Can San Francisco Use Lessons From Fighting COVID-19 to Reduce Fentanyl Overdose Deaths?

San Francisco Mayor London Breed, whose early and robust moves to contain the coronavirus made the city something of a national model, is now urgently trying to confront another public health crisis: drug overdoses and disorder in the city's Tenderloin neighborhood.

Over the past two years, the city has seen more than 1,360 drug overdose fatalities — more than double the total COVID-19 death toll. The majority of those deaths were in the Tenderloin and the nearby SoMa district, city data shows.

"What's so important is that we have solutions, and we don't just say, 'We don't like it, we don't want to see it,'" Breed told NPR. "This is about trying to help people, and that's exactly what we're going to keep fighting for."

Breed announced an "emergency declaration" for the area last month, saying drug deaths, open-air drug dealing, street chaos and violence there had gotten "totally out of control." She vowed "tough love" for those who break the law and expanded access to help for those with alcohol and substance use disorders.

The declaration allowed the city to fast-track the creation of a "linkage center" that recently opened. It's a walk-in, one-stop shop for expanded city services, such as drug, alcohol and mental health services, as well as homelessness support that includes possibly a shelter bed and eventually permanent housing. At least, that's the hope.

Breed says she has no illusions that the new linkage center will quickly transform the Tenderloin. But she hopes it offers a new lifeline that meets people where they are.

"The fact is people who struggle with addiction, it's not as easy as they're just going to walk through the door and ask for help or we can't force them into treatment," she says. "Part of the goal is to make sure that they know that there's a place where they won't be judged, and when they're ready for help or assistance, they can get help or assistance."

Another public health crisis

The Tenderloin's problems — homelessness, poverty, substance abuse and crime — have plagued the area for decades. And it's become even more a kind of containment zone for those challenges amid the steady rise of Bay Area tech wealth and its staggering inequality.

But the pandemic's dislocation mixed with the spread of a dangerously powerful synthetic opioid have recently made things here even worse.

"What is new here is fentanyl. That's the state of emergency," said San Francisco Supervisor Matt Haney of the drug that can be up to 50 times stronger than heroin.

Haney lives in and represents the Tenderloin. He points out the city is averaging nearly two overdose deaths a day. In 2021, almost three-quarters of all the overdose deaths in the city involved fentanyl in some form, often mixed with other drugs.

"If you're smoking or shooting a fentanyl, that's like Russian roulette. People are dying within minutes or seconds of buying drugs on a corner, and it has ripple effects throughout the entire neighborhood that are devastating," Haney said.

He says San Francisco's agile handling of the pandemic shows the city can do better in the Tenderloin. Government moved fast and forcefully to confront a health crisis. "Coordination, resources, urgency, staffing, facilities," Haney said. "Now we need all of that now if we are going to stop this drug epidemic."

The emergency order signals City Hall's potentially sharp break from a reliance on a system of nonprofits that have long aided the vulnerable in the Tenderloin but that some critics say have become a kind of homeless services industrial complex. The agencies provide important short-term help — food, showers and other support services — but don't really move the needle on the larger systemic issues of substance use disorder, mental health or housing.

"Let's be clear, this city spends more money on social services in the Tenderloin community than any other community in San Francisco," the mayor said. "So just pouring money into this or just doing the same thing is not going to give us a change."

What Tenderloin residents see and hear

So far, residents and businesses in the neighborhood — and across much of the city — are backing the mayor's moves to "take back our Tenderloin."

"They're tired of open-air drug dealing, seeing other people suffer and die on the street from drug overdoses, and they're tired of crime in the Tenderloin," said Rene Colorado of the Tenderloin Merchants Association.

So far, he says, early fears that the city's declaration would lead to harassment of the unhoused or sweeps of tent camps have not materialized. He's hopeful this is the start of ending what he calls a sense of anarchy and danger afflicting too many of the neighborhood's streets.

"That's what success would look like to me," Colorado said. "It's tough because to do that, you need police, you need to make arrests. And that's something that for some reason or another people who don't live in the Tenderloin are uncomfortable with. But residents here don't want drug dealing here."

The mayor's order certainly risks undermining San Francisco's reputation for compassion and freewheeling tolerance, an impression that's more myth than reality.

"Despite the view from the outside world, the governance of San Francisco today is not the Haight-Ashbury liberal '60s version that I think people imagine," said criminal defense attorney John Hamasaki. He's a member of the San Francisco Police Commission, a police oversight and policy watch group appointed by the mayor and Board of Supervisors.

Hamasaki remains only cautiously optimistic that the emergency plan will prove successful and mark a bigger shift toward non-police responses to the problems of the Tenderloin and throughout the city.

"Historically, and this has never been fair to police, we have said, 'You are in charge of cleaning up all of society's problems,'" he said, "so you don't have to say 'defund the police' to believe that we can address society's problems by employing the proper professionals. Ultimately, there are better-trained responders to deal with a lot of the low-level police calls," especially those that involve mental illness and substance abuse.

Business owner Aref Elgaali says that more than a month into the city's emergency order, he's already seeing modest, yet positive, changes. He runs a Sudanese restaurant in the Tenderloin and is active in the local business community.

"We want to see secure families," he says, pointing to a group of pre-K children and their teachers crossing the street near his restaurant.

"Asking for police, more enforcement, is to keep those [kids] safe, to tell them that, yeah, the Tenderloin is still a place that we can raise our kids on," Elgaali says.

But many unhoused people in the area, those most affected by the policy shift, say that so far, nothing has really changed.

"Hell, no!" says Shy Brown when asked whether she has seen changes or even heard about new options. Brown says she's lived in the Tenderloin — mostly on the streets — for about a decade.

She's sitting half in, half out of a small sidewalk tent as pigeons busily pick at remnants of a handout dinner. "I wanna know what the strategy plan is and how we gonna execute it, you see what I'm saying?" Brown says. "And I don't see that happening. I just don't. No, it's not gonna work."

Longer-term programs already in place have brought slow progress

The city, in partnership with a nonprofit, has boosted its program of "community safety ambassadors," people who hit the streets to clean up garbage and deter drug dealing. And the city has greatly expanded distribution of Narcan, the lifesaving opioid-reversal drug, in easy-to-use nasal spray kits.

But the biggest developments — launched by the mayor and city leaders during the pandemic — are Street Crisis Response and specialized Overdose Response teams made up of specially trained and organized paramedics and clinicians from the fire and health departments.

There are some modest signs that the city's overall efforts on overdoses are paying off. Preliminary data for 2021 shows that accidental overdose deaths in 2021 were down about 7%, according to the San Francisco Department of Public Health and the Office of the Chief Medical Examiner. That marks the first overdose death decline in the city since 2018, following years of an upward trend.

But a seamless coordination between the city's new response teams and the police, so far, appears more aspirational than real. In a recent encounter, police arrive to check on an unhoused man in serious distress.

"I'm sure there might be some mental health issues," says police Sgt. J. Emanuel as he and fellow officers check on the man. But there's really only so much they can do, he says. "I mean, we'll do our evaluation, but if he doesn't fit the criteria for anything, then that's about all we can do: Check on him, offer some resources. That's about it."

The pandemic greatly worsened the longstanding problems here. "It really increased homelessness and decreased economic activity," said Katie Conry, executive director of the Tenderloin Museum, which is trying to tell a more nuanced story about the area's colorful history, she says, including its pioneering role in the early fight for LGBTQ+ rights.

The area "is starting to bounce back [from the pandemic]," she says, "but we've got some ways to go to make it and keep it a vibrant, safe neighborhood for everyone."

On a recent day a man power-washes the street after a free lunch giveaway near Glide, a nonprofit that provides daily meals and other services to the unhoused and other people who need them in the Tenderloin.

Jean Cooper, chief impact and strategy officer with Glide, hopes the emergency plan — and new linkage center — result in real change. But she also worries it's just another patch addressing only surface symptoms.

"The reality is that the drivers to what we see on the streets here are deep-seated systemic issues that not only San Francisco struggles with, but major cities across the United States are struggling with right now," Cooper says, "and it's around a lack of affordable housing, a lack of access to affordable, quality health care, and that includes mental health and substance use treatment."

To underscore the challenges, as if on cue, a man stumbles down the middle of the street in a daze. He's mumbling. He's not wearing a shirt or shoes, and his pants are filthy and falling down. He's unresponsive when people approach him.

"Our staff will get him a pair of shoes and a shirt, you know, give him something to eat," Cooper says, watching the man teeter nearby.

But could her agency or the other nonprofits on the street get the shirtless and nearly passed-out man into a treatment bed or temporary housing?

"We don't have access to beds," Cooper says. "You know, so it's not like we can actually get someone into a bed directly."

And maybe that's really the challenge: How does the city turn its "emergency" order and linkage center into a viable strategy for long-term solutions to long-standing problems, ones that are more expensive and more complicated than the daily wave of triage in the Tenderloin?

"The measure of success is the number of people that we're able to help get off the streets into housing," Mayor Breed said, "the number of people we're able to help get into treatment and get off of drugs. My hope is that we will really change and save lives here."