Efforts to address the dueling mental health and substance abuse crises on California’s streets have ramped up in recent years. The latest and showiest of these efforts is the Community Assistance, Recovery and Empowerment Court, put forth by Gov. Gavin Newsom. Pitched as an “upstream diversion” to prevent people with severe mental illness from ending up incarcerated or conserved, CARE Courts would work like this: First, any family member, case worker, or first-responder, including police, who believes a person needs intervention for mental health or substance use issues, could make a referral to a civil court. The person in need of care would then receive a clinical evaluation by their county behavioral health system. A public defender and case manager would then be assigned, and a CARE plan would be drafted, which could include a 12-month plan for medication, housing , and behavioral health treatment.

The plan is flashy. It’s well-branded. But dig just a little under the surface, and things don’t look so shiny. For a bill centered around care, it’s remarkably careless. And if San Francisco officials were hoping CARE Courts will sweep in to solve our issues for us, consider that idea dead in the water.

San Francisco has long battled with the ethical quandary of whether it is more humane to force someone who is very ill into involuntary treatment or grant them the freedom to make their own decisions about their life and care. Much of the discussion around CARE Courts centers on this debate. And these are valuable conversations to have.

But it’s doubtful CARE Courts will even get that far.

The most glaring flaw is a lack of funding and key infrastructure. The bill creates an entirely new system that can be used to compel treatment but includes only $65 million to support court expansion. It relies on already oversubscribed county programs to somehow accommodate an influx of new patients in need of court-mandated drug abuse treatment, mental health care and housing.

That a lack of resources is available to accommodate these mandates is obvious. Our existing systems to address the intersection of mental health and substance use issues can hardly operate. People accepted to mental health diversion programs are languishing in the county jail for months waiting for a bed to open. The lead judge of San Francisco’s Adult Drug Court said at a March Board of Supervisors hearing that due to this shortage, his staff has abandoned hope of getting anyone with both diagnoses into a treatment program. And a Damning Board of Supervisors hearing last week discussed five people who have taken more than 1,700 ambulance rides in the past five years, costing the city upward of $4 million. When mental health professionals tried to preserve one person, there was nowhere to put them.

California — and in particular, San Francisco — is already suffering from a severe shortage of behavioral health workers. In interviews with employees from both nonprofit and city health programs, we were told repeatedly that there simply isn’t anyone to hire for a growing number of vacant positions.

Across the bay, it’s not much better. A civil grand jury report on Alameda County’s behavioral health found understaffing on crisis phone lines, and incarceration used in place of psychiatric treatment.

When asked about the lack of funding attached to this bill, Newsom’s senior counselor Jason Elliott said that, “The whole thing only succeeds if we massively expand the behavioral health clinical network.” He noted that since Newsom took office in 2020, $4.5 billion has been allocated for this purpose across the state. “I have a hard time with the argument that we haven’t invested enough sufficiently to be able to do CARE Court,” he said.

But the results have been slow to appear: In the past two years, San Francisco has added only 180 new psychiatric treatment beds. It currently has none to spare. And CARE Courts would be implemented next year.

With this lack of attention to resources, it’s almost certain that CARE Court will fall flat. If San Francisco, a city with a $14 billion annual budget, can’t find a single bed for someone racking up hundreds of thousands of dollars in ambulance rides, how will smaller, less wealthy, counties fare with these new requirements?

This, of course, begs the question: If people could already access health resources, why would they even need a court order?

Until we provide more housing and treatment beds, train, hire and fund behavioral health workers, and improve access to care for people at every step of their journey to recovery, we may never find out.

Correction: An earlier version of this column misstated the amount the state had allocated for behavioral health.

This commentary is from The Chronicle’s editorial board. We invite you to express your views in a letter to the editor. Please submit your letter via our online form: SFChronicle.com/letters.

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The misery experienced on San Francisco’s sidewalks has long offered a case study in the failure of California’s mental health care system. Now, the dire situation is inspiring a proposal for a sweeping overhaul.

gov. Gavin Newsom’s plan, to be unveiled Thursday, seeks to tackle two big flaws in the system: the shortage of desperately needed care and the strict limitations on compelling treatment for people who are too sick to understand they need help.

His proposal, called Care Court, would create a mental-health-focused arm of the civil courts in every county. For the first time, the state would require counties to provide comprehensive treatment to those suffering from debilitating psychosis — and risk sanctions if they don’t. The people in the program, in turn, would be obligated to accept the care.

In an exclusive interview Wednesday, Newsom grew visibly angry as he discussed his hometown — the city he presided over as mayor more than a decade ago — which prides itself on its so-called compassion as it lets people wither and die on its streets.

Previous efforts to compel treatment have often run into opposition from mental-health advocates who worry about a return to institutionalization, and say governments should focus on expanding voluntary care. But the governor said there’s no more time to debate people’s civil rights as they endure degradation, and no more time to argue about how to fund the much-needed help.

“There’s no compassion with people with their clothes off defecating and urinating in the middle of the streets, screaming and talking to themselves,” Newsom said. “There’s nothing appropriate about a kid and a mom going down the street trying to get to the park being accosted by people who clearly need help.

“I’m increasingly outraged by what’s going on in the streets,” he said. “I’m disgusted with it.”

Newsom, who has battled homelessness and mental illness in his official capacities for two decades — and has faced pressure to do more — sounded optimistic that this proposal could yield dramatic change.

Under his vision, people suffering from psychosis — whether from a mental illness such as schizophrenia or triggered by severe drug addiction — could be brought before a Superior Court judge under three scenarios: either they are suspected of a crime, an involuntary hold in a psychiatric emergency room is ending, or a family member or outreach worker believes they cannot care for themselves. A public defender would represent them.

A county clinical team would create a care plan with input from the person and their “supporter,” a county case manager who would help them navigate the process and make decisions.

The plan would likely include clinical services such as visits with a psychiatrist, prescriptions for medications and housing such as at a board-and-care facility. The person wouldn’t need to be homeless to qualify. If a judge ordered the plan, the county would be mandated to provide what’s needed and the person would be required to accept it.

If the person suffering from psychosis refused at any point to participate, their criminal case would proceed. If no crime was committed, they could face the existing state process, in which people who are gravely disabled or deemed to be a danger to themselves or others are placed under involuntary holds and eventual conservatorship. Medication could be court-ordered, but would not be forcibly given.

Failure to take mandated medications could mean the person reverts to the criminal court or eventual conservatorship. The idea is to help people long before either of those outcomes is necessary.

Care Court would need legislative approval, which Newsom hopes to secure by June for implementation in January. The legislative process will include debate over how much additional money to provide to the courts.

A loud contingent has fought increases in involuntary treatment and conservatorship for years—and may fight the governor’s plan, too. They include advocates for homeless and disabled people who say forcing people to accept treatment is cruel, as well as some politicians and mental health clinicians who say increasing the number of conservatorships without far more treatment beds and staff isn’t viable.

Newsom brushed off those concerns Wednesday, saying the status quo is intolerable.

It’s unclear whether his sweeping, expensive idea will pan out, but what’s certain is that the current system is failing miserably.

Every week in San Francisco seems to bring new, horrifying stories of people suffering because they are experiencing crippling mental illness or drug addiction. Last week, a homeless woman and mother of three whose ex-husband said she suffered from severe drug addiction, and whose friend said she had behaved erratically, died in a fire while taking shelter from the cold under a freeway overpass in Glen Park.

On Sunday, Leonard Krubner was riding a Muni train when another passenger shoved him, screamed about him being in the FBI, called him anti-gay slurs and brandished a switchblade. Krubner darted off the train and reported the incident to a Muni agent — who said a similar report had been made the night before.

“Hello! Someone, do something!” Krubner said in an interview. “I try to be sympathetic to people with problems. Nevertheless, we just can’t have them coming onto public transit and brandishing knives.”

On Saturday, a group of seven women and girls were celebrating a birthday at Ocean Beach when a man who said they seemed profoundly ill or high approached them, grabbed their food and threw it into the sand. He then grabbed a can of soda and hurled it into the face of Karla Flemmings, one of the celebrants, who passed out.

“I laid there and I literally asked, ‘God, am I dying today?'” Flemmings, 50, said. “Then I thought I’d lost my eye. I didn’t think it was even still there.”

A man sitting nearby called 911. Police responded and booked a 46-year-old man on suspicion of felony assault with a deadly weapon and misdemeanor vandalism. He remains in jail.

Flemmings was diagnosed with a concussion and multiple fractures in her nose. Her face was severely swollen and her eye was shut for days. She spoke compassionately about the assailant, who said she appeared to be homeless and clearly needed help.

“I’m born and raised in San Francisco, and I’ve seen the drastic changes that have occurred firsthand,” she said. “So many people don’t have money when there’s so much wealth and opulence in the Bay Area. Something better has to be done — real services and real support.”

Last year, the state approved spending $12 billion to address homelessness and mental health. Newsom’s proposed budget for this year includes another $2 billion. Of the $14 billion total, $4.5 billion is tagged specifically for mental health treatment.

The state’s Mental Health Services Act, a 1% income tax on the wealthy that passed in 2004, will provide another $3.8 billion this year to counties for treatment, a pot that’s grown significantly from last year as incomes of the wealthiest Californians have soared.

Whether the money will be enough to provide the huge amount of care Newsom envisions is a big question, but the governor’s team says the program would save money elsewhere in pricey jails and hospitals.

Darrell Steinberg, the Sacramento mayor who authored the Mental Health Services Act when he was in the state Legislature, said he supports the Care Court concept because it would finally compel counties to provide services on the state’s dime.

“Everything that cities and counties are called upon to do in providing help and treatment is voluntary and optional,” Steinberg said. “We don’t say to our local communities, ‘You know, provide a free public education to kids or don’t, whatever you choose.’ We require it.”

Clearly, the up-to-you approach for counties when it comes to mental health isn’t adequate. Under Laura’s Law, the program designed to compel outpatient treatment for seriously mentally ill people, just 218 people in the entire state were subject to enter court-ordered treatment in 2018-19, according to the governor’s office.

The foundation for mental health treatment remains the Lanterman-Petris-Short Act, signed by Gov. Ronald Reagan in 1967 in a bid to empower people experiencing mental illness. It allows for short, involuntary psychiatric holds if a person is deemed potentially dangerous, and allows a judge to appoint a longer-term conservator to make decisions for people who are “gravely disabled.”

But in 2019-20, though there were more than 55,000 short-term holds around the state, just 5,584 long-term conservatorships were put in place. Some of those could have been renewals in cases that are years or even decades old.

Last year, judges found 4,531 people incompetent to stand trial on felony charges, meaning they couldn’t understand the nature of their case or assist in their defense. Two-thirds of them were homeless, and nearly half had received no mental health treatment in the previous six months.

In June 2019, San Francisco opted into a controversial state law to expand eligibility for conservatorship to include those suffering from severe drug addictions and mental illness. But nearly three years later, just two people have been preserved.

Newsom called all of these initiatives “small ball” compared to Care Court, asserting that many of them involved years of fights for few results.

“This is a moral exercise,” he said. “The risk here is not taking one.”

San Francisco Chronicle columnist Heather Knight usually appears Sundays and Wednesdays. Email: hknight@sfchronicle.com Twitter: @hknightsf

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It’s no secret that much of San Francisco’s trash – especially in neighborhoods like Mission, Tenderloin, and Mission Dolores – ends up on the sidewalks.

Christine, an owner who lives on 21st Street near Mission Street, was outside her house one morning picking up bits and pieces armed with pliers with a pliers-armed grasping tool. “In an ideal world, people would have to deposit their rubbish somewhere,” she says.

Christine has garbage bags, metal garbage collectors, and gloves ready to pick up garbage that has been left in front of her home on the mission. She says if she picks up the trash herself, it is less likely to attract further dumping. But if she sees feces on the street, she’ll report it. Photo by Clara-Sophia Daly.

But in San Francisco, this place was on the sidewalk or on the steps of Christine’s property, where she regularly cleaned up trash – sometimes she had to call the city’s 311 hotline for human feces and diarrhea.

Angel Mayorga, a 63-year-old resident who lived in the Mission his entire life, frequently uses the 311 application on his iPhone to send notices to the San Francisco Public Works. You clean up, but the problem remains. “Clean streets and cleanliness are a basic human need,” Mayorga said. “It’s going to be disgusting.”

But it’s not just human feces that residents always call to clean up, it’s everyday trash – cans, old meals, food packaging – the kind of trash residents would normally throw in a jar.

A public works clerk loads trash left on the sidewalk into his truck at the mission. Photo by Clara-Sophia Daly.

The Mission and San Francisco used to have what most cities have: ubiquitous public garbage cans. But in 2007, Mayor Gavin Newsom decided that the best way to reduce garbage in San Francisco is to get rid of trash cans.

Ross Mirkarimi, former sheriff and supervisor of District 5, recalled a meeting with then Mayor Gavin Newsom and other senior officials. According to Mirkarimi, city guides believed that “trash cans become a magnet for more rubbish that goes beyond the can. They believed that cans become a marker for people to unload what they wanted.”

“I wasn’t in favor of taking away trash cans,” says Mirkarimi. “I didn’t find it intuitive, but the administration so insisted that this was an experiment we had to try.”

And they did. Around 1,500 trash cans were pulled from the streets of the city.

Nowadays, residents routinely walk several blocks before running into a trash can. On the way you can see to-go containers, paper bags, masks, gloves and other rubbish from other pedestrians who have simply given up trying to find a trash can. And that’s no wonder.

In 2007 the city had 4,500 trash cans. We now have 3,113 public trash cans – 1,500 fewer than 14 years ago.

And when compared to other cities, 4,500 doses added up to very few for a 47 square mile city. 3,113 even less. Manhattan, for example, has three times the number of trash cans – 9,144 – to cover its 23 square miles, according to the New York City Sanitation Department.

In contrast, the abundance of trash cans in Manhattan is easy to spot. Go everywhere and almost every corner has a trash can. In San Francisco, go with the trash in hand and keep walking. Anyone who has a dog knows that you have to walk at least a few blocks to find a garbage can.

Although the idea of ​​ridding a city of public garbage cans in order to clean them up doesn’t sound intuitive, it is based on the idea that when a city has many public garbage cans, people take advantage of them and for illegal dumping of household or business waste use. Other cities have come to the same conclusion.

In fact, New York City dumped 223 trash cans in Harlem in 2008 when officials decided the trash cans were attracting dumping. This experiment was also unsuccessful. Removing the baskets did not “significantly reduce litter,” according to the NYC Department of Sanitation.

The failure of Newsom’s plan to solve the city’s garbage problem has not gone unnoticed.

Experiment on the trash can for public works from 2017

In April 2017, Public Works, in collaboration with Mayor Ed Lee and District Supervisor Hillary Ronen, installed 38 new trash cans along the Mission Street corridor between 14th and Cesar Chavez streets. The aptly named “Yes We Can” pilot program in the Mission District was a direct response to the idea that more bins could mean less rubbish on the sidewalk and on the streets.

At the time, promises were made to see if “the extra considerations lead to less garbage and fewer complaints” until 311, which launched in 2008.

Public Works Spokeswoman Rachel Gordon examined the service request 12 months before the new cans and 12 months after and said, “We have seen more calls for overflowing cans, but we haven’t seen noticeably more complaints for garbage-related services . “

There is no data on calls for overflowing cans, but during the trial period the service calls for the scatter patrol increased from an average of 77 per month to 74 per month and the service calls for illegal dumping increased went from 70 per month to 61 per month according to the program.

Public Works’ Gordon believes the 38 new bins are still there.

Currently, San Francisco still has that 3,113 public trash cans left after Newsom’s plan went into effect, compared to 5,000 in 2007. Recology says the trash cans along 24th Street, Mission Street and Cesar Chavez are serviced at least twice a day, seven days a week.

Gordon says that if district overseers want more cans, they’ll add more so long as the cans “don’t cause more problems than they help”.

Supervisor Ronen said, “For starters, we need more bins outside of each of our parks – Garfield, Jose Coronado, Parque Ninos Unidos.” She added that she has “advocated more and better trash cans for District 9 for years.”
Indeed, San Francisco is in the process of choosing from a range of new designs.

For now, some say the trash cans in San Francisco are easy to search (for both rodents and humans) and difficult to tell whether or not they are for trash or recycling.

Honey Mahogany, a legal advisor to Supervisor Matt Haney, called the current cans “renaissance trash cans,” meaning they’re easy to abuse, and said they were picked by former public works director Mohammed Nuru, though he was told that they were ineffective by some superiors, including Mirkarimi, according to him.

Reporting of garbage and garbage to public works by 311

Tracking the amount of trash on the sidewalk in San Francisco is made possible by data from 311, a phone number, and now an app that residents can use to report trash on the streets of San Francisco.

The service launched in 2008, a year after Newsom got rid of 1,500 trash cans. So there are no comparisons before and after. Mayor Ed Lee introduced the 311 app in August 2013.

In the past five years, Mission Dolores had the second highest number of garbage complaints, adjusted for population size. Mission comes third, and fillet comes first because it has the most complaints about junk.

In 2019, the Mission had the second highest volume of 311 faecal removal calls with 14 percent of citywide inquiries or a total of 3,942 service calls. The demand for overfilled containers rose last year to 1,613 – and thus took third place in calls via trash cans.

If the garbage ends up on the sidewalk, residents call or file a report on 311 and the public works department crews pick up the garbage.

Fewer bins and bigger budgets for Recology and the Public Works Department

Although the city’s population has increased by a little more than 10 Percent since Newsom’s 2007 plan went into effect and the city has 1,500 fewer public bins. Even so, according to Recology spokesman Robert Reed, Recology’s budget has “increased by more than a third to more than $ 22 million a year”.

As for the public works department, which picks up street litter on the 311 calls, crews, which include workers, truck drivers and supervisors, have increased 25 percent over the past five years to 349.

Gordon said the goal is to respond to street cleaning requests within 48 hours. 24 hours for human / animal waste. “Public Works achieved that goal for 91.4 percent of inquiries, she said.

But much of the rubbish is not reported and remains on the street.

Anthony, a public works worker who picked up trash on Bartlett Street at Mission, said he was struggling to keep up with requests.

“Right now I’m backed up … still trying to catch up from two days ago and we have one thing in town where we should get it done in a certain time, so I’m just trying to do what I do can do to get it done. “

Paul Monge, an aide to Supervisor Ronen, referred to Proposal B, which 61 percent of voters approved in November, with no additional bins or crews.

No trash cans or garbage crews will be added, but it will provide oversight of the Public Works Department, and it will also create a new Sanitation and Roads Department in 2022 and a five-person Sanitary and Roads Commission to help them monitor.

Until then, the superiors appease their voters with different solutions.

Mahogany, who helped write Proposition B, says Haney used adback money, or money found through the town’s regular budget process granted to the community, to clean up the streets around the Tenderloin and Civic Center where excessive garbage hurt small businesses.

“Our office has taken the cleaning of the district into its own hands and has spent funds on street cleaning, invested more directly in cleaning and passed an ordinance making public bathrooms nearby [homeless] Warehouse. ”

“As a city, we do not invest in maintaining streets, and it is mainly people of color in urban areas who are affected by DPW who do not take responsibility for cleaning the sidewalks.”

Mission residents like Francesca Pastine, who has lived in the mission since 1994 and in San Francisco since 1976, regularly send Ronen’s office emails with photos of the littered streets.

She would like to see public works take on more responsibility and work proactively to clean up rubbish.

Gordon of Public Works says, “But we also need to focus on why roads are destroyed in the first place.”

She blames San Francisco residents for sloppy thinking and unconcern. She tries to confront this with public awareness campaigns in schools and elsewhere. But education has not worked so far.

Mirkarimi agrees that it’s up to the residents. “If there is no kind of accountability for social and personal responsibility to work,” the city will not be cleaned up.

Photo by Lydia Chavez

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