Shaneela Sadaruddin Khowaja  ( School of Nursing, Community Health Sciences, Aga Khan University Hospital, Karachi. )
Ambreen Jawed Tharani  ( School of Nursing, Aga Khan University Hospital, Karachi. )
Ajmal Agha  ( Community Health Sciences, Aga Khan University Hospital, Karachi. )
Rozina Sherali Karamaliani  ( School of Nursing, Community Health Sciences, Aga Khan University Hospital, Karachi. )

Pakistan is both a country of origin and destination as far as women trafficking is concerned. Poverty, gender discrimination, lack of education, and ignorance about legal rights are some of the underlying causes. Available data suggest several areas of concern, like, for instance: direct health effects, maladaptive coping leading to the use of illicit drugs, and inaccessibility to healthcare facilities. Therefore, numerous interventions would be required at three levels: the prevention of trafficking, the protection of victims and the prosecution of the traffickers.
Keywords: Women trafficking, Poverty, Drugs.

The life of a woman is always being challenged in patriarchal societies like Pakistan. The challenges markedly increased when a woman is out of her home. Fifteen years ago, deprived domestic circumstances made a poor girl, Amra, leave her home to secure a better job and stable income.¹ The innocent little girl, with more than 20 others, was unaware that they were being trafficked from Bangladesh to Pakistan. Indignities and exploitation started after they crossed the border. After entering a new country, Amra was forcefully sold to marry a man against her will. Subsequently, Amra suffered physical, sexual and psychological trauma. Such scenarios reflect the cruel realities of women trafficking that are repeated around the world. Women are physically beaten, sexually assaulted, psychologically traumatised, and economically deprived to create a reliance on the traffickers.² All this has major health consequences, but despite this, trafficking is hardly, if ever, addressed adequately as a health-related concern.^3,4 This paper represents national, regional and international reviews to address the concerns related to women trafficking and its impact.
The Concept:
Human trafficking is a major concern in most regions of the world, and is considered to be one of the fastest growing areas of international criminal activity.⁵ According to the United Nations Office on Drugs and Crime (2004), human trafficking comes under the category of transitional crime which is plaguing the nations and countries towards illicit outcomes.⁶ It is called the "modern day\\\'s slavery".⁷ Human trafficking is an unjust and awful act against the mankind and so it is also an issue of human rights.⁸ Besides, there are health threats and socio-economical consequences inrelation to the notion of human trafficking.⁹
Despite being a sensitive and critical issue, there is scarce evidence about its severity. Lack of the use of standardised methodology for collecting and analysing the data hampers and undermines efforts to get reliable data on human trafficking.¹⁰ About 800,000 people are trafficked each year worldwide for forced labour, domestic servitude or sexual exploitation.² The largest number of victims trafficked internationally still come from Southeast Asia; over 225,000 each year.⁴ India and Pakistan are the key destination countries.⁵
Although men are also persecuted, but predominantly those trafficked are women and children.⁵ Recent empirical evidences reveal that human trafficking, particularly related to women and children, is on the rise in the Asian region.¹⁰ The low status of women in some societies as well as the growth of sex tourism contribute significantly to the phenomenon.⁵ The Global Alliance against Trafficking defines \\\'women trafficking\\\' as: "All acts involved in the recruitment and/or transportation of a woman within and across national borders for work or services by means of violence or threat of violence, abuse of authority or dominant position, debt-bondage, deception or other forms of coercion".¹¹
The definition depicts three basic elements in identifying and differentiating the cases of trafficking. First, the process (what is done) includes recruitment, transportation etc.; second, the means (how it is done) that consists of threat, abuse, deception etc.; third, the purpose (why it is done) comprises exploitation for sexual or forced labour.^10,12 UNODC further stated that "the crime of trafficking be defined through a combination of the three constituent elements and not the individual components, though in some cases threes individual elements will constitute criminal offences independently".¹²
Underlying Causes:
Pakistan is both a the country of origin and destination for women trafficking.¹³ Like other regions in the globe, women in this part of the world are the most vulnerable to the trafficking phenomenon which is associated with poverty, gender discrimination, lack of education, and ignorance about legal rights.
Poverty is one of the prime determinant of women trafficking. Furthermore, poverty deprives these women from resources which further aggravate the issue. Poverty encompasses various dimensions which includes lack of access to basic services, insecurity in daily life, disempowerment as human agency, and the inability to speak out with dignity.¹⁴ As a result, the poor parents are forced to sell their daughters into domestic servitude, prostitution, or forced marriages.¹²
Gender inequalities and disparities in Pakistan are the added causes of women trafficking and exploitation. In this society, male has more influence, while woman has always been seen as a submissive daughter, sister or wife. Moreover, many societies still favour sons, and view daughters as an economic burden.⁵ Likewise, in Pakistan early marriages and traditional dowry practices also augment the financial burden; hence, forcing parents to sell their daughters.¹²
Lack of awareness and illiteracy are the other major factors related to women trafficking. In Pakistan, the female literacy rate is only 39% against 64% among males.¹⁵ Hence, gender discrimination is also observed in terms of educational opportunities. Moreover, lack of education limits the women from getting better earning opportunities, making them even more vulnerable to exploitation. Furthermore, in poorer regions of the world, lack of sex and health education in the curriculum can also lead societies into crime like human trafficking.¹⁶
Every individual in Pakistan has the right to have access to legal protection.¹² However, due to threats and terror, many of the victims remain hesitant to approach the legal system.¹² Besides, weak legislation and the poor enforcement of anti-trafficking laws are also cited as factors contributing to the menace in Pakistan.¹⁷
As the above reviews show, women trafficking in Pakistan is interconnected with socio-cultural, gender and economic inequalities and inequities. This leads to various health threats.
Areas of Concerns:
Women trafficking accompany potential lifelong and/or life-threatening health consequences.¹⁶ However, the health risks associated with human trafficking, especially for women, have not been well-documented. One of the few studies on trafficking that has focused on health was conducted in Europe.⁹ Available data suggest several areas of concern of women trafficking. These include direct health effects, maladaptive coping by opting for illicit drugs, and inaccessibility to healthcare facilities.
Despite having exploitation and cruelty attached with this criminal activity, there is limited data to be provided with adequate evidence and facts on the health risks associated with human trafficking.⁹ Moreover, lack of access to healthcare affects the achievement of the Millennium Development Goals, including combating Human Immunodeficiency Virus (HIV) and other diseases, improving maternal health, and promoting gender equality and empowering women.¹⁶
The most obvious and the direct health effect of trafficking are psychological, physical and sexual violence.¹⁶ Trafficking leads to weakened mental equilibrium of the victims who feel constant terror, guilt, embarrassment, hopelessness, denial and self-blame throughout their lifespan.¹⁸ Physical abuse results in the victims getting injuries such as bruises, broken bones, head wounds, stab wounds, mouth and teeth injuries, and it can even lead to death.¹⁶ Moreover, sexual abuse and coercion into involuntary sexual acts can lead to unwanted pregnancies, and gynecological complications.¹⁹ As a result, these victims are at a high risk of infertility, ectopic pregnancy and malignancies associated with Sexually Transmitted Diseases (STDs) (e.g. cervical cancer and AIDs).²⁰
A study found that the absence of emotional and social support has enormous implications for women\\\'s ability to withstand and cope with the stress of their situation.⁹ Consequently, these sufferers lead into maladaptive coping practices such as using illicit drugs and/or alcohol, and subsequently develop addiction. More so, in patriarchal societies, trafficked women are often socially stigmatised, and, thus, it is difficult for them to regain social status.¹⁶ Limited accessibility of health care is also due to the social stigma associated with trafficking and availability of inadequate assets and resources.¹⁶ As a result, trafficked victims are at a greater risk of complications arising from undiagnosed and untreated physical, psychological and sexual health concerns.¹⁶ A review concluded that in Pakistan, women are exposed to serious and numerous health risks, which have an impact on the nation\\\'s and the world\\\'s public health.²¹
Looking at the cruelty of the issue, the role of healthcare professionals can play a pivotal role in order to protect women from severe health consequences.
Framework for Care:
Women rafficking is now recognised as one of the global public health issue.²² Hence, numerous interventions would be required at all levels of care. Interventions to curb women trafficking can be done at three levels: (a) the prevention of trafficking, (b) the protection of victims and (c) the prosecution of the traffickers.²³
(a) Lack of awareness of the general population regarding the menace continues to be an issue. Therefore, there is a strong need to strengthen the nation\\\'s knowledge and understanding about this serious crime, its effects on individuals, and the identification of useful strategies to control this inhuman act. Prevention can be done through public awareness campaigns and by incorporating health and human trafficking information into existing programmes, policies, education and curricula.²⁴ Therefore, both governmental and non-governmental organisations should work in tandem to combat trafficking in Pakistan. In this respect, the Ministry of Interior produced and screened a film about the dangers of trafficking on state television and to vulnerable populations along the border with India.²⁵ Lawyers for Human Rights and Legal Aid (LHRLA) took up the issue of trafficking of women in Pakistan, for the first time, in its one-year project aimed at raising awareness about trafficking.²⁶ Above all, technical training is recommended for all professionals who work for the prevention of women trafficking.
There is also a need to improve social awareness about the concept of trafficking. This can be done at an early age through the school health curricula.²⁴ Moreover, awareness could also be increased through media. Additionally, initiatives to make women resourceful by establishing educational, technical, vocational, health and infrastructure projects can also prevent women from being trafficked.
(b) Unfortunately, victims are traumatised even if they are lucky enough to return home. They are usually stigmatised in their homes and in their social circles. These poor victims can be protected or supported by providing them with various resources, such as hotlines, shelters and counselling services. Although the Pakistani government does make plans, their implementation remains questionable. Protection for victims of commercial sexual exploitation remains limited. Internally trafficked women could access federal government-run Women\\\'s Centers^25,26 or 276 provincial government-run Dar-ul-Amaan centers offering medical treatment, vocational training and legal assistance to the abused women and children.²⁷ Moreover, the government claims that the services are available for the victims, including shelter, legal aid and medical and psychological care.6 However, the adequate and secure provision of shelter facility has not been available for many victims.¹³
Hence, providing reliable protection to these victims is strongly recommended, including operational plans to make them easily accessible, to repatriate the trafficked women, and to re-integrate rescued women into society.²⁴ Moreover, equal opportunities for participation in economic activities could be provided by empowering the victims, thus making them independent. As weak infrastructure and budgetary implications further limit the situation, there is a need to have inter-sectoral collaboration in order to reduce this gap.
(c) The government of Pakistan does not fully comply with the minimum standards for the elimination of trafficking. However, it is making significant efforts to do so.²⁷ A legislation titled Prevention and Control of Human Trafficking Ordinance (PCHTO) has been passed in 2002 which specifically addresses the protection of the victims of human trafficking.²⁸ The ordinance imposes a punishment of imprisonment for up to 10 years and a fine on anyone who:
"Purchases, sells, harbours, transports, provides, detains, or obtains a child or a woman through coercion, kidnapping or abduction, or by giving or receiving any benefit for trafficking the child or woman into or out of Pakistan for the purpose of exploitative entertainment.²⁹
The ordinance also provides for certain benefits to the victims, like allowing them to extend their stay in Pakistan; paying compensation and expenses to the victim; or making arrangements for shelter, food, and medical care of a victim who is an unaccompanied child or a destitute woman.²⁹ Despite all these efforts, including the prosecution of some trafficking offences, the government has not shown evidence of progress in addressing such a serious issue.
The government cannot achieve significant progress in terms of curbing this phenomenon without a comprehensive approach.¹³ Along with that, training would be required for legal professionals and judges for awareness related to trafficking. Illiteracy and unawareness about the law is another subject of concern. Therefore, facilities for the provision of legal advice and support to the victims to bring their cases to the courts should be made available.

Women trafficking is one of the major concerns in this part of the world. In Pakistan, economic deprivation, gender discrimination, inequality in education, and the ignorance about legal rights are the contributing factors. As a result, these victims could undergo various distressing health outcomes, especially related to reproductive health, substance abuse etc. Steps to facilitate healthcare providers in assisting the victims need to be taken. Hence, numerous interventions would be required at three levels: the prevention of trafficking, the protection of victims, and the prosecution of the traffickers. From holistic perspective of care, a health professional can play a pivotal role by providing preventive awareness. Besides, educational programmes need to be in place in order to protect women from severe health consequences.

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