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Running head: HUMAN TRAFFICKING 1

Health Impact Framework Research Paper

Human Trafficking

NUR 310 Global Health

Melissa H. Towe

4/10/2018
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Abstract

Human trafficking at the most simplistic definition consists of the transport/trade of human

beings for sexual exploitation. Human sex trafficking continues to be a growing international

problem that violates the most basic human rights of its victims despite the extensive

international attempts to bring it to an end. The following explores the various forms of human

trafficking and the multifaceted factors that may perpetuate its continued existence across the

globe with a direct focus on the regions of Nepal and India. The following also applies Frieden’s

Health Impact Pyramid on public health action to the issue of human sex trafficking and briefly

examines the role of the nurse in these interventions. Finally, it explores additional implications,

gives suggestions for needed changes, and explores some of the many opportunities for careers

in the global health field.


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Health Impact Framework Research Paper

Human Trafficking

Human trafficking is the third largest organized crime in the world (Deane, 2010).

Approximately “800,000 people are trafficked across international borders; 80% are female and

half of them are minors” (Rijal, Adhikari, & Aro, 2016, p. 3). There are different types of human

trafficking however, all forms share the exploitation of the victim and the use of some type of

force/coercion by the trafficker for the exchange of some type of profit (Deane, 2010). Sex

trafficking for the victims can result in debilitating and lifelong health consequences such HIV,

hepatitis infections, sexually transmitted diseases, unwanted pregnancies, physical/emotional

abuse, trauma, and stigma (Deane, 2010). The following will focus specifically on sex trafficking

in the regions of Nepal and India. Nepal and India share the largest burden of child/female

trafficking in South Asia, with India being the single largest foreign destination for victims of sex

trafficking (Deane, 2010). It is estimated that “10,000-15,000 Nepali women and girls” are sold

to brothels in India every year (Deane, 2010, p. 493). Nepal and India share an open border and

despite the current laws and protocols in place to prevent human trafficking, it still occurs

significantly. The following will explore these laws/interventions, give suggestions for

improvement, and explore career opportunities related to the global health field. It will focus on

addressing public health action in regards to human sex trafficking via Frieden’s Health Impact

Pyramid.

Frieden’s Health Impact Pyramid

Frieden’s Health Impact Pyramid addresses public health action and the effectiveness of

its interventions. The pyramid has five tiers of which the impact on the population is greater in

the bottom tiers than it is at the top, and the amount of effort required on the individual’s part is
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greater in the top tiers than it is in the bottom tiers. The pyramid identifies socioeconomic

determinants as the base of the pyramid, followed by public health interventions, protective

interventions (long-term), clinical care, and finally counseling and education (Frieden, 2010).

Socioeconomic Factors

The bottom tier of the pyramid discusses socioeconomic determinants. Socioeconomic

determinants are an extremely influential factor in health and wellness. Socioeconomic factors

include but are not limited to poverty, educational/employment status, cultural/family beliefs,

gender equality, sanitation, and access to healthcare (Frieden, 2010). In Nepal, the status of

women is “subordinate to men in the context of their access to knowledge, economic resources,

and political power, as well as their personal autonomy in the process of decision making”

(Deane, 2010, p. 495). This means that women and female children receive little to no education,

they have limited or no access to healthcare, and are severely limited in regards to employment

opportunities. Without education, women are seldom aware of the laws and their rights. “Only

66% of adolescent girls from one of the most vulnerable areas in Nepal were aware of sex

trafficking” (Rijal et al., 2016, p.5). This is problematic as women/girls in these areas may not

know their rights and may think what is happening to them/around them is acceptable. Poverty

and lack of employment opportunities in Nepal and India has increased women’s vulnerability to

sex trafficking by placing them in positions where they feel they have no other option than to

exchange sex for survival and basic needs such as food/water/shelter (Deane, 2010). Traffickers

use these gender disparities to their advantages to tempt women/girls with what appears to be a

better life, higher wages, or more suitable working conditions but in reality, they have just

entered into the human sex trafficking trade (Deane, 2010).

Public Health Interventions


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The second tier of the pyramid refers to public health interventions that change the

context to make individual’s default decisions healthy. These interventions “…change the

environmental context to make healthy options the default choice, regardless of education,

income, service provision, or other societal factors” (Frieden, 2010, p. 591). In layman’s terms

this means that interventions on this level yield results that individuals would have to go out of

their way to avoid benefiting from. In the context of human trafficking, these interventions

would include international laws, or at a minimum, stricter laws and enforcement of those laws.

Take for example, harsh border patrol between Nepal and India. If international laws against

human trafficking could be implemented and enforced via border control between the two

countries, individuals would have to go out of their way to avoid receiving that protection. Nepal

and India both currently have laws against human trafficking, however these laws are unspecific

and seldom enforced. These countries share an open border and have differences in what

activities are considered illegal. For example, prostitution is legal in India but it is not legal in

Nepal. According to Deane (2010), “Such legal incongruities will hinder a smooth

implementation of any strategy to combat trafficking” (p. 497). An international law could help

to solve this problem and enable these countries to work together against human sex trafficking

(Deane, 2010).

Protective Interventions

The third level of the pyramid discusses the infrequent but long-lasting protective

interventions. These interventions are thought to “…have less impact than interventions

represented by the bottom 2 tiers because they necessitate reaching people as individuals rather

than collectively” (Frieden, 2010, p. 592). This level of intervention can apply to sex trafficking

in a few different ways. In the medical aspect, vaccinating women and young children for
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hepatitis A, hepatitis B, and the human papillomavirus (HPV) would yield fewer transmissions

of these preventable diseases. Though vaccinations would yield long lasting protective benefits,

they do not actually have any direct effect on the incidence of sex trafficking. A protective

intervention could put precedence on educating women and young girls on their rights, and the

risk of human trafficking. According to Rijal et al., (2016) “Many people are simply not aware of

their rights, and the law against such crimes is poorly understood” (p. 5). An example of this type

of intervention can be seen in Nepal: “134,718 migrants were informed about possible trafficking

events at borders, 183 victims were rescued, and 2,904 were intercepted in 2014 alone” (Rijal et

al., 2016, p.5). It will take the involvement of institutions such as the Human Rights Watch

(HRW) and eventually the governments of both countries to curtail human trafficking, however

attempting to implement protective actions such as education and vaccinations for sexually

transmitted diseases is a good place to start.

Clinical Interventions

The fourth level of the pyramid refers to clinical interventions that are ongoing and

largely individual (Frieden, 2010). This aspect applies largely to human sex trafficking in the

aspect of health screenings. This level of intervention is often thought to be limited in its

effectiveness as access to healthcare differs for everyone. Thorough screening should still be in

place and capable of reaching every victim possible. As previously mentioned, human trafficking

increases the risk for “acquiring sexually transmitted diseases, including human

immunodeficiency virus/acquired immunodeficiency syndrome, vaginal tearing, unwanted

pregnancies, and miscarriages” (Rijal et al., 2016, p.4). Victims are also at an increased risk for

physical injuries from abuse, and mental disorders related to the trauma they have experienced

(Rijal et al., 2016, p.4). It is important that health clinics in these locations have sex trafficking
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questionnaires/screenings and provide education to these women and young girls about their

rights. Health care professionals should be aware of potential red flags when doing physical

assessments and know what to look for. They should also attempt to separate the patients as

many victims will not be upfront about any abuse if their abuser is present. Sensitivity training

should be implemented in these areas to improve the ability to recognize these victims and

potentially prevent them from returning into these conditions.

Counseling and Education

The final tier in Frieden’s Health Impact Pyramid is counseling and education. This level

of intervention “…is perceived by some as the essence of public health action but is generally the

least effective type of intervention” (Frieden, 2010, p. 592). This is because these interventions

require individualized education/counseling on repeated clinical encounters and reaching that

level of care is sometimes unrealistic. In Nepal and India, integrating women and girls who have

been trafficked back into their community is another challenge entirely. Many

communities/cultures believe “that bringing a trafficked person back into the community will

increase transmission of diseases like human immunodeficiency virus/ acquired

immunodeficiency syndrome (HIV/AIDS) and may lead to an increase in trafficking activity in

the community” (Rijal et al., 2016, p. 6). This way of thinking causes a stigma towards victims

of human trafficking and causes problems for them when trying to return to their community.

The role of the nurse is essential in this stage. Victims returning to their communities require

extensive evaluation and care. Both physical and mental health screenings are needed to assess

the need for medical treatment and therapy. Rijal et al., (2016) states that it is necessary to build

and implement specialized, violence-free centers for rehabilitating these victims prior to

returning them to their communities. These centers would require trained mental health nurses
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for counseling of anxiety, depression, and post-traumatic stress disorder commonly seen in

victims of human trafficking (Rijal et al., 2016, p. 4). These centers could drastically improve

reintegration into the communities by ensuring that victims “...receive the required health care

services, social and legal support, and livelihood training” needed to be successful in returning to

their community (Rijal et al., 2016, p. 6). This type of intervention is most likely unrealistic as it

would be costly to implement and healthcare access is often limited with this population

however, if it could be implemented it would be capable of a drastic improvement for victims of

sex trafficking.

This level of intervention also encompasses health behavior change theories. The theory

that most closely relates to human trafficking is the Stages of Change Model. This model

endorses that change is a process in which different individuals can be at different stages of

readiness for. (Skolnik, 2016). There are five stages in this theory; pre-contemplation,

contemplation, decision/determination, action, and maintenance. These stages move from

considering a need for change to actively implementing and then maintaining that change. This

best applies to human trafficking on an international level as some countries have decided that

any form of human trafficking is a direct violation of human rights and therefore must be stopped

entirely. In these countries, laws, protocols, and treaties have already been put into effect and

agreed upon with the intent to end human trafficking. However, some countries continue to make

a large profit from the trafficking of human beings and thus are reluctant to even consider

making the change. This goes to show the differences in the readiness of people to change, and

how change will only occur meaningfully when everyone is on board.

Interventions
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Ending human trafficking will not happen overnight. In order to implement a change that

lasts, the majority of the world will need to believe that this change is for the better.

Unfortunately, even in this century, we have not reached that belief for human trafficking.

Despite Nepal and India both having laws against human trafficking, they both remain on the

“Tier 2 watch list for their failure to combat trafficking in persons” (Deane, 2010, p. 506). Some

of this noncompliance may be contributed to their subpar legal system, and political refusal to

make human trafficking a priority (Rijal, 2010). Another contributing factor may be the open

border between India and Nepal, “it is estimated that between 7,000 and 10,000 girls between the

ages of 9 to 16 years, are trafficked each month from Nepal to India” (Deane, 2010, p. 494).

Structuring some type of border control between these two countries could drastically improve

these numbers. Not only would some level of border control help detect human trafficking, but it

could also be a source of employment opportunities for both countries which could be a gain for

their economies. Education is also a pressing intervention. Mass education in various languages

needs to be present in public places, not just in health clinics but in schools, public

transportation, and stores. Information on human rights especially women’s rights and the

injustice of sex trafficking should be widely displayed.

Professional Opportunities

There are a wide variety of employment options and volunteer options in the global

health field. It is even possible to obtain a major in global health. Career opportunities include

areas such as research, policy, program design and implementation, program evaluation, and

advocacy (Skolnik, 2010, p. 496). It is also possible to become an active part of a

nongovernmental organization (NGOs), these organizations offer several different opportunities

including hands-on fieldwork in developing countries providing clinical services people in need
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(Skolnik, 2010). Involvement in bilateral aid organizations and government agencies offer

positions in research, advocacy, and development/implementation/evaluation of health programs

in developing countries (Skolnik, 2010). It is also possible to volunteer in organizations such as

the Peace Corps or international disaster relief/emergency response. These options may not be

considered careers however volunteer opportunities typically expand into quality experience for

further professional opportunities.


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References

Deane, T. (2010). Cross-Border Trafficking in Nepal and India-Violating Women's

Rights. Human Rights Review, 11(4), 491-513. doi:10.1007/s12142-010-0162-y

Frieden, T. R. (2010). A Framework for Public Health Action: The Health Impact

Pyramid. American Journal of Public Health,100(4), 590-595. doi:10.2105/ajph.2009.185652

Rijal, A., Adhikari, T. B., & Aro, A. R. (2016). Ethical perspectives on combating sex

trafficking in Nepal. Medicolegal & Bioethics, 63-7. doi:10.2147/MB.S111877

Skolnik, R. (2016). Global health 101. Burlington, MA: Jones & Bartlett Learning
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