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SAN FRANCISCOSAFE INJECTION SERVICES TASK FORCE2017FINAL REPORT
SAN FRANCISCODEPARTMENT OF PUBLIC HEALTHDIRECTOR OF HEALTHBARBARA A. GARCIA, MPASan Francisco Department of Public Health101 Grove StreetSan Francisco, CA 94102For questions related to this report, please e-mail [email protected]: ember 2017SF SAFE INJECTION SERVICES TASK FORCE – FINAL REPORT2 of 14
TABLE OF CONTENTSMESSAGE FROM THE BOARD OF SUPERVISORS PRESIDENT4BACKGROUND6FACTS ABOUT INJECTION DRUG USE IN SAN FRANCISCO7TASK FORCE PROCESS OVERVIEW8TASK FORCE RECOMMENDATIONS9APPENDICESSF SAFE INJECTION SERVICES TASK FORCE – FINAL REPORT143 of 14
MESSAGE FROM THE BOARDOF SUPERVISORS PRESIDENTDear Fellow San Franciscans,Nationwide, the substance abuse epidemic is ravaging communities and taking far toomany lives. Sadly, the City of San Francisco is no exception. The Department of PublicHealth estimates the City is home to some 22,500 people who inject drugs andexperiences over 100 injected drug overdose deaths a year. We do not need numbers totell us how bad the situation is; we see the worsening conditions on our streets every day.You cannot walk from City Hall to Civic Center BART without seeing people shooting up inbroad daylight. Orange plastic syringe caps and used needles litter our sidewalks, notonly outside of City Hall, but in our neighborhoods. It is unsafe and it is unhealthy. As acaring City, we have an obligation to do better for those in need.I know the pain of drug abuse all too well. I lost my younger sister to an overdose. I knowhow difficult it is to get better, and how much help individuals in recovery need everysingle step of the way. San Francisco has long grappled with how best to serve peoplelike my sister. Yet, too many are still left to wither away on the streets without help,without solutions, and without hope.With our worsening heroin and opioid epidemic, we need to find real, innovative, andeffective ways of helping this population. It is simply not enough to provide voluntarydetox services or clean syringe exchanges; we need to provide a robust continuum of careand a welcoming environment for those struggling with drug abuse. We need a one-stopshop of wraparound services that provide hope for a healthier life and opportunities forrehabilitation. Safe Injection Services could potentially provide that opportunity.Through our Safe Injection Facilities Task Force, we learned that approximately 100 safeinjection sites now operate in over 65 cities around the world. No site has experienced anoverdose death and many have transitioned thousands of clients into detox services.Studies indicate that these services attract some of the most marginalized people whoinject drugs, promote safer injection conditions, reduce overdoses, enhance access toprimary care, and reduce public injection and outdoor syringe litter. More importantly, welearned that safe injection services have not increased drug injection, drug trafficking, orcrime in the surrounding area.A 2016 cost-benefit analysis of potential safe injection services in San Francisco foundthat the City would save 3.5 million per year if one safe injection program were opened,or 2.33 for every dollar spent on the services. Meaning, effective, alternative solutionscan end up saving taxpayer dollars while also saving lives.SF SAFE INJECTION SERVICES TASK FORCE – FINAL REPORT4 of 14
Still, I understand that some community members are unsure about this concept. I do notwant safe injection services to make it easier for people to use drugs. I do not want to seeneighborhoods divided, as some residents worry safe injection services might draw illegalactivity into their community. However, this is too big of an issue for us to rule out anypossible solutions. Inaction simply is no longer an option.Only together can we truly tackle this public health crisis and change the conditions on ourstreets. In this report, let us study the data, collaborate with one another, and takecollective action.Sincerely,London BreedSF SAFE INJECTION SERVICES TASK FORCE – FINAL REPORT5 of 14
BACKGROUNDNinety-one Americans die every day from an opioid overdose. In fact, opioid overdosedeaths have quadrupled over the past 20 years and is now a leading cause of death foradults under age 50.1 Two million Americans suffer from substance use disorders relatedto prescription opioids, heroin, and synthetics such as fentanyl. The availability of fentanyland its poisoning of drug supplies, in particular, poses additional concern due to its abilityto heighten the potency and toxic influences of heroin and cocaine when mixed. Themajority of overdose deaths from heroin and cocaine test positive for this additive.2Likewise, the rising toll of the nation’s opioid epidemic touches San Francisco. In recentyears, the city has continued to see overdoses from heroin, methamphetamine, andfentanyl and increasing attention has been placed on public injection drug use. Druginjection is a known risk factor for opioid overdose, and people who inject drugs havehealth needs that are of particular concern to public health. They are perilously at-risk forunhealthy substance use, the acquisition and transmission of HIV and hepatitis C, seriousphysical and mental health conditions, and premature death.Recognizing that addiction is a medical condition, San Francisco operates a continuum ofbehavioral health care services that range from prevention to treatment services andbases its services in the principles of harm reduction. Safe injection services represent oneevidence-based strategy that fits within this harm reduction model.In April 2017, the Board of Supervisors passed resolution #123-17 (Appendix A),introduced by Board President London Breed, urging the San Francisco Department ofPublic Health to convene a Safe Injection Services (SIS) Task Force to makerecommendations to the Mayor, the Board of Supervisors, and City departmentsregarding the potential opportunities and obstacles associated with safe injection services,the community need for such services, and the feasibility of opening and operating suchservices.In June 2017, DPH released its issue brief (Appendix B) covering topics requested by theBoard’s resolution, including: information on individuals who inject drugs in San Francisco; information on supervised injection services in other jurisdictions, including programmodels, effectiveness, and outcomes; potential risks and benefits of supervised injections services; and considerations for San Francisco regarding supervised injection services, includinglegal, community, and ntanyl-more-deadly-than-heroin/SF SAFE INJECTION SERVICES TASK FORCE – FINAL REPORT6 of 14
FACTS ABOUT INJECTION DRUG USEIN SAN FRANCISCOSF SAFE INJECTION SERVICES TASK FORCE – FINAL REPORT7 of 14
TASK FORCE PROCESS OVERVIEWPursuant to resolution #123-17, the Safe Injection Services Task Force was chaired byBarbara A. Garcia, MPA, Director of Health, and consisted of 15 members, appointed toseats identified by resolution.SAFE INJECTION SERVICES TASK FORCE MEMBERSNAMEAFFILIATIONErick ArguelloHolly BradfordSmall business ownerSan Francisco Drug Users UnionLydia BranstenLt. Troy DangerfieldSam DodgeMike DiscepolaDr. Vitka EisenBarbara GarciaTenderloin Health Improvement Partnership, St. Anthony FoundationSan Francisco Police DepartmentDepartment of Homelessness and Supportive HousingSan Francisco AIDS FoundationHealthRight 360Chair, San Francisco Department of Public HealthDr. Isaac JacksonDr. Alex KralWilma LongDr. Paula LumLaura ThomasJoe WilsonUrban Survivors UnionRTI InternationalHomeless Outreach TeamUniversity of California, San FranciscoDrug Policy AllianceHospitality HouseBarry ZevinSan Francisco Department of Public HealthThe Task Force convened three public meetings, between June 2017 and August 2017,and discussed specific focus areas identified by DPH through the review of publishedliterature and reports: types of safe injection service models, operations, services, location,and siting. The Task Force’s commitment, expertise, and contributions to developing thisreport and its recommendations are deeply appreciated and indispensable.In addition to Task Force members’ expertise, DPH sought to include a diverse set ofperspectives from an array of San Franciscans that included: a public online survey of business owners, neighborhood groups, and residents focus groups with business owners, neighborhood groups, and residents a survey conducted by HealthRight 360 with people in early recovery a community survey with people who inject drugs public comment at Task Force meetingsA summary of the surveys and focus group tools is included in Appendix C. Moreinformation on the Task Force’s meetings and materials can be found at the Safe InjectionServices Task Force webpage.SF SAFE INJECTION SERVICES TASK FORCE – FINAL REPORT8 of 14
TASK FORCE RECOMMENDATIONSThe following recommendations are the culmination of the Task Force’s work and areinformed by their diverse expertise, the local perspectives of people who inject drugs andthe public, and findings from independent research around the world. Therecommendations are intended to provide guidelines for the purpose of planning anddevelopment, and they are not designed to be mutually exclusive in supporting decisionmaking and implementation. They are organized by category below:1. Support creation of safe injection services in San Francisco.The Task Force’s overarching recommendation is to support the operation of safeinjection services in San Francisco. The rise in public injection drug use and its harmfulpublic health and safety outcomes has long reached critical mass in the City, and thisurgency is commonly felt by members of the Task Force and San Francisco residentsalike. Research consistently demonstrates that safe injection services are anevidenced-based harm reduction strategy that can address this public health issue.PROGRAM PLANNING & MANAGEMENT2. Recognize legal and real estate barriers to operating safe injection services anddevise necessary contingency plans.The possession of controlled substances – unless the possession is with the prescriptionof a licensed health professional – is prohibited by both state and federal law. Stateand federal law also prohibits building owners and operators from allowing themanufacture, storage, or distribution of a controlled substance, and criminal and civilpenalties may be imposed on all parties engaged in the property. San Francisco mustcontinue advocating for the passage of Assembly Bill 186 during the 2018 legislativesession – which would allow some counties to operate safe injection sites according tospecific requirements. In order to proceed with operating safe injection services, SanFrancisco must be deliberate in formulating a way forward for local agencies,community organizations, and building owners that includes local protections andprocedures to respond to potential legal repercussions.3. Conduct an assessment to determine the optimal service scale, site requirements,capacity, work flow, hours of operation, and staffing mix.In order to properly implement safe injection services in a potential area, a thoroughassessment must be completed to gauge the demand for services, needed capacity,and necessary operational components to ready a site and staff to operatesuccessfully. Preparing the right scope and size of a site is essential to supportingSF SAFE INJECTION SERVICES TASK FORCE – FINAL REPORT9 of 14
people who inject drugs, managing client flow, and optimizing the benefits to thesurrounding area.4. Design safe injection services as a safe, clean, and welcoming space for peoplewho inject drugs.Safe injection services are an opportunity to affirm the humanity and dignity ofpeople who inject drugs, and the space must reflect these values in providingcompassionate care and services. A hospitable and hygienic place that reduces thestigma and inherent dangers of public drug use will be more successful in buildingtrust, creating engagement, disseminating safer drug use practices, linking personswho use drugs to treatment, and improving health outcomes.5. Pilot small-scale integrated safe injection sites that can be flexible to emergingneeds.Allow for agility and flexibility at the onset of assessing and planning for a safeinjection site. While a site may begin operating at a smaller scale, anticipateopportunities to modify the scope and size of a site depending on emerging trendsand the needs of people who inject drugs and stakeholders in the surroundingcommunity.6. Ensure planning and implementation of safe injection services integrates clearprogram goals and metrics, including defined practices for data collection,monitoring, and evaluation to facilitate ongoing quality improvement processes.Develop an evaluation plan with clear goals and objectives to measure the success ofany safe injection services. It is critical to build in reliable data collection proceduresthat support active monitoring, evaluation and quality improvement efforts. Maintaintransparency with the public about the progress and impact of safe injection servicesin order to address concerns that may arise.MODEL7. Support an integrated model that includes on-site services and linkages to otherservices.An integrated model is generally the best fit for San Francisco's population andexisting system of care. It is consistent with DPH’s overall model and approach toconnected services which can optimize access to other important health and socialservices, linkages to substance use treatment services, and coordinating care forpersons with complex medical conditions.SF SAFE INJECTION SERVICES TASK FORCE – FINAL REPORT10 of 14
8. Incorporate a peer component in the staffing model.Research and feedback from people who inject drugs demonstrate the value ofincorporating people who currently or formerly inject drugs in staffing safe injectionservices. In addition to expressed preferences by some people who inject drugs, peerstaff are uniquely positioned to enhance the benefits of safe injection services byengaging those who encounter similar social and structural barriers to accessingsanctioned services. Harnessing their relationships with people who inject drugs andfamiliarity with experiences represents one of the most promising ways to leveragepeer networks and community expertise in addressing opioid drug use.9. Consider expanding the types of drug consumption allowed on-site.Individuals that consume drugs by other routes experience health disparities similar topeople who inject drugs. While injection drug use is the primary focus at this time,future considerations should explore expanding the types of drug consumptionallowed at harm reduction service sites.LOCATION10. Operate multiple sites throughout San Francisco.San Francisco would be best served by operating multiple safe injection service sitesin neighborhoods where public injection drug use, overdoses, and improperlydiscarded syringes most often occur. Having various sites would enable a distributionof capacity and greater penetration of services where people who inject drugs aremost likely to be.11. Locate safe injection services where drug use most often occurs.Safe injection services should be located near where public injection drug use mostoften occurs to best ensure they are used by the target population. Locating services inthese areas can offer the greatest benefit to the surrounding communities bypreventing improperly discarded needles, public overdoses, and other health andsafety advantages.12. Locate safe injection services where existing services are delivered to people whoinject drugs.Operating safe injection services where people who inject drugs already receiveservices can better ensure that safe injection services are administered by serviceproviders that have developed trusted relationships with people who inject drugs. Thislevel of engagement can increase the likelihood that safe injection services are utilizedand achieve success in linking people who inject drugs with treatment and otherservices.SF SAFE INJECTION SERVICES TASK FORCE – FINAL REPORT11 of 14
COMMUNITY ENGAGEMENT & EDUCATION13. Engage the public throughout the planning process to optimize the usage andbenefits of safe injection services to the surrounding community, including: people who inject drugs business owners stakeholders from potential neighborhood groupsneighborhoods San Francisco residentsPlanning for safe injection services must acknowledge a diverse set of communityopinions. It is crucial to engage residents and businesses in prospective neighborhoodsthroughout the planning process to develop common goals and objectives,troubleshoot concerns, and establish feedback loops for evaluation. Mechanisms forongoing public input, outreach, and education are vital to ensuring that thesurrounding community has a voice and constructive role in designing and supportingthe site. Importantly, the perspectives of people who inject drugs must be incorporatedto ensure the services are used and accomplish their purpose.14. Engage law enforcement, probation, and parole agencies to determine publicsafety priorities and strategies.These agencies must be fully engaged at all stages of planning, implementation, andevaluation to arrive at the careful balance of securing public safety while providingsafe injection services. Their involvement is critical in shaping the successful integrationof safe injection services in various communities.15. Partner with other city agencies and community organizations to developcollaborative, comprehensive, and sustainable harm reduction strategies.To meaningfully address injection drug use in San Francisco and the impairment anddistress that results requires robust and earnest collaboration across governmentagencies and community-based organizations. It is key that all parties commit to:sustaining funding and resources; cultivating cooperative and accountablerelationships; establishing clear roles and responsibilities; and equipping theirpersonnel with complementary, appropriate, and ongoing training.16. Develop a public-focused central information source and education campaign onthe benefits of safe injection services that also seeks to address stigma towardpeople who use drugs.Commit resources to outreach and educating the public on the purpose and goals ofsafe injection services, including their role as part of San Francisco’s continuum of harmreduction services and as a pathway to recovery for those seeking treatment. Such acampaign can serve to reduce stigma toward people who use drugs and facilitateengagement with communities to foster a supportive environment for a successfulprogram. The campaign should engage televised, audio, online, and social mediaformats, and leverage presentations at community meetings, social serviceorganizations, neighborhood associations, and other local gatherings. The City shouldSF SAFE INJECTION SERVICES TASK FORCE – FINAL REPORT12 of 14
establish a corresponding publicly-accessible and central information source thatprovides accurate and current information on harm reduction and substance usetreatment services.SPECIAL POPULATIONS17. Identify and commit resources for special populations that face health disparities,barriers to services, and/or risk for experiencing violence related to drug use,including, but not limited to: people of color LGBTQI women people in the sex trade transitional age youth recently/formerly incarceratedpeople people experiencinghomelessnessIt is important to identify the barriers and threats that members of many communitiesregularly experience that lead to heightened risks for injury and marginalization.Moreover, it is consistent with San Francisco’s enduring history of providingcompassionate care and services to extend culturally-appropriate and thoughtfulinterventions to people who inject drugs who are most vulnerable to harm.SF SAFE INJECTION SERVICES TASK FORCE – FINAL REPORT13 of 14
APPENDICESA. BOARD OF SUPERVISORS RESOLUTION: 123-17B. ISSUE BRIEFC. SUMMARY OF LOCAL SURVEY & INTERVIEW TOOLSSF SAFE INJECTION SERVICES TASK FORCE – FINAL REPORT14 of 14
APPENDIX A: BOARD OF SUPERVISORS RESOLUTION #123-17City Hall1 Dr. Carlton B. Goodlett Place, Room 244San Francisco 94102-4689Tel. No. 554-5184Fax No. 554-5163TDDffTY No. 544-5227BOARD of SUPERVISORSMEMORANDUMDate:April 24, 2017To:Barbara A. Garcia, Director, Department of Public HealthFrom: V ngela Calvillo, Clerk of the Board, Board of SupervisorsSubject:Urging the Department of Public Health to Convene a Safe InjectionServices Task Force (File No. 170353)On April 11, 2017, the Board of Supervisors adopted Resolution No. 123-17, sponsoredby Supervisor London Breed (File No. 170353, Urging the Department of Public Healthto Convene a Safe Injection Services Task Force); enacted on April 21, 2017.Please find the attached courtesy copy of the Resolution for the Department of PublicHealth's information and consideration.If you have any questions or concerns, please contact the Office of the Clerk of theBoard at (415) 554-5184.c:Board President Breed; Supervisors Sheehy, Ronen, KimDepartment of Public Health, Chief Financial Officer, Greg WagnerDepartment of Public Health, Deputy Director of Policy and Planning, ColleenChawla
I FILE NO. 1703531RESOLUTION NO. 123-17[Urging the Department of Public Health to Convene a Safe Injection Services Task Force]23Resolution urging the Department of Public Health to convene a Safe Injection Services4Task Force to make recommendations to the Mayor, the Board of Supervisors, and City5departments regarding Safe Injection Services.67891O1112131415WHEREAS, San Francisco has an estimated 22,500 people who inject drugs (PWID)according to the City's Department of Public Health; andWHEREAS, Injection drug use in San Francisco is responsible for approximately 100deaths a year from overdoses and continued health risks for thousands; andWHEREAS, deaths are often concentrated in high-poverty areas of San Francisco anddisproportionately affect African Americans,WHEREAS, The public, unsupervised use of injected drugs creates dangerous andalarming conditions in public spaces for residents, visitors and PWID themselves; andWHEREAS, As a city, San Francisco must acknowledge that more must be done to16promote public safety and that the public health risks from inaction are beyond what is17tolerable for a caring city, and18WHEREAS, On September 5, 2000, the San Francisco Health Commission19unanimously passed a resolution adopting a Harm Reduction Policy for the Department of20Public Health, and21WHEREAS, Harm reduction is a public health philosophy that offers multiple, non-22judgmental approaches to meet individuals "where they are" and assist them in their23movement toward better health, and.2425Supervisors Breed; Sheehy, Ronen, KimBOARD OF SUPERVISORSPage 1
1WHEREAS, The harm reduction model promotes methods of reducing the physical,2social, emotional, and economic harms associated with drug and alcohol use and other3harmful behaviors on individuals and their community, and45678g1OWHEREAS, Safe Injection Services (SIS), also known as Supervised ConsumptionServices, are an evidence-based harm reduction strategy that allows individuals to inject or, consume illicit drugs in a hygienic environment under the supervision of trained staff and haveopportunities to engage in other health and social services; andWHEREAS, SIS, embedded in a harm reduction-oriented system of care and supportservices, has the potential to address many of the concerns and issues listed above and isworth evaluating for their potential costs and benefits;11WHEREAS, SIS reduce overdose deaths for entire neighborhoods around the sites,12and there has never been a recorded overdose death in any of the nearly 100 sites around13the world, despite many overdoses in those sites; and14WHEREAS, SIS attract and retain a population of people who inject drugs and are at a15high risk for infectious disease and overdose, who are more likely to be homeless or16marginally housed, and who are at heightened risk for violence and trauma; and17WHEREAS, a 2010 study (Kral et. al.) entitled "Acceptability of a Safe Injection Facility18among Injection Drug Users in San Francisco" showed that 85% of the 602 people who inject19drugs that were surveyed said that they would use safe injection services, three quarters of20whom would use it at least three days per week; and21WHEREAS, SIS provide multiple health benefits, including reducing HIV and hepatitis22C risk behavior (i.e. syringe sharing); reducing the prevalence and harms of bacterial23infections; saving costs due to a reduction in disease, overdose deaths, and need for24emergency medical services; providing safer injection education, subsequently increasing25safer injecting practices; and increasing linkage to medical and social services; andSupervisors Breed; Sheehy, Ronen, KimBOARD OF SUPERVISORSPage 2
1WHEREAS, A 2014 systematic review concluded that, "All studies converged to find2that SIFs [Safe Injection Facilities] were efficacious in attracting the most marginalized people3who inject drugs, promoting safer injection conditions, enhancing access to primary health4I1care, and reducing the overdose frequency. SIFs were not found to increase drug injecting,5drug trafficking or crime in the surrounding environments . SIFs were found to be associated6with reduced levels of public drug injections and dropped syringes;" and7WHEREAS, A cost-benefit analysis of potential SIS in San Francisco (Irwin et al.,82016) found that the City would save 3.5 million per year if one SIS program were opened, org 2.33 for every dollar spent on the services; and1oWHEREAS, SIS have been supported by the Mayor's Hepatitis C Task Force in 2011,11the HIV Prevention Planning Council and HIV Health Services Planning Councils in 2015, and12the Human Rights Commission's community report on their hearing on the war on drugs in132014; now, therefore, be it14WHEREAS, The Mayor raised the issue in his 2017 State of the City speech, saying, "I15will continue to learn about the effectiveness of safe injection facilities. We must thoroughly16assess whether the public health and safety benefits outweigh any negative impacts"; and17WHEREAS, there is momentum at the state level to address issues around injected18drug use with California Assembly Bill 186, introduced by Assemblymember Susan19Talamantes Eggman and co-authored by Senator Scott Wiener and Assemblymember Laura20Friedman, would further allow localities such as San Francisco to explore the possibility of21such services and enhance legal protections for the operation and use of such services; and22WHEREAS, Other cities in the United States are actively evaluating the impact of SIS,23including Seattle, which has already decided to move forward with opening two sites,24Baltimore, Boston, Denver, Ithaca, New York City, Philadelphia, and Portland; and25Supervisors Breed; Sheehy, Ronen, KimBOARD OF SUPERVISORSPage3
1WHEREAS, There are approximately 100 SIS currently operating in over 65 cities2around the world in ten countries (Switzerland, Germany, the Netherlands, Norway,3Luxembourg, Spain, Denmark, France, Australia, and Canada); now, therefore be it4RESOLVED, That the Board of Supervisors urges the Department of Public Health to5convene a task force - and the City Attorney to advise the Department of Public Health in this6effort for the purpose of - advising the Mayor, the Board of Supervisors, and relevant City7departments regarding the possibility of operating safe injection services in the City; and, be it8FURTHER RESOLVED, That Board recommends that the task force consist of 15 or9fewer members chosen by the Department of Health from the following categories: (1) an10employee of the Department of Public Health designated by the Director of Health; (2) an11employee of the Police Department designated by the Chief of Police; (2) an employee of the12Department of Homelessness and Supportive Housing designated by the head of that13department; (4) a researcher with expertise in safe injection services and drug user health; (5)14a researcher or medical doctor with expertise in substance use treatment; (6) a homelessness15advocate or service provider; (7) a representative of a drug user advocacy organization; (8) a16I representative of a harm reduction organization; (9) a representative of a drug policy17organization, with expertise in safe injection services advocacy; (10) a representative of a18substance use treatment organization; (11) a small business owner in a neighborhood19affected by public drug use; (12) a medical clinician who works with people who use drugs;20(13) a representative of the Tenderloin Health Improvement Project; (14) a representative of21I the HIV Community Planning Council Substance Use Work Group; and (15) a representativei2223of the recovery community; and, be itFURTHER RESOLVED, That the Board urges the Department of Public Health to24convene the task force within 30 days of the enactment of this resolution and to submit to the25task force a report regarding the questions that the task force should investigate, including theSupervisors Breed; Sheehy, Ronen, KimBOARD OF SUPERVISORSPage 4
1potential opportunities and obstacles associated with safe injection services, the community2need for such services, and the feasibility of providing such services; and, be it3FURTHER RESOLVED, That the Board urges the task force to hold a series of public4meetings to solicit input from the public and from stakeholder groups, and to submit a report to5the Mayor and the Board of Supervisors within three months of its initi
DIRECTOR OF HEALTH BARBARA A. GARCIA, MPA San Francisco Department of Public Health . 101 Grove Street . San Francisco, CA 94102 . For questions related to this report, please e-mail [email protected] . San Francisco has long grappled with how best to serve people like my sister. Yet, too many are still left to wither away on the .
