Traf­fick­ing School

Hos­pi­tals train staff to spot vic­tims of hu­man traf­fick­ing

Modern Healthcare - - NEWS - By Mau­reen McKin­ney

Dr. Aisha Mays, a fam­ily physi­cian at the Na­tive Amer­i­can Health Cen­ter in Oak­land, Calif., uses a one-ques­tion sur­vey— “Have you ever traded sex for money?”—to try to iden­tify vic­tims of com­mer­cial sex­ual ex­ploita­tion. She re­calls a day last year when a ner­vous 16-year-old girl en­tered her clinic ac­com­pa­nied by a much older man whom she called her boyfriend. The girl com­plained of symp­toms Mays thought likely in­di­cated a sex­u­ally trans­mit­ted dis­ease. Af­ter the man re­luc­tantly left the exam room, Mays di­ag­nosed the girl with gon­or­rhea, treated her with a shot of cef­tri­ax­one and gave her a firm or­der: No sex for a week.

“When I said that, she looked at me like she’d seen a ghost,” Mays re­called. “She asked me if I was se­ri­ous, and when I said yes, she asked me to write the or­der down on a pre­scrip­tion pad. When she left, I saw her show the note to her boyfriend.”

A few weeks later, the girl re­turned to the clinic alone. Mays asked her di­rectly if some­one was mak­ing her trade sex for money. “She said yes, and we were able to con­nect her with ser­vices that day,” Mays said. Although hu­man traf­fick­ing is of­ten thought of as an is­sue faced by other coun­tries, it’s a grow­ing prob­lem in the U.S., af­fect­ing nearly ev­ery re­gion, ex­perts say. Hun­dreds of thou­sands of U.S. cit­i­zens, le­gal res­i­dents and for­eign­ers brought to the U.S. are at risk of be­ing traf­ficked for com­mer­cial sex­ual ex­ploita­tion or forced la­bor each year, ac­cord­ing to the Po­laris Pro­ject, a Wash­ing­ton­based anti-traf­fick­ing group.

Ex­perts who have stud­ied hu­man traf­fick­ing say a vic­tim’s most promis­ing life­line could be a healthcare provider—if that provider knows what to look for. That’s why a num­ber of hos­pi­tals and health sys­tems around the coun­try have launched train­ing pro­grams for their staff on how to iden­tify and treat traf­fick­ing vic­tims. Some states, in­clud­ing Florida and Michigan, now re­quire healthcare work­ers to re­ceive some type of hu­man traf­fick­ing train­ing as part of their reg­u­lar li­cens­ing process. Michigan’s law passed in Jan­uary as part of a pack­age of traf­fick­ing-re­lated leg­is­la­tion.

In 2014, Wi­chita, Kan.-based Via Christi Health launched a train­ing pro­gram aimed at teach­ing its physi­cians, nurses and other staff how to spot the tell­tale signs of traf­fick­ing, in­clud­ing pa­tients who ap­pear younger than their stated age and pa­tients who re­port hav­ing an un­usu­ally high num­ber of sex­ual part­ners. The pro­gram was de­vel­oped with the help of Dr. Jeff Bar­rows, di­rec­tor of U.S. train­ing at the anti-traf­fick­ing group Hope for Jus­tice, based in Nashville.

The first train­ing ses­sion drew 125 clin­i­cians, and sub­se­quent ses­sions have at­tracted sev­eral hun­dred each, said Skip Hid­lay, Via Christi’s se­nior ad­min­is­tra­tor of com­mu­ni­ca­tions. Hos­pi­tal of­fi­cials credit the pro­gram with help­ing clin­i­cians iden­tify and as­sist seven traf­fick­ing vic­tims since the train­ing be­gan.

Mas­sachusetts Gen­eral Hos­pi­tal launched its traf­fick­ing ini­tia­tive in 2008. Since then, Dr. Wendy Ma­cias-Kon­stan­topou­los, med­i­cal di­rec­tor

Ex­perts who have stud­ied hu­man traf­fick­ing say a vic­tim’s most promis­ing life­line could be a healthcare provider—if that provider knows what to look for.

of the hu­man traf­fick­ing ini­tia­tive at the hos­pi­tal, said she and her team have fo­cused on healthcare worker train­ing. They have pre­sented we­bi­nars and pro­vided other re­sources, and have led more than 80 traf­fick­ing-fo­cused grand rounds across the coun­try and abroad.

Physi­cians and nurses who at­tend such train­ing ses­sions of­ten re­al­ize to their cha­grin that pa­tients they’ve treated in the past may have been vic­tims, said Dr. Holly Atkin­son, di­rec­tor of the hu­man rights pro­gram at the Ic­ahn School of Medicine at Mount Si­nai Hos­pi­tal in New York. “I’ve led grand rounds where physi­cians have come up to me af­ter­wards and told me about pa­tients they saw mul­ti­ple times whom they la­beled as ‘dif­fi­cult,’ ” Atkin­son said. “Af­ter the train­ing, it oc­curred to them these pa­tients might have been traf­ficked.”

Nearly 88% of traf­fick­ing sur­vivors re­ported hav­ing some kind of con­tact with the healthcare sys­tem while they were traf­ficked, ac­cord­ing to a 2014 study in the An­nals of Health Law. “No other sec­tor plays a more crit­i­cal role,” Bar­rows said. The bad news is most healthcare providers know lit­tle to noth­ing about traf­fick­ing and re­ceive no train­ing on how to iden­tify and help vic­tims. “The vast ma­jor­ity are ab­so­lutely clue­less,” Bar­rows said. “Only a hand­ful are look­ing at it se­ri­ously.”

Ma­cias-Kon­stan­topou­los ac­knowl­edged that few hos­pi­tals have com­pre­hen­sive train­ing and vic­tim-as­sis­tance pro­to­cols in place. But she said aware­ness and ac­tion among healthcare providers is steadily grow­ing. “I’ve been do­ing this work since 2006, and when I started, it was very quiet,” she said. “Over the years, I’ve seen a big in­crease in in­ter­est on the topic. Hos­pi­tals and healthcare providers are start­ing to en­gage more than ever be­fore.”

Oth­ers in the field agree that there’s been an uptick in in­ter­est from healthcare providers. Natalie Gar­nett, as­sis­tant na­tional di­rec­tor of UnBound, a faith-based anti-traf­fick­ing group with an of­fice in Waco, Texas, said lo­cal hos- pitals are ap­proach­ing her group to host train­ing ses­sions, in­clud­ing one in May at­tended by staff from Bay­lor Scott & White Hill­crest Med­i­cal Cen­ter.

“Our ERs and clin­ics are see­ing these vic­tims,” Gar­nett said. “If our med­i­cal pro­fes­sion­als are trained, they might be the ones who can help.” Last year, the Na­tional Hu­man Traf­fick­ing Re­source Cen­ter re­ceived re­ports of 5,042 po­ten­tial traf­fick­ing cases in the U.S., nearly one-third of them in­volv­ing vic­tims un­der age 18. Among mi­nors, most cases in­volved sex­ual ex­ploita­tion while 9% in­volved la­bor.

In the U.S., for ex­am­ple, 16 ju­ve­niles were res­cued in a two-week FBI crack­down on sex traf­fick­ing in the New YorkNew Jersey area lead­ing up to the 2014 Su­per Bowl game. The mi­nors were ages 13 to 17 and in­cluded high school stu­dents and chil­dren re­ported miss­ing by

The bad news is most healthcare providers know lit­tle to noth­ing about traf­fick­ing and re­ceive no train­ing on how to iden­tify and help vic­tims.

their fam­i­lies. In 2010, a fed­eral grand jury in­dicted la­bor con­trac­tors on charges that they forced about 400 Thai guest work­ers to toil on farms in Hawaii and Washington state to pay off debts in Thai­land. Glob­ally, hu­man traf­fick­ing is es­ti­mated to be a $32 bil­lion in­dus­try with 2.5 mil­lion vic­tims, ac­cord­ing to United Na­tions data.

The red flags are there if healthcare staffers know how to spot them, ex­perts say. Traf­fick­ing vic­tims may not know what city they are in. They may have a fear­ful, sub­mis­sive de­meanor or have tat­toos bear­ing some­one’s name. A vic­tim may be ac­com­pa­nied by a con­trol­ling com­pan­ion who in­sists on an­swer­ing providers’ ques­tions. There may be signs of phys­i­cal abuse and trauma. And for la­bor-traf­fick­ing vic­tims, red flags can also in­clude hear­ing, vi­sion, car­dio­vas­cu­lar or res­pi­ra­tory prob­lems from work­ing in un­safe con­di­tions.

Provider train­ing typ­i­cally fo­cuses not only on red flags, but also on strate­gies for in­ter­ven­tion, such as in­ter­view­ing tech­niques and tips for work­ing col­lab­o­ra­tively with law en­force­ment and other lo­cal agen­cies. Hope for Jus­tice’s Bar­rows said hos­pi­tals and clin­ics should proac­tively reach out to law en­force­ment and other groups so they have solid re­la­tion­ships in place when they iden­tify a vic­tim. Ex­perts say chil­dren’s hos­pi­tals are, in many cases, ahead of the curve when it comes to ed­u­cat­ing their staff about traf­fick­ing. At Chil­dren’s Healthcare of At­lanta, for in­stance, all new clin­i­cal staff un­dergo train­ing, and cur­rent staff are en­cour­aged to par­tic­i­pate. The hos­pi­tal also has a six-mod­ule we­bi­nar se­ries on hu­man traf­fick­ing.

De­mand for those we­bi­nars “sky­rock­eted” in the last half of 2014, said Angie Boyd, pro­gram man­ager at the hos­pi­tal’s Stephanie Blank Cen­ter for Healthy Chil­dren. “We used to see de­mand from healthcare pro­fes­sion­als in Ge­or­gia but now we have much more of a na­tional au­di­ence,” she said.

Ma­cias-Kon­stan­topou­los serves on a tech­ni­cal work­ing group for an HHS pi­lot pro­ject that trains healthcare work­ers to iden­tify traf­fick­ing vic­tims. Through the pro­gram, known as the SOAR—Stop, Ob­serve, Ask and Re­spond—to Health and Well­ness Pi­lot, HHS hosted train­ing ses­sions in six cities last Septem­ber. At­ten­dees were re­quired to take a sur­vey be­fore the train­ing, another im­me­di­ately af­ter­ward, and a third fol­low-up sur­vey three months later to see how well they re­tained the in­for­ma­tion.

HHS is an­a­lyz­ing data from the SOAR pi­lot and may scale the pro­gram up if the re­sults are promis­ing, she said.

In March, Ma­cias-Kon­stan­topou­los spoke at a day­long traf­fick­ing train­ing ses­sion in Berke­ley, Calif., at­tended by more than 100 healthcare providers. “We had a few physi­cians who trav­eled all the way from Texas,” she said.

Even with high-qual­ity train­ing, providers still have to look at all of the signs to­gether and trust their in­stincts. “There’s an ar­ray of red flags, and no sin­gle one is spe­cific and in­dica­tive of traf­fick­ing,” Ma­cias-Kon­stan­topou­los said. “We al­ways say you need to put your think­ing caps on and put the pieces of the puz­zle to­gether.”

It would also help to have a val­i­dated and easy-to-use screen­ing tool, es­pe­cially in a busy emer­gency depart­ment, said Dr. Alan Janssen, di­rec­tor of the emer­gency medicine res­i­dency at Ge­nesys Re­gional Med­i­cal Cen­ter, in Clio, Mich. He and his staff are start­ing to use a six-ques­tion tool de­vel­oped by Dr. Jor­dan Greenbaum at Chil­dren’s Healthcare of At­lanta.

It con­sists of quick and straight­for­ward ques­tions, such as “Have you ever run away from home?” and “Have you had more than five sex­ual part­ners?” Those ques­tions suc­cess­fully de­tected 92% of traf­fick­ing vic­tims in a study, Greenbaum said. The re­sults are en­cour­ag­ing, but the sam­ple size was small and re­sults were from only one site. “We’re now try­ing to pi­lot and val­i­date the tool in EDs and clin­ics across the coun­try,” she said.

Michigan State Sen. Re­bekah War­ren, who spon­sored her state’s leg­is­la­tion re­quir­ing healthcare work­ers to re­ceive train­ing, said she was drawn to the is­sue af­ter speak­ing with one of her con­stituents, a foster mother of three sons who were traf­ficked from the African coun­try of Togo to the U.S. as forced la­bor­ers. A den­tist who treated the three boys rec­og­nized that their pa­per­work did not match their ages and med­i­cal his­to­ries. He no­ti­fied author­i­ties and the boys were res­cued from their traf­ficker and placed in the woman’s care. “For me, it shined a light on the fact that healthcare pro­fes­sion­als can re­ally help if they know the signs,” War­ren said.

Some say there’s a need for na­tional ac­tion to in­crease healthcare work­ers’ aware­ness of the prob­lem. In April, U.S. Sen. Gary Peters (D-Mich.) an­nounced he was co-spon­sor­ing the Traf­fick­ing Aware­ness Train­ing for Health Care Act of 2015. The bill would pro­vide fed­eral fund­ing for a med­i­cal or nurs­ing school to de­velop a healthcare pro­fes­sion­als train­ing pro­gram. That grantee would then se­lect 10 sites to pi­lot the train­ing pro­gram.

The best ap­proach re­mains to be seen, said Ma­cias-Kon­stan­topou­los, who cau­tioned that gov­ern­ment-man­dated train­ing could spark re­sis­tance among healthcare providers. But greater aware­ness can save vic­tims’ lives. “As easily as they come through our doors, they walk right back out again,” she said. “We have a win­dow of op­por­tu­nity that so far we haven’t been able to take ad­van­tage of. That needs to change.”

Even with high-qual­ity train­ing, providers still have to look at all of the signs to­gether and trust their in­stincts.


Fa­cil­i­ta­tors for UnBound lead healthcare worker train­ing ses­sions.


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