Pittsburgh, Deindustrialization, and the Birth of the Care Economy: On Gabriel Winant's "The Next Shift"

Gabriel Winant | The Next Shift: The Fall of Industry and the Rise of Health Care in Rust Belt America | Harvard University Press | March 2021 | 368 Pages

In a triumph of social and political history, Gabriel Winant transforms our understanding of deindustrialization by arguing that in its wake, it birthed a new industry and working class: the health care economy and the millions of poorly paid and mostly non-unionized white women and men and women of color who staffed it. The Next Shift: The Fall of Industry and the Rise of Health Care in Rust Belt America takes us to Pittsburgh, the postwar titan of U.S. manufacturing, and narrates the shift from a political economy and social world dominated by steel mills and forges in the 1950s and 1960s to that of hospitals and nursing homes in the 1970s and 1980s. Through a granular exploration of the ways this transformation affected individual neighborhoods to macro-level analyses of the private-public welfare state, collective bargaining, and the impacts and reforms of Medicare and Medicaid, Winant revises our understanding of the late twentieth century and the formation of the Rust Belt by centering the rise of health care as both a result of and response to the social crisis of deindustrialization.

The origins of the next shift can be found in the political economy and labor bargains of the immediate postwar period, none more important than the conservative reaction against organized labor in the late 1940s and the emergence of what labor historians have termed “the treaty of Detroit”: the dominance of federally mediated collective bargaining which traded industrial democracy for wage and benefit increases. In this pivotal moment, workers, firms, and the federal government formed a postwar public-private welfare state reliant on organized labor to dole out provisions and security through labor contracts. Through insurance paid in part by employers, and by 1965, Medicare and Medicaid, healthcare became a key aspect of the social economy. If industrial work was steadily available and robust unions represented workers, millions of industrial employers, including their families, absorbed the new social rights. But this system was on a timer, and even at its peak, it was uneven and differentiated by race, gender, and space.

The social worlds that steelmaking and steelworkers made were gendered and racialized, reproduced along social hierarchies, and unevenly laid across space and time. In a chapter about racial geographies and strategies of survival through cooperation, Winant outlines how one could see the emerging crisis of deindustrialization wrangle its way across the hilly Pittsburgh metropolis:

A person leaving a steel mill and walking uphill from the Mon Valley floor in 1960 would, within five or ten minutes, enter and exit the Black steelworker neighborhood. After another twenty minutes, the white steelworker neighborhood would come and go, still displaying some internal ethnic gradations: Slovaks and Poles here on the hillside, the Italians there, the Irish a bit higher, and managers over the ridgeline. With the spasmodic decline of the steel industry, insecurity worsened for many working-class people but did so more severely for African Americans. A wave of layoffs, as it ground its way through the steel mill seniority list and through hierarchies of race and skill, would creep up the hillside like a rising tide. 

Since the postwar welfare state “disbursed economic security to the working-class population through industrial breadwinners,” he writes, deindustrialization was a collective experience. Decades of scholarship on the social history of industrial decline demonstrated how layoffs and plant closures ruptured entire communities. Winant builds off this work to explore how the social crisis of deindustrialization led to a shattering of social reproduction and the reconfiguration of daily survival strategies. Those who had family and friends to turn to obtained loans, food, daycare, and for the lucky, a job prospect. Those who did not found aid in their neighborhood or at community institutions. At the level of the neighborhood, deindustrialization reconstituted familial structures and community relationships. When the smoke stopped coming out of the massive furnaces that dotted the riverside, all, however unevenly, felt its disappearance. 

Like mass incarceration, health care was a way for capital and the state to respond to the crises and surpluses of the late twentieth century. When deindustrialization shattered communities, traditional support structures fell apart. Young couples and single men left to look for work elsewhere. Many left their elders in nursing homes primarily staffed by low-paid women of color. While the decline of industry hit Black men the hardest, it opened opportunities for Black women. Care work was gendered and racialized, associated with domesticity and servanthood. This understanding of care labor devalued the work despite its social, political, and cultural importance. Existing hierarchies of race and gender, imposed by the postwar welfare state and the political economy of industrial production, were reproduced in the newly emerging care economy. 

A pivotal moment in this history, and perhaps the larger history of neoliberalism to which the book contributes, is the shift from decommodified health care to corporate health in the 1983 Medicare reforms. Congress and the President approved a major change from a “labor-intensive, durational model of care to a capital-intensive, interventionist model of treatment.” Here was the pinpoint for a major expansion and transformation of health. Prices skyrocketed while hospitals pursued new avenues of revenue generation and cost reductions. As the demand for care increased, the need for labor did as well. But the hospital as a workplace was unequal and precarity was spread on a gradient, much like the neighborhoods of Pittsburgh, across race, gender, and skill, with doctors and administrators at the top, nurses near the middle, and janitors and nurse assistants at the bottom. 

It was not a coincidence that care labor grew as industrial work declined. “The processes were interwoven,” Winant writes. When the industrial economy collapsed, the social problems its destruction generated “became translated, through the mediation of the welfare state, into the form of health problems.” Organized workers acted as “blocs of collective consumers,” which in turn expanded the system of care provision and “generated employment on a massive scale.” The big question for our times that Winant poses is whether this emergent working-class majority can become a potent political force. If the Covid-19 pandemic has taught us anything, it is that low-wage, service sector workers have an immense reservoir of power and public support. And with the Biden administration moving towards the most pro-labor policy since President Jimmy Carter in the late 1970s, mass unionization and militancy may be on the horizon. If a wave of organizing and strikes occur, cities like Pittsburgh and Detroit will be at the center of the future of the care economy labor movement.