HEAL Trafficking & ATEST Joint Comments to NACMH on Migrant Health and Human Trafficking in Agriculture

November 7, 2018

Esther Paul
National Advisory Council on Migrant Health
Health Resources Services Administration
Department of Health and Human Services
Submitted via email: [email protected]

RE: Request for Public Comment on Migrant Health and Human Trafficking in Agriculture

Dear Advisory Council Members:

Thank you for the opportunity to provide written civil society comments on important challenges
regarding human trafficking and the provision of essential health services for migrants in

HEAL Trafficking is a united group of multidisciplinary professionals dedicated to ending human
trafficking and supporting its survivors, from a public health perspective. The HEAL Trafficking
mission is to mobilize a shift in the anti-trafficking paradigm toward approaches rooted in public
health principles and trauma-informed care by: expanding the evidence base; enhancing
collaboration among multidisciplinary stakeholders; educating the broader anti-trafficking, public
health, and health care communities; and advocating for policies and funding streams that enhance
the public health response to trafficking and support for survivors. HEAL Trafficking has
approximately 2,500 network participants from all 50 states and the District of Columbia.

The Alliance to End Slavery and Trafficking (ATEST) is a U.S. based coalition that advocates for
solutions to prevent and end all forms of human trafficking and modern slavery around the world.
ATEST advocates for lasting solutions to prevent labor and sex trafficking, hold perpetrators
accountable, ensure justice for victims and empower survivors with tools for recover. ATEST’s
collective experience implementing programs at home and abroad provides the coalition with
unparalleled breadth and depth of expertise. ATEST member organizations include: Coalition to
Abolish Slavery and Trafficking (CAST), Coalition of Immokalee Workers (CIW), Free the Slaves,
Human Trafficking Institute, National Network for Youth (NN4Y), Polaris, Safe Horizon, Solidarity
Center, T’ruah: The Rabbinic Call for Human Rights, United Way Worldwide, Verité, and Vital Voices
Global Partnership. (https://endslaveryandtrafficking.org/)

Areas of Public Comment

HEAL Trafficking and ATEST are jointly providing public comment on Topic I. Patient Engagement
Strategies, and Topic III. Human Trafficking in Agriculture, for the November 14-15, 2018 meeting
of the National Advisory Council on Migrant Health.

Topic I. Patient Engagement Strategies

Often individuals who are being trafficked in agricultural situations face major barriers to seeking
health care. These barriers can include penalties from landowners, lack of transportation, lack of
knowledge regarding available resources, lack of English language capacity, and lack of awareness
about the need to seek medical care. A major barrier is the threat of deportation or other abuses
trafficked individuals may face from Immigration and Customs Enforcement (ICE).

“When we discuss engagement at the meso level within the health sector it is
important to first fully recognize the influence of environmental level factors. A
co-worker recently traveled to Vermont, near the Canadian border. During her
time in the field she noticed ICE vehicles were parked at the entrance to farms
where individuals were working and potentially being trafficked. The presence
of the ICE vehicles served as an aggressive deterrent for individuals leaving the
confines of the farm and seeking health care. This was verified when speaking
with the local health clinic, where it was acknowledged they provided care to
nearly none of the demographics representative of those individuals working on
farms in the area. This is because you cannot engage a client in care if the risks
for seeking care are too great.”

Kristin Potterbusch, director within the public health sector

In line with standards for culturally and linguistically appropriate services (CLAS), hiring
individuals from within a patient-population community to promote health in alignment with
culturally-specific understandings (health promotora model (1)) is a valued approach to creating
networks of trust, opening lines of communication, and improving health literacy of communities.
Empowering health promotoras to advise the health clinic in cultural humility and ways to adapt to
patient needs is an important step to ensuring patients both seek services and return for care in the
future. This advising can also be formalized, ideally through a consumer advisory board, with
representatives from the labor community taking part.

It may be necessary for federal programs to collaborate with health organizations to develop
pathways of understanding with landowners, farmers, labor contractors and agricultural
organizations who are in positions of authority in areas where individuals are potentially being
trafficked. Going onto farms and offering vaccinations and point-of-contact services may be the only
option in some cases due to transportation, access, and many other barriers. Federal program
officers should work with local authorities to ensure that patients can safely gain access to services
without jeopardizing their immigration status because sometimes the journey to a clinic can
increase an individual’s likelihood of being deported (as in the Vermont example above). It cannot
be assumed that an individual being trafficked would prefer deportation to their current situation.
Therefore, organizations working with individuals being labor trafficked must be prepared to
support patients, no matter their immigration status. Some individuals being labor trafficked may
choose to continue working under exploitative circumstances to prevent the risk of death or
violence that could come should they be deported. Organizations may need to be prepared to
support clients in accessing health services through understanding and making changes to local
policies and working with knowledgeable legal entities.

Additionally, if the new “public charge” rule, DHS Docket No. USCIS–2010–0012, goes into effect, it
will increase the vulnerabilities of all immigrants − including migrant workers − to human
trafficking and will exacerbate the challenges of getting migrant workers access to much needed
health care. Expansion of the “public charge” is likely to have a chilling effect even on those legally
allowed to access these systems of care and protection, as they are concerned about their loved
ones’ exposure. The proposed expansion undermines efforts by victims of human trafficking to
secure essential services that enable them to escape from or overcome abuse, violence, and trauma.
The proposed rule has long-term implications for the health and safety of human trafficking victims
and their children, and our communities of which they are important members. Expansion of the
proposed “public charge” rule would undermine efforts to engage communities of migrant workers
in health care.

Topic III. Human Trafficking in Agriculture

Human trafficking in agriculture yields many of the same consequences as other sectors of labor
trafficking, such as nail salons and cleaning services, due to the lack of access to supportive
resources. People may lack health care, (including immediate medical attention, sexual assault
evaluations, substance use disorder counseling), emergency housing, food, and clothing. Traffickers
engage in extortion by withholding wages/back pay and identification documents and by
restricting access to basic necessities. Commonly overlooked medical problems that agricultural
laborers sustain include chemical burns from pesticides, resulting respiratory problems, infertility
and birth defects. Unfortunately, access to health services is not consistent or reliable, and
individuals may face dire consequences if they miss work to heal. It is suspected that much of the
agricultural sector has relied on trafficked labor. Many companies may not (or purposely do not)
have knowledge of the trafficking involved in the maintenance of their fields. This is due to the use
of independent contractors that are responsible for staffing the fields. Such practices allow
companies to turn a “blind eye,” permitting the proliferation of trafficking within the agricultural

As some individuals purposely have sought to come to the U.S. to work in agricultural positions, it
can be challenging to differentiate between a situation where persons are working in positions
willingly and where they are being trafficked but are unwilling to leave (or think they cannot leave).
Often answers are not straightforward in that people may not realize they are being trafficked and
may think their experiences are “normal.” These experiences can include receiving little to no
wages, being prevented from having outside contact (sometimes individuals are told it is for their
own protection), not having access to resources, enduring verbal and physical violence, being
locked in contained areas, and having their documents or other personal items withheld. Young
children are also found in forced labor situations, via agricultural trafficking. These children may be
both an incentive for caretakers to seek help or a deterrent against seeking help, for fear the
situations they are in would be the only option for remaining with their children.

The situation of individuals who have come to the U.S. with work visas (or were told they had work
visas that turned out to be fake) and are then victimized for trafficking can be further complicated if
their visas expire without their knowledge because their traffickers are holding their documents.
Also, H-2A visas tie workers’ immigration status directly to their employer, creating a powerful
dynamic that facilitates labor trafficking. The federal government needs to hold “subcontractors”
who supply agricultural labor accountable for abuses, because many workers employed by farmers
are non-English speaking migrant workers.


Thank you for the opportunity to provide our public input, shaped by on-the-ground direct
experience as well as programmatic design and policy implementation expertise. We are available
moving forward to provide further information and recommendations to the Advisory Council if


HEAL Trafficking
Contact: Hanni Stoklosa, MD, MPH
[email protected]

Alliance to End Slavery & Trafficking
Contact: Anita S. Teekah, Esq.
[email protected]

1 A promotora is a lay Hispanic/Latino community member who receives specialized training to provide basic health education in the community without being a professional health care worker.

Download .pdf here