation of an immigrant and then threaten that victim with police arrest or deportation if they refuse to work. Another example, for someone with an addiction, the trafficker will control the supply of the substance to ensure compliance. And rape and sexual violence are Very often used against women.
- [15:55]
C
I think you're making a very successful argument that we all play a pivotal role in identifying and assisting these victims. Can you elaborate on some emerging strategies or interventions that have been successful in healthcare settings?
- [16:07]
A
Unfortunately, research on successful strategies for pre rescue identification, right now it's still really limited. Human trafficking is an underground criminal enterprise and it's just incredibly difficult to conduct robust research on this population. So most of our information has been collected through interviewing victims after they have been rescued. And it's been through these conversations that we have become aware of the frequency of their visits to healthcare providers during their captivity. These interviews also help inform us of what they encountered and during the healthcare visit, from intake to patient encounter to checkout. And all of this has helped us learn what may have helped to facilitate their identification and rescue. So we have some idea of certain questions we could ask or clues to look for. And those are the emerging things. And like I said, the HumanTraffickingHotline.org, that decision tool, that's a good place to start. That's one of several organizations that have. I think it's a wonderful job of compiling this information for us to use, but we still don't have a single validated tool that could be used across all healthcare settings. This population is just so difficult to conduct research with. But research is ongoing and I have faith that one day this will change.
- [17:34]
D
That's wonderful, Angela. And I have faith as well. I believe we are on the right path. So you just mentioned one resource, the HumanTrafficking.org, i believe so. What other resources are available both to help individuals and healthcare providers, including PAs, our listeners and communities, to combat labor trafficking? Because health care providers are in the front line and frequently come into contact with the victims, like you said of human trafficking. And sometimes that's the only time they are. They get out of their environment and we might be their only contact outside of their if you want their traffickers. So let's say we encounter this problem and also for the individuals, what resources can we provide to the victims and also that we can use to help these people.
- [18:22]
A
Great, Martina, thank you for asking. Yes. So for everyone, for the general community and clinicians alike, there are two really great resources I would recommend. One, my go to starting place online is the Polaris Project. This is an easy place to start. It provides a lot of good general information of what human trafficking is, both labor and sex trafficking. They also offer online training called Human Trafficking 101 and their website again is polarisproject.org and the second one, and I've mentioned it before, humantraffickinghotline.org, this is also the home base for the 24 hour National Human Trafficking Hotline. And this hotline is available 24 hours a day, every day of the year in more than 200 languages. Their website also hosts an online national human trafficking referral directory. And this is where you could just put in your zip code and it will give you local resources that are available for you. Now, specifically for clinicians, there are two online resources I like that are geared just for us. One is the American Hospital Association. They've developed tools or resources to assist health care system in the fight against human trafficking and they created ICD10 code categories for both confirmed and suspected victims in trafficking and you could find them. And the other one is called SOAR to Health and Wellness Program. Now SOAR stands for Stop, Observe, Ask and Respond. This program is jointly provided by the Postgraduate Institute for Medicine and the Department of Health and Human Services. And it awards AMA Category 1 CME credits. So if you want to access this training, just go to train.org and put soar to health and wellness in the search bar. Those four resources, I think are excellent places for everyone to start and then the other two for clinicians in particular.
- [20:37]
B
I think all of us here on today's podcast, as well as those that are listening with us today, probably have some form or sort of social media nowadays, whether this be Facebook, LinkedIn for our professional users, or even if you stretch out further to things like Instagram, TikTok, Snapchat, all of those things. And I can imagine if we again extrapolate that out even further to the general population, think about how many thousands of users on the social media platforms that there may be. Now, Angela, in your research, have you seen technology being used either as a tool for perpetrators or as a means for prevention and intervention in the field of labor trafficking?
- [21:17]
A
Great question, Clay. Yes to both. Traffickers have become experts at exploiting the Internet and social media as a means of recruiting potential victims. One of the more common tactics used is false advertisement. Traffickers will advertise online or through a social media platform for a work position that appears legitimate, be it housekeeping, agricultural work. But then once that person has been lured in, they will use force, fraud or coercion to keep them enslaved. Now, on the flip side, I've seen where the Internet and social media can also be used for intervention. So we gain understanding, awareness and training through various online sites. You know, and again with the National Human Trafficking Hotline. That's where people can report online tips or send emails, things like that. So it's, it's. I've seen it be used for both.
- [22:14]
C
Angela, you've described how we all need to become aware and learn about this problem. Like Martine, my own state of Virginia has recently acquired a CME requirement. But I think that there's probably more that our states and our national governments can be doing. Because besides requiring cme, what current policies are in existence now and what changes or improvements would you like to see?
- [22:36]
A
Well, Kim, ever since the Federal Victims of Trafficking and Violence Protection act was passed in 2000, there has been an overwhelming focus on human trafficking. However, this focus by both the public and by scholars has tended to be on sex trafficking as opposed to forced labor. I'm seeing this start to change as both law enforcement and industries become more aware of of labor trafficking. But we still have a long way to go in policies for even just becoming aware of the scope of all human trafficking now where it comes specifically for health care providers. I would love to see every state require comprehensive training and education on human trafficking. I would also like to see this education become embedded in PA education throughout the US but right now, each state has their own set of laws regarding reporting and educational requirements for clinicians. And for any of the providers out there who are unsure of what their state requires, they could find out@jonesday.org so Jones Day is a global law firm that gleaned the relevant statutes across the states and they compiled them into a single PDF. This information set is an at your fingertips kind of tool to help inform providers of their state laws regarding reporting and educational requirements. So I would encourage everyone to visit this website and see what your state requires. And that's JonesDay.org that's great, Angela.
- [24:14]
D
We still have a long way to go, but we're still lacking a lot of resources to deal with this problem. It can be overwhelming and difficult to deal with. But I believe that we are making progress. So, looking forward, what developments or initiatives give you hope for better identification, support and prevention of labor trafficking? And what role can the general public play in supporting these efforts?
- [24:39]
A
What gives me hope with this problem is the interest of people like you who want to learn more, both about the problem and what they might be able to do to help. As long as more people become interested and want to learn more, then we will get more development and initiatives. But it takes an increased awareness and an interest in doing their research to actually developments into place. If more people become Aware and attuned to recognizing potential victims. I think it would make our environment more hostile to traffickers because victims would be harder to hide. As long as we remain unaware, we don't know what to look for and can't possibly help facilitate a rescue.
- [25:22]
B
Angela, thank you so much for the information in totality today here thus far. And you know, one of the things that I feel like I run into personally in my practice and probably attends to a lot of PAs that are in primary care and even other specialties too as well, is how overwhelming perhaps each individual visit may become. You know, we look at our schedules and we see that someone supposed to be on my schedule in primary care for knee pain. But then you get into the visit and it ends up being three or four different things and ends up bleeding into a much more convoluted or complex type of visit. So taking into account of, you know, never knowing what you're going to run into in each individual encounter. And as a primary care provider, I like to picture and envision myself or our field and specialty as someone who can be a gatekeeper to the patient's overall health, that I can be someone that a patient can come to, the first person that they can come to in the medical field with X, Y or z concern and open up about that there. And with all of that taken into account, what message would you like to give to the listeners who might feel overwhelmed by the magnitude of labor trafficking as a problem, but may want to make a positive impact even in a time constraint type environment or practice?
- [26:48]
A
Just start with the Google search. Just start reading and let your questions and your curiosity guide your research. No one expects you to be able to recognize and rescue every potential victim who comes into your exam room. But just by raising your awareness and knowing what steps to take should you think you encounter someone that you suspect being trafficked, you have the potential to change the course of someone's life. No one's expecting you to catch every one of these. And yes, you put your finger on what I think is a huge problem and that is the lack of time that we have in primary care. It's the a lot of pressure on us to see a lot of patients come through every day. And we only have time to see one main chief complaint with maybe time to squeeze in one other one. So how can we tend to the representing problem? Oh, and maybe I have this too. And then keep this also at the back of your head. It's okay. No one's expecting you to be able to recognize this each and every time, and to rescue someone each and every time. So just by being aware, just by having this perhaps running in the background of your mind, that way, if you see a clue and it happens to trigger, oh, maybe I need to look more at this. That's all we're asking for. And that is enough to serve as a potential rescue for these victims. So just doing that is a huge start.
- [28:14]
C
What amazing closing words. Angela, thank you so much for the discussion around this important topic. You have taught us much about labor trafficking. We, and we hope our listeners will take this information forward with us as we care for our patients and communities. As always, please be sure that you're following us on JAPA and social media at Jaapa Online. That's all spelled out. And please let us know your thoughts about the topics that we went over today. Until next time.