Gabriel Winant’s brilliant book The Next Shift set out to answer this question: “How did steel city become a city of nursing assistants?” Along the way, Winant’s treatment of race, gender, and labor in the health care industry also helps answer a second one: Why is a city of nursing assistants so poor? These questions matter far beyond Pittsburgh, where Winant roots his book. One in five jobs in the industrial areas of the Northeast and Midwest are now in the “health care and social assistance” sector. Hospital complexes anchor many poor cities’ downtowns.
Winant wrote about Pittsburgh because the city “exaggerates key features” of national patterns, which helps illuminate the industry-to-services shift. In this post, I’ll take a similar approach, dropping down to an even smaller context to highlight lessons from Winant’s analysis. Braddock, a town about a half-hour away from Pittsburgh, helps teach how a steel town became a hospital town became a poor, broke town.
From Steel to Health Care
Braddock’s land was once so valuable that 500 soldiers in the French and Indian War in 1775 died fighting for it. A century later, on that same soil, Andrew Carnegie and his partners built the Edgar Thomson Plant, America’s first mill for the mass production of steel. At that mill and its kin along the banks of the Monongahela River, blast furnaces, coke ovens, and foundries helped grow U.S. Steel into the world’s first billion-dollar company. The workers at Edgar Thomson left their own mark on history, rising up as part of the Homestead Steel Strike, one of America’s deadliest and most formative labor uprisings.
By 1975, one more century into the future, Braddock’s soil had plunged in value. The town’s central architectural jewel, Carnegie’s first community library, had fallen into such disrepair it was slated for demolition. The town’s population had dropped by more than sixty percent since its 1920s high. The causes of this decline are typically portrayed in simple terms. Pittsburgh and its neighbors in the Mon Valley were steel towns, this story goes, so without steel, they drained jobs and population. A golden age of American steel (from about the 1950s through the 70s) came to an end, and the blue-collar middle class began a long slide.
Winant complicates this nostalgia for steel days, digging into the New Deal compromises that shaped an era of fragile and uneven prosperity, even at steel’s peak. Through his telling, we notice that Braddock was not just a steel town back in the 1970s, it was a hospital town. Demand for health care ran high in industrial areas. Hazardous jobs had combined with wretched environmental conditions to generate injury and sickness. (At steel’s peak, Winant tells us, soot and coal dust had to be swept from Braddock porches three times a day.) As steel declined, the Braddock Community Hospital grew. The outmigration of young people left behind an aging population with greater needs. The pressure on women to earn a paycheck meant fewer in-family caregivers. Funded by union and Medicare benefits, Braddock and other community hospitals absorbed the social and medical consequences of deindustrialization.
But starting in the 1980s, Winant shows, attempts to control costs in Medicare and Medicaid policy advantaged high-tech, academic medical centers. These changes devastated community hospitals, which provided more labor-intensive care and served a higher proportion of “unprofitable” Medicaid beneficiaries. The University of Pittsburgh Medical Center (UPMC) acquired several hospitals in the Mon Valley, including Braddock’s in 1996. UPMC vowed to keep the Braddock facility open, a concession that recognized the hospital’s local importance. Braddock had become the county’s most important detoxification center, with strong programs in behavioral health and drug and alcohol rehabilitation. But these services were not lucrative under new Medicare payment policies. Cost controls at UPMC, Winant argues, vindicated a “commodification” ideology for health care and replaced “the communitarian ideology” that had once governed community hospitals.
UPMC closed the Braddock hospital in 2010, taking the town’s only ATM and restaurant (the cafeteria) with it. By then, the post-steel economy of Pittsburgh had emerged. Health care played a role in that recovery, but that industry had consolidated at the expense of the region’s inner-ring suburbs. Pittsburgh remained a hub for an overworked and underpaid working class, but by the end of the twentieth century, they labored in hospitals, nursing homes, and rehab clinics. They were more likely to be women, less likely to be white, rarely covered by a union, and seldom paid a livable wage. Corporatization of health care in the 1980s and 90s, not just steel’s withdrawal, had shaped the Mon Valley’s decline.
From Health Care to Broke
The Next Shift humanizes the rise of this underpaid, non-union health care sector with stories from workers, including a brother-sister pair named Lou Berry and Earline Coburn. As Black children growing up in Braddock in the late 1960s, Winant tells us, Earline and Lou both assumed that their futures (through work and marriage) would turn on paychecks from steel mill jobs at Edgar Thomson. But during the steel industry’s “ruinous” downturn from 1975 and 1985, Pittsburgh lost 150,000 manufacturing jobs.
These losses fell hardest on African American workers, who had long been excluded from the safer, better paid positions at the mills. When civil rights enforcement finally reached the steel mills in the mid-1970s, it was too late to give Black workers the seniority to resist layoffs. Caught by this timing, Berry was shut out of steel work, then laid off from an electrical plant. Berry pieced life together for a few years of hustling and music. Displaced industrial workers like him were often technically eligible for training benefits under the 1975 Trade Readjustment Act, but the program was not funded anywhere near the scale of need. In 1983, Winant tells us, 576 applicants received training out of an eligibility pool of 17,000 people in Western Pennsylvania. Yet during that decade, the state spent $300 million constructing prisons. Research from the Mon Valley at that same time showed that at least nine of out of ten persons arrested were unemployed.
Berry eventually found steady work in a Pittsburgh hospital. He joined the housekeeping staff, hoping to later train for medical technician roles. But contrary to the hospital’s orientation session, Berry quickly observed that African American staff could accumulate decades of seniority without any path to advancement. “It’s almost like a class system in that place,” he told Winant in 2016. Food, housecleaning, and other service workers earned wages averaging $12.94 per hour and had no training ladder to strive for better jobs.
Berry’s sister Earline Coburn also worked in health care. She took a job as a nurse’s aide at Braddock Hospital early the 1970s, where she “changed sheets, took temperatures, washed bodies, and cleaned rooms.” She left this job after marrying a steel worker, but when his career and her other employment could no longer support their family, she returned to hospital housekeeping in 1997. In the intervening years, hospital employees had been squeezed by productivity targets that made work hours an oppressive rush. Coburn described her life on the ICU floor, where it wasn’t just the impossible schedule from management that set a frantic pace. It was her compassion for the next patient. “I wouldn’t want my mother sitting out in the hallway,” she said. She earned about $9 per hour.
Today, nearly one-third of Braddock’s workforce has jobs in health care, education, or social services. Unlike most regional steel mills, the Edgar Thomson Plant never closed, but it has been modernized and automated, with a workforce now numbering less than 1,000. Those higher skilled workers now largely commute in from more prosperous suburbs. Braddock’s population has fallen further, numbering only about 1,700 residents today. The median income is only about one third of the state’s number, and a devastating 37% of the population lives beneath the poverty line. Those numbers mean that Braddock is what I call a “border-to-border poor” town, which has a low median income as well as concentrated poverty. The town is nearly all Black—with neighborhoods that have served as a home for African Americans since the Great Migration and across decades of white flight and exclusionary zoning.
Poverty and racial discrimination have weakened Braddock’s tax base, helping to explain why, for thirty years and counting, Braddock’s government has been unable to afford rudimentary public services. County social services have been stretched impossibly thin since the 1980s, when falling public tax revenues caused budgets to flatline even as needs spiked. John Fetterman, the town’s celebrated mayor from 2005-2019, tattooed his arm with the dates of ten homicides on Braddock soil in those years, memorializing losses that seemed to keep coming.
We are not without answers to these challenges. Berry and Coburn’s experiences help underscore the importance of a training program I observed and wrote about in Lawrence, Massachusetts, which helps lift the area’s Latinx health care service workers up the skills and wage ladder. Instead of looking back with longing at Lawrence’s lost era of mass employment in textiles, local leaders have worked together to build a skills pipeline into the jobs that exist today. The city’s central hospital and neighborhood clinics have been essential partners in this effort, working with the community college, a community development organization, the school district, and others to make entry-level health care jobs a path, not a trap.
In 2010, Levi’s Jeans filmed an ad in Braddock portraying the town in the smoky hues of Rust Belt resilience. After a montage of residents working to repair a wounded landscape, the ad closes with a child narrator’s voice saying: “Maybe the world breaks on purpose so we can have work to do.” As someone who cares about the Braddocks of the country, I think those lines are wrong. Too many people got hurt along the way of Braddock’s decline to wipe away its hardships with a few purpose-driven lives today. But I think a slight edit could redeem the script. For every loss in Braddock, people elsewhere collected their wins. Inequality expanded within hospitals, within regions, and among regions. “Maybe the world breaks on purpose,” the revised ad might say. “We have work to do.” Part of that work, Winant reminds us, is improving wages, conditions, and educational opportunities for health care workers