No institution endured as much catastrophe throughout the coronavirus pandemic as nursing homes, whose patients and workers accounted for around 40 percent of all COVID-19 deaths in the United States. The crisis was years in the making and required far more than a novel pathogen alone to happen: a largely for-profit industry that cut every corner it could find, a woefully exploited marginalized workforce that shuffled between employers, profoundly sick patients warehoused together to tap into economies of scale, and a piecemeal financing system dominated by the austerity logic of Medicaid.

The women and people of color who overwhelmingly occupy the growing bottom rung of the health care industry were dubbed “essential workers,” but they often lacked personal protective equipment and usually made less than $15 per hour.

After the first wave of infections subsided, research revealed just how connected their plight was to their patients’: while nursing homes owned by private equity firms had 10 percent higher mortality rates, unionized facilities experienced 30 percent less mortality than their unorganized counterparts.

But the cruel systemic dysfunction revealed by the virus, argues University of Chicago historian Gabriel Winant, was itself borne out of an earlier crisis: deindustrialization and the social collapse in its wake. Winant’s new book The Next Shift: The Fall of Industry and the Rise of Health Care in Rust Belt America charts how Pittsburgh’s declining steel industry gave rise to one of the country’s most ruthlessly corporatized health care systems, and how the ability of each to deliver on its romanticized promises rested on the exploitation of care work. In so doing, Winant reframes an often reductive narrative of “good times, then demise” into one that foregrounds the women just as dependent on steel for survival as its mostly male unionized workers but without their wages and protections, who remained subordinated to capital as they were filtered into a health care industry that boomed within communities growing older and sicker as steel left them behind.

Readers are introduced to Pittsburgh as a bustling Rust Belt city in the years following World War II — an era Winant portrays through a lens far less rose-colored than our collective memory does. While the fabled steel plants synonymous with the place did provide the material basis for entire communities that supplied its unionized workers, this livelihood was neither stable nor secure: if the United Steelworkers had enough power to negotiate relatively high family wages and benefits, the industry reached its apex in the early 1950s with Korean War contracts — and its quest to bolster profits amid decline exerted serious downward pressure onto its workers and their families. For the workers in the mills, that translated into an increasingly miserable experience: not only did workers weather the chaos of being repeatedly furloughed and rescheduled, but those who did stay on were expected to meet ever more gobsmacking productivity goals with supervisors breathing down their necks to make it happen. Already physically strenuous jobs were made even more so with shrinking crews and sped-up machinery; many men turned to booze to cope.

After their shifts, men at the end of their rope returned home — a sphere Winant lends equal time to. After all, these workers had collectively bargained a so-called “family wage,” which distributed the means of survival to people well outside the mills themselves. If the men employed at steel plants faced gradually deteriorating conditions as the bosses squeezed them for profit, so, too, did the wives and children dependent on their wages and subject to the choppy rhythms of their lives. When only night work was available, these wives kept their homes dark and quiet during the day while caring for children and stayed up late into the night to feed their husbands; during strikes or layoffs, they shouldered the burden of stretching household resources and maintaining a sense of order.

The more that work dried up over time, the more pressure — and too often, domestic violence — these women faced, often combining households with other relatives or borrowing and lending among neighbors. Importantly, as Winant carefully narrates, the experiences of both workers and their families varied by race: black steelworkers held lower-waged positions in good times and were the first sloughed off in bad, leaving less material wiggle room for partners, extended family, and communities.

But as Big Steel began its slow, decades-long fade-out, the opposite happened to health care. In the 1940s and ’50s, unions were able to leverage the high point of their power into generous health insurance plans for themselves and their families. More patients and revenue became a reason to construct new hospitals, which began hiring the community members who felt the crunch of the ailing steel industry the earliest: mostly black women. With the passage of Medicare and Medicaid in 1965 came more and sicker patients, as well as obvious incentives to bolster hospital capacity by adding beds, building new facilities, and hiring more workers.

As steel sputtered in the 1970s, the collectively bargained wages that once sustained not only workers themselves but entire families and neighborhoods dwindled, too. But as communities’ wealth and buying power shrunk, demand for health care only rose: those lucky enough to retain union Blue Cross plans still enjoyed extensive access to care, whereas those who didn’t either qualified for Medicaid or migrated to find work elsewhere — leaving behind an aging and poor population weathered by the turmoil of social collapse and rife with the kind of health problems you might expect in people who spent decades doing backbreaking work on assembly lines.

As every other kind of welfare spending got slashed in response to a contracted tax base, health care spending did not — and the fallout unleashed by the unfolding crisis was more or less displaced onto the health care system. Hospitals continued expanding to serve a population whose mental and physical health was in ruins, thanks to the collapsing economic and social infrastructure atop which they’d balanced their lives; local officials were all too eager to green-light debt-financed hospital construction in their deteriorating districts.

And for the most part, Winant argues, those community hospitals that flourished in the 1960s and 1970s fulfilled a crucial social mission as a “medical shock absorber.” They provided jobs for women who needed to make ends meet as steelworkers’ hours got slashed, which largely mimicked the unpaid care skills they’d cultivated as wives and mothers — positions like cafeteria workers, orderlies, and nursing assistants. For patients, the hospitals provided care and support that wasn’t always strictly medical, often taking the form of quasi-counseling or even just restorative rest. As Winant tells it, these institutions remade the collective social worlds that formed around the steel plants: neighbors shared resources to soften the impact of ongoing crisis. And because community hospitals like Aliquippa, South Side, and Braddock lining the old steel neighborhoods were nonprofits that got paid fixed day rates by insurers for each patient, the arrangement made perfect sense to everyone involved.

The result for many patients was an affirming relationship with the health care system that would shock any present-day reader: “I’ve never had a bad experience in a hospital,” recounted one Pittsburgh woman for an oral history project. “I don’t have any complaints, whatsoever.” Another woman reminisced, “Doctors decided [how long a patient stayed]. Insurance companies did what they needed to do, doctors did what they needed to do, and the cost wasn’t so bad.”

There were some ominous signs in the 1970s of the impending collision of business and health care — overzealous eight- and nine-figure hospital expansions continued apace, and University Health Center at the University of Pittsburgh tapped a former Hallmark Cards exec as its new CEO, sparking serious outcry (and the resignation of its dean of medicine in protest). But things got really bad in the early 1980s, when most of the steel mills that were still standing shuttered for good, and Medicare overhauled its payment model.

The restorative experiences patients described having at community hospitals had been born not only out of the social contract that undergirded them, but also from payment models that reimbursed “cost plus extra” for whatever care they provided — a system that critics derided for promoting runaway health care costs by rewarding volume. In contrast, the new system imposed by Medicare and soon adopted by private insurers paid per service.

In Winant’s telling, the impact of this change was profound: it basically obliterated the material basis for the labor-intensive community hospital model of care, and replaced it with one that rewarded high-intensity treatments instead. The sort of unprofitable lengthy stays for patients who weren’t acutely ill but still had moderate needs — the kind of care that vigorous expansion sought to add volume to accommodate — was edged out into corporatized warehouse-esque nursing homes that maximized margins off the back of a new fleet of exploited workers, mostly women of color. Meanwhile, the hospitals that were able to sink resources into expensive technology and big-ticket health care services were able to command ever higher sums in reimbursement and unload less cost-efficient patients and workers. Inequality between providers soared, as smaller community hospitals struggled to stay true to their service missions while losing both revenue and patients, often still servicing debt they’d racked up to maximize volume under the previous payment model.

Thus the stage was set for slow-burning havoc not unlike the chaos wrought by Big Steel’s undoing mere decades before: throughout the 1980s and 1990s, health care costs continued to climb. The bigger players — a cohort topped by University of Pittsburgh Medical Center, which had approached things like a business, going all in on state-of-the-art medicine like transplants and hiring top-dollar clinicians and administrators to compete — began buying up the beloved smaller community hospitals, thereby buoying their market share and pricing leverage over insurers. And across the board, the lower-tier workers felt the squeeze: like the steelworkers once subject to rising productivity standards and increased shop-floor surveillance, low-wage feminized care workers found themselves overwhelmed with too many patients, unfair scheduling rules that derailed their personal lives, and stiff penalties for lateness and other infractions. Many such workers were surely ground down even further by care needs within their own families, forcing them to allocate sizable chunks of take-home pay to yet another exploited childcare workforce that could themselves be the focus of a parallel book.

As Winant’s analysis of labor records show, these measures led to levels of workplace injury and illness that rivaled far more stereotypically dangerous fields. But unlike the largely male mid-century steelworkers before them, the women most exploited by Pittsburgh’s new top industry received neither a family wage nor robust health benefits for their trouble. In one particularly haunting case, Winant describes a woman in medical debt to her own employer.

Told from the perspective of care workers, the history of the past seventy years takes a far different shape than the one we’re used to. In a world where owners of capital distribute the means of survival through labor markets, it falls mostly to women to tend to the logistics of love using whatever resources are left over for it. As Winant tells it, Pittsburgh’s two dominant industries each made fortunes by freeloading off the women whose care generated a steady supply of workers, later creating new markets to monetize that care as workers became patients. In both cases, the bosses exercised immense control over women’s care-working conditions, and the resources they have to build thriving communities. The Next Shift compels us to imagine a world in which care workers themselves had that power instead.