Articles Health of men, women, and children in post-traffi cking services in Cambodia, Thailand, and Vietnam: an observational cross-sectional study Ligia Kiss, Nicola S Pocock, Varaporn Naisanguansri, Soksreymom Suos, Brett Dickson, Doan Thuy, Jobst Koehler, Kittiphan Sirisup, Nisakorn Pongrungsee, Van Anh Nguyen, Rosilyne Borland, Poonam Dhavan, Cathy Zimmerman Summary Background Traffi cking is a crime of global proportions involving extreme forms of exploitation and abuse. Yet little Lancet Glob Health 2015; research has been done of the health risks and morbidity patterns for men, women, and children traffi cked for various 3: e154–61 forms of forced labour. See Comment page e118 London School of Hygiene & Methods We carried out face-to-face interviews with a consecutive sample of individuals entering 15 post-traffi cking Tropical Medicine, London, UK (L Kiss PhD, C Zimmerman PhD, services in Cambodia, Thailand, and Vietnam. We asked participants about living and working conditions, experience N S Pocock MSc); International of violence, and health outcomes. We measured symptoms of anxiety and depression with the Hopkins Symptoms Organization for Migration, Checklist and post-traumatic stress disorder with the Harvard Trauma Questionnaire, and used adjusted logistic Bangkok, Thailand (D Thuy MA, regression models to estimate the eff ect of traffi cking on these mental health outcomes, controlling for age, sector of V A Nguyen MA, B Dickson BA, P Dhavan MPH, R Borland MA, exploitation, and time in traffi cking. N Pongrungsee, K Sirisup); International Organization for Findings We interviewed 1102 people, of whom 1015 reached work destinations. Participants worked in various sectors Migration, Phnom Penh, including sex work (329 [32%]), fi shing (275 [27%]), and factories (136 [13%]). 481 (48%) of 1015 experienced physical Cambodia (S Suos MA); and International Organization for violence, sexual violence, or both, with 198 (35%) of 566 women and girls reporting sexual violence. 478 (47%) of Migration, Hainoi, Vietnam 1015 participants were threatened and 198 (20%) were locked in a room. 685 (70%) of 985 who had data available (J Koehler, V Naisanguansri) worked 7 days per week and 296 (30%) of 989 worked at least 11 hours per day. 222 (22%) of 983 had a serious injury Correspondence to: at work. 61·2% (95% CI 58·2–64·2) of participants reported symptom of depression, 42·8% (39·8–45·9) reported Dr Ligia Kiss, London School of symptoms of anxiety, and 38·9% (36·0–42·0) reported symptoms of post-traumatic stress disorder. 5·2% (4·0–6·8) Hygiene & Tropical Medicine, Faculty of Public Health, had attempted suicide in the past month. Participants who experienced extremely excessive overtime at work, Department of Global Health restricted freedom, bad living conditions, threats, or severe violence were more likely to report symptoms of and Development, depression, anxiety, and post-traumatic stress disorder. London WC1H 9SH, UK [email protected] Interpretation This is the fi rst health study of a large and diverse sample of men, women, and child survivors of traffi cking for various forms of exploitation. Violence and unsafe working conditions were common and psychological morbidity was associated with severity of abuse. Survivors of traffi cking need access to health care, especially mental health care. Funding Anesvad Foundation and International Organization for Migration International Development Fund. Copyright © Kiss et al. Open Access article distributed under the terms of CC BY-NC-ND. Introduction vulnerability or of the giving or receiving of payments or Traffi cking of human beings is a gross violation of human benefi ts to achieve the consent of a person having control rights that often involves extreme forms of abuse and over another person, for the purpose of exploitation. exploitation. Recent estimates suggest that more than Exploitation shall include, at minimum, the exploitation of 18 million people are in forced labour as a result of prostitution of others or other forms of sexual exploitation, traffi cking, although estimates are often questioned forced labour or services, slavery or practices similar to because of the hidden nature of traffi cking and diffi culties slavery, servitude or the removal of organs.” in defi ning it.1 Experts generally agree that the crime of human The most commonly used defi nition of human traffi cking traffi cking centres on acts of exploitation and coercion.3 comes from the UN Convention Against Transnational Other more specifi c elements that are commonly present Organized Crime and its Protocol to Prevent, Suppress and in defi nitions of traffi cking and used in treaties, policy Punish Traffi cking in Persons, Especially Women and documents, and operational indicators of traffi cking Children:2 “The recruitment, transportation, transfer, include restricted freedom of movement, abusive living harbouring or receipt of persons by means of threat or use and working conditions, confi scation of documents, debt of force or other forms of coercion, of abduction, of fraud, bondage, withholding of wages for prolonged periods, of deception, of the abuse of power, or of a position of intimidation, and excessive overtime.4–6 www.thelancet.com/lancetgh Vol 3 March 2015 e154 Articles People who are subjected to these extreme levels of labour in southeast Asia. We describe the health risks exploitation are exposed to many health risks, including and morbidity patterns, including the eff ects of various physical, sexual, and psychological violence, deprivation, forms of violence, occupational risk exposures, and living and severe occupational hazards, which often result conditions, on survivors’ mental health to inform in acute and long-term physical and psychological provision of services and policy. morbidity—sometimes death.7 For those who survive a traffi cking experience, many—if not most—will need Methods medical care for their physical and psychological health Study design and participants needs.8 Worldwide, post-traffi cking services have arisen We carried out this observational cross-sectional study in to care for survivors of these dangerously exploitative Cambodia, Thailand, and Vietnam. We used a two-stage circumstances, which are variously labelled as, among strategy to identify a sample of men, women, and young other terms, traffi cking, forced labour, and slavery. people (age 10–17 years) who used post-traffi cking Very little survey research has been published about services. First, we selected services in each country (six in human traffi cking and health, with most evidence Cambodia, four in Thailand, and fi ve in Vietnam on the coming from studies of women traffi cked for sexual basis of diversity of clientele (eg, age, sex, sector of exploitation, primarily in Europe and south Asia.7 Almost exploitation, country of origin), relationship with country no research has been done of the health of traffi cked teams of the International Organization for Migration, men and boys,9 or people traffi cked into sectors other and agreements with government agencies (eg, support, than sex work, such as agriculture, commercial fi shing, referral, and service arrangements). Several organisations domestic servitude, factory work, and street begging. had specifi c age and sex eligibility criteria (eg, only Although violence and intimidation are commonly women and children, only men). Second, we invited a associated with human traffi cking, little recognition has consecutive sample of individuals within the fi rst 2 weeks been given to the additional occupational and other of admission to these services to participate in face-to-face health risks of traffi cking-related labour conditions.10 interviews. Individuals were excluded if trained case- For example, migrant workers report more accidents and workers deemed individuals too unwell to participate or injuries than do non-migrant workers,11 suggesting that for that participation would cause harm. traffi cked workers (often deemed a subgroup of the larger Clients were referred to these services by various migrant worker population), common occupational sources, including police and immigration services, hazards may be worse, exacerbated by violence and abusive non-governmental and international organisations, and working and living conditions. Traffi cked people are likely government agencies (eg, Cambodia’s Department of to toil in physically arduous jobs and work extensive hours Anti-Traffi cking and Juvenile Protection, Thailand’s with few breaks—conditions associated with high injury Department of Social Development and Welfare, rates.12 Exploited labourers are unlikely to be off ered Vietnam’s Department of Social Evils Prevention). adequate training (in a language they understand) or The study was approved by the ethics committee of personal protective equipment to, for example, use heavy the London School of Hygiene & Tropical Medicine. equipment, work at heights or with harsh chemicals, or to Local ethics approval was granted by the National Ethics do repetitive tasks (eg, bending, lifting).13 Traffi cked Committee for Health Research in Cambodia, by the workers are also likely to work in sectors with few health Hanoi School of Public Health in Vietnam, and by the and safety inspections.14 Despite the evident health risks Ministry of Social Development and Human Security and probable harm associated with human traffi cking, in Thailand. most information about traffi cking comes from media coverage or reporting of individual cases, whereas survey Procedures data—especially for health—are scarce.15 The questionnaire was based on an instrument from a An estimated 56% of forced labourers worldwide live European study of women in post-traffi cking services19 in the Asia and Pacifi c region,1 especially in the Greater and adapted to local contexts and a wider range of labour Mekong subregion,16 which has more than 13 million sectors by the study team. It included questions about migrant workers.1 A small study of Vietnamese migrants socioeconomic background, pre-traffi cking exposures, estimated that 13% are traffi cked.17 Likewise, 17% of living and working conditions during traffi cking, violence, 596 Thai fi sherman reported that they were working health outcomes, and future plans and concerns.