The Nation, April 5, 2021
The Age of Care
Deindustrialization and the making of a new working class.
By Nelson Lichtenstein
A dozen years ago, I visited the Chicago offices of the National Nurses
Organizing Committee on the city’s West Side. Visible through a large
window was a gigantic parking garage, an annex to one of the equally
huge hospitals clustered within a dozen blocks. Cook County, Mount
Sinai, and three other medical complexes employed tens of thousands of
workers. Among those seeking to organize them was an African American
NNOC staffer.
BOOKS IN REVIEW
THE NEXT SHIFT: THE FALL OF INDUSTRY AND THE RISE OF HEALTH CARE IN RUST
BELT AMERICA
By Gabriel Winant
She told me she was the daughter of an autoworker in Flint, Mich., who’d
been a militant in his union during the heyday of the battles waged
between the United Auto Workers and General Motors. In Flint, she became
a radical activist, inspired by the power of the UAW and the moral
energy of the civil rights movement, and in time made a career as a
union organizer of nurses and other health care workers.
Hearing her story, I was moved by this example of intergenerational
working-class militancy, from her father’s activism in a manufacturing
sector now in brutal disarray to her own shop-floor organizing in the
booming world of metropolitan health care. But what I did not understand
was the degree to which these two kinds of employment were dialectically
connected, not just in terms of the consciousness of the workers but
also as a product of the very same political economy that had decimated
Chicago’s steel mills and Michigan’s auto plants. The old industrial
unions had bargained not just for higher wages but for pensions and
health insurance. As these unions declined, the private welfare states
they had done so much to construct became central to the economies of
these Rust Belt cities. With money from the federal government, new
hospital complexes arose across the Midwest and Northeast, and with
them, a new working class filled the economic and social vacuum left by
derelict mills and factory towns.
Gabriel Winant charts the rise of this new political economy and working
class in his terrific new book, The Next Shift. A study of the decline
of steel and the rise of a medical-industrial complex in Pittsburgh, it
explains how and why this great social, economic, and moral
transformation took place in regions like Western Pennsylvania, where an
old world of mid-20th-century steel mills, coal mines, and metal-bending
shops was soon replaced by a new one of care work, low wages, racial
stratification, and heavily female employment. Offering fine-grained
details of shop-floor industrial relations, the book is at once an
ethnographic probe into the lives of working-class families and a
comprehensive analysis of the larger dynamics of the US political
economy, and it gives an expansive new meaning to the community study,
which has long been a staple of labor history.
At 64 stories, the US Steel Tower dominates downtown Pittsburgh.
Completed in 1971, the modernist skyscraper once represented the power
and hubris of the largest corporation in one of the nation’s largest and
most profitable industries—a company that employed more than 100,000
workers in the metropolitan Pittsburgh region alone. But by 2007, US
Steel had become, like many of its rivals, a shadow of its former self,
and a new enterprise, the University of Pittsburgh Medical Center, was
the building’s largest tenant. As the employer of 92,000 health care
workers in the region, the UPMC had spent nearly $1 million to place its
initials in giant illuminated letters on the building. Looming over the
city from all three sides of the tower, the letters symbolized more than
just the medical center’s growing dominance over Pittsburgh’s economy;
they were also evidence of a profound occupational transformation. The
most recent regional census recorded 190,000 health care and social
assistance workers, compared with just 30,000 still employed in the
metal fabrication industries.
Pittsburgh was not alone in this transformation. Early in his book,
Winant lists the other postindustrial metropolises where health care
employment is disproportionately high, constituting a fifth or sixth of
the entire workforce. Almost all of them are Northern cities like
Boston, Cleveland, Philadelphia, Pittsburgh, and New York (the boroughs
of Brooklyn and the Bronx in particular). And like Pittsburgh, these are
cities where strong unions and collectively bargained health insurance
plans once thrived, and where the money negotiated by labor from
corporate coffers seeded a care economy that took on a life of its own.
As Winant shows, hospital growth was not just a question of money,
bargaining clout, or political influence. The care economy in Pittsburgh
and similar cities expanded not only because of the achievements of
organized labor but also because of what happened after union members
retired: Industrial workers in these cities relied on the hospitals,
nursing homes, and health care services as they aged and the giant mills
shut down.
As deindustrialization took root in Pittsburgh, Winant argues, the
communalism and solidarity that the working class had once invested in
parishes, neighborhoods, and union locals were now to be found in health
care and its allied social services. This was an epochal transformation,
but it was hardly triumphant. The construction of this new economy, and
the proletariat that sustained it, was deeply racialized, highly
dependent on the devaluation of women’s labor, and protective of only a
limited stratum of the overall population.
To understand the impulses that gave rise to these urban welfare states
and the dysfunctions they embodied, Winant offers a penetrating
examination of mid-20th-century working-class Pittsburgh, both on and
off the job. Today, a great deal of nostalgia colors the picture of
blue-collar America from the end of World War II to the early 1970s.
Liberals and labor partisans call this era the Great Compression, one in
which unions were powerful, real wages doubled, inequality declined, and
the civil rights movement transformed the nation; conservatives hail the
social norms and practices that put the male breadwinner at the head of
the household, kept wives at home, assured the loyalty of workers to
their employer, and maintained the stabilizing influence of the parish
church in close-knit ethnic communities.
Winant’s narrative draws from and transcends both of these perspectives.
Work in the steel mills did generate a sense of dignity, masculinity,
and comradeship, but these were combined with enough danger, insecurity,
and petty humiliation to subvert Fortune magazine’s claim that unionism
and postwar prosperity had made the American worker a “middle-class
member of a middle-class society.” If you didn’t bring a dinner pail to
work, the rats would often eat your lunch. There was no place to sit,
and the heat and smoke could be debilitating. Almost every steelworker
had a near-death experience at some point.
The USW pushed the companies to pay their workers enough to afford a
house and raise a family, Winant writes, but the postwar decades were
punctuated by recessions and strikes that slashed take-home pay and
generated the kind of anxieties that deformed family life for years. The
historian Daniel J. Clark makes the same point in his recent Disruption
in Detroit: Even as the automakers set new production records, layoffs,
plant closures, and short workweeks were an endemic experience, and
neither the union nor the Big Three could do all that much about it.
Working-class precarity is not entirely new.
Poor conditions in the factories were exacerbated by the relentless
management drive to increase shop-floor productivity. Steel industry
capitalists were conservative in the most profound sense: They feared
debt, overcapacity, foreign competition, and union or government efforts
to shape steelmaking’s future. To maintain profitability and avoid the
inflationary price hikes that weakened the US dollar, managers tried to
squeeze their employees by slashing crew sizes, intensifying work, and
turning foremen into compliant disciplinary agents. All this culminated
in the largest strike in US history, a four-month work stoppage in 1959
that Winant calls the “apex of proletarian manhood for a generation of
steelworkers,” though it is now long forgotten. At the time, the
sociologist Daniel Bell called it something close to a sham, a
“subversion of collective bargaining,” because he thought both
management and union leadership cynically used the long strike to
channel and demobilize worker discontent.
A[/dropcaps Winant argues, the 1959 strike was far more than just a way
for the rank and file to blow off steam over workplace frustrations. It
was as raw a contest between labor and capital as anything Friedrich
Engels or Eugene V. Debs witnessed in the mills of 19th-century
Manchester, England, or the Chicago rail yards. The capitalists wanted
the unilateral right to extract more labor power from nearly 1 million
workers without an investment in new technology. The fight eventually
made its way to the halls of Congress and the White House, where even
Richard Nixon, then the vice president, saw that working-class militancy
in the Steel Belt was genuine and potentially dangerous. As a result,
the steelworkers won: They stymied the management offensive and even got
more money in every paycheck.
But as with so many other strike battles and political fights in the
heyday of postwar unionism, the labor movement lacked the power, the
political allies, or the vision to transform momentary victory into a
lasting triumph. Many unions, including the USW, were becoming as stolid
and complacent as the steel industry’s management. They thought American
capitalism was on an upward trajectory that required little more than a
Keynesian economic tweak and a collective bargaining routine to see that
workers got their fair share of the profits. Yet with the rise of
foreign competition and the failure of either government or management
to modernize the mills, the 1970s instead inaugurated a disastrous
decade for heavy manufacturing and its workers.
Except for Pentagon-backed programs, the United States had no Japanese-
or German-style industrial policy that might have preserved steel
industry jobs. Neither did the government attempt to find some other
kind of dependable and humane employment for this shrinking industry’s
workers. Winant might well have explored such alternative possibilities,
which in the 1970s and ’80s were vigorously advocated by such disparate
figures as Ira Magaziner and Robert Reich, who urged an industrial
policy during the Clinton administration, and Edward Sadlowski, whose
New Left–ish campaign for USW president in the mid-1970s challenged the
unimaginative leadership of his union. But Winant does tell us what
actually happened: In the absence of concrete alternatives,
Pittsburgh-area steelworkers confronted a social disaster out of which
sprang a very different path toward income, security, and family welfare.
I[/dropcapn Pittsburgh and elsewhere, reproduction was just as important
as production. If social citizenship was forged in the factory, it was
distributed to the population via the family, which constituted the
“social machinery,” as Winant terms it, that linked the process of daily
life to the rhythms of industry. The working of this machinery was
imperfect and arduous: If the man came home from the late shift, a
spouse or daughter had to have a midnight dinner on the table; during a
long layoff, the women stretched the family budget, borrowed from
relatives, or went out to work themselves. Women in the mill towns
learned what different sirens and whistles meant. “We used to run to
grab our clothes off the line when we saw big clouds of smoke coming
from the mills!” declared one housewife, who described herself as ”an
unpaid clean-up woman for industry.”
But regardless of how grueling and constant the women’s work was, this
mythology of the early postwar decades—that men’s work deserved to be
paid while women’s was an innate labor of love—remained largely intact.
Yet as the city’s industrial economy began to weaken in the 1970s,
workers started to look for an institutional mechanism that could
sustain this often feminized work in an era of economic chaos, and they
found it in the hospitals and social services that were the one segment
of the US welfare state that continued to have funding.
Many of these hospitals, built or expanded upon in riverside steel
towns, seemed to embody the communitarian values that had flourished in
the ethnic neighborhoods that hugged the hills above the mills. Not
unexpectedly, hospital visits were disproportionately high in
southwestern Pennsylvania. By 1978, the region generated 1,366 inpatient
days per 1,000 people, compared with a national average of 1,192. The
population was aging, the pollution rife, and the work hazardous, but
steelworkers and their families also saw health care as the keystone of
a communal welfare state they had helped to build. Hospital visits were
“very good experiences,” one working-class spouse recalled. “The nurses
were always nice and the doctors were always there to take care of any
problems.”
And the money was there as well. Once the Supreme Court ruled in 1949
that collective bargaining over health insurance was a legitimate union
goal, the total annual Blue Cross payments to hospitals in Western
Pennsylvania more than doubled in just five years. In Homestead, which
had lost half its population since 1940, the local hospital was booming.
When Medicare came into existence in 1965, it generated a raft of new
clients over the age of 65, accounting for more than one-third of the
inpatient days there.
The financialization of hospital construction and operation soon
followed. With the interest rates on semipublic hospital bonds a couple
of percentage points lower than on comparable debt, and with a cash flow
guaranteed by the federal government, Pittsburgh’s hospitals became
machines for turning Medicare and Blue Cross payments into debt service
for private bondholders. Thus, in 1973, a hospital executive in
Homestead defended a controversial expansion program by saying,
“Investment bankers were willing to buy $27.5 million worth of bonds.
That’s good enough for me.” Throughout the 1970s, as the steel mills
crumbled, long-term hospital debt doubled.
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