The Tipping Point Revisited: An Excerpt

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Episode Transcript

Speaker 1 (00:15):
Pushkin. Hello, Hello, Revisions History listeners. We are back with
a very very special announcement. I have a new book
coming out. It's called Revenge of the Tipping Point. It's
a sequel to The Tipping Point, my very first book
from twenty five years ago. It's like a little silver

(00:37):
anniversary present for you, my loyal listeners. The original Tipping
Point was about how the best way to understand ideas
and behaviors and social change was to use the model
of the epidemic. This time around, in Revenge of the
Tipping Point, I'm taking those ideas and going one big
step deeper. Now I'm interested in the dark side. I

(01:02):
go to Miami and try and figure out why Miami
is so strange. I go to a seemingly perfect little
town called Popular Growth, where a tragedy is unfolding. I
have a chapter on the Holocaust that I think will
completely surprise you. Yet another takedown of Harvard University. I know,
I know, I'm a broken record, but I'm inordinately proud

(01:22):
of this one. On and on a mixture of narrative
ingredients baked into a highly entertaining suffle. And today we're
sharing an exclusive preview of Chapter one of the audiobook
of Revenge of the Tipping Point. It's all about bank
robbers and doctors. And that's all I'm going to tell you,

(01:42):
because you'll have to listen to find out more. But
that's not all. Coming up in the next couple of
weeks on revisionist history, we have all kinds of goodies
related to my book. We've got a two part episode
on maybe my favorite criminal trial ever, something I call
the Georgetown Massacre. Then an episode where I go back

(02:02):
and audit the chapter I wrote on crime in the
original Tipping Point. Did I get it right? And finally
we're going to run the comment station I'm having with
the editor of The New Yorker, David Remnick, at the
ninety second Street y in New York. Stay tuned and
for now enjoy this preview of Revenge of the Tipping Point.
You can find Revenge of the Tipping Point wherever you

(02:24):
get your audiobooks. Part one three Puzzles, Chapter one Casper
and Sea Dog. It was just like wildfire. Everyone was
jumping into the gate. One In the early afternoon of

(02:49):
November twenty ninth, nineteen eighty three, the Los Angeles Field
office of the Federal Bureau of Investigation received a call
from a Bank of America branch in the Melrose District.
The call was taken by an FBI agent named Linda Webster.
She was the person in the office who fielded what
were known as two elevens shorts. A bank robbery's there

(03:11):
had just been a hold up. She was told the
suspect was a young white male wearing a New York
Yankees baseball cap, slender, polite Southern accent, well dressed. He
said please and thank you. Webster turned to her colleague,
William Rader, who ran the FBI's local bank robbery division.
Bill it's the Yankee. The Yankee Bandit had been active

(03:39):
in Los Angeles since July of that year. He had
hit one bank after another, slipping away each time with
thousands of dollars in a leather suitcase. Raider was growing frustrated.
Who was this man? All the bureau had to go
on was that telltale baseball cap, hence the nickname the
Yankee Bandit. Half an hour passed, Webster got another to eleven.

(04:04):
This one was from a City National Bank sixteen blocks
west in the Fairfax District. They had been taken for
two thousand, three hundred and forty nine dollars. The caller
gave Webster the details. She looked at Raider, Bill, it's
the Yankee again. Forty five minutes after that, the Yankee

(04:24):
hit a Security Pacific National Bank in Centry City, then
immediately walked one block down the street and held up
a First Interstate Bank for two thousand, five hundred and
five dollars. Bill, it's the Yankee twice, back to back.
Less than an hour passed, the phone rang again. The
Yankee had just hid an Imperial Bank on Wilshire Boulevard.

(04:46):
If you drive from Centry City to the Imperial Bank
on Wiltshire, you pass right by the FBI's office. He
probably waived at us. Raider told Webster they were now unnoticed.
History was being made. They waited, could the Yankee possibly
strike again? At five point thirty, the phone rang. An

(05:07):
unknown white male slender an accent Yankee cap had just
robbed the First Interstate Bank in Encino, fifteen minutes north
on the four or five Freeway, for two thousand, four
hundred and thirteen dollars. Bill, it's the Yankee. One man,
four hours, six banks. It was a New World's record,

(05:30):
Raider would later write in his memoirs Still Unbroken two,
no criminal has ever held as exalted a position in
American culture as the bank robber. In the years after
the Civil War, the country was riveted by the exploits

(05:50):
of bands such as the James Younger Gang, who terrorized
the wild West with bank hold ups and trained robbers.
In the Depression, bank robbers became celebrities. Bonnie and Clyde,
pretty Boy Floyd John Dillinger, Billy brought.

Speaker 2 (06:05):
To Chicago recaptured after he had escaped from Lima, Ohio.
Despert public enemy now rises to fame as an underworld hero.
Where is Clyde Beryl and Bonnie Parker who died as
they lived by a gun.

Speaker 1 (06:20):
But in the years after the Second World War, the
crime seemed to be fading. In nineteen sixty nine, a
total of thirteen hundred and eighteen banks were robbed across
the entire United States, a modest number given the size
of the country. There was speculation that bank robberies were
headed toward extinction. Few major crimes had higher arrest and

(06:44):
conviction rates. Banks felt they had learned how to protect themselves.
A definitive study at bank robbery was entitled nothing to lose,
meaning that the act seemed so irrational that its perpetrators
must have run out of other options. It seemed like
the twentieth century equivalent of cattle rustling, who does it anymore?

(07:05):
But then came an epidemic. In a single year, from
nineteen sixty nine to nineteen seventy the number of bank
robberies nearly doubled, then rose again in nineteen seventy one,
and once more in nineteen seventy two. In nineteen seventy four,
three thousand, five hundred and seventeen banks were robbed. Two

(07:25):
years later, the number was four thousand, five hundred and
sixty five. By the beginning of the nineteen eighties, they
were five times more bank robberies than there had been
at the end of the nineteen sixties. It was a
crime wave without precedent, and it was just getting started.
In nineteen ninety one, the FBI fielded a two to

(07:46):
eleven call from a bank somewhere in the United States
nine thousand, three hundred and eighty eight times, And the
center of this astonishing surge was the city of Los.

Speaker 2 (07:58):
Angeles, the sprawling city that's home to Hollywood movie capital
of the world is also the bank robbery capital of
the world.

Speaker 1 (08:07):
A quarter of all bank robberies in the US in
those years happened in Los Angeles. There were years when
the local FBI office handled as many as twenty six
hundred bank robberies. So many robbers robbing so many banks
that Raider and the Bureau were forced to give them
nicknames to keep them straight. The man who disguised himself

(08:29):
with surgical gauze became the Mummy Bandit. The man who
are a single glove became naturally the Michael Jackson Bandit.
A two man team who wore fake mustaches with the
Marx brothers. A short o beast robber was Miss Piggy.
A beautiful robber was the Miss America Bandit. A guy
who waved a knife was the Benni Hahonna Bandit. On

(08:50):
and on it went. They were robbers named after Johnny
Cash and Robert de Niro. One group robbed in threes,
one dressed as a biker, another as a cop, and
the third as a construction worker. Do you need to
ask what they were called? This was the nineteen eighties.
They were known as the Village People. It was just
like wildfire, remembers Peter Hoolihan, one of the unofficial historians

(09:15):
of the La Bank robbery Surge. Everybody was jumping into
the game. Ten years into the surge, incredibly, things got
much worse. The first generation of Ellie robbers were like
the Yankee Bandit. They walked up to a teller and
they had a gun, scooped up whatever cash was on hand,
and fled. People called them a bit dismissively note passers.

(09:40):
But then came a two man group called the West
Hills Bandits. The West Sails Gang went back to the
grand tradition of Jesse, James and Bonnie and Clyde. They
came in hot in wigs and masks, waving assault weapons.
They would force their way into the teller's cage and
clean out the entire bank, empty the vault if they could,
before executing a meticulously planned escape. The Bandits had a

(10:04):
bunker in the San Fernando Valley filled with military grade
weapons and twenty seven thousand rounds of ammunition to prepare
for what their leader believed was an imminent armageddon. Even
by the standards of nineteen nineties Los Angeles, the West
Hills Gang was a little crazy. On their fifth robbery,

(10:25):
the West Hills Gang broke into the vault of a
Wells Fargo bank in Tarzana and made off with four
hundred and thirty seven thousand dollars more than one million
in today's dollars. And then Wells Fargo made a crucial mistake.
The bank told the press exactly how much the West
Hills Gang had stolen. It was like putting a match

(10:45):
to kindling. Four hundred and thirty seven thousand, Are you
kidding me? One of the first to take notice was
an enterprising twenty three year old named Robert Sheldon Brown.
His street name was Casper. Casper did the math. I've robbed,
I've done burglaries, I've done a little bit of everything,

(11:05):
he would explain later. But the money couldn't compare to
the bank. You could go into a bank and in
two minutes get what on the streets would take you
six or seven weeks to get. John Wiley, one of
the prosecutors who eventually brought Casper to justice, remembers him
as a standout. He said, Casper was really ripped and
really smart.

Speaker 3 (11:26):
Here he is he figured out the problem with robbing
banks is going into the bank, so he got somebody
else to do that. You would think, how could you
possibly get someone to rob a bank for you? And
that was his particular talent, was recruiting people to rob
banksworm and he recruited an unbelievable number of folks. He

(11:52):
was kind of a producer in Hollywood terms.

Speaker 1 (11:56):
Casper had a partner in crime, Donzel Thompson, also known
as Sea Dog. They would pick a bank they thought
was ripe for a hit, then it'd find a getaway car,
known in gangs speak as the g ride. In the
early nineteen nineties, Los Angeles also experienced an astonishing surge
in carjackings, which were treated in the press as another

(12:17):
indication of the random mayhem sweeping the streets. But a
good chunk of it was actually just Casper and Sea Dog.
They had a guy they paid to acquire their g rides.
If you were doing as many bank robberies as Casper was,
you needed a lot of cars. Then he would pick
the crew Prosecutor Wiley.

Speaker 3 (12:38):
Again, a lot of his robbers were just kids. I
think he probably paid some of them nothing. He just
coerced him into robbing. He was a big threatening guy,
and you know he was a member of the role
in the sixties was a very notorious crips gang.

Speaker 1 (12:57):
Wiley recalled a particular recruit who was very young, no
more than thirteen or fourteen.

Speaker 3 (13:03):
I remember he took the kid out of school and said,
you know, when can you rob this bank for me?
And the guy said during nutrition break. So during nutrition
break they picked him up and Brown and Thompson explained
how to do it. You go in scurbate to death,

(13:23):
get the money, get out.

Speaker 1 (13:26):
Casper taught his recruits a technique he called go and
com akazi. His kids would come busting in, waving their
machine pistols and assault rifles, firing rounds at the ceiling
and screaming obscenities on the floor.

Speaker 2 (13:39):
Mother.

Speaker 1 (13:40):
They would stuff all the cash they could into pillowcases,
grab wallets, and rip rings off women's fingers if they
wanted a little extra treasure for the road. On at
least two jobs, Casper borrowed a school bus to ferry
his young charges to safety. Another time he borrowed a
postal service truck. Casper had imagination he would exercise managerial

(14:05):
oversight of his operations from a position of safety parked
in a car somewhere far down the block, then follow
his hand picked team as they raced through the streets.

Speaker 3 (14:15):
These guys knew if they tried to get away with
them all the money that have these two roll in
sixties crips after him, and that would not improve their lives.

Speaker 1 (14:25):
The g ride would be abandoned. The whole crew would
retreat to Casper's hideout, usually in a motel, where he
would pay them a pittance and let them go. They
were kids, Chances are they would get caught, but Casper
didn't care. Here's Wiley describing his general attitude.

Speaker 3 (14:41):
I mean, okay, so that wasn't great. My guys got caught.
Now we have to get new guys. But we do
that all the time.

Speaker 1 (14:48):
In just four years, Casper produced one hundred and seventy
five robberies, which remains a lifetime bank robbery world record,
crushing the Yankee Bandits previous mark of seventy two. Casper
and Sea Dog even came close to the Yankee Bandits
one day mark of six heists on a single day.

(15:08):
In a August of nineteen ninety one, they produced five
a first interstate bank on Losienega Boulevard, then banks in
Eagle Rock, Pasadena, Monterey Park, and Montebello. And remember the
Yankee bandit was a one man show. Casper was doing
something infinitely more difficult, organizing and supervising teams of robbers.

(15:30):
Once Casper showed the world how easy it was to
take over a bank, other gangs jumped in. The eight
tray gangster crips started putting together cruise. A duo called
the Nasty Boys did almost thirty takeovers in under a
year just the two of them. The Nasty Boys were nasty.
They liked to herd everyone into the bank vault, talk

(15:51):
loudly about executions, and fire their guns next to people's
ears just for the fun of it.

Speaker 3 (15:57):
In retrospect, nineteen ninety two turned out to be the
peak year for bank robberies. Two thousand, six hundred and
forty one robberies in one.

Speaker 1 (16:06):
Year Wiley again.

Speaker 3 (16:08):
So that averages one bank robbery every forty five minutes
for each banking day, and the worst day was twenty
eight bank robberies in one day. This drove the FBI
completely crazy. I mean they were completely exhausted.

Speaker 1 (16:27):
Robbing a bank takes minutes. Investigating a bank robbery takes hours.
As the robberies piled up, the FBI would fall further
and further behind.

Speaker 3 (16:38):
So if you're having twenty seven robberies a day, if
one team is committing five robberies in one day, I mean,
just think physically, how you investigate that. These guys are
driving all over town as fast as they can robbing,
so just keeping up with them in La traffic is
a problem. You get to the bank and how many

(16:58):
people have witnessed the robbery, Well, how many people were
in the bank, You know, twenty people, So you need
to get witness statements from twenty witnesses. This is a
big project.

Speaker 1 (17:10):
Then just as you start, what happens.

Speaker 3 (17:14):
You're on the scene for five or ten minutes, and
there's another bank robbery emergency somewhere across town. The FBI
was being run ragged.

Speaker 1 (17:23):
The city of Los Angeles was the bank robbery capital
of the world. Wiley held up a chart of bank
robberies in Los Angeles from the nineteen seventies through the
nineteen nineties.

Speaker 3 (17:34):
There was no reason to think it would crust. If
you look at the trend line, it just seems like
it's heading for the moon.

Speaker 1 (17:43):
The FBI put fifty agents on the case. Over the
course of many months, they gathered what they could from
Casper and Sea Dogs, terrified recruits, sorted through the layers
of deception the two used to hide their assets and
track them from one address to another across South Los Angeles.
It took forever to get a grand jury to indict
Casper and Sea Dog, because what had they done? Nothing,

(18:06):
They didn't rob any banks. They were just sitting in
a car down the street. All the FBI had was
a testimony of terrified teenagers who skipped school between lunch
and recess. Finally, prosecutors thought they had enough evidence. They
found Sea Dog at his grandmother's house in Carson and

(18:27):
arrested Casper as he stepped out of a cab with
the two of them behind bars. The bank robbery fever
that had seized Los Angeles finally broke. Within roughly a year,
the number of robberies in the city dropped thirty percent,
then drifted even lower. Bank robberies didn't head for the moon.
The contagion passed. When Casper and Sea Dog got out

(18:54):
of federal prison in the summer of twenty twenty three,
they shopped their story around Hollywood and took meetings with
film producers. Movie executives who heard their story were incredulous
that happened here. Yes it did. Three. I want to

(19:24):
begin Revenge of the Tipping Point with a series of puzzles,
three interconnected stories that seem at first glance to defy explanation.
The third involves a little town called pop Lagrove. The
second involves the story of a man named Philip s Forms.
And this first chapter involves the exploits of the Yankee

(19:46):
Bandit and Casper and Sea Dog. The Los Angeles bank
robbery crisis of the early nineteen nineties was an epidemic.
It fit all rules. This was not an outbreak generated
inside each robber like a toothache. It was contagious. A
low grade fever surfaced across the United States at the

(20:08):
end of the nineteen six sixties. In the nineteen eighties,
the Yankee Bandit caught that bug in Los Angeles. The
West Hills Bandits later picked up that virus, and in
their hands it mutated into something darker and more violent.
They passed a new Strainnan to Caspar and Sea Dog,
who reinvented the process outsourcing the labor and scaling up

(20:30):
dramatically like the late twentieth century capitalists they were. And
from there the infection went clear across the city to
the Eight Tray gangsters and the Nasty Boys, and on
and on, sweeping up hundreds of young men, until by
the time the bank takeover boom peaked in Los Angeles,
the small time note passing of the Yankee Bandit era

(20:51):
seemed like a dim memory. Socio epidemics are propelled by
the efforts of an exceptional few people who play outsized
social roles, and that was exactly how the LA outbreak unfolded.
This was never a mass participation event like one of

(21:11):
those big city marathons where tons of thousands of people
sign up. It was a reign of mayhem, driven by
a small number of people who robbed over and over
and over again. The Yankee Bandit robbed sixty four banks
in nine months before the FBI finally grabbed him. He
went to prison for ten years, got out, then robbed

(21:33):
eight more banks. The Nasty Boys did twenty seven banks.
Casper and Sea Dog masterminded one hundred and seventy five.
If you focused only on the Yankee Bandit, Casper and
the Nasty Boys. You would have a pretty complete picture
of what happened in Los Angeles in the nineteen eighties
and early nineteen nineties, A contagious phenomenon that rose and tipped,

(21:56):
fueled by the extraordinary actions of a few Casper, while
he said, is the super spreader if you want to
talk about epidemics, was the context in the nineteen eighties
and the early nineteen nineties ripe for a bank robbery explosion? Yes,
it was. Between the nineteen seventies and the end of
the nineteen nineties, the number of bank branches in the

(22:19):
United States tripled. Casper and Sea Dog were shooting fish
in a barrel. The fever that swept Los Angeles in
the late nineteen eighties and early nineteen nineties makes perfect sense,
except for one thing. There's a puzzle.

Speaker 3 (22:40):
Four.

Speaker 1 (22:44):
In the early morning of March ninth, nineteen fifty, Willie
Sutton rose and applied a heavy coat of makeup to
his face. The previous evening he had dyed his hair
several shades lighter, so that he was almost blonde, and
now he wanted to pair that with an olive complexion.
He applied mascara to his eyebrows. To give them some substance.

(23:07):
He stuffed bits of cork inside his nostrils to broaden
his nose. That he put on a gray suit, tailored
and padded in such a way as to alter his silhouette. Satisfied,
did he no longer look like Willy Sutton? Willie Sutton
left his house in Staten Island for Sunnyside, Queen's to
a Manufacture's Trust Company branch at forty fourth Street and

(23:29):
Queen's Boulevard in New York City. Sutton had spent the
previous three weeks standing across the street every morning, learning
the routines of the bank's employees. He liked what he saw.
There was an elevated subway stop across the street, a
bus stop, and a taxi stand. The street was busy

(23:49):
and Sutton like crowds. The bank's guard, a slow moving
man named Weston who lived nearby, arrived every morning at
eight thirty, engrossed in his newspaper. Between eight thirty and nine,
he would let in the bank's other employees, culminating in
the bank's manager, mister Hoffman, who arrived like clockwork at

(24:09):
nine o one. The Manufacturer's Trust opened to the public
at ten o'clock, much later than most bank branches. This
too made Sutton happy. He regarded the time between the
arrival of the first employee and the arrival of the
first customer as his time, and his time in this
case would be more than an hour. At eight twenty,

(24:32):
Sutton mingled with the crowd waiting at the bus stop.
A few minutes later, the Castilian Weston turned the corner,
lost in his newspaper. As Weston took out his keys
to open the door, Sutton slipped in behind him. Weston
turned in shock. Sutton looked him in the eye and
said quietly, come inside. I want to talk to you.

(24:55):
Sutton wasn't a fan of guns. Guns for him were props.
His real weapon was a quiet authority that compelled the
attention of others. He explained to the guard what would
happen next. First they would let him one of his accomplices.
Then the remaining employees would be admitted, exactly as they
were each morning. As each one entered, Sutton's accomplice would

(25:19):
emerge and lead them by the elbow to a row
of chairs he'd set up in preparation. Once you've taken
control of the bank, Sutton would write years later in
his memoirs. Sutton was sufficiently famous by that point that
he wrote not one, but two sets of memoirs. Like
a statesman who feels the need to respond to the
turns of history, it doesn't really matter who comes to

(25:43):
the door. A trio of painters once arrived unexpectedly while
I was taking a bank in Pennsylvania, and I simply
told them to spread out their drop cloths and go
to work. The pay you guys get, the bank can't
afford to have you hang around doing nothing. They're insured
against bank robbers, but nobody would insure them against you robbers.
All during the robbery, I was able to keep up

(26:05):
a line of chatter about how I could have retired
by now if we bankrobb had as stronger union as
they did. Everyone had a good time, and by the
time we walked out the door with the money, they
had one of the walls completely painted. Sutton was terrifyingly charming.
Did the employees of the Manufacturer's Trust Company realize that

(26:26):
the famous Willie Sutton was robbing them that morning? Undoubtedly
they filed into the conference room one by one. Don't
worry folks. He told them, it's only money, and it
isn't your money. At nine oh five, four minutes late,
mister Hoffman, the manager, arrived, Sutton sat him down. If

(26:48):
you give me any trouble, I want you to know
that some of these here employees of yours will be shot.
I don't want you to have any false illusions about that. Now.
Perhaps you don't care about your own safety, but the
health of these here employees of yours are your responsibility.
If anything happens to them, the blame will be yours,

(27:11):
not mine. It was a bluff, of course, but it
worked every time. He scooped up the money from the vault,
ambled out the door to a waiting getaway car, and
vanished into the New York City traffic. Willie Sutton was
the New York version of Casper, although that doesn't quite
do Willie Sutton justice. Nobody knew much about Casper at

(27:34):
the time he was orchestrating his bank robbery spree. Even
his trial barely made a dent in the news. Not
so Willie Sutton.

Speaker 2 (27:42):
Willy Sutton, whose captur ends a five year manhunt still
carrying a big bank roll, the nation's most elusive bank
robber is arrested in Brooklyn, America's most wanted criminal, His
arrest brings promotion.

Speaker 1 (27:54):
Sutton was a celebrity. He did it's starlit's. He was
a master of disguise. He made not one, but two
daring escapes from prison. He was once asked why do
you rob banks, and he replied, because that's where the
money is. Later he would deny having said that, but
it didn't matter. To this day. His quip is known
as Sutton's law, and it's used to instruct medical students

(28:17):
on the importance of considering the likeliest diagnosis. First, Hollywood
made a movie about his life. A writer turned his
story into a biographical novel. In Today's Dollars, He claimed
to have stolen more than twenty million over the course
of his career. Casper wasn't even in the same tax
bracket as Willy Sutton, assuming of course, that they paid taxes,

(28:40):
which neither of them did. The point is that if
anyone were to start a bank robbery epidemic, you'd think
it would be Willy Sutton. You would think that the
impressionable criminal classes of New York City would look at
slick Willie effortlessly slipping into bank branches without firing a shot,
and making off with the king's ransom and say to themselves,

(29:02):
I can do that. In epidemiology, there's a term called
the index case, which refer to the person who kicks
off an epidemic. We're going to talk about one of
the most fascinating index cases in recent history later in
this book. Willie Sutton should have been the index case, right.

(29:22):
He turned the grubby job of holding up a bank
into a work of art. But Willie Sutton did not
start a bank robbery epidemic in New York City, not
in the nineteen forties and fifties, in his heyday, nor
in the years afterward, as he wrote one memoir after another.
After talking his way out of prison in nineteen sixty nine,

(29:45):
claiming ill health, he would live another eleven years, Sutton
recreated himself as an expert on prison reform, giving lectures
across the country. He consulted with banks on how to
prevent bank robberies. He even did a TV commercial for
a credit card company pioneering a card with a photo
on it.

Speaker 4 (30:04):
They call it the face God. You see it as
your face right on it. Now when I say, Lily Sutton,
if I believe me.

Speaker 1 (30:12):
Did that make the world want to be Willie Sutton?
Apparently not. In the days of Casper, New York City
suffered only a fraction of the bank robberies that Los
Angeles did. An epidemic, by definition, is a contagious phenomenon
that does not respect borders. When COVID first emerged in

(30:34):
China in late twenty nineteen, epidemiologists worried that it would
spread everywhere, and they were absolutely right. Yet in the
bank case, the fever engulfed Los Angeles but skipped other
cities altogether. Why this is the first of the three puzzles,

(30:56):
and the answer involves a famous observation made by a
physician named John Weinberg five life. In nineteen sixty seven,
fresh out of his medical training, John Wenburg got a

(31:17):
job in Vermont as part of a federally funded operation
called the Regional Medical Program. These were the years of
the Great Society, when the US government was making a
concerted effort to expand the American's social safety net. Weinberg's
job was to map the quality of care across the
state to make sure everyone was getting access to the

(31:39):
same standard of medicine. He was young and idealistic. He
had studied under some of the best minds in medicine
at Johns Hopkins University. Weinberg arrived in Vermont, he said later,
still believing quote in the general paradigm that science was
advancing and that it was being translated rationally into effective

(32:01):
care end quote. Vermont had two hundred and fifty one towns.
Weinburg began by dividing up those communities according to where
their local residents got their medical care. That left him
with thirteen hospital districts across the state. He then calculated
the amount of money that was spent on medical care

(32:23):
in each of those districts. Wenberg assumed that what he
would see was that in some far away corner of
Vermont where there wasn't much money, spending would be low,
and by the same logic, in wealthier communities such as Burlington,
the biggest city in the state, home to the University
of Vermont and Champlain College, where the hospitals were the

(32:44):
newest and most sophisticated and the doctors more likely to
have trained at prestigious medical schools, spending would be a
bit higher. He was completely wrong. Yes, they were differences
in spending from one hospital district to the next. But
the differences weren't small. They were enormous, and they didn't

(33:06):
follow any apparent logic. They were as when put it
without rhyme or reason. Surgery for removing hemorrhoids, for example,
was five times more common in some districts than in others.
Your chances of getting an enlarged prostate surgically removed, or
your uterus removed in a hysterectomy, or your appendix removed

(33:28):
after an attack of appendicitis were three times higher in
some districts than in others. Here's Wenberg years later, describing
his early work in an interview with the Community Health
Centers podcast Conversations on Healthcare.

Speaker 4 (33:43):
We first from at across this in Vermont, where we
looked at a whole bunch of different attributes of healthcare system.
The one that sticks out in most people's mind as
the incredible variation that we saw in time feleectomy rates,
where literally by going five miles up the road and

(34:05):
entering a new hospital service area, had jumped from about
a twenty percent risk of having a tonsil out by
age fifteen to well over sixty percent, So that gives
you an idea of what the basic variability was. And
this variation sembly could not be explained on the basis
of differences in the incidents of sword throats or tonsilitis

(34:30):
or anything like that, and it was traced pretty much
directly back to the medical opinion of the physicians and
the different communities.

Speaker 1 (34:37):
Weinburg saw this firsthand. He was living at the time
midway between the small Vermont towns of Stowe and Waterbury.
His kids went to school in Waterbury, a town where
tons electomies were rare, But had Weinberg's family been living
one hundred yards north, his kids would have gone to
school in Stowe, where everyone got their tonsils out. It

(34:59):
made no sense. Stowe and Waterbury were both idyllic small towns,
full of weathered nineteenth century buildings. Nobody seriously I thought
that one was more worldly or was in the grip
of a different medical ideology than the other. It wasn't
that Stowe attracted one kind of person and Waterbury attracted another,

(35:20):
very different kind of person. The people were the same,
except that is that the children of Waterbury tended to
keep their tonsils and the children of Stowe did not.
Wenburg was now deeply confused had he stumbled upon some
strange quirk of the small towns of Vermont. He decided

(35:42):
to expand his analysis to other parts of New England.
He compared Middlebury, Vermont versus Randolph, New Hampshire. These two
cities are essentially twins. But when he looked further at
the data, he found that in Randolph the doctors conducted
themselves in a kind of over caffeinated frenzy, spending freely

(36:04):
hospitalizing and operating on everyone inside. But Middlebury Middlebury was
a different world. Weinberg called what he had discovered small
area variation, and he found evidence of it across the
entire United States. And what started as an idiosyncratic observation
about the small towns of Vermont has turned into an

(36:25):
iron law that, half a century after Weinberg made his
startling discovery, shows no signs of going away. 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.

(36:47):
Why does place matter so much? The easiest explanation for
small area variation is that doctors are simply doing what
patients want. So, for example, let's pick a relatively simple
medical event, how many times a doctor visits a patient
in the last two years of their life. The national
average in twenty nineteen is around fifty four visits. In Minneapolis,

(37:12):
by contrast, the average is much lower, thirty six. But
you know what it is in Los Angeles, it's one
hundred and five. You get three times more doctor visits
in your dying days in LA than you do in Minneapolis.
That's a huge difference. Is it because dying Minnesotans behave

(37:33):
like stoic Scandinavians whereas the very old of Los Angeles
are needy in demanding The answer seems to be no.
Weenberg and other researchers have found that small area of
variation does not result from what patients want their doctors
to do. It stems from what doctors want to do
to their patients. So why do doctors behave so differently

(37:58):
from place to place? Is this just about money? Maybe
more people in Los Angeles have the kind of insurance
that rewards doctors for treating their patients aggressively. The technical
term for this is payer mix. A city with one
hundred percent of its citizens covered by fee for service
insurance where a doctor gets paid for everything they do

(38:20):
is going to have a very different pattern of care
than a city where one hundred percent of its citizens
are enrolled in managed care, where payments to doctors and
hospitals are fixed. But does Los Angeles have a radically
different payer mix than any other big city? No, it doesn't. Okay,
what if this is just random? After all, doctors are people,

(38:41):
and people are all over the map in what they believe.
Maybe Los Angeles is a place where, by chance, many
aggressive doctors happen to practice, while Minneapolis is a place where,
by chance, there are very few.

Speaker 2 (38:54):
No.

Speaker 1 (38:55):
Random would mean that aggressive doctors would be scattered across
the country in patterns that ebb and flow with each
passing year. Random would mean that every hospital would have
a different combination of physicians, representing a sampling of ideas
about how to practice medicine. They would be a doctor
Smith who always took out tonsils, and a doctor Jones
who never did, and then a doctor McDonald who was

(39:18):
somewhere in between. But that's not what Wemburg identified years ago.
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.
Jonathan Skinner, an economist at Dartmouth University who's one of

(39:41):
the heirs to Weinburg's work, said, it's a birds of
a feather flock together puzzle.

Speaker 5 (39:47):
Like, okay, doctors have different opinions, like people develop opinions
about what works. But the question is, what is it
about an area that causes some people to practice in
one way on average and something that's kind of in
the water.

Speaker 1 (40:16):
Six small area variation has subsequently become something of an
obsession for medical researchers. Books are written about it, scholars
spend their days studying it. But what's fascinating is how
the same inexplicable patterns of variation turn up outside the

(40:36):
world of medical care. Let me give you an example.
The state of California keeps the public database of what
percentage of seventh graders at any middle school in the
state are up to date with their recommended vaccines chicken pox, measles,
mom's rebella, polio, and so on. If you give the
list and it's a long list. A cursory glance, it

(41:00):
seems pretty straightforward. The overwhelming number of public school kids
in California have received all their shots. So what about
private school kids. Private schools tend to be smaller and corkier.
Could there be more variation there? Let's take a look.
Here are vaccination rates chosen at random from a selection

(41:20):
of private elementary schools in Contra Costa County east of
San Francisco. Saint John the Baptist one hundred percent, El
Sebrante Christian School one hundred percent, Contracosta Jewish Day School
one hundred percent. The list goes on. There are a
lot of private elementary schools in Contracosta County, and the

(41:42):
parents who live there seem pretty intent on protecting their
children from infectious diseases. Saint Perpetua one hundred percent, Saint
Catherine of Siena one hundred percent. But wait, there's one
school that's very different, East Bay Waldorf forty two percent.
Forty two percent. Is this a fluke, a chance deviation

(42:07):
from a consistent pattern. Let's take a look at private
schools in El Dorado County, just down the list alphabetically
from Contra Costa g HS Academy ninety four percent, Holy
Trinity School one hundred percent, and then wait for it,
Cedar Springs Waldorf thirty six percent. Estra Los Angeles. Most

(42:32):
middle schools, like their counterparts around the state are up
in the nineties or at one hundred percent, but once again,
there is an exception far on the west side of
the city, in the exclusive neighborhood of Pacific Palisades West
Side Waldorf twenty two percent. If you've never heard of

(42:54):
Waldorf schools, they're a movement started by the Austrian educator
Rudolf Steiner in the early twentieth century. Waldorf schools are
small and expensive and focus on holistic learning, seeking to
develop the creativity and imagination of their students. There are
several thousand Waldorff schools around the world, mostly kindergartens and

(43:16):
elementary schools, and about two dozen in California, and almost
without exception, the lowest vaccination rates in any California town
that has a Waldorf school are at the Waldorf school.
There are other schools with unvaccinateed rates as highest Waldorf,
but they're rare. Here is Sonoma County Saint Vincent de

(43:38):
Paul Elementary School one hundred percent, Rincon Valley Christian one
hundred percent, Sonoma Country Day School ninety four percent, Saint
Eugene Cathedral School ninety seven percent, Saint Rose one hundred percent,
Summerfield Waldorff School twenty four percent. California had two measles

(43:59):
outbreaks in the mid twenty tens.

Speaker 4 (44:02):
Right now there are nine confirmed cases of the measles
which are tied to Disneyland or Disney's California.

Speaker 3 (44:09):
As health officials try and contain the virus, parents are
being urged to vaccinate their children.

Speaker 1 (44:16):
The outbreaks led many to say that California was suffering
from a problem with vaccine skepticism. But that's wrong. Look
again at those elementary schools with one hundred percent vaccination rates.
It's actually small pockets of people within the state, such
as the parents who sent their kids to a very
specific brand of elementary school, who have a vaccine problem.

(44:38):
John Wenberg would recognize the pattern in an instant vaccine
skepticism is small area of variation. This is the first
lesson of social epidemics. When we look at a contagious event,
we assume that there is something fundamentally wild and unruly
about the path it takes. But there is nothing wild

(45:02):
and unruly about the La Bank robbery epidemic, or the
patterns of medical practice in Waterbury versus Stowe, or the
ideas of Waldorf parents. Whatever contagious belief unites the people
in those instances has the discipline to stop at the
voters of their community. There must be a set of

(45:22):
rules buried somewhere below the surface, which brings us to
puzzle number two. Thanks for listening to that preview of
my new book, Revenge of the Tipping Point. You can
hear the rest on audible, Apple Books, Barnes and Noble, Spotify, Pushkin,

(45:44):
dot FM, or wherever you like to listen. Coming up
next on Revisionist History, two narrative episodes about my favorite
trial of all time, and a deep dive on broken windows,
a theory that I helped popularize in The Tipping Point?
Did I get it right? And what's changed twenty five
years later?

Speaker 3 (46:03):
And I would go around and I would talk to
people in New York City, and the.

Speaker 5 (46:06):
Liberal people, progressive people say oh, well, you know, we've
had this miracle in New York.

Speaker 3 (46:11):
And some people would say, oh yeah, Malcolm Gladwell's idea.
Broken Windows.

Speaker 1 (46:17):
Revision's history is produced by Nina Bird, Lawrence, Lucy Sullivan,
and Ben ad F. Haffrey. Our editor is Karen Chakerji,
and our executive producer is Jacob Smith. Special thanks to
Sarah Nix. The Revenge of the Tipping Point audiobook was
executive produced by Kerry Colan, directed by Alexandra Garreton with

(46:37):
help from Louis Mitchell, Engineered by Nina Bird Lawrence, guitar
by Ged Corbin. It was produced by Alexandra Garreton and
Louis Mitchell. Nicole op den Bosch is Pushkin's VP of
Operations and Publishing. Special thanks to Jasmine Faustino and of
course el Hefe Greta. Come, I'm Malcolm Popple