Gabriel Winant is an historian at the University of Chicago and the author of The Next Shift: The Fall of Industry and the Rise of Health Care in Rust Belt America, which uses the case study of Pittsburgh to show how the decline of industry and the rise of the care economy are two sides of the same phenomenon. He spoke with Forge contributor Dave Kamper about the organizing potential in care work. The interview has been edited and condensed.


Let me begin by asking for your reactions to Biden's infrastructure plan because it specifically targets the care industry for dollars. It’s what your book's all about.

I think what's clear is the organizing of care workers and their activity over at least the last decade has seeped into the common sense of the Democratic Party. And there is some general understanding in the administration that the payoff in terms of labor market change, creating and improving the quality of jobs, is high. I think you can see the effect of workers organizing over the last two years.


In your book you describe the “trilemma”: low unemployment, high wages, fiscal restraint — policy makers can pick two out of the three. With the American Rescue Plan, it seems like Biden is giving up fiscal restraint. Do you see a way out of that trilemma?

I think the way out of the trilemma depends on a radically different organization of society. The trilemma emerges from the tension and contradiction between the connection of productivity to wages. [Owners of care industries] haven't found a way to get more care per dollar or per hour without degrading the quality of the service. They can try to manage this problem by holding down wages as much as possible, which often also takes the form of under-staffing. And if you talk to healthcare workers, it was always the number one complaint about the workplace, even in low-wage workplaces, they'll generally talk about staffing levels before they talk about wages.

That poses a profound problem for an economic system premised on growth. Growth is itself premised on increasing productivity, of self-sustained productivity increase over time. We tried to manage it within a capitalist economy. The most radical optimism of the book is that this problem may not be manageable in a capitalist economy and might form the basis of imagining different kinds of social organization.


One of the important parts of your book is how you describe the absolutely epic scale and scope of the care industry in this country. Can you describe for yourself how you saw the size of the care industry change over time and maybe an understanding of why you think we don't recognize its size and scale?

I had some sense of this when I started the project, and I picked Pittsburgh as a case study because I thought this would be a good place to understand what came after manufacturing. I was driving to Pittsburgh and stopped to get gas and lunch. Everywhere, I would see these signs, little sandwich boards stuck in the median or whatever saying, “hiring LPNs,” “hiring CNAs,” all over the place. I started thinking about like, what is that, where is that coming from? 

It's the largest sector nationwide in the country. It encompasses all categories of health care. So that's hospitals, doctor's offices, nursing homes, home care, things like physical therapy, dentistry, and other kinds of related phenomena you can imagine. And also social work.

[Care work] is about 14 percent of all employment. In places that were formerly heavily industrialized, it's significantly bigger. It's about 18 percent of all of Allegheny County (which includes Pittsburgh). If you look at big urban counties and rank order them, which I do in the book, by just how much of their workforce is in healthcare, social assistance, in the top ten are the Bronx, Philadelphia, Cleveland, Buffalo, Rochester, Pittsburgh. You immediately recognize what you're looking at.

There are neighborhoods in all of these cities where the proportion rises to thirty or forty percent. I looked up Co-Op City, the famous neighborhood in the Bronx, just to see. Nearly forty percent of workers who live in Co-Op City work in healthcare and social assistance.


You talk in the book about how the places where profit happens in this industry aren't the places where the people are employed. Our audience at The Forge is activists and organizers. Where should they be looking to find the closest intersections between the actual work that people are doing and the profits they are generating?

I think this gets to a key political question in the book. We have a paradoxical and inverted socialization of employment happening. And what's promising about that is it creates an opportunity to think about contesting the terms of employment politically through the workplace. The teachers’ mobilization in 2018 and 2019 is a perfect example of how you can do this in a somewhat more straightforward situation. I think this comparison is really helpful. 

Take the situation of  a town where they don't have a hospital. The biggest employer in the town is going to be the schools. Teachers are the most significant workforce and people know them, like them, and need them. So the teachers have potential for social and political leadership. That was at the core of the Red for Ed phenomena. Teachers are the people who, in some way, hold the place together. 

What's different between healthcare and education is two key things. One, education is overwhelmingly a public industry, particularly at the primary and secondary level. And healthcare is overwhelmingly private. At the level of who is your boss, it's overwhelming in the private sector. Second, in terms of occupational hierarchy, healthcare is much more stratified because of occupational hierarchy. Even a unionized hospital could very easily have five, six, seven bargaining units, spread out, parceled out across different unions. Differences of skill are part of that, often mapped on to differences of race or immigration status or gender. I mean, this gender hierarchy, it's not that school systems are without it, but it's much more compact or compressed.

It's clear who speaks for the needs of the school to the public. The teachers’ union can win that kind of trust. Who can say that for the healthcare system? There isn't an equivalent organization.


Does that mean that we should be paying more attention to things like doctor organizing? Can we win them over and bring them into the fight?

I think the question is whether nurses, paraprofessionals, and so-called “unskilled” workers in service, maintenance, etcetera, can figure out how to get together. I think that would give us a way of contesting not just the working conditions of these low-wage workers but also the question of the role of the care industry in our society. There are all of these organizational layers separating the public from the worker. It's very difficult to achieve political alignment between patient and worker. It is at the heart of trying to make it a more humane healthcare system.


Did you see places where there was greater connection that could be looked at by organizers today?

There's a story I tell in the book that's been really important to my own thinking. There was a struggle over a public nursing home in Allegheny County in the 1970s. It was called Kane Hospital, but it was a nursing home. It was 2,000 beds; your average general hospital is three hundred so that's an industrial institution. By the 1970s, it was a nightmare. It was in really bad shape and it was overcrowded.

And at the same time, de-industrialization was eroding the county tax rate. This group of activists, one of them was a social worker there and she got a couple of her friends to get jobs there so they could expose it. And they wrote up a report. This is in a moment in the late seventies when similar conditions are leading to nursing health scandals around the country. It was a federal investigation in the Senate. And then they formed an organization with elder rights activists and union activists and other kinds of lefties around town, called the Committee to Improve Kane Hospital, to pressure the county to both improve the conditions and also not to privatize it. There was a strike in 1977, but there was also this activist pressure not to privatize it. And they ultimately kept it public. It's still public today. 

I mean, it's not a transformative victory, but I think there's something important about how they built this coalition. There were questions of who could speak for the patients, but they involved patients to the extent possible and their family, involved professional workers, involved the unskilled, involved all. They managed to build a big coalition and to make the question of working conditions and caring conditions synonymous, which I think is the key thing.


If an organizer picks up your book and wants to dig into the subject more, what's the next place they should go look?

Well, Caring for America by Eileen Boris and Jennifer Klein is a great book on home care, which my book talks about a little bit. The documentary I Am Somebody, about the hospital strike in Charleston in 1969, is an amazing documentary on the historical struggles of healthcare workers. I also recommend Sweat by Lynn Nottage, which is a great play set in Northeastern Pennsylvania. It's about a generation of job loss and the damage it does. And one of the main characters winds up working at a nursing home. I remember watching it, thinking like, “Oh, no! Same story.” 


What's next for you? 

I'm starting a new project. I'm interested in going back to the origins of the New Deal and trying to understand the relationship between emancipatory aspects of the New Deal state and the ways that it reinscribes institutionalized forms of normative gender and reorganized white supremacy in a certain way. I want to think about this in a way that doesn't fall into the trap of either like: “the New Deal was actually racist and therefore bad” or “the New Deal was the only good thing that ever happened.” It seems to me like we've gotten polarized in some way between these, and it's important to try to understand how these different elements of that historical formation interlock with each other.


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