The signs were there.
Multiple visits to hospitals with broken bones and burns. Addicted to opioids and heroin, suffering from anxiety and post-traumatic stress disorder.
At 21, Simone Bell was lured into the clandestine world of human trafficking. She was sexually exploited by her trafficker and sold to men from Montreal, to Ottawa, Toronto and Niagara Falls. The ordeal lasted four years before she managed to escape.
That was 10 years ago.
Today, Bell is a survivor and is using her experience through the Hope Found Project, a non-profit program that helps others who've been trafficked. She also speaks to health-care professionals, teaching them how to recognize the signs that someone is being trafficked.
More than social services, more than police services, Bell says that "health care is the place where you're going to see a victim of human trafficking the most."
"I think if someone had spent more time to talk to me, to ask me, to probe more, like, does he make you do anything that you don't want to do? Does any of that involve forcing you to do sex work? What happens with the money?"
Human trafficking has been called modern day slavery. Besides sex trafficking, there is forced labour, too, where victims are coerced into working long hours, with very little pay in industries like massage parlours, nail salons and seasonal farming jobs.
Statistics Canada data between 2009 and 2014 showed there were 396 victims of human trafficking — nearly all of them women, most of them young. Because of the illicit nature of human trafficking and victims' reluctance to report a crime to police, the number of victims could be higher.
Watching for 'red flags'
Most human trafficking victims will need health care at some point in their exploitation, suffering from emotional trauma, physical, and sexual abuse.
A few years ago, Fraser Health in B.C. developed initiatives in how to identify patients who have been trafficked.
Tara Wilkie is a nurse with a Fraser Health team that specializes in dealing with trafficking victims
"We know this is an epidemic," says Wilkie, "and is much greater than we even understand."
Wilkie says many trafficking victims "look like any other patient that comes into the emergency department."
But there are some "red flags" the B.C.-based nurse says. Persons who are trafficked can be going through an illness from a neglected injury, like broken bones, bruises, and burn marks, she says. Some of the victims also present with branding.
The person comes in to deal with a medical issue "but you notice that they have tattooing that has some sort of insignia or name on it."
There are mental health consequences too like anxiety, thoughts of suicide, substance abuse. Many who are trafficked can also have sexually transmitted infections, genital injuries, pregnancies and miscarriages.
"It may also be that they're being monitored. Like, they have time limits set on when they have to be back. Or we've had people come in with being monitored on their phone through their GPS, or ankle bracelet monitoring."
Wilkie says the continuous checking in with their trafficker, the constant texting or talking on the phone as to their whereabouts, impedes the care that can be provided.
"I had a case just the other day, this exact thing happened and they couldn't continue on with their medical care because they had to report in."
Trafficking can happen across borders, but it can also happen inside a country, like Bell's experience.
At Fraser Health, health-care workers believe Indigenous women and girls are heavily represented among the patients being trafficked, Wilkie says.
Yvonne Boyer, who holds the Canada Research Chair in aboriginal health and wellness at Manitoba's Brandon University, co-authored a Public Safety Canada report into how aboriginal women and girls are forced into the sex trade.
She says that prejudice in the health-care system is an issue and women "who have been treated poorly in the health-care system just won't go back and their health suffers."
Boyer says "lots of work needs to be done in medical education on why women are being trafficked, the colonization in Canada and racism."
The efforts to educate health professionals aren't limited to Canada. Dr. Hanni Stoklosa, an emergency room physician at Brigham and Women's Hospital in Boston, says most doctors and health-care workers don't have human trafficking on their radar.
But things are changing. "We're starting to see a real shift in awareness," says Stoklosa. "More and more, health-care workers are starting to see trafficking as a real health issue."
In 2013, she co-founded HEAL Trafficking, a global initiative that advocates for survivors of human trafficking.
HEAL stands for Health, Education, Advocacy and Linkage. And so far, it has more than 800 health professionals around the world, including Canada, dedicated to fighting human trafficking from a public health point of view.
Stoklosa views it as "our moral obligation" to ensure that a survivor is first identified and then connected to services they need.
At Fraser Health in B.C., Tara Wilkie says once you've gained the trust of someone who has been trafficked, connecting them to those services can finally begin — by guiding them through the medical system, by starting the conversation with police, or shelters. It's all about bridging the gaps that are hard to navigate on their own, she says.
Looking back to the time she was trafficked, Simone Bell says she didn't even know what the term human trafficking meant.
"Just like everybody else, I thought that was something that happened to people that came from overseas."
Ashamed and afraid people would judge her, Simone would lie and tell nurses she was in a domestic abuse situation.
"If one person had told me what human trafficking was, that would have helped me self-identify and would have let me know that this is a thing that happens to others, that I'm not alone, and I can get help."