Prakash J, Kim I, Erickson T, Stoklosa H. Migrant worker safety, occupational health equity, and labor trafficking. Harvard Public Health Review. 2021; 33.
The US Occupational Safety and Health (OSH) Act of 1970 has helped reduce workplace fatalities and injuries. However, fatalities in migrant workers have disproportionately increased. This editorial discusses 1) how inequitably beneficial this health law has been for migrant workers 2) the unique occupational health risks labor trafficked migrants face 3) the role public health can play in addressing the needs of labor-trafficked migrant workers. Physical and emotional hazards, intrinsic to the notably dangerous occupations, are disproportionately felt by migrant workers due to systemic barriers including but not limited to economic hardship and coercion, language barriers, fear of legal repercussions, lack of protective equipment, racism and xenophobia. Labor trafficked workers also face additional significant occupational health risks and barriers to accessing medical care. Our recommendations to protect labor trafficked migrant workers involve improvements in research, policy, medical education, and health care delivery
In 1970, U.S. annual reports estimated up to 14,500 worker deaths via traumatic injuries and 390,000 cases of disease via occupational hazards (Report of the Senate Committee on Labor and Public Welfare, 1970). In response, the Occupational Safety and Health Act of 1970 was passed to create standards for safe workplaces and facilitate health and safety-promoting interventions. One major shortcoming remains the lack of protections for trafficked migrant workers, a population that experiences the most dangerous occupational hazards faced by migrant workers (Rothstein, 2020). In this paper, we contextualize the occupational hazards faced by migrant workers and focus specifically on the subset of migrant workers subjugated to labor trafficking. Upon marking the 50th anniversary of the OSH Act, we ask: 1) how has this worker safety and health law impacted extreme occupational risks for migrant workers? 2) What are the unique occupational health risks labor trafficked migrants face? 3) What role can public health play in addressing the needs of labor trafficked migrant workers?
In many countries, ensuring a worker’s health and safety is high priority, as it is fundamental to human dignity, benefits the economy and strengthens public health solutions (Quinn, 2003; Leong et al., 2017), however, mental health has become an increasing concern for employers around the world. Particularly in the EU, a higher portion of its national budgets are pouring into adequate infrastructures and services for mental health. (WHO, 2003). Epidemiological data comparing changes in health status before and after a life altering event (e.g. an economic recession) are consistent and report negative associations with mental health and increased mental health problems among workers (Frasquilho et al., 2016). For example, a longitudinal study from Greece showed a significant increase of mental health issues among individuals who’d lost their jobs during the 2008 economic crisis (Drydakis, 2015). Reeves et al. (2018) found that ‘economic suicides’ gripped most European countries after the onset of the recession in 2009. Conversely, the EU and member states’ national and regional governments have been working to develop EU quality frameworks and the relevant resources to guide psychosocial occupational safety and health risks management (European Health Parliament, 2020).
Certainly, a global health pandemic can be a significant source of uncertainty and crippling anxiety, placing virtually every working citizen at increased risk for psychological injury. However, there are certain professions impacted harder than others: suicide rates are highest among physicians and health care workers (Duthiel et al., 2019)
Stress in medical practice is nothing new, although key stressors such as role conflict, emotional labor, intense training, and a hostile work environment certainly magnify mental health issues for health care workers (Pandey & Singh, 2015; Shah, 2017: Miedema et al., 2009; Familoni, 2008). Nonetheless, previous viral outbreaks have taught us that additional stressors such as isolation, increased contact with infected patients, and reduced community support, only increase psychological risks (Wu et al., 2009; Maunder et al., 2006; Gulati & Kelly., 2020). Post-traumatic stress disorder, fatigue, depression and anxiety are common mental health disorders among physicians (de Jong, Nieuwenhuijsen & Sluiter, 2016). Frequent night-shifts could be argued as the main driver behind the prevalence of sleep disorders among health care workers, but this only furthers the point that prompt action from OSH (and other leadership in health and safety) is necessary to help reduce all known mental health risks (Henderson, Evans-Lacko, & Thornicloff, 2013; Kim et al., 2018. Unquestionably, the catastrophic impact of COVID-19 on the healthcare industry serves as a mighty wakeup call for OSH resources to expand into mental health services. Evidently, our current healthcare systems are unable to effectively help the helpers (Lai, 2020; Muller et al., 2020). Should OSHA fully support public health efforts to reduce mental health stigma and increase access to mental health care for struggling professionals, the course of history in healthcare would be forever changed.
Among migrant workers, those who are labor trafficked experience some of the worst occupational health risks (Zimmerman & Schenker, 2014). Human trafficking has been defined in the United Nations (UN) treaty, Protocol to Prevent, Suppress and Punish Trafficking in Persons, Especially Women and Children, as “the recruitment, transportation, transfer, harbouring or receipt of persons, by means of 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” (United Nations, 2000). Although quantifying victims of labor trafficking has been difficult, a study of unauthorized migrant workers in San Diego estimated over 30% of its workforce as victims of labor exploitation and 55% as victims of workplace abuse (Zhang et al., 2014).
Studies have found labor trafficking of migrant workers occurs most frequently in certain sectors, each carrying its own hazards. Agricultural and factory workers are exposed to chemicals and pesticides; construction, fishing, and mining workers face an increased risk of temperature stressors. Hospitality and domestic service laborers are at increased likelihood for acute and chronic musculoskeletal injuries (Ronda-Pérez & Moen, 2017). Hazards, intrinsic to the occupation themselves, are exacerbated in this vulnerable patient population. Trafficked migrant workers, compared to non-trafficked counterparts, generally undertake the most strenuous work, follow strictly enforced work schedules with minimal rest breaks, and lack of proper training with personal protective equipment (PPE). Outside of the workplace, housing conditions are crowded and unsanitary with poor access to nutrition and a safe water supply. Access to the outside world and connection with social support systems are highly restricted even though workers face direct and indirect abuse from their employers as well as co-workers (Buller et al., 2015).
Trafficked migrant workers may have difficulty accessing health care due to fear of deportation, limited options for transportation, risk of losing employment, and physical or emotional retributions when returning to the worksite (Muntaner et al., 2010; Vandermeerschen et al., 2019; Moyce & Schenker, 2018; Weitzer, 2015). As a result, trafficked migrants present in a delayed fashion for medical conditions, which can limit treatment for preventable diseases (Ottisova et al., 2016). Injuries from higher-risk labor can delay medical attention, especially without adequate follow-up, limited recovery time, and lack of resources such as physical and occupational therapy (Simon et al., 2015). Trafficked workers suffer from mental health problems such as depression, anxiety, and PTSD but are unable to access resources for counseling and treatment (Ottisova et al., 2016). Gaps within the healthcare landscape may perpetuate disparities in the medical status of trafficked migrant workers. Many health professionals may not have the skills to respond to labor trafficking or may hold implicit biases that prevent them from identifying a migrant worker’s exploitation (Powell et al., 2017; Holmes, 2006; Stoklosa, Stoklosa, et al., 2017; Homes et al., 2020).
Our recommendations to protect labor trafficked migrant workers involve improvements in research, policy, medical education, and health care delivery. In order to most effectively improve the harsh working conditions for this population and improve connection to care, we must characterize and document the safety, health, and occupational needs for labor trafficked migrants by sector, legal status, and geography. We should study the effectiveness of interventions to minimize occupational harms. We need to investigate the best ways to facilitate conversations in health care settings with those experiencing labor trafficking.
Worker rights should include free access to mobile health care services, regardless of documentation status, and employers should be required to facilitate access to that health care while workers should also have an enforceable right to seek care on their own without risk to their job. Measures must be taken to reduce the elevated risk of occupational hazards faced by this population. This involves culturally appropriate safety training instructions in workers’ preferred languages—with trainings conducted by workers themselves together with trusted community sources —mandatory regulations on work hours and workplace sanitation that are enforceable both through private action and through the government, free provision of PPE and worker-to-worker training on how to use it, ensuring the psychological safety of workplaces, and improving the living conditions of workers in particular at employer-provided housing. Furthermore, OSHA needs adequate funding to investigate safety concerns in all workplaces, requiring the elimination of budget riders that prevent such enforcement such as against small farm employers, and workers must have access to a complaint mechanism staffed by human beings who speak their preferred language with a prompt and thorough investigation of any complaints and vigorous protection against retaliation for filing such complaints (Hackett et al., 2020). Finally, recognizing that migrant workers have suffered from a legacy of underenforcement of the OSH Act and other legal protections, resulting in the systematic silencing of workers that facilitate the worst abuses, policymakers should devote resources to expanding the implementation of non-governmental systems that protect and amplify farmworkers’ voices in the workplace, in particular, the Worker-driven Social Responsibility model which is widely recognized as “the only existing model with the proven potential to afford protection for the most vulnerable and lowest-wage workers in global supply chains” (MSI Integrity, 2020).
Further measures must be taken in healthcare settings. We need improved medical education on how to identify and care for those experiencing labor trafficking, including implicit bias training. All health systems need to have protocols and policies in place to ensure labor trafficking survivors receive trauma-informed care and are directed to the resources they need when they pass through the doors of healthcare (Stoklosa, Dawson, et al., 2017; Stoklosa, Showalter, et al., 2017).
The authors would like to acknowledge the contributions of Matthew Blumin.
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Jaya Prakash is a medical student at Harvard Medical School. Her research involvement focuses on understanding the implications of interpersonal violence, especially for victims of human trafficking, intimate partner violence, and child abuse. She is particularly interested in the intersection between clinical care, social determinants of health, and trauma-informed work.
Inkyu Kim is an emergency medical resident at BMW/MGH.
Timothy B. Erickson, MD, FACEP, FACMT is in the Division of Medical Toxicology, Department of Emergency Medicine, Mass General Brigham, Harvard Medical School, Harvard Humanitarian Initiative.
Hanni Stoklosa, MD, MPH is Assistant Professor, in the Department of Emergency Medicine, at Brigham and Women’s Hospital, Harvard Medical School, Executive Director, HEAL Trafficking.