No Easy Fix | 2. Tolerance

Hey, it's Hanna, host of Radio Atlantic, here to tell you about the 17th annual Atlantic Festival happening in New York City this September.

We have an incredible roster of guests, including David Letterman, Scott Galloway, Dr.

Becky Kennedy, H.R.

McMaster, and many more.

I'll be hosting a live recording of Radio Atlantic, and we'll also have book talks and screenings, including a first look at season three of The Diplomat and a conversation with stars Carrie Russell and Allison Janney and creator Deborah Kahn.

Guys, you can ask them about that season two cliffhanger.

Learn more at theatlanticfestival.com.

This is Radio Atlantic.

I'm Hannah Rosen.

Today, we have the second episode of No Easy Fix, our three-part series about why San Francisco, one of the world's most innovative cities, can't seem to solve the very visible problems of homelessness and addiction.

If there was any series of tasks I could go through to get my best friend back, I would go through hell.

Last week we met Evan, who finally made the decision to try and get off the streets.

Yeah, I'm like falling apart.

And

in a way, I'm kind of

glad because it's kind of making me turn to like, to

stop.

If you missed episode one, I highly encourage you to go back and listen.

This week, Evan takes his first steps towards recovery, just as the city's mayor starts to implement a less tolerant approach.

Reporter Ethan Brooks takes it from here.

Before Evan's life began to look how how it does now, before spending all day and all night chasing fentanyl, it looked pretty normal.

For a lot of people who are addicted and living on the street, this is not the case.

Even the idea of a stable life is kind of an abstract thing.

But Evan had a good job.

He worked for his friend Joe in Northern California.

He had an apartment and a family and a dream of putting his son through college, something Evan's parents weren't able to do for him.

I've always been able to have a job and a house and everything and still have been able to use.

And when when it got to the point of losing all of that, I was able to make the choice to not use anymore.

But when fentanyl took hold of him, when he lost the job and the apartment, part of him thought it was only a matter of time before the scale of that loss woke him up, forced him back on the right track.

But it seemed to have the opposite effect.

Losing all of that, you would think it would be more of an incentive not to be like this, but it's like the more I've lost, the more I got like this.

Like if you've lost the job and family and all that stuff.

What is there else to lose, kind of?

This usually is called rock bottom.

And the thing about that phrase is that you pretty much only hear it when someone is telling a redemption story, their story of recovery.

While so many people who reach this point, who made it all the way down to rock bottom, don't end up telling a story at all.

That sense of having nothing left to lose, paired with an addiction to an opioid many times stronger than heroin, is a deadly, deadly combination.

But after five years with nothing to live for, Evan did not die.

One of the reasons Evan survived is because the city of San Francisco marshaled immense resources to keep him and people like him alive.

The city supplied clean pipes and foil and clean needles for injection users.

In 2022, it provided a place where people could use fentanyl under medical supervision.

It gave out Narcan and trained people to check on drug users if they seemed unresponsive and to reverse overdoses if they were not.

That's done by sliding a plastic nozzle into a stranger's nostril, which is a remarkably intimate act.

These measures prevent the spread of disease and bring people back from overdoses that would otherwise be fatal.

But in the tenderloin and in these pockets of open drug use all around the country, they can also contribute to a sort of limbo, keeping people alive without really living.

The idea behind this approach is that what it costs the city might one day be worth it if Evan can survive long enough to say something like this.

I don't know where to go.

And it's raining.

I'm cold.

I'm hungry.

And

I'm over it.

I'm so over it.

Those three words, I'm over it, which Evan was clear meant I'm ready to get off the street, ready for treatment, are supposed to be the magic words.

They're supposed to clear a path for Evan to walk out from this liminal existence back into the world of the living.

And together with the measures that helped keep Evan alive until he was ready, form a strategy that is more humane and more effective than the alternatives.

This is supposed to save Evan's life.

That's the theory, anyway.

From The Atlantic, this is no easy fix, episode 2.

Tolerance.

The set of strategies that helped keep Evan alive these last few years live under an umbrella of public health philosophy called harm reduction.

And immediately, if you start asking around, it becomes clear that no one agrees at all on what harm reduction is.

Harm reduction is safe supplies like clean needles, pipes, and foil that prevent the spread of disease.

It's also Narcan, the overdose reversal drug.

Medications like methadone and buprenorphine that reduce cravings and protect against overdose, that's harm reduction too.

Medically supervised injection is also harm reduction.

It's even been argued that certain drug dealers, the ones who provide a trustworthy and consistent product, should be called harm reductionists.

It's a term with a lot of space for interpretation, and recently the object of a lot of anger.

Save our dam!

Save us!

When we take the steps to be more aggressive with law enforcement and less tolerant

of all the bullshit that has destroyed our city.

We have gone in San Francisco from a point of compassion on our streets to enabling street behavior.

And from my point of view as mayor, that is understandable.

The fate of harm reduction and whatever shape it will take around the country will dictate when and how thousands of people like Evan seek treatment and whether or not they live long enough to seek it voluntarily.

San Francisco is one of the first places in America where this idea took root.

Now it's one of the places that will decide its future.

It appeared a year ago in New York's gay community, then in the gay communities in San Francisco and Los Angeles.

Now it's been detected in Haitian refugees.

No one knows why.

And in heavy drug users, especially in New York City.

No one knows why.

And in some people with...

In the early 80s, HIV was beginning to spread.

Across the country, people were dying with conditions that were normally seen in the very elderly or very frail, and no one knew how to help.

In New York, about a third of AIDS cases were found in IV drug users.

That's people injecting heroin or cocaine.

San Francisco wasn't yet seeing those types of numbers, but it seemed like only a matter of time before it caught up.

In the city, the message for people sharing needles, which was literally handed to people leaving the hospital after an overdose, was stop using drugs.

This was, at best, simplistic.

Nationally, the message was somehow even simpler.

It was the era of the Just Say No campaign.

But there was another way, a radical way.

A lot of people were counseling us that we shouldn't just go out and start a needle exchange because it was illegal.

We'd get in trouble.

We'd get arrested, blah, blah, blah.

This is Bonnie Ferguson, a health researcher living in San Francisco at the time.

The idea she's referring to is the photo negative of Just Say No.

The idea was free, clean needles.

They said we should focus on trying to get a law through the state legislature making it legal first.

That's what they wanted us to do.

But the problem is we knew that the virus was not going to wait until the law changed.

So if something effective was going to be done, it had to be done immediately.

Bonnie and a few others began an underground needle exchange called Prevention Point.

I was invited in because I had friends who were injection drug users that I was worried about.

And also because I have a history of doing nonviolent direct action.

Hilary McQuay was part of that original group.

So was Donnie Gann.

The initial idea was that we're going to do this.

It's going to end up essentially being a civil disobedience, actually.

There were two sides to their plan for an underground needle exchange.

One team would distribute needles.

They dressed up in ragged clothes to fit in, hid the clean needles and a bucket for the used ones in a stroller.

and pushed it around the tenderline.

That was called the roving team.

The roving team we thought would be the ones that would really be doing the needle exchange.

And then the sitting duck team, as we called ourselves,

would be the people who got arrested.

The point was to get arrested.

This was a group of volunteers that wanted to make a statement to force the city to start its own needle exchange.

We designated a time.

We got together, did like a little

circle together of like, okay, here we go.

What do you mean, a little circle, like a huddle?

Sort of, you know, hugged, circled up, and, you know, looked at each other.

I mean, it was, you know, Ethan, it was, I mean, we didn't know what was going to happen.

The first night, November 2nd, 1988, they exchanged only a few needles, and only a few more when they went out again a week later.

But slowly, word about this underground needle exchange started to spread, and people started lining up.

I always remembered it as the third week.

We were there at that stationary site, and up at the next corner appeared two middle-aged well-developed white men in leather jackets and they sort of strode down the street towards us and as they approached they had their leather jackets unzipped enough that we could read their police athletic league t-shirts which they were both wearing they came up and they said good evening citizens and we said good evening and they passed by so then We were like, well, now they know.

Donnie, Hillary, and the rest of the sitting duck team waited to get arrested.

But as the weeks passed and the lines at the exchange got longer, it didn't happen.

There were no consequences for handing out free needles on the street to drug addicts.

On their first night in November 1988, they exchanged only a few needles.

In the spring of 1992, Prevention Point exchanged 343,883 syringes.

A study at Prevention Point estimated that in the month of October of 1992, 3,600 syringes contaminated with HIV were removed from the environment by the syringe exchange program.

3,600 contaminated needles in one month.

What is so extraordinary about Prevention Point and this earliest phase of harm reduction is how undeniably superior it was to just say no, and not just at saving the lives of drug users, but at preventing the broader spread of HIV and improving the health of the city.

It was a program that was at once more tolerant and more effective than the status quo.

Over the next three decades, what was at first a radical approach worked its way from the fringes to the center.

President Biden made harm reduction a central pillar of the federal response to the opioid crisis.

It became national policy to supply Evan and people like him with free, clean supplies.

Thousands of opioid overdoses are reversed by Narcan every year.

Harm reduction expanded far beyond syringe exchange.

In the spring of 2020, just a few weeks into the citywide lockdown, billboards started appearing around San Francisco.

One showed a group of young, fashionable people smiling and laughing, looking towards the camera.

If you didn't see the text and you just looked at them, you would think these are probably beer ads.

This is Keith Humphreys.

He's a professor and addiction researcher at Stanford.

You know, because you have attractive young people, they're laughing, they're nicely dressed, they're in a cool apartment, you think this must be Miller time or something like that.

But the text next to the image says, do it with friends, use with people and take turns.

Try not to use alone.

And then to realize, oh, this is not about beer, it's about fentanyl.

Like, holy cow,

that's, that's, um, you know, unexpected.

The ads were part of a multi-state campaign from the Harm Reduction Coalition.

The group was founded in San Francisco in the early 90s, a product of that first needle exchange.

For Keith, the billboards clarified something.

In the early 80s, HIV was a death sentence, and heroin was the opioid in circulation.

By the time that billboard went up in San Francisco, the fundamental equation that had worked so effectively during the AIDS crisis, make injection drug use safe to prevent the spread of HIV, had undergone a kind of inversion.

Heroin use is dangerous, but the odds are if you use heroin for a year, you know, there's maybe a 1 in 100 or a 1 in 200 chance that you'll die.

Today, thank goodness, we can treat HIV and AIDS,

but fentanyl has a death rate annually perhaps as high as 1 in 20.

Now the math has to be different because HIV is a more manageable condition by far, and opioid addiction is a much less manageable condition by far.

So it followed for Keith that what was needed was a new equation for harm reduction.

Instead, it evolved much more to a drug user's rights point of view.

Drug use is a right that should not be infringed, nor should it be looked down upon or stigmatized.

The point is that supporting that person's individual choice to do this, their freedom.

It was just an odd politics that I hadn't seen before, because in some ways, people were very prominently identifying with the left for things like anti-racism and anti-policing.

But on the other hand, they were evoking a lot of libertarian arguments that are often more common on the right, like around gun rights or the right to refuse to take a vaccine because of the bodily autonomy should be unlimited.

Whether you think it's right or wrong, that's not a public health argument.

Safe supplies didn't cause San Francisco's crisis, but they are by far the most visible of the city-funded harm reduction services.

For a lot of San Franciscans, what they represented was a different kind of tolerance, acceptance of this visible suffering, of decline, and of an uncertain future.

Ethan is Daniel Lurie.

Hey, Daniel, Lurry.

Daniel Lurie is the mayor of San Francisco.

He's been in office now for about seven months.

Before that, he ran a nonprofit called Tipping Point Community, which has invested millions of dollars in housing and educational projects.

The job in front of Lurie is to pull the city out of the tailspin that started in 2020 with COVID and population decline and the fentanyl crisis.

We as a city

just got to this point where we were like, if somebody wants to keep harming themselves and really killing themselves, that's their right.

And we forgot about the 840, 850,000 other people that are raising families here, paying rent, taking their kids to school, and they don't feel safe taking their kids to a bus stop or just walking down the street because someone is struggling with addiction or is just not well.

I think we forgot that for a number of years.

I think we lost our way as a city.

So, the mayor's mandate is to find a new way.

When it comes to unsheltered homelessness and addiction and behavioral health, to redraw the lines around what the city will tolerate and what it will not.

Having someone out that is lost and hurting and in pain and us saying, oh, we're going to keep you out there, we're not going to help you, and actually we're going to allow you to do that,

that's not okay.

And these are not San Francisco values.

To let somebody struggle and

use

and die on our streets, there's nothing compassionate about that.

And so we have to change our approach.

In his first seven months, the city ended the practice of handing out fentanyl-safe smoking supplies without connection to counseling.

The mayor has made plans to increase the number of police officers and sheriff's deputies.

He designated San Francisco as recovery first, meaning its first priority is no longer just survival, but to push people off the street and into recovery.

Harm reduction is not being thrown out.

Clean needles, Narcan, these services aren't going anywhere.

But now, the idea is to do both.

I believe in harm reduction.

You have to keep people alive to get them into treatment.

There's always a sense in our city, and maybe this is in other cities too, like that they're competing, that treatment has to fight against harm reduction.

I don't see it that way.

We have to do both.

Back in the early days of the Needle Exchange in San Francisco, the rights and autonomy of drug users were aligned with the interests of public health.

The two could coexist, even thrive under the umbrella of harm reduction.

It's the reason those cops didn't arrest Donnie Gann on the spot.

But the potency of fentanyl requires that cities do more than reduce individual harm.

At the very least, they must clear the path to treatment for people like Evan, people who need it.

After the break, Evan tries to escape his addiction and life on the street.

Hey, it's Hannah, host of Radio Atlantic, here to tell you about the 17th annual Atlantic Festival happening in New York City this September.

We have an incredible roster of guests, including David Letterman, Scott Galloway, Dr.

Becky Kennedy, H.R.

McMaster, and many more.

I'll be hosting a live recording of Radio Atlantic, and we'll also have book talks and screenings, including a first look at season three of The Diplomat and a conversation with stars Carrie Russell and Allison Janney and creator Deborah Kahn.

Guys, you can ask them about that season two cliffhanger.

Learn more at theatlanticfestival.com.

When someone like Evan says they want to get off fentanyl and get off the street, when they demonstrate that they're serious about that desire, there is a vast machinery that's supposed to jump into gear.

In San Francisco, there are more shelter beds and more permanent housing for the homeless per capita than a lot of major cities around the country.

It's near the top spenders on both homelessness and addiction per capita.

The treatment machine is designed to be fast because when someone like Evan wants change, that window is often vanishingly small.

If the city gets it right, Evan can squeeze through and find himself, before long, living a normal life.

Recently, the mayor's office has been focusing on the first 48 hours off the street, how essential it is to get people on the right path within that time frame.

So, let's call this hour one of Evan's 48-hour treatment window.

It's 7:30 a.m., Thursday, February 28th, 2025, less than two months into the new mayor's administration.

Liz picks me up in the mission district.

Last night, Evan and Liz made a plan to meet at the shelter where he's been staying.

There are two things that need to happen before we can check him into residential rehab.

First, he needs to get on methadone.

That's an addiction treatment that reduces cravings.

Second, they need to get medical care for his leg.

They don't think rehab will accept him without treating it first.

All right, where's Evan at?

Hour one does not start well.

I talked to him last night and we were going to meet here.

He was saying he was even going to sleep out here so I could grab him this morning.

But maybe he went inside to get food or something.

Evan is not inside grabbing food.

In hour two and hour three, we learn that he doesn't seem to be grabbing food anywhere else either.

They're not in.

Of course, the phone's going straight to VoiceMeal.

I can't believe he's not here.

Around hour six, we try the methadone clinic.

Maybe Evan made his way over there on his own, but they won't tell Liz whether he's there or not.

Over and over, they say we can't confirm or deny that he's a client, while Liz begs them for information.

Eventually, Liz calls Joe.

That's Evan's best friend from before he became homeless.

Um, I couldn't find him, and I still can't find him, and now we've missed the window.

Oh, wait, the batnell junkie wasn't good at doing a date and time, mate.

Whoa!

Only at about hour 12 of Evan's window does Liz learn why she hasn't found him.

Right now, on the afternoon edition, police move in and take back a once tranquil square, then dubbed Zombie Park in San Francisco, arresting dozens of people for doing and selling drugs.

Last night, the police raided the park where Evan was.

They surrounded the park.

They brought in agencies from all over.

They had drones flying over.

And then they say, nobody leave the park.

Stay in the park.

You are under arrest.

The raid was a sort of statement of intent by the new mayor.

He said as much in a press conference afterwards.

And this is a message that I want everybody in the city to hear.

If you are selling drugs in this city, we are coming after you.

Have you ever seen anything like that in San Francisco before?

Never.

Never.

Never.

Never.

Evan got away without being arrested.

On one hand, the raid was a successful show of force, the type of display that many San Franciscans had been hoping for.

But on the other, it got in the way of another one of its goals, which was to get Evan off the street.

Evan was seeking treatment at a moment less than two months into the new city government when the city was beginning to build a new strategy that would use less carrot and more stick.

Those first hours of Evan's window went to waste.

Yeah, you want to talk, come talk to me.

The next day is Friday, February 28th, hour 26 of Evan's 48-hour window.

Liz is back at 9 a.m.

this time with a dozen doughnuts and five coffees.

Today, after all the uncertainty and searching the day before, Evan is right where we expect him.

What's up, man?

How you doing?

Good, good to see you.

Good.

Good, good to see you.

Evan is standing outside the shelter, leaning on someone's wheelchair for support.

Liz hands out coffee and donuts to people on the street while Evan video calls Joe.

Oh, my goodness.

Evan walks Joe through his efforts to get into treatment on his own before he linked up with Liz.

He says that over the last few weeks he tried to get into rehab but was not admitted because his leg was in such bad shape.

He says he got arrested for shoplifting too and released quickly, also because of his leg.

Evan's leg is in really bad shape.

If he doesn't get medical care for it soon, he risks losing it.

It's both the key motivator for Evan to seek treatment and the key obstacle.

So far, it's felt like the world has been telling him, we won't treat you because you're sick.

When people talk about fentanyl and the threat that it presents, what they focus on more than anything else is just how potent it is compared to its predecessors.

You'll hear that it's 25 times, 50 times more potent than heroin.

Then you hear about overdoses, an epidemic of overdoses, people who overdose two or three times a day.

But this singular focus on potency means that we overlook something else, which is time and the way that fentanyl distorts it.

On one hand, fentanyl demands a rigid schedule.

While a heroin user might get away with a few days without a fix, fentanyl users only have hours before the withdrawal symptoms kick in.

To avoid debilitating sickness, Evan uses about four times a day and tries to set aside enough for when he wakes up in the morning.

On the other hand, fentanyl users' experience of time is hazy at best.

Almost nobody has a phone or a working watch.

These are items that will be stolen immediately in the tenderloin.

Your experience of the passage of time becomes highly inaccurate.

And the longer you stay out in the street, the more disconnected from time you become.

Evan, for example, didn't know about Trump's re-election until about two weeks after it happened.

When his friend Joe mentioned using AI for something, Evan figured Joe was just joking, because as far as he knew, AI isn't real.

This is why when someone like Evan is motivated, pace is key.

Now that Liz had collected Evan, the clock was ticking.

Alright, we just gotta go in there.

That is with you.

The first methadone clinic that Evan and Liz try, the same one the day before wouldn't tell Liz whether Evan was there or not, won't take Evan.

Apparently there is a staffing shortage.

They give Evan a flyer with information about other methadone clinics in the city, but it's in Spanish.

The second methadone clinic says they won't take Evan either.

They're not taking any new patients today, and even if they were, Evan would need an ID, which of course Evan doesn't have because Evan doesn't have anything.

But Liz has Evan's ID.

a picture of it that she's had for years.

She convinces the clinic to make an exception.

They take Evan to a back room and start him on methadone.

The next step is treatment for Evan's leg, without which Evan won't be admitted to rehab.

There's a medical clinic just down the street.

It's not a hospital.

It's a low-barrier, urgent care facility geared specifically towards people experiencing homelessness.

It's a place where injuries like Evan's are a very common sight.

Liz and Evan go inside while I sit in the car, and then after only a few minutes, they're back.

They're gonna have to do it yourself.

They couldn't see me

The medical clinic says they won't treat Evan today.

These services that would need to work quickly are instead failing slowly.

It's now hour 36 of those first 48 crucial hours and the sun is going down.

On Evan's escape checklist is methadone, which is done, and medical treatment, which has been deferred.

Liz will now do Evan's wound care herself.

Without a proper examination room, Liz and Evan need to find somewhere private.

After some debate, they settle on the plaza in front of City Hall, in front of the huge, domed building where the mayor and the board of supervisors spend their days.

They choose it because the plaza is dark and Evan is ashamed.

Evan steps away to smoke fentanyl before Liz goes to work treating his leg.

Fentanyl, at least, is a painkiller.

We're not alone in the plaza tonight.

The San Francisco Symphony is playing a concert.

There is an auditorium packed with people in fancy dress just across the way, listening to Rachmaninoff's Symphony No.

2.

By hour 39, Evan's checklist is complete.

His leg is clean with fresh bandages, and he has 50 milligrams of methadone in his system, which will cut down withdrawals.

But it's Friday, and the rehab that Evan and Liz settled on doesn't take new people over the weekend.

So Evan will have to make it another 48 hours on his own until Monday.

The only answer to the pace that fentanyl sets for people addicted to it is a treatment response at a speed that can match it.

Fentanyl users will always fail to get on methadone if intake moves slower than the time it takes to go into withdrawal.

They will fail to to go to rehab if it takes too long to complete the steps required to get in.

And cities will fail to effectively reduce harm if it takes decades to recognize that the tactics that worked for heroin users during the AIDS crisis won't work in the same way for fentanyl users during an overdose crisis.

In July, Daniel Lurry signed his first budget as mayor.

The budget increased money for shelter beds and treatment beds for people dealing with addiction and reduced spending on permanent supportive housing and harm reduction programs.

All right, there you are.

Hey Liz.

Hey buddy.

Saturday.

What happened?

You sound sleepy.

The next day, I'm sitting with Evan while he talks to Liz on the phone.

It's hour 56 of Evan's 48-hour window.

Yeah, you kind of

wore me out a little bit.

I'm, you know, I know I look, I know I look amazing, but I'm not 20.

Liz has been thinking about what she saw last night when she changed Evan's dressing,

and you can hear that she's worried.

Evan is worried too.

Your leg is not gonna look drastically better anytime soon.

Right,

right.

So, you have what we call now a chronic leg wound.

Right, right.

From last night to today, Liz decided she wants to throw out the original plan,

quit the treatment infrastructure, enter the emergency medical system.

Now she wants Evan to go to the hospital, to San Francisco general, as soon as they get off the phone.

Go back to the general, tell him when you check in,

just the truth.

You've had, you know, increased swelling, increased pain, and the wound is a lot worse that you are trying to get into treatment and that they will not take you currently with no like wound care plan for your leg um

take a breath i'm proud of you this is a lot okay i'm sorry buddy i'm sorry this is a lot and i know that um

liz and evan wrap up their call

Evan and I stand at 16th and mission as the day turns into night, and we keep standing, keep talking.

I'm flying out soon, so I set up an email account for Evan so he can stay in touch from the hospital and write down my phone number on pieces of paper so he can call me when he arrives at the hospital.

Evan pulls out deodorant and Q-tips from where I don't know, cleans himself up to get ready.

He says he'll call me when he arrives.

That call never comes.

We have missed the crucial window, and now, in urgent need of medical care, Evan is gone.

Next week, San Francisco takes its first steps towards expanding a system that would force people like Evan off the street and into care, and Joe and Liz search for their missing friend.

No Easy Fix is produced and reported by me, Ethan Brooks, edited by Jocelyn Frank and Hannah Rosen.

Engineering by Rob Smirciak, fact-checking by Sam Fentris.

Claudine Abade is the executive producer of Atlantic Audio, and Andrea Valdez is our managing editor.

See you next week.

Hey, it's Hanna, host of Radio Atlantic, here to tell you about the 17th annual Atlantic Festival happening in New York City this September.

We have an incredible roster of guests, including David Letterman, Scott Galloway, Dr.

Becky Kennedy, H.R.

McMaster, and many more.

I'll be hosting a live recording of Radio Atlantic, and we'll also have book talks and screenings, including a first look at season three of The Diplomat and a conversation with stars Carrie Russell and Allison Janney and creator Deborah Kahn.

Guys, you can ask them about that season two cliffhanger.

Learn more at theatlanticfestival.com.