Courtesy Harvard University Press.

Arriving last year in Chicago, I couldn’t help noticing that the red-brick, chimney-stacked public schools looked like factories; shuffle students in, and churn them out. So, too, did University of Chicago Medicine look like an industrial plant, with smoke billowing from its rooftop pipes, the tremendous din from its generators and loading docks, and the cavernous parking garages on both sides—warehouses for storing the modes of transport for all the bodies moving in and out of the conveyor belt of care.

I have since read about how manufacturing jobs made Chicago a hub for Black Americans fleeing the Jim Crow South. I learned that tensions between returning white soldiers from World War I and newly arrived Black workers prompted one of the deadliest race riots in American history in 1919. I grimly read about City efforts to stem the wave of meatpacking and factory closures dating from the 1950s and 60s that largely failed to stem the decline. And then there was US Steel’s South Works, which after more than one hundred years of operation shuttered its doors in 1992.

If the South Side’s heavy industrial past leaves a mark on the architecture, infrastructure, and imagination of its inhabitants, might its waning economic power hold implications for our area’s future too? This question is posed and answered in The Next Shift by University of Chicago labor historian Gabriel Winant. He examines the decline of industry and the rise of the healthcare economy, and the implications of this transformation. Although Winant’s history deals with the particular case of Pittsburgh, many of its core insights apply to the South Side, and more broadly to Chicago.

Winant begins with the revelation that University of Pittsburgh Medical Center, a nonprofit research hospital with 85,000 people working in numerous care centers and clinics, claimed in legal filings to have zero employees. Zero employees. Winant explains this as “fissuring,” a common practice in today’s service economy in which major corporations and institutions subcontract labor to third parties that do not pay workers livable wages or ensure them safe working conditions. To illustrate the concept, Winant highlights the case of Diana Borland, a medical transcriptionist, whose pay went from $19 an hour to $6.36 after UPMC reclassified her as a contractor to be paid for her transcriptions on a per-line basis. To relate this case to Chicago, think Aramark, a multi-billion-dollar, publicly traded corporation that Chicago Public Schools contracts to handle its janitorial work and University of Chicago Medical Center contracts for its food services. These workers remain outside the purview of organized labor, and many have said that the company fails to pay its hourly employees livable wages.

Even as Chicago’s pharmaceutical (AbbVie, Abbott Laboratories, and Baxter Healthcare), health insurance (Blue Cross Blue Shield, United Healthcare, and Humana, Inc.), and medical technology companies rake in enormous profits, hospitals and nursing homes in the area operate on slim profit margins, leading them to suppress wage growth among care workers since they cannot reduce staffing in these positions. Entry-level medical assistants in Chicago can expect hourly wages lower than $15. Phlebotomists, customer service, triage, and scheduling representatives only command a couple dollars an hour more. Walk into any Whole Foods or Mariano’s, and you’re likely to be offered about the same. Despite these low wages, the care sector has grown tremendously in Chicago, almost doubling from 408,000 jobs in 1990 to nearly 700,000 jobs in the present day, coinciding neatly with the decline in manufacturing from 187,000 jobs in 1992 to 58,000 in 2013. The rapid expansion in the number of care jobs signals their crucial role in our community, even while care workers themselves remain chronically underpaid.

What to do about low-wage, socially important work like health care and education results in what Winant terms the “trilemma” for policymakers. They can pick two out of three from: low unemployment, high wage growth, and low public expenditure, but not all of them, because the low productivity gains inherent to service sector work mean that, absent public investment, market forces will tend to suppress wages. Thus, policymakers can either hold down wages for low unemployment and low deficits, or accept high unemployment for good wages and low deficits, or embrace costly state intervention to have low unemployment and sufficient wage growth. These choices have massive implications for the United States broadly and Chicago specifically, as the city’s population of residents between the ages of sixty-five and eighty-four is expected to double by 2040, indicating an even more acute need for elderly and infirm care.

Winant’s core insight is that the decline of the manufacturing industry and the rise of the care economy are not disparate, unrelated, or coincidental phenomena. Rather the latter is the historically informed product of the former. Winant reveals how a bargain struck between labor and industry after a series of nation-wide strikes mid-century led to the creation of a privatized health care system, and later a public safety net for the elderly and disabled (Medicare) and for the poor (Medicaid). As these privately health-insured industrial workers aged or succumbed to injuries, they required greater and greater amounts of care, necessitating an expansion in the number of care workers. “The insurance they had won and the system of supply built to meet their collective demand,” writes Winant, “endured through the decline of their own industry and buffered them somewhat against that shock.” Public subsidies through Medicare and Medicaid meant the number of Americans with insured healthcare expanded rapidly after the 1960s, thus adding to the care labor crush.

Winant’s detailed history charts this interwoven process through the context of steel manufacturing in Pittsburgh, from its heyday in the post-WWII years to its demise in the 1980s, and the growth of the University of Pittsburgh Medical Center after the 1970s into the economic behemoth it is today. He draws on the perspectives of steelworkers themselves, both Black and white, and their battles with management throughout the postwar era over working conditions.

Chapters devoted to roles of race and gender in the steel industry detail how caring for children and the infirm, seen as women’s work, became normative within the structure of the nuclear family in the 1950s. When husbands worked night shifts, wives stayed up to prepare their dinner hot, only to wake up a few hours later to ready the children for school; when husbands got home, they did not assist wives in the cleaning or cooking; and when husbands were laid off, wives picked up the slack, scrounging, asking for relatives for assistance, and making due with odds and ends.

Black workers were typically the first to get the pink slip as automation, capital flight, and overseas competition erased the industry’s profitability. Stuck at the lowest rungs of the steel plant’s seniority system as unskilled workers, they were “likely to be hired last and laid off first” and “exposed to the most dangerous and difficult work.” While Winant offers tantalizing snippets relating the decline of industry to mass incarceration, the opioid epidemic, and drug and rehab centers mushrooming all over the country, he does not explore these topics at length. Perhaps these will be the subject of his next book.

His sources are as varied as memoirs written by steelworkers, journals kept by their wives, and oral interviews with care workers recorded by sociologists and the author himself. One healthcare worker he interviewed noted that, “[The healthcare] industry is heavily dominated by working mothers, some of them single mothers, all of us doing everything we can to build a good life for ourselves and our families. We are the mothers and the caretakers in the hospitals but it seems like there’s no one taking care of us or looking out for our wellbeing.” Another woman tore both her rotator cuffs because of the heavy toll of cleaning thirty hospital rooms by herself. Many workers, requiring care themselves for stresses and injuries developed on the job, end up mired in medical debt to the very hospitals that employ them.

In the epilogue of The Next Shift, completed just as the COVID-19 pandemic began, Winant smirks at the irony of calling care workers “essential” or “frontline heroes,” even as thousands got sick and died often working without hazard pay, proper protective equipment, or sufficient training. He concludes by offering a glimmer of hope that increased labor militancy among care workers in the past decade will lead to better pay and conditions, and with an empathetic plea from one: “Healthcare workers like me are taking care of people with serious diseases and chronic illnesses—lifting them, emptying catheters, giving them baths. For that, I am only making $13.32 an hour. Is that really all I am worth?” For the South Side, with over 9,000 care workers employed at University of Chicago Medicine alone, not to mention the thousands of home health aides working in one of the largest personal care markets, the implications of this question are just as profound.

Gabriel Winant, The Next Shift: The Fall of Industry and the Rise of Health Care in Rust Belt America. $35. Harvard University Press. 368 pages.

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Max Blaisdell is an educator and basketball coach based in Hyde Park. He is originally from New York City and later served in Peace Corps Morocco. He last wrote about Afghan refugee resettlement for the Weekly.

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