SF’s new mental health director faces a huge challenge, starting with the fentanyl crisis

‘I know it’s a tough moment, but we will come through it.’

San Francisco’s most daunting public health battle still lies ahead.

Drug overdoses killed 713 people in San Francisco last year. Many attribute the crisis to fentanyl, an opiod far more potent than heroin.

The isolation and desperation of last year’s shelter-in-place order increased substance abuse, mental health issues and, ultimately, death by overdose, experts say.

Now, San Francisco is taking dramatic steps to tackle the crisis, allocating more than $600 million toward behaviorial health in its budget proposal for the upcoming fiscal year and hiring Hillary Kunins to spearhead the efforts.

Kunins arrives in The City after a lengthy public health career in New York City where, among other achievements, she oversaw a $60 million strategy to combat the opioid overdose epidemic.

She runs the San Francisco Department of Public Health’s Behaviorial Health Services unit and leads the implentation of Mental Health SF, a program created by legislation in 2019 designed to improve care for those living on the streets.

The City’s goals for Mental Health SF this year are lofty. They include 340 additional treatment beds in residential care facilities, improved case management, expansion of the existing Street Crisis Resposne teams and the creation of a Street Overdose Team.

“I know it’s a tough moment, but we will come through it,” Kunins said.

Q: How has your background led you here?

A: I’m a trained internal medicine physician and an addiction medicine physician. I have had a number of roles working directly with community members and patients, as well as training physicians to work in communities that are underserved and with populations who may have more complex health needs.

One of the things we say in harm reduction work is to meet the person where they are. That means keeping the person at the center of whatever you’re trying to do as a clinician.

Q: Tell us a little bit about your time in the Bronx.

A: I worked in the Bronx for 16 years. It remains near and dear to my heart.

The Bronx, and specifically the South Bronx where I worked and saw patients, is one of the poorest congressional districts in the country with a very long history of disinvestment and challenges around substance use that often co-occur with poverty and housing challenges.

Q: It sounds like you have a deep connection with New York. What compelled you to take this opportunity in San Francisco?

A: Well, I joined the New York City Health Department, where I was for nine years. We were contending with similar problems as here — a very deep and sudden rise in overdose deaths driven by fentanyl. We were able to flatten and decrease that curve.

The challenges San Francisco is facing are not dissimilar to challenges being faced across the country, including New York. I think what I found as a member of the NYC government and health department — and this is what attracted me to come out to San Francisco — is that to make change and to address what are certainly behavioral health problems, but not solely, really needs a whole of government, multi-sector approach to be successful.

What is exciting about San Francisco is that it’s an extraordinary moment here. This city and county is stepping in to make real efforts to address these complex and important issues, and we, as a Department of Public Health, are a significant part of the solution.

What I have also observed is the extent to which there is community participation, commitment from leadership and, of course, new resources to make all of this happen. That was a huge draw.

Q: We see a common narrative emerging around people experiencing homelessness and mental health crises in San Francisco, especially on our streets. How would you explain to readers what’s really going on for these individuals?

A: I feel really deeply about this. Lots of people see somebody on the street who might have a substance use disorder or be experiencing a mental health crisis, and I think it’s easy to forget the humanity of that person. Part of what I really want to convey is the extent to which recovery is possible, and how the person happens to look at that moment does not represent the full depth of their humanity.

I know that experiences people have on the street can feel uncomfortable at times, but I want to share that despite these perceptions, people with mental illness and substance use disorders are far more likely to be victims of crime or experience violence against them rather than commit violence.

Q: Given that, what are your goals for the behavioral health team at DPH more broadly?

A: Our goal is to increase our ability to create more models of care that engage people, that link them to care that consistently follows up with people to meet them where they’re at and promote behavior change and whatever recovery goal they have. It’s really possible.

I invite people to think about some of the people they’re seeing on the street as in need of assistance who are having a rough moment, but that is not necessarily who they are or who they will be.

Q: What is your vision for Mental Health SF?

A: The Mental Health SF legislation really sets forth a framework and key areas for prioritization in our approach to expanding The City’s ability to provide care, reach people most in need and improve our capacity to coordinate care.

There have been gaps in the continuum of treatment, but we are implementing new services to address those gaps. A good number of them are around residential care, or care that comes along with a bed, and that is in part driven by the housing and affordability crisis here, but not just here. That’s why it’s so exciting to be here at a time when we are working with Mayor London Breed and our colleagues at Homelessness and Supportive Housing to expand housing.

So we are building out new milieu-based services. Something like the Hummingbird Valencia. That is a project that offers a bed and additionally other kinds of supportive services. That’s a big chunk of what we’re doing — filling gaps in types of services that had been insufficient in supply in San Francisco.

Additionally, we are creating more proactive capacity, or the ability to be in community and on the streets to engage with people and link them to ongoing care. The street crisis team is a marvelous example of a really new approach. That started before me so I take no credit.

That team does not exist in isolation. It will connect with the Office of Coordinated Care, which we are building out right now. That crisis moment is a point in time, but we will have the ability to connect with the individual in an ongoing way. We can also decrease stigma and build collective empathy.

Another example of this more proactive, flexible approach is the street opioid response teams to treat people after a non-fatal overdose and street wellness teams. Those are coming later this year.

Q: How would you describe where we’re at now?

A: The problem is serious, but deaths are preventable. I think the unfortunate timing of both fentanyl and COVID really challenges San Francisco because we know that using alone can increase the chance of overdose. However, overdoses are preventable using both novel strategies and strategies in which San Francisco already leads. For example, the DOPE Project, a main distributor of naloxone, supported more than 4,000 overdose reversals in 2020 and 2,500 overdoses between January and March 2021. Not all of those would have necessarily resulted in dying, but that is certainly lives saved.

There’s been so much great work, and it is likely that we would have seen an even higher rate if not for it. That should give us hope — we know part of what we have to do and we should do more of it. That’s what we are planning to do along with new things.


Dire water warnings confront San Francisco and beyond

‘We will face challenges that I don’t think modern California has ever really seen before’

By Jessica Wolfrom
Debate over $150 million San Francisco school district windfall

‘We’re looking at the ways to boost morale’

By Ida Mojadad
Charlotte Mailliard Shultz, San Francisco’s longest serving chief of protocol, has died

‘Her warmth and verve are irreplaceable.’

By Catherine Bigelow