Drive through almost any American town, and you’ll notice one building shining brighter than the rest: a hospital.

The health-care industry has supplanted manufacturing as the United States’s biggest economic engine and source of employment. In the United States, it’s now one-fifth of the economy, a sector worth around $4 trillion, equivalent to the gross domestic product of Germany. Care workers now make up more than 20 million people, the most of any industry, according to the Census.

But unlike the factory, the hospital is often not the road to the American dream. Median pay for jobs like nursing assistants, phlebotomists, home health aides, and medical assistants is only $13.48 an hour, according to the Brookings Institution. That’s a maddeningly unfair wage in a sector that pays doctors so handsomely, costs the rest of us more than twice as much as the citizens of European countries, and doesn’t even cover everybody.

How the health-care industry replaced manufacturing while downgrading the quality of American middle-class life, furthering inequality, and fueling political bitter divisions is the welcome subject of Gabriel Winant’s The Next Shift. The author, an assistant professor of history at the University of Chicago, has developed a focus on the lived experiences of American workers during the rise and fall of American industry in the twentieth century. His subject, in other words, is, essentially, “the American dream.” That’s the focus of this work: dissecting what has happened to professional, social, and family lives of Americans in the last 70 years, and the role of race, gender, and class in post-industrial America.

The prism for his study is Pittsburgh, a smart pick for showcasing this change. Once the blazing heart of the global steel industry, the Paris of Appalachia is now home to something bigger—the University of Pittsburgh Medical Center, or UPMC. At one time a humble university medical center, UPMC now operates 40 hospitals with more than 8,000 beds, and pays its CEO almost $10 million a year. Technically, it’s a “non-profit,” but in the first nine months of 2020, UPMC’s revenues increased 11 percent to $17 billion. By comparison, U.S. Steel took in $7.2 billion over the same period. Atop Pittsburgh’s tallest building, “Steel Tower,” UPMC’s name has replaced that of U.S. Steel.

The problem is that UPMC’s more than 90,000 employees have never received the same generous treatment long afforded unionized steelworkers. Stubbornly fighting labor organizers, UPMC has managed to keep wages for much of its workforce under $40,000 a year, roughly half what steelworkers make.

Winant weaves together a convincing argument that this downward mobility has been driven by a gendered and racist political economy that values many things—from retiree health care to CEO pay—more than care work by women and people of color.

Winant’s book is an attempt to answer the question of why “poverty wages, understaffing, stress, precarious scheduling, and workplace disrespect often comes with the job for people who wash and feed bodies, do laundry, change sheets, clean rooms, administer medication, run tests, provide therapies, and proffer emotional support.”

Many health-care workers on the bottom rungs now find themselves, in some ways, back where industrial workers started in the nineteenth century.

Pittsburgh is centered around a triangle where two rivers essential to pre-interstate highway trade, the Monongahela and Allegheny, form the Ohio, which can take you all the way to New Orleans via the Mississippi. The land was rich in iron and coal when European settlers steamrolled their way west in the nineteenth century. Pittsburgh drew hundreds of thousands of immigrants, a story mythologized in novels like Out of This Furnace and movies like The Deer Hunter. The primary industries—gas, glass, coal, and steel—begat thousands of factories making everything from toys to car parts.

Workers finally secured a fair bargain with the rise of the labor movement in the 1930s and ’40s, as demand for steel skyrocketed, first during World War II, and then during the postwar manufacturing and construction boom. For a while, unions were so powerful they could shut down wide swathes of the economy.

As I learned while covering collective bargaining negotiations for The Wall Street Journal, when demand is strong, the supply of skilled labor is limited, and unions are focused on obtaining concessions, it’s actually not that hard to exact concessions from corporations. The result of these two forces—a powerful labor movement and economic boom—was “one of the best-paid industrial workforces the world had ever seen.”

In narrating Pittsburgh’s economy from mid-twentieth century to early twenty-first century, Winant is capturing a bigger story about America. In a well-crafted book about labor, it’s also helpful that Winant weaves in history, geography, and the chemistry of steelmaking. He’s an academic who knows how to let his reader breathe. The meat of the book, Winant’s first, is a rich trove of anecdotes, some from interviews he conducted himself, and some from archives. These could have used some pruning, but it is satisfying to witness, via oral history, Steel City turning into Hospital City as told through various people’s life stories. The aging of the steelworkers he chronicles helps drive this plot: As they grey and suffer from industrial ailments, they need care.

As America built suburbs and boomed after WWII, “steel was everywhere: in the frames of new interstate highways; in the shining appliances filling new suburban homes; in the pipelines that carried petroleum from oil fields; inside new towers rising in city centers undergoing urban renewal; and above all in the automobiles remaking American society.”

The place of steelworkers in American society was reinforced by cultural norms. There was something so American about a (usually white) head-of-the-household steelworker putting food on the table for his wife and 2.2 children. After the New Deal, Winant writes, “working-class people were supposed to form heterosexual nuclear families, have kids, hold down a factory job full-time and accumulate seniority if a man or marry a factory worker if a woman, buy a house and a car, go on strike during a contractually specified episodes, go the hospital when sick and retire with a pension.”

The mill “was an elemental force, like a Greek god,” declares Winant. “It demanded awe and sacrifice and instilled terror and resentment. But in return it yielded a living, and indeed a world, for its people and their city.”

To be sure, this was no utopia. One steelworker described finding his lunch bag torn apart by rats. One welder started work at 13 after his dad was killed on the job. Workplace accidents were common. Black workers were often assigned positions in the so-called “coke ovens,” where coal is baked before it’s mixed with iron ore to make steel, “the hottest, most noxious work in the entire steelmaking process.” In traditional blue-collar, Catholic Pittsburgh, women suffered from domestic abuse, a lack of choices, and a cultural norm that “wife-labor” was free labor. The people this system put at its center “were the heterosexual white men who held most factory jobs and headed most working-class households.”

Winant has a point, but even a rigid capitalist patriarchy must have included some happy families, something one easily loses sight of when Winant describes Christmas as “the ordeal of celebration—the struggle to have a holiday as happy as it was supposed to be—indicates a moment of compression in the normative power of family life.”

What clearly did destroy many families was American companies figuring out how to make stuff cheaply in other countries and ship that stuff at low tariff and freight costs.

The steel industry got nailed by foreign rivals, and old-school firms like U.S. Steel failed to keep pace with rival upstarts that made steel out of scrap metal instead of from scratch out of iron ore and coal in blast furnaces.

America’s industrial decline happened quickly. On “Black Monday,” in September of 1977, Youngstown Sheet and Tube shuttered, laying off 5,000 workers. By the 1980s, the American steel industry was operating at only 50 percent capacity. It was in that decade that big steel started shutting down operations in Pittsburgh. U.S. Steel mothballed parts of seven mills in the Pittsburgh area. In 1984, Duquesne Works, which had employed up to 6,000 workers, shuttered. Homestead, for many years the largest steel mill in the world, and the furnisher of metal for the Empire State Building and war-winning battleships, in addition to helping thousands of families reach the middle class, closed amid a global downturn in 1986. Today, the area is a massive strip mall, employing hundreds of workers making under $12/hour selling coffee, books, and shoes.

Unemployment in Pittsburgh doubled between 1980 and 1983. For all the discourse around retraining, skills built up by decades of work in the mills, including plumbing, painting, carpentry, electrical work, roofing, machine operations, and auto repair, were suddenly worth much less in an oversupplied market. The jobs that were available tended toward custodial services, kitchen aid, and yard work. Funds for retraining were limited. It was hard to get a new job in your fifties.

Between 1980 and 1990, Pittsburgh’s population shrank by 176,725, or 6.7 percent. And the people who stayed were old. By 1990, Pittsburgh was the second oldest metro area in the country, behind only Broward County in Florida.

At the same time, driven by a postwar political consensus that that white working-class workers needed care cradle to grave, hospitals flourished, as they morphed from places you went to die into booming corporate businesses.

Since the war, following restrictions on wage increases and an I.R.S. ruling that exempted health benefits from taxation, unions had insisted on health-care benefits for their members.

Boosted by these union insurance contracts, Medicaid and Medicare funds, and aging populations, hospitals poured billions into new expansions. In 1971, Allegheny County granted hospitals and nursing homes access to the municipal bond market, making it easier for them to borrow money to build. Steadily, hospital business became big business, especially as costs spiraled up.

The market kept growing. The number of people over age 85, who required the most care, including eating, dressing, bathing, and walking, doubled between 1970 and 1990. The unemployment crisis and its resulting crisis of mental illness added to the demand for care.

In 1974, the University of Pittsburgh hired a Hallmark Cards executive named Nathan Stark to run the University Health Center, a controversial decision that triggered the resignation of the dean of medicine. Stark consolidated UHC’s five hospitals and asserted centralized executive control.

As hospitals borrowed money to build, they came under pressure from bondholders insisting on strong balance sheets. This cost and price inflation was driven by capitalist demand, which “summoned corporate power and private capital in American medicine, as all benefited from the system’s growth.”

The workforce was remade to suit the health-care industry, relying especially on women and people of color. In the 1960s, automation had made big parts of housework redundant, putting domestic workers, especially Black women, out of work. The labor market in domestic work collapsed over the course of the 1960s, reports Winant, falling from 32 percent of African-American women’s employment to 13 percent. That made them available as the first generation of underpaid service workers.

Meanwhile, white working-class people enjoyed good care and “frequently found it a relief and pleasure to be handled by caring strangers,” Winant writes. “Black working-class and poor people often had a different relation to strangers in positions of institutional power over their bodies.” [p. 163] White patients would sometimes object to sharing a room with a Black person.

In one of many illustrative, and fascinating, sketches, Winant profiles two Black siblings, Earline and Lou, from Braddock, a town on the Monongahela River that still houses U.S. Steel’s Edgar Thomson Works. When they grew up in the 1960s, Braddock was bustling with movies theatres and car dealerships. Lou got laid off from his job at the steel mill, but Earline found work in health care. Their story illustrates how “the market in men’s labor contracted sharply, and the market in women’s labor expanded.”

But the more people who were sick and the higher their bills, the more money Medicaid and other social programs brought to hospital cities like Pittsburgh. A 1985 study found that steel towns in the industrial area known as the Mon Valley, which runs south from Pittsburgh down toward the West Virginia border, got $123 million in retiree benefits from U.S. Steel that year.

The transition to “meds and eds,” a reference to Pittsburgh’s many hospitals and universities, was now fully underway, gleefully celebrated by Pittsburgh city leaders. To the dismay of workers, unions were unable to maintain their institutional strength in the transition from industry to infirmary. Empowered by the New Deal and WWII labor shortage, unions in the 1950s had been a mighty force in society. But over time, unions grew insular, losing their place as advocates for all workers in society. In addition, the perception that care work was “easy” expanded supply, diluting wages further. Health-care workers found themselves outside any useful power structure.

UPMC, which has ruthlessly battled rivals, is now run by a chief executive who has, to justify business decisions, declared that health care has been transformed “from a social good to a commodity.” That mindset is behind the aggressive buying up of local hospitals, predatory pricing practices, and pay rises for senior executives. Like other hospitals, UPMC exerts monopolistic pricing power on patients and suppliers.

There is some hope yet. Some UPMC workers have successfully unionized. In the United States, 2018 saw the highest level of strike participation since the 1980s; and there’s been a lot of organization in health care. Still, unions face an uphill battle when UPMC and other hospital systems are seen as the solution to deindustrialization.

As Winant points out, the COVID-19 pandemic, which erupted just as he was finishing his book, confirmed his conclusion that “frontline heroes” are underpaid, overexposed, and badly in need of a change in the American political economy that benefits them. Seventy-three percent of health-care workers infected in the first two months of the pandemic were women, he reports.

Last century’s work was dangerous in different ways. Pittsburgh’s steelworkers corralled molten metal pouring out of burning furnaces. It was dangerous work that killed, crippled, chopped and cut. But, by luck of circumstance, culture and politics, they were paid enough to live decently.

Winant’s work makes it clear we need to address the question posed by a worker he quotes to close this important book: “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?”