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Human trafficking – what should our public health response be?

Posted in Asia, Children and young people, Global Health, HIV, human trafficking, India, poverty, prostitution, slavery, women on October 3, 2017| Leave a Comment »

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.

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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Public health, but in camouflage

Posted in Asia, Global Health, Health Inequalities, India, maternal health, midwifery, poverty on July 14, 2017| Leave a Comment »

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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We need to reduce the disability poverty gap, but benefit cuts are likely to increase it

Posted in Academic, austerity, disability, Health Inequalities, poverty, Uncategorized on March 6, 2017| Leave a Comment »

By Ben Barr, Senior Lecturer in Applied Public Health Research, University of Liverpool, and Lee Bentley, Research Associate, University of Liverpool

The Chancellor of the Exchequer is due to deliver this year’s Budget on Wednesday. It is imperative that he provides additional financial support for disabled people affected by the planned cuts to Employment Support Allowance (ESA) – or risk further widening the disability–poverty gap.

One in three working age disabled people are living in poverty. Their risk of poverty is one and a half times greater than for people without a disability. The government’s strategy, however, for improving the lives of disabled people, focuses almost exclusively on the disability-employment gap rather than this disability-poverty gap (1). It is true that the high risk of poverty amongst disabled people is largely because they are less likely to be in work and supporting people into employment is an important strategy for reducing poverty. Welfare benefits, however, also play a crucial role in preventing poverty by limiting the loss of income people experience when they can’t work due to disability.

People who have lost their jobs because of a disability are likely to be out of work for longer than people who become unemployed. For this reason, disability benefits have generally been set at a higher level than unemployment benefits. From April, this will no longer be the case. The government is reducing the level of ESA for disabled people who are assessed as being currently unable to work but potentially capable of work at some time in the future. The benefit will be reduced by 30% to £73 a week – the same level as unemployment benefits. But whilst 60% of new claimants of unemployment benefits will move off the benefit within six months, 60% of people on ESA will still be claiming this benefit two years later (2). This means that many people out of work because of a disability will have to survive for long periods of time without an adequate income.

Levels of poverty are already very high amongst people out of work with a disability and have been increasing since 2010, particularly amongst people who have a low level of education – the group most reliant on disability benefits (see Figure 1). Cutting these benefits will exacerbate this adverse trend.

Percentage of people with disability in poverty

FIGURE 1: % of people with a disability in poverty, aged 16-64, between 2007 and 2014, by employment status and educational level

The government argues that reducing these benefit levels will incentivise disabled people to stay in or return to work (3), but there is little evidence to support this assumption (4), and some that suggests it may reduce their employment chances (2). Strategies to reduce the disability-employment gap over recent decades have increasingly focused on more stringent assessment criteria for disability benefits, reduced payment levels and requiring claimants to do more to prepare for work or risk losing their benefits (5, 6, 7). These strategies have had little impact on the employment of people with disabilities (8). It remains to be seen whether the government’s new strategy to halve the disability employment gap will be any more successful (1).

Even if the government’s strategy does improve the employment of disabled people, it is likely this will disproportionally benefit disabled people with greater skills and education (9, 10). The planned cuts in ESA will increase the risk of poverty for the most disadvantaged disabled people who remain out of work, and this may increase the disability-poverty gap.

Increasing poverty amongst people out of work with disabilities will adversely affect their health and increase health inequalities. We know that poverty damages peoples’ health, and adequate welfare benefits for people who can’t work can reduce these effects (11). We have seen that in recent years inequalities in health are increasing (12) in part due to disability benefit reforms (13). The severe cut planned by the government will further exacerbate these inequalities, potentially increasing levels of disability.

1   Great Britain, Department for Work and Pensions, Great Britain, Department of Health. Improving Lives: The Work, Health and Disability Green Paper. 2016 (accessed March 2, 2017).
2   Work and Pensions Committee. Disability employment gap. London: House of Commons, 2017 (accessed March 2, 2017).
3   Kenedy S, Murphy C, Keen K, Bate A. Abolition of the ESA Work- Related Activity Component. House Commons Libr Brief Pap 2017.
4   Barr B, Clayton S, Whitehead M, et al. To what extent have relaxed eligibility requirements and increased generosity of disability benefits acted as disincentives for employment? A systematic review of evidence from countries with well-developed welfare systems. J Epidemiol Community Health 2010; 64: 1106–14.
5   Watts B, Fitzpatrick S, Bramley G, Watkins D. WELFARE SANCTIONS AND CONDITIONALITY IN THE UK. York: Joseph Rowntree Foundation, 2015.
6   Banks J, Emmerson C, Tetlow GC. Effect of Pensions and Disability Benefits on Retirement in the UK. National Bureau of Economic Research, 2014 (accessed Sept 26, 2015).
7   Baumberg B, Warren J, Garthwaite K, Bambra C. Rethinking the Work Capability Assessment. London: Demos, 2015.
8   Mirza-Davies J, Brown J. Key statistics on people with disabilities in employment. House Commons Libr Brief Pap 2016; 7540.
9   Burstrom B, Nylen L, Clayton S, Whitehead M. How equitable is vocational rehabilitation in Sweden? A review of evidence on the implementation of a national policy framework. Disabil Rehabil 2011; 33: 453–66.
10   Clayton S, Bambra C, Gosling R, Povall S, Misso K, Whitehead M. Assembling the evidence jigsaw: insights from a systematic review of UK studies of individual-focused return to work initiatives for disabled and long-term ill people. BMC Public Health 2011; 11: 170.
11   Cooper K, Stewart K. Does money in adulthood affect adult outcomes? York: Joseph Rowntree Foundation, 2015 (accessed July 30, 2015).
12   Barr B, Kinderman P, Whitehead M. Trends in mental health inequalities in England during a period of recession, austerity and welfare reform 2004 to 2013. Soc Sci Med 2015; 147: 324–31.
13   Barr B, Taylor-Robinson D, Stuckler D, Loopstra R, Reeves A, Whitehead M. ‘First, do no harm’: are disability assessments associated with adverse trends in mental health? A longitudinal ecological study. J Epidemiol Community Health 2015; : jech-2015-206209.

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Welfare reform is a reality

Posted in austerity, Health Inequalities, PH Spending, poverty, Urban health on September 30, 2013| 5 Comments »

by Paul Southon

Public Health Development Manager

UK Healthy Cities Network Local Coordinator

Welfare reform is a reality. Reviews of the likely health impacts suggest that they will be significant, are starting now and will last for a generation. (1) (2)

Work to quantify the financial implications for local areas shows that the financial impact will be disproportionately felt by the areas with the largest health inequalities. (3) There is also evidence that the impacts on already disadvantaged sections of communities – such as disabled people, black and minority ethnic groups and women – will be disproportionate. (4) (5)

All of this is happening at a time of major reductions in budgets and staffing across the public sector which limits the local ability to respond. This has been described as a perfect storm for local government. It will also have significant impacts across health services.

Over the longer term there is likely to be an increase in mental health problems, non-communicable diseases and related disabilities which will be felt across the health and social care system. Increasing poverty, especially child poverty, will have long term and generational impacts on child development, health outcomes and life expectancy.

GPs are reporting an increase in people with mental health problems. They are also reporting increasing numbers of requests for support with appeals against Work Capability Assessment decisions and the changes to disability benefits.

Currently the most visible part of the welfare reforms is the spare room subsidy or ‘bedroom tax’. Families on housing benefit who are defined as having extra bedrooms suffer a financial penalty. There is a severe shortage of available smaller properties for these families to move into. Their options are to move into the private rented sector, which may be more expensive, or stay where they are with a reduced income. Families are also moving to areas with lower rents, losing their social and support networks.

Councils are already reporting increases in rent arrears.(6)It is likely that this will lead to increased stress and family tensions, which could be exacerbated by the loss of social and support networks. A concern is that these families will resort to using alternative lenders, such as pay day loans, to cover shortfalls. One payday loan company has recently increased its typical APR to 5,835%.

For families experiencing poverty food becomes a major problem, both in access to enough food and in the quality of the food available. The rapid rise in food banks is testament to the difficulty families have in buying food. (7)

They also have to rely on the cheapest food which is often poor in nutrition and high in fats, including trans-fats. With the current food environment eating healthily is not a cheap option.

So, welfare reform is a reality. The evidence suggests that it is likely to have a major negative impact on public health and inequalities. It is now time to ask the key question: What can local areas do about it and what is the role of public health?

Much of the focus in councils has been on setting up the local systems to manage what were previously national benefit systems, the social and crisis fund payments and council tax benefits. Now these are operational the wider impacts of the reforms are being considered.

Many councils are mapping the local impact of welfare reforms to better understand the local challenges. (8) However, the scope to tackle these challenges at a local level is limited.

One of the stated aims of the welfare reforms is to encourage people into work. This is a laudable aim. Supporting someone into good quality work is a major public health win. The main way to reduce the numbers of people reliant on benefits will be to increase local employment.

However, increasing local employment is challenging in the areas where welfare reform will have the largest impact. Many of these areas have poor levels of educational attainment. Much of the available employment is low paid and insecure. A recent report estimates the local financial impact.

For example, Sandwell will lose around £119 million from the economy each year resulting in less money spent within the local economy, affecting local business and resulting in fewer local jobs.

With the limited scope for minimising the impacts of welfare reform at a local level it is essential that the most is made of local resources. This will need joined up working across councils, health, voluntary and community sectors and local businesses.

Public health has a role in raising awareness of the changes and the health impacts across all parts of the council and partners. It can also support the mapping and analysis of local impact, helping identify the local priorities for action and ensuring local plans are evidence based and monitored effectively.

Welfare reform is here, it comes with a real risk of significant negative impacts on health and inequalities at both local and national levels. Public health in councils needs to recognise this and ensure that it is fully involved in local efforts to minimise these impacts. At a regional and national level public health must lobby for changes to policy to protect population health and the disproportionate effects on the most vulnerable.

(1)Institute of Health Equity (2012). The impact of the economic downturn and policy changes on health inequalities in London.

(3) Beatty C, Fothergill S. Hitting the poorest places hardest: the local and regional impact of welfare reform. Centre for Regional Economic and Social Research. 2013

(4) Oxfam GB. (2010) A gender perspective on 21st century welfare reform.

(5) Welsh Government. (2013) Analysing the impact of the UK Government’s welfare reforms in Wales – Stage 3 analysis.

(6) Inside Housing (2013) Rent arrears up in wake of bedroom tax.

(7) Trussel Trust (2013) Increasing numbers turning to food banks since April’s welfare reforms.

(8) Sandwell Trends: Welfare Reform Topic Page (2013).

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