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BY: COLLEEN SCANLON, JD, RN, and LAURA KRAUSA, MNM

Human trafficking is modern-day slavery — an insidious, criminal industry that generates billions of dollars in labor trafficking alone. It knows no boundary of continent, country, race or class; it is a shattering, impartial predator that robs individuals of their basic human dignity.

 

Across the globe, human trafficking impacts an estimated 20.9 million people —individuals, families, communities and the greater society.¹ Its effects are devastating, with deep and lasting consequences for both immediate and long-term health. Health care providers, including Englewood, Colo.-based Catholic Health Initiatives (CHI), are uniquely positioned to identify and respond to victims, because it is almost inevitable that they will need physical or mental health care at some point. In recent research published in the Annals of Health Law, it is estimated that up to 87 percent of sex trafficking victims reported being seen by a health care provider during their trafficking.²

With the Vatican and women religious around the world sounding the call for a multisector response, CHI and other Catholic health care providers awakened to this human-rights issue that deeply violates the dignity of the human person. The call warranted action from the health provider community, and we began our organizational journey to answer it.

More than five years ago, a group of leaders at CHI began a dialogue that was an expansion of the health system's commitment to violence prevention — a dialogue specifically focused on human trafficking. The initial response was a bit hesitant, recognizing that there was limited internal knowledge of the issue and a lack of understanding about the scope of the global problem afflicting millions of people, including the many "invisible" victims within our own communities.

CHI's journey began simply, but it has grown and ultimately has developed into a multifaceted, organizational approach to mitigation, prevention and response. Components of the approach include education and awareness, public policy activism, socially responsible investing, contracting, community-based initiatives and partner collaboration. These efforts were created to assist local ministries and the greater provider community in addressing the devastating realities of persons who are trafficked.

EDUCATION AND AWARENESS
From the beginning, CHI recognized that it must ground its efforts in reliable and comprehensive information. Thorough self-education was the crucial first step, initially obtained by culling available resources, searching websites and literature and talking with experts. We were able to develop internal web pages with links and resources and an initial overview document we disseminated organizationwide and shared externally. We saw this phase of education as the foundation for raising awareness and a cornerstone for more advanced learning.

In the next phase of education, we developed an 11-minute video, Human Trafficking: Understanding a Complex Issue. The video and internet resources introduced the subject by providing basic definitions, facts, figures and information to expand understanding of the issue, its risk factors and health consequences. We deliberately gave the educational program a broad focus, as we intended to attract a large audience that included nonclinicians as well as individuals and organizations within the communities we served. We felt it was not enough to educate internally, because trafficking is too pervasive and clandestine for us to assume that isolated education for health care providers would be sufficient to ensure victims would receive the services they need.

For the learning audience, the content was difficult to absorb. Colleagues expressed shock, disbelief and sorrow that human trafficking really was occurring, and they wondered what could be done and how they could help. Initially, people approached the resource as interested colleagues, but they came away as family members, friends and neighbors, deeply affected by the information. Exposing trafficking's stark realities was an essential first step in heightening interest and awareness. The video has become a foundation for the collaborative and comprehensive work necessary to ensure victims' needs are fully met.

After the initial phases of education, we followed with clinician-specific education that addressed what they needed to know to be effective in victim identification and response. The web-based educational course for clinicians, Addressing Human Trafficking in the Health Care Setting, is a 25-minute learning resource designed to provide clinicians with comprehensive guidance in identifying and responding to victims. Developed in conjunction with two experts from the Massachusetts General Hospital Human Trafficking Initiative — Roy Ahn, MPH, ScD, and Wendy Macias-
Konstantopoulos, MD, MPH — the course has been distributed nationwide and even internationally.

Speaking about the importance of addressing human trafficking as health providers, Macias-Konstantopoulos said, "An egregious human rights violation, human trafficking has undeniably profound repercussions on the health and well-being of individuals, communities and society at large. The exact magnitude of the impact has yet to be determined, but we know from experience that it takes comprehensive, integrated care efforts to effectively address the complex physical, behavioral and social service needs of trafficked persons. In addition to education and training of providers, health care must strive to develop evidence-based prevention and intervention strategies, harness available institutional and community resources, advocate for additional ones when appropriate and partner across agencies and organizations to actuate an effective interdisciplinary and multisector response to trafficked persons."

RESOURCES FOR CLINICIANS
The course, which is based on a publication from the Massachusetts initiative — Human Trafficking: Guidebook on Identification, Assessment, and Response in the Health Care Setting — is an abbreviated yet comprehensive version of the guidebook.³ It is short enough for a busy provider to read, but it offers sufficient information for those who want to delve deeper into the issue. CHI also developed accompanying resources, including a brochure and a downloadable quick reference guide that practitioners can access from a mobile device, which ensure that the modules' details can be quickly reached in a clinical setting.

The course objectives cover the principles of trauma-informed care; red-flag indicators for identifying potential victims; factors affecting screening; considerations for the physical exam; and post-visit patient needs. Detailed information within each objective allows the learner to expand skills and knowledge around effective screening approaches, potential barriers to disclosure and considerations for clinical documentation. In addressing post-visit patient needs, the course covers the importance of risk assessment and safety planning, engaging internal and external stakeholder-collaborators, and legal issues around mandatory reporting and immigration relief options.

Survey responses from the course evaluation confirm what was true when CHI began its initial education — the issue still is shocking and difficult for many people to fully understand. Respondents reported repeatedly that they were unaware of the frequency with which this happens in their communities; of the hidden nature of the crime and the victim; and of the delicate, sensitive approach necessary in identifying and responding to victims.

One respondent said, "I had not thought of human trafficking as a health care issue, but this has opened my eyes, and I will be more aware of this possibility."

Another respondent noted, "This is a misunderstood and unacknowledged health concern in the population. Human trafficking commonly happens in our country, despite what many believe."

PUBLIC POLICY
CHI understands that laws and regulations can have substantial impact — both positive and negative — for victims and service providers alike. Work at the federal, state and local levels has been ongoing to promote the development of policies that appropriately address human trafficking. Legislative and regulatory advocacy at the federal level serves to affect national and international prevention strategies, and our local markets in 18 states engage in advocacy to influence policy that affects state and regional issues.

The difference in federal, state and local public policy responses is a reflection of the particular governmental entity's capacity to address the issue. It is simultaneously a reflection of the distinct experience of human trafficking in various states and communities, thus requiring unique policy solutions. Public policy efforts need to ensure humane protection of persons who are trafficked, funding for victims' long-term services, development of appropriate prosecutorial processes and robust prevention programs.

COMMUNITY-BASED EFFORTS
Understanding that this crime exists differently in various communities requires community-based responses that go beyond public policy. As a result, CHI invests through an internal grant program in local, community-based initiatives to address human trafficking.

An example of such a grant-funded initiative began with one of our founding congregations in Kentucky. Through local efforts that ultimately generated a much larger response, a countywide coalition developed with a comprehensive set of stakeholders who were able to address the unique issues around human trafficking in Kentucky — the Human Trafficking Task Force of Nelson County. The coalition's efforts were instrumental in the 2013 passage of one of the first truly comprehensive pieces of legislation addressing human trafficking. In addition to imposing greater penalties and providing for multisector training in identification and response, the bill also provided safe harbor for victims.

The importance of the collaborative effort cannot be overstated. Marissa Castellanos, executive director of Catholic Charities of Louisville's KY Rescue & Restore program and a member of Human Trafficking Task Force of Nelson County, explains, "When we raise community awareness and begin talking about human trafficking and the trauma dynamics experienced by victims, we experience a paradigm shift among professionals and the larger community where victims are seen and heard. Professionals collaborate in new ways to ensure victims have access to services as well as to the justice system. The community dynamics are so vital for victims to engage in as they work to rebuild their lives as survivors."

Mary Boyce, who was chair of the human trafficking task force in Kentucky at the time the legislation was passed, believes the diversity of the coalition and access to funding was essential to the success of its outreach efforts and the passing of legislation that would protect victims.

Boyce said, "Because those serving on the task force are from diverse community organizations, they have brought important expertise and influence to this horrific issue, thus making outreach even more powerful. [We] always will be grateful for the CHI grants that gave us the ability to maximize our efforts."

INVESTING AND CONTRACTING
CHI seeks opportunities to influence corporations through socially responsible investing and contracting practices. We want contracts with external vendors to include language firmly asserting that due diligence will be undertaken to ensure, to the best of the company's ability, that they are not unintentionally complicit with any practice involving human trafficking.

A CHI partner, Kendis Paris, executive director of Englewood-Colorado-based Truckers Against Trafficking, believes, "When companies are willing to amend their contractual language in order to combat human trafficking, it signals their entrance into the abolitionist movement and encourages their suppliers and fellow industry members to follow suit."

With regard to the investment portfolio, CHI works with companies to encourage the development of prevention strategies within their supply chain, as well as workforce education and effective monitoring practices. Though the harsh reality of human trafficking has risen in public consciousness, it can still be a slightly distant issue for many companies. We prefer to employ strategies that foster dialogue and increase awareness, understanding that such interventions have greater potential to impact long-term outcomes.

PARTNERSHIPS
Perhaps one of the most significant things we have realized in addressing human trafficking is that the work requires partnerships and collaboration. There is no room for efforts that exist in silos, or for expertise that is inaccessible.

CHI has a very significant collaboration with the Massachusetts General Hospital Human Trafficking Initiative, an affiliation instrumental in helping the organization create the educational resources so widely available. We are also a member of the National Academies of Sciences Health and Medicine Division (formerly known as the Institute of Medicine) Forum on Global Violence Prevention and have had the opportunity to work on the issue of global human trafficking.

CHI joined with Covenant Health System and the Catholic Health Association in 2013 to launch a coalition of stakeholders within the Catholic health care community — Faithfully United Against Human Trafficking: Awareness, Advocacy, Action. The group was formed to raise awareness among CHA members of the problem of human trafficking, with particular attention to clinicians in primary and emergency care and other offices that might impact the issue, such as events/meetings and investment offices.

Julie Trocchio, CHA's senior director of community benefit and continuing care, and staff lead for the human trafficking coalition, said of the initiative, "Coming together as a coalition and by forming a network, we were able to accomplish together much more than any one organization could do alone. Because of our collaboration, Catholic health care organizations shared their stories and were able to build on the experience and success of others. We were also able to help shape how the ministry thought about this issue and, I believe, moved our organizations to action. I can't think of a more important role for a national association."

Throughout the years, more health systems have become actively engaged in initiatives against human trafficking and are making important contributions. Moreover, organizations across the nation — including governmental agencies, nonprofits, academic and faith-based institutions — provide significant opportunity for learning, sharing and collaboration.

Today, more and more health care providers are recognizing the enormity of the problem, the critical need to address it and, perhaps most importantly, the unique and vital role health care providers play in prevention, mitigation and response. We believe the health care community is and will continue to be an important leader in the battle against human trafficking, because the wounds of this crime will always require our attention and care.

COLLEEN SCANLON is senior vice president and chief advocacy officer, and LAURA KRAUSA is director, advocacy, both at Catholic Health Initiatives, Englewood, Colorado.

NOTES

1. International Labour Office, ILO Global Estimate of Forced Labour: Results and Methodology (Geneva: International Labour Organization, 2012) 13. www.ilo.org/wcmsp5/groups/public/---ed_norm/---declaration/documents/publication/wcms_182004.pdf.
2. Laura J. Lederer and Christopher A. Wetzel, "The Health Consequences of Sex Trafficking and Their Implications for Identifying Victims in Healthcare Facilities," Annals of Health Law 23, no. 1 (Winter, 2014): 61-89. www.globalcenturion.org/wp-content/uploads/2014/08/The-Health-Consequences-of-Sex-Trafficking.pdf.
3. Elaine J. Alpert et al., Human Trafficking: Guidebook on Identification, Assessment, and Response in the Health Care Setting (Boston: Massachusetts General Hospital and Massachusetts Medical Society, 2014). www.massmed.org/Patient-Care/Health-Topics/Violence-Prevention-and-Intervention/Human-Trafficking-(pdf)/.