Intended for healthcare professionals

Views & Reviews Round Table

The Tipping Point

BMJ 2010; 340 doi: (Published 27 January 2010) Cite this as: BMJ 2010;340:c479
  1. Katharine Thomas, general practitioner, Wellington, New Zealand
  1. marshykd{at}

    The 1990s saw a dramatic increase in the incidence of syphilis in Baltimore. Epidemiologists at the US Centers for Disease Control noted that the use of crack cocaine had risen among the patients, while doctors from the local sexual health clinics wondered whether a reduction in their staff numbers was the cause of this outbreak. A possible third factor was the relocation of patients as part of a public housing programme. Malcolm Gladwell began his first book, The Tipping Point, with this case study from Baltimore. He points out that all the above factors or “agents of change,” as he calls them, may have caused this epidemic. However, he goes on to emphasise that the changes in the agents themselves …

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