The young woman, an intravenous drug addict, lay dying in Miami’s Jackson Memorial Hospital when Hansel Tookes entered her room. She had been infected with HIV and hepatitis C, and was battling a devastating lung infection and an abscess on her spinal cord.
Although Tookes was then only a third-year medical student at the University of Miami, the cause of the infection wreaking havoc on her body was clear to him: a dirty needle.
The year was 2012, and Florida was one of 17 states with no legal way for intravenous drug users to exchange dirty needles for clean ones. Cities such as Los Angeles, New York, Chicago, Seattle and Boston have long allowed people to obtain clean drug paraphernalia anonymously to help combat disease, but politicians in many other parts of the country have refused to introduce this policy. They argue that doing so would weaken their fight against illegal drug use by tacitly condoning it.
Overtown, a neighborhood just northwest of Miami’s gleaming downtown, was home to open-air drug markets and legions of junkies. Used needles littered sidewalks and vacant lots. Addicts desperate to shoot up the dope they had just purchased often didn’t want to pay extra to dealers for clean needles - if they were even offered. So they simply picked up a needle from the ground and stuck it into a vein. The sometimes-dull, always-unsanitary needles often caused painful abscesses and terrible infections.
By the time Tookes was in medical school, South Florida had the nation’s highest rate of new HIV and hepatitis C infections. Tookes saw resignation on the part of Miami doctors who had been treating drug users. They had given up hope that legislators in Tallahassee, the state capital, which is as staid as Miami is freewheeling, would ever legally permit people to exchange soiled needles for clean ones.
A yoga aficionado whose wide smile is framed by a close-cropped beard, Tookes was too idealistic and too young to resign himself to what he deemed “a manifest injustice.”
He was propelled by the memory of the young woman he saw in the ward at Jackson Memorial. In his eyes, her death had been totally preventable.
And he was inspired by the barrier-breaking example of his grandmother, the first African American to become the head nurse at the Veterans Affairs hospital in Miami.
His quest would span four years - and face a wall of opposition.
Through it all, Tookes refused to give up. “It was the fight for justice that kept me going,” he says.
“They’re all people. They’re not injection drug users - they’re people who inject. They were being completely ignored, like their lives didn’t matter. And that completely enraged me.”
One of the first people Tookes met in Tallahassee was Tim Stapleton, the chief executive of the Florida Medical Association, the lobbying organization that represents 22,500 physicians in the state. Getting the group on board was key to winning over legislators.
When Tookes made his case for an exchange program at their initial meeting in early 2013, describing in grim detail what was occurring in Miami, Stapleton was at first dismissive.
This is not gonna happen in Florida, he thought.
As Tookes continued to press his case, however, Stapleton began to think that he should help the young medical student. “I was convinced by his passion,” Stapleton remembers. “Here’s a person who is in medical school. He’s busy. He could be doing a lot of other things. But he’s chosen to give his time to this cause. It caused me to dig deep in my heart and say, ‘Why am I doing what I’m doing?’ It’s because of people like Hansel, and I owe it to him to see what I can do to help.”
Stapleton introduced Tookes to the association’s board of directors. Despite opposition from some members, a majority reacted as Stapleton did: Tookes won them over, and they decided to throw their support behind needle exchanges in the state. But their backing was just the first step in an arduous legislative journey. A bill would have to be written, sponsored, debated in committees, and then approved by both houses of the state legislature.
“I thought, he’s going to fizzle out,” Stapleton says of Tookes. “He’ll become discouraged. He’ll see that the obstacles are too hard to overcome and he’ll figure out another way to help people without having to go through this arduous process.”
But “every time he hit a wall, he figured out how to get over it,” Stapleton recalls. “He wasn’t going to let anything stop him.”
Tookes kept making the seven-hour road trip to Tallahassee when the legislature was in session, often bringing medical student friends with him. To save money, they crowded into one hotel room and bedded down in sleeping bags.
Stapleton grew impressed with Tookes’ courage to walk up to legislators he had never met and ask them to support the bill. Some listened politely. Others brushed him off. “He wasn’t intimidated by anybody,” Stapleton says.
Tookes initially tried to enlist legislators by describing the public-health crisis unfolding in Miami. That worked with those who represented South Florida and other urban areas where intravenous drug use was rampant. But those who hailed from rural communities in the central and northern part of the state, where the heroin epidemic had not yet burst into public view, remained unmoved.
Once he found a sponsor to author legislation permitting needle exchanges, the bill languished in committee. Then the state’s former surgeon general sought to torpedo it. As did the Florida Sheriffs Association.
With Stapleton’s guidance, Tookes narrowed the scope of his request: Instead of asking for needle exchanges statewide, he agreed to start with a pilot site in Miami. And he mounted a new argument: The exchange, he told skeptics, would save state taxpayers money.
“It costs $380,000 to treat somebody for a lifetime of HIV, and $80,000 for a cycle of the new hepatitis C drugs,” he said at a state senate hearing. “As these patients rarely have private insurance, the costs fall directly on Florida taxpayers.”
That won him new converts. As did news reports of growing intravenous drug use in small towns across the state. By 2015, the national opioid crisis had hit Florida hard, and legislators from rural areas began reconsidering their opposition.
“He managed to bring people from both parties together,” says Oscar Braynon II, a Democratic state senator from Miami Gardens who sponsored the exchange bill.
“People that saw this as a real crisis, period. People. Not Democrat, not Republican, just people.”
“People that saw this as a real crisis, period. People. Not Democrat, not Republican, just people.”
In March 2016, after vigorous floor debate that included graphic descriptions of people who had fatally overdosed, both houses of the legislature passed the bill, and the state’s Republican governor, Rick Scott, unexpectedly signed it into law. Despite his four-year campaign, it was an outcome for which Tookes had not prepared.
The bill authorized one exchange, in Miami-Dade County, but it provided no funding for it. If Tookes was to realize his dream, he would have to raise operating funds, which he estimated at $200,000 a year.
As he called his former classmates to share the news - by then, they had graduated and entered residency programs - he thought to himself, What are we going to do?
His savior was a wealthy Bal Harbour philanthropist, Joy Fishman, whose late husband had invented the drug naloxone, the most commonly used medication to treat opioid overdoses. Although it is now used by paramedics and even ordinary people to revive dying drug users, it was not always easy to obtain.
For decades, the drug, which Jack Fishman had created in an effort to alleviate constipation caused by painkillers, was restricted to physicians, and many hospitals didn’t stock it.
Joy Fishman was motivated to help Tookes, by then a resident at Jackson Memorial, not just because she could afford to write a check. In a cruel twist of fate, her son, Jonathan, had died of a heroin overdose in 2003. The Florida hospital at which his drug dealer dumped him did not have naloxone in its cupboard.
Tookes’ mission to prevent other drug users from contracting serious illnesses resonated with her. “He wants what every parent of a child who is using drugs wants: to keep their loved ones alive,” she says. “Tough love doesn’t work. This is an illness. Treat it with a little gentleness. Treat it with a little kindness.”
Soon after the bill was signed into law, she hosted a fundraiser in her tony apartment overlooking the Atlantic Ocean. Tookes managed to raise $100,000 in one night, a sum that was matched by an AIDS fund created by the cosmetics giant MAC. “Wow,” Tookes said to the crowd at Fishman’s. “We’re actually going to do this.”
The exchange, which opened on Dec. 1, 2016 - World AIDS Day - is housed in two metal shipping containers in an Overtown parking lot. Staff members crowd into one of the trailers, next to shelves full of syringes, alcohol swabs, condoms, and aluminum spoons addicts use to heat heroin.
On the days the exchange is open, a steady stream of people walk inside. Clean-cut suburbanites in late-model cars. Strung-out guys who spent the night on a bench. Men and women. Whites, blacks, and Latinos. A cross-section of Miami.
Those who enter are granted anonymity, but their exchanges are tracked with a unique code so Tookes can keep accurate records. Participants are required to dump their dirty needles in a secure collection bin before they can receive clean ones.
Everyone is offered free HIV and hepatitis C screening, and they are provided information about free drug-treatment programs.
Demand for clean needles quickly surpassed Tookes’ expectations: Within six months, the exchange had logged more than 250 regular users. But he gauges his efficacy differently.
His measure of success is the sidewalks and freeway underpasses in Overtown. Each time he walks the streets, he sees fewer discarded syringes.
Another measure is the 16 lives saved in the first month since the exchange began handing out naloxone nasal spray in the spring of 2017. Distributing the drug wasn’t part of his initial plan, but the growing prevalence of a synthetic opioid called fentanyl has resulted in a spike in overdoses.
“So many people were dying,” he says. “We had a responsibility to do something about that.”
Dustin Jones, a balding, bearded 36-year-old from Tennessee, arrived in Miami in 2012 after years of on-and-off abuse of opioid pain pills. He had hoped to get a clean start.
Within a month, he was hooked on heroin.
When he went to Overtown back then, he recalls, “it was like something out of the movies.”
“There was people getting high on the side of the road. Cops driving by, not sayin’ anything to them,” he says. “They were smoking crack, shooting heroin. Before I had made it a hundred feet into Overtown, I’d been asked ten times if I wanted heroin.”
Before the exchange opened, Jones often would pick up a needle from the ground, try to clean it with bleach, and shoot up with it. “When you got a habit as bad as mine, you didn’t have a choice,” he says. “You do what you have to do.”
He says it was like playing Russian roulette. “Your first priority is to get another fix so you don’t feel sick anymore. But then you worry. ‘Oh, my God, did I just get HIV? Did I contract hepatitis?’”
Soon after the exchange began to offer naloxone, Jones took a box and stowed it in his backpack.
Within a few weeks, he saw a man lying passed out on the ground. His breathing was labored. A group of people stood around, not doing much.
“I’ve seen enough to know he was overdosing,” Jones says. “And he was almost out of there.”
Jones pulled out his vial of naloxone and squeezed a puff into the victim’s nose. Within a minute, the man’s eyes were open and he was attempting to sit up.
“We may be addicted to drugs, but we don’t want to die,” Jones says. “None of us do.”
As Jones left the exchange with a new box of naloxone, Tookes walked up to him in the sun-drenched parking lot.
“You did great with the Narcan,” Tookes told him, using the drug’s trade name.
“I saved his life,” Jones replied, beaming with pride.
Then an expression of humility washed over his face. He realized that the clean needles on which he relies and the box of naloxone were only there because of Tookes. “Thank you,” he said to the young doctor. “He wouldn’t be alive without you.”