Intended for healthcare professionals

Editorials

Modern slavery: a global public health concern

BMJ 2019; 364 doi: https://doi.org/10.1136/bmj.l838 (Published 26 February 2019) Cite this as: BMJ 2019;364:l838
  1. Elizabeth Such, research fellow1,
  2. Elizabeth Walton, clinical lecturer1,
  3. Toby Bonvoisin, academic foundation year 1 doctor2,
  4. Hanni Stoklosa, instructor in emergency medicine3
  1. 1University of Sheffield, UK
  2. 2Hull and East Yorkshire Hospitals NHS Trust, UK
  3. 3Brigham and Women’s Hospital, Harvard Medical School, USA
  1. e.such{at}sheffield.ac.uk

Health professionals are well placed to identify and advocate for victims

Modern slavery is a global public health concern,1 yet health professionals are often unaware of what it is, what it looks like, who it affects, and what, if anything, they can do about it.2 There were over 40 million victims worldwide in 2016, with every region affected.3 It is a largely hidden crime, but one hidden in plain sight. It thrives on human vulnerability, such as where there is poverty or people escaping war. It is evident in our local communities in places such as car washes, beauty salons, farms, and factories.4

Modern slavery—which is often called and is inclusive of human trafficking—is an umbrella term that includes the recruitment, movement, harbouring, or receiving of children, women, or men through the use of force, coercion, abuse of vulnerability, deception, or other means for the purposes of exploitation.5 It includes holding a person in a position of slavery, servitude, or forced or compulsory labour, or facilitating their travel with the intention of exploiting them soon after.6 It includes sex trafficking, forced labour, forced criminality, domestic servitude, and forced marriage.4

Modern slavery is a gross manifestation of social and economic inequality that violates basic rights, including a right to health.7 Complex comorbidities are characteristic of this population; survivors are at high risk of physical injury, exposure to infectious diseases, suicide, restricted access to healthcare, and serious mental health problems.89 While modern slavery has been considered mainly a law enforcement matter, clinicians should also be concerned because many victims seek healthcare at some point during their exploitation.1011 Healthcare professionals also occupy a trusted, privileged position with unrivalled access to vulnerable populations11; these advantages can be mobilised to protect exploited patients and prevent harm. Healthcare is therefore at the frontline of identification, and of ensuring victims access their rights to health, security, and liberty.

To provide care for this population, clinicians need to know what to look for and how to act and optimise outcomes. A 2015 cross-sectional UK survey of 782 healthcare professionals in secondary care found that 87% lacked knowledge on how to identify victims and 71% had had insufficient training to assist trafficked people.2 There are several “red flags” that practitioners should look out for: victims may be nervous, might not speak for themselves, or may appear to be under the control of others; companions might translate for or talk over them; victims may have old or untreated injuries, may be submissive and afraid, could be unregistered with health services, or have moved frequently within or between countries.1012

In response, clinicians should try to talk to patients suspected of exploitation alone, and arrange professional interpreters where needed. They should be reassuring, highlighting that it is safe to speak, and should take time to build rapport. Furthermore, they should recognise that victims are likely to be traumatised so should ask non-judgemental and sensitive questions and give the patient time to talk about their experiences if they wish to.

If slavery is suspected, helplines are available in most countries to connect with specialist support including safe accommodation, the Global Modern Slavery Directory has a comprehensive list.13 Law enforcement matters need to be considered carefully. Victims may not want to engage with the police for fear of reprisals or deportation. Healthcare professionals should seek advice from national helplines, their colleagues, and local guidelines, and work with the patient to make informed decisions about involving authorities.14

The development and testing of training, guidance materials, and practice protocols are in their infancy and there is an urgent need to improve practitioner awareness, skills, and processes.15 Awareness materials are growing quickly and focus on “spotting the signs” but validated tools to assist patient screening are limited. The HEAL Trafficking toolkit16 and the Adult Human Trafficking Screening Tool and Guide17 use a best practice approach. There is still a long way to go before training is mandatory. In addition, clinicians need knowledge of, and confidence in, victim referral systems. The UK national system, for example, has encountered many problems, including inadequate inspection of care facilities.18 Finally, practitioners can be important contributors to an emerging public health approach to tackling modern slavery that promotes a preventive agenda.19

Health professionals should be alert to possible signs of modern slavery in their patients and communities, and take all opportunities to learn about the problem. Locally, this can be through anti-trafficking or anti-slavery organisations.13 Clinicians are uniquely placed to help people affected by this crime, through the patients they see, the power of their voice, and the opportunities they have to advocate for broader preventive measures.

Footnotes

  • Not commissioned, peer reviewed

  • Competing interests: We have read and understood BMJ policy on declaration of interests and declare the following: ES is a NIHR knowledge mobilisation research fellow and a research fellow for NIHR CLAHRC Yorkshire and Humber and was supported by MRC Proximity to Discovery funds as a secondee to Public Health England to examine modern slavery as a health matter in January-July 2017. EW is a NIHR clinical lecturer at Sheffield University and a GP at the Whitehouse Surgery, Sheffield, UK. She co-founded the Deep End Yorkshire and Humber network of family practices working in the most disadvantaged wards in the region. TB is a foundation year 1 doctor at Hull and East Yorkshire Hospitals NHS Trust. As a medical student, he provided training sessions about modern slavery to healthcare professionals and received expenses for some of these sessions. HS is an emergency physician at Brigham and Women’s Hospital, Harvard Medical School and is executive director of HEAL Trafficking, a network of multidisciplinary health professionals combating trafficking through a public health lens. The authors declare no other relationships or activities that could appear to have influenced the submitted work.

  • The views expressed in this publication are those of the authors and not necessarily those of the NHS, the National Institute for Health Research, Health Education England, or the Department of Health and Social Care.

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