Witnessing human beings in desperate mental and physical conditions is an inevitability in San Francisco. The epicenters of the most tragic visible street residency are the Tenderloin, Civic Center, and South of Market neighborhoods. Just who these thousands of people are, where they came from and what should be done to abate the sickness and squalor is common fodder for conversation.
Enter Margot Kushel, medical doctor and UCSF professor of medicine, division of health equity and society. As director of the Benioff Homelessness and Housing Initiative, in 2023 Dr. Kushel led the largest representative study of homelessness in the United States since the mid-1990s: the California Statewide Study of People Experiencing Homelessness.
However, many San Franciscans, particularly who live or work in the most affected areas dispute much of the report, from the data to the recommendations.
For answers, the Voice of San Francisco asked the questions most on residents’ minds.
According to the study 75 percent of homeless people lived in the same county as their last housing. That includes 19 percent from prison and jail. What qualifies as residency can be as little as one month living someplace without paying rent. The majority of those on San Francisco streets aren’t from the city, though. How do you explain the discrepancy?
Seventy-five percent was the average in the state. In every county we were in we did proportional observation. Individual neighborhoods may differ.
Obviously there were a lot of folks in San Francisco who were in heavily impacted areas. I looked at point-in-time count data from San Francisco, and in 2019, I think it was 19 percent who had lived in the city for a year or more before they became homeless. This year it’s 36 percent.
San Francisco has adopted the housing first model but how does it apply to people who come to the city to live on the streets? Why not insist on shelter instead?
I think the real question is how much should each county be responsible for providing services for people who come from that county versus others, whether it’s shelter or housing. Every county makes their own decision. In San Francisco there is such a long waiting list for housing, that objectively people have been here for many years.
The state has been working on improving data collection and data sharing so we can see where people are moving, who’s moving, and better assign resources. That has been hard to do today.
The report concluded that only 11 percent of those living on the streets used nonprescription opioids. However, illegal fentanyl is by far the most used drug. Why wasn’t it addressed in the study?
Again, these are statewide estimates and certain neighborhoods can differ.
Methamphetamine has been the dominant drug statewide for everyone who experiences homelessness. It’s the person in the heavily impacted areas, the person working as a janitor sleeping in their car, the mom with the kid living in the shelter, the older adult living in the older adult shelter. Everybody.
People who use opioids are also using methamphetamine. A third of every adult experiencing homelessness across the state was using an illicit drug three or more times a week.
I am concerned about the incredibly high overdose rate. Many people are overdosing when their main drug is methamphetamine but they’re using opioids intermittently and overdosing. It’s obviously a huge problem that needs to be solved.
I don’t think our statewide data is in contrast because it’s asking a different question to what you’re asking. But you ask a very important question, which is what’s going on in these heavily impacted, very visibly homeless neighborhoods? Those were absolutely included in our study but were not the only folks included. So I think that might be the discrepancy.
I was just on Willow Street. Scores of people were passed out, the stench of urine and feces was overwhelming. A door opened and a family with a little girl emerged. This is her daily experience. Would you agree that clearing areas like this — I hate using the word “sweeps” because it’s wrong — is the compassionate approach for the community?
Yes, absolutely. The current situation of people living outdoors, doing drugs, living their lives in public is not good for anyone. It’s certainly not good for the person living outdoors and not good for the other people who live in the neighborhood.
My role is to look around the country for best practices to end encampments, because that’s frankly what we all want. We point to Houston as a place that had a huge decrease in encampments. The city of Berkeley is really adhering to these best practices and getting people inside.
We’re looking for the best route to try to get people indoors, eventually permanently housed. Every time someone is permanently housed, it opens up another shelter space. I think that’s what we need to be doing to try to end the encampments — which I couldn’t agree more are really terrible for everybody.
Regarding “permanently housed” — isn’t “becoming self-sufficient” ultimately most important?
Maybe that’s the same thing. To get self-sufficient is to help them heal. Getting people out of the situation they’re in and into a better situation. It’s a win-win for everybody.
The latest initiative to move people off the streets appears to be a failure. About 90 percent rejected any sort of shelter. Why?
A lot of people who are not comfortable in a shelter do accept different options. When they offered people noncongregate shelter and quickly moved them to housing, so they could sort out their lives, and received wrap-around services, that’s where they found real success.
If it doesn’t work, it doesn’t work, so we want to move to something that does work.
The report states that “people who are members of populations marginalized by racism and colonization face economic and structural disadvantages.” I see a lot of young white people on the streets, so how do they factor in?
If you look statewide, black folks are overrepresented about five times compared to the population of the whole. Indigenous folks who were represented, about four or five times. San Francisco is the same.
What does “colonization” mean here?
I think it’s just a word that is often used by indigenous communities as anti-indigenous racism.
Last is recommendations. One is to give people a cash payment of between $5,000 to $10,000. It was based on what the study’s participants said would have prevented their homelessness. Who wouldn’t want to have thousands of dollars with no strings attached, though? And with substance abuse so prevalent, why was the potential for overdose ignored?
This recommendation was to consider and test it, to see if it worked.
There was a small but super interesting study done in Vancouver, Canada where they gave cash payments to people in the most heavily impacted area of downtown Vancouver. They didn’t actually see an increase in overdose but did see an increase in housing.
We’re not saying this should be a widespread case for implementation but to see who might benefit. Not large scale, but in small select groups.
Notes
- The Voice of San Francisco recognizes that this is a highly controversial and emotional topic. We appreciate Dr. Kushel’s participation in the interview.
- The Q. and A. was edited for length and readability. Audio is available upon request.
- Fact check: Per a 2019 Vancouver, Canada Cheque Day Study, providing people who use drugs with income assistance payments produced alarming outcomes, including:
“As cheque day approaches, making ends meet becomes harder. People often become angry and frustrated as resources become scarcer. Borrowing often picks up a few days before cheque day, particularly from people selling drugs who are willing to provide clients drugs at a premium, knowing they will be able to pay them back in a few days.
On cheque day, a substantial amount of money flows into communities with a high number of income assistance recipients. There are long lines at banks, stores, and ministry offices where people are picking up cheques. There is more drug and alcohol use. There are more people selling drugs, more cars on the roads, more overdoses, and more people in poor shape on the street.
Cheque day disrupts what is normally a very caring and supportive community. People report a higher number of assaults, altercations, and emergencies. We also heard how some people will take advantage of vulnerable people when they receive support payments, whether on cheque day or another day.
Cheque day can be really hard. While cheque day is the best day of the month for some, for others it can end up being extremely challenging. People spoke about how hard it is to avoid using drugs when they receive a lump sum payment, especially in communities where drugs are easily available. We heard that it can be a scary day, with people losing track of their friends after payments come through, drug dealers collecting on drug debts and some people getting taken advantage of. We also heard that for some there is shame that comes up when the money is gone.”