San Francisco Scales Back Harm Reduction Policy
57:52 Share

Support for KeyQED Podcasts comes from Landmark College. Register for their Summer Institute for Educators before April 15th for a discounted rate. More information at landmark.edu slash lcsi. With reliable connectivity, enhanced cybersecurity, and advanced fiber solutions, Comcast Business is powering the engine of modern business. Switch today and ask how to get a $500 prepaid card on a qualifying gig speed package. Offer ends 4-21-25. New customers only with a two-year agreement. Other restrictions apply.

From KQED. From KQED in San Francisco, I'm Alexis Madrigal. Drug use in San Francisco is a highly contentious issue. The city long had a permissive approach stretching back decades. It was one of the leaders in reducing HIV transmission among drug users via a series of practices known as harm reduction.

But in the fentanyl and meth era of the last decade, the practices of handing out clean supplies have come under fire. Now, Mayor Daniel Lurie is altering some of the city's public health practices. We're going to talk about what's happening and why. It's all coming up next, right after this news. Welcome to Forum. I'm Alexis Madrigal.

Here's a pretty brutal truth. Most drug treatment doesn't work. I don't mean one type or another, just that once people are fully hooked on a drug like fentanyl or meth, few things work the first time or even after many times. Especially for people without family support or a roof over their heads. That leaves our cities with a real conundrum. We've got people on the streets using drugs and they're unlikely to stop immediately.

Often in San Francisco, public health officials have tried a series of practices under the label harm reduction to try to mitigate the worst effects of disordered drug use and addiction, while hypothetically at least moving people towards choosing treatment. Advocates often call what they're doing evidence-based, but it's also not a magic wand. There's a lot of people still suffering on the streets, and the people who live in the neighborhoods with large numbers of drug users are also a real and important constituency.

San Francisco is starting to make a few changes to its practices and here to discuss what's been happening and what might change. We're joined by Sydney Johnson, reporter with KQED News. Thanks for joining us, Sydney. Hey, Alexis. Thanks for hosting this. Keith Humphries also joined us, professor of psychiatry and behavioral sciences at Stanford School of Medicine. Thanks for joining us, Keith. Thanks for having me. And we've got Dr. Tyler Termeer, who is CEO of the San Francisco AIDS Foundation. Thanks for joining us. Thanks so much for having me.

We also asked the San Francisco Department of Public Health to join this conversation. They're unavailable, but just so you know. Sydney, let's start with you. Last week, San Francisco Mayor Daniel Lurie announced a shift in the city's approach to harm reduction. So what has Lurie proposed?

Yeah. So just to start with the most recent news, Lurie announced that beginning April 30th, health providers that are contracted with the city will no longer be allowed to distribute safer smoking supplies. So things like pipes, foil, straws to drug users out in the street. So street medicine or outreach workers who maybe would go out to meet people where they're at and provide some of these supplies.

materials. In addition to that, they also are going to require that anyone who wants harm reduction supplies, if they're going indoors to receive those, must also agree to participate in some form of counseling or treatment. And then

that is also going to be required by those health providers to, you know, check whether people are receiving that if they're going to be participating in these programs. Would you describe this as a big change, a small change? Like, how do you interpret this change?

Yeah, I think it is pretty significant. You know, San Francisco, going back to the AIDS crisis in the 80s, has really been a pioneer in harm reduction. We became known internationally for safe needle exchanges during the AIDS crisis. And now there's

years and bodies of research to suggest how that has helped cut down on spread of disease and soft tissue infection for drug users. So that's kind of the history, you know, here in San Francisco. And as, you know, drug trends shifted and fentanyl became, you know, the more popular opioid in recent years,

Other shifts started happening, too. You know, we saw more people smoking fentanyl as opposed to injecting it. And so the state actually updated some of its harm reduction guidelines in order to allow safer smoking supplies to be a part of that toolkit. So, you know, the city is essentially saying, you know,

to be clear, they are not saying that these programs are ending entirely. Um, you can still get these supplies if, if you are agreeing to participate in, in some form of counseling. Um,

But, you know, they are adding that extra requirement to obtain them. And it's really marking a shift in kind of trying to push people towards treatment. And I think that that is a pretty different approach from what we've seen in terms of how the city has distributed harm reduction supplies over the last few years. Yeah.

Tyler Tremier, how do you see the change? San Francisco AIDS Foundation, I think, would be sort of in the set of organizations that pioneered harm reduction. Yeah. We are deeply disappointed that the distribution of safer smoking supplies is going to be limited throughout all public spaces in San Francisco. We really believe that this

ignores guidance from leading authorities and evidence-based drug policy. Rather than preventing people from using drugs, this may push people towards injection drug use and increase the risk of fatal overdose.

and transmission of HIV, hepatitis C, and other infectious diseases. You know, as Sydney was pointing out, the fact is that smoking is far less risky and dangerous than IV drug use. You know, there are far less risk of overdose of HIV and hepatitis C transmission and of things like soft tissue infection. When people...

who use substances have access to things like safer smoking supplies, including the things that are controversial like foil or straws and pipes. Many may smoke drugs instead of injecting them. And this we know from peer reviewed research studies helps prevent them from injecting drugs, which is just far more risky.

One question I've had about this is just about kind of the second order effects. Like I think, you know, I've seen the research that you're talking about, you know, that it improves health outcomes for an individual person, say, in an individual instance. But if a community starts to see people openly doing drugs, does it over time change?

both sort of erode support in the community for drug users if there's a lot of, you know, open-air drug use, therefore kind of cutting in a longer-term way the support that might be available for people who are, you know, experiencing drug addiction or disordered drug use? Listen, I get it. I don't think anyone who is working in social services or in harm reduction or in behavioral health thinks that

The conditions on our streets here in San Francisco are okay. In fact, in some ways, they're worse now than they were before COVID. I understand the frustration that many San Francisco's feel when they witness the visible impacts of substance use in our neighborhoods. These are very real concerns, and I'm not here to dismiss them. But I also know that

What some label as perhaps too much compassion for people who use drugs is in fact a necessary and life-saving public health approach in our city. We know that these are humane, evidence-based, compassionate ways to improve not only the lives of the people with substance use disorders in our city, but also the conditions that everyday San Franciscans experience. You see, compassion

it isn't a finite resource. It's not something we have to ration between those who are housed and those who are unhoused neighbors or between people who use drugs and those who don't. If our city is really going to heal in this time, we have to recognize that everyone, and I mean everyone, deserves

dignity and safety and support. And that includes those that are struggling with addiction and those impacted by the fallout of a broken system that has failed to respond effectively. Keith Humphries, let's bring you into the conversation here. You've called what Lurie is trying to do a philosophical shift in how we think about treating substance abuse. What do you mean by that?

Well, harm reduction is a long-term public health strategy that's been around for 40 years and which has saved many, many lives and is going to continue to do so. But it did go through a philosophical change in our part of the country in the last few years where its traditional sort of allied with other parts of public health, like treatment and prevention, changed such that it became the only thing, that the only thing of value in many of the eyes of people who did it was to support the right or

drug using people to use drugs as they wished, wherever they wished, without much regard for harm to others, as well as a lack of interest in treatment and sometimes even hostility to treatment as a kind of moralistic imposition.

And what I see is happening with this policy is still going to keep with harm reduction, but bringing it back to its traditional public health role where it is allied with the rest of public health such that we will not miss the opportunities we have been missing to get people into treatment. Because in the long term, that will reduce harm much more than keeping them alive for another 24 hours, even though that is a good thing to do. But of course, what we all want is people to be alive and thriving for the rest of their lives.

not just for one more day. Hasn't the argument been that, you know, by that what it means to meet people where they're at is to take seriously the notion that until people are ready to seek treatment or help that they are, that treatment's not going to succeed, that you can try and push people into treatment, but it's not going to work unless it's kind of freely chosen.

I think we've actually gone beyond. I'll just give you an anecdote. So, Herman Lopez is a reporter from New York Times and came and spent a couple weeks in our city. And he quoted in his story talking to a harm reduction worker and said, what would you do if someone you were doing harm reduction with said, I'd like to quit drugs and enter treatment? And the harm reduction worker surprised him by saying, I would encourage them to set different goals. That's not realistic.

So we're at a point where it's not a question of, you know, are we being too pushy with treatment, but rather where it's not even being mentioned. Same thing happened at the linkage center, which was supposed to link people, as its name indicated. And an audit of the record showed less than one in 300 people who used that got even a referral to treatment.

So we're a long way from being too pushy. I think we just we're missing a lot of opportunities to bring it up. Yes, some people will say no. Maybe many people will say no. But you don't know if you don't try. And we need to get back to trying because in the long term, that's going to generate huge public health and public safety benefits for the city.

We're going to return to this topic when we get back from the break. We are talking about San Francisco's harm reduction policies. The mayor has announced his administration is going to shift things a little in how the city does harm reduction. Joining us this morning, we've got Keith Humphreys, a professor of psychiatry and behavioral sciences at Stanford School of Medicine. We've got our own Sydney Johnson, reporter at KQED News, covering this topic.

Issue and we've got dr. Tyler term year who is CEO of the San Francisco AIDS Foundation We would love to hear from you have you or a loved one, you know used harm reduction strategies to deal with addiction How did it work? Are you in favor of a move away from harm reduction or a change in the sort of posture of harm reduction? Why or why not you can give us a call. The number is eight six six seven three three six seven eight

866-733-6786. The email is forum at kqed.org. And you can find us on social media, Blue Sky, Instagram, et cetera. We're KQED Forum. I'm Alexis Madrigal. Stay tuned for more right after the break. Support for KQED Podcasts comes from Landmark College, offering executive function and social coaching support for neurodivergent individuals online or in person at the Bay Area Success Center in San Mateo.

The Bay Area Success Center provides neurodiverse teens, young adults, and adults with access to unmatched resources and support based on Landmark's academic and student life elements of their campus in Vermont, ensuring success in their academic and social skills development journey. Learn more at landmark.edu slash success center.

Fast and reliable solutions from Comcast Business can help turn your business into a reliably up and running, cyber securing, performance boosting, storm preparing, reliably connected, modern business. Powering the engine of modern business, powering possibilities. Get started for $49.99 a month for 12 months. Plus, ask how to get a $500 prepaid card on a qualifying gig package. Call today.

Welcome back to Forum. I'm Alexis Madrig. We're talking about the city of San Francisco's harm reduction policies and how they are shifting a bit. We're joined by Sydney Johnson, reporter with KQED News, Keith Humphreys, professor of psychiatry and behavioral sciences at Stanford School of Medicine, and Dr. Tyler Termeer, who is CEO of the San Francisco AIDS Foundation. I was going to

get to some of your calls and comments. But you or loved ones using harm reduction strategies to deal with addiction, how it's worked, you can try [email protected] or give us a call 866-733-6786. Tyler, I wanted to come to you on something that Keith Humphrey said before the break.

About an outreach worker who suggested in, you know, as quoted in your Times article that someone might set a different set of goals from quitting drugs. Can you like sort of imagine a reason why harm reduction outreach worker might suggest to someone to set a different goal than just quitting drugs?

Yeah, I mean, I think first and foremost, I would just say that San Francisco AIDS Foundation and our harm reduction provider community, our community partners across the city are our treatment providers. We have never changed our relationship with public health.

And we know that when someone is forced to abandon what little stability they may have in our city, the access to a syringe access program, a community clinic, a peer support program, or even just a trusted face who checks in on them, they're more likely to end up having to use

alone to use in an unfamiliar place or to lose access to Naloxone to be cut off from the very services that reduce the risk of overdose and death. So when we disrupt services in the city in the way that we're talking about, we're creating a very dangerous environment. Stability is safety and disruption is danger.

San Francisco Aid Foundation is a treatment provider. So I think it's just important that I say that, you know, we talked about the linkage center as an example, and this example was given that one in 300 clients were referred to treatment, were referred to addiction treatment. But what also is important is,

is that more than 300 overdoses were reversed at the center while it was open showing its effectiveness in saving lives and at the same time san francisco aids foundation as a treatment provider in the last year alone uh had 306 residents that were referred to drug treatment and detox programs as a part of our harm reduction programs 1019 residents were referred to shelters

and housing from our harm reduction programs. And 6,217 residents were referred to medical care from our mobile sites and harm reduction programs. So we are not just programs that hand out a handful of supplies that are highlighted in the news. We provide a vast array of wraparound services that are saving lives and referring folks to treatment and recovery every single day.

You know, I think one of the things that I have wondered about in this last few years, you know, I'm just looking at like a chart of deaths from drug overdoses in San Francisco. Uh, and they're just tremendously high. I mean, peaking, uh, in 2023 at 810 people, uh, dying. I mean, during this time period, um,

Harm reduction practices were in play across the city too, right? I mean, is it just that we needed a different set of harm reduction practices? We needed a different set of things to prevent these deaths? It just strikes me that, you know, San Francisco had done such a good job before fentanyl came into widespread use that it seems like maybe, I don't know, there needed to be a different strategy or do you, like, what would you say? Like, how do you explain it?

I think we're in the midst of a very complicated crisis. And I understand a desire to have immediate, bold solutions. But what I do know is that we can't arrest our way out of this epidemic, nor can we expect people to enter treatment without first addressing the immediate risks to their health. You know, substance use disorder is

is highly complex. It's influenced by trauma and poverty and mental health and systemic inequality. And there's not going to be a one size fits all approach. If we tried that, it would in fact

But what we do know is that people are going to be more likely to seek help when they are treated with dignity and respect rather than stigma and shame. And harm reduction, as it has been for decades, is not about choosing between public health and public safety. It is about saving lives today so that recovery is possible tomorrow. Mm-hmm.

Sydney, I wanted to ask you, one listener writes in, for example, to say, you know, it's not the city's job to promote drug use, give out supplies to the blight of San Francisco, time to issue some tough love. And I feel like the politics around this have changed a bit, or at least are uncertain right now. Like, what have you heard in your reporting about how San Franciscans are feeling about these policies?

Yeah, I mean, I think harm reduction has long faced, you know, political battles. The early days of needle exchanges were not necessarily popular and were supported by activists. But, you know, in the last few years in particular, we definitely saw some swings politically as it related to harm reduction.

Mayor London Breed was a pretty vocal supporter of harm reduction and also in her campaign for mayor in 2018 said that the city should open supervised consumption sites as part of its approach to tackling the overdose crisis. And this was kind of just before fentanyl really started to impact the city. Yeah.

And, you know, by 2024, when she's running for reelection, she really had flipped on some of those policies. The city had closed down the Tenderloin Linkage Center, which did provide safe consumption services. She said explicitly that harm reduction wasn't helping and had really sort of turned her tune on the approach and was optimistic.

You know, saying that the city needed to kind of scale some of that back and lean more into recovery. So we did see some pretty dramatic shifts, at least from the mayor's office, in terms of how, you know, the city was talking about this. Let's bring in a caller here. Let's bring in Gina in Berkeley. Welcome, Gina.

Hi, good morning. I wanted to share some thoughts that I had. I worked in community mental health both in San Francisco and in Oakland for many years and my first-hand experience, you know, it's

Substance abuse and mental health go hand in hand, extremely complicated. But harm reduction, we can't put barriers up to it, barriers against it, because it's extremely effective in keeping people alive until they're ready to make changes. And it's also going to be there for them, you know, should they have relapses, right?

So I think that we have to have really easy access to harm reduction, but we also have to have easier access into substance abuse treatment programs because they're not enough and there's barriers to getting into them. Thank you. Yeah. Thank you for that, Gina. Keith Humphries, thank you.

What do you think about this? Well, I agree with what the caller just said. Like, you want to have much better access to treatment than we have, and using harm reduction as one route for that, which is what this policy is designed to do, seems like a very wise idea to me. I also want to pick up the point you raised about fentanyl, which I think is a game changer in a bad way for all of us, which is that it's just a lot more deadly than any drug we've had on the street before.

So even if we're very successful in harm reduction, we can reduce the risk of using it by half. There's still, you know, that means about maybe a one in 40 chance that person will die in the next 12 months. And because fentanyl death rate is probably about 5% per year.

And so that makes the need for treatment a lot more urgent than it would have been 40 years ago where heroin was risky for sure, which is the era in which a lot of harm reduction grew up. But nowhere near as risky as fentanyl. And we just have to keep adjusting to the reality of the situation we're in where we just need to emphasize treatment more than we have been because leaving people on the streets, even with harm reduction, and I'm a supporter of it,

is still very, very dangerous. Mm-hmm.

Do you think, Keith, that that is an argument for safe injection sites, which, you know, going further than the city has gone and sort of sanctioning that? You know, the model I've seen that works the best is the Canadian model where they actually do support for people who are using through telephone and Internet and people zoom in and all those sorts of things because it resolves all the geographical problems of very few people will, you know, travel an hour to go use drugs at a government facility facility.

And also you don't have to deal with the harms to a neighborhood because living next to a supervised injection site can create a lot of challenges for families or for businesses and so on. But that can work, again, with the proviso that if those sites operate, they need to make an emphasis on we're keeping you alive today. We care about you. We want the best for you. And as part of that, we're going to try to get you into treatment and that they be funded in part on their success at doing that. Yeah.

Patrick writes in, and this one's coming to you, Tyler. Patrick writes in to say, you know, if harm reduction works, please cite the public health results. Like how many people are long-term sober in San Francisco after the billions spent? Are there quantifiable metrics other than the tremendous number of deaths and the dollars spent? The current system is a failure. The addicts need to be moved out of the environment of cheap drugs and low barriers. Set up a remote detox camp. Too many people are dying.

What do you, what do you think Tyler about this? I mean, I, I'm sure you've heard things like this before. Yeah. I mean, I think while there is certainly a lot of, uh, folks that talk about the, um, the quote unquote lack of data around, um, robust data around safer smoking supply, um, uh, research in the United States, um,

There is plenty of data around syringe access needle exchange in our country. And around the world, there is a ton of data that supports

safe consumption, that supports needle exchange, and there is the everyday anecdotal research from the people on the ground that tells us that harm reduction best practice is working.

We also know from the work that we're doing every day that when we disrupt the fragile stability of the most vulnerable people in our city, especially those living with substance use disorders, we risk irreparable harm. If we keep rushing in during the height of someone's use without trust, without relationship and without consent, an attempt to force treatment or recovery, we're not meeting them where they are. We're not supporting them with

with compassion or with evidence. And we're using the same tools that have failed time and time again, those of criminalization, of coercion, and of displacement. And perhaps the best way to explain

is to tell a story of one of our participants. And, you know, often the people that come into our sites

face life-changing experiences. There is a person I know that comes into one of our sites every day. They started coming into our program in their 20s when he was using and out on the streets of San Francisco, coming in and going to our needle exchange was really his only connection to people beyond being out on the street.

He was feeling so beaten down by his circumstances, you know, drugs, being on the streets and stigma, really feeling like people hate them when they're out there on the street, people treating you like you're not human each and every day. And

coming into our place of work, the place that we create for them was the lifeline for him. The staff that we had in place was the only place that people were nice to him. And it was really just, you know, the place that we were friendly and understanding. I guess I say this to say that we created a space

of understanding and the simple facts that simple fact saved his life we helped him understand that over the years when we were there for him creating a space of connection each and every time sorry I get I get a bit emotional when we talk about our clients yeah was this person able to come to

a better place in their life? - Yes. We were his lifeline. He told our staff at the needle exchange that we were the only people that were ever nice to him. He told us that he couldn't see a way out of the mess that he was really in. And it was really us that helped him get into a treatment program. Over the years, he found his way into treatment.

And it was our harm reduction staff that helped him get access to treatment and into these multiple drug treatment programs. And eventually, um, one of those drug treatment programs stuck and that was a turning point in his life. And it was that treatment program that really helped him trade, change his relationship to drugs and alcohol. Um, he ended up getting off the streets eventually. And, um,

even eventually ended up working in a harm reduction program,

which is not an uncommon story. Lived experience is something that is very common in our harm reduction field. There are many staff here at San Francisco AIDS Foundation and many harm reduction providers that have lived experience, but giving back to the community is what helped him turn around his life. So I say this to say- A happy, a good outcome. I just want to get to a couple other comments from other folks.

Johnny writes in to say, well, let's go. Let's do Diane first. Diane says, I started my nursing career at SF General in 1982 and have been an HIV nurse for the past 43 years. Without harm reduction, I could not have done my work. It changed how I relate to my patients, gave me tools beyond the ridiculous discharge instructions that given to patients treated for drug or alcohol OD of stop using drugs.

Drugs. I was able to do this in part because Frank Jordan, our police chief, and then our mayor issued a state of emergency to allow needle exchange sites to operate. Our current political leaders lack this political courage and no one could accuse Frank Jordan of being soft on crime. The issue in 2025 is twofold. Overdose deaths are overwhelming, but this is also a question of poverty.

What the public doesn't like is seeing people using drugs on the street. This is happening because of our housing crisis. People have no other option than to use in the streets. The answer to immediately dealing with public drug consumption is to open safe injection sites that exist in cities that are making progress, Vancouver, Zurich, Lisbon, for example.

Johnny writes in to say, "By the way, whatever the harm reduction people are doing is not working. Open your eyes. What they're doing is making the situation worse. When you find yourself in a hole, the first thing you should do is stop digging." Obviously, there are people who are experiencing what's happening on the streets in very, very different ways. We're talking about San Francisco's harm reduction policies. The mayor has announced some slight shifts in the way that San Francisco is going to be applying kind of harm reduction principles.

Joining us to discuss the shift, we've got Dr. Tyler Termeer, CEO of the San Francisco AIDS Foundation. We have Keith Humphreys, professor of psychiatry and behavioral sciences at Stanford School of Medicine. And we have Sydney Johnson, reporter with KCBS.

KQED News who is covering this for us and of course we're inviting you into the conversation as well people who have direct experience with harm reduction or addiction we'd love to hear from you as well as folks who are members of the general community and are in this together with the whole community you can give us a call number is 866-733-6786 you can email forum at kqed.org I'm Alexis Madrigal stay tuned

At Sierra, discover top workout gear at incredible prices, which might lead to another discovery. Your headphones haven't been connected this whole time. Awkward. Discover top brands at unexpectedly low prices. Sierra, let's get moving. Fast and reliable solutions from Comcast Business can help turn your business into a reliably up and running business.

cyber securing performance boosting storm preparing reliably connected modern business powering the engine of modern business powering possibilities get started for $49.99 a month for 12 months plus ask how to get a $500 prepaid card on a qualifying gig package call today

Welcome back to Forum. We're talking about San Francisco's harm reduction policies, joined by Sidney Johnson, reporter here at KQED, Stanford's Keith Humphreys, and the San Francisco AIDS Foundation's Tyler Tremere. Sidney Johnson, you know, Daniel Tsai, the new director for the city's Department of Health Services, says that he's going to be looking closely at data to sort of monitor how the city is doing along the way.

these lines of harm reduction drug use in the city. Do you know what measures the city will be using to kind of try and gauge success?

Yeah, they did say that they're going to track overdose rates as well as rates of HIV and hepatitis C and some of these other, you know, associated medical harms related to overdoses. And I think the listener's question about data is a really interesting one, too, because, you know, I think harm reduction –

Has kind of taken a lot of the blame for overdoses, which are increasing again in San Francisco, actually, since last October. And, you know, that's that's true. And I think that it's worth looking at, you know, kind of all the different approaches that the city is taking right now. So, you know, is it that it's harm reduction? You know, the city has also increased.

arrests of drug users, mostly for loitering near outdoor drug markets. And when I spoke to the police chief about that and the outcomes, they said that many people did not take offers of treatment after they were detained and then released. So I think that there are a lot of different data sets that could be called to question related to this. And then another one, you know, I just have

on my laptop in front of me here, is just the number of treatment availability beds or treatment beds that are available. You know, it's true that, you know, if you do need and are ready for treatment, it can be possible to get that. But it's limited. You know, I'm looking right now and there are six beds for men and five beds for women posted on the city's

Yeah.

You know, one of our listeners, Jones, writes in to say, I work in direct service with encampment residents just across the bay in Contra Costa County, and I face tremendous difficulty placing clients into rehab or other treatment centers when they do express a desire to go. Most programs have months-long wait lists and the ones that don't have prohibitive costs.

Harm reduction helps people who are waiting for care in an overloaded system. Ending these programs without first increasing capacity for mental health and substance program treatment will cause more harm than good. Keith Humphrey, talk to me about these two issues. What data you would like cities like San Francisco to look at and also what chance is there that we're going to substantially increase the amount of treatment available to people?

It's definitely unfair to harm reduction or treatment or policing or prevention to say, you know, San Francisco has a lot of problems, which it does, and that's all your fault. You have to have all four of those things working together. And as a city, I don't think we have been very successful at that in recent years, you know, and, you

If we don't have the data, as Sydney just mentioned, to track people through or even keep track of all the nonprofits that we have and what they're doing. And there's some things that two or three groups are doing redundantly and other important things that are falling through the cracks.

So a huge task for the mayor is just technocratic management of where is all the money going, what is everybody doing, and are we all singing from the same song sheet? I think actually the people he's chosen are very good at precisely that task. They have that kind of technocratic expertise, and I think that will be helpful to...

both to make the system work better, but also to make it more transparent. Because it is very hard if you're a resident of San Francisco paying taxes and wondering what you're getting for them to know, well, you know, it's $3 billion going to public health. Why does my neighborhood look like a disaster zone?

And it's legitimate to want to know, like, are we giving treatment? Are we giving that? And I have to say on the treatment, I work in this field too. I share the frustration. It's often very hard, not just here, but in a lot of the country, to find treatment and also to find decent treatment. I mean, the quality of addiction treatment is wildly uneven in the country. And some programs, unfortunately, are worse than nothing. We have some tremendous ones, but we also have some that are

you know, an embarrassment. Let's bring in another call here. David in San Carlos. Welcome. Hi. Good morning. Oh, go ahead. So I'm listening to you guys and it just seems like if you're giving drugs away to people to quote reduce harm. I don't think anyone is giving drugs away. I think just to, just to be clear, David, no one's giving drugs to people in that way. Right.

You're facilitating that. Stop, you know, again, we're dodging the question. So when you're doing that, you're keeping people in this altered state. If they're not, you know, it's difficult for them to make a good decision. And so I just don't understand why you would want to keep people in this state for years and years and years.

Um, instead of, um, forcing them to make hard decisions and it's their decisions to make, but it's hard decisions. And, you know, I've run into this with my sister. And so only when she's up against the wall that it's like, okay, now I've got to make a real decision as opposed to, I can just keep moving, moving the goalpost. Yeah.

David, sorry to hear that about your sister. And I think, you know, a lot of people, I think, share your frustration. I mean, Tyler, why don't we make people go to drug treatment? Yeah, you know, research shows that people who were forced into drugs

Opioid withdrawal are at extremely high risk of overdose after being released from jail or prison. We know that people that are coerced into treatment aren't as successful in being sustained in their recovery in the long run.

And it is just not an effective practice. We need to meet people where they're at in their journey. And what we do know is that as we meet people where they're at in their journey to recovery, when they make the choice, that they are more likely to be successful when they choose that path.

You know, what about the point that David also raised that people just aren't in the right minds because they're on drugs? You know, I mean, I think it's difficult to make clear decisions when you are in this kind of cycle of drug use, no? Yeah, I think, you know, we are dealing with, as I said earlier, a highly complex issue. But again, we have...

an issue that requires a multi-pronged approach and there is no one including myself that's saying that handing out supplies is the one and only way of resolving the crisis that's happening in our city this is one tool in our toolkit of addressing uh the crisis happening we need um

much more housing stability in our city. We need a more robust set of behavioral health services in our city. And until we have all of those things, we need to keep intact

all of that toolkit, including these harm reduction services so that we ensure the stability of the people who are living on our streets, who are unhoused, who are in the height of their addiction. And so they are kept alive and well until those resources for a pathway to recovery are available to them.

A couple other listener comments here and Keith Humphries coming to you. One listener writes, "I'm listening to the program. I agree with the mayor's change on this issue. I've lived in San Francisco since 1985. I live downtown and I see the drug abuse on the street daily. I see the aftermath of what's left behind, the condition of the streets.

Broken windows, broken doors, uh, we need change. We need tough love, stop enabling these people you haven't discussed to people that have to witness this every day and who go to work to try to live here. Now the listener writes, uh, "As a former employee of the Hate Ashbury Free Clinic, I have seen the positive effects of harm reduction time and time again. There's plenty of statistical evidence to support this as far as I can tell. The only argument against harm reduction is one rooted in selfishness. It's not focused on helping users, but rather a complaint by those who must witness it in their neighborhoods.

The neighborhood belongs to everyone in the community, not just those who are clean and sober and live inside. How do you address this, Keith? Yeah, that latter comment expresses that philosophy of, which is a change in harm reduction, because harm reduction, for example, if you go back and look at the city's wonderful endorsement of harm reduction in the 80s, was for everybody, not just for people with HIV. It was for the community, for the families, for everyone.

But there's now a part of the movement that is more akin to sort of gun rights rhetoric or vaccine denial rhetoric of the person has a right to do whatever they want and harms to others are not important. That's pearl clutching. Stop being so judgmental.

And I find it very hard to stay. I volunteer in the Tenderloin, and I watch parents walk through traffic with six-year-olds trying to get to school with cars whizzing by because the sidewalk is just completely clogged with dealers and users. And when I look at those parents and the agony they must feel and the terror those kids feel, I don't think that's pearl-clutching to worry about that. And we forget that.

those people at our peril. They are part of the city too. I've spent 35 years trying to persuade people that people who use drugs matter. They're human, they have rights, they matter. In San Francisco, I often have to remind people in harm reduction, you know, people who don't use drugs matter too. And the harms to them need to be taken seriously. And it is not some, you know, petty bourgeois excess to not like being robbed or not liking your child being terrified to go to school.

We need to start caring about those things again. But even if we stopped all harm reduction, which to be clear is not what's actually happening in San Francisco. That would be crazy, by the way. But even if we did, that actually wouldn't solve the problem that you're gesturing at of people using drugs on the street, would it? I mean, that would take a whole other draconian set of policies outside of what we're even discussing here. Well, I think this particular policy is actually a step in that direction. Rather than handing someone on the street...

a smoking kit so they can keep sitting and smoking wherever they're smoking, having them come indoors and talk to someone for counseling, that is an effort to get it off the street. That is responsive to the business that is going bankrupt because there's people camped out in front, you know, smoking fentanyl and someone handing them their kit to keep smoking fentanyl. So I think there is a move in that direction. That's not

by itself going to solve it, obviously, but at least it is accepting that the rest of the city matters also. Anna Berg writes in to say, I'm currently the clinical program director at the Harm Reduction Therapy Center. Your guests have accurately described the origins of harm reduction as rising out of the acute need and advocacy of communities most impacted by the HIV epidemic in the 1980s.

Advocacy and human rights are key components of a harm reduction approach, so are public health and treatment. Harm reduction requires all of these things to work together. I fundamentally think we are asking the wrong questions by focusing conversation on harm reduction supplies. We need to look at treatment. What treatment is being offered? Where? Does it actually meet people's real needs?

Focusing on providing quality treatment and housing and services that meet people's real needs must be where we put our efforts, not criminalization and removing key services that offer people improved health, safety, and keep them alive to consider all their care and treatment options.

One question for you, Sydney Johnson, as we think about what I think Anna Berg's question is getting at, which is to, you know, what would be a large increase in the treatment options offered and better housing offered people and all these things. One of the things that you hear from listeners is that we can't ever provide enough services because providing services induces demand for those services. People come to use them.

What evidence do we have that that is or is not something that happens on the streets of San Francisco, Sydney? Sorry, can you rephrase that? Oh, yeah. Just that people say, well, you know, if San Francisco provides all these services for people, then that will bring more people to San Francisco to take advantage of those services. So it's like, you know, if we build a freeway, it generates more traffic. I think that's kind of the same argument style that people are making. Sure, sure.

You know, I think there is some evidence just from looking at things like police reports at arrests at drug markets that, you know, some people do cross the bridge or travel from other counties to buy drugs here. But at least according to the data that I've seen from some of the recent mass arrests, the majority of people who arrested were from San Francisco. And

And yeah, I think to Anna's point also, you know, the health providers that are now tasked with providing these counseling services are wondering, you

where they're going to get the resources and staffing to uphold that end of the deal. You know, many of these providers are already really strapped for cash. Social workers receive very low pay. You know, it's kind of adding a whole nother component that I think people are willing and already doing in this space. But, you know, saying we need more of that and we're waiting to hear from the mayor's office on what that support and funding could look like, you know,

Dr. Tsai did say that the city was going to, quote, put its money where its mouth is there. But we're still waiting to see what that actually entails. Yeah.

You know, Tyler Tremere, one question that has come up from listeners, too, is like what the role of police should be in in all of this. And in particular, I wanted to ask you about what you think the role police should be in drug dealing. Like, do you think drug dealers should be arrested? Like, what is there? What is do you have a position on that?

I mean, certainly drug dealing itself is an illegal

thing in our country, in our state. And we are not in support of people who are dealing drugs in our community. We want people to be safe in our community. And as community-based providers, we understand that there is a role for

police. There are many harm reduction programs around the country, including San Francisco AIDS Foundation, that have partnerships with the police. We have active conversations with the local police department all the time, where we are coordinating to ensure that we are taking care of the participants of our programs.

So, you know, I think there is an active role when treated appropriately and when people are treated with compassion and dignity. San Francisco has historically led with compassion and science. Since the earliest days of the HIV crisis, our city has been at the forefront of harm reduction. And I do hope that elected officials will go beyond

short-term political solutions and stick to evidence-based approaches that work, including in these partnerships with police as we move forward. Last listener comment here. I lived in the streets of the Castro for several years and we, I depended on the Tuesday night Safeway needle exchange for medical care street medicine staff were warm, supportive faces who treated us with dignity and respect.

We live in the community and our health problems can become public problems easily. They also trained me and provided me with life-saving Narcan. I saved at least a dozen lives. I encouraged many people associated with our camp to see the practitioners there and at H Street where they explicitly state it's okay to discuss drug use. I know a small handful of friends got sick of being sick and obtained help like Suboxone thanks to those sites.

We've been talking about the changes to San Francisco's harm reduction policies. We've been joined by Tyler Termeer, CEO of the San Francisco AIDS Foundation. Thank you so much for joining us. Thanks so much for having me. We've also been joined by Keith Humphries, Professor of Psychiatry and Behavioral Sciences at Stanford School of Medicine. Thank you, Keith. Thank you. We've been joined by Sydney Johnson, a reporter with KQED News. Of course, thank you so much, Sydney. Thanks. I'm Alexis Madrigal. Stay tuned for another hour of Forum Ahead with Mina Kim.

Funds for the production of Forum are provided by the John S. and James L. Knight Foundation, the Generosity Foundation, and the Corporation for Public Broadcasting.

Support for Kiki Weedy Podcasts comes from Landmark College. Register for their Summer Institute for Educators before April 15th for a discounted rate. More information at landmark.edu. Looking to save on internet and mobile? Get the best of both with Xfinity. Because now you can get Xfinity internet with unlimited mobile included for $25 a month for the first year. And get a free 5G phone. Switch today. Xfinity.

Hey, it's Glenn Washington, the host of the Snap Judgment Podcast. At Snap, we tell cinematic stories that let you feel what it's like inside someone else's skin. Stories that let you walk in someone else's footsteps. Storytelling like you've never heard. The highs, the lows, the joys, the pain, the twists, the turns, the laughs, the life. Snap Judgment drops each and every week. Listen wherever you get your podcasts.