Revenge of the Tipping Point: Overstories, Superspreaders, and the Rise of Social Engineering

by Malcolm Gladwell

If the world can be moved by just the slightest push, then the person who knows where and when to push has real power. So who are those people? What are their intentions? What techniques are they using? In the world of law enforcement, the word forensic refers to an investigation of the origins and scope of a criminal act: “reasons, culprits, and consequences.” Revenge of the Tipping Point is an attempt to do a forensic investigation of social epidemics.

Social epidemics are propelled by the efforts of an exceptional few—people who play outsize social roles

How your doctor treats you, in many cases, has less to do with where your doctor was trained, or how well he or she did in medical school, or what kind of personality your doctor has, than with where your doctor lives.

Wennberg and other researchers have found that small-area variation does not result from what patients want their doctors to do. It stems from what doctors want to do to their patients.

What he found instead were medical clusters, where the doctors in one hospital district took on a common identity, as if they had all been infected by the same contagious idea.

Whatever contagious belief unites the people in those instances has the discipline to stop at the borders of their community. There must be a set of rules, buried somewhere below the surface.

Canadian medicine is, in many ways, very different from American medicine. Canada has national health insurance, not a bewildering network of private insurers. In 2022, the United States spent 17.3 percent of its Gross Domestic Product on health care. In Canada, the equivalent number was 12.2 percent—about a third lower. In Canada, there is much more of an emphasis on asking whether expensive interventions are worth it. (That’s another of the reasons why Canadian doctors were so quick to adopt radial insertion: It’s cheaper than inserting the tube through the thigh.)

wonder about the impact that people like Rick Scott had on people like Philip Esformes. Scott used to be the CEO of the large national for-profit hospital chain Columbia/HCA. In 1997, federal agents raided Columbia/HCA. In the first wave of the investigation, five senior company officers were ordered to appear before a grand jury. What division of the company were they all from? You can guess: Florida. Scott was not charged in the case, nor implicated in any wrongdoing. But he was forced to resign in disgrace. And a few years later, Columbia/HCA pleaded guilty to fourteen felonies—involving kickbacks to doctors, false billing, making illegal deals with other providers, and on and on—and ultimately paid what was then a record $1.7 billion in civil settlements. Where did Scott end up moving after leaving HCA? You can guess that too: Florida. A few years after that, he decided to run for governor of… you guessed it: Florida, where he served two terms before moving on to represent… yes, Florida, in the United States Senate. For a portion of the years that Philip Esformes ran a billion-dollar scheme of kickbacks, false billing, and illegal deals, the governor of his state was someone who had presided over a hospital system that ran a billion-dollar scheme of kickbacks, false billing, and illegal deals.

Through his trial, Philip Esformes insisted that he was innocent. He refused to consider a plea bargain, which might have spared him jail. He didn’t say a word to defend himself until the sentencing hearing. He just sat there, while Willy and Gaby Delgado dug a grave for him. A: Philip had always told us that he had an ace up his sleeve… and he told me one day that he had connections to make things go away. Which he did, by the way. We saw things go away… Q: Let me stop you right there. So what did he mean—or what did you understand him to mean by he had aces up his sleeve…? A: Well, he said he had some government connections. There was a guy, Jeremy, [who] was connected to the government. I found out—my brother told me he gave a huge donation to a presidential campaign. So he was always throwing it around. Willy Delgado said that under oath in federal court in February 2019. In December 2020, Philip Esformes had his sentence commuted by Donald Trump.4 And where did Donald Trump move after leaving the White House? South Florida. Of course.

A monoculture, on the other hand, offers no internal defenses against an outside threat. Once the infection is inside the walls, there is nothing to stop it. Richard, the real-estate agent who knew Poplar Grove as well as anyone, understood this. He chose to live and send his daughters to school in neighboring Annesdale, the town that so many Poplar Grovians disdained. “It was a parenting decision,” he said. I felt like it was more “real world.” And there wasn’t as much pressure. [Poplar Grove] is notorious for this high pressure to be extraordinary. Be the best in the band. Be the best basketball player.… You’ve got to go to MIT. You’ve got, you know, I mean, this real intensity around being the best. That’s part of their reputation. My mom is a middle-school teacher [in Poplar Grove] and would talk about parents coming in and she’d given the kid a B and they were apoplectic that this is going to ruin their Ivy League chances.

The best solution to a monoculture epidemic is to break up the monoculture.

In the 1950s, many major cities of the United States faced a problem. African Americans were moving out of the South in greater and greater numbers, trying to escape economic frustration and the heavy hand of Jim Crow. But time and again, in the supposedly liberal cities they were moving to, white people wanted nothing to do with them. In some cases, that meant the newcomers faced intimidation and violence. In other cases, it meant that the minute black families moved into a neighborhood, white families just moved out. The term everyone used was white flight.

Quantitative analyses are called for in order to provide precise documentation of the points at which interaction shifts because enough people of the “other kind” have become members of a group… Exact tipping points should be investigated.

When the US Supreme Court issued its opinion, Harvard University released an angry statement. “We affirm that,” the school said: To prepare leaders for a complex world, Harvard must admit and educate a student body whose members reflect, and have lived, multiple facets of human experience. No part of what makes us who we are could ever be irrelevant. Harvard must always be a place of opportunity, a place whose doors remain open to those to whom they had long been closed, a place where many will have the chance to live dreams their parents or grandparents could not have dreamed. It would take a Jesuit to make sense of the many layers in that statement. But let us try. When the university says that “no part of what makes us who we are could ever be irrelevant,” we can assume it is referring to its determination that Harvard should always be a place where only one group gets to be above the Magic Third. When it calls Harvard an institution where “many will have the chance to live dreams their parents or grandparents could not have dreamed,” we can assume it is making a small, inside joke about the special deal it grants to the children of alumni. (What they really mean is the opposite: Harvard is a place where many have the chance to relive the dreams their parents and grandparents already dreamed.) And when Harvard says it wants a student body that represents “multiple facets of human experience,” we can assume it is referring to the extraordinary lengths the school goes to,...

Enter the aerosolists. One of the most important tools in the aerosol world is an aerodynamic particle sizer, or APS machine. It’s a box, fed by a funnel. It’s the human equivalent of the magic box that Donald Stedman invented for measuring the emissions of cars. If you breathe into it, it runs the air that comes out of your mouth through a series of lasers, which count the number and measure the size of every aerosol particle in your breath. In one crucial early experiment, William Ristenpart’s lab gathered a group of volunteers and had them breathe into an APS. The study subjects repeated vowel sounds. They shouted and whispered. They performed “vocalizations.” And the researchers confirmed what all those UFO sightings over the years had suggested: A small group of their sample was off the charts.

Airborne viruses do not operate according to the Law of the Few. They operate according to the Law of the Very, Very, Very Few.

Predicting or identifying people who might be high virus emitters, perhaps even before they are infected, is of interest because they could be prioritized for interventions to block transmission.

“OXYCONTIN IS OUR TICKET TO THE MOON.” 1. The opium poppy is a beautiful flower with a long stalk. After it blooms, the petals fall away to reveal a pod the size of a small egg filled with a thick yellowish sap. And for thousands of years, that sap has been the object of human fascination—a chemical cornucopia, in the words of one historian, “containing sugars, proteins, ammonia, latex, gums, plant wax, fats, sulphuric and lactic acids, water, meconic acid, and a wide range of alkaloids.”

Denmark and Finland, the chart tells us, started out with one of the worst problems in the group, but then things got better. Canada, the United Kingdom, and Australia have a steadily worsening crisis, but their overall numbers still lag behind the world leaders. And do you see that tangle of gray lines at the very bottom that barely rise above the zero mark? That’s Austria, Italy, Germany, Japan, the Netherlands, Portugal, Spain, and Switzerland. They never had an opioid crisis at all. Only one country has had a truly catastrophic experience with opioid overdose—the country represented by that thick line rising well above all the others. The United States.

Purdue’s management team read the Groups Plus report and took it seriously. The launch of OxyContin—one of the most sophisticated and aggressive drug-marketing campaigns the world of medicine has ever seen—was targeted at states without triplicate laws. So, no big push in New York State. But yes to West Virginia. No to Illinois. But yes to Indiana. No to California. But yes to Nevada. No to Texas and Idaho. But yes to Oklahoma and Tennessee—with the result that the opioid epidemic did not hit the entire United States equally. It became, instead, a perfect example of small-area variation. Opioids rained heavily only on those states where there was no triplicate program or Madden overstory to keep them in check.

Overstories matter. You can create them. They can spread. They are powerful. And they can endure for decades.

“I find that non-triplicate states at the time of OxyContin’s introduction experienced a relative rise in both property (12%) and violent (25%) crimes compared to states with the triplicate prescription policy (triplicate states).” In their analyses, economists are used to seeing differences of 1 or 2 percent. 25 percent is unheard of. “That’s an absolutely huge impact,” Sim continued. “Honestly, when I first got this result, I didn’t really believe [it] myself.”

The majority of doctors—the overwhelming majority of doctors—treated opioid painkillers such as OxyContin with appropriate caution. The medical community as a whole behaved admirably. They were thoughtful. They looked at the evidence. They heeded the wisdom of the Hippocratic Oath: First do no harm. But that was not enough to prevent us from the worst overdose crisis in history. Why? Because a tiny fraction of doctors was not so thoughtful. And that tiny fraction was enough to kick-start the epidemic. Once again we are well beyond the Law of the Few here. This is the Law of the Very, Very, Very Few.

Epidemics have rules. They have boundaries. They are subject to overstories—and we are the ones who create overstories. They change in size and shape when they reach a tipping point—and it is possible to know when and where those tipping points are. They are driven by a number of people, and those people can be identified. The tools necessary to control an epidemic are sitting on the table, right in front of us. We can let the unscrupulous take them. Or we can pick them up ourselves, and use them to build a better world.