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
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The issue of reporting and acting on suspicions of modern slavery by healthcare professionals is not straightforward. In each national setting there will be statutory duties and a range of possible routes to less formal – and more variable – advice, guidance and support. First, in the UK, current legislation does not specifically give healthcare professionals a duty to notify the authorities of potential cases of modern slavery (Modern Slavery Act 2015 chapter 30, part 5, section 32). More globally, the goal is not to force disclosure or to report, but to create an "open door" through which to generate trust and a flow of information so that victims know where they can go for help, if and when it is safe. The PEARR (Provide privacy, Educate, Ask, Respect and Respond) tool aims to do that https://www.dignityhealth.org/hello-humankindness/human-trafficking/vict.... The open door approach has been used and tested in domestic abuse cases and subscribes to models of care based on shared decision making and recognising victims’ trauma and autonomy.
In the UK, the Modern Slavery Helpline have to refer cases to the relevant statutory authorities in the police or local authority where the person concerned is under age 18 or a "vulnerable adult". Vulnerability is generally left to the referring frontline professional to determine, for example if the medical team looking after a patient do not deem them to have mental capacity to make informed decisions. The UK Modern Slavery Helpline can assist by giving a victim or concerned professional a case reference number, can get permission to proactively re-contact the caller, can help with a victim safety plan, provide information about legal rights, identify avenues of help other than the police, and signpost to other services that can help victims. Over the course of several calls, a victim or a frontline health professional can receive tailored support.
For someone judged to have capacity, there are often very good reasons why victims might not want to tell the authorities. Criminal organisations often control victims by threatening to harm them or their loved ones. Silence can be the rational choice for victims - healthcare professionals should avoid reporting without patient consent in these circumstances.
Local adult safeguarding systems in health services need attention in the UK to better serve modern slavery victims. For example, few NHS safeguarding teams have rigorous policies and procedures for identifying and referring victims of modern slavery to the correct source of help. This is changing somewhat with local partnerships driving forward their own plans. These localised responses, however, mean that effective responses cannot be guaranteed; many victims may be falling through the cracks. A more coordinated NHS-wide approach is needed. This includes better centralised advice from NHS England and the DHSC for all health professionals across the sector.
Key to victims’ access to help from the National Referral Mechanism is finding a First Responder to do the referral, and one who is trained to do it well. Safeguarding teams within healthcare organisations are not First Responders. Local authorities are First Responders, but – reflecting system-wide issues – not all social workers are trained on how to interview a potential victim and fill in the NRM form. Other First Responders include the police, Unseen (who run the modern slavery helpline), the Salvation Army and several other charities.
Competing interests: No competing interests
As I went through the article I was looking something new since the title said "Modern Slavery". But it has the same class which has been discussed over and over. The one which comes in the class of "Modern Slavery" is the workers from BPO-Business Process Outsourcing industry. The people who are working in Indian BPO sector are more or less belong to this category. India being the hub for the skilled labour and the large young population (of course the costing) BPO industry is exploiting the situation. These workers working in shifts and the odd and long hours in office is impacting their health. Recently many offices extended their working hours to 8 hours 30 minutes, 5 days a week, excluding the lunch/dinner hours. Which makes the worker to stay for more than 11 hours which includes commuting! Also the life span of many of these workers in any company is 2years. During the work these individuals are monitored the pattern of working. The plus point of this industry is the employment, good ambience and improved quality of life (more financially than physical health). I think more research needs to be done in these population both health and mainly the impact on cognitive health.
regards
Mohan
Competing interests: No competing interests
Color, wealth, greed and power have led to slavery in the ancient time from the days Roman Empire to modern day apartheid. Slavery is one form approach to extract work for their benefit - it may be for the building of monuments or the skyline structures of today. Previously such actions were labeled as slavery and now a days wage workers. We have labor laws, International Labor Organization (ILO) and trade unions to fight for the rights of workers along with possibly protecting the labor force from exploitation. Forced labor in the form recruitment by agencies to serve in other countries for monetary benefit is still prevalent. Forced child marriages by certain nations take place for serving the interests of the marriage buyer. One can still witness human trafficking as a global phenomena where the network of underworld go unnoticed sometimes and at times punished in the court of law.
Wherever sugar plantations are there, one could see burnt down barren agriculture lands as a mark of great human injustice done for years to the black race. Even in households one could witness young adolescent girls are being employed servant maid undergoing psychological as well as physical trauma. The animal instinct in humans is still prevalent under the coat of sophisticated exterior.That is why somebody said " it is required to be great. To remain as human itself is great". The human legacy is tainted with slavery ancient or modern.
Competing interests: No competing interests
It is all very well, clinicians being aware of Modern Slavery - but what are they expected to do about it?
More often than not, clinicans will have suspicions, but nothing certain.
There is a 24-hour "modern slavery helpline" ( 0800 0121 700 or email info.mshelpline@unseenuk.org) - but the response will be "we cannot do anything unless the [putative] victim contacts us directly - please advise them to contact us if..."
There is no proactive investigation of concerns by this charity.
The other alternative is to report suspected cases through the local adult safeguarding systems. Can the authors advise what will happen if this is done?
Competing interests: No competing interests
Re: Modern slavery: a global public health concern
Elizabeth Such and colleagues are right in describing modern slavery as a public health as well as a law enforcement issue. They also highlight the missed opportunity for healthcare professionals to protect victims as a consequence of inadequate training in, and awareness of, its signs, consequences and effective responses. This is especially the case in relation to sexual exploitation.
Data from the UK National Crime Agency show that this was the second largest type of modern slavery and human trafficking exploitation in 2017, accounting for 34% of all victims and, by far, the largest type for female victims at 66% (1). There is little published research on the characteristics or consequences of this crime or victim engagement with the healthcare system but the signals are dismal. In-depth interviews with Albanian (the largest ‘nationality of potential victims’) female survivors of sex slavery in England revealed repeated challenges accessing primary healthcare for themselves and their children. The primary barriers identified were confusion around eligibility criteria and poor understanding of modern slavery in the healthcare system. Victim experience improved dramatically when accompanied by an advocate (2). A study of trafficking survivors in England found that 32% had been sexually abused, 29% had one or more pregnancies while trafficked, 89% of whom had experienced a mental health disorder, and 43% of whom had at least one termination (3). Both victims and clinicians reported difficulties in accessing appropriate healthcare, the latter recognising their need for mandatory training. Barnado’s Panel for the Protection of Trafficked Children and the Modern Slavery Police Transformation Unit have identified an especially egregious exploitation for fraudulent benefits claims involving the late presentation at maternity services of young vulnerable pregnant Roma who are subsequently removed beyond the reach of healthcare and other services (4).
Given that a recent survey of 33 of the 34 UK medical schools found that only nine currently provide any teaching on modern slavery and that there was little appetite amongst the rest to do so in the future (5) this is a serious gap. We can currently have little confidence that the UK experience is not as parlous as that of the US where while 88% of female survivors reported being assessed by a clinician at least once while trafficked, not a single one had been identified as a victim (6).
1. National Crime Agency. 2018. National Referral Mechanism Statistics-End of Year Summary 2017 EOY17-MSHT http://www.nationalcrimeagency.gov.uk/publications/national-referral-mec....
2. Dando CJ, Brierley R, Saunders K, Mackenzie J. Health inequalities and health equity challenges for victims of modern slavery. J Public Health 2018; 10.1093/pubmed/fdy187.
3. Bick D, Howard LM. Oram S, Zimmerman C. Maternity care for trafficked women: Survivor experiences and clinicians’ perspectives in the United Kingdom’s National Health Service PLOS One 2017 Nov 22;12(11):e0187856.
4. Rachel Hooper and Jason Grove. 2018. Child Trafficking –Roma Children, Pregnancy and Exploitation. Barnardo’s West Midlands PPTC and the Modern Slavery Police Transformation Unit.
5. Arulrajah P and Steele S. UK medical education on human trafficking: assessing the uptake of the opportunity to shape awareness, safeguarding and referral in the curriculum” BMC Med Educ 2018; 18:137.
6. Macias-Konstantopoulos W. Human Trafficking: The Role of Medicine in Interrupting the Cycle of Abuse and Violence. Ann Intern Med 2016; 165(8):582-588).
Competing interests: No competing interests