It’s 9am in San Francisco’s Tenderloin district and sleeping bodies line the sidewalks as Felanie Castro sets out on her route in Glide Memorial church’s harm reduction van.
Along Ellis Street, hungry people queue up for the church’s daily breakfast of buns, hard-boiled eggs and plastic-wrapped muffins. Down the block, a fire department truck, part of a city response team, awaits the day’s first drug overdose call.
This neighborhood and the adjoining South of Market (SoMa) district have become ground zero in an opioid overdose crisis that is killing thousands of California residents, including many experiencing homelessness. In the past two years, more than 1,300 people have died of overdoses in San Francisco, a rise driven by the emergence of fentanyl, a super-potent synthetic opioid that’s 50 times stronger than heroin. Nearly half of those deaths have occurred in these two hard-hit neighborhoods alone.
Castro and Glide’s harm reduction team are fighting one front in the battle to keep people alive.
Glide, a nearly century-old church, has been advocating for the rights of the poor and disenfranchised communities since the 1960s. Today the church runs dozens of programs, including support for those struggling with homelessness and addiction. Armed with supplies such as clean syringes, glass pipes, alcohol wipes and bottles of water, their team aims to give people the health tools to make drug use as safe as possible, while working to build the trust that drug users may need to eventually seek help.
Among the most powerful tools in their arsenal are nasal spray bottles of Narcan, each containing 4mg of the life-saving opioid-reversal drug naloxone. Castro says she has already reversed 50 overdoses using Narcan, in the Tenderloin and around the city.
But she can’t save everyone alone. As part of a broader harm reduction strategy, providers are offering Narcan at clinics, meal programs and homeless drop-in centers and distributing it directly into the hands of drug users and anyone living around them, increasing the chances someone can act.
“The idea is to have Narcan available everywhere,” said Laura Guzman, a senior director at the National Harm Reduction Coalition. .
As the Glide outreach van pulls up to a collection of tarps and tents under the shadows of a freeway overpass that morning, Castro and her partner, Rizzy Spoer, call out to the occupants, who appear to be sleeping inside.
“Hi, sorry to bother you. We’re from Glide. We have harm reduction supplies and basic needs stuff. Do you need anything?”
A bearded young man in a baseball cap comes out and asks if he can have some “longs” and some “shorts”, referring to two different sizes of syringes.
Castro loads a paper bag with the supplies and offers some water. Then she calls to the soft-spoken young man as he turns to go back to the tent: “And also, do you have any Narcan in there?” The man gratefully takes a single-dose Narcan dispenser wrapped in foil packaging.
A historic neighborhood faces new crises
The Tenderloin, a historic neighborhood in the heart of San Francisco’s downtown, comprises roughly 50 square blocks, most built just after the 1906 earthquake. During the 20th century its gently sloping streets and residential hotels developed a reputation as the city’s seedy underbelly, known for drug dealing, sex work and vice.
Today the Tenderloin is grappling with the interlocking crises of homelessness, poverty and addiction. It’s home to hundreds of people trying to survive without housing, many living just steps from glitzy high-rise apartments, luxury brand shops, and the headquarters of tech companies such as Twitter and Uber.
The city supervisor Matt Haney, who represents and lives in the district, describes it as a place of last resort for people who have fallen through the social safety net.
“The Tenderloin is a place where people who have been pushed out, stepped on and who are struggling can find a home and refuge,” he said. “That’s a powerful and beautiful thing. It also brings with it a lot of need.”
In recent years, new forces have intensified those challenges. One is the rise of fentanyl, now the substance of choice for many illicit drug users in San Francisco. Another is soaring rents and a statewide housing crisis that experts say has pushed even more people on to the streets.
Resolving the situation has become one of the city’s most divisive issues. Facing mounting pressure to act, San Francisco’s mayor, London Breed, declared a “state of emergency” in the Tenderloin in December 2021 – promising a crackdown on drug dealers, more interventions for users and cleaner streets.
The declaration reignited a debate at the heart of drug addiction treatment: should users be given “tough love” and urged to abstain from drug use? Or should the city make drug use safer and help people rebuild their lives at their own pace?
Opinions range, with some in favor of the abstinence-based approach, a philosophy often associated with America’s “war on drugs” era, and some who want the city to use a firmer hand to clear the Tenderloin of visible drug use and encampments.