Art for The Health Care Crucible.
Postcard from Pittsburgh, ca. 1898–1931. | NYPL
John Merrick,  April 8

The Health Care Crucible

In the ruins of industry, a new sector rises, and with it a new working class

Postcard from Pittsburgh, ca. 1898–1931. | NYPL
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The Next Shift: The Fall of Industry and the Rise of Health Care in Rust Belt America by Gabriel Winant. Harvard University Press, 368 pages.

Before the decisive shifts of the late 1970s and early 1980s reconstituted the economies of the Global North, politics turned on the management of labor and capital. But since the end of the post-war boom—and with it the era of full employment—our social order has to an increasing degree revolved around the question of how to manage those populations now denied access to the American dream. As unemployment has repeatedly spiked since the 1970s while the meager leftovers of the New Deal state have been slowly dismantled, so those populations who have clung on to society’s precarious fringes have proved to be an intractable problem.

If such concerns could once be ignored by those in the liberal establishment, even while discontent simmered at the margins, then the election of Donald Trump, with his repeated promises to bring industry back to Rust Belt towns, brought them once more to national attention. Even as Trump’s promises proved hollow, political pundits have continued to prod the open wounds, each one armed with their own diagnoses and each clasped tight to a patronizing image of the working class—invariably white and male, and almost always the holder of reactionary opinions. This is the Hillbilly Elegy story, often told by those who struggled and strived to drag themselves out of the stagnating pond of Rust Belt America, then perpetuated by liberal and conservative pundits ad nauseam. What we’re far less likely to hear is what became of those who never made it out.

When industries left the United States, whether because of offshoring, automation, capital flight, or a combination of all three, they took with them the jobs that had long sustained large swaths of the industrial working class. Capital is inherently mobile, always on the move, looking for new and more productive avenues for investment; it cannot (nor would it want to) take the workers with it. The problem with people is that they are rooted in particular places, embedded in specific communities. The ties that bind are strong, forming the country’s dense social fabric. Or they were, once. In many communities, deindustrialization left a social fabric that was wearing thin and a population that was, in the words of historian Gabriel Winant, “poorer, sicker, and older.”


Paul Brooks was forty-eight when he lost his job as a truck driver hauling steel from the mills near his home in Vanport, Pennsylvania. After the steel mill that he worked for closed in 1982, he spent the next twelve years in and out of work, sometimes driving a truck for a local bakery and later picking up steel from the area’s few remaining mills. His wife, Dorothy, took work as a sales clerk to help cover the living expenses for herself, Paul, and their ten children. By the mid 1990s, a broken shoulder left Dorothy unable to work, and the family were living on social security checks and the small pension Paul received from the Teamsters’ Union. Then doctors found a lump on Paul’s larynx. In 1996, the couple were struggling with mounting medical debt and rising living expenses, their finances stretched to breaking point. A pending round of state-level cuts to Medicaid felt to the couple like a “form of euthanasia.” “I’m scared,” Dorothy told the Pittsburgh Post-Gazette, “God forbid I should get some type of illness.”

The factories of industrial America didn’t just make steel or cars or the vast mountains of consumer products that fueled postwar growth; they also made whole social worlds.

Such stories, recounted in Winant’s new book The Next Shift, are not uncommon in America’s Rust Belt. As manufacturing fled areas like Brooks’s home near Pittsburgh, the lives of those who relied on it started to disintegrate. The aspects of the welfare state that remained plugged some gaps, but little else. In The Next Shift, which deftly charts the twin processes of deindustrialization and the rise of the health care sector in Pittsburgh, Winant sets out to present a broader narrative than the one often given in discussions of America’s long downturn from the 1970s to today. The factories of industrial America didn’t just make steel or cars or the vast mountains of consumer products that fueled postwar growth; they also made whole social worlds. Work doesn’t end when the hard-hatted laborer clocks off for the day. It relies on the labor of whole communities, of families and friends, and the informal and formal networks of care and support that they sustain. In turn, such social labor makes and remakes those very same communities.

When industrial employment dominated the nation’s economy, such worlds were formed around the lives of the industrial working class. And when industry left, the social worlds that it sustained began to crumble. What emerged in its place was a recomposition not only the economy, but of the working class itself. As Winant writes, “the collapse of the industrial core of the economy created social problems that became translated, through the mediation of the welfare state, into the form of health problems.” What replaced industry was a vast apparatus of health and social care to treat these now elderly and sick populations, and, in turn, new forms of working-class employment as nurses, carers, and the vast army of support workers that the old and poor required.


Pittsburgh was once famous as Steel City. The vast complex of mills that ran along the banks of the Monongahela River brought prosperity to the area and gave America many of its most famous industrialists—Carnegie, Heinz, Westinghouse—great names that still adorn many of the city’s buildings. By 2000, though, it wasn’t steel that was the area’s biggest employer, but health care. The health sector at the turn of the millennium accounted for some 14 percent of the workforce, a figure approaching that of the steel industry at its peak. Yet the image of the working class held so dear by so many across the political spectrum has stuck fast. Ask most people who the working class is, and you’ll likely be told about Appalachia’s soot-covered miners, or the dirt-flecked laborers on Detroit’s vast production lines, or, as in Pittsburgh, those who toiled in the infernal mills that produced the nation’s steel. Who you’re less likely to hear about are the nurses who change the bedpans of those former steel workers, now often disabled by industrial disease, addiction, and mental health problems.

“It was not a coincidence that care labor grew as industrial employment declined,” Winant writes. “The processes were interwoven.” Industrial employment brutalized its workers, leaving them with hacking lungs and damaged bodies. Incidence of industrial disease was high, and its effects long lasting. Yet if such work was difficult, then it also made workers heroic. The masculine image of the working class was formed in the crucible of the working day. Once that day was over, many took to alcohol to wash away the harsh reality of their working lives. The social consequences of such a system run deep, and their effects linger.

However punishing the work, it was also relatively well rewarded. Thanks to the struggles of organized labor, these industrial jobs gained some measure of dignity and decent wages, as well as earning workers the right to employer-funded health insurance. The union-won family wage made single-earner households common, although as Winant points out, not ubiquitous and rarer for Black workers, particularly outside of Pittsburgh. Still, the role of such households was crucial to postwar society, enabling the social reproduction of the workers and their family, “holding in alignment the formal economy and the rhythms of the family members’ lives.” In such a world, social problems were in effect privately borne by the family and the community.

When the industries began to decline, the conditions of the post-war boom were remolded into today’s low-wage, low-productivity service economy. Many industrial workers retained access to health care long after they lost their jobs, either through retirement benefits, state medical assistance, or short-term emergency insurance programs. The people left behind may have been older, sicker, and unemployed, but they were still in some way covered. As pressure on families grew, women were increasingly forced into the labor market, and often into the now-booming care sector as nurses, carers, or nurses’ aides, thus reducing the amount of time they had for the kind of unpaid care work that had kept the post-war family afloat. Such processes were replicated across the economies of the Global North to varying degrees. In Britain for instance, there are currently around 1.5 million people working in adult social care, and, as in the States, this work is often concentrated in deindustrialized areas, in the north of England, Wales, Cornwall, and parts of Scotland.

Alongside this, there’s another, parallel, story to be told. While the formal care sector grew to look after those left behind by deindustrialization, other groups deemed surplus were dealt with more harshly. One of the unusual effects of neoliberalism, usually associated with the stripping back of the state, was that while state spending was cut in many areas, it grew in two: health care and prisons. As Ruth Wilson Gilmore has written, the growth of the carceral state was an economic “fix” to the multiple crises formed by the restructuring of the economy, acting to remove those who were criminalized, often due to their race, from the population, while at the same time providing new forms of investment and jobs. Following Winant, we can see health care as another such fix. The welfare state and the carceral state worked in tandem to soak up the deep and long-lasting effects of deindustrialization, removing those sick, aged, disabled, criminalized, and racialized from the general population while creating new forms of work for others.

There’s a divide in how the old are regarded in America, torn between their access to social goods denied others and their own forms of social exclusion.

Where care work had once been relatively decommodified, its social role embedded in families and local communities, changes that occurred to the way that the private-public welfare state was funded also changed the nature of the work itself. The Social Security Amendments of 1983 were, Winant writes, “the health policy equivalent of the Volcker Shock.” They incentivized hospitals to focus on more acute illnesses, while unprofitable long-term care was displaced into nursing homes and home-based care. Such care work is labor-intensive. Any savings to be made are usually found by forcing workers to work harder and longer for less. Talk to any nurse, and you’ll quickly hear about the difficult conditions of their work. They are overworked and underpaid, and often subject to increasingly punishing work schedules. Yet you’ll also find out how much caring they actually do. While such an ethic of care is vital for patients, it gives management significant leverage over workers: no matter how hard they are pushed, they know that workers won’t neglect this vital aspect of their work.

These changes in the funding and nature of care work have had an effect that has trickled down through many parts of society. One such effect can be seen in America’s growing generational divide. Older people may still reap the benefits of the New Deal state’s remains, but younger workers are entering a precarious job market built up to an increasing degree of low-paid service work, often as carers of the old and sick. Under such conditions, generational conflicts spring forth. We’ve seen signs of this already: the politics of the Sanders campaign and its youthful activists one side of the divide, the revanchism of Trump on the other. But the situation could just as easily create new solidarities.

There will be a need to overcome some of the binary thinking involved in many forms of generational politics. While it’s true that older generations have access to forms of social citizenship that remain blocked for the young, there’s also a large, and growing, number of the elderly living in poverty. For the older poor to access long-term care, many must immiserate themselves further to gain access to Medicaid, a health care program for those living in poverty which, unlike Medicare, offers access to indefinite nursing home care. There’s thus a divide in how the old are regarded in America, torn between their access to social goods denied others and their own forms of social exclusion, with many consigned to the particular hell that is the nursing home system. In this crucible, where a precarious and exploited workforce and an elderly and sick population whose access to such care is itself precarious meet, new collectives could emerge. At the very least, a crucial first step will be in rethinking what the working class means today, and understanding that while typical American workplace may have changed, it’s still formed in the conflict between workers and their bosses.

As Winant says, the historical paradox at the heart of his book is “between care workers’ absent presence and industrial workers’ present absence.” While the image of the working class remains that of solidly-built masculine industrial workers, the working class of today is more likely to be changing bed linen in a hospital than forging steel. How exactly this reality might remake class struggle is difficult to know, but we can start to trace its contours if we know where to look. After all, as Winant says, “we all need care.”

John Merrick is a writer and an editor at Verso Books in London.

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