It has become a grim annual ritual. Each winter for the last three years, religious leaders and social service workers have marched across this city's Tenderloin District to the solemn beat of a drum, pausing for moments of silence in places where homeless people have died.
This winter's march, held last month, made its first stop at Eddy and Mason streets, where Andrew Terry, 45, collapsed and died of alcohol-induced hypoglycemia on Feb. 2, 1987.
Next was St. Anthony's women's shelter at Jones and Golden Gate where Betty Jane Maslak, 58, died of heart disease on Jan. 12. Frank Joseph Stewart, 57, died on the same corner Sept. 6, the victim of multiple stab wounds.
The last stop was Hyde and Market streets, where Bruno J. Chiappolini, 39, was found May 14 dressed in the multiple layers of clothing typical of street people. He died of pneumonia.
Then, breaking with the purely religious format of past years, the group of about 50 walked to the Civic Center where they called on city officials to make caring for the city's estimated 6,000 homeless a higher priority.
The marchers did not visit other sites where at least 65 other homeless people died in the last 12 months ending Nov. 30, according to the annual survey of San Francisco coroner's records that prompted the vigil.
Shelter workers and health professionals who work with the homeless here say that these deaths reveal the shortcomings of a system that is only able to put a roof over the heads of about half of San Francisco's homeless on any given night. Health care programs for the homeless are largely administered through shelters, thus posing enormous difficulties for health and social workers trying to reach the "hard core" homeless population that never makes it inside.
Homeless people here fail to find shelter or make use of government services such as county health care programs for a variety of reasons: a shortage of spaces in shelters, poor coordination between government and agencies offering services, a preference for freedom outside the shelter, or health and psychiatric problems that prevent individuals from seeking aid when they need it most.
Often, several of these factors combine to keep those who are most in danger of severe illness or death from getting the assistance they need.
Mark Muenter, director of the St. Vincent de Paul Shelter near San Francisco's Civic Center, said that even proposed expansions of services here will probably fall short of solving the problem.
"They (city officials) talk about doing outreach, and, without trying to be negative or simple, I asked where they were going to put them when they had allocated all the money" for a van that would pick up homeless people, Muenter said. "There are not enough shelter beds, there are not enough hotel rooms in this city to take care of the homeless."
The 69 deaths recorded in the 12 months ending Nov. 30, 1987, represent a 28% jump over the 54 deaths verified the year before and are suggestive of the rising number of homeless people. In 1985, the first year the survey was done, 16 deaths were confirmed among the homeless.
In response to the plight of the homeless, Mayor Dianne Feinstein's administration has spent $7.5 million a year to put up 3,000 people a night, or about half of the city's homeless population, in 27 hotels and three shelters.
In the Los Angeles area, in contrast, only about one-fifth of the estimated 30,000 to 35,000 homeless find their way into shelters or hotels each night, government and private agency officials say.
The most recent survey of homeless deaths in the Los Angeles area was conducted by the Inner City Law Center in 1983. Center Director Nancy Mintie said the study examined county records and found about 200 homeless who died of a variety of causes including exposure, assault and disease.
Now, Mintie says, she would expect that number to be much higher.
Dr. Daniel Wlodarcyzk, San Francisco's medical director of health care for the homeless, said that those dying in the streets "are the really hard-core people who seem to be using a lot of alcohol and drugs." People in this group, unlike the majority of homeless who are not alcoholics or drug abusers, do not seek medical treatment "until the very end," Wlodarcyzk said.
Temporary shelters do not halt the cycle of homelessness for this population, Wlodarcyzk said. "It makes a big case for housing of a permanent nature" where substance abusers can be "completely removed from their environment to deal with their medical, psychiatric and employment problems," he said.
But not all of those who shun the city's homeless shelters and hotel rooms are substance abusers. Some homeless here say that staying outside is a deliberate choice to avoid what they consider substandard housing.
In November, two homeless men filed a suit in federal court that alleged that hotel rooms that San Francisco provides to the homeless are uninhabitable and asked that funding for the program be blocked. A federal judge rejected the suit on Dec. 30, saying that even if the buildings did not meet local health and safety codes, no federal civil rights or constitutional rights would be violated.
Feinstein, whose term will end Friday, said in an interview that the homeless problem "is much more complicated than anybody believes. What was thought to be a temporary problem, which really governed the establishment of our program, has turned out to be a chronic one. It becomes clear that just a room in a hotel won't solve the problem."
Feinstein said she would like to see the city adopt a more comprehensive, three-stage program now being developed. It would provide temporary shelter, then long-range shelter with personal counseling and job training and, finally, assistance in moving back into the community.
"It won't happen," said Bob Prentice, director of the Health Care for the Homeless Program, a grant-supported social service agency in San Francisco. "It's not even pie in the sky. It's pie in the mud."
Prentice said that Feinstein's proposal is little more than a continuation of current shelter programs.
"Essentially, what we've had is a lot of city money going to pay landlords of these single-occupancy hotels. What we haven't done is address the need for low-income housing."
Until housing is within the reach of people living on the $311 a month that San Francisco doles out in general assistance, Prentice said, no amount of counseling and assistance will solve the problem.
Prentice said he is optimistic that incoming Mayor Art Agnos, who was once a social worker, will make more headway in providing affordable housing.
The report on homeless deaths released last month was compiled from coroner's records by a weekly neighborhood newspaper, the Tenderloin Times. Coroner's office administrator Joseph Surdyka confirmed that the survey was "a true count" of those who had died in the city with no known address and whose clothing and circumstances seemed to indicate homelessness.
The survey paints a bleak picture of the harsh conditions under which the 69 homeless individuals lived and died in abandoned vehicles, vacant buildings, doorways and shelters.
Suicide was either proved or suggested in six of the 60 deaths for which coroner records showed a cause, according to the report. At least 13 of the deaths, from pneumonia, hypothermia, appendicitis and other diseases, could have been prevented through better health care and living conditions, medical authorities familiar with the survey said.
Warmer nights are a mixed blessing for L.A. homeless, as special cold-weather shelters are closed.