A new chief of mental health
New Yorker will lead S.F.’s sprawl of aid programs
San Francisco has hired a new chief for its sprawling network of substance use and mental health care programs — a critical position that has been held by acting directors for the last two years amid a deadly drug epidemic and an often crowded psychiatric emergency room.
Dr. Hillary Kunins, who will join the Department of Public Health later this month, will take charge at a particularly distressing time in San Francisco. About 700 people died of an overdose in 2020, a nearly 60% jump over the year prior, mostly due to fentanyl. Meanwhile, 2021 is already off to a tragically deadly start: 61 people died of an overdose in January, compared with 38 during the same month last year.
Drug use, mental illness and homelessness often cannot be addressed separately, but San Francisco is woefully short of services for all three. As the new Behavioral Health Services director, Kunins will help improve the city’s disjointed system of mental
health and drug treatment programs, which serves some 30,000 vulnerable people a year. She will also lead Mental Health SF, a massive $100 millionayear initiative intended to overhaul the city’s entire system of care.
Kunins will come from New York City, where she recently left her job as executive deputy commissioner at the Department of Health and Mental Hygiene. She will take over from Marlo Simmons, who has been San Francisco’s acting director of Behavioral Health Services since February 2020.
“San Francisco is a great, progressive visionary place,” Kunins said in a brief interview with The Chronicle last month. “This job was an exciting opportunity to work on some difficult issues that I care about very deeply.”
When she moves to San Francisco, Kunins will step into a department that critics say has inadequately responded to the dramatic rise of fentanyl in the city’s drug supply. Even though the opioid has proliferated throughout San Francisco for years, city leaders do not have a clear, urgent and cohesive plan for how to stem the tide of death. More than 70% of last year’s overdose victims had fentanyl, an opioid that can kill someone with just 2 milligrams of powder, in their system.
Those who’ve seen the devastation up close have lost faith that the city’s current leaders are equipped to handle the epidemic.
“We had three overdoses in my community last night,” Jeris Woodson, a case manager for Westside Community Services, a clinic that offers mental health and substance use programs, said last month. “It’s really easy to be a drug addict in San Francisco.”
What’s harder, she said, is getting appropriate help when someone’s ready for it. There’s a shortage of options on the city’s southeast side, she said, where the drug, mental health and homelessness crises have disproportionately hurt African Americans. A fourth of the people who died last year from an overdose were Black, despite the fact that Black people make up less than 6% of San Francisco’s population.
A 2019 report found nearly 4,000 people — 35% of whom are Black — are suffering from mental illness, homelessness and addiction. Experts say that number has likely swelled amid the pandemic.
Kunins will come to San Francisco with valuable experience: Fentanyl hit the East Coast drug supply long before many in the West began choosing it over heroin. In New York, she helped implement and scale Mayor Bill de Blasio’s 2017 HealingNYC initiative, a $60 million program that focused on substance abuse prevention and treatment.
Kunins said she focused on offering treatment in the “most flexible ways,” which included medicationassisted treatment. Similar to leaders in San Francisco, Kunins also embraces the idea of harm reduction, an approach that gives drug users the tools they need — like clean needles and Narcan — to use as safely as possible
Drug overdose deaths in New York City have largely plateaued since 2016, but at a very high number. According to city data, 1,463 people died of an overdose in 2019. Nearly 70% of those deaths involved fentanyl. Consistent with nationwide trends, New York City also experienced an uptick in overdose deaths during the first few months of 2020.
Kunins said she wants to make San Francisco’s system easier to navigate for those struggling with drug use and mental illness. It’s an idea that city leaders have promised for years, but have struggled to achieve.
“We have failed to keep up,” said Supervisor Catherine Stefani, who held a hearing on the city’s treatment options last month. “People cannot get sober when there is someone selling fentanyl next to you.”
Rico Hamilton, a recovering drug addict and a community activist in neighborhoods like the Western Addition, said along with harm reduction, the city also needs more access to different kinds of treatment tailored to certain communities.
At a hearing last week, Hamilton and a group of recovering addicts in a working group convened by a division of the Adult Probation Department, called on the city to expand a number of initiatives — such as funding a Blackled, abstinencebased treatment program in the Bayview and expanding drug and alcohol treatment stays beyond 90 days.
“We have friends and family members who have relapsed on fentanyl, and their addiction is costing them their life,” he said. “And then there is no response to that. And that’s our frustration.”
Supervisor Matt Haney plans to propose a package of reforms this month specifically targeted toward controlling the fentanyl epidemic. The proposal will likely cost $6 million to $7 million a year.
Along with the city’s substance use services, Kunins will also oversee the implementation of Mental Health SF, a system overhaul that is already partly under way. New initiatives over the past year include two new Crisis Response Teams.
But for people like Hamilton, those changes have yet to make any noticeable difference on San Francisco’s streets.
Hamilton, who has been sober for about 20 years, said he’s grieved friends and family lost to fentanyl, and the city’s response to the epidemic has been “technical and robotic.”
Kunins knows that local and cultural contexts are important to addressing the crisis, and she said she will make sure that community voices are heard. And even though she has yet to move from New York to San Francisco, Kunins already has many people who want to talk to her.
“There’s not (only) a single solution in New York City,” she said. “And I expect that that will be similar in San Francisco.”