Migrant Worker Safety, Occupational Health Equity, and Labor Trafficking

By Jaya Prakash; Inkyu Kim, MD; Timothy B. Erickson, MD, FACEP, FACMT; Hanni Stoklosa, MD, MPH



Prakash J, Kim I, Erickson T, Stoklosa H. Migrant worker safety, occupational health equity, and labor trafficking. HPHR. 2021; 33. 


Migrant Worker Safety, Occupational Health Equity, and Labor Trafficking


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?

How equitably beneficial has this worker safety and health law been for migrant workers and those who are labor trafficked?

Migrants comprise a growing population that is particularly vulnerable to workplace hazards (United Nations Population Division Department of Economic and Social Affairs, n.d.). The dangers imposed upon migrant workers as a whole involve environmental exposures such as temperature extremes, pesticides, and chemicals (Garcia & De Castro, 2016; Spector et al., 2016; Vega-Arroyo et al., 2019; Stoklosa et al., 2020; Hsieh et al., 2016; Fung, 2014). Working conditions impose occupational risks: physical hazards, unregulated safety standards, and workplace abuse (Pannikar et al., 2014; Quandt, Kucera, et al., 2013; Tribble et al., 2016; Marín et al., 2009; Arcury et al., 2014; Liebman et al., 2013; Quandt et al., 2006; Underhill & Rimmer, 2015; Preibisch & Otero, 2014; Murphy et al., 2015; Panikkar et al., 2015; Tsai & Thompson, 2013). These hazards are intrinsic to the inherently dangerous occupations, colloquially known as “3-D jobs” (dirty, dangerous, and demanding), that traditionally employ migrant workers (Quandt, Arcury-Quandt, et al., 2013).


Compared to their non-migrant counterparts, migrant workers are disproportionately more likely to face these occupational hazards due to policy, legal, and political vulnerabilities. Undocumented workers are twice as likely to face minimum wage violations and less likely to formally complain about workplace transgression, especially given the threat of deportation (Bernhardt et al., 2009; Fussell, 2011). Language and cultural barriers increase the likelihood for migrants to experience more hazards in already dangerous occupations due to troubles understanding safety information not offered in the worker’s native or cultural language (Orrenius & Zavodny, 2009; Flynn, 2014; Simon et al., 2015). To make matters worse, migrant workers are also forced to navigate legal structures—such as visa restrictions or familial sponsorship—that systemically predispose recruitment into unsatisfactory employment (Liebman et al., 2013; Preibisch & Otero, 2014; Human Rights Watch, 2008). Amplifying these systemic injustices are changes in the political climate that can perpetuate xenophobia or racism, creating situations for targeted labor exploitation (National Immigrant Law Center, 2009). When accessing medical care, migrant workers face significant barriers such as 1) lack of health insurance and 2) inability to establish transportation or availability when scheduling medical appointments (Preibisch & Otero, 2014; Simon et al., 2015). As a result, although the OSH Act has contributed to reduced overall workplace fatalities by 50% and occupational illness and injury rates by 40%, the Office of Inspector General observed a record number of migrant worker fatalities in 2000, as cited by the Bureau of Labor Statistics (Loh & Richardson, 2004). In fact, there have been sizable gaps in OSHA’s investigation of migrant worker fatalities, raising questions regarding enforcement of regulations for foreign-born workers in the US (Office of Inspector General, 2003).


A current example of the repercussions encountered by migrant workers is the heightened risk of COVID-19 disease for workers that occupy an essential, albeit expendable, position (Greenbaum et al., 2020). Without proper infection-prevention measures, social distancing, and working condition regulations, migrant workers face increased susceptibility to SARS-CoV-2 transmission (Reid et al., 2021; Handal et al., 2020). Migrant workers’ living situations further increase the likelihood of viral outbreaks as a result of congregate living, lack of PPE, and inadequate access to health care (Reid et al., 2021; Handal et al., 2020). This is compounded by aforementioned barriers that migrants face to identification: lack of awareness by medical professionals, implicit bias about trafficking, lack of regulation, and narrow-spectrum language or cultural services.

What are the unique occupational health risks labor trafficked migrants face?

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).

What role can public health play in addressing the needs of labor trafficked migrant workers?

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.


Arcury, T. A., Summers, P., Carrillo, L., Grzywacz, J. G., Quandt, S. A., & Mills III, T. H. (2014). Occupational safety beliefs among Latino residential roofing workers. American journal of industrial medicine57(6), 718-725.


Bernhardt, A., Milkman, R., Theodore, N., Heckathorn, D. D., Auer, M., DeFilippis, J., & Perelshteyn, J. (2009). Broken laws, unprotected workers: Violations of employment and labor laws in America’s cities.


Buller, A., Vaca, V., Stoklosa, H., Borland, R., & Zimmerman, C. (2015). Labour exploitation, trafficking and migrant health: multi-country findings on the health risks and consequences of migrant and trafficked workers (p. 171). International Organization for Migration.


Flynn, M. A. (2014). Safety & the diverse workforce: lessons from NIOSH’s work with Latino immigrants. Professional safety59(6), 52.


Fung, K. A. (2014). Gel, acrylic, or shellac: the impact of Southeast and East Asian immigrant nail salon workers on the health care system. U. Md. LJ Race, Religion, Gender & Class14, 121.


Fussell, E. (2011). The deportation threat dynamic and victimization of Latino migrants: Wage theft and robbery. The Sociological Quarterly52(4), 593-615.


Garcia, G. M., & De Castro, B. (2017). Working conditions, occupational injuries, and health among Filipino fish processing workers in Dutch Harbor, Alaska. Workplace health & safety65(5), 219-226.


Greenbaum, J., & Stoklosa, H. (2019). The healthcare response to human trafficking: A need for globally harmonized ICD codes. PLoS medicine16(5), e1002799.


Greenbaum, J., Stoklosa, H., & Murphy, L. (2020). The public health impact of coronavirus disease on human trafficking. Frontiers in public health8, 685.


Handal, A. J., Iglesias-Ríos, L., Fleming, P. J., Valentín-Cortés, M. A., & O’Neill, M. S. (2020). “Essential” but Expendable: Farmworkers During the COVID-19 Pandemic—The Michigan Farmworker Project.


Holmes, S. M. (2006). An ethnographic study of the social context of migrant health in the United States. PLoS Med3(10), e448.


Holmes, S. M., Hansen, H., Jenks, A., Stonington, S. D., Morse, M., Greene, J. A., & Farmer E. (2020). Misdiagnosis, Mistreatment, and Harm-When Medical Care Ignores Social Forces. The New England journal of medicine382(12), 1083-1086.


Hsieh, Y. C., Apostolopoulos, Y., & Sönmez, S. (2016). Work conditions and health and well-being of Latina hotel housekeepers. Journal of immigrant and minority health18(3), 568-581.


Human Rights Watch. (2008). ” As if I am not human”: abuses against Asian domestic workers in Saudi Arabia. Human Rights Watch.

Liebman, A. K., Wiggins, M. F., Fraser, C., Levin, J., Sidebottom, J., & Arcury, T. A. (2013). Occupational health policy and immigrant workers in the agriculture, forestry, and fishing sector. American journal of industrial medicine56(8), 975-984.


Loh, K., & Richardson, S. (2004). Foreign-born workers: trends in fatal occupational injuries, 1996-2001. Monthly Lab. Rev.127, 42.


Marín, A. J., Grzywacz, J. G., Arcury, T. A., Carrillo, L., Coates, M. L., & Quandt, S. A. (2009). Evidence of organizational injustice in poultry processing plants: possible effects on occupational health and safety among Latino workers in North Carolina. American journal of industrial medicine52(1), 37-48.


Moyce, S. C., & Schenker, M. (2018). Migrant workers and their occupational health and safety. Annual review of public health39, 351-365.


Muntaner, C., Solar, O., Vanroelen, C., Martínez, J. M., Vergara, M., Santana, V.,  & EMCONET Network. (2010). Unemployment, informal work, precarious employment, child labor, slavery, and health inequalities: pathways and mechanisms. International journal of health services40(2), 281-295.


Murphy, J., Samples, J., Morales, M., & Shadbeh, N. (2015). “They talk like that, but we keep working”: sexual harassment and sexual assault experiences among Mexican indigenous farmworker women in Oregon. Journal of immigrant and minority health17(6), 1834-1839.


National Immigrant Law Center. 2009. Overview of key issues facing low-wage immigrant workers. Los Angeles, CA; Washington, DC: National Immigrant Law Center, p 1.


Occupational Safety and Health Administration. (1970). Occupational safety and health standards: Occupational health and environmental control (Standard No. 1910.95).


Office of Inspector General. Evaluation of OSHA’s Handling of Immigrant fatalities in the Workplace. 2003. Retrieved February 25, 2021, from https://www.oig.dol.gov/public/reports/oa/2003/21-03-023-10-001.pdf


Orrenius, P. M., & Zavodny, M. (2009). Do immigrants work in riskier jobs?. Demography46(3), 535-551.


Ottisova, L., Hemmings, S., Howard, L. M., Zimmerman, C., & Oram, S. (2016). Prevalence and risk of violence and the mental, physical and sexual health problems associated with human trafficking: an updated systematic review. Epidemiology and psychiatric sciences25(4), 317-341.


Panikkar, B., Brugge, D., Gute, D. M., & Hyatt, R. R. (2015). “They See Us As Machines:” The Experience of Recent Immigrant Women in the Low Wage Informal Labor Sector. PloS one10(11), e0142686.


Panikkar, B., Woodin, M. A., Brugge, D., Hyatt, R., Gute, D. M., & Community Partners of the Somerville Community Immigrant Worker Project. (2014). Characterizing the low wage immigrant workforce: a comparative analysis of the health disparities among selected occupations in Somerville, Massachusetts. American journal of industrial medicine57(5), 516-526.


Powell, C., Dickins, K., & Stoklosa, H. (2017). Training US health care professionals on human trafficking: where do we go from here?. Medical education online22(1), 1267980.


Preibisch, K., & Otero, G. (2014). Does Citizenship Status Matter in Canadian Agriculture? Workplace Health and Safety for Migrant and Immigrant Laborers. Rural Sociology79(2), 174-199.


Quandt, S. A., Arcury‐Quandt, A. E., Lawlor, E. J., Carrillo, L., Marín, A. J., Grzywacz, J. G., & Arcury, T. A. (2013). 3‐D jobs and health disparities: The health implications of Latino chicken catchers’ working conditions. American journal of industrial medicine56(2), 206-215.


Quandt, S. A., Grzywacz, J. G., Marin, A., Carrillo, L., Coates, M. L., Burke, B., & Arcury, T. (2006). Illnesses and injuries reported by Latino poultry workers in western North Carolina. American journal of industrial medicine49(5), 343-351.


Quandt, S. A., Kucera, K. L., Haynes, C., Klein, B. G., Langley, R., Agnew, M., … & Nussbaum, A. (2013). Occupational health outcomes for workers in the agriculture, forestry and fishing sector: implications for immigrant workers in the southeastern US. American journal of industrial medicine56(8), 940-959.


Reid, A., Ronda‐Perez, E., & Schenker, M. B. (2021). Migrant workers, essential work, and  COVID‐19. American Journal of Industrial Medicine64(2), 73-77.


Report of the Senate Committee on Labor and Public Welfare (submitted to accompany S. 2193 the Williams Bill), S. Rep. 91-1282, 91st Cong., 2d Sess. 1–5 (October 5, 1970).


Ronda-Pérez, E., & Moen, B. E. (2017). Labour trafficking: Challenges and opportunities from an occupational health perspective. PLoS medicine14(11), e1002440.


Rothstein M. A. (2020). The Occupational Safety and Health Act at 50: Introduction to the  Special Section. American journal of public health, 110(5), 613–614.


Simon, J., Kiss, N., Łaszewska, A., & Mayer, S. (2015). Public health aspects of migrant health: a review of the evidence on health status for labour migrants in the European Region.


Spector, J. T., Bonauto, D. K., Sheppard, L., Busch-Isaksen, T., Calkins, M., Adams, D., & Fenske, R. A. (2016). A case-crossover study of heat exposure and injury risk in outdoor agricultural workers. PLoS one11(10), e0164498.


Stoklosa, H., Dawson, M. B., Williams-Oni, F., & Rothman, E. F. (2017). A review of US health care institution protocols for the identification and treatment of victims of human trafficking. Journal of Human Trafficking3(2), 116-124.


Stoklosa, H., Kunzler, N., Ma, Z. B., Luna, J. C. J., de Vedia, G. M., & Erickson, T. B. (2020). Pesticide exposure and heat exhaustion in a migrant agricultural worker: a case of labor trafficking. Annals of emergency medicine76(2), 215-218.


Stoklosa, H., Showalter, E., Melnick, A., & Rothman, E. F. (2017). Health care providers’ experience with a protocol for the identification, treatment, and referral of human-trafficking victims. Journal of Human Trafficking3(3), 182-192.


Stoklosa, H., Stoklosa, J. B., & MacGibbon, M. (2017). Human trafficking, mental illness, and addiction: avoiding diagnostic overshadowing. AMA journal of ethics.

Tribble, A. G., Summers, P., Chen, H., Quandt, S. A., & Arcury, T. A. (2016). Musculoskeletal pain, depression, and stress among Latino manual laborers in North Carolina. Archives of environmental & occupational health71(6), 309-316.


Tsai, J. H. C., & Thompson, E. A. (2013). Impact of social discrimination, job concerns, and social support on Filipino immigrant worker mental health and substance use. American Journal of Industrial Medicine56(9), 1082-1094.


Underhill, E., & Rimmer, M. (2015). Itinerant foreign harvest workers in Australia: The impact of precarious employment on occupational safety and health. Policy and Practice in Health and Safety13(2), 25-46.


United Nations, Population Division, Department of Economic and Social Affairs. (n.d.). Retrieved February 25, 2021.


United Nations. Treaty Collection. Chapter 28. 12a. Protocol to prevent, suppress and punish trafficking in persons, especially women and children, supplementing the United Nations convention against transnational organized crime. New York. 15 November 2000. treaties.un.org/pages/viewdetails.aspx?src=ind&mtdsg_no=xviii-12- a&chapter=18&lang=en


Vega‐Arroyo, A. J., Mitchell, D. C., Castro, J. R., Armitage, T. L., Tancredi, D. J., Bennett, D. H., & Schenker, M. B. (2019). Impacts of weather, work rate, hydration, and clothing in heat‐related illness in California farmworkers. American journal of industrial medicine62(12), 1038-1046.


Weitzer, R. (2015). Human trafficking and contemporary slavery. Annual review of  sociology41, 223-242.


Zhang, S. X., Spiller, M. W., Finch, B. K., & Qin, Y. (2014). Estimating labor trafficking among unauthorized migrant workers in San Diego. The Annals of the American Academy of Political and Social Science653(1), 65-86.


Zimmerman, C., & Schenker, M. B. (2014). Human trafficking for forced labour and occupational health.

About the Authors

Jaya Prakash

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, MD

Inkyu Kim is an emergency medical resident at BMW/MGH. 

Timothy B. Erickson, MD, FACEP, FACMT

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

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.