Reduction or Production: Is San Francisco’s Harm Reduction Approach Working?

Figure A


What is harm reduction?

Harm reduction is a national approach to drug abuse. The Harm Reduction Coalition, a national network encouraging the Harm Reduction approach, considers a list of central principles. These include acceptance of the presence of substance abuse, the establishment of wellbeing for drug addicts without the cessation of drug use, and the affirmation of drug users reducing their own drug usage. It is a very controversial topic, though effective in certain cities and countries that have established policies.

Harm reduction in SF: A History

Figure B

Harm reduction in SF: A Look

Is harm reduction good or bad?

Whether harm reduction is “good” or “bad” is a long-argued question. There are certainly arguments for both sides, and these differ from city to city. Within San Francisco, there has been quite an uproar following certain ideas, and some of the arguments are both valid and intriguing. 


The San Francisco Department of Public Health hands out an average of 4.45 million needles yearly to approximately 25,000 intravenous drug users. Without an adequate disposal system, a large percentage of needles continue to litter the streets of San Francisco, and needles such as that in Figure A are a common sight. Though the SFDPH has organized a volunteer team to dispose of needles, there is a lack of resources and staff resulting in an inability to retrieve all the needles. This failure is one of the most evident, as most neighborhoods within the city are littered with needles, and they can be nerve-wracking for parents and pet owners, who may struggle to keep their children and pets away from them.

Unfortunately, there have been spikes in the amount of overdose deaths of Fentanyl and methamphetamine, as shown by Figure C below. Between 2012 and 2019, the number of serious drug addicts increased by approximately 2000 people. The Harm Reduction Policy’s aim is not to decrease the amount of users of drugs, but to decrease the risks involved in using drugs. This can be useful in decreasing the quantity of overdose deaths, but can also leave room for higher amounts of drug addicts, as the focus is not decreasing the amount of drug addicts. 

Figure C
Figure D


San Francisco’s harm reduction efforts have not been without positive results. As shown by Figure C, the overdose deaths caused by opioid painkillers have drastically lessened, and those caused by heroin and cocaine are slowly decreasing. With further efforts, this success could be reflected in other drugs. 

Figure D shows the decrease in HIV diagnoses in San Francisco, which is caused in part by the distribution of free needles as well as the work of the needle cleanup crew. With accessibility to free, clean needles, and the means of disposing of them, the risk of infection by shared needles is greatly lessened.

The formation of the needle cleanup crew was impactful and, although not completely successful, there is still a somewhat noticeable difference, though there are still many needles scattered across the ground.

Harm Reduction Education is also infinitely important. At my school, we had a woman come speak to us on several occasions, and her view was that we choose what we do (we choose if we use drugs) and her role was to inform us of the dangers without attempting to influence our decision, so that we have knowledge of what we are risking by partaking in certain actions. This is really important in my opinion, and I believe it would be beneficial for other schools to follow suit. One of the reasons that it works is because, psychologically, youth feel more inclined to do things that they know aren’t allowed: another reason why the decriminalization of drugs in Portugal had such a positive effect. By giving us the information to make our own choices, teachers are ensuring that we know how to stay safe but still feel in control of ourselves, and not controlled by adults.

These are only some of the successes that San Francisco has had with Harm Reduction, and with a little more work, it is sure that things can turn for the better. Figure B, above, shows the progression that has already happened in a short span of time. With a few more years and more, well-planned action, solutions and a positive outcome are practically inevitable.

Safe Injection Sites: How will they play out?

The push for safe injection sites in San Francisco has been going on for quite some time, but was vetoed by former Governor Jerry Brown. Now, Governor Gavin Newsom supports the idea, but the bill has yet to pass, and would need involvement from the federal government and the Department of Justice.

Safe injection sites are very controversial, as are many of the elements of harm reduction. The side that supports the sites argues that the majority of people who die because of drug overdose were injecting alone. These sites would provide a place where intravenous drug users can inject themselves with others, and have access to Narcan (naloxone), a drug overdose reversal.

The opposition of the idea worries that the sites will encourage drug use, and turn into social hangout areas. Looking at the success of sites in Canada, Europe, and elsewhere, this hasn’t been an issue, but opponents argue that it is different in San Francisco. Their argument is backed by their opposition to the idea of harm reduction as a whole: opponents believe that it is a method of worshiping and normalizing drug abuse.

The mock injection site that opened in San Francisco operated for four days in 2018 in the Tenderloin District, one of the poorest and most drug-riddled neighborhoods in San Francisco. It was described as “built like a high-end private medical clinic” by Sarah Holder in the City Lab magazine. It was modeled after those in British Columbia and Melbourne. 

San Francisco is not the only US city attempting to implement these sites. New York City is doing so as well, while Seattle has already implemented several.

Studies have suggested that the sites have a positive impact, though there have been some studies proving the opposite. In my opinion, these sites can work if incorporated and supervised properly. The social aspect of the sites is not horrible. With support from others, it is proven that it can be easier for addicts to begin rehabilitation and endure withdrawal.

Worldwide Harm Reduction: A Look At Portugal

Similarly to San Francisco, Portugal suffered an opioid crisis and, just like SF, incorporated a Harm Reduction Policy. However, their success vastly outdid that of San Francisco. Their first step was decriminalizing the use and possession of narcotics among other drugs. An innovative law, by far, but a strangely effective law. This is harm reduction at its largest presence. 

In 2001, over 100,000 inhabitants of Portugal used heroine, and in 2018, that number had dropped to only 25,000. Within Western Europe, Portugal has the lowest drug-affiliated death rate. It has one-fiftieth of the amount of drug-related deaths in the United States. Additionally, the amount of HIV diagnoses dropped by over 90%.

So what are they doing that’s working?

Portugal follows the harm reduction morals quite strictly: they value the person with the drug addiction, and view the issue as an illness that they can care for. Clinics are not specialized: addicts can go to one location and be cared for mentally, physically, and socially by a treatment team formed of specialists in each division. Portugal accepts that people may not be ready for treatment, and that’s where harm reduction comes in. 

To do so, psychologists will go out to the streets and work directly with drug users. They are joined by medical staff who will screen for diseases and offer free needles. The psychologists and social workers aid their patients in finding rehab centers, treatment programs, and just general mental health. These mobile clinics have made a huge impact: since they were first introduced, the amount of patients testing HIV-positive has dropped from 55% to 13%.

My “For Now” Response

Eventually, big steps like those taken in Portugal may be needed to solve this problem for good. But in the meantime, there are several smaller steps that can be taken to improve the current issues.

First of all, further implementation of harm reduction education in schools would be impactful. Psychologically, students would feel as though they have the ability to make their own decisions regarding their lives. Additionally, the positives of harm reduction would be understood by youth and adults alike. To do so, schools could seek specialists in the topic or staff could attend educational activities themselves and bring back the information to a school assembly.

To adequately collect most to all needles, it is crucial that San Francisco enforce a stronger focus on disposal. The cleanup crew is helpful, and with a few more volunteers and better funding, there would be a big difference. However, there should be easily accessible disposal systems in which users themselves can dispose of their needles. Several stores have done so, but a widespread, government-run system would be excellent in helping alleviate the issue, although this is a larger step that would take time to execute.

What youth can do to help is stay educated and educate others. After reading this, I encourage you to research harm reduction or other approaches in your hometown. Petition for your school to bring in a harm reduction advocate to speak at an assembly or donate to a harm reduction center.

Your Response

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  1. April 26, 2020 by Michelle

    Hi Isabelle! This is a really well-done project, and it taught me a lot about the successes and failures behind harm reduction in SF. I live near SF, so this is a topic that resonates with me. Thank you for including a section of your “For Now” response, as that’s the next step to solving this problem. Great work!

    • April 26, 2020 by Isabelle

      Hi Michelle! Thank you for taking the time to look at my project! I’m glad you enjoyed it and learned from my work!

  2. April 27, 2020 by Jenna

    Hi Isabelle! The project was super interesting to me. I visited San Francisco in December and my mom used to work there many years ago. The harm reduction approach is very interesting, and I loved reading the case study of Portugal. The statistics are jaw-dropping. I can’t believe how low the drop in HIV rate is there! I found the education about drugs in your school very different from mine. In my school, we had a police officer who came in and essentially worried and scared us that drugs would completely “ruin our lives”. I like that the expert who came to your school said that doing drugs is an individual decision, especially considering that youth are so vulnerable; and did not encourage or scare any of you. Great work on your project, it is clear that you spent lots of time researching this!

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