HHS asks doctors to watch for human trafficking

Over the years, David McCollum, MD, has seen patients who seemed to be in an abusive situation but didn't quite fit the profile for victims of domestic violence. But there were common themes. Someone was always with these patients, never letting them speak for themselves, and even if they did, their English was limited or nonexistent. They also always seemed insecure and uncomfortable.

Dr. McCollum, an emergency physician from Chanhassen, Minn., and chair of the AMA National Advisory Council on Violence and Abuse, now thinks these patients may have been victims of human trafficking -- a modern form of slavery in which people are moved across borders and subjected to sexual exploitation, forced labor or indentured servitude. "A lot of people are being trafficked, but it's underreported," he said.

Thanks to the Dept. of Health and Human Services, resources are now becoming available to help physicians identify the problem. HHS is rolling out its "Rescue and Restore Victims of Human Trafficking" awareness campaign to provide physicians and other health care professionals tools to detect victims of this crime.

Additionally, the agency hopes the campaign will raise the index of suspicion among physicians. It also will provide a suggested list of questions to ask to confirm the need for a referral and a national toll-free number to link patients with prescreened organizations that specialize in the problem.

"Victims of trafficking may look like many of the patients you encounter every day," said Wade F. Horn, PhD, assistant secretary for the HHS Administration of Children and Families. "We urge health care professionals to be vigilant in looking for potential victims of human trafficking so they can help victims escape bondage and restore their lives."

A hidden population

The campaign comes on the heels of recognition that this problem is increasing and that the Trafficking Victims Protection Act of 2000 has had little impact so far. An estimated 14,500 to 17,500 people are victimized in this way in the United States each year, with another 600,000 to 800,000 victimized around the world. Since the passage of this law, only 700 people have availed themselves of the significant benefits and protections it provides, including protection from deportation. Nearly all were rescued by law enforcement officials.

"True trafficked people are something of a hidden population," said Chris Beyrer, MD, MPH, associate professor of epidemiology and international health at the Johns Hopkins School of Public Health in Baltimore. "They may not be very aware of victims rights and benefits and will be very fearful."

Experts feel that numbers rescued to date are just the tip of the iceberg, and that many more victims might be found when physicians are more involved.

"Traffickers allow access to health care in order to protect their investment," pointed out Steven Wagner, who serves as the director of the HHS human trafficking program. "Physicians are one of most important intermediaries to getting help."

Anti-violence advocates said recommendations for identifying those at risk fit neatly with the domestic abuse screening that many doctors already do. But they also expect the incorporation of human trafficking awareness into medical practice to be bumpy, just as it has been for detecting other forms of abuse.

"When domestic violence became an issue, initially it was viewed as beyond the realm of doctors," said John Schumann, MD, assistant professor of general internal medicine at the University of Chicago Pritzker School of Medicine, who has organized workshops on human trafficking at his institution. "But if we don't ask, people aren't going to tell us. We can hook them up with resources."

Some physicians maintain, however, that screening for human trafficking is not appropriate on a broad scale. Rather, it should be used for more targeted populations, such as immigrants, because trafficking is a relatively rare event and primary care physicians already have plenty on their plates in terms of screening for more common conditions.

For example, screening for domestic violence is more widely accepted than ever before but still lacks the official blessing of the U.S. Preventive Services Task Force. In March 2004, the USPSTF issued a statement that evidence was insufficient to recommend screening for family and intimate partner violence.

"If your grandma comes into clinic, are you going to screen her for human trafficking?" said Thomas Gavagan MD, MPH, vice chair for community health in the Dept. of Family and Community Medicine at Baylor College of Medicine in Houston. "It's a needle-in-a-haystack situation, and there are a million things to screen for in primary care. It would be reasonable to screen immigrants for that kind of trauma."

Experts agreed that not every patient needs to be asked questions related to human trafficking, such as if they are free to change jobs and come and go as they please, but it is important for physicians to be aware of the problem. If the situation seems suspicious, then these kinds of questions should be asked.

"The materials that HHS has distributed really appeal to common sense and won't unduly impede the logistics of patient care. Overall, I think that there is a lot to gain," said Kenneth Chuang, MD, assistant clinical professor in psychiatry at the University of California, Los Angeles. Dr. Chuang is also a volunteer at the Venice Family Clinic's human trafficking clinic, the first facility of its kind in the nation.