JONES DAY TALKS®: Helping Health Care Providers Fight Human Trafficking

Health care providers hold a unique position in the fight against human trafficking. To help them understand their reporting and education obligations related to anti-human trafficking activities, Jones Day has prepared :Human Trafficking and Health Care Providers: Legal Requirements for Reporting and Education."

Jones Day's Alexis Gilroy, Curt Kirschner, and Taylor Goodspeed, along with Dr. Hanni Stoklosa of HEAL Trafficking and Claire Zangerle of the American Hospital Association, explain how hospitals and providers should use the tool, Talk about how providers can overcome barriers to identifying and reporting trafficking incidents, and discuss the significant role of telemedicine.

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Read the full transcript below:

Dave Dalton:

We've talked on previous Jones Day Talks podcasts about the firm's global efforts in the fight against human trafficking. The firm has committed significant resources and devoted countless hours of pro bono service to this endeavor. Most recently, as part of the American Hospital Association's Hospitals Against Violence initiative, the AHA, Jones Day and HEAL Trafficking have come together to provide resources to healthcare providers across the US. Specifically, Jones Day has prepared a very practical tool titled, Human Trafficking and Healthcare Providers: Legal Requirements for Reporting and Education. This resource will help providers navigate the complex roadmap of their reporting and education obligations. We've assembled a panel to tell us all about it. I'm Dave Dalton, you're listening to Jones Day Talks.

Dave Dalton:

Jones Day partner, Alexis Gilroy is a national leader in the digital health industry. She advises on complex transactional and health regulatory issues with an emphasis on virtual health methods, such as telemedicine, telehealth, and mobile health.

Dave Dalton:

Jones Day associate, Taylor Goodspeed focuses on regulatory compliance and civil litigation matters involving the healthcare industry. She counsels and defends hospitals, health systems, and other healthcare entities in civil fraud and abuse investigations and litigation.

Dave Dalton:

And we're very lucky and very pleased to welcome two special guests to today's program. Dr. Hanni Stoklosa, MD is an emergency medicine physician at Brigham and Women's Hospital in Boston. She is also executive director at HEAL Trafficking, an integrated network of over 3,500 survivors and multidisciplinary professionals in more than 30 countries dedicated to ending human trafficking and supporting its survivors from a public health perspective.

Dave Dalton:

And finally, Claire Zangerle is a chief nurse executive at Allegheny Health Network in Pittsburgh. She's a board member at the American Hospital Association and formerly held a similar role at the American Organization of Nurse Executives. Claire holds a doctorate in nursing practice and a master's of business administration.

Dave Dalton:

Everybody, thanks for being here today. Hey, all four of you panelists, thanks so much for taking some time to be with us here today. Terrific, let's go to Taylor first. The tool is called Human Trafficking and Healthcare Providers: Legal Requirements for Reporting and Education. What exactly is this new tool that Jones Day has produced?

Taylor Goodspeed:

Yeah, Dave. As some background, we have worked with the American Hospital Association, HEAL Trafficking and other provider organizations, and have come to understand that healthcare providers who treat victims of human trafficking are subject to a patchwork of sometimes inconsistent laws regarding their reporting obligations. Which patients should or must be reported and to whom, varies from state to state and are often not congruent with federal law obligations. In addition, an increasing number of states impose education requirements for healthcare providers related to human trafficking.

Taylor Goodspeed:

This tool is therefore born out of that need. It outlines the federal and state statutes and corresponding regulations for mandatory reporting and education requirements for healthcare providers. Specifically, it summarizes applicable laws on the following topics: the reporting of child abuse, the reporting of sex and/or labor trafficking and the regulation of anti-trafficking education of healthcare providers. In addition, in the minority of states that require reporting of adult rather than child trafficking victims, we have highlighted those additional reporting laws. And as you might imagine, this tool is the result of many hours of pro bono work by several of our attorneys at Jones Day. The effort is a part of the firm's ongoing and multi-disciplinary initiative to fight human trafficking.

Dave Dalton:

I think you hit on probably the core issue here. You've got 50 jurisdictions plus the District of Columbia, 51. They all have got their own rules, their own regulations, their own requirements, their own enforcement actions, I would expect. It is a patchwork, isn't it? And coordinating that and putting some semblance of order to that is a valuable tool for the healthcare community to use. Is that right?

Taylor Goodspeed:

Oh, definitely. Given how individualized each of these state requirements are, having in one place is incredibly valuable.

Dave Dalton:

Sure. And I'm guessing this was what they call a heavy lift. You didn't knock this out in a couple of afternoons. This is a lot of hours, a lot of weeks, a lot of months, a lot of hard work and research and digging around. Am I correct?

Taylor Goodspeed:

Oh, definitely. And hats off to a number of the San Francisco associates who helped me and Curt Kirschner in their San Francisco office really pulling together and identifying all of these relevant statutes, regulations and requirements and putting them all in one place. It was definitely a months long effort.

Dave Dalton:

Certainly a great effort and certainly a very, very worthy endeavor. Let's go over to Dr. Stoklosa. Why is this report being released now? Talk about the timing and why early 2021 makes sense?

Dr. Hanni Stoklosa:

Thanks, Dave. We have known for a while now that the majority of trafficked people, at least in the United States context, access healthcare at some point while they're being exploited. That has always meant that healthcare systems and health professionals should be equipped to respond when a trafficked person comes through their doors. In terms of the timing now, we know that COVID-19 has categorically changed the way that healthcare providers engage with patients on so many different levels. Heal Trafficking's analysis reports from the field indicate that COVID-19's impact is leading to increased vulnerability to trafficking across the board.

Dr. Hanni Stoklosa:

We're seeing that on a number of different levels. We're seeing that there's an uptick of violence in the home, which includes human trafficking. And due to the magnified economic pressures that we're seeing across the globe and in the United States, based on an inability to just meet basic human needs, people are taking riskier jobs. Including ones that end up crossing over into trafficking situations, in order to just survive and provide for their families. We feel now more than ever really, healthcare needs every tool possible to make sure the response to trafficked persons is as robust as possible.

Dave Dalton:

You'd be hard pressed to find anybody say something good about this pandemic. It's ridiculous to even phrase it like that. But in a sense, had COVID not happened, it was time to do this anyway, obviously. But bizarrely, did COVID help somehow?

Dr. Hanni Stoklosa:

Well, I think it's an interesting question and I'd love to hear Taylor's thoughts as well. But I think because of the ways that COVID has fundamentally changed the way we interact with patients in the healthcare setting, there are actually new opportunities to intervene. Whether it be recognizing that essential workers need to have testing for COVID, or vaccination. Where some populations may have been completely invisible and not interacting with healthcare, there may be new opportunities that this pandemic has brought, in addition to the unfortunate increase in vulnerability.

Dave Dalton:

Absolutely. Okay. Let's stay with Dr. Stoklosa and then I'd like Claire's input on another matter. But doctor, how exactly are healthcare providers to use this new tool?

Dr. Hanni Stoklosa:

Thanks so much for the question, Dave. We at HEAL, have recognized that a growing number of health systems recognize that their approach to human trafficking needs to be proactive and not reactive. That health systems have policies and procedures in place to provide the highest quality of care possible to trafficked persons. So this tool, used in combination with guides like the HEAL Trafficking Protocol Toolkit, provides two levels of assistance. The tool can be used to assist individual providers about their specific state requirements. And in addition, on the hospital or health system level, which often spans state lines, it can also provide benefits to make sure that they're getting all of the information in one central location.

Dave Dalton:

Okay, okay. Let's go to Claire Zangerle. Specifically, who in the healthcare field would likely benefit most from a resource like this?

Claire Zangerle:

Well, that's a great question. I can tell you, being in the healthcare field every day and seeing what we're doing at the bedside and in acute care settings every day, it's really useful for anyone in healthcare settings. Healthcare settings are everywhere. They're not just within the four walls of the hospital. So it's helpful for those who are in acute care and ambulatory care. If somebody is going in for an outpatient visit and even in post acute care, home care, those types of things, where people may be seen as victims in these areas. Because we know that human trafficking occurs everywhere, in every healthcare setting and the value of this in those settings is immeasurable.

Dave Dalton:

Sure. Claire, rookie question coming. Of course, all my questions are rookie questions. But how do you make healthcare professionals know that this is available and something they need to use and implement and benefit from? It's the right thing to do. How do you get the word out from a practical standpoint?

Claire Zangerle:

As you can imagine, there's a lot of barriers that we have to overcome in identifying and reporting incidences of human trafficking. What's really most important is to educate staff. That the staff in the hospitals and ambulatory clinics or wherever any victims may present. The education actually helps them understand what to look for and how to respond to what they're seeing. We also know it's important to address any of those unconscious biases that the staff may have toward the victims. That happens a lot. I think through education, we can make sure that we address that unconscious bias. Sometimes this is really hard for individuals who are working in healthcare settings to overcome if they don't understand this entire phenomenon. If they have this type of bias, the victim is not actually going to get the help that they need. They also need to understand the process for reporting in the state where they're practicing so they can report it correctly and expeditiously because time is of the essence in many of these situations.

Dave Dalton:

Absolutely. Claire, would you mind talking more about that unconscious bias? I've heard that term, even in these sorts of settings, healthcare settings. But for people maybe listening that aren't exactly sure what that means, could you maybe define that a little bit and maybe give us an example or two, if you're comfortable with that?

Claire Zangerle:

Yeah, sure. The way we look at unconscious bias for victims of human trafficking is a judgment that you might have somebody who comes in, who's a young woman who comes in with an older man. You may think that it's a different situation than what it really is. You might think that that's a girlfriend boyfriend situation. The caregiver may say, "Oh great. Well, she's got herself, a sugar daddy," or something really awful like that. And it's not that situation at all. The situation is that she is being trafficked. You might have somebody come in who is a laborer and you think, "Oh gosh, they're coming in because they've got an injury and oh, how nice is this boss to bring them in." Yet, they're not letting that laborer answer any questions. You're leaning more toward the boss saying, "Gosh, what a nice person," where you really need to pay attention to the person who's coming in, who's injured. Because it might have been some type of elicit injury that you have to pay closer attention to.

Dave Dalton:

Sure, sure. And those examples you gave are stunning, really. Now that you talked about it, it becomes clear and a little more obvious. But if someone isn't informed, not educated or just plain naive, it's easy to see how something like that might just go unnoticed. Great examples. Let's swing over to Alexis Gilroy, a crafty Jones Day Talks podcast veteran who's been suspiciously quiet up till this point. But we're about to put an end to that. Alexis, telehealth applications are relevant to this discussion we're having today, aren't they?

Alexis Gilroy:

Absolutely. I think in a couple of really unique ways. As mentioned previously, obviously COVID has really transitioned how patients access healthcare. In particular, we have seen just skyrocketing utilization of telehealth for necessity. Folks that are quarantining at home, providers that needed to close their door. They still needed to deliver care where the patient was. So telehealth became that method for accessing the care that was needed. What's interesting here is while telehealth can certainly be a tool, an implement, a methodology for delivering care by traditional healthcare providers, there's also a host of different telehealth focused organizations that have been in operation for a number of years now that are able to come in and be part of this effort that we've been hearing about in making sure that healthcare providers are there to support and identify trafficked victims and to help in those situations.

Alexis Gilroy:

This tool that's been mentioned, is very beneficial for health systems that might also have operations in multiple states or may through telehealth be supporting patients in multiple states. And need to have a one-stop shop where they can go to a resource and see in the various states where they're delivering patient care or where patients are traveling and moving about, what are their requirements in those particular states. Similarly, with these telehealth focused organizations that are often delivering care in all 50 states and DC, they now have a very usable resource for understanding how they can be an advocate and meet the compliance requirements of their patients. Whether that's related to child abuse or related to sex trafficking or other labor trafficking issues as identified in the tool. I think those are all really great aspects of this resource and why it was put together.

Alexis Gilroy:

If I might also propose a few thoughts on where telehealth in particular could be something down the road that could further benefit and mitigate the issues of trafficking. I think what's interesting about putting in an individual patient's hands, a resource or a smartphone to access healthcare, that also potentially puts in their hand a resource for seeking help. For not having to depend on a handler or a boss to take them to some location for healthcare needs, but that they could reach out directly. Maybe those handlers and bosses would be comfortable with them doing so and that becomes an easier method to seek help both for their immediate healthcare needs and to alleviate their situation.

Alexis Gilroy:

There's also some interesting things we have learned about telehealth and some healthcare providers in working with them, have been very pleased with some of the information that you gather about a patient when you see that patient in their, if you will, natural habitat. In their home, in their workplace where they live and breathe and exist. Those kinds of telltale signs could also benefit different trafficking projects and provide additional clues and information to providers. So I think it is very important and what this effort attempts to do, provide that resource, help healthcare providers comply with their relevant needs, give them information and support their desire to help in this way. But I think hopefully down the road, telehealth itself will be viewed as a way to be that link in the hand of the patient and also perhaps provide clues that you might not get when a patient just comes to a bricks and mortar facility.

Dave Dalton:

Sure. And most of the healthcare professionals I've met have good intuition about these sorts of things. They talk about these stories. So even if you're not having the traditional, conventional, the patient's sitting in the chair across my desk in the office, in a telehealth situation, you're still communicating. I think with some training and some experience, certainly at some point this could be very invaluable, couldn't it Alexis, in terms of detecting these kinds of activities?

Alexis Gilroy:

Absolutely, right. We're all in the very early innings of telehealth and its development. But we got a rapid lesson in the last 10 months and this is something that all healthcare providers, as they recognize that telehealth is really a foundational tool in their ability to meet patient needs. As part of broader resource points like bricks and mortar locations for healthcare services. But I think you're exactly right that we'll need to continue to evaluate, educate, to help both traditional providers and telehealth only providers be adept at cluing in to those unique telltale signs. It comes through education, which is identified in the tool. Some of the states do recommend or require for healthcare providers to be better informed about how to assist and to identify trafficked victims.

Dave Dalton:

Sure. And once it works, once there are case studies or success stories, whatever you want to call them, when people figure out how this can work and how it can be used as a tool or a weapon really, in this fight against human trafficking and so forth, people figure out here's what happened here. Ooh, this sounds like my situation. I think as the experience builds and as the giant case file builds, I think this can only lead to much better things down the road. This is a great endeavor, I think, and a hat tip to everybody already.

Dave Dalton:

Claire Zangerle, you talked a minute ago and we got ahead of ourselves, but you hit on the importance of educating the hospital administrators and healthcare workers and so forth. Any other advice you'd have for providers or hospitals working to overcome? You talked about the barriers in terms of reporting and getting authorities involved, whatever. Any other thing you'd like to leave the audience with in terms of what hospital administrators need to know?

Claire Zangerle:

Yes. There needs to be some type of resources that are delineated for this education and training and continuous review of how they're going to keep their staff educated. It's not necessarily the hospital administrators who need to be educated. They need to provide the resources for education. It's the people who come face to face with these victims that need the education. And if the administrators and the leaders of each hospital or ambulatory center or whatever healthcare organization it is, provide the resources for the education, then I think that those barriers can be knocked down pretty quickly.

Dave Dalton:

Certainly awareness is only being elevated through efforts like this. I think there are better things to come, certainly, certainly. Let's go back to Taylor Goodspeed for a second. This report or tool clearly involved a significant amount of research and analysis. What did we learn? Are there any conclusions worth noting you want to bring out today?

Taylor Goodspeed:

Yeah. Dave, I can really speak to two. The first is that many states have dovetailed sex trafficking victim reporting into the jurisdiction's child abuse laws. Therefore, there is generally some consistency between the reporting obligations of child abuse and sex trafficking involving minors. But this overlap does not exist really with respect to adult victims of human trafficking. Trafficking of adults generally don't fall under the state's vulnerable adult protections and those reporting schemes. And broadly speaking, is not currently addressed by state mandatory reporting laws. Secondly, state requirements for reporting instances of labor trafficking are additionally spotty and not uniform and reporting of these incidents is still currently a patchwork effort.

Dave Dalton:

The two things you just talked about, are those matters that need to be addressed legislatively? Is that what we're talking about here? I mean, raising awareness is one thing, and someone's got to take action. Are these kinds of things that might be handled on a state by state basis in the Capitol house?

Taylor Goodspeed:

Correct. So these are all state individual laws, whether it be through uniformity across states or a general effort that would be to help with this kind of patchwork scheme that I addressed.

Dave Dalton:

Okay, good summary there. Doctor Stoklosa, anything you might add to what Taylor brought to the table in terms of what we've learned, conclusions come about, that kind of thing.

Dr. Hanni Stoklosa:

Yeah, I think that's excellent. I also have this unique lens as an emergency medicine physician on the frontline caring for trafficked persons. And then this bird's eye view really as executive director of HEAL Trafficking, seeing how a number of these mandatory reporting laws and education laws have been implemented over the years. As I look across that landscape, I see that there are some lessons learned in both of those categories. Related to mandatory reporting laws, one of the real positive examples we've seen from health systems is that they work to develop relationships with the entities that are receiving those reports on the other end. In some states, those are child welfare, some states those are our law enforcement entities. But really proactively building those relationships allows that report to really serve the victim as much as possible.

Dr. Hanni Stoklosa:

This relates to the education piece, but making sure that health professionals and providers that are making that report are trained in how to have what's called a limits of confidentiality conversation with their patient. Basically, before a patient discloses that the exploitation of trafficking is happening, that they let them know if they were to cross over into that, that they would need to report that. That's really at the end of the day, very trauma informed and patient centered. Then along with that, when a report needs to be made. The goal is really to serve the patient and make sure that they access all of the resources that they need. To think about that just as we would for those patients that are trafficked, that we're not doing a mandated to report on where, in addition to making that report, we're thinking about ways that they can support that victim, whether it's with legal services or whether that's with housing or substance use.

Dr. Hanni Stoklosa:

Again, going back to the patient centered approach and thinking about how that patient may even be involved in the report to the entity that the report needs to be made to. Those are some lessons learned in the mandatory reporting side of things. But I think as health systems are really considering their obligation here to think about the how's of the ways that they're implementing that.

Dr. Hanni Stoklosa:

Then on mandatory education laws, there's a whole spectrum, jigsaw puzzle, as Taylor was saying earlier, in terms of what these laws look like. I would say the most robust laws that are out there are ones that have some sort of standards that are integrated in the ways that they're implementing those education laws. I recall the example of Texas, where they passed their mandated education law and then they thought really about which educational modules and tools would meet the standards for the requirement of that law. What that allows is other states consider either updating their mandatory education law around trafficking or creating their new one is really standardization and making sure that at a bare minimum, no harm is done.

Dr. Hanni Stoklosa:

Also, that health professionals know about the full spectrum of what trafficking may entail. I can't tell you how many trainings I've seen out there unfortunately, for health professionals, that don't even cover labor trafficking, for example, which is an entire form of exploitation. What that means is if you don't cover the whole spectrum of trafficking, then you're going to have an entire state that's educated on only one form of trafficking and that can do harm or incorporating misconceptions. Those are both positive and negative examples that I've seen in the implementation of mandatory education laws. I'm really excited about this tool from Jones Day again, because it's going to be catalyzing. I think what we're going to see is that states will step up and realize that they need to have these laws in place. Also, will look to see how they can improve their existing law. So really excited to see this tool's implementation.

Dave Dalton:

This is bigger than the healthcare industry. It's bigger than law firms. It involves so many parts of this constellation. You mentioned child services, organizations like that. There are state governments involved. You've got other what we call NGOs, non-governmental organizations. Who carries the ball on something like this? As a healthcare provider, as a physician, you have what you used to call moral suasion. Certainly, you know how important this is, but who pounds the table in a state legislature, in a state Capitol and say, "We need some advancement. We need some reforms. We need some uniformity. We need to make sure our reporting requirements are up to standards." Who would champion something like this out there as we're trying to make progress here?

Dr. Hanni Stoklosa:

I love that question. I mean, I see all of this as movement building really. And movements don't happen with one or two individuals, but they come from that power of a collective. I think it's really important for that energizing and catalyzing to come from a diversity of stakeholders. Whether that be those with lived experience, those that have survived trafficking themselves, along with health professionals, along with law enforcement, that can be really, really powerful when you have all of those voices. And in particular, those that have had the experience of trafficking in their life to come to state legislatures and say, "Hey, this is what we need in our state."

Dave Dalton:

That's powerful. That's powerful. Let's wrap it up with a word from Alexis. What do healthcare providers and administrators and leaders need to know about this report that maybe we haven't covered yet?

Alexis Gilroy:

Well, the best news that most people enjoy hearing is that it's free. It is free, it's available. You can access it on the Jones Day, the American Hospital Association or the HEAL Trafficking websites. So really encourage any of the listeners here today to check that out, download it. It's all yours, use it for the purposes that we've mentioned or tell us about other ways that you think it would be useful. It is updated through August, 2020 and as Taylor just mentioned, these are state specific rules. That's important to note because state laws do evolve and they do change.

Alexis Gilroy:

This is not intended to be legal advice. Rather, it's a good tool, a good starting point, a good way, especially if your healthcare services are offered in multiple different jurisdictions, to get a handle quickly in one resource, what your requirements are among those jurisdictions. A lot of thanks goes to Jones Day's pro bono initiative to combat human trafficking, the tremendous work that Taylor Goodspeed and a number of other attorneys at Jones Day put into this. Also, the American Hospital Association and its Hospitals Against Violence Initiative, to further this goal. We really appreciate our partnership with them and their ability to let us get involved in what we believe is a very important and worthy topic for the firm to participate in.

Dave Dalton:

Absolutely. Very well said and I promise you, I promise you Alexis, the link to the tool will be prominently displayed when people download this podcast. They won't have any trouble finding it.

Taylor Goodspeed:

Terrific.

Dave Dalton:

Hey, so two things. Number one, most importantly, thank you all for what you're doing about this. This firm, the resources, the reach it has, the good work it does sometimes often gets overlooked. But this is just compelling and terrific and thanks for all the time you've put into that. I think it's going to only lead to good things and bear fruit for years and years to come, number one. Number two, thank you for being here today. Taylor, thanks for quarterbacking this, organizing everything. Let's do this again maybe mid-year or so. Maybe something changes to the report. Maybe there are developments. Anytime you want, we'll do this again. But we'd love to stay in touch and keep bringing our listeners more information as the tool is implemented, as it's used. Hey, maybe we'll have some success stories you can impart at some point.

Taylor Goodspeed:

That'd be great. Thank you.

Dave Dalton:

Awesome. Hey, thank you all for being here today. Talk soon, take care.

Taylor Goodspeed:

Thanks so much, Claire and Dr. Stoklosa. Take care.

Dave Dalton:

For complete biographies of Alexis Gilroy and Taylor Goodspeed, visit jonesday.com. You'll also find their contact information there. And while you're at jonesday.com, be sure to check out our Insights page. There you'll find all sorts of practical, valuable content, more podcasts, videos, publications, newsletters, blog postings, and other pertinent information for interested parties. Subscribe to Jones Day Talks at Apple Podcasts and wherever else podcasts can be found. As always, we thank you for listening. I'm Dave Dalton, we'll talk to you next time.

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