San Francisco is moving to upend decades of widely accepted, research-based policy on housing and substance use—and other than 48hills and Mission Local, most of the local news media isn’t paying much attention.
Housing First—the concept that moving the unhoused inside, with few or no restrictions—has the support of medical and social service professionals around the world. From the Journal of the American Medical Association:
Housing First programs are among the most effective policies there are for addressing homelessness, especially among people with SUDs and behavioral health issues. Housing First programs have been studied for decades and have demonstrated improved outcomes related to health care use, recidivism to incarceration, and housing stability, particularly in the population with SUD and behavioral health issues. A systematic review showed that, compared with Treatment First and abstinence-based programs, Housing First programs decreased homelessness by 88%, increased housing stability by 41%, decreased emergency department use by 5%, decreased hospitalization by between 7% and 36%, improved quality of life, and improved community integration.
Harm reduction, also widely studied around the world, starts with the idea that people have used mind-altering substances since the earliest days of human civilization, and will continue to do so, and that, according to “Harm Reduction, National and International Perspectives,” (Sage Publications, 2000):
The fact or extent of a person’s drug use per se is of secondary importance to the risk of harms consequent to use. The harms addressed can be related to health, social, economic, or a multitude of other factors, affecting the individual, the community, and society as a whole. Therefore, the first priority is to decrease the negative consequences of drug use to the user and to others, as opposed to focusing on decreasing the drug use itself. Harm reduction neither excludes nor presumes the long-term treatment goal of abstinence. In some cases, reduction of level of use may be one of the most effective forms of harm reduction. In others, alteration to the mode of use may be more effective.
The idea is that nobody can get treatment or live a clean and sober life if they die first. Vitka Eisen, the director of Healthright 360 and an expert on recovery, openly says that she was a heroin user and sought treatment for its impacts (infections, abscesses, etc) nine times at what was then the Haight Ashbury Free Medical Clinic. Nine times, the staff helped her with no judgment, keeping her alive without mandating sobriety. The tenth time, she asked for help. That’s pretty common.
Both approaches are under attack in San Francisco, and thanks to a San Francisco member of the state Assembly, in Sacramento.
Mayor Daniel Lurie and Sup. Matt Dorsey are pushing to cut off all city funding, every penny, for permanent supportive housing that doesn’t evict people who use “illicit drugs.” The Housing First and Harm Reduction models would be gone for all city-funded PSH.
That measure passed the Public Safety and Neighborhood Services Committee Thursday with no dissenting votes. It will now go to the full board, which, packed with Lurie loyalists, will pass it.
Dorsey, who is a communications pro, is selling this as a “choice:” Some people want to live in sober housing. Nobody disagrees, and the idea that some city money should go for drug-free housing is an easy argument.
The problem is that Dorsey’s bill would ban any money for housing that doesn’t evict people for drug use. That would mean, for example, that the Marvel in the Mission, which broke ground this week, would not have happened. It includes 186 units of PSH, which will not automatically evict people for drug use and send them back to the streets, where they will have little hope of recovery and might die.
The bigger problem is the subtle, but clear shift in policy priorities away from Housing First and Harm Reduction. That would move the city backwards, by decades, toward the Reagan-era “Just Say No” approach that was a radical, horrifying failure leading to mass incarceration, community devastation, and tens of thousands of deaths.
Sup. Connie Chan, who chairs the Budget and Appropriations Committee, is holding a hearing Wednesday/29 that could offer some pushback on the Lurie/Dorsey approach. The hearing will consider
proposed changes to the budget impacting homelessness and supportive housing systems to examine the following: the importance of Housing First, outlines for any housing for homeless people in the pipeline, plans to decommission Permanent Supportive Housing and the impact on systems, loss of beds over the past two years and impact of planned closures.
That’s a chance to push back on the pretty radical shift in city priorities. The hearing starts at 1:30 pm.
