Homelessness, Substance Use, the Tenderloin—and the Missing Headline

All In Team April 4, 2022
On December 17, 2021, Mayor London Breed declared a state of emergency in the Tenderloin. The Emergency Declaration allowed the City to expedite the implementation of programs to quickly open a temporary linkage site where people with substance use issues can receive behavioral health services. Three months after its implementation, All In asked several local partners and experts for their perspective on the emergency declaration. After Mary Kate Bacalao last week, hear from Gary McCoy,Vice President of Policy & Public Affairs for HealthRIGHT 360, this week.

Everyone agrees that conditions in the Tenderloin have needed focus for decades. I’ve lived in San Francisco since late 2001, and as a person experiencing homelessness and substance use disorder, I called the Tenderloin and Castro home throughout my twenties. At any given time, the suffering of those living on the streets, hanging out on sidewalks and in doorways, and using drugs was noticeable – and often those behavioral challenges were at odds with residents, parents, children, and the business community.

As a person living on the streets and using drugs during that period of my life, I can tell you without a doubt, no one wants to live like this. But the risk of using, especially in isolation with nowhere to live, tends to outweigh the embarrassment of getting well in front of others – and those risks of using can run the gamut from health complications such as abscesses and infections, consequences with law enforcement creating more negative barriers to housing, benefits, and employment, and the possibility of violence from others. In the last several years, those risks have increased exponentially with the inclusion of deadly fentanyl analogs in nearly every supply of illicit drugs.

While I was on the streets, harm reduction strategies kept me alive. Today I have been in abstinence-based recovery for over 11 years, I have been happily married for 7 years, and I have a flourishing career doing what I enjoy. I’ve had the privilege of working for a number of incredible legislators and alongside wonderful advocates with a personal mission of helping others and providing people who are struggling with the same opportunities I had. I’ve learned quite a bit in the process.

What Decades of Personal and Professional Experience Has Taught Me

The biggest thing I’ve learned, from both my personal and professional experience, is that as much as we tend to think substance use disorder treatment would be best for others, they must want it for themselves in order to be successful. There are always people incredibly ambivalent to substance use disorder treatment, but what I have seen from my own experience and decades of evidence-based research is that there is a large population of people who are unlikely to immediately leave the streets to walk into a treatment program to never again use drugs for the rest of their life. Many have made multiple attempts at treatment and carry shame that they’ve let themselves or others down for not completing it, or shame from having returned to using after attempting treatment programs.       

The second most significant thing I’ve observed over the years is that we’ve always had a large population of people suffering from substance use disorder and co-occurring mental health challenges that we’ve never been able to connect with. Often, these are the most visible but hardest to reach folks who are in need of the most help.

“This program is filling a need we’ve had for decades in reaching the very people we’ve struggled to serve: those most at risk of dying on our streets, populations ambivalent to treatment, our broken and most visible neighbors; the very people who most desperately need our help.”

They’ve spent years attempting to access programs and resources spread across the city with many barriers to qualify for housing opportunities, finding safe places to be and out of the elements, all while trying to figure out how to sustain their substance use disorder, trekking around town and standing in long lines to eat a meal three times a day, and desperately looking for somewhere to sleep for the night. Years of this can be daunting, and these folks eventually learn to simply accept where they are in life. They’ve been broken, continue to suffer from many traumatic experiences, have lost all self-confidence, and find it difficult to trust anyone.

In both my professional experience and lived experience, the most notable thing Mayor Breed, the Department of Emergency Management, and the San Francisco Department of Public Health have accomplished with the Tenderloin Emergency Declaration appears to have gone completely unnoticed by the general public. 

The Missing Headline

While many folks still critical of the plan have been very vocal about the “failures” of this program in connecting people to treatment and other resources, they’ve overlooked something huge. This program is filling a need we’ve had for decades in reaching the very people we’ve struggled to serve: those most at risk of dying on our streets, populations ambivalent to treatment, our broken and most visible neighbors; the very people who most desperately need our help.

In the first 90 days of Mayor Breed’s Tenderloin Emergency Plan, the drop-in resource center saw over 15,000 voluntary visits. On most days, over 400 people left the streets, sidewalks, doorways, parks, and other public places, to visit 1172 Market Street where they felt safe and had access to meals, showers, laundry services, respite, and most importantly – a place where they are treated with dignity and respect. At last, they’ve found a place where people care about them, prevent overdose deaths, and have important conversations about how to live healthier lives, be it harm reduction services, drug and alcohol detox or treatment options, housing assessments, medication assisted treatment like methadone or buprenorphine, primary health care and dental care, behavioral health programs, and so much more.

Research has proven that consistent conversations lead to meaningful change in behaviors. We’ve struggled to figure out how to do this for many decades, and it seems as though we’ve finally found the solution – and one that is completely voluntary and welcoming.      

San Francisco may have finally found the secret sauce to helping folks we’ve struggled to reach, and now it’s our job to continue this model while continuing to innovate, expand, and invest in human-centric programming and resources for our unhoused neighbors and friends.


Gary McCoy is currently Vice President of Policy & Public Affairs for HealthRIGHT 360, a non-profit provider of substance use disorder treatment, mental health services, and primary care to over 49,000 Californians annually.

Gary experienced homelessness as a young adult, having lived on the streets of San Francisco throughout his twenties. Since getting back on his feet over a decade ago, Gary has been heavily involved in advocating for policies and spearheading public health responses that directly relate to people experiencing homelessness, people in recovery from substance use disorder, and life-saving harm-reduction approaches for people who use drugs.

Previously, Gary has worked for House Speaker Nancy Pelosi as a Senior Congressional Aide, with San Francisco Recreation and Parks Department, and as a Legislative Aide to three Members of the San Francisco Board of Supervisors. Previous community commitments have been on the boards of the California Homeless Coordinating & Financing Council, and the Castro Country Club, a sober gathering space for queers and allies in recovery from substance use disorder.

Gary McCoy lives in the Twin Peaks neighborhood of San Francisco with his husband, Kory Powell-McCoy and his dog Xander.

About HealthRIGHT 360: HealthRIGHT 360 is a non-profit provider of substance use disorder treatment, mental health services, and primary care to over 49,000 Californians annually, including more than 15,000 San Franciscans. HealthRIGHT 360 provides care that is compassionate, non-judgmental, and evidence-based. We provide services, regardless of one’s ability to pay; inspired by our belief that healthcare is a right, not a privilege.