Hanni Stoklosa, MD, MPH, Co-Founder and CMO of HEAL Trafficking
In this thought-provoking episode of Health2049, we have a captivating conversation with Dr. Hanni Stoklosa, Chief Medical Officer of Heal Trafficking. Explore the transformative potential of healthcare in preventing human trafficking and envision a global system that actively responds to and prevents such exploitation. The podcast emphasizes the importance of incentivizing health systems, measuring success and concludes with a vivid portrayal of a compassionate, trauma-informed healthcare experience in 2049. Join the discussion on shaping a brighter, equitable healthcare future through interventions today.
Hanni Stoklosa, MD, MPH, is co-founder and CMO of HEAL Trafficking, an emergency physician at Brigham and Women's Hospital (BWH) with appointments at Harvard Medical School and the Harvard Humanitarian Initiative.
Dr. Stoklosa is an internationally-recognized expert, advocate, researcher, and speaker on the wellbeing of trafficking survivors in the U.S. and internationally through a public health lens. She has advised the United Nations, International Organization for Migration, U.S. Department of Health and Human Services, U.S. Department of Labor, U.S. Department of State, and the National Academy of Medicine on issues of human trafficking and testified as an expert witness multiple times before the U.S. Congress. Moreover, she has conducted research on trafficking and persons facing the most significant social, economic, and health challenges in a diversity of settings including Australia, China, Egypt, Guatemala, India, Liberia, Nepal, Kazakhstan, the Philippines, South Sudan, Taiwan, and Thailand.
Among other accolades, Dr. Stoklosa has been honored with the U.S. Department of Health and Human Services Office of Women's Health Emerging Leader award, the Harvard Medical School Dean's Faculty Community Service award, has been named as an Aspen Health Innovator and National Academy of Medicine Emerging Leader. Her anti-trafficking work has been featured by CNN, the New York Times, National Public Radio, Fortune, Glamour, Canadian Broadcasting Corporation, STAT News, and Marketplace.
Dr. Stoklosa published the first textbook addressing the public health response to trafficking, "Human Trafficking Is a Public Health Issue, A Paradigm Expansion in the United States."
Show Notes
Dr. Hanni Stoklosa shares her healthcare background. [03:35]
Healthcare is a powerful force to end trafficking. [08:43]
Focusing on and responding to trafficking can create a ripple effect in transforming healthcare. [18:54]
What is trafficking and how is the healthcare system positioned to address it? [21:08]
How can we measure the success of training protocols? [26:29]
Should the definition of the social determinants of health include individuals who are either being trafficked or at risk? [30:52]
An example of a holistic, trauma-informed system with better care for those being trafficked. [32:33]
Transcript
Jason Helgerson
I'm Jason Halverson, and you're listening to Health2049.
Dr. Hanni Stoklosa 00:07
It doesn't even have to be officially labeled as a trafficking program, but in health care if we're addressing social determinants of health, we're also in a way preventing trafficking from happening in the first place like that primary prevention piece. So if health care can be the gateway to housing, for example, and housing could have been a vulnerability to trafficking, there you've actually helped prevent the trafficking.
Jason Helgerson 01:42
Today, we have an incredibly distinguished guest joining us Dr. Hanni Stoklosa. She is an internationally recognized expert, advocate, researcher and speaker on the complex issues surrounding human trafficking. Dr. Stoklosa is the Chief Medical Officer and Co-Founder of Heal Trafficking, and an emergency physician at the Brigham and Women's Hospital. Her extensive experience and expertise spans the wellbeing of trafficking survivors in the United States and across the globe, and approaches her work through a public health lens. Her efforts have influenced policy and practice on a global scale, as she has advised renowned organizations including the United Nations, International Organization for Migration, the US Department of Health and Human Services, the US Department of Labor and the National Academy of Medicine. Dr. Stoklosa's invaluable contributions extend beyond her advisory roles. She has testified multiple times before the United States Congress as an expert witness shining a light on the urgent need for action in combating human trafficking. Through these experiences, she has gained a comprehensive understanding of the social, economic and health challenges faced by survivors and marginalized populations. Given her experience and laser-like focus on some of the world's most vulnerable persons, we at Health2049 can't wait to hear her vision for health and health care in the year 2049. I'm Jason Helgerson, and you're listening to Health2049. And it's my pleasure to welcome Dr. Hanni Stoklosa to the program, Hanni, welcome.
Dr. Hanni Stoklosa 03:25
Thanks so much for having me, Jason.
Jason Helgerson 03:27
Well, thanks for being here. And first, maybe you could tell our audience a bit more about your very interesting background.
Dr. Hanni Stoklosa 03:35
Thanks so much, Jason. And thanks so much for this opportunity to really speak into with intentionality what the future of health care looks like from my lens. So a little bit about me, I am from rural Pennsylvania, I'm a pastor's kid. And immediately for some folks that may bring to mind certain perceptions. And for me, really, that was about growing up in a space where I saw social justice as front and center. I watched my father, as a pastor, embody what it looks like to really care for our community, outside the walls even of the faith community and really live out his faith and values. So that was during my formative years. I knew growing up that my life was for others and that at each and every step of my path, I would have a calling. I know it sounds weird to say as a kid that's what I would think about but I was looking for, what is that big calling in my life? How can I be prepared to answer that call? And so that frame of reference brought me not surprisingly to medicine and brought me to become a doctor. I had the opportunity when I was in High School to shadow a physician in Guatemala who worked for this really vulnerable population on the Guatemala City dump and saw the scavenging community that got their livelihood from culling through the trash. How this physician could not only treat their illnesses one by one, but also make a greater impact on their health and well being through public health solutions. So early on in health care, I knew that I didn't want to just be the kind of physician that was treating patients one by one, but that was having a macro level impact in the work that I was doing. Then that led me to try to fill my toolbox of skills along the path of becoming a doctor with things like policy making. I spent a year between second and third year of medical school working in DC at a policy think tank. I spent as much time as I could abroad knowing that outside of US walls we have a lot of lessons to learn and wanted to understand what was being done in the health care space and other settings to be able to translate that back to health care here. And really learning from all throughout the community, how they think about change and organizing. So during my medical school years, that led me to work on issues like HIV AIDS and be involved in community activism, including with Act Up. Then fast forward, this is a very abbreviated version, but all of those ingredients led me to choose emergency medicine and really focus during that time on becoming a good doctor. Then at the end of my training, I was graduating from Harvard Medical School's program and I found that I was at this place where, okay, I've trained to become an emergency medicine doctor, I can save lives in all of these ways. I know I want to have a bigger impact on society. What does all of that mean, what is all of that for? At that time, the research on trafficking in health care came out and showed that the majority of people who access health care have some touchpoint with emergency departments, with urgent care centers, with primary care clinics. I knew at that moment as I read this literature that this was my calling. That if I as this Harvard trained emergency physician didn't know anything about trafficking, how many practicing clinicians were out there around the world practicing that didn't have this information, how many health systems didn't have the tools in place and how many folks are being trained currently that will not have this as part of their curriculum. And so I stepped into that big chasm in partnership with our amazing group of co-founders and we created Heal at that point. So Heal Trafficking is now a network that's in 45 countries around the globe. And we're building a movement in health care to respond to human trafficking and making sure that each and every touchpoint with health care that a trafficking victim has leads to healing. So that's a little bit about my background and kind of what led me to trafficking and working on trafficking.
Jason Helgerson 04:30
That's a great background and I think it really helps to give the audience a sense of who you are and how you got to be who you are today and what your influences are, your motivations, which I think sets us up for the next big question which we always start with with our guests which is, in your view, what does health and health care look like in the year 2049?
Dr. Hanni Stoklosa 08:43
Thanks so much for that question, Jason. So to inform how I think about this question, we've already talked about the fact that I think all health systems should have plans in place for trafficking. And I'll get to that, but my perspective is informed by working clinically in an emergency department and I'm in the midst of a slew of shifts. And so I say all that to say, I see all of the reality of what health care currently looks like very much so. It's what I live and breathe every day and I work with medical students. I work with physician assistants and trainees in those specialties and really have the opportunity in the emergency department to be on the front lines and really work collaboratively with many other places in health care because we are that catch all and because we do take a multidisciplinary approach in our work and so I have these kind of like, hats and perspectives as Chief Medical Officer of Heal Trafficking and then also grounded in that kind of clinical experience. Each and every day, I do a lot of reflection and I feel like I'm constantly updating how I think about what health care looks like currently and where we should be going, where we can be going. It's constantly evolving. So I just wanted to share that. This process for me has also involved a lot of unlearning of ways that I had of thinking and updating that based on evidence, based on listening to survivors of trafficking and other forms of violence, listening to colleagues. So to answer your question, Jason, what does health and health care look like in 2049? I believe in a world where all health systems, it doesn't matter whether we're talking about in the US context, whether we're talking about Malawi, or India, or Australia or China, that every health system does have a plan in place not only to respond to trafficking, but to identify trafficking and to help survivors get the resources that they need. I believe that health care is the most powerful force to end trafficking. Trafficking is a crime. It's a crime against people, but if we're only using criminal justice tools we can't arrest or prosecute our way out of trafficking. And who better than health care to respond to trafficking. Health professionals are trusted individuals in society, our health systems do have safety nets, we're thinking actively about social determinants of health. So we need to learn from how we've worked successfully with other forms of interpersonal violence, like domestic violence and child abuse, and expand those to thinking about trafficking and be that safe space to help those who are experiencing trafficking get out of those situations. I think it is possible. I think it takes a lot of political will to make that happen. But we're seeing that every year as I look at the kind of global benchmarks on trafficking, the US State Department puts out this Trafficking in Persons Report, every year I'm seeing more and more countries where there's engagement by the Ministers of Health who used to not be at the table when it came to anti trafficking efforts. They're saying, Hey, this is a health care priority. Every year, we're seeing more and more education and training of health professionals as it relates to trafficking. So those are all really positive indicators to me that we are heading in the right direction. But where we are right now is not enough. Heal just co-published with the World Health Organization a review of all the literature over the last year on trafficking and health care responses. As we looked at where that literature stands, there were significant gaps. Most of the literature and the research on trafficking comes out of the Canadian context and UK and US contexts and we're really not hearing as much as we should and could be from low and middle income countries as it relates to health care's response to trafficking. I have optimism that we can get there and also, we have a long way to go. So that's one piece, of course, I'm going to talk about trafficking. But I think trafficking is an extreme form of violence and how health systems respond to trafficking is really a litmus test and tells us how we're caring for other vulnerable patients, including other survivors of violence. If we can get the trafficking response piece right, we're going to be providing that safety net for other forms of violence. So it's an expansion of that safety net and it also has that ripple effect for so many of our other vulnerable populations. Just to get a little bit more specific about how I think about that, I do a lot of thinking about trauma-informed care and I'm not sure how much any of your other interviewees have talked about trauma informed-care, but just starting with kind of the basics and also just from where I first thought about this, so when we think about trauma, whenever I was first trained as an emergency physician, I thought about trauma as, are we talking about gunshot wounds, are we talking about motor vehicle accidents and really the physical versions of trauma, but what we're really talking about with trauma informed-care is acknowledging that trauma is not just physical, it's emotional and that it impacts everyone in society, some folks more than others. In a healthcare setting, if we're not acknowledging that people are showing up with past traumatizing or bad experiences in their lives and taking a really a universal approach of being a safe space for those who've experienced trauma, which is really all of our patients, then all of the medical stuff, it's not that it's not, but it really may not be as impactful as it possibly could. And we're definitely not engaging with our patients as well as we could if we're not providing trauma-informed care. So there's been this movement in health care on trauma-informed care, which is great, but it needs some expansion. So as I look forward to 2049, I also see this expanded lens of how we provide trauma-informed care. This comes out of again, my lived clinical experience that it's all well and good to say, I need to be there and empathetic and show up for my patients to acknowledge their trauma. And I know in my head that I can provide high quality care that might even be more efficient. But the reality is that we as health professionals are traumatized, too. And sometimes we even traumatize each other. So the full 360 view of trauma-informed care is being trauma-informed towards ourselves and being trauma-informed towards our colleagues. I had this moment with a nurse the other night on a shift where we were doing just that, the patient-facing form of trauma-informed care and really trying to be mindful of where this patient was coming from in terms of their background. The nurse came up to me afterwards and she said, What about my trauma? What about my trauma and I saw her as just burnt out and tired, and also not seen by her fellow colleagues in the emergency department. And that was really a moment where I realized that we really have to think about this as a three legged stool, how are we trauma-informed towards ourselves, towards our patients and then also to each other. And when we have all of those legs of the stool, then the stool doesn't fall. But if one of them is missing, then it will topple over. So that broader context of having health care be this trauma-informed place which takes culture shifting work, is the environment, is the groundwater, is the change in ecosystem that will allow us to take better care of trafficking victims, of the gunshot victim, of the victim of community violence, of child abuse, or of trauma from their cancer, it changes the ecosystem of health care. So as I zoom out even from the trafficking piece and think about what health care can really look like in the future, I think we need to be actively talking about trauma-informed care in this really holistic way that will allow us to take better care, not only of our patients, but of ourselves.
Jason Helgerson 18:02
Yeah, so very interesting. So basically, it's almost like what you're describing is a ripple effect where if by focusing health systems around the world on meeting the needs of trafficked individuals and in order to do that effectively, you need to provide trauma-informed care and create a trauma-informed health system that is you say is responsive not just to patients, but also to providers. By focusing on the traffic population and responding to those needs, then that will create a positive ripple effect of really transforming the operating system of health care in fundamental ways. Is that the right way to describe your vision for the future?
Dr. Hanni Stoklosa 18:54
Yeah, I think that's exactly right. It's both, culture and operations have to go together. There's statements about culture eating policy every time, but the reality is also if a trafficking victim comes to an emergency department, Saturday 2am, you have an excellently trained nurse who identifies that the person is trafficked and offers resources, they have to know what those resources are and can they access them on Saturday at 2am and what is the plan? So these have to go hand in hand. They're not mutually exclusive. But I think by health systems really asking themselves, are we an environment that can care for trafficking victims, you realize instantly that there are these fundamental shifts that need to take place. And don't get me wrong, I've talked about it on the sort of interpersonal level and I think that's a really important component, but also we have to think about how do we change the structures so that as much as possible, the environment allows us to practice that trauma-informed care towards each other.
Jason Helgerson 20:16
So maybe just in terms of trafficking, it might help our audience to wrap their heads around the degree of the problem. I think there's a lot of people out there who, especially in countries like the United States under appreciate how much trafficking actually is happening on a daily basis and the fact that it's not something that's limited to third world countries or something that happens only in urban settings, but maybe give the audience a sense of the degree to how much traffic is actually happening and why do you think the healthcare system is so well positioned to address that?
Dr. Hanni Stoklosa 20:59
Yeah, great question. So I might back up even more and just say what trafficking is, if you think that's helpful?
Jason Helgerson 21:07
That'd be great.
Dr. Hanni Stoklosa 21:08
Okay, great, when most of us think of trafficking, probably the instant image that comes to mind is someone that's locked away in a basement, maybe for a sex trafficking situation. But I'm just gonna start with some fundamentals about what trafficking is and how it's actually much more beyond that and involves so many more experiences of exploitation that what instantly comes to mind. So the way that I encapsulate trafficking is thinking about a person profiting from the labor of another individual. So it's commercial, there's some element of profit for the trafficker that's happening. And that person that's being trafficked is trapped. So from their perspective, they're not able to leave that situation and they may be experiencing being literally physically trapped in a space, but it may be psychological. We know from domestic violence how powerful that psychological coercion is and keeps people in situations that are so awful, but that that trafficker is using all these forms of manipulation and coercion to keep them in that situation. So someone is profiting off the labor of someone else and that person is trapped in that situation. And then another caveat to give to this which is in the UN definition of trafficking and then also in the US definition is that anyone under the age of 18 who's engaged in commercial sex is considered to be trafficked. The reason that age cutoff is really important is that that person might not say that they're being trapped. It's a very inclusive definition, under the age of 18 any commercial sex is considered as trafficking. That's meant to be really protective so those individuals who unfortunately in the past were considered by law to actually be criminals, we're saying, there is no such thing as a child prostitute. So just knowing how expansive that definition is a really helpful starting place. So we know trafficking affects folks of many genders, sexual orientations and demographics, ethnic and racial demographics across the globe. And at the same time those are who come to mind as when you think of the word marginalized, those communities that are undomiciled, folks that are disabled, folks that are coming through foster care systems. All of these folks are highly vulnerable to trafficking because the traffickers are able to exploit these vulnerabilities and provide some basic needs for individuals at the cost of exploiting them. So given all of that, it's not surprising then that we know that lots of trafficking victims have touch points with health care and that we know that trafficking is much more prevalent than what we're even able to count. To give some numbers to it, what we look at is the International Labor Organization's prevalence estimates. We do not have great estimates of prevalence in the United States, so I'm not going to quote those ones because they're not great. But in 2022, the International Labor Organization released the estimates of 50 million people that are worldwide in as they term it, modern day slavery because it encompasses all forms of trafficking on that global level, so 50 million people. And then I mentioned as I was talking about my own journey of coming to this issue and it really being a calling for me, that there was a study that showed that there's touchpoints with health care. Well, we now know that up to 70% of trafficking victims in the United States whether their traffic for labor or sex trafficking have some interface with health care. So what that means is every day, there are trafficking victims that are going through our primary health centers, that are seeing community health workers, that are coming through our hospitals, their emergency departments, OB GYN that are experiencing trafficking, and to me that represents that huge opportunity and responsibility to respond to trafficking.
Jason Helgerson 21:10
Right. So the 50 million number globally, unfortunately, we do not have a good US number. But is that part of the challenge, too, is that it's a hard thing to measure? I mean, I heard you loud and clear up front that one of your goals, Heal's goals is to make sure that all health systems around the world have programs, have protocols or have the right training to be able to respond, identify individuals who are trafficked and hopefully get them out of that traffic situation. But back to the bigger goal is not just to have the training, it's also to try to actually begin to reduce the number of people who are being trafficked. I'm just wondering about the challenge around statistics. How do you measure success in your efforts beyond just the number of health systems that actually have training protocols in place?
Dr. Hanni Stoklosa 26:29
That's the million dollar question, Jason. I love it. So a couple of points there, as we think about estimating it, you're right we're talking about a clandestine crime. So it's difficult to count in that way, but also because many people who are victims of trafficking actually don't know that they're victims of trafficking. They're not coming forward and to say, this is what's happening to me partly because it's relatively new that we're talking I mean it doesn't seem new to me because I'm embedded in this work, but it's only been relatively recently that the government has really stepped up in the last 20 years codifying trafficking laws as a cascade from the UN laws, which is relatively new in the scheme of crimes. So one of the things about trafficking is that victims themselves are not labeling their experience as such. Some of that's because they're not seeing what they're experiencing reflected in media portrayals of trafficking. But some of that's just purely the manipulation of the trafficker, like the trafficker saying, you don't have rights in this country. And because that victim doesn't speak English and all the information is in their native language, that trafficker is telling them all the information in their life and telling them, if you don't do X, Y, or Z, you're gonna get deported. And by the way, you have this debt and that person just feels like it's an awful situation, that victim, but they don't realize that that's actually trafficking and they have rights as a victim. So I think that's another added layer to the estimates and also an important component as we think about health care response. But to your question around measurement and intervention, I absolutely agree that this is beyond identification, that health care's role. The goal is really to help connect them with resources to prevent them from being re-trafficked. So what are the social determinants of health or what are the Maslow's hierarchy of needs? What are those basic things that that person needs, so that they're able to leave that situation and have a better life. And health care is obviously not going to provide all of those things, but they can be that connecting portal to those resources where they exist in communities and therefore be able to prevent re trafficking. And this kind of gets to that ripple effect thing. If we're identifying folks, it doesn't even have to be officially labeled as a trafficking program. But in health care if we're addressing social determinants of health, we're also in a way preventing trafficking from happening in the first place like that primary prevention piece. So if health care can be the gateway to housing, for example, and housing could have been a vulnerability to trafficking there you've actually helped prevent the trafficking. And then as we measure impact. So I'm laughing because there's so many conversations around prevalence and it's not a laughing matter, but it is really complicated. And how do we measure success? It's a really important thing to think about because is this intervention working in the first place and is it working for some people but actually creating harm for other communities? Those are all things that are really important to track not only unlike the community level or city intervention level, let's say, but also keeping an eye on is the prevalence changing? And how confident are we in the prevalence measures? So they're kind of like multi layered ways of measuring that we need to keep an eye on in terms of intermediate outcomes. Some of these like proximal indicators, as well as that kind of final goal, are we actually reducing trafficking from happening in the first place? And how much do prevalence estimates play into that? Does that make sense?
Jason Helgerson 30:32
Yeah, it does make sense, it makes me actually wonder whether or not we need to expand the definition of the social determinants of health to include individuals who are either being trafficked or maybe even individuals at risk of being trafficked, as just another example.
Dr. Hanni Stoklosa 30:52
Yeah, this is something that I think about in relation to incentivizing this work for health systems. Because there's so much conversation around social determinants of health that I see the direct line to other forms of violence and risk for violence. And what are the implications then in terms of reimbursement, because as much as I can say this is my vision and I think this needs to happen in 2049 unless our health systems are also incentivized besides the goodness of their hearts to get involved in trafficking and see the direct links and the ripple effects across their system, including for workforce retention. I don't know if we'll get there. And so I think making that link to social determinants of health is actually critical and strategic.
Jason Helgerson 31:49
All right. So one more question. I could ask you questions all day, but this is a very interesting topic. But one more question for you for this session, maybe you could describe for the audience, if we get to this point where whether it's through trafficking and better care for individuals who are being trafficked, this idea of getting to a health system that's truly trauma-informed, holistically trauma-informed, what would that feel like? What would that experience be like for someone say, going into the emergency room or going into a primary care office? Maybe you can give our audience a sense of, if we actually got there by 2049, what would the patient's experience be like?
Dr. Hanni Stoklosa 32:33
It would be beautiful. It's so funny, because I'm a pragmatist, a pessimist and an optimist and all those things come together as I think of the future state and all that it entails. But I actually go back to a specific patient example where this is a person that comes to mind when I think about this future state. So she had a horrible past growing up and that trauma is probably the reason why she had diabetes type one, but she has come to the emergency department numerous times because of medical issues. In that future state, while she will still probably have the diabetes that's a direct result of the trauma in her past, when she comes to the emergency department, we're not going to traumatize her by asking her to retell any pieces of her past. We're going to knock on the door, before entering the room we're going to ask her when we have to do her ultrasound guided IV, what arm does she think is the one that we should utilize. We'll provide her with pain medication that she needs as part of any painful procedures and any pain she's experiencing. And we're not going to ask her to repeat herself multiple times as to like what's happening today, that we'll ask her once as part of that clinical visit and she'll get the medical care that she needs for her diabetes complications. Then be discharged to a space where ultimately she has housing and she has access to the insulin that she needs. So it's funny because I didn't tell her story in the negative and I guess I could because I know this same person has come to our emergency departments and been traumatized and just left the emergency department because it was so disconcerting and so chaotic and people asked to repeat herself. Even though she was in need for dire medical attention that required intensive care unit level of medical care, she'd rather leave and risk death to herself than stay in our emergency department. So what trauma-informed care does is flips that script, it acknowledges the past trauma and shows up in the ways that she's identified that she can receive care. I don't know if that helps. I have a very specific patient that comes to mind, but that's just one example that comes to mind.
Jason Helgerson 35:21
Actually, I think that example is fantastic. And I think it really helps our audience wrap their heads around the possibility of what a trauma-informed health system could look like. And hopefully, your vision of it being achieved by 2049 if not achieved earlier actually comes to be. And with that, that was Dr. Hanni Stoklosa's vision for health and health care in the year 2049. As always, thank you for listening to Health2049. If you enjoyed what you just heard, please subscribe to us on Apple Music and Spotify and share this podcast with a friend. Thank you and see you next time.
