Editorial

Since the adoption of the United Nations Palermo Protocol to Prevent, Suppress and Punish Trafficking in Persons and passage of the U.S. Trafficking Victims Protection Act (TVPA) twenty one years ago, approaches to human trafficking (HT) largely have been rooted in a criminal justice framework. The criminal justice system focuses on the identification, capture, and successful prosecution of traffickers, relying primarily on the threat of criminal sanctions as a deterrent (Todres 2011). By 2013, all 50 U.S. states had enacted laws to enhance law enforcement activity toward people classified as human traffickers (Farrell et al. 2016).

A public health paradigm for HT, on the other hand, recognizes that HT results from modifiable policies and often-preventable human behaviors (Todres 2011). HT has major health consequences and negatively impacts individuals, families, communities, and society at large, requiring prevention and intervention strategies, laws and policies, and cultural shifts to reduce risk and build resilience at each of these levels (CDC, n.d.; Krug et al. 2002). Given that available metrics suggest that the criminal justice approach to HT has yielded limited success, a public health approach to HT through multi-disciplinary, collaborative, evidence-based, trauma and survivor-informed approaches is warranted (Chacon 2006, Chuang 2013, Mehlman-Orozco 2016), Van der Laan et al. 2011).

In this issue of the Journal of Human Trafficking, Gonzalez-Pons reports on public health department employees’ perceptions of, and experiences with, identifying and serving victims of domestic minor sex trafficking (DMST). Respondents in the study provided feedback “centered around the health department as a safe place for DSMT victims and their ability to reach diverse populations.” Gonzalez-Pons outlines important roles that health departments play in advancing health at the local, state, and federal level. These include the provision of direct services, including outreach to and health care for underserved populations; prevention programming, as through health education and screenings; collection and sharing of health data; collaboration with multidisciplinary stakeholders; and policy making.

State and local health departments are fundamental components of the U.S. public health infrastructure and workforce and thus could be key partners in addressing trafficking. Health department staff routinely interact with other government agencies, community based organizations, academic partners, and the business community, so are well-positioned to engage in or lead multi-disciplinary efforts to prevent and respond to human trafficking.

Efforts to frame trafficking prevention and response within the public health domain align with the understanding, first widely recognized in the 1980’s, that violence is a public health problem. In 2016, the Association of State and Territorial Health Officials, the nonprofit organization representing public health departments for U.S. states, freely associated states, territories, and the District of Columbia stated, “ … Violence can no longer be viewed as solely a ‘police or criminal justice problem.’ The communities people live in can both protect them from violence or increase their risk of violence. We’ve learned that efforts to prevent all forms of violence must address social, emotional, and behavioral elements, as well as family and community environments.” (ASTHO, 2016) Similarly, the National Association of City and County Health Organization (NACCHO), which represents local health agencies, notes, “Local health departments (LHDs) play an important role in coordinating the broader public health system’s efforts to address the causes of injury and violence. LHDs are well suited to unite community partners to address the causes of injury- and violence-related inequities through policy, environment, and system change.” (NACCHO, n.d.a).

Public health programs offer opportunities to identify, support, and empower trafficked people – including children and adults of all origins trafficked in any industry. One way public health department employees interact with trafficked people is through health care provision, which expands beyond public hospitals and community clinics. For example, state and local health departments provide much of the tuberculosis (TB) care rendered in the U.S. (Cole et al. 2020). While TB rates are declining, patients are overwhelmingly immigrants (71% in 2019) and people of color (88%), as well as people experiencing homelessness (5%) and injection drugs users (1%), all of whom face elevated risk for trafficking (CDC, 2020). And while the current sexually transmitted disease (STD) epidemic impacts a broad swath of the U.S. population, STD infection is most common in youth (ages 18–24) and is also commonly associated with sex trafficking. In 2017, 65% of counties in the U.S. were served by an STD clinic affiliated with a local or state health department, highlighting the importance of engaging these health department workers in anti-trafficking training and response protocols (Meyerson et al. 2017). Eighty-eight percent of local health departments provide child and adult immunizations, providing opportunities to engage marginalized people who may not receive other health services (NACCHO, 2021).

Health department employees also encounter the public in myriad venues outside the clinical setting, as through nurse home visitation, community health worker and health educator outreach campaigns, emergency response operations, substance use prevention and control programs, and communicable disease investigations. All of these settings allow for identification of trafficked individuals and those at risk, who can then be provided education, options, and linkages to health and social services as well as legal service providers. Environmental health specialists who conduct inspections of homes, restaurants, massage parlors and other businesses can engage public sector and community based organizations if they observe signs of abuse at these locations. Outreach workers and if needed, interventionists, can then link at-risk individuals with services, while law enforcement can be notified as needed. Some public health departments partner with correctional health, another juncture in which staff engage with vulnerable and marginalized populations, including trafficked people arrested for crimes committed during trafficking.

How often do departments of public health engage in anti-trafficking activities? A 2015 survey of state health departments, conducted by the Association of State and Territorial Health Officials (ASTHO), Global Health Promise, and I found that nearly half of 33 responding state health departments collaborated with public, private, community and/or faith-based agencies to advocate for and/or provide services to trafficked people. Among the 36% of agencies who reported direct service provision, specific services for trafficked people included testing for sexually transmitted infections, refugee health assessment, immunizations, family planning services, health screenings, primary care, and interpretation services. Thirty percent of state health departments said they were engaged in a multisector response protocol to identify and provide services to trafficking victims/survivors, some as part of a HT task force made up of various government agencies. Another 46% of health departments reported training their own staff on trafficking, while 36% trained external audiences. Only 25% conducted any data collection around human trafficking, primarily for minor sex trafficking. The survey response rate was 56%, so response bias may have influenced the results.

In subsequent years, some state health organizations have implemented policy and program changes to improve responses to human trafficking. Enacted in 2017, New York State PHL § 2805-y requires that every general hospital, public health center (italics added), diagnostic center, treatment center or outpatient department “shall provide for the identification, assessment, and appropriate treatment or referral of persons suspected as human trafficking victims, and in the case of persons under eighteen years old, the reporting of such persons as an abused or maltreated child” (Leslie, 2018). In 2019, the Florida Department of Health (FDOH) developed a human trafficking strategic action plan, noting, “Given the diverse populations FDOH serves, there is great potential for victims of human trafficking to come into contact with FDOH … The primary goal of this action plan is to educate all FDOH employees and licensees about human trafficking, how to recognize human trafficking and what action to take when they identify human trafficking.”

Efforts to address human trafficking as a public health problem align with existing health department programs targeting sexual violence and domestic violence/intimate partner violence. However, these forms of violence, which are much more pervasive in our society than human trafficking, are still not part of the portfolio of many public health departments. In 2019, 54% of state health departments reported programming in sexual assault victim services and 34% in DV victim services (ASTHO, 2020) Meanwhile, a search of state health departments’ and the District of Columbia’s websites during the first week of June 2021 revealed that 31% explicitly include human trafficking on their website. On an additional 23% of websites, a search yields at least one document pertaining to human trafficking, such as a training announcement or links to other community resources.

One barrier to health departments engaging in violence prevention and response activities, in general, and anti-trafficking work, in particular, is inadequate funding. The Trust for America’s Health (2018; 2021) has documented chronic underfunding of the nation’s public health infrastructure and workforce at the federal, state, and local levels. Public health’s share of health spending by federal, state, and local governments, adjusted for inflation, decreased 17% from 281 USD per capita in 2002 (when spending briefly surged following the 9/11 and Anthrax attacks) to 255 USD in 2014, a loss of 40.2 USD billion from the public health portion of the nation’s health budget (Himmelstein and Woolhandler, 2016). Between the Great Recession of 2008 and 2017, LHDs lost 55,590 jobs (NACCHO, 2017). These jobs were not regained prior to the onset of the pandemic (NAACHO, 2020). NACCHO’s annual surveys of LHDs have consistently demonstrated funding and staffing challenges and the negative impacts these challenges have on LHDs throughout the U.S.

The Biden Administration’s budget proposal for FY 2022 promises to begin reversing this dangerous trend, with the largest proposed budget increase for the Centers for Disease Control and Prevention in nearly two decades (CDC, 2021). The new budget includes increases for injury and violence prevention programs that will help to address the growing crises of domestic, sexual, and gun violence and a new evidence-based community violence intervention initiative. As the nation reimagines public safety in the era of Black Lives Matter, community violence intervention initiatives offer the promise of supporting violence survivors with more holistic, trauma informed, multi-disciplinary responses that do not necessarily involve law enforcement.

The proposed federal budget also significantly expands efforts to address the social determinants of health. In her article, Gonzalez-Pons notes that public health department’s “education efforts should include discussions on systemic issues, including wealth inequality, racism, and other forms of discrimination and their relationship to sexual exploitation.” Efforts to address these social determinants, the upstream conditions that shape health in the places we live, learn, work, play, and worship, are critical to public health departments’ work to advance health equity (Public Health Accreditation Board [PHAB], (2013); ASTHO, 2018); NACCHO, n.d.a). Health equity is achieved when every person has the opportunity to “attain [their] full health potential” and no one is “disadvantaged from achieving this potential because of social position or other socially determined circumstances.” 2020 (Robert Wood Johnson Foundation, n.d.) It is through the creation of opportunities for health equity that we build individual and community resilience and reduce vulnerability to all forms of human trafficking – not just domestic minor sex trafficking – and other forms of violence, as well as to communicable and chronic disease. While public health programs that improve social determinants impact many in the community, these efforts could prove to be the most targeted and effective means to reduce human trafficking.

Gonzalez-Pons’ article brings a much-needed focus to the promise of public health departments playing a greater role in anti-trafficking work. A new, sustained investment in human trafficking as a public health issue – at the federal, state, and local levels – would open doors to innovative, creative approaches for supporting trafficked people and reducing harm through primary, secondary, and tertiary prevention.

Acknowledgments

Katie Chun, PhD, MA; Brian Willis, JD, MPH; Maggie Carlin, MPH, Samantha Colquitt, Shangnon Fei