Out of more than 100,000 American pharmaceutical prescribers, just 2,500 or so are responsible for the opioid addiction crisis that killed a million or more. All told, then, most in the medical community acted responsibly. Unfortunately systems commonly have such “superspreaders” and “small-area variation” is common.
That’s the close of Revenge of the Tipping Point, celebrity intellectual-journalist Malcolm Gladwell’s book marking the 25th anniversary of his first bestseller with a new approach. Gladwell is a victim of his own popularity. But I respect him for developing, popularizing and mastering the form of narrative reporting that makes light-reading of seemingly dense subject matter.
Though the opioid crisis is his grand finale, the book’s theme is actually about how narrative shapes our understanding of ourselves, and of a place. He calls these “overstories,” or broad geographic identifiers that shape behaviors and culture.
“Overstories matter. You can create them. They can spread. They are powerful,” he wrote. “And they can endure for decades.”
Below my notes for future reference.
My notes:
- “Small area variation”: Wennberg’s 1973 paper on the wide variability in health treatments
- David Molitor: a Boulder, Colorado-based cardiologist moved to Buffalo, NY and immediately changes how he prescribed different operations. Why?
- “Communities have their own stories, and those stories are contagious”: Author cals these “overstories”
- Nicholas Griffin 2020 book The Year of Dangerous Days: Riots, Refugees, and Cocaine in Miami 1980: He argues that cocaine trafficking and then the Mariel boatlift (125k Cubans brought in October 1980) dramatically changed Miami’s makeup, that money and social networks changed the city from sleepy southern city to what it is
- Cheetah population likely collapsed 12k years ago so variety is very limited today
- Bradford Brown: social groups in high school let kids discover themselves, and social armor of punk kids help shy kids find each other
- But without variation there’s a monoculture (This high achiever status also discussed in Jonathan Haidt’s most recent book)
- Iatrogensis: an illness caused by intervention. For example, a monoculture to block out one thing (like academic underperformance), can let other things breed (suicide patch because all the kids are doing the same thing)
- Morton Grodzins in 1957 part of the first wave of white flight researchers, introduces the “top point” of a neighborhoods
- Rosabeth Moss Kanter’s research on group proportions, including “tokenism”, highlights how the relative size of different social groups within a larger group influences individual behavior and group dynamics (what Gladwell calls the magic third)
- Damon Centola UPenn research puts it 25% or the magic quarter — the point of that there’s a threshold where the group changes
- Ursula Burns at Xerox and Narendi Nooyi at Pepsi (famous, influential and rare women CEOs of big public companies) both tell stories of having to be exotic and exceptional to justify their success
- The Palo Alto “fair play committee” kept a racial ‘tipping point’ with the Lawrence Tract. Resident Willis Williams: “it was the practice of a mild discrimination so that a vicious discrimination might be prevented”
- Labor activist and author Saul Alinsky on these “benign quotas”: “what is in an unjust instrument in one case can serve justice in another”
- Jerome Karabel’s 2005 book The Chosen about Ivy League: Raising admissions standards flooded in studious Jewish students, who overcame underperforming legacy students. Lawrence Lowell at Harvard was concerned: Extra curricular and references mattered now too
- “Varsity sports are a mechanism by which Harvard maintained its group proportions.”
- In contrast to caltech, which has a far-more studious Asian population than still-white Harvard
- Prestige sports like basketball and football are different than Harvard women’s rugby or tennis which require a certain kind of person (rich!)
- “The game that Harvard is playing with rugby and that Georgetown is playing with tennis is of course also affirmative action. Except that instead of admitting under-privileged students with lower academic credentials, athletic affirmative action admits privileged students with lower academic credentials. It is only the first kind of affirmative action, however, that universities were unwilling to defend”
- His three epidemics: overstory, group proportions and (from his original book) law of the few —- that a small number impact a lot
- Donald Stedman: smog checker, 5% of automobiles contributed 55% of emissions (so smog checks for everyone was a waste, and instead his smog machines should be used to write tickets)
- Ristenpart aerolists in Covid: initially WHO focused on cough/sneeze whose particulates were too heavy to carry for long. But aerolists added the idea that talking and breathing emit lighter weight aerosols that carry longer
- Superspreader understanding from 1970s were further understood in Covid as super emitters
- Adam Kurcharski in his 2020 book The Rules of Contagion argues that focusing on superspreaders causes an us vs them attitude (but Gladwell notes it appears it would be effective)
- The Holocaust movie on NBC in April 1978 introduces the term (See Google Ngram below); NBC Exec Herbert Schlosser changed the series name back to The Holocaust, which gave it the name: Author adds: “that’s what storytellers can do. They can change the over story.”
- Larry Gross USC: in 1970s those who watched the same TV programs were more likely to have same opinions, otherwise big political divide
- Andrew Fletcher: “Let me make the songs of a nation, and I care not who makes its laws”
- Weeks before Russian Revolution of February 1917, Lenin thought he might never live to see the moment
- Evan Wolfson identified gay marriage as the key issue but after President George W Bush backed in February 2004 a constitutional amendment to ban gay marriage, many advocates thought they were decades away — but progress developed quickly from there, peaking in 2015
- Author argues the NBC sitcom Will and Grace (1998-2006) was quietly important — gay men spending time with each other just being themselves. They were the tipping point
- Opioid epidemic had different state variation inside United States surge (more than other countries), and Gladwell thinks the “overstory” comes from Paul E Madden crusading for pharmacy pads
- Russell Portenoy’s oral history in 2003 about prescribing opioids: treat pain itself not only the cause. In spring 1991, he pushed against NIDAbuse recommendation of triplicate pharmacy pads at federal level. Paul E Madden wanted triplicate
- Percocet is oxycodone with acetaminophen, difficult to abuse because it’ll destroy your liver— “a governors switch “ Purdue Pharma’s innovation was to remove this governor’s switch and make it slow release to make OxyContin
- Triplicate states (Texas) suffered less opioid abuse than non triplicate. Groups Plus marketing strategy focused on non triplicate states
- “Overstories matter. You can create them. They can spread. They are powerful. And they can endure for decades.”
- Fentanyl deaths now mirror where those triplicate states
- In 2002, McKinsey consultant Martin Elling advised Pharma sales rep develop, and consulting for the Sackler family (Elling later served a prison term for obstructing justice)
- The medical community acted “admirably” in the face of research but 2,500 or so of 100k+ super spreading prescribers in small area variation of geographies caused the epidemic
- In 2010, the reformulated OxyContin made it harder to abuse (gummy form can’t be crushed and snorted), but tragically this just meant those addicted moved to heroin and fentanyl and overdoses surged