Outside the Ninth Circuit Court of Appeals in downtown San Francisco, a woman urinates on the sidewalk and smokes a crack pipe.
Inside her purse are about a dozen used heroin needles. She shoots heroin up to 10 times per day, she says.
Continents and regions
Drugs and society
Health and medical
Political Figures - US
Poverty and homelessness
Social and economic status
Southwestern United States
Business and industry sectors
Business, economy and trade
Epidemics and outbreaks
Pharmaceuticals and prescription drugs
Prescription drug abuse
About 50 yards away, a man injects another woman in the neck with a needle. She puts her thumb in her mouth and blows on it to make her vein more visible. Her right arm is caked with dried blood.
This San Francisco neighborhood is home to the headquarters of Uber, Twitter and Salesforce. But stroll around here, and you're also likely to find used drug paraphernalia, trash, and human excrement on the sidewalks, and people lying in various states of consciousness.
Public drug usage and homelessness are not new problems for the city of San Francisco. But residents say the situation has gotten worse in recent years. As of October, 7,500 complaints about discarded needles have been made this year, compared with 6,363 last year. In 2015, the number was less than 3,000.
It's moved some locals -- so-called "video vigilantes" -- to document the mess they see, in an attempt to get the city's attention.
Adam Mesnick, a restaurateur who lives and works in the South of Market (SoMa) neighborhood, started posting daily photos and videos of people using drugs in public, urinating near his restaurant, or lying passed out on the sidewalk.
"More mrsa and staph on the streets of San Francisco," Mesnick wrote in one post, accompanied by photos of angry sores on people's backs, hands and legs.
One photo shows a man planted face down on the sidewalk, his shorts pulled down exposing his rear. In another, human feces lies nestled in front of a doorway. In a video apparently taken from inside Mesnick's restaurant, a man can be seen urinating in a doorway across the street.
Mesnick isn't trying to shame homeless people with his Twitter posts, he says, but "to actually find help for these people." He's been giving leftover food from his restaurant to the homeless for the past ten years, he said.
Over the past five or six years, Mesnick says, visible homelessness and drug use on the streets have seemed to spread from areas of San Francisco where they were once concentrated, like the Tenderloin.
"It's like third world squalor," Mesnick said. "I'm a small business (owner) trying to exist, and basically surrounded by decay that continues to get worse and worse and worse."
Others fear that the situation will impact tourism. "If we can't find a solution to this problem," said Joe D'Alessandro, CEO of the San Francisco Convention and Visitors Bureau, "it will tarnish the city's brand."
Another longtime resident tweets about the state of the neighborhood using the handle @cleanupwestsoma. He asked to remain anonymous because his friends don't know he runs the account, and says he's lived in San Francisco for 21 years, 12 of them in SoMa.
"I post as I go to work. I'll sometimes come home from lunch and see a giant drug deal going on," he said. "I'll leave and go back to work and see someone going to the bathroom in the street. It blows me away that this continues to happen in the city."
Mesnick and @cleanupwestsoma want to send a message to city officials about what's happening in their neighborhoods. They often tweet at San Francisco Mayor London Breed, who took office in a special election in July after the death of Mayor Ed Lee.
"You know what? I already had the message, as a native San Franciscan, as someone who's been here all my life," Breed told CNN. "It isn't acceptable."
Breed, 44, made tackling homelessness and drug addiction a signature of her campaign platform. She says the city has been making changes since she took office, and that they're slowly starting to have an impact. "It's not an unsolvable problem," she said.
Last week, the mayor announced a detailed plan to direct a $181 million cash windfall the city received from the state to homelessness, affordable housing and related problems. The proposal includes nearly $20 million to be spent on beds for patients who have addiction and mental health problems. An additional $4 million would go toward expanding street cleaning.
And Breed says visible progress has already been made.
"If you walk with me right now, you will see the difference," she said. "You'll see more police officers. You'll see the homeless outreach team. You'll see people power-washing on a regular basis and picking up trash." Tent encampments are down by 27% since she took office, she said.
Kevin Schwing, who works in SoMa, said that despite the city's efforts, he doesn't see a change in the numbers of people on the streets.
"I don't really know what the city can do," he said. "The city cleans up sidewalks every day. But I don't see any difference in terms of the amount of people."
"I see human waste. Injections. Probably 10 times per day," he said. "Sometimes people look like they're dead."
Breed says the city is cracking down on drug dealing, and aims to open at least 1,000 new shelter beds by the end of 2020.
And she's looking at new ways to approach these entrenched problems, she says. Breed supports safe injection sites -- facilities where people can inject heroin in a private setting and under the supervision of health care workers. The sites would "not only be a way to get people off the streets and get the needles off the streets, but to get people into treatment," Breed said. California Gov. Jerry Brown vetoed legislation earlier this year that would have allowed safe injection sites in the state.
She also supports conservatorship programs for the severely mentally ill, which would allow the state to "make decisions for them in order to place them into mental health stabilization beds, instead of our criminal justice system." Gov. Brown recently signed a bill that would allow such action to take place.
Breed says she hopes the "video vigilantes" tag 311, the city's non-emergency complaint service center, in their posts. The information they're putting out helps the city address challenges in specific neighborhoods, she said.
The city's Department of Public Health recently partnered with the San Francisco AIDS Foundation, essentially hiring contract workers to fan the streets and collect used needles.
Crisis intervention teams have also stepped up their efforts to provide addicts with the drug buprenorphine, a narcotic to help reduce a person's addiction to heroin and other opioids.
"We go to people that are using drugs and offer them treatment instead of the traditional model which has people coming into a clinic," said Dr. Naveena Bobba, the department's deputy director of health.
The city has also launched the so-called "poop patrol," a team that responds to complaints of feces on city streets.
SoMa resident Alesia Panajota said she sees an impact. "They're doing the best they can," she said. "I think things are getting better under London Breed."
San Francisco may also see an influx of cash to help solve the crisis, after a controversial ballot measure passed in November. Known as "Prop C," the measure is viewed as a "homeless tax" -- it aims to raise $300 million a year to spend on homeless services by taxing big businesses.
Salesforce Chairman and Co-CEO Marc Benioff spent at least $7 million of his own money to help ensure Prop C's passage. "We have to say enough is enough," he recently told CNN.
But legal challenges could prevent the city from receiving the funds for several years.
In the meantime, Mesnick keeps posting. He recently put up a video interview with a homeless man talking about how difficult it is to find a place to go to the bathroom after dark.
"Help this guy," Mesnick wrote. "Keep the restrooms open at night? Perhaps we change usage of our space and make it a bathroom share? Better than on our front stoop..."
"We are in a severe epidemic here," he told CNN. "My angle may seem to be a little rough around the edges, but it's really about compassion."
- The impact homelessness and the opioid crisis are having on San Francisco streets
- See the opioid crisis plaguing San Francisco
- Inside the battle over San Francisco's homeless tax
- San Francisco voters approve homeless tax on businesses
- Opioid Crisis Fast Facts
- San Francisco Homeless Man Helps Save Gas Station Clerk From Strangler
- Tech CEOs Dorsey and Benioff face-off over San Francisco homeless tax
- Military Bazooka Turned In at San Francisco Gun Buyback
- San Francisco police officer donates kidney to save a stranger