Human Trafficking and Implications for Workers’ Compensation

Survival Tactics for Healthcare Professionals on the Front Lines of Tragedy

By Karen C. Yotis, Esq.

The trafficking of humans—both for labor and for sex—is a twisted version of the #metoo behavior template, with serious and far-reaching implications for the workers’ compensation community—especially healthcare workers and first responders who are often the only outsiders to glimpse the every-day horrors of a resource fulfillment practice that is essentially modern-day slavery. Jeanine Zukerman, RN, BSN, CCM, the Director of Clinical Innovation of MTI America, tackled the raw issues surrounding this ugly topic in a webinar sponsored by the folks at WorkCompCentral and titled “Human Trafficking: A Primer for Workers Compensation Health Care Professionals.” As set forth in the sponsor’s promotional material, the program identifies the social, economic, and immigration factors that contribute to trafficking, discusses how force, fraud and coercion are used to exploit labor and sex markets, and describes complex scenarios where ethical decision-making may cloud reporting protocols. Zukerman presents an excellent eye-opener, that uncovers the heart-breaking reality of a human commodity market which is global in scope yet “hidden in plain sight.”

Human trafficking is incredibly big business, producing profits almost equal to the global drug trade. According to Zukerman, “the average sex trafficker earns an average of $49,000 per victim” over the course of each individual’s enslavement. Throughout the agriculture and fishing sector, garment industry, domestic labor market, construction industry, and the home health care market, undocumented laborers are threatened with deportation unless they lie about work-related injuries and apply for public assistance to pay medical bills.

Slavery by the Numbers         

The data supporting Zukerman’s presentation comes from the Counter Trafficking Data Collaborative, the first global data hub on human trafficking that launched in November 2017. The CTDC publishes what its website calls “harmonized” information from counter-trafficking organizations world-wide. CTDC’s published data is based on case management information that is recorded when protection and assistance services are provided, or when victims contact a counter-trafficking hotline. The International Organization for Migration (IOM) and Polaris are the founding partners and the first contributors to the CTDC.

Wrap your head around some of these numbers that are published on the CTDC website . . . Total victims reported has more than doubled in two years, from 5,863 in 2015 to 10,924 in 2017. Eighty-two percent of reported victims are female. The overwhelming majority (74%) of individuals are victims of sexual exploitation; 22% are victims of labor exploitation, and 4% suffer both types of trafficking. Although victims range in age from children younger than 8 to adults over 65, one-fifth of all trafficked victims are children, with young girls (56%) being trafficked slightly more often than young boys (44%).

Zukerman also recounted the story of a 50-year-old sex slave from the other side of the spectrum from trafficked children who had been trafficked since her teens. Cut loose after losing their street value and lacking the most basic life skills, women like this have never filed a tax return, balanced a bank statement, or applied for a job.

In addition to overwhelming numbers of women and children, trafficked humans are the most vulnerable among us: the physically and intellectually disabled, addicts, foreigners with no language skills, and sexually transgendered youths. The trafficked also perform menial tasks in low-skilled categories. As Zukerman explained, “they clean and cook for us, they grow and harvest our food, they do our hair and nails, they care for our children and elderly, and staff residential and nursing home facilities.” The trafficked are found at truck stops and in residential brothels and are also found in manufacturing facilities that don’t bother with safety protections.

The trafficked are also marked. As in branded. They’re tagged like cattle on a Wyoming ranch, although not nearly as well fed or cared for. Whether it’s a tattoo or other skin-altering scar, the mark on a trafficked resource indicates ownership. According to Zukerman, the signs vary from a trafficker’s initials, to a crown, a rose, or even a barcode; they appear on the eyelids, back of the neck, breasts, and other private areas.

According to the CTDC website, a full 57% of all victims report themselves as U.S. citizens, and almost all speak English. The top country for trafficking is India where women and children comprise 71% of sponsored labor, followed by China, Pakistan, and Thailand. Zukerman added some national context to CTDC’s global story when she explained how easy access to foreign countries and a large immigrant population have made California the leading state for human trafficking in the United States, followed by Florida, Ohio and New York. Many are misled into visa contracts or coerced to pay off drug debts through sex trade or various forms of forced labor.

One of the most difficult aspects to pin down are the traffickers themselves. With almost 25% of victims sharing a family relationship with their recruiter, 33% coming to trafficking through an intimate partner, and 12% being persuaded by so-called friends, trafficking transactions and the trafficking lifestyle in general are shrouded in secrecy. Recruiters (who Zukerman said are sometimes referred to as “Romeo Pimps” or “Lot Lizards”) monitor their sex and labor slaves very closely, often speak for them in front of medical providers, and take over Visas and other documents as an incredibly effective means of control. Additional complications arise from the phenomenon that victim advocates are calling “trauma bonding,” where a trafficked person forms a bond with their trafficker over long periods of time.

Health Care Workers Front-lining the Resistance

According to Zukerman, law enforcement uses a three-part query that looks for force, fraud or coercion to distinguish between trafficking and legal consent. The Action-Means-Purpose Model—which looks at the “what,” “when,” and “why” of any given scenario—also helps law enforcement determine whether a situation involves trafficking. These efforts are producing results, including the well-publicized sting operation called Operation Trade Secrets, which netted upwards of 85 arrests in June 2019 and ensnared New England Patriots owner Robert Kraft.

However, because of their unique positioning in emergency rooms and urgent care facilities across the country, health care professionals (rather than law enforcement) are the front-line warriors in the war to stop human trafficking. Zukerman referenced a 2017 American Journal of Ethics article which reported that 88% of trafficking victims came into contact with a health care provider at some point during their slavery, but none were identified or offered help to get out of bondage during the encounter.

As an RN herself, Zukerman was able to provide a long list of “tells” that assist with crucial early identification of trafficking victims. In general, whether trafficking involves labor or sex, victims are often accompanied by a “representative” who does not permit the patient to speak for themselves and become unusually fearful or anxious when law enforcement is mentioned. These individuals are not in control of their own identity documents and are often unable to clarify any information that can be used to track them, like a street address, phone number, or email.

In addition to these social indicators, Zukerman stated that these victims exhibit poor dental care, unexplained injuries or infections that have never been treated, signs of drug abuse, and other evidence of neglect. In addition, Zukerman explained how many victims, especially the younger ones, appear in ERs two to four times per month because they have no primary care. She also outlined psychological similarities common to labor and sex slaves, who are often depressed and exhibit “flat” behavior, demonstrate lost time or lack of awareness about their past whereabouts, and refuse to make eye contact.

The signs specific to labor trafficking can be obvious, but most are subtle and require a sharp eye. Some of the key indicators that Zukerman mentioned are:

• High levels of paranoia or conflicting stories when asked how or where an injury occurred
• Horrific injuries which suggest a patient worked on machinery with guards removed
• Malunions of previously fractured bones
• Exposure to harmful chemicals and/or unsafe water

The signs specific to sex trafficking that Zukerman relayed often mimic those of labor trafficking, but include the following additional horrors:

• Multiple sexually transmitted infections and abnormally high numbers of sex partners
• Trauma to the vagina or rectum, or signs of rape
• Bondage marks on ankles or wrists
• Frequent complaints of headaches or abdominal pain

The Reporting Conundrum

Once the signs of sex or labor trafficking are recognized, the person in a position to help must decide what in the world to DO. If the patient victim is a minor, an immediate report to law enforcement is the only available option. Let me repeat: reporting is mandatory in all U.S. jurisdictions for minor victims of labor or sex trafficking. Call the National Human Trafficking Hotline. Call the U.S. Department of Justice. Call your state’s abuse hotline. Zuckerman has even spoken to agents from Homeland Security.

Other situations call for a more discerning approach, especially with sex trafficking where reporting can result in more harm befalling the victim. Zukerman told a story about a young female with a pocket full of hotel room keys who received a high volume of cell phone calls while seeking treatment as an atypical patient who should raise a red flag with health care personnel. She talked about individuals “who claim they are 21 but don’t look a day over 15,” who could present a situation requiring mandatory reporting, and suggested that an additional inquiry be conducted (perhaps with the help of another healthcare colleagues) before releasing the victim from a medical facility without a report. For victims with clear telltale signs who deny being victims or provide rehearsed responses to questions, Zukerman suggested that these patients be given hotline numbers or general information without the sharing of written resources that a trafficker/recruiter might see. Whatever scenario presents itself, the health care professional must consider the ethics involved and determine if a situation really does involve human trafficking, and whether an official report will help or cause more harm to the individual patient.

Hope for a Way Out

Education about human trafficking—at all levels and in a host of arenas—is paramount going forward. This is beginning to happen in a variety of essential contexts. Zuckerman recounted numerous examples in her home state of Florida, such as the 2019 start in Orlando schools of classes that teach students to recognize and understand human trafficking, and mandatory training for law Florida law enforcement officers (4 hours) and Florida nurses (2 hours) on how to investigate and/or recognize human trafficking. Similar requirements are expected to be imposed upon Florida physicians. In addition, on July 1, 2019, Florida enacted H.B. 851, which requires spas, hotels and other entertainment venues to train staff to identify the signs of sex trafficking.

Zukerman finished up with an explanation of how trafficked individuals suffer from a pyramid of stressors that includes fear of criminal proceedings against their traffickers, fear of immigration and asylum procedures, the stigma associated with sex work, returning to families that are not aware of their activities while away, lack of basic life skills, and the inability to find a place to live that they believe is safe from their traffickers. She also explained that global organizations are beginning to address the myriad complexities of human trafficking and dismantle its social and economic underpinnings. Fortunately, resources like the Department of Homeland Security’s Blue Campaign, which is a national public awareness campaign, are available to educate the public, law enforcement, and other industry partners on how to recognize the indicators of human trafficking and appropriately respond to possible cases.

We can all join the battle against human trafficking. Protection and prevention increase when parents learn and then talk to their school-aged children, when business owners advocate for the older victims who need life skill training, and when those in a position to influence hiring offer jobs, internships or training to people in recovery. The trafficking market shrinks when people become conscientious consumers and refuse to do business with companies that exploit labor trafficking. And the spark of hope ignites when we open our eyes and actually SEE the prisoners “in our own backyards.”

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