To grow up in Pittsburgh in the 1990s and 2000s—as I did—was to experience something paradoxical: slow-motion whiplash. In my early childhood, everyone seemed to agree that the city was dying around us—another victim of deindustrialization and globalization and a general brain drain, the factories gone forever and talented young people fleeing for greener pastures. A city that had once provided the steel to win world wars and been home to more Fortune 500 companies than any other except New York and Chicago had, by the early 1990s, lost almost half its people (down from a peak in about 1950) and nearly all of the industry that had employed generations and made the resplendently bearded robber barons—like Carnegie, Frick, Heinz, Mellon, and Westinghouse, whose names adorn virtually all of the city’s institutions—so damn rich. Pittsburgh exemplified “Rust Belt decline.”
Yet by the time I was finishing high school, Pittsburgh was back. Everyone said so. Former mills and shuttered factories converted into upscale shopping centers; biotech companies, startups, and cool new restaurants dotted the cityscape; affluent hipsters were moving back from those greener pastures. Soon companies like Google, Facebook, and Uber would arrive, drawn by the city’s top-notch universities (and relatively cheap cost of living). Pittsburgh had “transformed itself into a vibrant cultural and artistic hub, all while remaining true to its Rust Belt roots,” pronounced The New York Times. And at the heart of this transformation was “the relentless growth of healthcare jobs,” added the Los Angeles Times, with the health care sector replacing “manufacturing as the region’s powerhouse.”
Yet, as many have pointed out, this narrative of decline and resurgence—all on a foundation of health care jobs, all in the brief span of my childhood—masked darker truths. The city itself hadn’t really been dominated by manufacturing since the late nineteenth century, the scholar Patrick Vitale noted in an excellent article titled “The Pittsburgh Fairy Tale.” Instead, its corporations had extracted wealth from the true midcentury mill towns, which existed in Pittsburgh’s outskirts—communities like Aliquippa, Braddock, Clairton, McKeesport, McKees Rocks. It is these communities that are still largely desolated by deindustrialization, with many abandoned storefronts, crumbling homes, and widespread poverty and addiction. The story of Pittsburgh’s renaissance has been constructed on the erasure of its exploited environs. Further, as the University of Pittsburgh law professor Jerry Dickinson recently wrote, Pittsburgh “remains one of the most racially segregated cities by neighborhood in America,” with profound disparities in income and medical outcomes (especially for Black women).
It is this complicated, contested transformation that forms the backdrop for Gabriel Winant’s trenchant new book, The Next Shift: The Fall of Industry and the Rise of Health Care in Rust Belt America. Winant—a prolific essayist and historian at the University of Chicago—has delved deep into the region’s archives and made excellent use of oral history collections and original interviews to describe the transformation of the working class in places like Pittsburgh and its outlying communities. At the start of the 1950s, few people in the region worked in health care, while nearly 20 percent of jobs were in the metals industry, especially steel; today, few people in or around Pittsburgh work in steel or other industrial jobs, but health care jobs account for nearly 20 percent of the area’s workforce.
“It was not a coincidence that care labor grew as industrial employment declined,” Winant writes. “The processes were interwoven.” The industrial jobs wrought havoc on workers’ bodies, prematurely stooping them or poisoning them over time; the decline of these jobs wrought further havoc on the workers’ mental health. As steel jobs fell, health care jobs rose, with more and more workers needed to care for the aging, suffering former industrial laborers, especially as neoliberalism dismantled community institutions and punctured the social safety net. Yet while the steel jobs had been unionized and often provided enough to support an entire family, the health care jobs are largely low-wage and excluded from numerous labor protections. It is also no coincidence that while the industrial jobs of yesteryear were the province of men (largely, though certainly not exclusively, white men), the care jobs of today belong disproportionately to women, especially to women of color. To many, these care workers are “invisible, or disposable,” Winant writes, but they are the vanguard of the new working class.
The city of Pittsburgh sits at the confluence of three rivers, in the foothills of the Allegheny Mountains, at the heart of northern Appalachia. It is a critical port on the Mississippi River system, a vital meeting place for rail and for steam, once the artery connecting the big cities of the Atlantic coast with the resource-rich Midwest. By the late nineteenth century, the city’s status as a commercial hub and its proximity to the iron ore mined near Lake Superior and the coalfields of Appalachia gave rise to the biggest steel operations in the world, which generated extraordinary wealth and attracted waves of migrants.
Few jobs have been as fetishized, as mythologized, and as misunderstood as that of the steelworker. It’s certainly true that the steel mills of western Pennsylvania provided steady, relatively stable employment for generations throughout the twentieth century. By the 1940s, these jobs were heavily unionized. Years of strikes and solidarity led to average hourly wages of $3.36 by the early 1960s (equivalent to $28.53 in 2020 dollars). But these jobs were also brutal and dirty and dangerous. They slowly wrecked men’s bodies, and often injured them much more quickly. In one mill in McKeesport, Winant notes, 500 injuries were routinely reported per month in a facility with just over 4,000 employees. Coke ovens, blast furnaces, and open hearths exuded a punishing heat, with some workers inhaling so much burning dust that they vomited blood. “Working-class men did not only love and draw strength from this work,” Winant writes. “They also dreaded spending their lives doing it, imagining all that it would require of them and all that it would do to them.”
The hell of steelwork was distributed unevenly across racial and ethnic lines, with Black workers being subjected “to the damage and humiliation of the job in greater concentration, more minutes per hour, more hours per day,” Winant writes. They were disproportionately shunted into “unskilled” positions and excluded almost entirely from the skilled trades. They were often forced to live “at the bottom of the valleys, where air pollution collected around smokestacks.”
The physical and ecological wages of steelwork had significant ramifications for their wives and families. Fumes and filth meant considerable cleaning labor for women—rubbing overalls with lard to remove industrial grease or scrubbing the basin of a washing machine to excise dust and silt. One steelworker’s wife described herself as “an unpaid clean-up woman for industry.” Fathers, sons, and brothers often worked different shifts, necessitating women being “in and out of the kitchen all day long,” as one steelworker’s daughter recalled. Surveys revealed housewives working more than 50 hours a week. And, in an industry where pain and slow violence were the norm—and where to “drink, fight, drag heels, or sleep constituted a form of resistance,” as Winant notes—many men had trouble turning this off at home; mental and physical abuse were not uncommon.
As a result of automation and capital flight, the steel jobs gradually began to disappear in the 1960s. From 1960 to 1970, the number of metal manufacturing workers in the region fell from 162,514 to 128,142, part of a broader, massive decline in blue-collar industrial jobs across the country. This decline hit Black workers hardest. Layoffs often affected them at more than three times the rate of their white counterparts. Relatives, churches, and ethnic community centers had long shared money, food, and assistance, pooling their resources to care for families suffering as a result of a strike, an injury, or a death. But these ties and institutions began to strain under the weight of so much need.
As community networks frayed and mutual aid resources started crumbling, former steel families were increasingly forced to turn to the health care system for care—and, eventually, for jobs. Steelworkers had won robust health insurance decades before; Medicare had “seemed to open a faucet of limitless funds” for hospitals and insurers, and facilitated greater access for elderly people. This was of enormous importance in the Pittsburgh area, as more and more people were becoming sick. The economic downturn and decline of manufacturing jobs brought devastating health impacts; rates of heart attacks, schizophrenia, alcoholism, depression, and suicide rose sharply, far outpacing the national average.
In the wake of the industrial layoffs of the 1960s, many people in western Pennsylvania—but especially Black people, and in particular Black women—turned to the booming health care industry for jobs. These jobs were not terribly pleasant or well paid. Nor, for the most part, were they unionized, in spite of federal legislation and considerable organizing at the grassroots. The state legislature’s failure to intervene in 1970 “locked in place a dynamic in which 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,” Winant concludes.
In the years that followed, hospitals expanded and began drawing administrators from the corporate sector. These administrators began pushing for privatization and imposing harsh austerity regimes on the facilities, constricting budgets even as sick and laid-off industrial workers were showing up at the hospitals more and more. As a result of such conditions, overcrowding and ultimately abuse became common.
Throughout the 1970s and 1980s, the layoffs continued, with the region shedding another 150,000 manufacturing jobs in a single decade. By 1983, unemployment in the Pittsburgh area reached 17.1 percent, 60 percent higher than the national average and double the rate of just three years earlier. For Black workers in the area, it was 25.6 percent. This further increased insecurity for men and led still more women (especially women of color) to enter the labor market, especially in the care industry, “doing the laundry, cooking and serving the food, changing the sheets, and cleaning the bodies.” Steel plants began closing outright. Meanwhile, the Reagan revolution decimated welfare services and the social safety net.
Because of steel’s seniority-based job-security structure, layoffs disproportionately impacted the young, many of whom fled Pittsburgh. As this process continued over decades, the city lost hundreds of thousands of residents. The result was a “graying” of the population; soon, Allegheny County was the second-oldest county in the country. These older people—many of their bodies ravaged by years working in or living near steel mills—required increased care. But the women who, in years past, had served as caretakers were now working outside the home in greater numbers, and many of the community institutions and state support systems of yesteryear were gone.
Nursing home populations exploded, and home-care agencies were soon overburdened. The health care sector flourished. It added new jobs at a clip of 3 to 5 percent per year, but these jobs were generally more meagerly compensated, more poorly protected, and more irregularly scheduled than preexisting care jobs. People of color in particular were shunted into “unskilled” parts of the industry, including in nursing homes and ambulatory care. Big insurance providers—including Blue Cross of Western Pennsylvania (later Highmark) and the University of Pittsburgh Medical Center—grew ever wealthier, gobbled up community hospitals across the region, and began battling for dominance in the 1990s, each resisting unionization and attempting to squeeze more labor out of fewer people working shorter hours.
“Where there had once been a service ethic—exploitative but also with real resonance—there was now something more like servitude,” Winant writes. One medical secretary, whom he interviewed in 2018, said she believed she’d incurred damage to her bladder by trying to hold in urine for so long, because her unit was so overworked; sometimes she actually had to urinate on herself. Yet today, care workers personify not only the new conditions of work but also the resistance to these conditions. Winant notes that horrendous contemporary labor conditions led to a resurgence of collective action in the late 2010s, with health care accounting for more strike activity than any other industry.
The Next Shift is a deeply upsetting book. It meticulously charts the transformation of the working class to show how the destruction of workers’ unions and bodies occurred in a feedback loop, with capitalist exploitation demanding care, demanding more exploitation, demanding still more care. The demolition of state support and state protections served to speed up this feedback loop. It has long since spun out of control.
Although sometimes dense, Winant’s language often feels imbued with a sort of restrained, righteous fury. And while a lesser historian might have overlooked or given short shrift to the gendered and racialized aspects of the transition from steel to health care, Winant ably blends social and political history with conventional labor history to construct a remarkably comprehensive narrative with clear contemporary implications.
In light of such careful, comprehensive accounting, it almost feels nitpicking to focus on an apparent omission, but it is a shame Winant devotes so little space to environmental history. He does occasionally note the rampant air pollution produced by industrial processes, but he mainly does this to illustrate the “ecological domestic labor”—the cleaning, washing, and sweeping—it produced for women, especially Black women. He does not dwell on one of twentieth-century Pittsburgh’s defining characteristics—its built environment stained by the omnipresent soot, an industrial poison so pervasive that it often blocked out the sun and resulted in the nickname, “Hell With the Lid Off.” And Winant’s last mention of such ecological conditions is a brief reference to the fact that air pollution stood at twice the federally recommended level in 1970, resulting in an upsurge of patients presenting at hospitals with chronic lung disease.
Yet in the years since 1970, pollution in the region’s water and air has lingered, and today Pittsburgh’s air is still some of the dirtiest in the nation. The only mentions of mesothelioma or black lung are in the book’s epilogue, but their profusion and their symptoms—to say nothing of the immense number of former extractive industry workers who are denied medical coverage for these conditions as a result of industry lobbying—go unmentioned. Meanwhile, for decades, industrial discharge darkened the area’s sewers and groundwater, a situation that is arguably even more dire today, in light of the spread of fracking in western and central Pennsylvania, which also goes entirely unmentioned. Although it is banned within Pittsburgh’s city limits, fracking continues unabated in the region’s exploited outlying areas, a devastating ecological and medical disaster described in Eliza Griswold’s excellent recent book, Amity and Prosperity. Indeed, the rise of fracking complicates the narrative of the “fall” of industry in the first place. Today, Pennsylvania is home to more Superfund sites than almost any other state. Stretches of Pittsburgh’s rivers still stink.
The way this ecological crisis manifests today—in lingering pollutants and the abandonment of dying industrial laborers—is inextricable from an understanding of the evolution of the Rust Belt and its dominant forms of work and suffering.
Despite this omission, Winant’s book is a stunning achievement, sure to become a classic in the field of labor history, a study of the denial of care constructed with, well, admirable care.
In The Next Shift’s epilogue, Winant notes that he completed the manuscript amid the rise of the coronavirus. “Like a flash of lightning,” he writes, “the pandemic illuminated our society, revealing who is valued and who is dispensable”—those left to die in prisons and in nursing homes, as well as those unable to work from home. Seventy-three percent of the health care workers who became infected in the first two months of the pandemic were women. In December 2020, men in the U.S. gained 16,000 jobs, while women (nearly all of them women of color) lost 156,000. And, as The New York Times reported, the coronavirus has disproportionately affected Black and Latinx people across the country—in part because of medical racism, in part because of inequities in health care coverage, and in part because of inequities in the labor market.
It’s hard not to see a solution to some of the suffering, staring back at us from the pages of The Next Shift: organized labor. It was unions that secured health care for their members; it was unions that made steel jobs so remunerative, in spite of their myriad other flaws; it is unions that health care bosses continue to try to deny to care workers. The first anti-poverty program, Martin Luther King Jr. once noted, was the union, and labor organizing is a program in which women have always been at the forefront. Pittsburgh itself has a proud history as a vanguard of the American labor movement.
Our society—descending ever deeper into privatized suffering and a desperate fight for scraps—is in the midst of an acute “crisis of care,” the scholar Emma Dowling recently argued. This crisis is plainly apparent in postindustrial western Pennsylvania. “There is no sense of community here,” one heroin overdose survivor from the region said in an addiction study cited by Winant. “Left to your own devices, somebody that’s drinking and drugging is gonna continue drinking and drugging. Nothing else, cause there ain’t shit else to do.” The steel jobs aren’t coming back, nor should we want them to. But the security and stability—the care—that the steel jobs promised are very much worth fighting for.