>> Leilani Funaki: Okay.
We're going to go ahead and get started.
So, once again, if you can't hear me, go ahead and type, "No" in the chat box.
But I think we've worked out our issues with sound.
So, once again, great, everyone can hear.
Wonderful.
Welcome to our webinar.
Today we're going to talk about an introduction to a public health framework for human trafficking.
We're really excited to have all of you join us here.
Today's speakers are Dr. Hanni Stoklosa and Dr. Kimberly Chang.
I'm going to give them each a minute here to speak about themselves.
>> Hanni Stoklosa: Hi, everyone.
This is Hanni Stoklosa.
I'm super excited about this webinar and excited to be speaking today.
I'm an emergency medicine physician and executive director of HEAL Trafficking, a network of
over 1,200 professionals that are dedicated to combating trafficking through a public
health lens.
I'm super excited to be here today.
>> Kimberly Chang: Hi, everyone.
My name is Kimberly Chang.
I'm a family medicine physician at Asian Health Services in Oakland, California and also working
with Dr. Stoklosa on HEAL Trafficking as a co-founder and an executive committee member.
I'm happy to be here, and I'm glad that so many of you are here listening.
You'll hear more about the respective work that we're doing around this area in the public
health intersection for human trafficking.
>> Leilani Funaki: So, we're super excited to talk you through all of these different
learning objectives for the day.
Historically, the approach to trafficking globally and nationally has focused on a reactive
approach to trafficking.
What's unique about public health response is that it allows communities to identify
and respond to the complex needs of all survivors of trafficking while addressing the root causes
that make individuals, families, and communities vulnerable to trafficking.
In this webinar, we are going to apply the upstream-downstream metaphor to public health
response, discuss how it applies to human trafficking, and we're going to compare the
differences between the criminal justice and public health approaches to human trafficking.
We're also going to talk through three critical components of the public health framework
for trafficking including using an evidence base to develop relevant policies, and programs
and actively working to prevent human trafficking from occurring, and examining and addressing
the societal behaviors and views that increase the risk of human trafficking.
And finally, we're going to apply the public health framework to a real-life case of trafficking.
But first, we want to hear from all of you.
So, what are your fields of expertise?
We'd love to know the work that you're doing so we get a snapshot of who's on the webinar
with us.
Hi.
So far, it looks like we have people joining us who work in sexual assault and domestic
violence prevention, people who work in victims' services, human trafficking prevention, someone
who is a midwife, and sexual assault coordinator.
We've got people who are forensic nurses who work in direct services, others who work -- it
looks like mathematical modeling of social issues.
That's interesting.
We've got a wide variety of people, more nurses, people who work within crisis shelters, case
managers.
So, a good swath there of people in public health.
>> Hanni Stoklosa: A lot of expertise across the country.
So, I want to get to the core of what a public issue is first before we move on.
So, you may have heard this term kind of batted around.
The 2017 Trafficking in Persons Report has a page dedicated to the public health response
to trafficking.
The Office of Trafficking in Persons is dedicated to a public health response to trafficking,
but what does that actually mean?
So, I'm going to start off with a story, and the story involves in this river in the picture
here.
Once upon a time, there was a dangerous river.
Many people were drowning in that river.
Rescue workers struggled to pull them out, but the rescue workers soon realized that
no matter how hard they worked, they could not save all the victims.
They discussed raising funds to hire more rescue staff, suggested that warning signs
could be installed, and considered even arresting some of the drowning victims as a deterrent
to other people from entering the river.
But despite doing all of this, people continued to drown in the river because they weren't
taking the public health approach.
So, the public health approach is unique because it goes beyond rescue and looks upstream to
figure out why people are falling into the river in the first place.
The public health approach, then, takes that information about why people end up in the
river, and comes up with solutions.
You may have heard the public health words, risk and protective factors.
For example, in this case, maybe the issue is that most folks are simply trying to cross
the river because they need to get to the other side.
An upstream public health solution might be to build a bridge to make the crossing easier,
and safer for everyone involved.
Clearly, most public health problems are not -- don't have solutions that are that simple
or we would have solved them all.
But you can see that it's so easy to be busy investing all of one's human and financial
resources in rescuing people, and it can look really great for headlines.
But preventing the drowning in the first place can truly save lives and resources.
The other thing that I want to touch on this slide is the difference between health or
medicine and public health.
And I hear people using those words kind of interchangeably, and it's important to know
the distinctions between those two terms.
So, public health and health are different in how we look at a problem as well as how
we respond to problems.
So, in health or in medicine, a patient is an individual person.
So, one person.
And we're looking at them one by one.
In public health, the patient is actually a whole community or a whole population.
So, it's taking that macro lens, that macro view.
So, going back to the stream analogy, a health response is much more downstream.
It's part of the response, but it's downstream.
And it's limited specifically to the medical needs of the survivors of drowning.
And certainly, something can be both a health issue and a public health issue.
HIV is a wonderful example of that.
So, I just wanted to make that clarification of terminology just before we get started.
Many of you have probably seen this social ecological model before.
It really forms the foundation of how public health thinks about a problem, and how public
health breaks down risk as well as protective factors.
I know on the slide here, we have risk factors.
But we think in both regards.
So, as I'm going through this model here, I encourage you to think at each of these
layers of risk and protection of some of the risks and protective factors that come to
your own mind based on the populations that you work with.
So, on a societal level, what are the factors that create an acceptable climate for trafficking?
Those that reduce inhibitions against trafficking.
The second level is the ecological model; it examines the community context in which
social relationships are embedded such as schools, workplaces, and neighborhoods.
And seeks to identify the characteristics of these settings that are associated with
being victims of trafficking.
The third level explores how proximal social relationships, so relationships with peers,
intimate partners, and family members increase the risk for trafficking victimization.
And the final level is the individual level which focuses on the individual characteristics
including personal history of abuse, or personal behaviors that may increase the likelihood
of a victim of trafficking.
Or the conversely, being protected from it or resiliency.
So, let's apply the social ecological model to trafficking.
Going down the line, a societal risk factor may be the demand for cheap goods in society.
A community level risk factor may be a lack of worker rights.
A relationship risk factor may be family conflict.
And finally, an individual risk factor may be being an immigrant who is undocumented.
So, as I mentioned before, this is the foundation for designing prevention programs.
The first step is really understanding risk and protective factors before policy and community
organizations go about their work, so that they can be targeted and strategic.
Another thing that I just want to point out here is that as you're listening, you may
notice that upstream, and on kind of those larger nested eggs of the society in the community
level, that there's a lot of overlap with other communities that we work with, other
communities who experience interpersonal violence: community violence, elder abuse, child abuse,
and sexual assault.
And what this means is that we can glean from lessons learned from public health responses
to other forms of violence to inform how we respond to trafficking.
So, now we're going to transition to talking about why a public health approach is really
a frame shift from the way that trafficking has been historically approached.
I'm going to turn it over to Kimberly.
>> Kimberly Chang: Hi, everyone.
Thank you, Hanni, for the socio-ecological model and explanation for public health approach
to trafficking.
I do want to emphasize that historically, the criminal justice system has played the
primary role in combating human trafficking.
And that has been really wonderful in bringing up a lot of awareness and prosecuting traffickers
who are exploiting and victimizing individuals.
However, there is an important role for the public health in a prevention framework, and
the reason there is an important role is that there are differences between the two systems.
Preventing a crime and holding the traffickers to account has been paramount historically.
However, as we learn more about the effects of being trafficked on people, we are starting
to realize that the toll and the harms of being trafficked has on people in the long
term and in the shorter term, that these are -- that there are medical, mental health,
and social harms to being trafficked.
As many social services and health care professionals reach out to provide services to those who
are exploited, much as many of you who are listening on this webinar today, we've all
come to realize that there are differences in the way the systems approach the issue.
And, therefore, a public health framework and system is essential to working with the
criminal justice system.
So, we should be aware of these system differences in these frameworks and systems.
Mind you, these are not slides about the level of care or concern of the individual professionals
in the different systems, but rather that the goal, and the set ups of the systems and
frameworks are different.
So, let's go a little bit through some of these differences.
In a criminal justice framework, the paramount goal is to uphold the laws of the state.
For the public health and the prevention framework, the goal is to advance the population's health.
You heard Dr. Stoklosa talk about public health as advancing the population rather than the
medical framework which advances individual's health.
Secondly, even our language is different.
Criminal justice framework refers to the individuals who are exploited as victims, and we refer
to them as patients if you're in the medical field, or as clients in a social services
field.
Criminal justice framework often is a more defined timeframe.
How long does the case take to be prosecuted, investigated, and punishment meted out?
Whereas, in the public health and the prevention framework, we're looking at a longer-term
process from the cradle to the grave, from the risk and protective factors.
And then, after someone has transitioned out of being trafficked, how do we care for those
individuals in the long term?
On a criminal justice framework, there is a justice orientation, and it might be more
government-based, whereas a public health and a prevention framework is an individual
orientation, and it could be more community-based.
And finally, in regards to the goals of upholding the laws of the state, criminal justice framework
wants to, you know, punish the traffickers.
Whereas, we're focused more technically on the individuals who are being exploited, and
prevention, and treating those harms.
So, I'm going to turn it over to Hanni to talk about how the Department of State framework
goes along with this.
>> Hanni Stoklosa: Thanks Kimberly.
So, as Kimberly has pointed out, given that these different systems have different goals,
they are incentivized differently and, therefore, you know, their success is also defined differently.
So, many of you are familiar with the government's -- the U.S. Government's P's of response.
They're laid out in the U.S. law on trafficking, the TVPA.
They're also present -- you may have seen them in the Trafficking in Persons Report.
So, the core P's of response to trafficking are prosecution, protection, prevention, and
then the fourth P is the P of partnership.
So, as you can see here, uniquely, public health focuses on prevention; and then uniquely,
criminal justice focuses on the prosecution side of things.
But what they do share is that partnership and protection piece.
So, the protection piece is caring for victims after they've been identified and thinking
about their long-term care.
And they have different lenses to that, but they're both thinking about that and then
partnership.
This slide is just to remind us that no one of us, no one sector, is going to be able
to solve trafficking.
This is a huge problem, and it really takes a multi-sectorial response, a multidisciplinary
response, that requires all of us to work together in partnership.
And what's beautiful about public health is it gives us that framework, that umbrella,
to be able to work together across all these different sectors.
>> Kimberly Chang: So, now that we see how the systems are set up differently, how there
are overall different goals and priorities, how then do we develop an evidence base to
address human trafficking and the public health response to help us develop policies?
This slide is based on a framework article by Jonathan Hodges, a law professor and colleague
of ours in Georgia who served on the 2011 Institute on Medicine seminal report on the
Commercial Sexual Exploitation and Sex Trafficking of Children and Youth in the United States.
He notes that there are three components of a public health response to human trafficking.
They are -- one, using an evidence base to develop relevant policy and programs.
Two, actively working to prevent human trafficking from occurring.
And three, examining and addressing societal behaviors and views that increase the risk
of human trafficking.
So, I wonder -- I wonder, Hanni, or Dr. Stoklosa, how do we develop an evidence base to address
human trafficking, and the public health response to help us develop policies?
>> Hanni Stoklosa: Thanks so much for that question, Dr. Chang.
[Laughter]
>> Hanni Stoklosa: So, this is something that HEAL Trafficking with a wonderful network
of over 1,200 professionals that are fighting trafficking from a public health perspective
have thought about, and we actually decided to approach this internally with a consensus
process to take folks who have been thinking about this field for a while and really take
a look at where the field is at, and what are those -- where are those critical gaps
in research.
And the findings of that consensus process were just published in June of this year in
the American Journal of Public Health.
And the five main pieces to our proposed agenda for the public health research on trafficking
are: One, determine the prevalence and incidence of human trafficking with better precision.
Two, estimate the cost burden of human trafficking.
Three, identify risk and protective factors for human trafficking victimization, perpetration,
survival, and resilience.
Investigate effectiveness of health care screening and response protocols, and implement and
evaluate human trafficking prevention strategies.
So, I'm just going to go through a couple of these here, but the first two, in terms
of getting at better numbers as well as the cost, really are -- to better understand the
impact of trafficking on our society, particularly in the U.S.
This is the U.S.-focused agenda.
And this is really important with any framing of a public health issue to be able to engage
with our policy makers, as well as to better understand the populations that we're trying
to target, to have a better sense of who is truly impacted and what is the cost.
And then as we've gone through the social ecological model, this very much harmonizes
with that, but we really don't understand what are the risk and protective factors for
trafficking, not only victimization, but also perpetration and survivorship as well as resilience.
There's so much to learn, and we are, you know, we're at that stage with trafficking
that we were with other fields of violence over a half a century ago.
So, you know, there's a lot to -- there's a lot to still to understand.
And then finally, I'm going to talk about implementing and evaluating human trafficking
prevention strategies.
We really need to learn from what other fields of complex social problems, such as gender-based
violence, have learned from their journey of coming up with prevention strategies.
And I'll just give you a brief example here, but just to -- as a kind of cautionary tale,
what is intuitive and what seems to make sense to a researcher or to a policymaker may not
be the best thing for a community or for survivors.
And one example would be whenever microfinance programs were first used to combat gender-based
violence, they were implemented in isolation in poor communities.
And what they found initially when they were implemented in isolation is actually the unintended
consequence of increased intimate partner violence as a result of microfinance programs
going into place.
And it was super well-intentioned, but had this unintended harm.
Now, years later, they've discovered that if you combine microfinance programs with
changes in social norms, such as gender transformative approaches, which is just kind of fancy lingo
to talk about changing the way people think about gender roles, but coupling that program
together with the microfinance program results in decreased interpersonal violence.
So, there's two lessons there.
One is to realize that what seems like the best idea may not [laughs] always be the best
idea, and to really -- to be thoughtful about any of the prevention initiatives that we
undertake to make sure that we're doing constant, continuous evaluation as we do implement prevention
programs.
And then number two, to engage our communities as well as engaging the survivors that we're
aiming to serve in the design and the implementation of any of the evidence that we're building,
and any of the programs that we're doing because they may be able to see, you know, way down
the line, see those unintended consequences coming from miles in a way that we would not.
And ultimately, this is for them.
So, those are just some lessons learned from the interpersonal violence community, gender-based
violence research world as well as just to give you a snapshot of the agenda that we
put forward.
>> Kimberly Chang: Thanks for that, Hanni.
I see a question someone's asking how difficult is it to determine -- given how difficult
it is to determine the prevalence of a hidden crime, do we have any suggestions for how
to do this?
So, I want to turn this over back to you, the audience, because many of you are experts
in this field.
And we'd love to get your perspective.
What do you think are the most pressing research gaps in the public health response to trafficking?
And, perhaps, see if you have any suggestions for how to determine prevalence studies for
a hidden crime such as this.
And, Hanni, maybe you have some ideas to answer that question from one of the audience.
>> Hanni Stoklosa: Yeah, I'm happy to chime in on the [laughs] prevalence piece.
There are many, many brilliant folks that have been thinking about this over the years,
and there's going to be a new global estimate that's about to be released.
I believe it's going to be next week, based on, kind of, some new statistical modeling
that brought together the International Labor Organization with another large NGO.
There are folks that have been thinking very thoughtfully about it within the United States,
and there are working groups that are working on this particular piece.
So, it is something that's of interest.
There are people that are working night and day on that question.
>> Kimberly Chang: That's great.
I wasn't aware of that new initiative with the ILO, so that's wonderful that that's happening.
And it's great that there's a mathematical modeling person on this webinar as well.
So, let's see some of the responses are legal help, lack of awareness of human trafficking
happening right in the local community.
Someone thinks that the research gap is an outcome analysis on the prevention efforts.
Does anybody else have any thoughts on what might be more pressing gaps in the public
health response to human trafficking?
>> Leilani Funaki: It looks like we have a few people who are typing in their answers
at the moment.
We'll give you just a few more seconds to finish your thoughts.
There we go.
Someone says there's a lack of a standard protocol.
A few more people still typing.
Okay.
Another response here is that there is misinformation that because a person discloses that they
have been the victim of crime, domestic violence as an example, that they don't look into the
person for further assessment to see if they have also experienced human trafficking.
That's a really good point.
There's also a lack of parental and community awareness.
And then someone else is saying that they see is it more as a societal issue and that
awareness needs to be addressed, as well as how to intervene once you suspect that trafficking
is occurring.
These are good responses.
So, we're definitely seeing some common themes there like, you know, needs for standard protocols
and what not.
I don't know with either one of you, Dr. Chang or Dr. Stoklosa, have any thoughts about that.
>> Kimberly Chang: I was thinking -- as I'm reading these awesome comments and suggestions,
I was thinking about what we came across at Asian Health Services.
And we were seeing a number of young Southeast Asian, and girls who were being commercially
sexually exploited and sex trafficked back in the early 2000s.
And we really didn�t have an idea of how big, or how small, or how much of a problem
this was in our community, but we knew we were seeing a lot of patients who were being
affected.
And so, what we did was a retrospective chart review and analysis, and it only pertains
to our clinic.
It only pertains to our teen clinic and our patients who come here.
But, you know, it basically just confirms that there were patients who were being trafficked.
It's not generalizable, but I wonder if we could get a critical mass of community health
centers or health delivery systems that have a standardized protocol and were able to capture
that information, and if that information or that data could be analyzed and would give
a, you know, much larger sample across diverse community groups.
And if that would make an impact.
I'm not a researcher by trade.
I'm a family physician and health policy person, but I wonder if that might make a difference.
What do you think, Hanni?
>> Hanni Stoklosa: I really like that idea.
I'm going to get back to kind of the together we're stronger, and the patterns that we're
seeing across the United States may vary based on whether we're in a rural versus urban community,
and the populations that we serve.
I will point out that HEAL does have a research committee, and it's an excellent space to
form these kinds of collaborations.
When people are looking for protocols as a starting point, we also have a spot on our
website with healthcare-specific protocols, but there are ones that are already developed
in communities.
They're more community based as somebody has been asking for.
So, I'm happy if our -- my contact information is shared if people want to get in touch about
further research, I'm happy to share.
But we have a -- as a resource in addition to looking at kind of examples, which I think
is really helpful, we also have a protocol toolkit which walks you through kind of from
A to Z how to do stakeholder analysis, analyze what your resources are in your community
all the way through to monitoring and evaluation of your protocol.
So, it's a huge resource that's free to download on our website too.
>> Kimberly Chang: There's a lot of great comments on the chat room.
>> Hanni Stoklosa: Yeah.
>> Kim: It's very active.
Leilani, do you want to share some of those?
>> Leilani Funaki: Yeah, yeah.
So, an interesting comment that just popped up was that the general media representation
of what trafficking looks like is not always accurate.
You know, I think that it's very true that when people hear the term trafficking, that
their minds do jump to movies like Taken and Liam Neeson, and tend to overlook that there
are other types of trafficking.
And it may be not quite the way that the media has portrayed it.
That kind of feeds in with these other comments about changing society's perspective about
trafficking.
Another one is saying that you could change our perspective that states that poverty and
trafficking must go together.
So, this person lives north of Seattle, and the differences that they see are more urban
and rural.
That's a good point.
Also, good to note that trafficking doesn't just happen in other countries.
It happens here, and it's not only in immigrant populations.
So, yeah, a lot of good comments here.
>> Hanni Stoklosa: Great.
Let's keep the conversation, and we'll have a couple other spots in this presentation
to hear from others, but continue to share your thoughts.
So, [laughs] as I was preparing for this, I was thinking, you know, whoever is listening
to this is going to get like a mini public health degree [laughs] because we're going
through a lot of really core principles of public health, which I think is really exciting.
It's the nerd in me, but this next little bit is to talk about what we mean by prevention,
when we use the word prevention.
There's actually three different main categories of prevention, and these are the main buckets
that you see.
And Kimberly is going to go into more depth about this in just a second, but I want you
to cement these pictures in your mind as she's going through so you remember what each of
these types of prevention mean.
So, what is primary prevention?
Primary prevention is what I was referring to when I gave that stream analogy at the
beginning.
So, it's stopping something before it even starts.
So, stopping trafficking before it would start.
So, for example, if they installed that bridge that crossed over the stream, then no one
would be falling into the river.
Secondary prevention.
So, here you see an adult talking to a child.
Here is early identification of trafficking and reducing the harm of trafficking.
So, there hasn't been harm yet.
The trafficking has just started.
So, in this picture, this may be a caseworker interviewing a foster child, and there's a
screening assessment.
And that child is identified as being trafficked, but it�s early on.
They had just started to be trafficked.
So, that's secondary prevention.
And then tertiary prevention: this picture is a revolving door.
What I should insert in that revolving door is like a brake or something [laughs], like
a wedge underneath there to stop it.
So, tertiary prevention is really preventing, in the context of trafficking, is preventing
somebody from being re-trafficked.
So, they've been trafficked, and now your goal is to prevent them from being re-trafficked.
So, they got out of that situation, but how do we prevent them from ending back in that
situation by addressing their underlying vulnerabilities.
So, Kim wrote this amazing chapter in our book on public health and trafficking that
focused on community health centers as well as prevention, and she's going to talk through
in more detail what each of these terms mean.
>> Kimberly Chang: Okay.
This is a basic two-by-two box, and I'm going to walk you through it, explain it a little
bit to help you understand what we mean by this.
So, on the top here, this is what would be the direct service professional is diagnosing
or observing.
So, in the first column, the direct service professional, whether it's a social worker,
or an outreach worker, or a clinician, nurse, what have you, caseworker, is making the determination
that, or not suspecting that there's any human trafficking.
So, this column, human trafficking is absent.
In the second column from the top, the direct service professional is making the determination,
or the diagnosis that human trafficking is present in their patient or their client.
Here on the left side, we have the patient or the client, what the patient or the client
is experiencing.
And so, in the first row, we have that the patient or client has not experienced any
health harms.
So, the harms of human trafficking are absent.
This row is absent.
Harms are absent.
On the second row from the left side, what the patient or the client is experiencing
are harms, harms from being trafficked.
So, this second row is harms being present.
So, if we go through this two-by-two box, and we say whenever a client or a patient
is interfacing with the professional, healthcare professional or direct service professional,
primary prevention is really when there is no human trafficking present.
Human trafficking is absent, and there are no harms.
So, examples of primary prevention could be identifying any risk factors for trafficking
such as violence in the home, or exploited labor, or risks for exploited labor and connecting
patients or clients to appropriate services.
Also, building awareness, I see some folks in the chat room are very interested in working
in primary prevention, and primary prevention is when there is no trafficking.
And there are no harms yet, but maybe communities are at risk or populations or individuals
are at risk.
And so, you're trying to raise that awareness and build up those resiliencies so that human
trafficking does not occur.
In the next box, secondary prevention, there is human trafficking being present.
The patient or the client is being trafficked.
You can see here human trafficking is present, but there are no -- not yet any harms, no
medical harms, or mental health harms, or social harms.
It could be very early during, for example, in a case of a child who is being commercially
sexually exploited; it could in the grooming phase.
They may not yet have experienced any physical violence, or have come to the awareness, or
idea that there is any mental health harms.
So, an example of a secondary prevention could be screening tools for identifying clients
early in the clinics or schools.
In the third box here, this would tertiary prevention.
Human trafficking would be present.
Harms would be present.
Example interventions would be Dr. Stoklosa's work, for example, working in the emergency
department, referral to services that are needed for physical and mental health, housing
services, job training, legal services, criminal justice interface is very much a tertiary
prevention type of service.
And so, that's very important.
That's where a lot of our work is being done right now in terms of intervention.
And so, this is what tertiary prevention is.
And finally, this last box, it doesn't have a prevention name.
But I call it long-term care where perhaps a patient or client has been transitioned
out of being trafficked, but harms are still present.
And what does that mean?
How can harms still be present if a patient or a client is not still being trafficked?
Well, there are long-term harms of being trafficked.
Many of you experts listening on this webinar know that there are a lot of mental health
harms.
There are social harms to being trafficked: lack of education, lack of job training or
job opportunities, mental harms, trauma, anxiety, depression, substance abuse issues from the
force prior to coercion from being trafficked.
And so, long-term care in a public health approach and prevention model is essential.
It is essential because we want to prevent patients or clients who have already been
trafficked from being revictimized or re-trafficked, and we want to help those who have been exploited
reintegrate and move forward with a healthier life.
So, example interventions include providing long-term health, and behavioral healthcare,
and social services for people who have a history of being trafficked.
I hope this makes sense.
It's a very detailed table, and so, if you have any questions, perhaps type them into
the box.
>> Hanni Stoklosa: Thank you, Dr. Chang.
There may be some questions pop up, but we can answer them as they come along there.
So, going back to your new favorite diagram, the social ecological model, we're going to
-- I'm going to touch on here the third point of the Todres framework on the public health
response trafficking, which is addressing societal behaviors and views that increase
the risk of human trafficking.
So, that takes us out here to this most outer ring of risk and protection.
So, here we have listed societal risk factors of lack of resources, lack of knowledge of
labor, and sex trafficking, health and economic disparities.
And I'm sure that we could all fill in a number of other pieces here.
I had mentioned earlier just the demand for cheap goods, for example.
This is arguably one of the hardest layers to focus on whenever we're thinking about
prevention efforts because we're talking about shifting societal norms [laughs].
It's no easy task, and it's really kind of the long game when we think about prevention.
And at this highest level, you can imagine just, you know, how I showed that the intersectionality
of other forms of interpersonal violence with trafficking, as we're looking upstream to
prevent trafficking thinking about these societal risk factors, we're also going to be thinking
about other forms of violence in those prevention efforts.
A couple of points that I wanted to make here very briefly is that awareness raising, which
is one of the prevention efforts that gets at this level, needs to be done really, really
thoughtfully.
So, we've learned from kind of the anti-smoking public health campaigns that actually some
of the campaigns that, you know, the ones that you see that have all the scary messaging
or have like really grotesque kind of like burned lungs, et cetera; many of us have seen
those, have sometimes a counter effect.
So, sometimes cause people to smoke more, or have no deterrent effect at all.
And so, it's really important as we -- if, as organizations or as policymakers, we decide
to invest money in awareness efforts, that we think about kind of the psychology behind
those efforts and work closely with those that have worked on other public health campaigns
and have really market tested the awareness efforts before kind of launching it out kind
of full force because it can have unintended consequences.
There was a recent study in Nepal that was specific to trafficking that did a nationwide
awareness campaign, and what I found fascinating about that was that it raised overall level
of awareness that trafficking was happening in this country, but it never made a dent
in the local communities feeling that they might be at risk.
So, it's almost like psychological dissonance that okay, I can imagine that it happens maybe
in my country, but in my community?
No.
No way.
Not in my neighborhood.
And so, how do we creatively as public health experts, how do we get at that psychology
and create messaging that will really have an impact on behavior change, and will help
people to realize that those that are at risk realize the risk and prevent them from being
trafficked?
So, awareness campaigns have a lot of caveats just to kind of keep in mind, and we should
certainly learn from other fields as they've learned along the years.
So, we're just going to go onto the next slide here.
What I'm really excited about here is now we can take all of these lessons that we've
talked about in terms of the public health framework and apply them to a case.
And Dr. Chang is going to walk us through that.
>> Kimberly Chang: Okay.
So, this is a patient of mine from several years ago.
So, this is Asian Health Services.
It's a federally-qualified health center where I work in Oakland, California.
I've worked there for about 14 years now.
It's a typical health center in that it's deeply rooted in the community and has a long
history of advocacy on behalf of its patients.
And so, one night several years back, a patient came into see me at the clinic very, very
sick.
She was a young Southeast Asian girl.
She was about 15 years old.
She was born in the United States.
Her parents were refugees from the Cambodian genocide.
So, this night she came in, she had a high fever.
She had rashes all over her body.
She had swollen, painful joints and a 30-pound weight loss over three months.
She needed to go to the hospital.
And when I told her this, she absolutely refused.
And she told me that she would rather die than go back to jail.
On a previous hospitalization, BK [spelled phonetically] was discharged to jail because
there was a bench warrant for her arrest for failing to appear in court on solicitation
or prostitution charges.
So, BK did not go to the ER that night.
And really, this was a turning point case for me, an ah-ha point, where I needed to
start becoming more involved in the public health response because what I was doing in
the clinic in a direct service level was not changing many of the structural causes of
why these patients were coming in and being trafficked.
So, that's a little vignette, a little case patient study.
And we wanted to put out to you what do you think, based on this case patient, what are
some risk factors for patients or clients of populations like BK at each level of the
socio ecological model?
And Hanni is going to sort of facilitate this and take you through some of that.
>> Hanni Stoklosa: Yeah, so, maybe I'll just click back for a second on our model.
And we can go back -- so, just thinking about her case, and actually let's just -- so, you
were -- as Dr. Chang was talking through her case, what are some of the pieces -- and it
can be -- it doesn't matter which level you pick.
What are some of her risk factors that put her at risk for trafficking?
>> Leilani Funaki: If you have any ideas, just go ahead and type those into the chat
box there.
Sorry, Dr. Chang, were you going to say something?
>> Kimberly Chang: No, I was going to -- I mean, I have a lot of her social history and
family history.
If people ask questions, I can give some of that for the answers if they're going to write
in the box what some of her risk factors are.
>> Leilani Funaki: Great.
So, we have a few responses that have come in.
One says social isolation as well as a history of being system involved.
>> Kimberly Chang: [Affirmative]
>> Leilani Funaki: A few more people are typing.
>> Hanni Stoklosa: So, the social isolation would put it -- that would be a relationship
risk factor here.
The systems involved, a community risk factor.
>> Leilani Funaki: Another response says the trafficker may be a member of a close-knit
community, so there could be cultural barriers when interacting with law enforcement as well.
>> Hanni Stoklosa: That's important to keep in mind, and that's another community level
one.
And yes, social isolation is a community risk factor as well.
A lot of these are cross-cutting.
Thank you.
Great.
Dr. Chang, do you want to share some of her social history that might --
>> Kimberly Chang: Yeah, so, she was systems involved.
She had run away many times, and she was not in school.
She had been truant for several years.
She had a lot of peers who were involved in commercial sexual exploitation.
And let's see, her family, she had, they were very poor, refugees.
The mother did not -- was a single mom, and she did not speak English, did not have any
education because they were refugees from the genocide actually in Cambodia.
And so, those are some of the family history and social history background for her.
>> Hanni Stoklosa: And then I see one of the participants identified some individual risk
factors for her as well, former sex work -- I'm just going to click forward, Dr. Chang.
So, from there, fill us in.
We're on the edges of our seat.
>> Kimberly Chang: Oh [laughs].
Hanni says fill us in.
Okay.
So, this is an individual case.
We had a number of other patients who were just like BK.
So, a number of patients, young teenage girls who were being commercial sexually exploited.
And so, what did we do from an individual organizational level?
What did we do for a public health response as an individual FQHC, or Federally Qualified
Health Center?
What we did was we went back to our basics.
We went back to what is a community health center supposed to do?
And we have a dual mission at Asian Health Services.
It's to provide service, healthcare services, outreach services, and health education services,
and advocacy, meaning -- advocacy meaning trying to change the structural barriers that
are affecting our patients -- that are affecting or obstructing our patients from achieving
optimal and wellbeing.
So, we went back to our basics, and what we did was we looked at a programmatic approach
to this public health prevention approach to these commercially sexually exploited children
or domestic minor victims of sex trafficking.
And we developed programs in three different areas direct services, research, and policies.
So, in terms of direct services, what we did was we worked with -- we had a youth outreach
program and a lot of community partnerships with youth development organizations in Oakland,
California.
We did a lot of outreach to the youth about this topic.
We did a lot of health education.
We created our own youth development organization for at-risk or currently commercially exploited
minors, called [unintelligible] and we had our direct services.
We had our teen clinic.
We had primary care pediatrics, and we have a behavioral health integration, meaning we
have social workers, counselors, mental health, onsite, where we're working together in the
medical and the mental health fields in close collaboration with warm hand-offs during the
clinic day.
So, that's our direct services.
In terms of research, we developed a screening tool for use with our clinicians.
We shared that widely.
We let it be adopted.
We let it be studied.
We helped to inform other research protocols and screening tools and evaluation of clinical
risk indicators.
In the policy level, and policy is very important because policy drives how we develop these
programs, and you heard one of the objectives for our webinar today was to learn how evidence
base is used to create public health policies for human trafficking.
And so, in the policy level, we were very involved in the local, state, and national
levels in forming human trafficking policies on how they would affect the health of our
patients.
And so, we really, really tried to structure our programs in these three different areas
so that we could apply a public health model instead of just having myself, a clinician,
or other clinicians do the one-on-one work, which really wasn�t ending or helping to
change the conditions that were pre-disposing our patients to being trafficked.
>> Hanni Stoklosa: We want to --
>> Kimberly Chang: Go ahead.
>> Hanni Stoklosa: No.
Go ahead.
>> Hanni Stoklosa: So, we wanted to open it back up to all of you.
We've really enjoyed engaging you and hearing all of your expert thoughts.
So, for this -- for cases like BK, but also just thinking, again, with that public health
lens, thinking broadly in terms of communities that have a number of patients like BK.
What types of prevention efforts might be helpful?
If you were designing programs alongside Asian Health Services, or if you were approaching
this from scratch.
Are there other prevention efforts that you think might be helpful?
>> Leilani Funaki: And, once again, just if you have any thoughts go ahead and enter them
into the chat room.
>> Kimberly Chang: What's that?
>> Leilani Funaki: Sorry.
I'm just reminding people to use the chat box if they have anything to say.
Yeah, but go ahead, Dr. Chang.
I didn't mean to talk over you.
>> Kimberly Chang: Oh, I was going to say or some of the prevention efforts that they
are working on -- that you attendees are working on in your communities because I know many
of you are already doing much of this work.
>> Leilani Funaki: Okay.
It looks like we have one response talking about how people pull together more rather
than allow people to fall through the social cracks.
And we can't deny that human trafficking may occur in the aftermath of events such as hurricanes
and things we've experienced lately, but it's not the most likely scenario.
Let's see, another comment here.
Are you [unintelligible] mentoring especially in cases like BK.?
These young people turn to human trafficking because they see no other possibilities, which
follows along with the next comment which says education for youth on risk and protective
factors especially around healthy relationship dynamics, or how to properly vet job opportunities.
That's a good point.
Another commenter here says human trafficking programming specifically for refugees that
focuses on their particular needs with language-appropriate information with trusted resources within
the community and intentional relationship building with law enforcement and other community
partners.
Okay.
Another comment here.
This person has worked with a group that's developed a research-based curriculum to educate
youth about human trafficking, and to help them build skills to navigate risk.
They're implementing this in schools, child welfare, and other settings.
Someone else is talking about self-esteem classes to cover healthy relationships as
a good starting point, but also tackling low self-esteem as a core issue.
Someone asked about access to the comments.
When we post the recording for this webinar, you can go through and see them.
But we don't have a way to share them with you.
Sorry.
Another comment here in San Diego they need child serving systems, excuse me, to use the
same screening tools so that they may develop an interdisciplinary perspective and begin
to work upstream.
That's a really good comment there.
>> Kimberly Chang: There was also another comment above.
Somebody said or wrote I would have a law enforcement liaison who would work with and
education of law enforcement officers.
We did do some of that actually with Asian Health Services.
We worked closely with the National District Attorneys Association for many years worked
with them on providing training and technical --
>> Leilani Funaki: Okay.
One more comment here that says educating homelessness and child protective services
or state service providers on risk factors for the folks that they serve.
>> Kimberly Chang: A lot of very rich comments.
>> Hanni Stoklosa: [Affirmative]
>> Kimberly Chang: And a lot of great work that people are doing.
>> Hanni Stoklosa: Yeah, it really highlights the interdisciplinary component across the
board.
>> Leilani Funaki: Okay.
I think that might be the end of the comments we have.
>> Hanni Stoklosa: So, I just want to thank you all for engaging with us today.
This has been a really, really rich discussion.
And I hope that it's more than just kind of learning a new vocabulary, or getting a little
mini public health course.
I hope that we've been able to elucidate some of these terms in a way that's really practical
for you and a way that you can go back and apply them in your context in the populations
that you're serving.
Hopefully, they'll be helpful as you're seeking funding to have this language as well so that
you can better serve your populations, but also to expand the way that you think about
the prevention work that you're doing, and the way that you think measuring effectiveness
and looking for the evidence-based tools out there.
And thank you for what each and every one of you is doing each and every day to fight
trafficking.
I can just tell from the chat box that you're doing so much good work across the country.
And often we're not thanked for the work [laughs] that we do.
So, thank you for your tireless work.
> > Leilani Funaki: All right.
We'd like to thank you all for joining us today.
And if you're interested in further resources that might be of help, there are a few different
examples located here on the screen.
So, the Office for Victims of Crime has a training and technical assistance center that
can provide you with more resources, specifically for serving victims of crime.
As you've heard Dr. Chang and Dr. Stoklosa speak today, they both are affiliated with
HEAL Trafficking.
They have got a great amount of resources there.
And then there's also the National Human Trafficking Training and Technical Assistance Center,
and we are here to really, you know, try and support you as you deliver.
And we do that by delivering training and technical assistance to inform and enhance
the public health response to human trafficking.
So, if you're interested in more training or technical assistance, please do reach out
and get in touch with us.
We offer the SOAR training.
I'm not sure if any of you are aware of that, but that's something that we do to help expand
public health approach to human trafficking.
Our information is there on the screen.
We'll also share this with you when we send out the recording of the webinar, which will
again be posted online later.
So, unless we have any further questions, I want to say a big thank you to our facilitators
today, and the wonderful information that they shared with us.
And thank all of you for joining us.
We're all going to sign off here and leave you in the webinar room.
If you have some time, we'd really appreciate your answering a few questions about today's
session to help us better prepare for other webinars we might provide in the future.
So, once again, thank you.
And we appreciate your attendance today.
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