1.       Introduction

The exploitation, abuses, and mistreatment of men, women, and children have been considered an abysmal part of human evolution since the beginning of mankind. From the onset of creation through today, various forms of slavery, including labor and sexual, occur throughout the world. The 15^th century marked the start of recorded European slave trading in Africa, and it is estimated over 35 million people worldwide are currently enslaved in one form or another [1]. Mary de Chesnay authored chapter 5, ‘Human Trafficking: The Pandemic of Modern Slavery’ and Kathie Aduddell authored chapter 18, ‘Global Health of Children’ in the book Global Health Care: Issues and Policies, 3^rd edition by Carol Holtz, used in this course and referenced in this paper. The term ‘Human Trafficking’ (HT) has been applied since the 1980’s and is used to identify victims of this global health issue and concern. The purpose of this paper is to explore several facets of human trafficking, including the impact on the vulnerable children who are often used in either sexual or labor activities, and identify areas within human trafficking where further health care exploration is needed, using identifiable social determinants of health, epidemiological research design, and moral guidance to determine clinical practice pathways to assist in eradicating the scourge of HT.

2.       Social Determinants of Health

Social Determinants of Health (SDH) are defined as “the conditions in which people are born, grow, live, work and age…” [2]. This description gives latitude to the health care needs and disease perils encountered by the victims of human trafficking including, but not limited to, mental health concerns, drug/alcohol abuse, sexually transmitted disease(s), and recidivism. The risks for each listed SDH are enormous for a variety of reasons including the known limitations of targets of human trafficking to receive any type of health care and an even smaller chance of these victims receiving any type of follow-up care. The concern of not receiving appropriate medical care is due, in part, because of the rigid control exerted by the human traffic organizers and the often-transitory nature of the trafficking business. Victims of human trafficking are rarely identified. Often victims of human trafficking are intimidated because those who control them frequently inflict physical harm; sometimes victims of human trafficking simply know no other way of life, so they remain victims.

Recidivism remains a core concern for those in health care, law enforcement, and social work who collaborate to positively support the victims of human trafficking [3], and focused effort has gone into the development of strategies to reduce this concern. It is recognized that some victims are identified, begin treatments or therapeutic interventions, but then they return to trafficking when therapies end. This is a topic that continues to be analyzed. Mental health issues are seen in a majority of known human trafficking survivors and these issues include depression, anxiety, Post-Traumatic Stress Disorder (PTSD), substance-related disorders such as alcohol and drug abuse, and other even more serious diagnoses including Disorders of Extreme Stress [4]. A significant problem with treatment for mental health concerns are there are no fluid processes or treatment plans in place to continue therapies due to the ephemeral encounters most health care providers have with the victims of human trafficking.

Sexually Transmitted Disease (STD) concerns are omnipresent in the world of human trafficking. While working in a local hospital emergency department and treating suspected victims of human trafficking this writer has been witness, following the diagnosis of a Sexually Transmitted Disease (STD), to the degradation of the victims’ psyche as he/she realizes they may have life-threatening sequalae if the STD is not treated, and they may not get the necessary treatment due to the controlling nature of human trafficking. Survivors of human trafficking cite their inability to seek proper care, inability to have a condom worn during physical contact, and/or the sheer magnitude of the sexual assaults as reasons for the continuing onslaught of STD’s [5].

3.       Epidemiological Research Design

The history of enslavement is centuries old; the research into the mores of human trafficking has barely scratched the surface despite studies continuing to show the widening disparity between prosperity and poverty, a circumstance linked to human trafficking as women and children are typically subject to more poverty-like conditions throughout the world [6]. Due to the overall ‘new-ness’ of human trafficking in the research milieu, the epidemiological research designs are limited. An observational-type, prospective cohort study could be used as this type of study allows the researcher to observe as “In an observational study the investigators do not intervene in any way but record the health, behavior, attitudes, or lifestyles choices of the study participants” [7], a methodology appropriate for tracking this loosely known consortium. This type of study allows for any follow-up to occur as able, it is not predicted nor mandated, another invaluable commodity for this difficult-to-identify, often difficult-to-track group.

4.       Theory of Health Behavior and Health Promotion

A significant factor to consider when contemplating the correct way to assess needs, implement plans, and then evaluate the benefit of the work is understanding the impact of the socio-economic inequality which continues to allow the perpetuation of Human Trafficking (HT). Barner, et al. [6] opined, “One of the most serious contemporary effects of inequalities between and within nations is the phenomenon of global sex trade or human trafficking for the purposes of sex” (p.148). Appropriate health behavior and health promotion alliances do not come easy for the victims of human trafficking. Trust, and the ability to make decisions, are difficult for a HT victim who has been abused, sexually and mentally, and whose identity and dignity were long ago stripped away. Sponsorship of a social norms’ health theory, to rationalize behaviors and promote understanding of the perils faced by the victims of human trafficking and the ability to delve into the victims’ mind set, will allow researchers, health care clinical providers, and others the insights needed to tackle the issues. Social norms have guided and greatly influence the actions of individuals [8], and using this theory can offer a profound impact on understanding why victims of human trafficking act as they do.

The concept of changing social norms to promote clinical health prevention and population-based health care is not without peril. Learning what works and what does not work with this specific population can be difficult due to the evanescent nature of most of the victims of human trafficking. Health care providers must consider this when assessing needs and planning interventions for this population on the micro, meso, and macro-level if change is to occur [9].

5.       Social Marketing and Health Communication Strategies

Internal inconsistencies amongst most government agencies, health care authorities, and the public related to a clear understanding of who the victims of human trafficking are, and what human trafficking involves, often deprive those being trafficked the care they deserve. Social marketing is beginning to coordinate efforts to depict the vulnerable human trafficking populations as being a part of a modern-day pandemic [10]. The United Nations crafted a document in 2000, a publication known as the Palermo protocol, noted to benefit victims of HT by eliminating differences in national legal systems and standardizing domestic laws. This now decades old, globally-driven effort was conceptualized as a tool to assist in the prosecution of those who were accused of being human traffickers [11]. This effort led to the introduction of 17 global goals known as the Sustainable Development Goals created in 2015 by the United Nations General Assembly. This global initiative advocates as “a blueprint to achieve a better and more sustainable future for all” [12], including the adult and child victims of human trafficking. Relevant goals include no poverty, zero hunger, good health and well-being, helping children to read, gender equality, clean water and sanitation, and reduced inequalities, all goals that will help victims of human trafficking [12]. Lourdes University espouses the value of reverence, a belief that ‘recognizes and respects the dignity of all’ which is a principle easy to commit to. It is imperative to hold reverence near and dear as the expectations to provide expert, unbiased, professional clinical care is essential.

6.       Impact of Human Trafficking on Children

Children are not immune to human trafficking. Global estimates that over 5 million children…children who should be enjoying “a time of innocence, play, love, and security” [13] are instead entrapped, starved, and beaten if they do not perform deviant duties as assigned. These children are not immune to the same social and physical ills suffered by adult victims of human trafficking. Separation from their families, physical violence, the inability to receive appropriate medical treatment, and mental health concerns are prevalent with this population. Various factors force children “To bear an undue share of global disease” [14] and an analysis of these factors including social determinants of health, morbidity and mortality, and overall access to care concerns ensues.

7.       Social Determinants of Health

Children who are victims of human trafficking have an unfair burden of health concerns placed upon them for several reasons including an invisibility among society, poor access to health services, and limited opportunity to change their circumstances. It is essential for society to recognize these concerns and strive diligently to remediate them. Mental health concerns. Research into mental health concerns related to children suspected of being trafficked remains limited but presentations of suspected traffic victims to health care providers have shown diagnoses of Post-Traumatic Stress Disorder (PTSD), depression, and anxiety disorders [15]. Researchers are gathering data that shows these mental health issues may be caused primarily by the traumatic nature of the forced lifestyle and the inability of the brain to develop and process what should be considered ‘normal’ hormonal balance and growth [4].

Sexually Transmitted Diseases (STD). It remains imperative that health care providers remain ever-vigilant when treating children. Tattoos, illegal before the age of 18 in most countries, are often used to ‘brand’ a victim of trafficking [16]. Children presenting with pelvic/rectal pain, repetitive urinary tract infections, bruises, poor dental care and any type of STD must be considered as a possible victim of human trafficking and law enforcement must be notified. What makes this tough sometimes for health care providers is they may know the child, or the family, and they are apprehensive to report. What is never acceptable is for the health care provider to simply assume all is copacetic when these types of presentations occur.

8.       Morbidity, Mortality and Risk

Across the globe child victims of human trafficking suffer more illnesses, death and are exposed to significantly higher risks of violence than their counterparts who are not victimized [17]. Globally there has been an overall reduction by 53% in child mortality since the 1980’s [14] and while this number and positive trend forward is excellent, much work remains. Today, nearly 6 million children die annually from a multitude of disease processes including, but not limited to, low birth weight, abuse, diarrhea, trauma, HIV/AIDS, and other infections [18].

The United States revised the Trafficking Victims Protection Act (TVPA) in 2013 with the continued goal of assisting victims of human trafficking, both adults and children, but issues remain today over how best to define what/who is a victim [19]. Despite the rhetoric, it cannot be forgotten that children remain imperiled as victims of human trafficking. As noted by Aduddell [14] three areas of concern remain including: lower socioeconomic status; gender; and education, and all need to be addressed and improved. It is inherently unfair for anyone to become a ‘victim’ simply because they do not have the financial means to pay for appropriate medical care, are a child or are born female, or cannot afford to go for schooling. Inequalities such as these are unfair and the continued exploitation of these victims, due in part to a lack of basic services, is abhorrent.

9.       Summary

The challenges to implementing positive change to assist those within the human trafficking milieu are formidable but not disheartening. The tragedy known as human trafficking continues and joining forces with others who share the passion, and have the strength, to help identify, embrace, and treat the incredibly vulnerable and fragile victims of human trafficking remains and is needed. Reaching out to those who experience the pain of human trafficking victimization and partnering with them as they attempt to re-socialize is crucial. Demonstrating passion while treating these victims with appropriate therapies and working to reduce recidivism within this group is essential. Tremendous progress has occurred, but problems remain for the child and adult victim of human trafficking and more needs to be done. Identifying the issues that can lead to victimization is imperative, but also resolving the global health concerns caused by a lack of basic services remains essential. The concerted efforts to date by many who espouse reverence and compassion while working to lessen the wrong-doings against the victims of human trafficking will be the foundation as this succor journey moves forward.

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