National Academy of Medicine

Human Trafficking is a Public Health Problem: Here’s Why

An Interview with NAM Fellow Dr. Hanni Stoklosa

The National Academy of Medicine’s 2015-2017 American Board of Emergency Medicine fellow is Dr. Hanni Stoklosa. She is an emergency medicine physician at Brigham and Women’s Hospital and an expert on human trafficking. Dr. Stoklosa co-founded HEAL Trafficking in 2013, an independent, interdisciplinary network of health professionals working to combat human trafficking. She has advised the U.S. Department of Labor, the U.S. Department of Health and Human Services, and has testified before the U.S. Congress on issues related to human trafficking.

Human trafficking is a modern form of slavery in which people are forced into sex or labor by threats of violence, fraud, coercion, or other forms of exploitation (U.S. Department of Homeland Security). The International Labor Organization estimates that human trafficking rakes in $150 billion a year and that there are 20.9 million trafficking victims worldwide.

In the following interview, Dr. Stoklosa frames human trafficking as a public health issue and explains why she is motivated every day to end the practice for good.

How did you become interested in human trafficking?

I have been interested in issues concerning violence against women for a very long time. In fact, earlier in my career, I did research on HIV, AIDs, and women in rural China who were victims of domestic violence. So, I had been working on issues related to domestic violence for a while. Then, while training to become an emergency medicine physician, I heard a presentation about human trafficking and learned that it was happening in the United States. My initial reaction was, “Wait a second. I’m an emergency medicine physician, trained at a highly prestigious medical program, but no one has told me that trafficked victims are a population I should be identifying.”

I was aghast and shocked. I started educating myself about what we know about the intersections of health care and human trafficking in the United States. At that time, we thought that about 25% of trafficking survivors in the United States interfaced with health care during their time of being trafficked. Now, the latest studies are actually showing that up to 88% of trafficking survivors interface with health care. Yes, nearly 9 out of 10! I’m an advocate and an activist at my core, so when I see a huge need, my natural response is to step into that gap and try to figure out how I can use my talents and my energy to be a solution to the problem.

I found great people that were working individually on human trafficking and I thought we would be stronger if we combined our efforts. We recognized that there was no need to reinvent the wheel—but that we could learn from each other. That’s how we ended up creating HEAL Trafficking. We now have almost 800 interdisciplinary professionals working on the public health response to human trafficking. We also have committees working on: research; education and training protocol development; advocacy; and direct services. We believe we are moving the needle.

We’ve been able to push forward some key legislation on health and trafficking. Over 11 health professional societies have policy statements on health and trafficking now. Our education and training group has been involved in informing federal efforts on what a human trafficking training program for health professionals should look like.  It’s been really exciting to see what can happen when you bring people together and provide a synergistic connection point.

 

 

 

 

 

 

 

Do you find that Congress is responsive to this issue?

Very much so. This is modern-day slavery—it’s hard to get more compelling than that.

Funding is always an issue. There’s been a lot of funding directed toward the criminal justice side of trafficking. In the short term, it’s exhilarating to do rescues or raids or prosecution but it’s harder to invest in long-term health, healing and restoration because it’s expensive. The issue as a whole has a lot of bipartisan support, though—there’s been a lot of momentum.

 

 

 

How are health care providers, and emergency medicine physicians in particular, uniquely positioned to help victims of human trafficking?

When it comes to the role of health care systems and providers, there have been so many missed opportunities for so long. Health care providers, in particular, are positioned to be able to intervene. Most service providers that someone might interact with while being trafficked are people they may be less likely to trust. This includes people who work in the criminal justice system, child welfare system, and other systems that may be less inviting for someone who is in a really hard place and may feel a lot of shame about their predicament. Health care providers have a unique opportunity to provide that space of trust and safety.

As an emergency medicine physician, I may only see a patient once. The limited data that we have on human trafficking shows that, preferentially, trafficking survivors go to urgent care or emergency departments. Emergency departments have been prepared for incidents of domestic violence, gang violence, and child abuse for years. This includes social work resources and referral systems. So the bedrock of a similar system that we need to have in place for human trafficking is already in a lot of emergency departments because they have had to think about parallel issues.

When people are going through a medical crisis, they may be more willing to share other concerns and problems because they’ve hit that moment where everything is reaching a critical stage. For trafficking survivors, they may be at a point where they want to get out of that situation of exploitation—and that’s one reason emergency departments have a unique opportunity to intervene.

Are physicians given any specialized training in human trafficking?

It depends on where you go to medical school and do your residency. Some organizations have developed curricula related to human trafficking but the methods and content of education on human trafficking varies widely (Powell et. al., 2016). I would love for human trafficking to be incorporated into training for all medical and health professionals alongside other forms of interpersonal violence, like domestic violence and child abuse. Right now it’s really at the whim of individual programs and schools. Some states have adopted mandatory education programs on trafficking for health care providers. Massachusetts, Michigan, and New Jersey are some examples. In order for health care providers to maintain their medical license in some of these states, they have to show that they have training on human trafficking.

 

 

How has the opioid crisis impacted human trafficking?

Dramatically! In our emergency department, about half the trafficking survivors we identify were born in the United States and have an addiction to an opioid—usually heroin. When you think about it, addiction is a trap a trafficker can use to keep someone locked in a situation of exploitation. Someone being trafficked may already be addicted to drugs, or they may become addicted during the trafficking process as a way of numbing some of the pain. Their trafficker simply continues to provide them with drugs. Once you are addicted to heroin, you’d rather be dead than go through the feeling of withdrawal. That’s the way addicts describe it to me. You want that painful, awful feeling to go away. So you use again. It’s a vicious cycle.

I’ve been thinking a lot, along with many of my colleagues, about how do we create systems that are uniquely tailored for trafficking survivors? Our addiction treatment systems are all too often completely separate from our (psychological) trauma treatment systems in the United States. The design of addiction treatment doesn’t address underlying trauma. The whole trafficking experience is trauma after trauma after trauma. In order to avoid painful memories and awful flashbacks, using drugs is a way of treating that emotional pain. Furthermore, a lot of trafficking survivors experienced some sort of abuse in their past prior to being trafficked. So it’s ridiculous to think that we’ll be able to treat trafficking survivors who also have opioid addiction without treating their underlying trauma. Treatment programs that address both addiction and trauma are usually only available to those who can pay for it themselves. As you can imagine, most victims of trafficking can’t afford these programs. From a public health perspective, we have to think about prevention and how we can stop this vicious cycle.

 

 

Are there any trafficking cases that have stuck with you over the years?

There are a couple that I go back to often both in terms of sad and hopeful endings. One case I shared before Congress involved a girl who had been addicted to oxycodone, then got hooked on heroin, and had been in and out of detox centers for years trying to kick the habit. She had a loving family, but addiction is powerful. She met a woman at her addiction treatment facility who connected her with a guy who ultimately locked her in a hotel room and forced to have sex with over 100 clients in the course of a week. She escaped and called her mom, who got her directly to our emergency department. She needed treatment for her addiction and depression. We were trying to find a place that would meet her needs and accept her insurance and we couldn’t find anything. She started withdrawing like crazy and walked out of the emergency department. I hope that she doesn’t get trafficked again but we didn’t address the underlying vulnerabilities that caused her to be trafficked in the first place—and she’s back out there.

These cases are really hard because it feels like we did everything right in terms of identifying her as a trafficking survivor, but then there was a huge system failure. We didn’t have the capacity to meet her needs in the moment.

Are there any promising examples of other medical specialties caring for victims of human trafficking? 

I work within the Partners Health Care system and there is an in-patient psychiatric program that has been able to identify trafficking survivors and get them into treatment. They often identify survivors by noticing that their stories aren’t consistent. In one case, a patient was in treatment for suicidality and drug addiction, and when she was asked how she got her drugs, she got really quiet. The next day, the provider circled back with her and mentioned human trafficking. The patient completely opened up and shared that she was part of a trafficking ring and felt trapped and was afraid for her safety. Had the health care provider not created a safe space, nor been trained to even ask the right question or mention trafficking, it’s likely that the patient would not have disclosed. The provider was then able to get the patient into a good treatment facility. In this particular case, the system not only worked to identify, but also had the capacity to care for the underlying issues.

What is unique about a public health response to human trafficking? 

For too long, the approach to trafficking has been a purely criminal justice one. But we cannot arrest our way out of trafficking. To believe so is short sited. A public health approach looks upstream to understand the societal, community, and individual factors that lead to trafficking. Prevention is critical to our efforts. Moreover, a public health approach recognizes that once an individual is identified as being trafficked, unless the vulnerabilities which led them into exploitation are addressed, they will likely end up re-trafficked. I have seen too many of my patients stuck in revolving door of trafficking. A public health approach thinks about how we break that cycle through truly restoring and healing trafficking survivors.

 

 

 

 

What motivates you to continue to work toward combating human trafficking?

There is so much left to do. However, I am motivated by seeing that we’re making a dent. I do see trafficking survivors who got out and are thriving. We’re making a difference. If we as health care providers are not leading the public health response to trafficking, who will?

You recently received the 2016 Emerging Leader Award from the Office on Women’s Health at the U.S. Department of Health and Human Services. Do you have any advice for women who are just starting out their careers in medicine?

It sounds totally cliché, but I think it’s important for men and women starting out in medicine to follow their passion, figure out what they’re good at, and partner with people that fill in skills they don’t have. That may be through peer-level partnerships or mentors that can help build you as a person.

One of the myths out there about career trajectories is that they’re linear. I didn’t continue to work specifically on HIV/AIDS and domestic violence, though there was a time when I thought that was what I’d do for the rest of my career. I kept my mind open and listened to opportunities that came along. All of the experiences that have come my way have informed me and helped me grow in my leadership and management skills, which are so integral to being able to make a difference.

There can also be a fear within the medical community of working on policy. It’s scary and unknown. I encourage folks that are training in medicine to engage directly with policy makers early on to get a sense of what it’s like to talk to a staffer or a Congressperson. I wish medical schools required a lobby day or similar experiences because it’s scary until you’ve done it. Then you realize that your voice is really, really powerful.

Don’t be afraid to fail and try things because that’s how you learn. We don’t do everything perfectly the first time. Having the humility to accept that and also the strength and resilience to move on and grow is important.

 

Dr. Hanni Stoklosa recently received the Emerging Leader Award from the U.S. Department of Health and Human Services

You’ve been the National Academy of Medicine’s ABEM Fellow for over a year now. How has this fellowship allowed you to further your impact when it comes to human trafficking?

I’ve been working with the National Academies on a workshop funded by the U.S. Department of Labor on issues of child labor and forced labor. It’s been really exciting because I’ve been able to engage with policy leaders in a way that I would not have been able to otherwise. Working on designing the workshop in brief as well as writing on the literature review that helped inform the workshop, has been an amazing opportunity. And I was just recently honored to present on Communicating to Policymakers in the Context of Anti-trafficking for the Academy’s Effective Public Policy Solutions for Global Violence Prevention Workshop.

 

Dr. Hanni Stoklosa (far right) with NAM fellows and HPEPF Director Marie Michnich

 

Dr. Stoklosa will release her first book later this month entitled Human Trafficking is a Public Health Issue: A Paradigm Expansion in the United States. The book will examine the public health dimensions of labor and sex trafficking in the United States, the scope of the crisis, and possibilities for solutions. 
Additional Resources
From 2013-2014, the Institute of Medicine released a series of reports on commercial sexual exploitation and sex trafficking of minors. Download the reports here.