What you should know about modern day slavery
Stopping human trafficking is a government priority in the UK
Slavery in Britain was officially abolished two centuries ago. Yet 13 000 people in the United Kingdom today might be modern day slaves, forced to work unpaid in jobs such as labouring, cleaning, and domestic service.
The scandal has become a government priority. In one of her first moves as prime minister, Theresa May pledged £33m (€37m; $40m) of the UK’s aid budget towards the fight against modern day slavery, and she plans to establish a UK task force to tackle the problem, which she has called “the great human rights issue of our time.”
A study published in 2015 found that up to one in eight NHS staff and one in five maternity staff said they’d known or suspected that a patient was a victim of human trafficking. However, research suggests that health professionals, as well as medical students, lack confidence in identifying and responding to people who might have been trafficked.  
What is human trafficking?
Human trafficking is the fastest growing form of slavery today. Trafficking entails the recruitment and movement of people, often by force, fraud, or coercion, to be exploited for their labour. It is also a lucrative and clandestine business that can affect people of any age, sex, ethnicity, or sexuality.   Police investigations have uncovered cases of human trafficking in nail bars, cleaning companies, and car washes, as well as among people forced into sex work, domestic servitude, and other forms of labour. 
People may be lured by a romantic relationship with a trafficker or by the promise of opportunities to study or work abroad, or they may be fleeing poverty and violence. A study of women from Moldova who had been subjected to human trafficking found two thirds had previously been unemployed, two thirds had experienced childhood physical abuse, and a third had experienced childhood sexual abuse.
Traffickers exploit their victims’ hopes for better lives. Many have relationships of trust with their victims. The International Organization for Migration’s counter trafficking database showed that 46% of victims knew their recruiter.
Many trafficked people find themselves in situations of debt bondage. They are told they must repay the costs of documents, transportation, accommodation, and subsistence before they can regain their freedom. The costs are often inflated beyond what they can pay. Traffickers might threaten them and their families and subject them to physical, sexual, and psychological abuse. Without friends, money, and documentation to show their right to be in the country, people are dependent on their traffickers.
Box 1: Scale of human trafficking
- Almost 21 million people worldwide are subjected to forced labour as a result of human trafficking
- People who have been trafficked come from over 127 countries—including the UK—and are trafficked within and across international borders
- A protocol to prevent and punish human trafficking has been signed by 117 nations, but 40% of them have yet to convict a trafficker 
- Human trafficking is one of the largest sources of global illegal income, with an estimated value of $31.6bn
Box 2: Ash’s story
Seventeen year old Ash* is the eldest of six children of a widowed mother living in rural Albania. He was desperate to support his family, and his uncle promised to get him a well paid job in the UK.
When Ash arrived in the UK under a false passport, his uncle told him that he must repay the cost of his documentation and travel. Ash had to serve around the house and was punished for not doing so—sometimes going for days with little food or water. Later, his uncle forced him to work for a construction agency and withheld his wages. Ash endured abuse from his uncle and aunt, who were often drunk and violent. He was burnt with cigarettes and repeatedly hit and kicked.
*Ash is a pseudonym
Harmful to health
In addition to psychological, physical, and sexual abuse, trafficked people might experience poor living and working conditions. A woman who had been trafficked who was interviewed in a European study said: “I was beaten in the abdomen and head, but never in the face because they didn’t want to ruin the merchandise.”
Many have a range of acute and chronic health problems as a result of their treatment.   Symptoms commonly reported include headaches, stomach pain, back pain, dental pain, memory problems, and loss of appetite.
Trafficked people may also face sexual health problems, unwanted pregnancies, and terminations. Studies show that 44% of trafficked women reported sexually transmitted infections and 17% reported at least one termination of pregnancy.  Mental health problems among trafficked people include post-traumatic stress disorder, depression, and anxiety. Substance misuse may be used to improve compliance with traffickers or as a coping strategy.  One victim said: “Sometimes I don’t see the point in doing anything. It seems useless. When someone has controlled you and made decisions for you for so long, you can’t make them for yourself anymore.”
What to do if a trafficked person presents
Seeking medical attention for injuries or illnesses and for pregnancies means victims may encounter healthcare professionals in general practice, sexual health, emergency departments, and maternal health services, among other settings. These encounters are important opportunities to help victims, both with clinical care and information about support options and safe referral.
People who have been trafficked might be reluctant to talk about their situation. Sometimes they are accompanied by their trafficker. Even when alone, they may fear arrest, deportation, or consequences to their family. Liz Murphy, a general practitioner from The Haven, a “first stop” clinic for newly arrived asylum seekers in Bristol, says, “It may be that something doesn’t quite add up in the history”. She suggests using open ended questions, such as “How safe do you feel?” to get sufficient information before a more detailed second assessment.
It is important to meet patients’ immediate health concerns and to use a patient centred approach when treating someone who is a suspected or known victim of trafficking. The handbook Caring for Trafficked Persons: Guidance for Health Providers describes the need to create a “safe space” and “rights based” environment. The patient should understand they have the right to:
- Speak to their healthcare professional in confidence
- Give and withhold informed consent
- A private consultation space
- Non-judgmental treatment
- Accurate and easily understandable information
- Choose who can treat them.
Murphy says “listen, respect and believe the patient—you need to try and establish a trusting relationship. Do not expect to do it all in one go . . . be aware of the complexity of trafficked people, the health and social problems that interplay, requiring a holistic approach.”
She says this approach will help the healthcare professional to find out more about the patient’s situation and encourage them to continue to use health services. It can also be empowering, by promoting the patient’s autonomy—something most will have been deprived of.
Health professionals should familiarise themselves with local and national support arrangements and referral pathways and consider a safety plan. Potential victims of trafficking who enter the UK National Referral Mechanism can receive government funded temporary accommodation and support. The National Referral Mechanism was established by the government to aid victim identification and ensure appropriate support and protection. Health professionals can refer individuals by completing a form on their website or calling the National Referral Mechanism for guidance (box 3). The Ministry of Justice and the Home Office have produced information leaflets in 12 languages detailing the support available.
Box 3: Hannah’s story
Hannah* is a 26 year old Nigerian woman who attended hospital after collapsing in the street. She came with an acquaintance from her church. The doctor explained that Hannah would need to be seen alone and showed her to a private consulting room.
She asked Hannah whether she felt safe to talk. Hannah said she was afraid because she hadn’t ever gone far from the house and that she wasn’t sure where she was. The doctor asked Hannah where she had been living. She said she lived with a family, cooking, cleaning, and looking after the children. The doctor said that she would like to understand more—where did she sleep, for example? Hannah said that she slept on the floor of the children’s room.
The doctor noticed that Hannah’s face was swollen and asked whether the injury happened while she was working. Hannah started to cry and said her employer had hit her several times and had thrown her out of the house. The doctor acknowledged that Hannah was upset and thanked her for telling her what happened.
The doctor reassured Hannah that the hospital was a safe place and asked if she would like to be put in touch with an organisation that might be able to help. She explained what type of support might be available, and asked questions to make sure that Hannah understood. Hannah gave the doctor permission to call a confidential trafficking helpline and she was referred to a charity that provided accommodation and support for trafficked people.
*Hannah is a pseudonym
Box 4: Checklist for a suspected trafficked person
- Do not raise concerns about trafficking with the person accompanying a patient
- Use an independent, qualified interpreter who has been checked by the police or Language Line, a UK translation service. Bilingual co-workers may also be able to assist
- If there are immediate risks to safety, be ready to call 999 or support organisations, and use safety plans already in place
- You have a legal obligation to safeguard children that present to you. If you suspect that someone is under 18 years of age and a victim of trafficking, follow child protection procedures and talk to your child protection lead
- Salvation Army 24/7 referral hotline (victim support helpline and authorised to refer into the National Referral Mechanism) 0300 303 8151. Alternatively, contact the NSPCC CTAC (0808 800 5000) in cases of suspected child trafficking. The UK Modern Slavery Helpline and Resource Centre will be launched later this year
Remember that the primary goal is patient care rather than disclosure or rescue. Not all victims of trafficking will agree to police contact or referral to support services. In that case, says Murphy, “Remember to be proactive and follow-up, you want to know what has happened to them. Don’t forget them.”
Box 5: Screening tool to identify trafficked people
- R—Not registered with general practitioner/nursery/school
- A—Accompanied by a person (or people) who seems controlling
- F—Foreign language
- F—Frequently moving location
- I—Inconsistent history and clinical findings
- C—No control of documents
- K—Keep alert, follow up cues, and trust your instincts
- E—Evidence of injuries—acute and chronic—or neglect
- D—Does not attend future appointments
In 2015, there was a 40% rise in the number of potential victims of trafficking identified and referred into the National Referral Mechanism.
May has identified several key areas for improvement, including raising awareness, improving training for those who might encounter trafficked people, and strengthening support for victims.
Medical students have an important opportunity to support people who have been trafficked through the provision of care and, potentially, through identification and safe referral. Integrating human trafficking into the undergraduate medical curriculum would enable medical students to become part of the struggle against modern day slavery.Lucy Williams, fourth year medical student1, Eghoihunu Ireo, fourth year medical student1, Siân Oram, lecturer in women’s mental health2
1University of Bristol, UK, 2Institute of Psychiatry, Psychology and Neuroscience, King’s College London, UK
Competing interests: SO has been funded by the Department of Health Policy Research Programme (Optimising Identification, Referral and Care of Trafficked People within the NHS 115/0006).
Provenance and peer review: Not commissioned; externally peer reviewed.
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