Daniel Tsai, Mayor Daniel Lurie’s choice to lead the Department of Public Health, has a blue-chip résumé: After studying at Harvard University, he landed a prestigious consulting gig before jumping into government, leading Medicaid programs in Massachusetts, then federally under former President Joe Biden.
Along the way, Tsai, in his capacity as an employee with McKinsey & Company, helped to market a powerful painkiller called tramadol during the company’s years-long streak of pushing opioid sales. The company’s actions ultimately led to a criminal probe, more than $1 billion in settlements, and a public mea culpa over its role in fueling an overdose epidemic that has killed more than 500,000 Americans over 25 years.
Tsai’s actions at McKinsey are detailed in a tranche of documents that were released as part of a settlement with the consulting firm in which it was accused of accelerating opioid sales despite growing awareness of the risks.
The records show that Tsai — who worked for McKinsey from 2007 to 2015, according to his LinkedIn page — helped develop a marketing strategy for tramadol sold under the brand name Ultram ER, an effort that involved cultivating relationships with doctors who became prolific prescribers. The records are housed at the UCSF-JHU Opioid Industry Documents Archive.
In a March 2008 PowerPoint presentation, Tsai outlined a marketing strategy for the drug that included guidance on targeting “specific physician segments to grow high-prescriber group (i.e., physicians more sensitive to patient needs)” and an idea to introduce “coupons” for the drug as part of a pilot program.
“We hope to be interviewing some high-prescriber physicians next week,” Tsai wrote in an email the same month, attaching a list of questions that could be used to screen doctors.
Lurie’s office defended Tsai’s appointment as Public Health chief. In a statement, the mayor’s office wrote, “Nearly 20 years ago, Dan Tsai was a 23-year-old entry-level staffer assigned to conduct research for a project at work. He has spent nearly his entire two-decade career supporting those struggling with homelessness and addiction and helping tens of millions of our most vulnerable neighbors access critical medical care, and he will continue that work in San Francisco.”
Several drug and homelessness service providers in the city said they were disappointed by a lack of transparency surrounding Tsai’s appointment process. The revelation of his past role at McKinsey intensified those concerns, they said.
“You’d want a public health official of that caliber to articulate what his participation was in that role,” said Laura Guzman, director of the National Harm Reduction Coalition. “This is an important moment to bring in people with federal bureaucracy expertise. But if [Lurie] wants to address the lack of treatment, we need leadership with expertise in evidence-based interventions.”
Others were less diplomatic in their reaction to the news.
“Holy fucking shit,” said Liza Murawski, co-chair of the city’s Behavioral Health Commission, when told of Tsai’s role at McKinsey. “Why would he be the director? Why don’t you have someone in there who’s a mental health expert?”
It wasn’t immediately clear who Tsai’s client was when he was marketing Ultram ER. The brand, which has been discontinued, was developed by a Canadian company and licensed to a subsidiary of Johnson & Johnson in 2005, according to PharmaTimes.
Experts say tramadol was initially thought to be less harmful than OxyContin, another product McKinsey marketed for Purdue Pharma. But that view has changed.
Tramadol is a Schedule IV drug — in the same category as Xanax, Valium, and Ambien — and has more recently been linked to addiction in Africa. “It was seen as this alternative,” said Dr. Rachel Sussman, a South Bay-based addiction medicine specialist. “It is just as risky and just as dependency-creating as any other opioid medication.” In fact, the drug carries more complications than some other opioids, including a risk of seizure and negative interactions with antidepressants, said Sussman.
Dr. David Juurlink, an expert on tramadol, called the drug a “minor player in the opioid crisis, but a player nevertheless.”
He added, “To the extent that McKinsey helped advertise it as a notionally safer opioid, I think they did a disservice in doing so. The main reason I say tramadol is a minor player is because it wasn’t prescribed like candy, like OxyContin was.”
McKinsey’s method of targeting high-volume prescribers was part of its playbook to juice opioid sales, despite mounting evidence that the drugs could be highly addictive. In other emails uncovered in the McKinsey documents, employees wrote excitedly about finding doctors who were willing to write opioid prescriptions. In one instance in 2015, a McKinsey partner wrote, “The challenge which we need to start working on is to identify the sweet spot of docs so we can do targeting. … Fun be[g]ins on Monday!”
San Francisco’s fentanyl crisis is part of a broader trend of opioid overdoses that traces back to the 1990s, when prescription opioids became popular among doctors for chronic pain management. Companies such as Purdue Pharma, which manufactured OxyContin, brought in consulting firms like McKinsey to help with sales strategies. After a Department of Justice probe and settlement, McKinsey acknowledged that it knew the dangers of OxyContin but continued working with Purdue Pharma — even after several of the drugmaker’s executives pled guilty in 2007 to misrepresenting addiction risks.
McKinsey, along with a slew of drug companies and pharmacies, agreed to pay billions in settlement funds over their roles in fueling opioid addiction. California received roughly $60 million from the 2021 McKinsey settlement. San Francisco, under the 2023 settlement of an opioid-related lawsuit, was expected to receive about $230 million from Walgreens.
In both instances, the funds were slated to be used for opioid recovery efforts.
In 2019, McKinsey said it would no longer work on opioid-related businesses. Last year, McKinsey formally apologized for its Purdue Pharma work, saying it was “deeply sorry” for its role in selling OxyContin. “This terrible public health crisis and our past work for opioid manufacturers will always be a source of profound regret for our firm,” the company said in a statement.
At the San Francisco Department of Public Health, Tsai replaced Dr. Grant Colfax, who took the reins in 2019 and led the city through the pandemic before stepping down in January. The role paid $546,133 in 2024, one of the highest city salaries.
On Monday, the San Francisco Health Commission unanimously nominated Tsai as director of Public Heath. Dr. Laurie Green, president of the commission, said the governing body conducted a “multi-hour” interview.
“In the interview with Mr. Tsai, the Health Commissioners focused on his preparedness to address the current public health challenges facing San Franciscans and his ability to sustain the Department through a potential tumultuous time ahead,” Green wrote in a statement. “This includes his unique expertise in Medicaid funding and programs, in addition to healthcare innovations and transformation.”
Tsai is expected to work with Kunal Modi, another McKinsey alum, whom Lurie has tapped to lead the city’s response to health and homelessness. In a statement this week, Tsai highlighted the city’s opioid and homelessness crises and said he was looking forward “to partnering with stakeholders and individuals with lived experience to find new, data-driven approaches to tackling this important challenge.”
Representatives of McKinsey did not respond to a request for comment.
Richard Beal, director of recovery services at the Tenderloin Housing Clinic, said he appreciates Lurie’s early focus on the fentanyl crisis and remains optimistic about Tsai’s appointment.
“Just like [Tsai] distributed the drugs, maybe he can distribute the solution to the drugs,” Beal said. “Hopefully, he can use the knowledge he has from helping to create the monster to figure out how to solve it.”