Tenderloin health efforts break from tradition as support for supervised injection sites grows

Solving intractable problems in an urban environment like the Tenderloin takes some creative ideas — like baking cinnamon rolls for a drug dealer.

That’s what Kate Robinson did. As the director of Safe Passage, a program in the Tenderloin that escorts children to and from schools on routes that avoid exposure to negative activity, Robinson routinely interacts with drug dealers.

“Our relationships on the corner, it’s a daily process,” Robinson said. “We gave some ‘thank you’ cards to some dealers who really help us and clear the corners for us. We let them know they are a part of this. I made Cinnabuns for a drug dealer the other day. We show our appreciation because they are as involved in this and really determine how effective and safe this is going to be.”

The program, which began in 2008, stations 20 paid “captains” for an hour and a half on street corners, spanning some 17 blocks to create “a safe corridor for an average of 650 school children per week.” The service is planned to expand to seniors.

Robinson was among those who attended last week’s Health Commission meeting, which, in a break from tradition, was held at Glide Memorial Church in the heart of the Tenderloin. The meeting focused on the longstanding health challenges facing the neighborhood and some of the new efforts to address them. The efforts include several programs, such as activities at the renovated Boedekker Park, under the Tenderloin Health Improvement Partnership, which is funded by the Saint Francis Foundation.

The dichotomy between the socioeconomic conditions of those who live in the Tenderloin and the affluence of technology workers who work just a few blocks away at companies like Twitter is often used by the media as an illustrative example of the stark inequality that permeates San Francisco.

Half of The City’s homeless population lives in the Tenderloin. One third of the residents housed there spend at least 50 percent of their income on rent. The median income there is $19,094, and 34 percent are below 100 percent of the poverty line.


As advocates work to improve the living conditions of the Tenderloin, they stress that no one should be pushed out, only helped.

“We really have to have a different response to people who are not well. And that includes people who are using injection drugs,” said Lydia Bransten, the dining room manager at St. Anthony’s who is part of the Tenderloin health partnership. “We need to reach out to these folks and find a non-judgmental way to bring them into our communities, rather than continuing to push them out of our communities.”

Call for new methods

To help more drug users and homeless people, some on the outreach frontlines are arguing for programs that are not focused on abstinence. The programs include “wet houses,” where people can drink alcohol on-site but still receive city services, and supervised injection facilities, where people are permitted to use intravenous drugs like heroin.

But advocates have found it difficult to change the entrenched thinking that has long guided social services. Add to that a political system that has already this year proven resistant to the idea of allowing wet houses and safe injection sites in more lax homeless shelters called Navigation Centers, and the goal becomes largely insurmountable.

Yet, a high rate of drug use in the Tenderloin has occurred for years, and some say it’s worse than ever. The U.S. Surgeon General took an unprecedented measure last month in sending a letter to health professionals to help address the epidemic. “Now, nearly two million people in America have a prescription opioid use disorder, contributing to increased heroin use and the spread of HIV and hepatitis C,” the letter said.

Bransten at St. Anthony’s said drug use in the Tenderloin has increased during the past decade.

“I walked from St. Anthony’s to Glide and in that time I counted seven people who were publicly injecting,” she said. “The captain in the Tenderloin told me that someone OD’d yesterday and died. Two people OD’d today, and they were able save them because of Naloxone. This is an epidemic that’s happening in The City right now with public injection drug use and opiate use.”

Paul Harkin, the HIV/Hep C and Harm Reduction Programs Manager at Glide, argued the Department of Public Health needs to shift focus away from abstinence-based programs for drug users. He has more than a decade of experience working with those on the street in the neighborhood, including handing out safety drug-injection kits.

“We’ve done a lot of really good things in San Francisco,” Harkin said. “We’ve been a pioneer, but one of the main drawbacks, I think, from working with substance users is an abstinence-based focus of a lot of programs where you cannot continue to use drugs.”

He added, “We are spending millions of dollars on certain programs … and they are not working with them because they use drugs. It’s something to rethink.”

DPH spokesperson Rachael Kagan defended the department’s current programming policies.

“The Public Health Department has a long-standing policy of harm reduction, which meets people where they are to diminish harm as much as possible,” Kagan said.

Injection facilities

In addressing the commission, Bransten said there was support in the community for safe injection sites.

“It is something that we would like to see in this community and have it be a demonstration project that is not only supervised so that people can safely inject without overdosing, without the spread of disease and having clinical care there for them, but also to be able to measure it so that we can see if this is, in fact, a good solution for many of the issues that are happening with public injection,” she said.

Greg Berardi, spokesperson for the St. Francis Foundation’s Tenderloin Health Improvement Partnership, wouldn’t address specifically Monday if a supervised injection site is being discussed by its members.

“Tenderloin HIP, together with its community partners, are actively exploring a range of harm-reduction strategies in response to public injection drug use in the Tenderloin,” Berardi said in an email.

San Francisco is among other major cities across the United States debating how best to address increasing use of heroin and other opiates. A Heroin Task Force formed by Seattle Mayor Ed Murray endorsed supervised injection sites for addicts, which would be a first in the U.S, the Seattle Times reported last month.

“A majority of the task-force members support a place or places for addicts to use heroin and other drugs besides public restrooms, alleys or homeless encampments,” Dr. Jeffrey Duchin, task force co-chair,” told the Seattle Times.

Sam Dodge, San Francisco’s Homeless Department deputy director, said Monday, “For us, it’s always been a concern it’s just going to pile on in the Tenderloin in a community that’s already pulling a weight” around programs for homelessness. Dodge added, “I’m just concerned if it means things will get worse there.”

Jeff Kositsky, director of the Department of Homelessness and Supportive Housing, said, “We’re committed to looking into it. We’re just not there yet.” He added that if anything like that did advance, it would be under DPH.

Kagan, however, said DPH has “many priorities and programs to address intravenous drug use, with both harm reduction and treatment. These include syringe-access programs, Naloxone to reverse overdoses, methadone on demand, drug treatment and rehabilitation, among others.”

“A safe injection site would require strong community support and significant resources,” Kagan said.

But some advocates say support could grow by educating residents about the need and effectiveness of safe injection sites in reducing overdoses and the spread of disease.

“As evidenced by high mortality due to unintentional drug poisoning and high rates of homelessness, behavioral health is a top health issue in the Tenderloin,” DPH wrote about health in the Tenderloin. “Emergency room admissions for self-inflicted injury, alcohol use disorder and drug poisoning are all 3.5-5 times higher in [the Tenderloin].”

The citywide rate for those admitted to the emergency room for self-inflicted injury is 9.85 per 10,000 residents. In the Tenderloin, that rate is 35.11. The differential is even greater when it comes to emergency room admissions for alcohol and drug poisoning: Citywide, the rate per 10,000 residents for alcohol abuse is 58.10 (227.34 in the Tenderloin) and 23.18 for drug poisoning (119.89 for drug poisoning).

Humane approach

Michael Anderer, a school official at De Marillac Academy, which teaches children in the fourth through eighth grade, described how he interacts with homeless near the school in the 100 block of Golden Gate Avenue.

“[The school asks] homeless neighbors not to lie on the sidewalk from six in the morning to six at night,” Anderer said. The school also partners with the so-called Golden Gate Safety Group to host an event one Friday every month on four corners of an intersection “to do something fun and positive, instead of what may normally be happening on some of those intersections.”

Anderer’s comments drew the attention of Health Commissioner Cecilia Chung.

“We have some laws that are not so popular that actually criminalize homelessness and to have this kind of compassionate humane approach is a breath of fresh air,” Chung said. “It might help other neighborhoods as well.”

Anderer does the same with drug dealers.

“Many of them I almost consider they are day laborers doing piece work,” Anderer said. “They are not the ones who are really in control of what’s happening out there. They are just trying to put food on the table just like everybody else. You go out, introduce yourself, say what you are there for, and say do you mind taking a 10-minute break. ‘No problem.’”

Addressing needs

The department’s health report identified other challenges that The City is actively addressing such as the higher rate of pedestrian fatalities and HIV infections and how pregnant women in the Tenderloin are receiving less prenatal care than pregnant women citywide, which could be the cause for the higher rates of
premature births.

Those diagnosed with HIV in the Tenderloin are treated at lower rates than those with the disease in other neighborhoods.

“HIV is another illness that a disproportionate amount of Tenderloin residents contend with,” the report said. “Between 2013 and 2014, the number of new diagnosed cases of HIV was 2.3 times higher in the Tenderloin compared to The City, and second highest in The City overall, after the Castro neighborhood.”

At the conclusion of the Health Commission hearing last week, DPH director Barbara Garcia said, “It is really important that we acknowledge the mortality issues that were brought up today and also that we will be working very closely with all the groups.

“[There is] lots of work to do in this community, and we need to really focus in particularly on this community because it really is the mission of the department.”

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