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The Introduction to Revenge of the Tipping Point describes the purpose of the book. Gladwell’s first book, The Tipping Point (2000), examined different situations where a small, local action caused a large-scale phenomenon. In Revenge of the Tipping Point, Gladwell more closely examines the dark side of this effect. He starts with some transcripts of a judicial hearing, where three different witnesses who are part of an unnamed business empire each avoid taking blame for a widespread epidemic. The transcripts will be revisited again at the end of the book.

Chapter One: Casper and C-Dog

Chapter One discusses the epidemic of bank robberies that plagued Los Angeles in the 1980s and early 1990s. The chapter starts with a description of the Yankee Bandit, who robbed 64 banks in nine months. Later, two criminals named Casper and C-Dog orchestrated 175 bank robberies. Unlike the Yankee Bandit, who worked alone, Casper and C-Dog recruited schoolchildren to rob the banks, so they never had to be physically present at heists. Between 1980 and 1990, the number of bank branches in the United States tripled, so it would make a certain amount of sense that robberies rose dramatically. However, Gladwell sees a puzzle: Willie Sutton, a wildly successful (and famous) bank robber in the 1950s, stole more than two million dollars during his lifetime—which would, as Gladwell estimates, be 20 million in today’s dollars. This was far more than Casper and C-Dog, but Sutton did not start a bank-robbing epidemic. Why, in the ‘80s and early ‘90s, were there so many more bank robberies in Los Angeles than there were elsewhere?

Gladwell then discusses John Wennberg, a medical researcher who, in 1967, was assigned to examine the quality of care Americans were receiving in different parts of the country. Wennberg started in Vermont and then expanded after making a startling discovery: Two different areas in Vermont with roughly the same population and access to health care had quite disparate rates of tonsillectomies. The pattern persisted on a larger scale: Different regions had vastly different patterns of medical treatment, but nothing in the data could explain why. Gladwell observes that a person in Minneapolis will see a doctor about 36 times in the last two years of life. In Los Angeles, the number is 105. This is not due to differences in insurance coverage, nor to differences in the patients’ cultures. Rather, it has to do with small-area variation, which in this case is caused by medical practitioners in a given area coming to have the same beliefs, as if they were all infected with the same idea.

Chapter One closes with a look at vaccination rates among elementary schools in California. Waldorf private schools (which do not cater to a specific religion) have the lowest student vaccination rate of any schools in their respective districts. Vaccine skepticism, too, fits the small-area variation model: The parents who send their children to Waldorf schools are more likely to be vaccine skeptics. Gladwell states that small-area variation is the first of three puzzles and that there must be a set of rules beneath the surface.

Chapter Two: The Trouble with Miami

Chapter Two opens with court testimony and a description of crimes committed by Philip Esformes, Miami-area medical entrepreneur. Esformes owned many nursing homes and committed millions of dollars in Medicare fraud. He had hundreds of bank accounts. During his sentencing, it was argued that Esformes lost his way, ethically speaking, when he moved from Chicago to Miami. Gladwell revisits the vaccination anomaly of the Waldorf schools to try to discern whether a location can change people. Testimonies from Waldorf students (and parents of students) show that the school encourages a somewhat reckless confidence that makes people doubt experts. Gladwell uses the term “overstory,” which is another term for a forest canopy, to try to explain how a location could quickly change someone’s thinking and habits. Referencing the previous example of medical procedures, Gladwell gives examples of doctors who move from one location to another and quickly adopt the techniques and habits of their new environment. Gladwell then asks what overstory could have changed Esformes. The second puzzle: How can environment influence an individual?

Not only does Miami have a very high incidence of Medicare fraud, but it also provides some of the most brazen examples. In 1980, Miami was transformed by an influx of drug money, a surge of more than 100,000 refugees from Cuba, and widespread corruption in law enforcement and government. Gladwell explains how in the 1980s, banks in Miami helped launder millions of dollars a day. The institutions and practices that were the foundation of Miami were completely changed. To get a better understanding of the scale of Medicare fraud, Gladwell accompanies two agents on the Medicare Fraud Strike Force. They visit an office building and strip mall that contain dozens of medical offices, many of which have no employees and others that have just a single receptionist without a working phone. The offices are fronts for Medicare fraud scams, and they are not discreet about it. Gladwell revisits Philip Esformes’s trial and sentencing. Esformes oversaw a complicated network of nursing homes and assisted living centers that billed over a billion dollars to Medicare, with the help of doctors willing to sign fraudulent orders and prescriptions. Gladwell notes that during his trial, witnesses stated that Esformes had associates who made large donations to political campaigns. In 2020, Donald Trump commuted Esformes sentence.

Chapter Three: Poplar Grove

Chapter Three opens with a description of a small town in the United States, dubbed Poplar Grove in place of its real name by two sociology researchers. Although the town was a fairly normal suburban community a generation ago, it has recently transformed. Most of the families are now affluent, almost all of the properties are single-family homes, and the high school posts excellent test scores and fields successful athletic teams. The town lacks affordable dwellings and thus has few low-income families. Poplar Grove, in short, has a monoculture characterized by pressure to succeed. The third puzzle: How much control do members of a community have regarding the overstory? Gladwell uses a zoo crisis in the 1970s to further explain. Zoos badly wanted to breed animals in captivity but were having difficulty with cheetah populations. Biologists investigated and found that cheetahs have very little genetic diversity, so much so that they have difficulty breeding. It is likely that the world cheetah population was reduced to very small numbers more than 10,000 years ago and only survived through inbreeding. Gladwell states, “Epidemics love monocultures.”

While the students at Poplar Grove did have different social crowds, all of the crowds were focused on academic success and extracurricular activities. It was a culture of pressure. Gladwell returns to the discussion of cheetahs and describes how a group of them in Oregon became sick. All the cheetahs died because they were all equally susceptible to the same disease. The panther population in Florida had similar health issues due to lack of biodiversity. The solution there was to ship cougars in from Texas to interbreed and break up the monoculture. This plan succeeded. Gladwell then revisits the students of Poplar Grove. From 2005 to 2016, the suicide rate among the students (and recent graduates) of Poplar Grove was 10 times the national average. To fix the epidemic, the monoculture would need to be broken up—but the monoculture was what the parents wanted.

Next section Part Two: The Social Engineers (Chapters Four-Six)

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