Abstract
This reflective article was drafted in November 2020. Since this time, the authors have worked with the counter-slavery sector to co-develop a refined public health framework to address modern slavery (Such et al, 2021). Significant knowledge mobilisation has also occurred with a range of stakeholders, and the Independent Anti-Slavery Commissioner has encouraged the UK Home Office and the Home Secretary to embed a public health approach within the UK’s response to modern slavery (IASC/Home Secretary, 2021). Key references and insights from research in 2021 are available as a collection.
Introduction and background
Modern slavery is an umbrella term that describes a range of exploitative practices. It is a crime under the Modern Slavery Act 2015 and includes human trafficking, sexual exploitation, forced labour, domestic servitude and forced criminal activity. It involves recruiting, holding and/or moving people through the use of force, coercion, abuse of vulnerability, deception or other means1 for the purpose of exploitation. It can be regarded as both a human-rights and a public health issue (Chisolm-Straker and Stoklosa, 2017; Such et al, 2020). Not only does it have severe consequences for the physical and mental health of victims and survivors, it also has considerable economic and social costs for communities and wider society (Reed et al, 2018). It contributes to health inequalities by further worsening the health outcomes of individuals who usually already have poorer health than the general population. Its hidden nature, however, makes its size and spread and the scale of harm difficult to quantify.
Public Health can be defined as ‘the science and art of preventing disease, prolonging life and promoting health through the organized efforts of society’ (Acheson, 1988). Historically focused on infectious diseases, public health has moved to a stronger focus on non-communicable diseases in recent years, but also offers a framework to understand and act on areas that are not traditionally seen as ‘health problems’. This was most notably recognised by the World Health Organisation (WHO) in their application of a public health approach to violence (Krug et al, 2002) but has also been applied to knife violence (Brohi et al, 2019) and violent radicalisation (Bhui et al, 2012).
The strength of a public health approach lies in its clarity and comprehensiveness. Firstly, it captures the big picture, focusing on the needs of the population, rather than individuals. It then uses well-established methods to assess the problem, identify areas for action, and develop, implement and evaluate interventions to address that problem. This is underpinned by two fundamental principles: reducing inequalities and partnership working. Prevention of ill-health and ill-being is central to public health.
Despite its apparent advantages, a public health approach to modern slavery has not yet been fully articulated or appraised. The purpose of this article is to consider: i) what constitutes a public health approach to modern slavery? ii) why it might be of (added) value and, iii) what are the challenges and future directions for the further development and operationalisation of such an approach?
A public health approach to modern slavery
A public health approach to modern slavery is at an emergent phase. A review conducted by Public Health England and the University of Sheffield revealed that public health as a field of theory and practice had much to offer the counter-slavery agenda but that it was underdeveloped (Such et al, 2017). Evidence synthesis and consultation within the modern slavery field in the UK produced a subsequent framework that formulated the beginnings of a public health approach (Such et al, 2020). This is reproduced in Figure 1.
An emergent public health approach to modern slavery (Such et al, 2020)
Citation: Journal of Poverty and Social Justice 30, 2; 10.1332/175982721X16449406109455
Source: Such et al, 2020. Reproduced with permission from Elsevier license number 5075291208897.An emergent public health approach to modern slavery (Such et al, 2020)
Citation: Journal of Poverty and Social Justice 30, 2; 10.1332/175982721X16449406109455
Source: Such et al, 2020. Reproduced with permission from Elsevier license number 5075291208897.An emergent public health approach to modern slavery (Such et al, 2020)
Citation: Journal of Poverty and Social Justice 30, 2; 10.1332/175982721X16449406109455
Source: Such et al, 2020. Reproduced with permission from Elsevier license number 5075291208897.The components of the approach draw on public health understandings of the wider determinants of health (distal or upstream factors) as well as an acknowledgement of the risks to individuals (proximate or downstream factors) that need to be addressed to prevent harm. Its multifactorial, multi-level structure reflects the acknowledged deeply rooted and complex causal chains embedded within the problem of modern slavery. Global, national, local and service level protective and preventative factors are identified. These are familiar to those working in the counter-slavery field. Less familiar is the unifying framework and, potentially, the underscoring principles of public health outlined above. While the framework requires further development and testing, we offer a series of propositions that identify how and why this emergent approach is helpful.
Advancing our understanding of and action on prevention
Eradicating modern slavery requires grappling with the problem of prevention. Public health preventative action starts with patterns of events and phenomena across populations. This population focus is evidence and intelligence driven. We have evidence that modern slavery has damaging effects on the physical and mental health of victims and survivors. We also know that a range of disadvantageous social factors place some populations at higher risk of exploitation than others. Preventative action can be mapped, tailored and applied across populations – in this case, populations experiencing or at elevated risk of exploitation.
In addition, public health science uses the model of primary, secondary and tertiary prevention to target preventative action (Figure 2). First, primary preventive action includes activities, interventions and policies that prevent the problem from occurring. These ‘immunising’ strategies (Brohi et al, 2019) promote upstream solutions that challenge known risk factors such as poverty and forced migration. Secondary prevention includes early interventions such as the disruption of perpetrator networks, community-based or youth-based support (for example, for county lines trafficking) and the appropriate regulation and inspection of employers. Finally, tertiary prevention tackles the on-going problem of reducing the harmful effects of modern slavery. These include victim-centred, trauma-informed services. A holistic model of prevention across these levels therefore challenges both the causes of modern slavery and the ‘causes of the causes’.
Public health model levels of prevention
Citation: Journal of Poverty and Social Justice 30, 2; 10.1332/175982721X16449406109455
Public health model levels of prevention
Citation: Journal of Poverty and Social Justice 30, 2; 10.1332/175982721X16449406109455
Public health model levels of prevention
Citation: Journal of Poverty and Social Justice 30, 2; 10.1332/175982721X16449406109455
Reframing the anti-slavery response
A public health lens offers an opportunity to partially reframe or reconceptualise the criminal justice approach that has historically dominated responses to modern slavery. Critics have noted the limitations of this perspective (Haase, 2014; George et al, 2016); that it risks focusing on perpetrators rather than victims, is largely reactive and risks stigmatising and criminalising victims. A public health approach has the potential to offer a unifying framework that encompasses human rights, humanitarianism, justice under the law and global, national and local sustainable development while placing the health and wellbeing of populations front and centre. There is also a crucial window of opportunity with a recent commitment between policing and health to adopt public health principles in policing in the UK (ADPH et al, 2018; see Violence Reduction Units, 2022).
Improved victim-centredness and focus on the needs of affected communities
A product of a reframing of modern slavery using a public health approach is an improved focus on the needs of victims, survivors and people at risk of exploitation. By refocusing the problem away from law enforcement solutions and towards maximising the health and wellbeing of populations, a public health approach offers improved victim-centredness and focus on the needs of affected communities. This is necessary as since 2009 the number of victims identified in the UK has increased from 546 referrals into the National Referral Mechanism (NRM) to 10,627 in 2019 (Home Office, 2020). This has been, in part, a product of the introduction of the Modern Slavery Act in 2015 which served to improve both awareness of the problem and the structures and processes for identification. It is very likely that many more are never identified or do not wish to engage with the NRM. Many victims experience significant barriers to disclosure including mistrust of authorities, presenting additional challenges to identification and fewer intervention opportunities. Narrow criminal justice approaches can limit the extent to which these issues can be addressed. In Jonathan Todres’ terms: ‘Criminal law, while still necessary, is no longer the primary tool for preventing harm’; the threat of criminal sanctions has proved an insufficient deterrent (Todres 2011: 453).
Using a complex systems perspective to identify intervention opportunities
Preventing modern slavery involves understanding risk and protective factors within complex and often hidden systems of cause and effect. We have some evidence of what these risk and protective factors are and partial knowledge of how complex systems of exploitation operate. Public health science, along with other disciplines, has embraced methods such as systems mapping and modelling using data, intelligence, research, evaluation and participatory methods to identify the components and dynamics of complex systems to inform interventions and increase opportunities for action to avoid or reduce health harm. Such methods have only recently been applied and in a limited way in specific trafficking contexts, revealing helpful insight. Kiss and colleagues, for example, explored trafficking risk factors among women in Nepal using Bayesian mathematical models to test some of the underlying assumptions about what caused exploitation. They revealed that living and migration conditions rather than personal vulnerabilities determined risks to trafficking (Kiss et al, 2020). In particular they found that interventions to enhance migrant women’s personal awareness was unlikely to prevent human trafficking or exploitation at a population level. This challenges organisations which are developing and commissioning prevention interventions to think beyond individually targeted interventions designed to alter the behaviours of those at risk and to invest in improving the living and migration conditions of those seeking a better life. Similar methods are being adopted to help understand the dynamics of county lines trafficking (Hayes et al, forthcoming). Such methods remain at the cutting edge of public health science and practice (Meier et al, 2019) and are an opportunity to identify and disrupt the complex, intertwined causal chains responsible for exploitation.
A public health approach can drive both policy and practice
A public health approach to modern slavery has a dual function: to inform both policy and practice. The concern of public health for both the upstream and downstream causes of health-damaging and health-promoting outcomes offers an opportunity for a holistic consideration of the policy environment that promotes health and wellbeing (salutogenesis) and the service responses that fulfil that policy ambition. As indicated in Figure 1, these include culturally sensitive, trauma-informed services and practices, wrap-around multi-agency care and tailored, specialist services to meet survivor needs. Indeed, examples of policy–practice coherence using public health principles have been developed by some state coalitions in the US and are promoted by health service action groups seeking to change health professional practice (see HEAL Trafficking, 2022 [US]; VITA Network, 2022 [UK]). The North Carolina Coalition Against Sexual Assault, for example, have created a Human Trafficking Prevention Toolkit that identifies how policy and practice can follow nine steps to prevention and operationalise an anti-oppressive lens (NCCASA, 2020). These examples can serve as helpful trailblazer guides to inform further intervention design and implementation that would be suitable for testing.
An organising framework for anti-slavery partnerships
Partnership working lies at the heart of a public health approach. Indeed, most areas of the UK now have an anti-slavery partnership, some of which already operate under public health principles. However, research has identified a need for greater emphasis on outcomes alongside ‘input’ focused activities such as awareness raising (University of Nottingham Rights Lab, 2020). The West Midlands approach in the UK provides an example of good practice. Activity has included mapping victim support pathways, data sharing between PHE, policing and the Strategic Migration Partnership to identify high-risk groups, as well as research with Westminster University on health equity challenges for Albanian female survivors of sexual exploitation (Dando et al, 2019). At a national level, there is a need for more coordination; an overarching public health prevention framework may assist. Examples of similar resources have been developed in other policy areas including child sexual exploitation (PHE, 2019).
Further considerations, challenges and limitations
While there are multiple opportunities afforded by a public health approach to modern slavery, it is important to also think about its limitations, challenges and a way forward. Some communications on public health approaches to similar complex policy areas have used a ‘disease’ metaphor. It is unknown if framing modern slavery as a social ‘disease’ that requires a ‘cure’ is an effective or appropriate framing, and this metaphor cannot be confused with the notion that there is a single solution. However, approaches to health protection offer something from which the counter-slavery sector can learn. Once developed, a public health approach to modern slavery must continue to be dynamic and evolve, incorporating learning and good practice from other complex policy areas where this exists.
Upstream components
Gaps in data
The use of data to inform action is a fundamental principle of a public health approach, however in the context of modern slavery there are still significant gaps in understanding. This includes prevalence, with estimates ranging from 10,000–13,000 to 136,000 (Silverman, 2014; Walk Free Foundation, 2018), the extent of re-trafficking and the specific health needs of this vulnerable population. In addition, relevant data is often held in disparate datasets, with many organisations holding a different part of the picture. There is some encouraging work in progress aimed at addressing this issue. This includes the Traffik Analysis Hub which brings together datasets and maps reporting instances of modern slavery, and research being undertaken by the Modern Slavery Policy and Evidence Centre on responsible data flows, data sharing, privacy and security (Modern Slavery Policy and Evidence Centre, 2020).
A need for coherence and consistency across policy
To tackle upstream factors, there is a need for cross-government collaboration as modern slavery is an issue that cuts across multiple policy systems including health, welfare, asylum and immigration and criminal justice. This may be challenging to attain in practice and would require a shift in ways of thinking and working by system leaders including politicians, law enforcement leaders, civil servants, counter-trafficking advocates and researchers. Cross-sectoral collaboration has proved challenging in other policy spheres such as in the pursuit of health equity through ‘health in all policies’ (Cairney et al, 2021; Such et al, 2022). Committed leadership of collaborations is, however, likely to be a critical success factor in the implementation of an alternative approach to this complex problem. In addition, many of the policy areas connected to modern slavery such as immigration and asylum are controversial politically; this may present obstacles that limit progress to the adoption of a collaborative public health approach.
A public health approach is also likely to require financial investment and a re-framing of organisational priorities to enable a focus on prevention. Research has demonstrated how public health approaches can be cost-effective in the long-term (Owen et al, 2017), however in times of austerity it can be difficult to justify and encourage a move away from reactive responses. The implementation of Violence Reduction Units to tackle serious violence is a positive step in generating momentum for this type of approach and there may be helpful learning that is relevant to modern slavery. However, this is currently a short-term funding commitment and their impact is still to be evaluated.
The UK Home Office has begun to explore the development of a modern slavery prevention strategy. This provides an ideal opportunity to carefully consider the merits of a public health approach, where its principles can be embedded within strategic government responses and inform practice at a local level.
Maintaining health sector engagement
This article discusses how modern slavery has significant health impacts and how health professionals have a crucial role in identifying and offering survivor centred, trauma informed care for victims. Yet, there are currently many competing priorities, specifically the COVID-19 pandemic, which has placed unprecedented demand on the health sector and has required a renewed focus on the control of infectious disease. Consequently, there is a risk that the efforts to develop a response to modern slavery through a public health lens could stall, prompting a return to the default position that places a criminal justice response led by law enforcement at the fore.
Downstream components
Modern slavery is both a complex and dynamic issue
Modern slavery is affected by migration cycles, life cycles and exploitation cycles. Any public health approach is therefore required to be dynamic and responsive to societal, communal, family and individual level change. In addition, modern slavery encompasses four broad exploitation types, broken down further into 17 different offences (Cooper at al, 2017). Therefore, it is necessary to think about how a framework may need to adapt to various forms of exploitation. Within the context of criminal exploitation there are also complex nuances between those who are identified as potential victims and those who are recognised as perpetrators. This emphasises the need for, and value in, taking a preventative approach but also demonstrates the need for careful consideration to determine the most appropriate strategies for intervention.
Incorporating diverse survivor voices and lived experience
The incorporation of survivor voices and lived experience is an important aspect of policymaking. However, the ability to do so in a meaningful way that empowers survivors requires further exploration. The UK Home Office has recently undertaken research with survivors on their experiences of support within the NRM. This is a positive step, but it is vital that the findings from this and other similar research, are used to inform future policy and practice.
Conclusion
Responses to modern slavery have historically been dominated by criminal justice approaches, with some elements of human rights and humanitarian approaches. A public health approach that places responses to modern slavery on preventative footing, utilising the value of partnerships and incorporating elements of a criminal justice approach, offers an opportunity to reframe the current response. This article has identified multiple benefits that could be brought by adopting this approach but has also acknowledged the areas where there may be limitations. There is general consensus that responding to modern slavery using a public health lens could add value (Oram et al, 2021). Indeed, the UK’s Independent Anti-Slavery Commissioner and the Home Secretary have corresponded on the issue and have agreed that prevention must be a key element of our approach to tackling modern slavery (IASC/Home Secretary, 2021). There are on-going efforts to continue to refine and develop the current framework through additional research, review and validation. A proposed means of strengthening this emergent public health approach into effective action is to apply the principles in developing a practical framework for use by anti-slavery partnerships at a local level.
Note
For children the means is not required as they cannot consent to their exploitation.
Conflict of interest
The authors declare that there is no conflict of interest.
References
Acheson, D. (1988) Public Health in England: Report of the Committee of Inquiry Into the Future Development of the Public Health Function, London: HMSO.
ADPH (Association of the Directors of Public Health), APCC (Association of Police and Crime Commissioners), PHE (Public Health England) et al. (2018) Policing, health and social care consensus: working together to protect and prevent harm to vulnerable people, https://www.npcc.police.uk/Publication/NEW%20Policing%20Health%20and%20Social%20Care%20consensus%202018.pdf.
Bhui, K.S., Hicks, M.H., Lashley, M. et al. (2012) A public health approach to understanding and preventing violent radicalization, BMC Medicine, 10: 16, doi: 10.1186/1741-7015-10-16.
Brohi, K., Vulliamy, P., Marsden, M. et al (2019) A public health approach to knife violence reduction: immunize, protect & rescue, London Major Trauma System, https://www.c4ts.qmul.ac.uk/downloads/pdf-downloads/a-public-health-approach-to-knife-violence---lmts-v10.pdf.
Cairney, P., St Denny, E. and Mitchell, H. (2021) The future of public health policymaking after COVID-19: a qualitative systematic review of lessons from Health in All Policies [version 2; peer review: 2 approved], Open Research Europe, 1: 23, doi: 10.12688/openreseurope.13178.2.
Chisolm-Straker, M. and Stoklosa, H. (2017) Human Trafficking is a Public Health Issue: A Paradigm Expansion in the United States, Cham, Switzerland: Springer, doi: 10.1007/978-3-319-47824-1.
Cooper, C., Hesketh, O., Ellis, N. and Fair. A. (2017) A typology of modern slavery offences in the UK, https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/652652/typology-modern-slavery-offences-horr93.pdf.
Dando, J.C., Brierley, R., Saunders, K. and Mackenzie, J.M. (2019) Health inequalities and health equity challenges for victims of modern slavery, https://academic.oup.com/jpubhealth/article-abstract/41/4/681/5155322?redirectedFrom=fulltext.
George, E., McNaughton, D. and Tsourtos, G. (2016) An interpretive analysis of Australia’s approach to human trafficking and its focus on criminal justice over public health, Journal of Human Trafficking, 1–12, doi: 10.1080/23322705.2016.1153367.
Haase, E. (2014) Human trafficking, public health and the law: a comprehensive analysis of intersections, Journal of Public Health, 22: 121–29. doi: 10.1007/s10389-013-0603-6
Hayes, K., Kadirkamanathan, K. and Such, E. (forthcoming) Building a Systems Model of County Lines Trafficking: Components, Dynamics and Outcomes, PhD thesis, Sheffield: University of Sheffield.
HEAL Trafficking (2022) https://healtrafficking.org/
Home Office (2020) National referral mechanism statistics UK: end of year summary 2019, https://www.gov.uk/government/statistics/national-referral- mechanism-statistics-uk-end-of-year-summary-2019.
IASC (Independent Anti-Slavery Commissioner)/Home Secretary (2021) Delivering a public health approach to prevent modern slavery, correspondence between the UK’s Independent Anti-slavery commissioner and the home secretary, Priti Patel MP, 12 August 2021, http://www.antislaverycommissioner.co.uk/media/1671/iasc-exchange-of-letters-with-the-rt-hon-priti-patel-mp-home-secretary-september-2021.pdf.
Kiss, L., Fotheringhame, D., Mak, J., McAlpine, A. and Zimmerman, C. (2020) The use of Bayesian networks for realist evaluation of complex interventions: evidence for prevention of human trafficking, Journal of Computational Social Science, no. 0123456789, doi: 10.1007/s42001-020-00067-8.
Krug, E.G., Dahlberg, L.L., Mercy, J.A. et al. (2002) World Report on Violence and Health, Geneva: World Health Organization, https://apps.who.int/iris/bitstream/handle/10665/42495/9241545615_eng.pdf.
Meier, P., Purshouse, R., Bain, M. et al. (2019) The SIPHER consortium: introducing the new UK hub for systems science in public health and health economic research, Wellcome Open Research, 4: 174, doi: 10.12688/wellcomeopenres.15534.1.
Modern Slavery Policy and Evidence Centre (2020) Enabling trust, security and privacy in addressing modern slavery. https://modernslaverypec.org/research-projects/enabling-trust-security-and-privacy-in-addressing-modern-slavery (Last accessed 14 March 2022)
NCCASA (North Carolina Coalition Against Sexual Assault) (2020) Human Trafficking Prevention Toolkit, Raleigh, NC: NCCASA, https://nccasa.org/announcements/human-trafficking-prevention-toolkit/.
Oram, S., Loader, I., Saunder, K., Such, L. and Thornton, S. (2021) A Public Health Approach to Modern slavery – Opportunities and Challenges, London: King’s College London, https://www.antislaverycommissioner.co.uk/media/1591/a-public-health-approach-to-modern-slavery-opportunities-and-challenges-november-2020.pdf.
Owen, L., Pennington, B., Fischer, A. and Jeong, K. (2017) The Cost-effectiveness of public health interventions examined by NICE from 2011 to 2016, Journal of Public Health, 40(3): 557–66, https://academic.oup.com/jpubhealth/article/40/3/557/4160397. doi: 10.1093/pubmed/fdx119
PHE (Public Health England) (2019) Child Sexual Exploitation: How Public Health Can Support Prevention and Intervention, London: PHE, https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/793351/Child_sexual_exploitation_how_public_health_can_support_prevention_and_intervention.pdf.
Reed, S., Roe, S., Grimshaw, J. and Oliver, R. (2018) The Economic and Social Costs of Modern Slavery, Research Report 100, London: Home Office, https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/729836/economic-and-social-costs-of-modern-slavery-horr100.pdf.
Silverman, B. (2014) Modern slavery: an application of multiple systems estimation, Home Office https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/386841/Modern_Slavery_an_application_of_MSE_revised.pdf (Last accessed 14 March 2022).
Such, E., Laurent, C. and Salway, S. (2017) Modern Slavery and Public Health, London: Public Health England, https://www.gov.uk/government/publications/modern-slavery-and-public-health/modern-slavery-and-public-health.
Such, E., Laurent, C., Jaipaul, R. and Salway, S. (2020) Modern slavery and public health: a rapid evidence assessment and an emergent public health approach, Public Health, 180: 168–79, doi: 10.1016/j.puhe.2019.10.018.
Such, E., Hayes, K., Woodward, J. and McCoig, A. (2021) Campos-matos I. Refining a public health approach to modern slavery, https://www.antislaverycommissioner.co.uk/media/1606/final-report-24-may-21.pdf.
Such, E., Smith, K., Woods, H. and Meier, P. (2022) Governance of intersectoral collaborations for population health and to reduce health inequalities in high-income countries: a Complexity-informed systematic review, International Journal of Health Policy and Management, doi: 10.34172/ijhpm.2022.6550.
Todres, J. (2011) Moving upstream: the merits of a public health law approach to human trafficking, The North Carolina Law Review, 89(2): 447–506.
University of Nottingham Rights Lab (2020) Partnerships for freedom: improving multi-agency collaboration on modern slavery, https://www.nottingham.ac.uk/research/beacons-of-excellence/rights-lab/resources/reports-and-briefings/2020/september/partnerships-for-freedom.pdf.
Walk Free Foundation (2018) Global slavery index 2018, https://www.globalslaveryindex.org/.
VITA Network (2022) https://vita-network.com/
Violence reduction Units (2022) https://www.gov.uk/government/collections/violence-reduction-unit
