Diagnosing “Keys Disease” — between paradise and hell on Earth, Florida’s Lower Keys fight to survive, from the railroad relics of Pigeon Key to Margaritaville

Pigeon Key, Florida. November 25, 2016. (Stefanie Fernández)

“Oh my god, we have to play Margaritaville,” I tell my father as we near the end of A1A in Key West. As far as I can tell, we’re driving on three highways at once. There is Florida State Road A1A, the state highway that runs from West Palm Beach to Key West and the namesake of the estimable but oft-forgotten 1974 Jimmy Buffett album — the only one in my father’s possession — upon which Jimmy sits on a lawn chair by the ocean drinking what conscionably can only be deemed a margarita. There is US1, the older sister to I-95, twin interstates, that begins in Maine. And then there’s the Overseas Highway, jutting out of the southernmost mainland of Florida, past the Everglades and the Last Chance Saloon, into the vast expanse of blue stretching south indefinitely.

Depending on who and where and when you are, you will choose one of these highways to take you down the Florida Keys. On that morning in August 2015, we were driving down A1A, the highway of Buffettian escapism and watered-down cocktails. We were listening to “Margaritaville” as we turned onto Duval Street, and we would stay for only one night. It was the kind of August in which my father needed a vacation more than in other Augusts, and we didn’t talk much about that on our brief vacation, choosing instead to discuss the man he was thirty years ago, remodeling hotels in Key West.

Behind us, A1A disappeared. All I saw was blue, the Overseas Highway, and the ghost of a defunct railroad that stops short of most islands throughout the Florida Keys today, the railroad that was once called the eighth wonder of the world, its gargantuan scaffolding slouching into the sea. A bridge to nowhere.

Beneath this massive testament to human labor lies a less impressive testament to human deterioration — in many ways, an unparalleled level of poverty, violence, substance abuse, and fear that afflicts so many of the flock that flew down to the Keys, in search of what Jimmy would call a “new life in the palm trees.” This phenomenon, known colloquially as Keys Disease, was described to me by one local on an online forum who preferred to remain anonymous under the username StarfishKey. “People come here from all over the country to escape reality, and their personal problems, in the ‘tropical paradise at the end of the road,’” StarfishKey wrote me. She’s no expert, merely a hobbyist, she insists — but in Florida, it’s often the non-experts that pay the closest attention. “The problem is, a large percentage of those people are escaping problems caused by substance abuse and mental illness in the first place. ‘Paradise’ doesn’t fix these issues, which are rooted much deeper than they realize.”

With its grueling heat, mosquito infestation, isolated geography, and limited resources, it’s a wonder the Keys were ever inhabited by outsiders in the first place. In 1904, however, Henry Flagler conceived of a different kind of escape. As the father of the Florida East Coast Railway and a former sales clerk before he struck oil, Flagler was the prime developer who pulled Florida out of the swamp and the mud. All along the Eastern coast of Florida, Flagler built hotels all the way down to Homestead, the southernmost settlement in Florida at the time and a precursor to what would later become Miami. And by 1905, when the United States announced the creation of the Panama Canal, Flagler lifted himself from his laurels to build a railroad across the sea — to Key West, an island of about 20,000 people and the closest deep-water port to Panama.

Make no mistake, this was not a passenger service; such services were reserved only for the very wealthy. This was a cargo train travelling south to a trading port of the world. The center of construction for the project’s most marvelous feat — the Seven Mile Bridge, from Knight’s Key to Little Duck Key — was Pigeon Key, an uninhabited island off the coast of what would later become milemarker 47 of the Overseas Highway, now unreachable by car or foot. On January 22, 1912, Henry Flagler took his first passenger trip down the last branch of the FEC, past the sparse population of Pigeon Key, toward his legacy.

Today, Pigeon Key remains frozen in time, forgotten for the most as people forge their own way south to Margaritaville. Outside, the Keys tremble with epidemic. Heroin use, increasing with a slow growl across the rest of the country comparatively, has more than doubled among adults between the ages of 18 and 25 in Monroe County from 2002 to 2013 according to the Center for Disease Control. 8,200 people fatally overdosed on the drug in 2013. The county’s death rate from suicide according to the state Department of Health is 27.7 per 100,000 residents, nearly twice as high as the state rate of 14.1 deaths per 100,000 residents. These numbers are the symptoms of the real Keys Disease: a vicious cyclone of circumstances — “lack of affordable housing, lack of jobs with livable wages and benefits, highest cost of government healthcare in the state (starting at around $400 a month for a young person with no history of smoking),” StarfishKey lists, “coupled with high rates of uninsured [people], domestic violence, homelessness, access to drugs and alcohol, little else to do but drink or get high and fish, Monroe County Sheriff’s Office arrest records, DUI fatalities, high rates of mental illness; as well as additional stressors like poor dating pool, high rate of skin cancer…” and the list goes on.

Despite so much community strife, in the broken glass, silent mangroves, and colossal iron railroad of Pigeon Key, I found a new window into the hubristic roots of a disease that, for better or worse, prompted Jimmy Buffett to sing in “Growing Older But Not Up”: “I’d rather die while I’m living than live while I’m dead.”

After a two-and-a-half-hour drive from Miami in November 2016, I step cautiously into a small ferry boat, and on our fifteen-minute ride I see Knights Key recede into a postcard — the old red traincar painted with the words PIGEON KEY VISITORS CENTER, a lighthouse that (until the Eiffel Tower was built) was briefly the tallest iron structure in the world, and innumerable fishing boats parked stalwartly, bearing honorable crests of FISH FEVER and DIRTY DIVER. And the Seven Mile Bridge, no longer tethering me south.

“First things first,” says our tour guide, Eric, before an audience of five people — three of whom are my party — much smaller than his performance anticipates. He pulls off his sunglasses, which rest neatly around his neck thanks to a sunglasses retainer, the badge of authority of the Florida Keys. “That’s first.” We chuckle.

Once seated on plastic picnic chairs placed idyllically in the shade of the Bridge, Eric drawls the first name of this place: “Cah-yo Puh-low-ma.” Or Cayo Paloma, as it was deemed by Juan Ponce de León and his cohort in 1513 before Flagler called it Pigeon Key. Paloma, meaning dove — or pigeon, bright or dark, lightning or the night — so called for the omnipresence of doves or pigeons that circled the island.

If the lesser islands of the Lower Florida Keys were tracks on the Jimmy Buffett album A1A, most of them would be without their own Wikipedia page — a “Life Is Just A Tire Swing” or “Trying to Reason With Hurricane Season.” Lignumvitae Key, a tree island whose namesake arbor’s unique scent is a natural mosquito repellant, was thought of by railroaders in Flagler’s day as the real paradise for “Nautical Wheelers.” Money Key, according to a 1969 article in the Key West Citizen, received its name because “pirate loot was found there; the actual amount was never revealed.” Today, as a privately-owned residence and big-budget film site, it reads like “Dallas.” Knockemdown Key is owned by retired Milwaukee Brewers pitcher Dave Voit, a “Tin Cup Chalice.” Indian Key, now uninhabited, holds a tiny ghost town and a handful of graves — “Stories We Could Tell.” And thousands of others — Don Quixote Key, Old Dan Mangrove Key, Anonimo Key, and the rest — will never be the stuff of Buffett songs. Pigeon Key would be “A Pirate Looks at Forty,” which does have a Wikipedia page, and probably strikes some chord among seasoned Buffettheads, though you’ve never heard of it.

Our pirate looks at his sneakers and white socks. He looks up and tells us, “Henry Flagler was richer than God.” After Hopewell, New York gave birth to an unmemorable Flagler, he was born again in Florida, the seat of his empire and the vector of his material gain. In 1908, Pigeon Key was inhabited for the first time by lonely railroad workers, searching for their own gain.

“Now, this was a lu-crative job.” On an average day, Flagler’s men would earn about $4.50 a day working on the railroad — about $120 by today’s standards, and their contracts were permanent — that is, most of them stayed until construction was completed in 1912. Flagler funded the railroad extension project with $50 million of his own wealth.

On a short walk between tour stops, I tell Eric I’m writing an article about this island, this bridge, and this Disease. He tells me he’s been interviewed by Norwegian newspapers, Los Angeles reporters, and fifteen Canadian journalists before me. “But I’ll tell you whatever you want.”

At critical mass, Pigeon Key housed over four-hundred laborers in addition to engineers, cooks, laundresses, and a handful of wives. Most had no families. They lived in dormitory buildings, ate in the section gang’s quarters that now serves as a mess hall for kids in 8th grade and above at Pigeon Key’s science camps, the primary source of funding for the island’s upkeep today. Each month, 4.5 million gallons of fresh water were transported to the island, for drinking and cement-mixing only; hygiene was not part of the budget. All eight structures on the island were built three feet off the ground to protect against hurricane storm surges and flooding. After devastating hurricanes in 1906, 1910, 1911, 1935, and beyond threatened the survival of the project and its laborers, Eric boasts the pride of their construction, their “glass not shattered” through so many natural disasters, and the impenetrable hardwood pine of its frame. “Verrry, verrrrrry sturdy.” Alcohol was expressly forbidden by Flagler, but what he couldn’t know wouldn’t hurt him. Paths, or “streets,” between the few buildings were named after avenues in the hometowns of workers across the U.S. or in Spain, a small piece of home.

Census data from 1910 tells us that most of the railroad workers came from across the United States — from 21-year-old engineer and launch Edward Frederick of Minnesota to 55-year-old widowed steward and cook Thomas Carleton of Ohio — and Spain, whose men mostly bear the title of “laborer” rather than “engineer.” 211 people total lived on this five-acre island, 28 of whom were Black cooks and laundresses, and only 14 women, wives and daughters of the lucky few families of supervisors. One daughter, Priscilla Pyfrom Coe of the Coe family (the first to live on Pigeon Key), described the island as a “magical place where children could spend hours finding shells, fishing, swimming, and enjoying a special childhood.”

For others, however, life on Pigeon Key wasn’t so magical. Stanley Livingston, a supplyman on the railroad from 1909 to 1911, remembered most vividly the mosquitoes and the hurricanes that plagued daily life. Livingston lived through three hurricanes that nearly destroyed the labor camp, his home, and segments of the railroad; in his later life, he retreated to the Florida mainland. The constant threat of malaria, Livingston recalled, was combated by laborers with an “occasional” swig of whiskey, which quickly became a problem on the Key, as Flagler had expressly forbid all alcohol from the island, believing it would slow down his men. When a boat called the “O.B. Roberts” anchored off the shore of Pigeon Key bearing thirty cases of whiskey and beer, Livingston requested they move to Little Duck Key. Dozens of men flocked to the island, desperate for a cure.

Maureen Kempa, Area Director for the Guidance/Care Center of the Upper, Middle, and Lower Keys, tells me of a similar desperation a century later. Kempa has been working in treatment for mental health and substance abuse in the Keys for over fifteen years. She is not a Florida native; she was born in Chicago, and came to the Keys in 2004. Kempa started as a therapist, then Program Coordinator, and now Area Director for the Keys branch of the Guidance/Care Center, a subsidiary of WestCare Foundation, a national nonprofit that provides a variety of behavioral and mental health services at three sites in Key Largo, Marathon, and Key West. The center offers over 20 treatment programs — “everything from substance abuse prevention to assisted living for the mentally ill” — and is the only Medicaid provider for psychiatric treatment in the Keys, as well as the only clinic besides the hospital that has crisis and stabilization units.

Kempa tells me that she and the clinic are accustomed to treating “the whole gamut” of patients: “from very young children to people in nursing homes.” The Marathon location — the closest to Pigeon Key — is the only inpatient facility, and none offer residential care. “There is no [treatment center] in the Keys for adults or adolescents that is fully residential,” she shares. “For that, you have to go to the mainland.”

A common misconception among Keys residents is that the barrier to curing Keys Disease is a lack of treatment centers in general — not the residential ones. Kempa clarifies that this is not the case. “Part of the problem is that the Keys is rural,” she declares flatly. The isolation of paradise is its beauty and its curse. “There aren’t a lot of [healthcare] providers because it’s a rural area.” It’s not as if those in need of treatment aren’t aware of the resources available to them, either. “Over 600 people in Miami-Dade and Monroe Counties are waiting for residential treatment on any given day,” Kempa continues. Because clinic space is limited, people seeking treatment have a better chance of admission if they have a representative recommend their case. “You have to get on a list, and everybody’s vying for the same bed. Every [representative] has to call at 10:00 AM, and if you call at 10:05 that bed for your client that bed might be gone,” Kempa tells me.

Once patients are admitted and treated in local facilities, however, Kempa tells me that “there’s nobody to refer [patients] outward to maintain them” — that is, to assure their wellbeing outside the treatment facility. The grant funding from the South Florida Behavioral Network, the managing entity of state funds that allows clinics like the Guidance/Care Center to treat patients and ideally provide residential care, remained notoriously stagnant under Rick Scott’s former governorship amidst rising state and national opioid and mental health crises. For some patients, this means relapse. “It’s a difficult environment,” Kempa says. The cost of living in the Keys is high due to high property values for vacation homes, and with housing at a premium, “there’s not housing for clients or staff,” Kempa explains. “We’re losing staff. Clients are not able to stay in the facility.”

She also makes sure to correct me in my assumption that the symptoms of Keys Disease are limited to Monroe County. “The Keys have the same problem that they have in Miami and other areas — lack of housing, a high cost of living. Salaries are low.” In Kempa’s opinion, the national introduction of the Affordable Care Act in 2010 hasn’t made much of a dent in helping patients get coverage. “I personally think it’s the same [as it was before],” Kempa confesses. “Down here we still have 48 percent of people uninsured. People can’t afford the premiums.” It is life’s natural stressors, exacerbated in the strangled chain of islands that Henry Flagler unified, that cause people to relapse and fall into substance abuse.

Not to mention that Buffettian romance that plagues Monroe County. A friend of mine, Victoria, tells me bluntly of the weekends she spent in her family’s second home Key Largo: “My family would come home from fishing trips drunk off their asses because that’s what you do on fishing trips.” Kempa shared also that the majority of substances are provided to users, especially adolescent ones, by family or friends. In addition, Monroe County has gained a reputation for being notoriously slow to process DUI infractions, and so people believe they can get a DUI and “get away with it.” People’s senses of substance “abuse” are warped, Kempa believes. “Parents say things like, ‘well, they’re smoking weed, but at least they’re not drinking.’” Kempa combats these cultural symptoms in her work outside the Guidance/Care Center as the president of the Monroe County Coalition. Through local campaigns like “In No One’s House” and “Parents Who Host Lose the Most,” Kempa hopes that the community has begun the work of healing despite the daunting statistics.

StarfishKey, in our informal correspondence, makes sure to tell me that no one is immune to the Disease. “People come here to escape their problems and find a world of new ones, compounded with an already fragile disposition, and it sends them over the edge into utter hopelessness,” she writes. “After all, if you can’t be happy in ‘paradise’ or ‘heaven on Earth’ the problem must be YOU, right? Because everybody else seems so happy, and their lives so easy, and they have so much money and all that…living the Keys dream. And you can’t even afford a small boat to ever see the water, nor keep a job or place to live, and there is no one to be close to, but plenty of people to gossip about you…” What cure remains?

Once at the Pigeon Key museum, the last stop on our tour, Eric pauses by a display case of ancient glass bottles found in the surrounding waters of the Key. He unlocks the case, and pulls out a brown bottle. “I [found] a bottle like this…that read GLOVER’S IMPERIAL BLOOD PURIFIER,” he says, like this is a normal thing. “Now what would you imagine blood purifier to be?”

My dad chimes in. “Other than Jack Daniels, I have no clue.”

“Well, it wouldn’t be whiskey because that comes in a bigger bottle,” Eric explains. “If I had to guess? It would be morphine.”

Our faces express a unanimous oh.

“Back then, all they had was morphine. And believe me, they used it. They used it.” Oh. “Anybody that wanted to be a junkie back then could go to the pharmacy and say ‘Hey, I want some morphine,’ and the pharmacist would say ‘how much?’”

Sometimes, newer bottles wash up on the shore. Brown. Green. “They got a real drinkin’ problem down here,” Eric tells me. And syringes. “Heroin, too.”

After this digression, Eric encourages us to take a look around the museum, explains that he is a volunteer for the island, and takes a seat, ending our tour. A black cat comes out of the woodwork and hops into Eric’s lap. I ask where it came from.

“Well you know in Big Pine, they have these miniature Key Deer?” Sure. I begin to remember this cat from the Pigeon Key Foundation’s website, where he is listed as the island’s Leisure Coordinator. “Here on Pigeon Key we have one miniature black panther. Watch this.” He carries the cat in his arms like a baby and scratches him. “Some people like to call him Buddy, I like to call him TC. That Cat.” We are charmed. “I’ve been holding him like this for twelve years.”

After my own strange entry into this island, and the long hours spent by the strangers he taught us about, I ask Eric how he ended up here. He still looks tall sitting down, like a shirt stretched long when it’s hung out to dry.

“Well, fourteen years ago I was diagnosed with Multiple Sclerosis. That’s why I keep sittin’ down. That’s why I’m a volunteer. I was waitin’ tables when I got sick, and… MS and restaurants don’t go together,” he tells my dad and I. Oh.“So I had to find somethin’ that I could do where I didn’t have to walk fast, or carry stuff. I never, ever in my life tried so hard to get a job as I did this one.” Eric explains that in Marathon, the biggest town near here, he was used to getting hired on the spot in his previous jobs. “Quality, sober help that’ll show up? On time…? They wanted me to go to work right now,” he laughs.

When I ask him if he’s from Marathon, he chuckles a no as if I’d asked him if pigs could fly yet. “No, I came here for the winter. Twenty-two years ago.” His hometown is a drawled Fort Braaaaagg, North Carolina. He doesn’t linger on the subject.

“I came here on vacation. I never left.”

On our only night in Key West in August 2015, my dad and I drank Coronas as a dreadlocked white man in his fifties sang Buffett karaoke with three sunburnt, poloed tourists. We made up stories about them beneath the tiki roof. Who was flirting with whom. How long his locks had been dreaded.

The next evening, as we drove back up the Seven Mile Bridge, I saw Pigeon Key to my left, the defunct railroad-highway that was closed in 1979, just a fishing pier now.

A year later, I ask Eric what will happen to it.

“What do you mean?” he asks.

“I mean, what happens now? Does the decay of the bridge harm the environment at all? Are there people that take care of its removal? Are we just going to let it fall into the sea — ”

“It ain’t gonna fall,” Eric interrupts, shaking his head with a smirk. We sure are a ways from Margaritaville. The mangroves that surround the island at every edge reach upward toward the massive concrete body. Even Jimmy acknowledged in “A Pirate Looks a Forty” that “one of the inescapable encumbrances of leading an interesting life is that there have to be moments when you almost lose it.” And for all the bodies that Keys Disease has stolen in the past century, its population remains a testament to survival and salvation. In the quiet air of Pigeon Key, I don’t hear a single sign of life outside it.

Eric repeats: “It ain’t gonna fall.”

This story was last updated in March 2017.

I devote my work to the uplift of marginalized voices. I’m a producer of events at The Atlantic and curate NPR Music’s weekly new Latin music column.