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Introduction

“Trafficking in human beings” (THB)/“trafficking in person” (TIP) – both are used in the international documents – is one of the most prolific areas of international criminal activity (Wyler and Siskin 2010).

In their recent publication, Zimmerman et al. (2011), the team of the London School of Hygiene (LSHTM) that has published numerous studies on the health consequences of THB state: Although trafficking-related violence has been well-documented, the health of trafficked persons has been a largely neglected topic. For people who are trafficked, health risks and consequences may begin before they are recruited into the trafficking process, continue throughout the period of exploitation and persist after individuals are released. Policy-making, service provision and research often focus narrowly on criminal violations that occur during the period of exploitation, regularly overlooking the health implications of trafficking. Similarly, the public health sector has not yet incorporated human trafficking as a health concern (Zimmerman et al. 2011).

Trafficked persons, regardless of whether trafficking is for the purpose of labour, sexual or any other form of exploitation, are exposed to a range of health-related problems. During captivity, they may experience:

  • Physical violence,

  • Sexual exploitation,

  • Psychological abuse,

  • Poor living conditions and

  • Exposure to a wide range of diseases.

These exposures may have long-lasting consequences on their physical, reproductive, and mental health. The provision of appropriate health assistance to these victims who were exposed to complex multiple abuse, requires special attention preparation and training from the caring personnel (mostly NGOs running special shelters) and health professionals.

It should be noted that providing appropriate health promotion and care services for trafficked persons is not only a humanitarian obligation, but also a public health concern for countries of origin, transit and destination alike (Szilard and Barath 2007). Since the general population is also exposed to the high health risks associated with trafficking, states should commit themselves to both disease prevention and control in this area. This problem does not merely appear in the context of spreading sexually transmitted infections (STIs) and ‘common’ infectious diseases, such as the (re)-emerging problems of TB, HIV/AIDS and of Hepatitis B and C. A significant public health risk may also emerge if – as a consequence of the deteriorated public health system in the majority of countries of origin – ‘vaccine preventable diseases’ are spread to transit and destination countries where most physicians have not been confronted with these pathologies before. Providing appropriate and adequate care in the first line of service is the best security measure against such a risk. To achieve significant advances in this field, governments must harmonize their public health policies including service provision, availability of specially trained practitioners, and data and information sharing.

In this chapter we aim to give a short overview on the nature and magnitude of this ‘modern type’ of slavery as well as its special health consequences.

Definitions

The United Nations Convention against Transnational Organized Crime (2004) definition states:

“Trafficking in persons” shall mean the recruitment, transportation, transfer, harbouring or receipt of persons, by means of the threat or use of force or other forms of coercion, of abduction, of fraud, of deception, of the abuse of power or of a position of vulnerability or of the giving or receiving of payments or benefits to achieve the consent of a person having control over another person, for the purpose of exploitation. Exploitation shall include, at a minimum, the exploitation of the prostitution of others or other forms of sexual exploitation, forced labour or services, slavery or practices similar to slavery, servitude or the removal of organs this definition has been adopted by INTERPOL as well.

Importantly the phrase “victims of trafficking” (VoT) does not denote a homogenous group of exploited people. The US State Department report of 2011 (US State Department 2011) explains the situation from the angle of “enslavement”. At the heart of this phenomenon are the myriad forms of enslavement – not the activities involved in international transportation.

This report classifies the major forms of human trafficking in 8 categories (forced labor, sex trafficking, bonded labor, debt bondage among labor migrants, forced child labor).

Forced Labor

Also known as involuntary servitude, forced labor may result when unscrupulous employers exploit workers that became vulnerable by high rates of unemployment, poverty, crime, discrimination, corruption, political conflict, or cultural acceptance of the practice. Immigrants are particularly vulnerable, but individuals also may be forced into labor in their own countries. Female victims of forced or bonded labor, especially women and girls in domestic servitude, are often sexually exploited as well.

Sex Trafficking

When an adult is coerced, forced, or deceived into prostitution – or maintained in prostitution through coercion – that person is a victim of trafficking. All of those involved in recruiting, transporting, harboring, receiving, or obtaining the person for that purpose have committed a trafficking crime. Sex trafficking also can occur within debt bondage, as women and girls are forced to continue in prostitution through the use of unlawful “debt” purportedly incurred through their transportation, recruitment, or even their crude “sale” – which exploiters insist they must pay off before they can be free. It is critical to understand that a person’s initial consent to participate in prostitution is not legally determinative if they are thereafter held in service through psychological manipulation or physical force. They are trafficking victims.

Bonded Labor

One form of force or coercion is the use of a bond, or debt. Often referred to as “bonded labor” or “debt bondage,” the practice has long been prohibited under US law by the term peonage, while the Palermo Protocol. This Protocol was adopted by the United Nations General Assembly in 2000 and entered into force on 25 December 2003. As of August 2014 it has been ratified by 161 states. Workers around the world become victim to debt bondage when traffickers or recruiters unlawfully exploit an initial debt the worker assumed as part of the terms of employment. Workers also may inherit debt in more traditional systems of bonded labor. In South Asia, for example, it is estimated that there are millions of trafficking victims working to pay off their ancestors’ debts.

Debt Bondage Among Migrant Laborers

Abuses of contracts and hazardous conditions of employment for migrant laborers do not necessarily constitute human trafficking. However, the imposition of illegal costs and debts on these laborers in the source country, often with the support of labor agencies and employers in the destination country, can contribute to a situation of debt bondage. This is the case even when the worker’s status in the country is tied to the employer in the context of employment-based temporary work programs.

Involuntary Domestic Servitude

A unique form of forced labor is the involuntary servitude of domestic workers, whose workplaces are informal, connected to their off-duty living quarters, and not often shared with other workers. Such an environment, which often socially isolates domestic workers, is conducive to exploitation since authorities cannot inspect private property as easily as they can inspect formal workplaces. Investigators and service providers report many cases of untreated illnesses and, tragically, widespread sexual abuse, which in some cases may be symptoms of a situation of involuntary servitude.

Forced Child Labor

Most international organizations and national laws recognize that children may legally engage in certain forms of work. There is a growing consensus, however, that the worst forms of child labor, including bonded and forced labor of children, should be eradicated. A child can be a victim of human trafficking regardless of the location of that nonconsensual exploitation. Indicators of possible forced labor of a child include situations in which the child appears to be in the custody of a non-family member, who has the child perform work that financially benefits someone outside the child’s family and does not offer the child the option of leaving.

Anti-trafficking responses should supplement, not replace, traditional actions against child labor, such as remediation and education. When children are enslaved, however, their abusers should not escape criminal punishment by virtue of long-standing administrative responses to child labor practices.

Child Soldiers

Child soldiering is a manifestation of human trafficking when it involves the unlawful recruitment or use of children – through force, fraud, or coercion – as combatants or for labor or sexual exploitation by armed forces. Perpetrators may be government forces, paramilitary organizations, or rebel groups. Many children are forcibly abducted to be used as combatants. Others are unlawfully made to work as porters, cooks, guards, servants, messengers, or spies. Young girls can be forced to marry or have sex with male combatants. Both male and female child soldiers are often sexually abused and are at high risk of contracting sexually transmitted diseases.

Child Sex Trafficking

According to UNICEF, at least two million children are subjected to prostitution in the global commercial sex trade. International covenants and protocols obligate criminalization of the commercial sexual exploitation of children. The use of children in the commercial sex trade is prohibited under both the Palermo Protocol and US law as well as by legislation in countries around the world. There can be no exceptions and no cultural or socioeconomic rationalizations preventing the rescue of children from sexual servitude. Sex trafficking has devastating consequences for minors, including long-lasting physical and psychological trauma, disease (including HIV/AIDS), drug addiction, unwanted pregnancy, malnutrition, social ostracism, and possible death.

Smuggling in Person

Trafficking from juridical and criminal point of view differs significantly from people smuggling because it involves the exploitation of people. Smuggling in person involves people who are willing to pay (using cash or other favors) in order to gain illegal entry into a state or country of which they are neither citizens nor permanent residents. However, very frequently they became also victims of the smugglers and at the end stage they health harms will be very similar to that of the VoTs.

Historical Overview

International trafficking of human beings is a growing phenomenon, as hundreds of thousands of men, women and children are trafficked by businessmen (Baráth et al. 2004).

Surprisingly, many follow the trafficking routes of the Middle Ages or the Renaissance when mainly Eastern European women and children were sold in slave markets in Western Europe.

The first known phase of trafficking occurred during the Middle Ages, when each year thousands of women and children from East Prussia, the Czech lands, Poland, Lithuania, Estonia and Latvia were sold in the slave markets of Italy and southern France.

The second phase occurred during the latter part of the Middle Ages and the early Renaissance when Eastern European women and children were trafficked, mainly from Russia and the Ukraine, and sold into slavery in Italy and the Middle East. Others came from Bosnia, Albania and the Caucasian Mountains. They also ended their days as slaves in Italy and France. This trafficking route into Western Europe ceased when the Ottoman Empire conquered Constantinople. Western European countries then turned their attention to West Africa as a source of slaves.

The modern slavers from Serbia, Albania, Bosnia, Turkey, Russia and Eastern Europe model themselves on the slavers of the Middle Ages and the early Renaissance. Not much has changed, except they now dress in expensive suits, carry mobile phones and drive flashy automobiles.

The Severity and Scope of the Problem

Because of the nature of the problem, only limited data are available and they are based on estimation. A United Nations report speaks about 127 countries as origin of trafficked people worldwide in the period of 1996–2003 (UNODC 2006). The US government estimates that approximately 600,000–800,000 people are trafficked across borders each year – 80.0 % of whom are female and up to 50.0 % of whom are minors (US Department of State 2008). If trafficking within countries is included in the total world figures, official US estimates are that 2–4 million people are trafficked annually. The International Labor Organization (ILO) estimates that there are at least 2.4 million persons in the process of being trafficked at any given moment, generating profits as high as $32 billion USD (International Labor Organization 2008).

The Global Initiative to Fight Human Trafficking (http://www.unglobalcompact.org/docs/issues_doc/labour/Forced_labour/HUMAN_TRAFFICKING_-_THE_FACTS_-_final.pdf) speaks about similar figures. According to its referred data:

  • The majority of trafficking victims are between 18 and 24 years of age (International Organization for Migration 1999).

  • Many trafficking victims have at least middle-level education (International Organization for Migration 1999).

  • An estimated 1.2 million children are trafficked each year (UNICEF 2003).

  • Ninety-five percent of victims experienced physical or sexual violence during trafficking (based on data from selected European countries) (The London School of Hygiene and Tropical Medicine 2006).

  • Forty-three percent of victims are used for forced commercial sexual exploitation, of whom 98.0 % are women and girls (International Labour Organization 2007).

  • Thirty-two percent of victims are used for forced economic exploitation, of whom 56.0 % are women and girls (International Labour Organization 2007).

Political and Human Rights Reflections

The problem of trafficking of human beings, as one of the most inhumane phenomena of modern societies, was raised first by human rights campaigners at the beginning of the twentieth century (Szilárd et al. 2004). At that time much attention was paid to British women, who were forced into prostitution on the European continent. In this way, the term of “white slavery” appeared. The phenomenon became a political issue in the early 1900s. In 1902, the International Agreement for the Suppression of the White Slave Traffic was drafted. Its purpose was to prevent the procuration of women and girls for immoral purposes abroad. After a few years, 12 countries around the world ratified it. This eventually led to the USA passing the Mann Act of 1910, which forbids transporting a person across state or international lines for prostitution or other immoral purposes. With the problem of sex trafficking still growing in the middle of the century, the United Nations felt it necessary to address the problem. This was done by the 1949 Convention for the Suppression of the Traffic in Persons and of the Exploitation of the Prostitution of Others, which was ratified by 49 countries. As a significant step UN adopted in 2000 the United Nations Convention against Transnational Organized Crime as well as the Protocol to Prevent, Suppress and Punish Trafficking in Persons Especially Women and Children, supplementing the United Nations Convention against Transnational Organized Crime (‘Palermo Protocol’)

Until recently, much of the support in the fight against trafficking has focused on information exchange, criminal and juridical cooperation, and return and reintegration assistance. Only in the last few years have been published studies that have called the attention to the serious health concerns related to trafficking (Zimmerman et al. 2003, 2006; Editorial 2006). These documents also highlight the need to develop minimum standards of care and provide specialized services that specifically match the needs of the victim.

In recognition of these health concerns, the Budapest Declaration (USAID 2003) notes that more attention should be dedicated to the health and public health concerns related to trafficking. Specifically, it recommends that trafficked persons should receive comprehensive, sustained, gender, age and culturally appropriate health care (…) by trained professionals in a secure and caring environment. To this end, minimum standards should be established for the health care that is provided to trafficked victims with the understanding that different stages of intervention call for different priorities.

As a recent development on this field during the EUPHA 3rd Conference on Migrant and Ethnic Minority Health in Europe (Pécs, 27–29 May 2010) the so called Pécs Declaration has been adopted.

It states among others:

  • Health professionals, border guards and helpers should be specially trained in order to be able to provide quality health care and assistance, with emphasis on intercultural (religion, language, etc.) aspects and mental health.

  • Interdisciplinary basic and advanced training programs should be developed and launched for helpers making them capable to cope with this complex task addressing both, assistance provision and occupational health aspects.

  • Minimum health care standards should be set up.

  • Mental health aspects and psychological counselling play a crucial role in establishing a confidential relationship with victims and in helping them in social reintegration.

  • Cooperation should be improved between law enforcement, labour and health authorities, NGOs and academia.

  • Women, children/unaccompanied children and adolescents are especially vulnerable groups with specific assistance and health care needs (e.g. sexual and reproductive health of women, legal issues concerning guardianship of minors).

  • Prevention should be improved by creating hostile environment (police and judicial cooperation) for trafficking in target countries.

  • Health of taficked persons – notably victim assistance, health/mental health care and rehabilitation/reintegration – should well represented under the ‘4 Ps’: Prevention, Protection, Prosecution and Partnership and be included into the European Union (EU) Anti Trafficking Coordinator’s action as declared in the Stockholm Programme. (The Stockholm Programme sets out the European Union’s (EU) priorities for the area of justice, freedom and security.)

Misbelieves Regarding THB

It is a known fact that the general public’s awareness about trafficking all over the world countries is blurred with prejudices and myths about trafficking and its victims, on one hand, and on the other, it is overwhelmed with very low-level, incoherent, sporadic knowledge of traficking resulting from biased and sensation-seeking public media reporting only on a few number of “really striking” cases, whereas for the general public the entire phenomenon is either a “taboo” or a “far-away” world, ignored as much as possible. To illustrate the case, here we quote a few common myths about the victims of trafficking that Ukrainian researchers and health professionals hear and record on a day-to-day basis (Bezpal’cha 2003):

  • Myths about awareness: According to this myth: All the girls and women who go abroad (from Ukraine) know what will be awaiting them there… These women are guilty because they broke the law and agreed to work illegally; they naively believed all the tales about big money in other countries, so they don’t deserve our compassion and help.

  • Myths about prostitution: A woman who returns after trafficking is a prostitute. She had fun; she earned a lot of money. Why should anyone help her? …Once a prostitute, always a prostitute. She’ll never change. Why should she get help?

  • Myths about choice: The woman went there of her own accord and earned money, just as she wanted to. So what does it have to do with us? (…) Look at the way she’s all dolled up and covered with make-up. She’s just a whore, not someone who was victimized by traffickers.

  • Myths about responsibility: All these women, who went onto trafficking about all the things the claim to went through. They just want to get help, to gain basic benefits from her lies (…). These women could have escaped from their pimps. Why didn’t they?

One can find virtually the same or similar pattern of myths and misbelieves about trafficking all over the world, such as: the common say that All prostitutes are willing to participate in trafficking, All participants involved in human trafficking are criminals, and the like.

However, behind all myth-makings and violent attitudes one can easily discover a “double-bind” (Janus-faced) morality typical for the value structure of modern (Western-type) societies, in particular regarding sex and labor, as the two most sensitive moral issues that persist and regenerate themselves probably since colonial times (Foucault 1976). The essence of this double-faced morality lays, on one hand, in the fact that modern societies typically and permanently tend to create, enforce and reinforce a full range of myths about own “clean morality”, “high-standard values”, the “superiority of own culture” (over others), while on the other side, they create, maintain and re-incarnate an abundance of prejudices, violent attitudes and mechanisms of social exclusion towards all those social groups, who – for one or another reason – are considered “unfit” to the normative standards of living, as imagined by the mainstream (civil) society. These are usually labeled as “outcast” groups, many of them “underclass”, and can be of very diverse kind and origin – the “poor”, the “Gypsies”, prostitutes, gays, immigrants, trafficked and smuggled people, to name only a few. Needless to emphasize, that one of the first and most important steps in a public health approach to trafficking is the task of debunking public myths and biased attitudes about both the victims and their perpetrators.

Dynamics and Process of Trafficking – Push and Pull Factors

From a sociological point of view, trafficking in humans is a special kind of migration process, and as such, it shares to some extent two basic features common to other types of migration. One of these features is the dynamics of mass migrations, which rests, among others, on balancing between two forces. One of these forces is the complex of push factors (moving from, flight from), and another is the complex of pull factors (moving towards, attracted to certain values and goals). This two-factor model is one of a classic (economic) approaches to migration, also known by the name “the laws of migration”. It was formulated by the British economist, Ravenstein (1885) in the 1880s. As far as the trafficking in humans is concerned, this theory can highlight many personal motivation factors that “move” great many victims onto the web of trafficking, but there are still great many other push and pull factors that have little or nothing to do with the personal motivation of potential victims. In Table 12.1 we listed a sample of this factor specific to the dynamics not only of trafficking but to other types of modern migration (e.g. smuggling).

Table 12.1 Most frequent push and pull factors underlying trafficking
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Another base of comparison of trafficking with other types of migration is the fact that trafficking is also a stage-wise process, yet with a host of specific features in contrast to any other types of either legal or illegal migration. Migration researchers in the past usually distinguished three major phases in this change process: (1) pre-departure stage, (2) transient stage, and (3) adaptation or integration stage (Jansen 1970). This rather simple three-stage model rests on the assumption that the migration trends are linear moves of people from one social setting to another, from one’s country of origin to one or more other settings, where some of those other settings will be a kind of life-long “final” destination, other not. At this time however, such kind of three-step linear moves appears to be rather atypical in more recent trends of migration, both within countries and in trends of cross-border migration. Specifically, more typical is for the currently unfolding migration trends the kind of, so called, “open-ended” migration process, where moving from one site of residency to another is not at all a linear, but rather a circular process, where “circularity” means moving forth-and back to one place or country of residence to another, and that goes along with permanent changes both in individual and social identities (Lifton 1992; Volkan 1999).

Testimonies of Victims

Viewed from this perspective, trafficking apparently represents an extreme case of fully “open-ended” migration processes, which typically starts at some “fixed” point both in space and time, yet it is fully uncertain whether and how, if ever, it ends at any point in space and time. The most frequently quoted stages of trafficking experience in the literature are the following (Motus 2004):

  • pre-departure stage,

  • travel and transit,

  • “destination” stage to a kind of recently created global “slave market”, and “moved around” from one to other places or countries,

  • rescue or escape, detention and/or deportation, criminal evidence, which at the best eventually ends with return and reintegration, or

  • at worse, it continues with re-trafficking from the place and country of origin, or from anywhere else.

The flow-chart below clearly indicates that after one or more “destination” sites, the future of a trafficked person is typically blurred and full with uncertainties, and her/his fate is completely out of personal control. The truth is that the bulk of victims never, if ever, would reach any of the last two closing phases of trafficking experience. According to rough estimates, some 85.0–90.0 % of victims is never, if ever, able to return home and back to civil life. Moreover, an unknown number of ex-victims even after rescue and fortunate return home would be re-trafficked under life-threatening pressure from the side of local and/or international traffickers (Fig. 12.1).

Fig. 12.1
figure 1

Major stages of the trafficking process

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Let us look at closer victims’ testimonies stage-by-stage, as they go through the hell of trafficking (Zimmerman et al. 2003)

Recruitment and Distribution

I was just 15 when I left Romania. When I was 12 my mother died, my father became an alcoholic and would beat my brother and me. A cousin said he would get me out of this situation and into a ‘normal’ life. He sold me like a slave.

Caroline, Romania to UK

Transport Conditions

Two men escorted us. We were fed only bread and water. We crossed through Poland, Germany, and Holland. At the border with Poland we crossed without any problems, but at the border with Germany we were told to leave the bus and cross the border on foot late at night.

Nadia, Ukraine to Belgium

Destination Stage

They beat me and kicked me. They told me ‘Don’t scream, or we kill you.’ I kept quiet. I was a virgin before they raped me.

Ellen, Albania to UK

Specific Health Consequences of Trafficking

One can conclude that the adverse effects of trafficking must be enormous and in combinations of many diseases and ill-health conditions. One can also assume that all the adverse health consequences impact not only the victims themselves, but directly or indirectly, large segments of the general population worldwide. That is all those “others” who ever come into close contacts with them, either physically or mentally. In the past ten years, great efforts were invested by numerous international organizations, including IOM, WHO, UNICEF and many others, to draw medical and epidemiological statistics on health consequences of trafficking in those countries most vulnerable to this kind of migration. Thus far with rather modest results, however. This is due to serious obstacles of different kind (ethical, legal, methodological etc.) that practically make impossible to conduct any large-scale epidemiological surveys of representative samples of victims, since the vast majority of them are irregular migrants, kept away from public view and local authorities. The only reliable medical (clinical epidemiological) statistics can be drawn from a few specialized rehabilitation centers established for ex-victims, who are returnees to countries of origin, such as IOM Rehabilitation Center in Chisinau (Moldova), in Kiev (Ukraine), Sofia (Bulgaria). However, all these are relatively small clinical samples, thus no generalizations could be made from such small samples neither across countries, nor across different rehabilitation centers and their specific diagnostic procedures.

The table below illustrates the types and prevalence rates of physical and mental health impairments of 171 assisted trafficked women, who went through a 3-day standard diagnostic procedures at the IOM Chisinau (Moldova) Rehabilitation Center upon arrival (Gorceag et al. 2004) (Table 12.2):

Table 12.2 Health conditions of ex-trafficked victims upon arrival to the IOM Rehab Centre
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One of the most comprehensive qualitative research ever done in the field, quoted earlier (Zimmerman et al. 2003), was a 2-year study on trafficking in the European Union, involving a total of 28 trafficked women and adolescents in Italy, United Kingdom, the Netherlands, Ukraine, Albania and Thailand, and 107 informants in 8 countries from the health, law enforcement, government, and NGO sectors (Zimmerman et al. 2003). The principal findings highlighted 9 major categories of health risks and abuse, parallel with the potential consequences, listed as it follows:

  • physical abuse/physical health;

  • sexual abuse/sexual and reproductive health;

  • psychological abuse/mental health;

  • forced, coerced use of drugs and alcohol/substance abuse and misuse;

  • social restrictions and manipulation/social well-being;

  • economic exploitation and debt bondage/economic well-being;

  • legal insecurity/legal security;

  • abusive working and living conditions/occupational and environmental well-being,

  • risks associated with marginalization/health service utilization and delivery.

Just to illustrate of what specific issues were targeted within each of these categories, the table below is an excerpt from the authors’ original study report (Table 12.3)

Table 12.3 Health risks, abuse and consequences of trafficking
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120 out of the 176 (68.0 %) eligible women participated in a recent study (Ostrovschi et al. 2011) of Moldavian VoT upon their return and rehabilitation. At 2–12 months after their return, 54.0 % met criteria for at least one psychiatric diagnosis comprising post-traumatic stress disorder (PTSD) alone (16.0 %); co-morbid PTSD (20.0 %); other anxiety or mood disorder (18.0 %). Eighty-five percent of women who had been diagnosed in the crisis phase with co-morbid PTSD or with another anxiety or mood disorder, sustained a diagnosis of any psychiatric disorder when followed up during rehabilitation.

The Case of Unaccompanied Minors – Special Health Considerations

The most vulnerable populations in trafficking are the children and minors, who make more than half of the total population of victims, according to UNICEF estimates (2005). Children and adolescents are trafficked into many of the same forms of labour and for similar purposes as adults (e.g., factory work, domestic service, sex work, and as brides). They are also exploited in ways that are particular to children (e.g., child pornography, camel jockey, begging, mining, and organ donation). According to the same source, the following factors make children especially vulnerable (UNICEF 2005):

  1. 1.

    Poverty: Poverty heightens children vulnerability to traffickers. One of the most obvious ways, material poverty, leads to exploitation and abuse through child labour.

  2. 2.

    Inequality of women and girls: The legal and social inequality of women and girls is as breeding ground for trafficking. Where women and girls are objectified and seen as commodities, a elimate is created in which girls can be bought and sold.

  3. 3.

    Low school enrolment: Children who are not in school can easily fall pray to traffickers. The estimated global number of children not attending school is 121 million, the majority of whom are girls.

  4. 4.

    Children without caregivers: Children who are without caregivers are extremely vulnerable to trafficking and exploitation, including orphans, and street children. Those placed in institutions grow up without any closer ties to any kind of community (except bonding to own gangs). Millions of children in Africa are orphaned by HIV/AIDS, and in Asia and Eastern Europe the threat of HIV/AIDS is on the rise.

  5. 5.

    Lack of birth registration: Children who are not registered are more susceptible to trafficking. It has been estimated that 41.0 % of the children born in 2000 were not registered at birth.

  6. 6.

    Humanitarian disaster and armed conflict: During conflicts, children may be abducted by armed groups and forced to participate in hostilities. They may be sexually abused or raped. Conflicts and natural disasters contribute to porous border, increasing traffickers’ ability to transport people.

  7. 7.

    Demand for exploitative sex and cheap labour: Trafficking and the skyrocketing demand for exploitative labour and sexual services are closely linked. The drive for rising profits often annihilates all kinds of ethics, resulting in children being exploited in factories and sweatshops.

  8. 8.

    Traditions and cultural values: Trafficking with children intersects the traditional role of extended families as caregivers and an early integration of children into the labor force. The ‘traditional placements’ of children in families of distant relatives or friends have mutated into a system motivated by for-profit economic objectives.

During a trafficking experience, the child is exposed to a physical and psychological environment that damages her/his potential for normal and healthy development. Chronic abuse likely affects personality development and can cause pathological personality development. For example, children learn to “survive” through taking the path of very diverse criminal activities; feeling compelled, even while they are abused; they tend to form attachments and develop trust with their criminal caretakers. After all, children tend to trust adult caretakers, comply with authority figures and blame themselves and feel guilty for what others impose on them. This has disastrous effects on their future capacity to form healthy relationships based on mutual trust and intimacy.

Children are not small adults, and the medical staff and other persons assisting children victims of trafficking should not treat them as such, but be sensitive to the special needs of a child in such difficult conditions (Grondin 2003):

  • Developing approaches that demonstrate respect and promote participation.

  • An understanding of the complex ways in which their past experience has harmed them.

  • Tailoring services to meet the needs of each age group and in ways appropriate to the age and characteristics of the child concerned, and never merely following programmes designed for adults.

  • Implementing strategies aimed at mitigating the effects of past trauma and fostering healthier patterns of development.

The right of children and adolescents to health and to health services appropriate to their age and particular requirements are not only essential for their survival and well-being, but are also fundamental human rights grounded in international human rights conventions in particular the Convention on the Rights of the Child (CRC), which states that the best interests of the child shall be a primary consideration (CRC 1989).

Perspectives to Tackle Trafficking

There is an abundance of scholarly papers, case studies, handbooks, guidelines and training manuals aiming to assist both the professional and general public to take responsibility in combating trafficking in a meaningful, effective and organized way. Hereby we only highlight two possible perspectives (Szilard and Barath 2007).

Health Promotion Perspectives

It is a generally acknowledged fact that one of the most salient changes in the entire philosophy of public health came around in the mid-1980s, with the WHO initiated Ottawa Charter on Health Promotion (WHO 1986). The turning point was, the critical re-conception of health as a positive social construct, and the paradigm shift of moving away from its rather narrow, largely “disease-focusing”, mostly bio-medical conception as it was propagated over decades by clinical health sciences. A key axiom of the statement, which says: Health is a positive concept emphasizing social and persona resources, as well physical capacities. Therefore, health promotion is not just the responsibility of the health sector, but goes beyond health life-styles to well-being.

Another famous axiom of the Ottawa Charter was a brief call, Act locally, think globally!

Put it differently, the Ottawa Charter ‘86 on Health Promotion made quite clear, for the first time in the history of health sciences and related disciplines, the health and the future of the modern societies is not, and cannot be left anymore to illusionist (utopist) thinking, rather it out to be a grand plan of social action drawn upon the following ground principles:

  • social change,

  • physical (environmental) change,

  • healthy policy development,

  • empowerment,

  • community participation,

  • equity and social justice, and

  • accountability (of any social action).

Although the document was not aimed at any kind of crime prevention, and it was created far ahead in time before trafficking became one of the key public health issues world-wide, the above listed ground principles of social action can equally be applied to violence and crime prevention in modern societies. As far as counter-trafficking is concerned, of the above listed range of interlocking principles, community participation strikes out as one of most and urgently needed avenue for social action. Community development, in general, drawn on existing human and material resources in a community to enhance self-help and social support, in the case of counter-trafficking, offers, at this time, one of most viable strategies both for early prevention and victims’ protection.

A Feminist Perspective

If taken this perspective seriously and critically, it must have little, if any, connection with the fact that the vast majority of the trafficked persons in Europe are young girls and women. Rather, the importance of this perspective dwells on the historic fact that not the men, but the women became first watchful about the rise of trafficking and other mass violence in modern societies (the bulk of which, if not all, are committed by men). On the other hand, women’s understanding of the roots and lasting consequences of trafficking on family life, in particular on children and reproductive health of a society as a whole, seems to make the feminist perspective more viable and important on the whole scene of counter-trafficking than any other, mostly men-dominated, “strong-hand” law enforcement. Hence, it is no wonder that so far counter-trafficking programs and helping resources for victims of trafficking are created mostly by women’s voluntary organizations, both on national and international levels, such as White Ring in Hungary, “Payoke” in Belgium and Holland “La Strada” in Italy, Albania, Macedonia and Bulgaria, “Winrock International” in Ukraine, Moldova, Rumania and Russia, to name only a few. That is also the reason why the International Organization for Migration (IOM), the most powerful intergovernmental organization that is active in this field, is widely cooperating with these NGOs within the frame of its counter trafficking programs.