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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 Dr Justin Varney, National Lead for Adult Health and Wellbeing, Public Health England

Public Health England estimates that between 2-5% of the population identify as lesbian, gay, bisexual or other – comparable to many ethnic minority and faith populations. Despite legislative reform many LGBT people continue to experience discrimination, marginalisation and harassment.

  • 38 per cent of trans people have experienced physical intimidation and threats and 81 per cent have experienced silent harassment (e.g. being stared at/whispered about)
  • One in five (19 per cent) lesbian, gay and bi employees have experienced verbal bullying from colleagues, customers or service users because of their sexual orientation in the last five years
  • Almost 1 in 4 trans people are made to use an inappropriate toilet in the workplace, or none at all, in the early stages of transition. At work over 10% of trans people experienced being verbally abused and 6% were physically assaulted.

The impact of this discrimination on mental health is easy to understand, however the stark data on suicide and self-harm demonstrates the depth of the impact that this discrimination can have:

  • 52% of young LGBT people reported self-harm either recently or in the past compared to 25% of heterosexual non-trans young people and 44% of young LGBT people have considered suicide compared to 26% of heterosexual non-trans young people
  • Prescription for Change (2008) found that in the last year, 5% of lesbians and bisexual women say they have attempted to take their own life. This increases to 7% of bisexual women, 7% of black and minority ethnic women and 10% of lesbians and bisexual women with a disability
  • The Gay Men’s Health Survey (2013) found that in the last year, 3% of gay men have attempted to take their own life. This increases to 5% of black and minority ethnic men, 5% of bisexual men and 7% of gay and bisexual men with a disability. In the same period, 0.4% of all men attempted to take their own life
  • The Trans Mental Health Study (2012) found that 11% of trans people had thought about ending their lives at some point in the last year and 33% had attempted to take their life more than once in their lifetime, 3% attempting suicide more than 10 times.

The impacts aren’t limited to mental health, and the level of inequalities in lifestyle behaviours such as smoking and substance misuse will almost certainly play out in a great burden of chronic disease and premature mortality over the life course.

The evidence base of inequalities affecting LGBT populations continues to grow as we get better at incorporating sexual orientation and gender identity into the demographics of research and population surveys. Positively, as the NHS rolls out the sexual orientation monitoring information standard this year, this understanding will no doubt continue to grow.

As public health professionals we have a responsibility to advocate for the populations in our care, and this should include advocating for LGBT populations. Lesbian, gay, bisexual and trans communities are diverse, vibrant and varied and have many assets, although the LGBT community sector has faced fiscal challenges due to the economy there remain many small local LGBT organisations that are keen to work with public health teams to address these inequalities.  This is population who clearly need our professional expertise, advocacy and support to co-produce solutions for change and one where we could have a real impact.

So during this lesbian, gay, bisexual and trans Pride season please take up the opportunity to engage, empower and partner with your local LGBT community.

FPH is committed to improving the health and well-being of the LGBT population. If you would like to join us in our work please consider joining our Equality & Diversity Special Interest Group or our LGBT Health Special Interest Group. To express an interest in joining please email policy@fph.org.uk and we can help you get started!

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Gelada baboons
Move along there: Gelada baboons

By Dr Jackie Spiby

We are still here in Addis Ababa. We have survived the rainy season and the sky is blue again.

Many of you will have seen the news about the famine in the south east of Ethiopia where it borders Sudan and Kenya. Sitting in Addis, it is as difficult to understand the whole story here as it is at home. We pick up the news and some of the debate from the BBC when the internet is working. When we travelled to the south recently, everywhere looked really fertile and verdant as it was just after the rains. But at work I do hear about problems with food-aid delivery and families that can’t feed their children.

As recipients of Global Fund money, my organisation has to have pristine financial arrangements. The management audit letter we received recently could have been one found in any PCT. By the way do PCTs still exist? The only difference was that they were querying why a goat had been bought. I recently found myself on an appointments committee for an internal auditor – something I have managed to avoid in the UK. Amazingly my interviewing instincts rose to the fore. I was delighted that my first choice was the same as the finance director’s. It did help that the interviews were in English. So, another country another culture but actually much is the same.

We took a few days off to travel north to trek in the Simien mountains. Ethiopia lies in the East African Rift Valley so much of the north and central areas are hilly in stark contrast to the desert areas bordering Sudan and Somalia. We were walking at three to four thousand metres and were surprised that it was still scattered with villages, and, wherever we went, small children were keeping an eye on the cattle and sheep. They said they went to school but I wasn’t really convinced.

Walking into a BBC crew filming the gelada baboons was quite surreal. We had just stopped to put on our macks as it was raining when we heard a very posh voice asking if we could move please as they were trying to film the baboons running down that particular hill. If you ever see a documentary on these baboons in the Simiens we were there, and we saw the locals on the other side of the hill ‘encouraging’ the baboons to move.

One of my areas of work is developing a volunteers’ strategy. Not international volunteers but local volunteers. PLHIV associations are similar to charitable organisations in the UK so their boards are all volunteers and most of the programmes workers are also volunteers. However they do get expenses. The latter get 206 birr a month for travel. That is £7.60. In the focus groups they tell me they do it for humanitarian reasons. However when I asked if they also had paid work, they said it was hard to get work as they were HIV+. So what is a volunteer? I really enjoy the focus groups: however formal I try to make them, we have to have a coffee ceremony, and they usually end with music and dancing. The highlight last week was meeting a 22-year-old woman who finished school at grade 6 but was carrying a beautiful, chubby smiling baby who everyone proudly told me was HIV negative.

Am I making any difference? Not an unusual question for anyone in public health. I’ve been asking it my entire career. I’d better get back to work and make sure that I am.

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Monkey drinks Cola in Addis Ababa

A monkey drinks cola in Addis Ababa

By Dr Jackie Spiby

Hello from Addis Ababa.

It is a warm and sunny morning. By lunchtime it will be hot, but not too hot as we are 2,400m high and there is usually a breeze. When I go out it will be dusty, smelly and, if I noticed it anymore, the air will be polluted. This is mainly due to the huge volume of taxis, buses and lorries, most of which are ancient and belch out dark smoke which hangs around the city. I walk everywhere or go on a crowded, filthy line-taxi; so am I green? I came on a plane so blew my green travel limit and I use plastic water bottles – well I have to as I can’t drink the water but I do boil and filter so I reuse the bottles. Plastic bottles are everywhere.

I am a VSO volunteer and working in a local NGO (though virtually totally funded by external donors).  After 32 years in the NHS it was time for a change. For me that is, not the NHS because, as we know, that happens all the time. It took some time getting through the VSO process especially as my husband is here as an accompanying partner. Attending the assessment day together was a new experience. Try doing a group activity (you know one of those management games) with your partner. VSO then sends your CV out to local VSO programmes for them to see if they want you. You don’t get a choice; you just get to say yes or no to an offer. The first one was way outside of my experience, the next we had to go in five weeks; the next wasn’t viable for my husband.  Despair; but finally Ethiopia came up, an HIV organisation at national level and a country of spectacular scenery with mountains. It wasn’t the Far East which was my preference but we are here and at some point we will get to the mountains.

I am working in an organisation called the Network of Networks of People Living with HIV (PLHIV) or NEP+ for short. The HIV epidemic in Africa is heterosexual. When it emerged in the early ’90s there were no HIV services.  PLHIV started to form groups to help themselves and a few very brave souls (many of whom are dead now) came out and said that they were positive and demanded acceptance and support. My organisation arose out of the formation of these groups. There are nine regional networks, two city networks and three national ones with some 400 local networks. Civil engagement is one area of activity but primarily they are organisations that help provide prevention, treatment and care as well as projects to increase skills and employability. However, that is changing as the government starts to provide a health service. So, as ever, an organisation in change.  To think I didn’t know about the Global Fund six months ago and now I can quote the rules chapter and verse.

HIV is about poverty here, the treatment may be free but food and shelter are not and many PLHIV can’t afford the basics. Nor is the treatment for opportunistic infections free, so TB and malaria are the main killers.

So here I am. NEP+ is some 30 people – all Ethiopian, except me. It is primarily male, except me. Originally the organisation’s staff were PLHIV. As the donors started to require financial statements, governance and the like, the professionals arrived. Now the balance has changed. Is that right? Should there be positive discrimination toward PLHIVs? Can someone who is sero-negative really know or understand what it is like to be positive or even what it is like to live in a family affected by HIV? All questions that I remember discussing in the ’80s when working at the King’s Fund. All answers gratefully received.

Now more and more HIV infected people are getting treatment and living. But there are still 14,000 HIV-positive babies born a year. In the UK and US the numbers are way below a hundred. Why? Many women don’t use antenatal services or won’t get tested. Why? Lots of reasons but for some their husbands won’t let them, accessing services is too difficult or their families tell them to use traditional services. Even if a woman is diagnosed, follow up is logistically difficult and complying to the full treatment and breast feeding regime complex in a developed country, let alone a rural village with no water or electricity. The net result is a take up of about 12% of prevention-of-mother-to-child-transmission treatment. One of the worst levels in Africa. Tragedy. All those avoidable deaths and HIV+ kids, let alone the number of women who don’t get treatment. The number of orphans is horrendous. The international, political voice on this one just isn’t there.

VSO volunteers work in local organisations and are paid a stipend which is equivalent to local salaries. So I am paid the same as our drivers, but I do get accommodation. That means we live and work in the community much more than the majority of ex-pats (called Farangis here) who work for international NGOS, the private sector or embassies. I think I am going native as I am starting to really empathise with my colleagues as we try to use the EU process for submitting a bid on a slow dial-up computer link or listen to a well-meaning expert from a big international NGO tell us we must do more on civil rights. Of course we should but at the risk of immediate shut down. There is a law forbidding NGOS to speak about civil rights. A classic case of can you do more inside the system or outside.  Only here is it outside the system but in the country or outside internationally? Oh I have a lot of learning to do.

Public health issues are everywhere including my diet. My hips are vanishing as my diet has drastically changed to minimal dairy with fruit, veg and carbs instead. Having had a fractured hip a couple of years ago I am a bit concerned about my calcium intake. I was taking supplements in the UK but stopped when there was a report on increased incidence of heart disease. I am eating injera, the local, unique dough that is eaten with everything. It looks like a chamois leather but isn’t too bad and is suppose to have some calcium in it.  Should I get Steve (my husband) to bring some calcium tablets back when he visits the UK in the summer?

Must go as visiting a local community project for orphans. More to come.

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