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By Dr Tina Maddison, CCDC PHE West Midlands Team

Human trafficking is the acquisition of people by improper means such as force, fraud or deception, with the aim of exploiting them (1). Sexual exploitation is by far the most commonly identified form of human trafficking (2), with women and girls disproportionately affected (3). This is a problem that is not diminishing.

Indian brothel

Inside an Indian brothel

My husband and I are currently volunteering in South East Asia for an NGO that rescues and rehabilitates children from human trafficking and sexual exploitation. My husband has recently returned from India where he witnessed first-hand the prolific nature of this trade. Many of the women and children are subjected to sexual exploitation either by the families into which they are sold or in the public brothels that line the backstreets of countless cities.

 

In New Delhi, home to a myriad of brothels and massage parlours, children as young as 12 are sold to men up to 40 times a day. This abuse is beyond comprehension. The damage to the individual, both physically and emotionally, is catastrophic. Babies born to these girls are also used for the gratification of perverted minds.

Abha was just 12 when she was trafficked into a brothel in Delhi (4). “I was kept day and night in that place. They made me go with men all day and all through the night. If I resisted the owners would cut my arms, burn my face with cigarettes and scald my body. They would open up my wounds the next day to remind me not to disobey. They would inject me with drugs and force me to drink alcohol to make sure I did what I was told.
Whilst I was there I caught TB from the other girls. Seven men escorted me to hospital; they did not let me out of their sight. I was a prisoner, and I lost all hope of ever escaping. Eventually I tried to kill myself by cutting my wrists. They stitched me up so I could carry on making money for them.”

Across South East Asia, in the poorest of towns and villages, families are forced to make agonising decisions just to survive. Fathers will sell their oldest daughters to feed their younger siblings. The fundamental human rights of a child have no meaning in a world of extreme poverty.

Cultural issues in some countries contribute to the problem. Women and girls are viewed, by many, to be of little significance or worth. This diminished social standing is exploited by organised criminal gangs who view young girls as objects to be bought, auctioned and sold. To them women have a high value but for all the wrong reasons.
The crisis in India, where woman and girls routinely face sexual exploitation, harassment and lack of human worth has, in recent years, been amplified by the availability of pornography on the internet. One exasperated Indian social worker put it like this: “Pornography has intensified the lack of respect for women here. The problem has become much worse in a short space of time.”

Where does our public health duty lie in response to the appalling reality faced daily by girls such as Abha? Poverty, disregard of a woman’s worth and the prevalence of pornography are all underlying factors in this human tragedy. Should our response be to attempt to deal with these fundamental problems?

If these root causes are just too enormous a challenge, then should our public health response be to deal with the aftercare of individuals directly affected? Children rescued from the brothels have been broken mentally, physically and spiritually. Many suffer with rejection, they cannot reconcile the fact that their own families could have sold them. For others, the shame they burden for the abuse they have suffered is a barrier to ever being reunited with loved ones. They become outcasts.

Those still trapped within this insidious industry suffer with even greater self-degrading effects. A sense of hopelessness inevitably leads to depression. Many try to take their own lives as their only means of escape. Others develop a dependency upon the drugs and alcohol they are plied with in an attempt to block out the fear and pain they have been sentenced to.

Our public health response could be to identify and develop services to deal with these devastating emotional effects on young lives. Or as public health practitioners we could respond to their physical needs; screening and treating TB, HIV and other STIs, improving their poor nutrition and working to ameliorate their squalid living environments.

However, within India and neighbouring countries, for many there is still an unwillingness to admit that such problems exist. On the flight into Delhi one Indian passenger was adamant there were no issues with prostitution in India. “You will not be able to show me even one woman or child in prostitution. There is no problem here, this does not happen!”

Perhaps, therefore, our public health duty first and foremost should be to continue to raise awareness about this atrocity so that no one can honestly deny that the problem exists. Unless the issue and scale of human trafficking is recognised and acknowledged by all countries, and political pressure applied at the highest levels to invoke change, then those on the ground who fight daily against such evils will continue to fight alone.

“The only thing necessary for the triumph of evil is for good men to do nothing” – Edmund Burke

References:

1. UNODC. UNODC on human trafficking and migrant smuggling. Available at URL: http://www.unodc.org/unodc/human-trafficking/ (Accessed 8 May 2017)

2. UNODC. Global Report on Trafficking in Persons. Executive Summary. February 2009.

3. International Labour Organization. Summary of the ILO 2012 Global Estimate of Forced Labour. June 2012

4. Abha – not her real name. Notes from a personal conversation with a girl rescued from a brothel in Delhi, May 2017.

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By Claire Beynon MFPH

BACP Travelling Fellowship
Every two years the Faculty of Public Health (FPH) awards a BACP travelling fellowship to assist members of FPH in training to undertake educational travel. This fund was established in 1994, using funds donated by the British Association of Community Physicians (BACP) on its dissolution.

At the FPH Conference in Telford in June I was delighted to receive the travelling fellowship funding based on my application to travel to Japan to experience its culture and make observations about why its levels of childhood obesity were so much lower than those in the UK, and to present my public health work at a conference in Japan.

Observations on Childhood Obesity in Japan
Before I left for Japan I read many articles that explored the differences between childhood obesity rates in the USA and Japan. Their focus was on lifestyle factors including diet and physical activity.

Whilst in Japan I met with several academics who specialised in obesity, physical activity and diet. They were all most welcoming and shared their research and experiences readily.

The key points they raised were:

  • Younger children spend less time in school. As age increases so does the length of the school day. This gives more free time for outdoor play.
  • 90% of children walk to school daily.
  • Children do three hours of physical activity each week in school time.
  • There are no cleaners in Japanese schools; part of a child’s everyday activities includes cleaning their own school – children are active when cleaning.
  • Schools often have before-school sports clubs as well as after-school sports clubs.
  • Between each lesson there is a five-minute break to allow children to run around in the play area. This is in addition to morning break, lunch and afternoon break.
  • There are multiple opportunities in school for competitive sports, with regular competitions and celebrations. Children spend time practising for these with friends.
  • Children have three hot meals a day at breakfast, lunch time and in the evening.
  • Children serve each other a cooked meal at lunch time and sit and eat this hot meal together.

Further Observations
Whilst travelling in Japan I observed a number of additional environmental factors that tip the balance in favour of walking and cycling:

  • Priority is given to the pedestrian, then cyclist, then the motor vehicle. Encouraging walking and cycling. By giving priority to more vulnerable road users speed of motor vehicles is also decreased.
  • Cyclists and pedestrians share the pavement area, which is often separated from the road with a barrier and/or low-level bushes. This makes for a safer cycling experience than the UK where cycle lanes are often shared with buses.
  • There were a number of covered shopping areas, which were accessible only to cyclists and pedestrians and proved very popular thoroughfares.

    Shopping area in Japan

    Covered shopping area where pedestrians and cyclists share space

  • There was consistent and regular signage for cyclists and pedestrians, including details of directions and distances to the nearest public transport options.
Example of road, cycling and walking space in Tokyo

Example of road, cycling and walking space in Tokyo

• The number of employed people working on any urban street was much higher than the UK, with police highly visible, construction staff, cleaners, car park attendants and others all adding to the sense that the street was a safe place.

 

Policeman on the street in Japan

Presence on streets of local police make a space feel safe

• Public art installations make walking and cycling spaces more interesting and appealing.

Street art in Japan

Example of simple art installation

We know from the 2007 Foresight Report that obesity is a complex issue with multiple factors influencing obesity levels in adults and children. My own research looking at the risk factors for obesity in children in Wales using Welsh Health Survey data showed a reduced risk of obesity for children who met the one-hour physical activity guideline.

 

The new experiences and culture that I have experienced from this educational trip make me more determined than ever to tackle childhood obesity in Wales. I am looking forward to being involved in the drafting of an obesity strategy for Wales as part of my placement with the Welsh Government and will share my experiences with other registrars and colleagues at every opportunity.

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By Andy Beckingham FFPH, Fernandez Hospital, Hyderabad

Giggling Girls!

The scope of our profession gives opportunities to branch out. These may not always look at first glance like ‘public health’.

In 2010, working in India on maternal mortality, someone asked over dinner if I thought UK-style midwifery might be useful in India where doctors provided all the care. “Perhaps if you try the bits that work for women,” I said. “And avoid the bits that the NHS got so wrong.” My dinner companion turned out to be the MD of India’s most famous maternity hospital, and I found myself designing her midwifery pilot programme.

The midwife who had run the UK’s most woman-friendly midwifery service (the Albany Practice, which achieved great outcomes for disadvantaged women) was inveigled into joining us as a mentor. Eight anxious trainees found themselves becoming India’s first evidence-based woman-centred midwives (pictured). They began to develop their own profession, promoting choice about labour and supporting and empowering women to have more natural births. They had to challenge established obstetric practice. Our hospital’s maternity care began to change. Babies had been routinely separated from the mother at birth, although this impedes attachment and breastfeeding. The midwives worked with paediatricians to change that. Now most mothers have immediate contact and breastfeed their babies in the first hour.

Now leaders in their own right, those first eight have since mentored other trainees to become strong professional midwives, supporting thousands of Indian women to have better births.

Like most countries, India has unnecessarily high rates of intervention in childbirth. A local public hospital’s c-section rate is 52%. A local private hospital’s is 90%. But thanks to the midwives, ours has come right down. Instead of epidurals being routine, midwives ask women what pain relief they want. They offer choice. Women get continuity of care. The outcomes are better. Satisfaction rates are high.

In 2017, the state government invited us to train midwives to work in their hospitals too. They want c-section rates to come down. But they also want compassionate, respectful maternity care for the large numbers of women who are mostly ‘below poverty line’. So maybe, just maybe, this could become a model for wider public maternal-health improvement in lower-income countries. I have to assess its impact.

Designing a midwifery programme and curriculum doesn’t at first look like a public health role. But it is starting to address unmet needs, inequalities and disadvantage, improve care quality and effectiveness, show that Indian women and their choices matter. Of course, it will need to be part of wider action on social and economic determinants of maternal health.

And now, this alternative to the medical model is available, and the state government is actively promoting compassionate, effective midwifery care and supporting us to roll out professional midwifery more widely, among very disadvantaged women.

Public health, in disguise.

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