“We are seeing these patients, period. We are taking care of these patients, period.” – Dr. Kimberly Chang
Human trafficking is a global issue, as well a local one. Trafficking is, simply stated, a form of slavery, and it is a crime. Trafficking is complex; it entails “the exploitation of someone for the purpose of compelled labor or a commercial sex act through the use of force, fraud, or coercion.” Sex trafficking of youth under the age 18 is a crime regardless of whether there is any force, fraud, or coercion. While there is no shared profile of victims, human trafficking most effects marginalized individuals in society – the poor, immigrants, and refugees, and those with unstable living situations. Within the United States, victims of trafficking are disproportionately girls and women of color, and those who have been in contact with the child welfare system, have run away from home or foster homes or have aged out of the foster care system, and people who are experiencing homelessness. Many victims are foreign nationals, who face unique challenges and language barriers. It is estimated that in the U.S. alone, the total number of human trafficking victims, including adults and minors, reaches into the hundreds of thousands. From 2007-2017, 40,987 cases were reported to the National Human Trafficking Hotline, with 8,759 cases reported in 2017.
Increasingly, trafficking is becoming a public health concern. As victims experience health problems, they may make their way to local providers. Community health centers, which by mission provide essential care to the uninsured, underserved, and to marginalized communities, are likely encountering trafficking victims daily, and are uniquely situated to identify, help and support them. As Dr. Kimberly Chang, family physician at Asian Health Services in Oakland, California, and a nationally-recognized clinician advocate, explained, it’s not a question of if health centers are treating trafficked victims: “We are seeing these patients period. We are taking care of these patients period.” To bring visibility to the issue, Dr. Chang, helped found HEAL, Inc. a multidisciplinary group of professionals dedicated to ending human trafficking and supporting its survivors from a public health perspective.
Dr. Chang has works in multiple capacities to heighten awareness of trafficking among healthcare providers. Together with Dr. A. Seiji Hayashi, she has co-authored “The Role of Community Health Centers in Addressing Human Trafficking” in Springer’s Human Trafficking Is a Public Health Issue. We reached out to Dr. Chang and a few of our CHC colleagues to learn more about this difficult problem and how our colleagues are tackling it.
La Maestra Community Health Centers (San Diego, CA)
La Maestra Community Health Centers (La Maestra) is a nonprofit, 501(c) 3 and a Federally Qualified Health Center (FQHC). The organization is headquartered in City Heights, San Diego, just 16 miles from the USA-Mexico border. City Heights is a large resettlement area, therefore, the health center serves immigrants, refugees and people at heightened risk, including people who may have been misled by the promise of work and a visa in the U.S., and coerced into forced labor, sex work, smuggling or related activities.
Originating as an Amnesty Center, the organization began providing legal advocacy services in 1986 to underserved immigrants and refugees, including human trafficking survivors. In response to the needs of the community, in 1990, additional social services were offered at La Maestra’s clinic. In 2006, La Maestra’s CEO, Zara Marselian, was a member of a bilateral human trafficking taskforce comprised of the FBI, CIA, local law enforcement, and local community-based nonprofit organizations. As the only representative from the healthcare field, Mrs. Marselian recognized that human trafficking victims in the community were in need of subsidies to obtain healthcare services. Therefore, Mrs. Marselian established and sponsored the “Maddalena Fund” to enable human trafficking survivors to obtain health care, counseling and additional social services free of charge until their cases were processed by Homeland Security.
In 2011, La Maestra officially merged its legal advocacy and social services programs to form the Legal Advocacy and Social Services Department (LMLASS) specifically to provide education, assistance, and support to people who face rights violations and are survivors of crimes, including trafficking. Carmen Kcomt is a legal advocate and the director of La Maestra’s human trafficking program. Many of her clients are immigrants; they lack identifying documents and are often not eligible for benefits.
In an interview, Ms. Kcomt described La Maestra’s Circle of Care TM services. She likes to call it a “flower of care” – where each department is a different petal of the flower. When a trafficked individual accesses services at La Maestra, they are connected to all of the services provided by La Maestra’s Circle of Care TM. Services include medical, dental and behavioral health, public program application assistance, nutritious food and basic necessities assistance, and financial, social, legal, and wellbeing programs.
La Maestra’s staff members, many of whom are refugees or immigrants themselves, collectively speak more than 28 different languages and dialects and know first-hand the barriers that must be overcome in order to access health care, and the unique risks that their patients face. La Maestra’s Medically Trained Cultural Liaisons provide translation services in-house to ensure that translations are both accurate and trustworthy. Translation is not left to a casual source or to the person accompanying the patient, because that individual may be the very one victimizing the person presenting for care. Recently, La Maestra has seen more transgender patients accessing services. Ms. Kcomt has noted that many current clients have been referred by friends or family who accessed services themselves, reflecting their comfort with and trust in the health center. The availability of culturally and linguistically appropriate services helps patients feel safe and empowers them to seek services. Ms. Kcomt advocates for people who face rights violations, and as she states, “Our main goal is to help.”
Colorado Community Healthcare Network (Denver, CO)
In Denver CO, staff at the Colorado Community Health Network recognized the prevalence of trafficking in their community and have started to work on helping member health centers respond to this issue. CCHN has partnered with the Colorado Department of Public Health and Environment, the Department of Justice, and the Colorado Human Trafficking Council. CCHN was surprised to learn that these organizations were largely unfamiliar with community health centers and the valuable services and resources they might offer for trafficked victims and as community partners.
This past May, CCHN hosted a training program for CHC behavioral health, dental, medical, and operations directors. The purpose of the training was to provide an overview of trafficking, create awareness, and provide members with connections to community partners for broader and more intensive training. Dr. Kimberly Chang provided a keynote, highlighting the resources available to CHCs, and survivors of human trafficking also spoke about their experiences and shared resources, including an anonymous hotline that can be utilized by both victims and other concerned parties to report incidents.
Jessica Sanchez, the Vice President of Quality and Operations at Colorado Community Healthcare Network, told us that “Dr. Chang brought it to our attention that people come in for very regular visits…providers need to think more about why a patient is coming in multiple times for the same reason.” For example, a patient coming in once with a STD isn’t necessarily suspicious, but if they come in several times for the same STD that could be a sign that there is something going on. Dr. Chang explained that she wants providers to focus less on identifying victims with screening tools, and more on asking their patients basic questions. Creating a rapport with a patient is much more likely to lead to successful support. Here, a few extra questions can make a difference in a person’s life. The training crystallized for the participants that many encountered and treated far more trafficking victims than they realized. Going forward, CCHN wants to help health centers make more connections with law enforcement, public health departments, and other partners. To that end, CCHN plans to maintain its partnership with the Human Trafficking taskforce and promote their trainings with Colorado CHCs.
Kokua Kalihi Valley Comprehensive Services (Honolulu, HI)
Kokua Kalihi Valley Comprehensive Services (KKV) has provided healthcare and social services to predominantly low-income Asian and Pacific Islander immigrant populations since 1972. Dr. Nicole Littenberg, a physician at KKV as well as a co-founder of HEAL Trafficking, told us that “Our patients face significant challenges, including Hawai’i’s extremely high cost of housing and food and relatively low wages, which mean that many of our clients face overwhelming financial hurdles in establishing themselves. For the sex trafficked population, these financial pressures, combined with lack of stable social support, extensive histories of trauma, and drug dependency compound their recovery.” At KKV, staff help patients receive the medical care that they need, and connect them with the Pacific Survivor Center (PSC), co-founded in 2007 by Dr. Littenberg. PSC was established to address the need for trauma-informed healthcare for victims of human rights abuses. Through a unique partnership with KKV, trafficked persons are able to receive primary care at KKV and additional subspecialty and ancillary services through PSC’s extensive community-based Human Rights provider network (HRPN).
Dr. Littenberg recommended that health centers “identify champions within the health center who can connect with trafficking-specific-community-based resources.” These champions can then create and forge partnerships with both non-governmental and governmental organizations to create a multidisciplinary program that helps victims access the full range of legal, social, and medical services that they need.
La Maestra, KKV and the Colorado health center members of CCHN serve different communities in the United States, but the people they serve have shared experiences, and the organizations themselves are examples of how health centers can be successfully involved in the fight against trafficking.
Collaborations are essential. Ms. Sanchez noted, “There is a hotline in each state – they will share resources to give to CHCs. There are experts in the state who are willing to travel to the CHCs to do staff trainings. NACHC has great resources on their website.” Also essential is the identification of funding to ensure the stability and continuity of effective programs and development of new resources.
Community health centers, which are deeply embedded in their neighborhoods, can be a point of care and a point of action. At a recent panel at the 2018 NACHC Policy and Issues Forum, Dr. Chang quoted muckraker Jacob A. Riis: “When nothing seems to help, I go and look at a stonecutter hammering away at his rock, perhaps a hundred times without as much as a crack showing in it. Yet at the hundred and first blow it will split in two, and I know it was not that last blow that did it, but all that had gone before.” Working together, and in partnership with other health centers, PCAs, and public agencies, health centers can both elevate the issue and help provide a pathway for victims to become survivors.