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Projects Hidden Slaves
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6. Health and Medical Consequences of Forced Labor Those subjected to forced labor are at significant risk of developing health related problems, ranging from minor to life-threatening. Because forced labor is largely hidden from public view, its health and medical consequences have never been systematically studied in the United States. Yet our case studies as well as morbidity and mortality studies of refugee populations and workers in industry and agriculture provide a general picture of the health needs of victims of forced labor. The health status of forced labor victims can be considered in four discrete but interdependent phases: predeparture, journey, forced labor, and postrelease. Our study found that most victims of forced labor were trafficked into the United States and that they came from impoverished areas of the world. Poverty is an important indicator of health, and many diseases, such as tuberculosis (TB), hepatitis B and C, and sexually transmitted diseases, are more prevalent in impoverished populations where access to adequate health care is limited or nonexistent. Because many forced labor victims circumvent formal medical screenings for migrants, many will arrive in the United States without proper immunizations and bearing communicable diseases. Studies have found that even legal migrants to the United States have caused TB caseloads to increase, largely because those infected had not received proper care in their home countries.104 In one study thirty-one to forty-seven percent of migrant farm workers tested on the East and West Coasts of the United States were TB positive, and those groups were six times more likely to develop TB than the general population. Smuggling and some forms of trafficking of migrants constitutes the most dangerous form of migration.105 This illegal process can take place within a country, across a single border, or through multiple borders. During the journey, which may last only a day or a matter of months, trafficked and smuggled migrants are exposed to grave risks of injury or death. In addition, in long and complicated journeys, these migrants may be exposed to illnesses and diseases, including malaria, or find preexisting illnesses become aggravated along the route. Trafficked and smuggled migrants enter the United States by several different modes of transportation, including aircraft, boat, and overland vehicles, all of which can pose potential health risks. People who are hidden among cargo shipments during transport risk injury or death by drowning, freezing, or suffocating, or by being crushed or exposed to toxic materials.106 The potential for health complications is further exacerbated by overcrowding, lack of food, poor sanitation, severe dehydration, and environmental extremes.107 In May 2003, for example, seventeen undocumented migrants from Mexico and Central America perished from asphyxiation and heat stroke inside an abandoned tractor-trailer located in southern Texas. As many as one hundred people had been packed inside the trailer.108 In transit, power is displaced between traffickers and migrants to create an ongoing relationship of dependency that can complicate a survivor's recovery in the post-release phase. This is particularly true for young trafficking victims who have been kidnapped or entrusted to the care of traffickers by their parents or other family members. Traffickers often confiscate personal identification and travel documents to prevent victims from trying to escape.109 Traffickers confiscated the documents of victims in four of our eight cases studies. (In the remaining four, the victims did not have any identification documents to begin with.110) During the journey traffickers may use threats and beatings to maintain control over their victims.111 Should victims require medical treatment because of an illness or physical abuse, it is almost always the trafficker or smuggler who decides if it will be provided or not. Once trafficked migrants reach their destination in the United States, they continue to face a variety of health risks. Because many have entered the country illegally or because their captors keep them isolated through violence or intimidation, victims remain hidden and continue to depend on their trafficker or "employer" for shelter, food, and safety. Forced labor victims are likely to enter and be held in high-risk, poorly regulated work environments. Those who work in the sex trade are at risk of contracting AIDS or other sexually transmitted diseases. While published evidence is limited, there are media reports that indicate children born to some forced labor victims are separated from their mothers and returned to their mother's place of origin.112 Victims of forced labor increase their susceptibility to ill health because they often are forced to live in overcrowded housing with poor sanitation. In the case against Kil-Soo Lee, one survivor, Tuyen, described thirty-six workers sharing one to two showers and two to five toilets. There was no hot water or toilet paper. The bathroom facilities were not maintained and some remained permanently broken. Sometimes in the mornings the lines to use the facilities were so long that not everyone had an opportunity to do so before having to present for work. Those who missed out had to wait for a meal break to use the toilet or to wash their face. Drinking water was only available in the bathroom.113 A similar situation prevailed in the Florida citrus harvesting case, where forty or more workers slept in a large trailer. Worse yet were the living conditions of the Florida forced prostitution victims. The women and girls were made to live and work in filthy, rubbish-strewn trailers, duplexes, and houses that were located in isolated agricultural areas accessible only by dirt roads running through citrus groves. The windows were broken or boarded up. Inside, soiled mattresses were strewn on the floor. The women were forced to service strangers and sleep on those same mattresses each night. The mattresses were separated from each other, if at all, only by hanging sheets. Garbage and used condoms littered the brothels. The psychological consequences of forced labor remain largely unexplored. Despite the paucity of research data, we do know that when people enter exploitative work situations against their will, they risk losing their sense of personal efficacy and control, attributes that mental health professionals have long considered essential to good mental and physical health.114 Under the control of their traffickers or "employers," victims may experience feelings of isolation, shame, and betrayal. They may fear being sent home without any money, especially if deceived by a promise of bona fide employment.115 They may experience or witness repeated threats and verbal abuse, involuntary confinement, torture, and sexual assault. A manager at the Daewoosa garment factory in American Samoa, for example, frequently sexually abused female Vietnamese workers by slipping into their sleeping quarters at night. Removed from their family and friends, forced labor victims lack a social support network to help cope with these traumatic assaults. Some, like the victims in the Florida forced prostitution ring, turn to drugs and alcohol, where available, as a coping mechanism. "I would go to bed drunk because it was the only way I could fall asleep," one victim said. All of these conditions can cause forced labor victims to lose their sense of control and become increasingly dependent on those who hold them captive, if merely to survive. Captivity brings the victim into prolonged contact with the perpetrator and creates a special type of relationship, one of coercive control. "In situations of captivity," writes psychiatrist Judith Herman, "the perpetrator becomes the most powerful person in the life of the victim, and the psychology of the victim is shaped by the actions and beliefs of the perpetrator." The methods of establishing control, she adds, are based on "the organized techniques of disempowerment and disconnection . . . [so as] to instill terror and helplessness and to destroy the victim's sense of self in relationship to others." As victims become more isolated, they grow "increasingly dependent on the perpetrator, not only for survival and basic bodily needs but also for information and even for emotional sustenance."116 Lakireddy Bali Reddy used techniques of disempowerment and disconnection to create dependency among the teenage girls he trafficked into the United States. Because of their age and low-caste status, the girls were already susceptible to the power and dominance of a higher caste male who was older than most of their fathers. Reddy frequently rewarded the younger girls with gifts and favorable treatment. If girls exhibited maturity, they would cease to receive such favorable treatment. Since Reddy was constantly bringing younger girls into his estate, it was to a survivor's distinct advantage not to "grow up." For this reason, according to one of the attorneys in the case, one of the survivor's psychological and emotional development has been grossly stunted.117 Over a period of time Reddy brought his favorite girls to Berkeley, California to provide him with sex and to work in his restaurants and apartment buildings. Once in the United States, Reddy's control over the girls intensified—they were now in a foreign land under fraudulent circumstances where they did not speak the language or understand the customs. Housed in Reddy's apartments and fed at his restaurants, the girls were prevented from going to school and having contact with people outside of the Reddy network. To reinforce his control Reddy frequently beat the girls or threatened to turn them in to the authorities. One of Reddy's victims, a girl who had been brought to Berkeley at a very young age, exhibited a great loyalty to him. She, in fact, helped to hold down other girls while Reddy raped them. This ultimately caused some confusion for police investigators who apparently mistook her for a possible perpetrator and held her in jail for over a month.118 Court records show that some of Reddy's victims still bear psychological scars, including depression, reoccurring nightmares, and panic attacks, as a result of their captivity, sexual abuse, and dependency.119 In the case of Khai, the Thai domestic worker, the trafficker used similar methods of intimidation and separation, including reminding Khai of her employer's higher socio-economic status. Khai's employer, Veerapool, would often jab a finger at her and say, "Do you know who you are? Do you know who I am?"—the implication being that Khai was from a lower class and that the perpetrator was an important and respected person.120 Veerapool also trained her to be physically "lower" than she was. If her employer sat in a chair, the domestic servant had to sit on the floor. The servant served her employer's party guests as she served her employer, on her knees, to reinforce her lowly status. In an effort to isolate her, the employer forbade Khai to talk to neighbors or shopkeepers. Khai was allowed to answer the telephone but not to make outgoing calls. Louisa Satia and her husband used the same kind of tactics to denigrate and isolate sixteen-year-old Maryse121 in their Washington, D.C., apartment. Maryse's employers forbade her to leave the apartment complex, warning that they would deport her if she did. One morning, as Maryse was sending the children off to school, she stopped to talk to a man at a bus stop near the apartment complex. Louisa happened to see the encounter and later beat Maryse.122 On other occasions, Louisa would forcibly cut Maryse's hair, put glue and soft drink in her hair, and spray cleaning liquid in her eyes.123 Louisa's husband also sexually assaulted Maryse by exposing his genitals to her, attempting to take off her clothes, and trying to touch her breasts.124 In an effort to keep her from communicating with her parents, her employers confiscated Maryse's letters and tried to convince her that her parents were indifferent to her situation.125 The physical consequences of forced labor are many and varied. Because forced labor is largely a clandestine practice, it is also likely that many of these health problems go untreated for long periods of time. Perpetrators of forced labor frequently use violence as a means of "breaking" and controlling their workers.126 Vietnamese workers at the garment factory in American Samoa reported that Samoan guards and workers frequently beat them if they complained about their working conditions. The factory managers, the workers said, encouraged the beatings as a form of punishment or as a way to maintain order. In one incident, a Samoan worker in the process of beating several workers thrust a PVC pipe into the left eye of a female employee, causing her to lose the eye. Violence-related injuries associated with forced labor include bruises, broken bones, head wounds, stab wounds, and mouth and teeth injuries.127 Because they are at the mercy of their captors, victims of forced labor are rarely in control of their own health-care decisions. Women and men who are forced into prostitution face the risk of contracting HIV because they may lack the power to insist on the use of condoms.128 Women who become pregnant while in captivity lack access to appropriate prenatal care or are forced to abort. Some resort to unsafe abortions.129 Women can suffer severe consequences as a result of undiagnosed and untreated gynecological infections and complications, including pelvic inflammatory disease, chronic pelvic pain, ectopic pregnancy, and sterility.130 Forced labor victims who become malnourished in captivity are at risk of developing long-term illnesses. Our study found that perpetrators of forced labor failed to provide their workers with adequate nutrition and at times withheld food as a form of punishment. In February 2002 the New York Times, citing an unpublished report from the Department of Labor, wrote that the Vietnamese workers at the American Samoa garment factory looked like "walking skeletons" and that their "diet, consisting primarily of watery broth of rice and cabbage, is of a type and quality that may lead to malnutrition." The newspaper revealed that the factory management "admits that they withhold meals from employees as a form of punishment when workers complain about food."131 A nutritional expert who testified on behalf of the workers in the civil case before the High Court of American Samoa argued that because of the absence of fresh vegetables and fruit, the meals failed to meet U.S. Department of Agriculture nutritional guidelines.132 According to one of the garment workers, the first in the serving line might get some solid ingredients in the soup but the last in line would get only broth. She described sending word to new workers to bring seeds with them so that they could plant vegetables. They grew cabbages but it was not enough to feed them. Another garment worker described meals of rice, cabbage, and potatoes that did not provide him with enough nutrition to do the work that was expected of him and left him hungry.133 Likewise, the asparagus harvesters testified that although they were provided between two to three meals per day, they were at times fed spoiled eggs and meat, the food was often overcooked or undercooked, and they often went hungry.134 The Oklahoma factory workers also reported suffering from malnourishment. At the Pickle plant, the owner John Pickle allegedly maintained complete control over the food purchases and rationed the daily food allowance. The cooks testified that the kitchen was too small and that they lacked the appropriate utensils to cook meals for fifty-two workers.135 Workers testified that the cooks were made to cut whole apples into fourths and serve half-glasses of milk as a way to ration food.136 When the workers complained, Pickle and his agents allegedly told the workers to be quiet and accept it or they would be sent back to India. Forced labor victims working in agriculture, construction, and manufacturing are at risk of developing repetitive strain injuries, chronic back pain, and visual and respiratory problems if they fail to receive proper medical care.137 If these conditions remain untreated, they can become debilitating and require long-term treatment and rehabilitation. Perpetrators of forced labor maintain near total control over their victims, including access to health care. Perpetrators expressly cultivate a fear of law enforcement and other "outsiders" among laborers.138 Even if movement is less restricted, victims often decide not to seek health care or risk the consequences of "breaking the rules" because they fear reprisals from their captors. Three survivors of the California asparagus worker case and the Florida citrus worker case had no access to medical care in the labor camp where they were housed. In each case, armed guards patrolled the camp at night to ensure that no one tried to leave. No health professionals visited the camp, and workers used their own painkillers and other medications to ease their ailments. In the case of the Oklahoma factory workers, victims reported suffering from work-related injuries but were denied access to proper medical care. In one instance, a worker stated he became ill and received no medical help. Even when a fellow American worker tried to take him to the doctor, the company owner allegedly stopped them and forced the worker to stay and work.139 Some workers claim they suffered injuries, such as eye infections or vision impairment, for which they were denied treatment.140 Even if victims have a means of leaving their premises, they may be reluctant to seek professional care because they are unfamiliar with U.S. currency, unsure of how to use local transport, unable to speak English, or fear health providers may report them to immigration or labor officials.141 While Khai, the Thai domestic worker, traveled almost daily from her employer's house to the restaurant, she was forbidden to speak to any neighbors or shopkeepers she might encounter en route or near the restaurant.142 Because of the clandestine nature of forced labor, victims may receive regular but unsanitary and inadequate care under the strict supervision of their employer.143 Finally, without access to proper health care, victims can potentially pass on communicable diseases to members of the community where they are held captive. The most immediate needs of those who survive forced labor are safety and housing. Some survivors may require immediate hospitalization or specialized medical care. But most will be able to forgo medical screening and medical care until after they have settled into their new surroundings. It is important, however, that survivors undergo screenings to identify any preexisting or acquired health problems. Health professionals who are familiar with migrant health issues usually are best suited to conduct screenings, as diseases common in a survivor's country of origin may not be commonly recognized in the United States. Screening should include questions about the patient's labor conditions, housing, past and current medical history, and nutrition.144 Social and cultural factors will significantly influence how survivors present health problems to service providers. If a survivor is from a country where similar health services are not available, she may find it difficult to trust care providers.145 Alternatively, services may not correspond to the kind of help survivors think they need.146 While forced labor victims may suffer mental health effects including post-traumatic stress disorder (PTSD) as a result of their enslavement,147 the nature, severity, and prevalence of these effects after release from captivity requires further research. Studies in groups of undocumented migrants indicate that the prevalence of psychiatric disease, including depression and suicide, is higher in these populations.148 In the case of children, the Pan American Health Organization reports that "traumatic sexualization, betrayal, powerlessness, and stigmatization involved in sexual exploitation are particularly damaging to child and adolescent development and can lead to various types of psychiatric morbidity."149 Children who witness acts of violence or repeated sexual abuse are at significant risk of developing PTSD, among other disorders.150 Psychologists have noted, for example, that one of Reddy's victims may be plagued with psychological problems for the remainder of her life because of the sexual abuse she suffered and because Reddy forced her to watch as he sexually abused her older sister.151 People diagnosed with PTSD tend to repeatedly relive the ordeal through nightmares, flashback episodes, and memories. They may also avoid reminders of the event and experience excessive alertness. Other common symptoms include emotional numbness, depression, irritability, inability to sleep, difficulty concentrating or completing tasks, and outbursts of anger. These symptoms can be severe and last long enough to have a significant adverse effect on the individual's daily life.152 Despite the suffering from trafficking, Florrie Burke, a mental health expert with Safe Horizon, notes that traditional psychotherapy may not be appropriate for survivors: "Many times they're not ready for it right away. That comes later, when they're ready to deal with it. Sometimes all someone wants is a paying job, and processing [the experience] comes later."153 Forced labor survivors who seek mental health services need to perceive the physician or therapist as part of a secure environment. Finding culturally appropriate mental health services presents another challenge, as Nancy Hormachea, an attorney in the Reddy case, noted: "All the survivors [in the Reddy case] had psychological issues, yet it has been nearly impossible to provide them with good therapy. Western-style therapy is foreign to them and not culturally appropriate. ... Most refused to go because they didn't like it and they couldn't keep their scheduled appointments. I'm not sure that they derived any benefit from it. There has to be another model for psychotherapeutic help."154 According to Hormachae, many of Reddy's victims felt stigmatized by the very fact that they were experiencing emotional difficulties and in need of therapeutic assistance. "You have to understand that...[there] are derogatory sayings about people who seek [psychological] help [in the village] where these girls come from," Hormachae said. "They are seen as being ëcrazy' and described as being like ëa chained, rabid dog.'"155 People who survive forced labor and participate in the T visa program must agree to participate actively in the prosecution of their trafficker or employer. But a decision to participate in potentially contentious legal proceedings should not be taken lightly. Studies of torture survivors indicate that to achieve a favorable therapeutic outcome, survivors must have an acceptable self-concept and see the world as a fairly secure and predictable place.156 Courtrooms are hardly safe and secure environments for the recounting of traumatic events. Judges can—and often do—admonish witnesses who stray from the facts, which in turn can frustrate victims intent on telling their story publicly. The adversarial nature of trials also can result in unanticipated and unexpected events in the courtroom. The sight of the defendant, a long-repressed memory, or the sight of a loved one or co-worker can devastate even the most confident witness. So can the hardscrabble of cross-examination as defense attorneys set out to poke holes in a witness's testimony or impugn his or her credibility. Witnesses may also feel that the court does not "respect" them, especially if they have to endure an intense cross-examination. Based on research on victims and witnesses who have appeared before the International Criminal Tribunal for the Former Yugoslavia, the level of fear or concern experienced by witnesses throughout the pretrial process depends on the stability and safety of living conditions, the amount of time elapsed between the end of the war and their participation in the trial, fear of reprisals that might affect a witness's children, and whether the witness lived in the same town or village as the accused and his family.157 To avoid further trauma all of these factors need to be considered when attorneys approach forced labor survivors to testify against their former traffickers and/or employers.
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