Improving Anti-trafficking Response in Bihar and Uttar Pradesh: Lessons Learned From a Qualitative Analysis of Stakeholder Interviews


 Background: Human trafficking is a critical public health issue particularly pervasive in the Indian states of Bihar and Uttar Pradesh, which share a border with Nepal. In advocating for human rights in this area, there is a need for research to identify problems hindering the efficacy of anti-trafficking programs, focusing on their success in assisting people from being re-trafficked. Methods: A qualitative study was conducted using semi-structured interviews and focus groups with key stakeholders in Bihar, Uttar Pradesh, and Nepal. Results: Thematic analysis revealed that barriers hindering the anti-trafficking movement include police corruption, lack of enforcement of national law, discrimination toward trafficking victims, lack of funding, and lack of government involvement. Recommendations for overcoming these barriers were increasing cooperation, coordination, and communications between NGOs and the government, and empowering survivors. Conclusions: In mitigating these barriers and increasing survivor autonomy, anti-trafficking interventions have the opportunity to create individualized environments for those with an experience of trafficking to thrive. Ultimately, elevating community accountability, honoring individual autonomy, and recognizing the value of the persons with a lived experience of trafficking are critical as we continue to use a public health lens in the fight against human trafficking and for human rights.

abduct minor victims, after which the children are reared as their own. Upon adolescence, the victims are prepared for commercial sex, which includes forced employment at dance bars in Mumbai and commercial sex in Middle East countries. This occurs in tandem with the use of oxytocin, an injection that can make adolescent and minor girls look like adult women [3]. Additionally, child labor is also rampant in the Uttar Pradesh carpet belt area and brick kilns industry, with children procured from Bihar for this labor [3]. As per a 2010 National Commission for Protection of Child Rights (NCPCR) report, Uttar Pradesh accounts for the largest share of all child workforce in India, at about 15 percent [3].
Existing government anti-tra cking initiatives in India Given the pervasive nature of tra cking within these Indian states, several anti-tra cking initiatives have been implemented by various governmental ministries in the country, in collaboration with NGOs. The varied nature of these region's programs must be understood when considering targeted strategies to bolster response efforts.
The Ministry of Home Affairs has implemented Anti-Human Tra cking Units (AHTU) in a majority of districts across India [3]. The AHTU functions primarily to coordinate anti-tra cking response among law enforcement, prosecutors, civil society organizations, and NGOs. These anti-tra cking responses include coordinating efforts for criminal prosecution, assisting victims in leaving situations of tra cking, and then caring for them after this occurs. Every AHTU has an appointed nodal NGO that helps law enforcement identify victims and coordinates post-tra cking care [3]. This nodal NGO manages government or private shelters for rehabilitation and the subsequent reintegration or repatriation, if applicable. NGOs additionally serve a vital role in helping law enforcement understand the regional nuances of tra cking in their speci c area, as they are closely tied with the community [3]. Often, parents will contact the NGOs directly about missing children instead of approaching law enforcement. Then, it is the role of the NGOs to coordinate with law enforcement to investigate and conduct an operation to dissolve situations of tra cking and aid victims, with police conducting the operations under predetermined protocol. The NGOs monitor anti-tra cking responses to ensure follow-through on these cases [3].
The Ministry of Women and Children has developed schemes and protocols to target services toward victims of commercial sexual exploitation of children (CSEC). This includes the ministry's development of manuals for various providers, as well as the protocols for best practices before, during, and after helping people exit tra cking. In 1998, the government formulated a National Plan of Action to Combat Tra cking to reintegrate women and child victims of commercial sexual exploitation into society [4]. Schemes, or anti-tra cking programs, were formed to implement this goal of reintegration, which included the Ujjawala Scheme, Swadhar Scheme, and Integrated Child Protection Scheme.
The Ujjawala Scheme began in 2007 and functions to assist women and children tra cked for commercial sexual exploitation in their exiting of tra cking, in addition to their rehabilitation, reintegration, and repatriation. The scheme also coordinates widespread tra cking prevention and awareness efforts at the community level [5]. However, there are no standard operating procedures established, and as such, this scheme's projects are not monitored to a set standard [3].
The Swadhar Scheme was launched in 2002 for 'women in di cult circumstances' as a continuation of the 'Short Stay Home' scheme, which provides temporary accommodations and rehabilitation services for homeless women and girls [6].
Food, shelter, clothing, counseling, vocational training, medical care, and legal aid are provided, and Bihar has three shelters under this scheme. While the Ujjawala Scheme serves as the primary scheme for tra cked victims, the Swadhar scheme is a safety net for those victims whose needs are not met [6].
In 2009, the Integrated Child Protection (ICP) Scheme was launched and provided funding for most states, who then dispersed these funds to the state and NGO-operated components. This led to efforts such as the 24-hour CHILDLINE hotline, which functions to connect CSEC victims to services in their area ranging from shelters to medical aid. It handles tens of thousands of calls per year from across the country and has a well-designed documentation system to identify types of services to which the children are linked [3].
The Ministry of Labour and Employment established the Protocol on Prevention, Rescue, Repatriation, and Rehabilitation of Tra cked and Migrant Child Labor. The ministry has also assembled a "rehabilitation package" for bonded laborers to receive INR 10,000 from federal funds in addition to a separate, state-funded package. This state package includes allotment for a house-site, agricultural land, farm animals, skill development training, and education for their children. However, no evaluation has been found on the actual success in implementing this rehabilitation package or its impact [3].
Lastly, the Initiatives on Missing Children Department has been involved in anti-tra cking efforts since 2004, when the National Human Rights Commission Action Research Report highlighted the link between missing persons and human tra cking in India. It is not uncommon in the Bihar-Uttar Pradesh region for signi cant numbers of missing children to be left uninvestigated [3].

Aims
This study aimed to identify the problems hindering and strengths facilitating the e cacy of anti-tra cking programs in the Indian states of Bihar and Uttar Pradesh along the India-Nepal border.

Methods
A qualitative study was conducted using semi-structured interviews and focus groups with key stakeholders in Bihar, Uttar Pradesh, and Nepal. Qualitative methodology was chosen given the exploratory nature of our aim. The study received ethical approval from the institutional review board of [redacted] and from the institutional ethics committee of [redacted] in India. We gathered key stakeholder input through semi-structured interviews and focus groups.

Research team and re exivity
Interviews were conducted by HS, a female MD, MPH who has conducted multiple published qualitative studies in the past.
No relationship with the participants was established prior to the study commencement. The participants were aware that the researcher was conducting the research to improve the anti-tra cking response in the region, given the fact that almost no peer reviewed literature has come out of the region. The interviewer's bias that the anti-tra cking response could be improved was stated.

Study design
This study took a content analysis approach. Participants were selected via snowball sampling until saturation was achieved [7]. Participants were approached initially via email. No participants were younger than the age of 16. A total of 43 individual and 7 focus group interviews were conducted in June 2014. No participants refused to participate. The interviews took place in a private location of the interviewee's choosing. In some cases, due to space constraints, other staff may have been in earshot of the interview, but the utmost care was taken to nd the most private setting possible. The key stakeholder interviewees fell into the following categories: NGO employees who implement anti-tra cking programs, anti-tra cking program participants, government o cials, law enforcement, and prosecutors.
The semi-structured interview guide which was developed for this study had two main areas of inquiry on 1.) identi cation of problems hindering the progress of the anti-tra cking movement and 2.) recommendations for overcoming these issues to accomplish the common goal of helping people exit the cycle of tra cking. No repeat interviews were carried out. The interviewer provided assurances of anonymity, answered questions regarding participation, and obtained informed consent immediately before each interview. Interviews were audio recorded then transcribed and translated for data analysis. Field notes were made during and/or after the interview. Interviews lasted between 40 and 90 minutes. Each transcript was reviewed for accuracy against the recording and coded using NVivo software. Due to logistical constraints, transcripts were unable to be returned to participants for comment or correction. A unique identi er linked participant interviews and survey data. All identifying information was removed from transcripts, including the interviewee's organizational a liation, to protect anonymity.

Analysis
Using an inductive content analysis approach, a coding structure was developed [8]. The transcripts were then independently coded by two separate researchers, KC and TK, compared for agreement, and nalized. Participants did not provide feedback on the ndings due to logistic constraints. The coding tree with themes and subthemes can be found in Appendix A.
Findings are presented in the results section.

Results
Barriers to anti-tra cking initiatives Thematic analysis revealed that several common problems were hindering the anti-tra cking movement that victims and leaders alike believed need to be addressed. These barriers include police corruption and lack of enforcement of national law, discrimination toward tra cking victims, lack of funding, and lack of government involvement. Below we summarize interview content, including quotes from interviewees.

Police corruption and lack of enforcement of national law
Interviewees reported that despite the existence of tra cking laws on the national level, the implementation and enforcement of these laws had been neglected, often hindered by limitations of capacity and resources. This fragmentation of enforcement of national law was problematic. Interviewees stated that national law has a very high standard, and often there is sometimes limited cooperation from the Child Welfare Committee (CWC) and police to appropriately comply with it, largely due to the governmental staff's lack of awareness towards the law and its application. There were cases in which procedural issues to document and/or declare bonded labor resulted in opportunities for police corruption. Examples of corruption mentioned by respondents included utilizing court date delays to tamper with evidence, falsifying evidence, relying on the unscienti c age veri cation test, incorrectly applying the wrong legal section (e.g. rape cases are not led as rape), tampering/threatening the witness, bribing o cials, rejecting bail, and appealing to higher courts.
Furthermore, respondents mentioned that there had been several instances of police o cers forcing tra cked girls to change their statements against their tra ckers and tampering with medical records and age veri cation. This allowed for a more lenient sentence for tra ckers, delay of investigations, and the prolongment of the time tra cked girls were kept in the police station.
Criminalization of victims. As a result, tra cking survivors were sometimes criminalized instead of their tra ckers, rather than being treated as victims in need of assistance and protection. An interviewee from an NGO narrated one instance in which innocent individuals were taken away by the police, some of them previous victims of tra cking.
"There was one incident where a girl named Varuna [pseudonym] disappeared. When the police came to investigate, my brother was tied with a chain and dragged away by the police. Other women were also taken under the premise that they were 'bought.' Some of these girls had already been rescued from the esh trade. Now the same exploitation is happening to them." These instances pointed to the pervasive nature of police corruption throughout the system. While several NGOs have led public interest litigations against the police, they expressed frustrations with the di culty in properly ling cases and getting such cases tried in court. Even when cases proceeded to court, the NGOs continued to encounter corruption and tampering of evidence.
Distrust of police. As a result of the police o cers' corrupt acts, victims felt extremely uneasy in the presence of the police.
One survivor stated that the police did not respect their privacy nor listen to their grievances: "The police do not let us live in peace. We can't sleep, in fear of the police, because they might come any time for interrogations. They ask us to open our wardrobes, suitcases, and then our personal belongings. They never listen to our grievances." Discrimination Not only have tra cking victims experienced mistreatment by the police, but they have also faced widespread discrimination by others in the community, one example being their mistreatment by merchants. One survivor stated that when merchants learned that they are tra cking victims, they signi cantly raised the prices: "Whenever we go shopping, if the shopkeepers know we are tra cking victims, they automatically increase the price of goods. Taxi drivers also ask us for more money. It is not just the police, everyone harasses us here." Lack of funding for NGO activities Many NGOs have expressed limitations in their activities due to a lack of funding and resources. One grassroots NGO said that working in anti-tra cking is di cult and that one NGO alone cannot make a difference against the most organized crime in the world today, especially as operations to help people exit the situations of tra cking are not always followed by a criminal case. Multiple respondents discussed how it was clear that an NGO requires funding to survive in this industry, but fundraising requires time and manpower, which detracts from eldwork. This challenge was immense for them, as they believed that grassroots NGOs understand the issue of tra cking and what is happening on the ground and are a particularly signi cant source of support in villages.
Lack of investment in infrastructure. Furthermore, interviewees reported that nding placement for tra cking victims after leaving their situations of exploitation could be extremely challenging due to a lack of adequate safe havens. This created potentially retraumatizing environments for victims that had exited tra cking, and who may have also experienced prolonged stays in the police department due to the presence of inadequate and inappropriate shelter homes. One NGO staff person remarked, "There lacks infrastructure for tra cking victims, especially the mentally challenged. They push all the mentally challenged women to this particular shelter home, which is supposed to house vulnerable people who are in need of care and protection. But these mentally challenged victims need more psychological support than the average person and there isn't adequate infrastructure that gives them this support."

Lack of government involvement
While it is the government's role to provide shelter for children, documentation (e.g. release certi cates, provisions, and sustainable rehabilitation solutions), and home veri cations, many tra cking victims expressed a lack of governmental support and action, and the need for more collaboration between NGOs and the government. One government o cial stated, "Two years ago, the government was not thinking so much about this type of issue. It is the NGO who actually took charge of setting up a connection with the government and only then do villages start functioning in the districts." Moreover, while it is the role of the government's CWC to handle tra cking cases in terms of home veri cation, assistance for children in exiting situations of tra cking, parental identi cation, and linkage to shelters, the number of tra cking cases far surpassed the government's capacity to handle them. The bureaucracy, lack of e ciency, and politically in uenced CWC team member selection further hindered the prosecution of tra cking cases. In turn, these ine ciencies delayed the release of children from shelter. In addition, CWC only worked during business hours, which posed a challenge when anti-tra cking operations are performed outside of these times.
Low capacity. Additionally, there were delays in aiding people in exiting situations of tra cking due to low capacity of the government o cials, who must follow all protocols, and accordingly could not always act quickly enough, leading to some children being tra cked away from the site of concern prior to anti-tra cking intervention to that site. Low capacity also created a large backlog of cases, which is exacerbated by high turnover, including investigation o cers being transferred at any time.

Interviewee recommendations
While we asked for and were given ample information as to what members of the community felt were problems that hindered the progress of the anti-tra cking movement, major themes also emerged from interviewees regarding how efforts could be improved. The two most common recommendations were increasing cooperation, coordination, and communication, in addition to empowering tra cking survivors. Interestingly, interviewees discussed more about empowerment as the main tool of reform than the other recommendation. This is because they believe empowering tra cking victims by giving them the tools needed to rebuild their lives post-tra cking is the most sustainable solution to prevent them from falling victim to tra cking another time.

Increase cooperation, coordination, and communication
Respondents discussed how heightened collaboration between the government and NGOs would sustain a robust, systematic approach to anti-tra cking programs' shared goal of helping people permanently exit the cycle of tra cking.
While there are many government schemes, programs, laws, and legislations in place to address tra cking, the e cacy of these anti-tra cking measures in accomplishing programs' common goal is hindered by government corruption.
Subsequently, it then becomes the NGO's responsibility to investigate this and ensure that protocols are being followed. In doing so, NGOs can ensure that tra cking victims successfully gain access to government schemes, programs, and legal compensation by following standardized operating procedures and protocols in line with existing government and law enforcement efforts. If existing processes established by the government and law are enhanced and executed properly by NGOs, victims are more likely to successfully remain removed from tra cked situations. For example, the government-run CWC's scope encompasses the removal of victims from exploitation as well as monitoring. In that realm, there is signi cant room for collaboration with NGOs to provide necessary treatment for victims. However, one interviewee from an NGO stressed that NGOs currently must take it upon themselves to actively facilitate better communication with the government: "We need more communication with the government, but the government has to come in front and take the initiative. It is important that we have this communication established because if we are not working together, only parallel to each other, then there will not be as much momentum as if we were pushing for the same thing on the same set of tracks." Another interviewee from an NGO expressed similar sentiments, stressing also that active efforts on the part of the government to reach out to and work with NGOs would be greatly appreciated: "The government can improve NGO-government relationships if they take the time to call us, listen to us, or share news and updates with us." Furthermore, a common sentiment expressed by NGOs was that they felt a lack of adequate infrastructure provided by the government to NGOs. In one interview, a member of the CWC said that there is a need for higher quality facilities to better serve every member of the CWC as they pursue their full potential.
"I think the government should improve the facilities given to the CWC, as it is currently not good enough now." While interviewees touched upon several issues between the government and NGOs, they also mentioned where they believe there have been existing successes. These successes demonstrate the immense anti-tra cking potential inherent in increased cooperation, coordination, and communication between the government and NGOs. Notably, interviewees believe that one very important success by the government is recognition of the contributions NGOs make to the anti-tra cking movement in India. According to one NGO employee, "The government acknowledges that NGOs are doing marvelous work. They do not deny the number of cases that have been entrusted on us and the successes we have had with helping tra cking victims get back on their feet." Interviewees believe that this governmental recognition is responsible for many of the NGOs' ability to make positive impacts on tra cked victims through conducting successful operations to dissolve situations of tra cking, providing safe shelters and centers for children, providing education, providing life skills training (e.g. computers, sewing) and vocational training, and giving children a future. Governmental recognition of NGOs' abilities is also important for turning research into policy. An NGO employee stated, "The research and studies that NGOs have put before the government allow the government to establish shelter homes, rescue teams, provide more compensation for the victims. The data and gures that we collect promote change and put pressure on policymakers and bring awareness to the public." Ultimately, if steps are taken to address interviewees' concerns and build upon these current successes to increase dialogue, collaboration, and notions of shared responsibility between the government and NGOs, the needs of tra cking victims will be better served as they pursue safety, healing, community reintegration, and more post-tra cking.

Empowerment of tra cking victims
Interviewees representing NGOs and tra cking victims alike believe in the e cacy of community centers, CWCs, community vigilance committees, and microsavings groups in preventing cases of re-tra cking. They also recognized the importance of victims coping with discrimination and lack of acceptance from society. Many interviewees expressed the need to sensitize communities, police, and government workers to promote awareness of tra cking, and decrease this stigma. Increased awareness also has the potential to inspire vigilance within the community and cause the recognition of tra ckers and illegal activity. Furthermore, many felt that it was important to raise awareness within vulnerable populations about the lure of foreign employment as a front for tra cking. Members of this community were often unaware of the various forms of tra cking, as well as the legal system and their rights. The following include a myriad of the aforementioned empowering avenues of increasing anti-tra cking e cacy mentioned by interviewees.
Community centers. One interviewee started as a volunteer at one of the community centers and is now a program manager. They discussed projects that bring members of both the tra cking and local community together in a joint effort to decrease the possibility of re-tra cking.
"With the help of local people who want to break the lock that threatens to chain their children to the tra cking business, we have built a large community center. The girls that have been saved from or are trying to escape tra cking work for the community in these centers. This is a sign of our success." CWCs. Members of the CWC stressed that the collective pressure of a committee to demand justice from the system is not only a sign of the strength of an organization, but also a convincing reason to invest in and join CWCs.
"When the local police took away our innocent girls, we went to the Inspector General of Police who listened to us and made a phone call to get the girls released. At midnight, they were dropped off in their houses. This was an organizational achievement and showed the strength of persistence and organization." "The girls here have lots of talents, like singing, dancing, painting, but they score very low in exams because the teachers who know they have been tra cked before deliberately give them low marks. The committees help by talking to the teachers and demanding just treatment for the girls." Members also stressed that the committees educate and give children skillsets that help them secure a better future.
"The committees run educational classes that give the children con dence. They are learning skills and progressing with their lives." "The committee is full of bene ts. Our children were previously uneducated, as we could not afford to send our children to school. Our kids now know how to read and write. They taught our kids very well." Community vigilance committees. Interviewees highlighted the role of women in community vigilance committees and the overall importance of women's empowerment in the anti-tra cking movement. Empowering women both economically and politically through self-help groups and community vigilance groups creates nancial independence and promotes participation in local governments, ultimately fostering intergenerational resilience and prosperity.
"With the help of local people and leaders, we form community vigilance groups. These groups give women political empowerment to address and raise tra cking issues to the local administration." "Women in the community vigilance committees sell bangles and sell them from village to village. At each village they collect information. If any suspected cases of tra cking arise, they inform the community vigilance leaders." Microsavings groups. Many agreed that the rst important step toward the prevention of re-tra cking is to understand the origins of tra cking. Interviewees agreed that even if victims exit tra cking and are reintegrated back to their families, they will be re-tra cked if the original situation that they came from does not change. Such risk factors identi ed were poverty, socioeconomic factors, family issues, cultural norms, lack of education, debt bondage systems, and gender discrimination.
Poverty was the fundamental driving force for tra cking and re-tra cking and was what shaped socioeconomic disparities and family dynamics. One NGO said that the lack of livelihood options in villages created a power imbalance between tra ckers and victims, and that it was important to provide livelihood opportunities to stop tra cking. Victims are lured by the tra ckers' money and the false prospect of a better life, causing all potential victims experiencing nancial vulnerability to face an increased risk of tra cking and re-tra cking. For this same reason of nancial insecurity, many children were pushed into tra cking by their families. Families believed that "if I send my child, I can earn more money", and saw their children as the breadwinners of the family. One NGO member described the state of the community that they worked in: "they send their children to earn. To earn, to survive their livelihood", as households often included eight to 12 children each, rendering it di cult to take care of them all. Because families' nancial constraints often pushed them to send their children into tra cking, interviewees recommended that starting microsavings groups would help to break the chain of re-tra cking and bonded labor. Microsavings groups are informal, community-based savings groups utilized globally as a method of fostering community resilience and nancial stability. One committee member stated: "We found that if we could organize the women, give them the opportunity to save a little money with some group members, it makes a big difference. Last year, these women received a bank loan because they were able to deposit regularly at the bank. Because a lot of these women are illiterate, it is important that we teach them how to keep accounts, how to manage the savings groups, how to authorize meetings, etc." Another committee member stated: "Savings groups can be used as a prevention method for keeping women out of tra cking situations. Economic development activities like income generation in local trades help women earn money and develop economic self-su ciency so that they will not willingly put themselves into the tra cking business." Core to these recommendations from respondents is the fact that nancial resilience at the individual and family level is necessary to prevent someone from being re-tra cked.

Discussion
To address the burdens faced by tra cked persons, this study points to the critical need for both enhancing coordination between NGOs and the government and empowering victims. Such focused efforts have the potential to improve the antitra cking response along the India-Nepal border, and examples and speci c practices for doing so can be drawn from the literature.
Nonpro ts and the government exist in a web of mutuality which is not unique to the anti-tra cking response. There are a variety of mechanisms that have worked in other contexts to increase coordination between NGOs and the government. Core tenets of improving this coordination include "the standardization of government applications and reporting requirements, formal feedback mechanisms for evaluation of organizational activities, development of NGOs' organizational capacity to apply for and implement government grants and contracts, and increased public education and awareness regarding the importance of government grants" [9].
Mirroring these international standards, the government of the Netherlands has provided an outline of best practices for interprofessional collaboration speci cally in the anti-tra cking movement, with its contents highly applicable to the joint work of government and NGO stakeholders in Bihar and Uttar Pradesh. It encourages the use of protocols to clearly delegate responsibilities to be handled by each organization, especially in the case of operations performed to dissolve situations of tra cking. Examples of important considerations include deciding which organization is responsible for funding victim assistance after operations and for how long, con dentiality rules between organizations, and the creation of an evaluation mechanism to identify needed areas of growth in the NGO-government partnership [10]. In states such as Bihar and Uttar Pradesh encompassing a large number of NGOs and anti-tra cking programs in response to the particularly high level of tra cking, following best practices such as these may lead to increased anti-tra cking success.
Across the anti-tra cking literature, co-production of interventions and survivor-led interventions are critical for empowering survivors. Laurie et al. describe a Nepalese program functioning as a marriage between victim empowerment and increased interprofessional collaboration -an NGO operated by formerly tra cked women that carries a focus on cultivating external partnerships [11]. Another successful organization with similar empowerment of tra cking survivors can be found in the United States in California. Thus far, it has drawn upon the expertise and skills of the survivor-staff members to conduct antitra cking trainings for over 10,000 professionals encompassing a variety of elds, including those within government organizations [12].
However, it is not realistic to believe that each and every NGO will practice a survivor leadership model. Despite this, NGOs should still make a concerted effort toward integrating tra cking survivors as equal partners in the anti-tra cking movement. The Women's Consortium of Nigeria (WOCON), Children in Solidarity with Africa and the World (ESAM) in Benin, and the Association for the Advancement and Defense of the Rights of Malian Women (APDF) recognize the importance of using community-based interventions for anti-tra cking work [13]. They place a particular emphasis on re ecting survivor opinions in policy agendas, with WOCON saying, "the strength of [projects] is in the active involvement of the community dwellers in identifying the causes and nding solutions to the prevention of tra cking" [13]. Engaging tra cking survivors in an activist role not only provides stable employment opportunities, but also cultivates their leadership experience and familiarity with anti-tra cking resources. Importantly, it also provides a natural channel for amplifying to the government and other stakeholders the true, rather than perceived, needs of victims.
These anti-tra cking programs and guidelines highlight that successful advocacy is best born from a co-production of knowledge that spans across professional a liations and is dependent on a network of trust built between all involved -in this case, NGOs, the government, and the tra cked persons they serve. This trust underpinning anti-tra cking efforts' e cacy is critical and can lead to long-term strategic network building and the implementation of activist-informed policy optimally effective for helping victims permanently exit the cycle of tra cking. The magnitude of trust serving as a determinant of program success was phrased eloquently by authors pro ling the survivor-led NGO in Nepal, who said trust is, "at the heart of a politically engaged understanding of collaboration which aims to raise the pro le and listen to the voices of excluded marginalized actors" [11]. If this lens of empowerment-inspiring trust was seen in Bihar and Uttar Pradesh, signi cant and long-lasting change toward health and prosperity may be observed in the lives of thousands of individuals experiencing tra cking in these Indian states annually. To bring this goal of empowerment to fruition, it is also vital that NGOs intervening in tra cking in India place greater importance on understanding the lived realities and needs of victims, rather than externally imposing their ideas of what victims may nd essential [14].

Conclusion
In seeking to assist in the prevention of people being re-tra cked, we also recommend an intentional shift away from immediate instances of 'rescue' being the yardstick for considering anti-tra cking efforts successful. Due to the cyclical nature of human tra cking, success must instead be de ned through long-term victim engagement permeated by practices speci cally designed for empowerment and autonomy. By reconceptualizing anti-tra cking efforts' e cacy in this wayproviding less emphasis on 'raid and rescue' operations and more emphasis on addressing the structural underpinnings of each persons' pull toward tra cking -we have the opportunity to create individualized environments for victims to thrive.
This also contributes to building communities more deeply valuing the lives of one another. Ultimately, elevating community accountability, honoring individual autonomy, and recognizing the value of the persons with which we each interact are critical as we continue to use a public health lens in the ght against human tra cking and for human rights.