BOOKS OF THE TIMES <https://www.nytimes.com/column/books-of-the-times>
How Health Care Became the Big Industry in Steel City
ByJennifer Szalai <https://www.nytimes.com/by/jennifer-szalai>
* NYT, March 31, 2021
Credit..
//
The Next Shift
The Fall of Industry and the Rise of Health Care in Rust Belt America
By Gabriel Winant
Illustrated. 350 pages. Harvard University Press. $35.
Bad times for American labor have also meant boom times for a certain
strain of American nostalgia. According to a well-worn narrative, the
postwar era was an idyll of heavy industry and stable union jobs; a
family with 2.5 children could get by with just one breadwinner — the
archetypical working-class man, who toiled in a sooty industrial plant
before coming home to a house that was impeccably maintained by his
doting wife.
Decades after the collapse of its steel industry, Pittsburgh exemplifies
how the trace memory of an old identity can live on in a football team
(the Steelers), a nickname (Steel City) and even a local beer (Iron
City), while the industry that actually flourishes there now — health
care — garners no such reverence or recognition. The fastest growth in
the sector isn’t for anesthetists or X-ray technicians but for poorly
paid caregiving jobs; most of these care workers are women, and many of
them are Black.
During the pandemic, these workers have been called “essential” — but as
the historian Gabriel Winant explains in “The Next Shift,” remuneration
and job protections haven’t kept up. “Care workers are at once
everywhere and nowhere,” Winant writes. “They are responsible for
everyone, but no one is responsible for them.”
The replacement of blue-collar work by pink-collar work has been much
discussed, but what makes this book stand out is Winant’s argument that
two seemingly distinct phenomena are in fact inextricably connected: “It
was not a coincidence that care labor grew as industrial employment
declined.” In the 1970s, deindustrialization pushed an ailing and aging
population into unemployment, toward the welfare state — always
tentative, in the American case — for their survival. Unlike other
social institutions, which buckled under political pressure and
austerity cuts, the American health care system flourished, having grown
already in response to the rise of collectively bargained health
insurance during the flush postwar years.
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Winant traces the surprising story of how this happened, taking
Pittsburgh as his focus. The city and its surrounding county offer one
of the starkest examples of a local economy not simply shaped but warped
by the steel industry, whose reach extended through the entire social
fabric, right down to the level of family relationships. Winant, who
teaches at the University of Chicago, consulted the archives, examined
the data and conducted his own interviews to glean an intimate look at
how a city of steel became a city of health care aides.
Image
Gabriel Winant
Gabriel WinantCredit...Jeannette Estruth
“The Next Shift” is an original work of serious scholarship, but it’s
also vivid and readable; Winant has an eye for the telling, and
occasionally crushing, detail. One ambivalent steelworker recalled that
he always brought his lunch in a brown paper bag that consistently
failed to protect his sandwich from hungry rats; he resisted getting a
proper lunch pail like the others because it would mean that he was
resigning himself to staying put. A woman remembered growing up amid the
hushed silence of a house that had to be kept quiet and dark so that the
father she barely saw, who worked night shifts, could get some sleep
during the day. Households had to organize themselves around the needs
of the industry. Each family became “a little factory.”
Despite the sentimentality that has attached to the steel mill, the work
it generated was not only dangerous, it was also unpredictable and not
infrequently alienating. Winant describes how a coke shoveler working
night shifts lost “control over his body’s rhythms — eating, sleeping,
toiling,” which in turn made it harder to maintain the performance of
masculinity that was so central to his identity. Not to mention that the
job security afforded by the union’s collective bargaining wasn’t evenly
distributed. In the 1950s, as the demand for steel slackened with the
end of the Korean War, layoffs hit Black workers first — they tended to
be marginalized within the union, and kept in the worst positions at the
mill.
For a time, steelworker unions obtained higher wages, outstripping
inflation; then, responding to government pressure to keep wages down,
they bargained for better health insurance, which generated its own
inflationary dynamic in the health care system. Winant offers a lucid
explanation of how the peculiarities of this system developed into what
he calls the “public-private welfare state” — a dysfunctional realm of
escalating health care costs and entrenched and entangled interests that
no one seems capable of replacing.
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This public-private welfare state was what awaited the workers cast off
by a collapsing industry. Winant notes that the two social institutions
that have prospered since the 1980s have been prisons and health care
delivery: “Like the expansion of the prison system in the final decades
of the 20th century, the rise of the health care industry afforded an
economic fix to the social crisis brought about by deindustrialization.”
Hospital work was labor intensive, and it opened a job market for those
Black Americans, including domestic workers, who were the first to be
displaced by automation and industrial decline. Their exploitation,
Winant says, “formed the basis of the bonanza for everyone else.” This
work force was largely excluded from the midcentury prosperity and
security it helped to create, and the ensuing cycle was vicious:
“Caregiving could be offered at large volume to the insured fractions of
the working class because its costs were passed on in such significant
proportion to hospital employees via low wages.”
This system, as depicted in Winant’s eye-opening book, is not only
inhumane but unsustainable. Toward the end of “The Next Shift,” he
introduces us to Nila Payton, a medical secretary who takes calls all
day from patients with mesothelioma and black lung at the pathology
office where she works. The place is part of Pittsburgh’s enormous
hospital complex, but her office is so understaffed that it’s sometimes
hard to find someone to cover the phone when she needs to use the
bathroom. She says this has damaged her bladder, and in nine years of
working there she has never received more than a 15 cent raise.
“Like many patients,” Winant writes, “Payton is now in medical debt —
though in her case it is to her own employer.”
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