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• Consider the possibility of repetitive work injuries if a patient is suffering from persistent pain.
• Examine skin carefully for burns, wounds and other occupational injuries.
• Consider the possibility of exposure to toxins and other dangerous materials in the workplace that may contribute to headaches or breathing difficulties.
• Check vision because eyesight may be compromised from working in dimly lit workplaces.
• Ask about ventilation in the work environment; poor ventilation may lead to respiratory problems.
Common infections (see action sheet 15 for more details)
With the emphasis on the patient’s presenting symptoms, you may inadvertently overlook other common communicable diseases associated with the patient’s travel history and exposures, including airborne, waterborne and mosquito-borne illnesses. You should have easily accessible information on local epidemiology for all the places in which a trafficked person has been. Websites such as http://www.cdc.gov/travel/default.aspx offer up-todate information on outbreaks, changes in antibiotic resistance and endemic areas.
Preventive care, immunizations and presumptive care
While the scope of the physical and mental health needs of trafficked persons is often overwhelming, this systematic approach offers a methodical way to assess patients with complex medical problems. Because of the multitude of acute concerns, preventive care – including blood pressure screening, eye exams, immunizations and cancer screening (testicular and cervical, as well as breast and colorectal for older patients) – may be overlooked.
The question of presumptive care, or the treatment of diseases without test results, is a controversial area in the care of persons who have been
66 CARING FOR TRAFFICKED PERSONS: GUIDANCE FOR HEALTH PROVIDERStrafficked. If it is unlikely that the trafficked person can be contacted after the initial visit to discuss test results, some providers will opt to treat patients presumptively for common diseases such as chlamydia, in particular if the treatment costs less than the laboratory test. Consider having policies and procedures in place to determine under what circumstances such presumptive care would be delivered, if at all.26 Because this health assessment may be the only clinical encounter for the patient, consider offering comprehensive preventive care if resources exist for this. There should be a protocol in place for patients to receive results and be directed to follow-up care as needed.
See World Health Organization, Syndromic Case Management of Sexually Transmitted Diseases: A guide for decision-makers, health care workers and communicators, WHO Regional Office for the Western Pacific, Manila, 1997 and United Nations High Commissioner for Refugees, Reproductive Health in Refugee Situations: An inter-agency field manual, UNHCR, Geneva, 1999.
CARING FOR TRAFFICKED PERSONS: GUIDANCE FOR HEALTH PROVIDERSZimmerman, C. et al.
2003 The Health Risks and Consequences of Trafficking in Women and Adolescents: Findings from a European study, London School of Hygiene and Tropical Medicine, London, 2003.
AC Action Sheet 5:
RATIonAle Children and adolescents are frequent targets of traffickers; they may have been trafficked by a family member or acquaintance or may have been indirectly trafficked when they accompany parents who are trafficked or when entire families are trafficked together. Children and adolescents require physical and mental health assessments according to their developmental stage. At the same time, the developmental age of a child may not be congruent with that child’s physical age, for example, due to chronic abuse or deprivation. While providers must obviously assess children to determine urgent health needs, they must also pay particular attention to health consequences of trafficking that may affect a child’s long-term health and development.
Children who have been exposed to the abuse, trauma and deprivation of trafficking are likely to have a wide range of care needs. They may have been physically and sexually abused; they may have experienced or witnessed traumatic events or been forced into forms of labour exploitation subjecting them to dangerous or life-threatening health hazards.
In child trafficking cases, a young person’s mental and emotional health is of particular concern. Severe and prolonged stress can cause cognitive and emotional developmental delays and possibly developmental regression. If forced to participate in adult activities, young persons may also have adopted behaviours, perceptions or language seemingly beyond their age. Early psychological trauma or syndromes may be predictors of longterm psychological morbidity and future risk-taking (see action sheet 12).
Children who have been chronically undernourished may also risk longterm cognitive and behavioural problems. Children’s mental, emotional and social health needs will require age-appropriate health care and various other forms of support designed for young persons.
72 CARING FOR TRAFFICKED PERSONS: GUIDANCE FOR HEALTH PROVIDERS
Examination and review of systems27 In addition to a standard paediatric review of systems and physical examination, there are trafficking-specific issues that require attention. Please see action sheet 4 for general information on review of the following systems in any trafficked person: oral health, ear/nose, neurological, respiratory, gastrointestinal, genitourinary, reproductive health, musculoskeletal, dermatological, nutrition, laboratory studies, and forensic examination. The following is additional information for children and adolescent trafficked persons.
neurological Infants should have an ophthalmological exam for retinal haemorrhages, which may indicate physical abuse or ‘shaken baby’ syndrome.
Reproductive health Assess every child using a focal examination for trauma and infection, and testing for specific sexually transmitted infections. Girls should receive assessments related to their reproductive health, including menstrual history and possible pregnancy. Boys should be examined for genital and anal trauma. Care must be taken not to re-traumatize the adolescent; their refusal See action sheet 4.
74 CARING FOR TRAFFICKED PERSONS: GUIDANCE FOR HEALTH PROVIDERSmust be respected. Every examination should be done by a practitioner of the gender requested by the patient. The practitioner should talk the patient through every step with appropriate explanations and expectations. Requests by a child or adolescent to delay or suspend an examination should be responded to appropriately and with patience, even if this means delaying or terminating the exam (see action sheet 12).
nutrition Children are more dependent than adults for security of food and safe water. Since food is often restricted in a trafficking situation, vitamin, protein and mineral deficiencies are common. Poor nutrition impacts the growth and development of children more dramatically than that of adults.
Therefore, health professionals should assess each child’s nutritional status against international standards (e.g., World Health Organization standards) and immediately start providing for nutritional needs. Assessment includes weight-for-height measurements or a mid-upper arm circumference.
Nutritional deficiencies put children at greater risk of contracting certain infectious diseases (e.g., vitamin A deficiency). Hair color and presence of oedema should also be noted.
Infectious diseases Infectious diseases are very common among children and can present differently from similar diseases in adults. Every practitioner must have a high degree of suspicion for infectious diseases in every child and adolescent (see action sheet 15).
Substance abuse This must not be overlooked in children and adolescents. A toxicology screen can help identify drugs of abuse and poisons that are either intentionally taken or administered to a child. It is important to rule out toxic substances as an organic cause of altered mental status, behavioural abnormalities and other medical conditions. Withdrawal from some substances can present as a medical emergency (see action sheet 11).
forensic examination Health professionals should have specific training in evaluation of violence towards children that is appropriate for the patient’s age and developmental stage. Sexual assault is common among trafficked children and therefore needs to be addressed urgently, but in a delicate way. If any evidence is likely to be used in any legal proceedings, a professional trained in collection of forensic evidence should perform the examination. Appropriate national or local guidelines for collection, reporting and chain of custody of forensic evidence need to be followed. It is also essential that sexually
CARING FOR TRAFFICKED PERSONS: GUIDANCE FOR HEALTH PROVIDERSassaulted or exploited children and adolescents receive mental health care as soon as possible (see action sheet 12).
Treatment • Administer immunizations according to each country’s expanded protocol for immunizations. You may consider other preventive measures including hepatitis B immunoglobulin (HBIG), post-exposure prophylaxis for HIV and emergency contraception (see action sheets 13 and 15).
• Consider prescribing a vitamin and mineral supplement for all children in the acute care setting with continued supplementation for those who demonstrate deficiencies.
Infants with mothers should continue to breastfeed, unless contraindicated.
• Referral to a dentist, if necessary, should be done rapidly to reduce potentially serious complications.
• When dosing medication, it is important to remember that medicine is often dosed according to weight. If paediatric dosages are not available, it is important to determine the correct dosage of adult medication. Children metabolize medicines differently from adults and some medicines are contraindicated in children because they are harmful to a child’s physical development.
• Treatment protocols for such infections as HIV and tuberculosis are highly specific to children; such protocols should be reviewed, and a paediatric infectious disease specialist consulted if possible.
Legal considerations (see action sheet 16 for more details) • Be aware of local laws pertaining to the treatment of children, consent to test for and/or treat specific conditions in children (e.g., the requirements to obtain consent for treatment of a minor), as well as legal requirements that may cover reporting of certain conditions (e.g., child abuse) and diseases in children.
• Adolescents in some places may be regarded as emancipated minors, which means that despite being younger than the legal age of adulthood, they have complete autonomy to make decisions regarding consent, refusal and direction of care.
76 CARING FOR TRAFFICKED PERSONS: GUIDANCE FOR HEALTH PROVIDERS
RATIonAle The health care system is in a unique position to provide protection to trafficked persons. Health providers may treat persons who have already been identified by assistance organizations or police; however, there may be times when a provider receives a patient that has not been formally identified as a trafficked person. A provider may detect signs that the individual has been trafficked in the past or may still be in a trafficking situation.
Situations where trafficked persons have not yet been identified could happen in settings such as a general clinic or private practice; through care for individuals in immigration detention, at a reception facility or in prison; or via outreach services for sex workers or migrant populations. In each case, it is important to safely assess the situation and decide on appropriate response options (see action sheet 17).
Reacting to a person who is still in the trafficking situation requires wellconsidered responses that prioritize the safety of the individual, the health provider and possibly those near to them (see action sheet 7). Although trafficked persons caught in the trafficking situation are generally kept away from potential sources of assistance, given the nature of the abuse and exploitation associated with trafficking, it is not unusual for trafficked persons to become ill or injured, limiting their usefulness and decreasing their profitability to the trafficker. Because of someone’s need for medical attention, and because traffickers may consider health providers to be less of a threat compared to other service providers, traffickers may seek medical care for those they have trafficked.
This action sheet focuses on what the health provider needs to consider in a clinical setting when encountering patients whom they suspect may have been trafficked or otherwise caught in an abusive or exploitative situation
80 CARING FOR TRAFFICKED PERSONS: GUIDANCE FOR HEALTH PROVIDERS(e.g., smuggling or abusive labour exploitation), but who are not yet linked to any protection services. It outlines ways to recognize signs of trafficking and offers information on intervening in a safe, well-thought-out and professional way.
Seeing the clues, spotting red flags Although no single set of symptoms or signs indicates definitively that a person has been trafficked, human trafficking situations are associated with common features that, if linked together, may suggest that a person has been trafficked. Figure 3 lists key factors that might suggest a person has been trafficked.
These indicators are particularly relevant when a patient is an international migrant or appears to have migrated within a country for work.