The Rise of the Care Economy

If there’s a photo that best exposes just how hollow the political and corporate praise for “essential workers” was over the past year, it might be one taken in March 2020 at a Manhattan hospital: three nurses, standing with their hands on their hips, their faces shrouded by masks, their bodies garbed in makeshift gowns — garbage bags — while one displays a Hefty box.

“NO MORE GOWNS IN THE WHOLE HOSPITAL,” the caption on the Instagram post read.

Even as care work and carers — mothers, teachers, home health aides and nurses — are labeled “essential,” they face meager wages and unsafe working conditions, including exposure to the COVID-19 virus.

Two new books address this paradox: The Next Shift: The Fall of Industry and the Rise of Healthcare in Rust Belt America by American historian Gabriel Winant and The Care Crisis: What Caused It and How Can We End It?, by British sociologist Emma Dowling.

In The Next Shift, Winant asks why the industrial union man is praised and conjured as the icon of the American worker, despite his decimation by deindustrialization decades ago, while the care workers who take our vital signs, teach our children or perform other critical services and are disproportionately women, Black, Latinx and Asian, are undervalued, underpaid and until the pandemic, mostly invisible to their fellow Americans.

In surprisingly well-written prose for an academic, Winant concentrates on the collapse of manufacturing in Pittsburgh, the city once synonymous with American steel production, and its replacement by health care as the largest sector of the local economy.

Reading Winant’s descriptions of the grueling, blisteringly hot and dirty work of steel mills from the vantage point of the 21st century, one questions the claims that such labor offered workers their best bet in the golden days of welfare capitalism. But indeed, it did.

Coming out of World War II, the U.S. government accommodated a militant labor movement establishing a tripartite system between industry, labor and the welfare state. It provided economic security for the nation’s steelworkers and other working-class people, albeit much more for white men than anyone else. With a national health care system blocked as “socialized medicine,” the crown jewel among the workers’ collectively bargained benefits was employer-funded, government-subsidized health insurance.

A long period of deindustrialization culminated in the early 1980s, when the steel mills laid off tens of thousands of workers. Nonetheless, through their collective bargaining agreements, these men and their families retained their hard-won health insurance, the use of which by this aging, financially declining population fueled the rise of the hospitals sprouting rapidly along the formerly factory-lined Monongahela River.

White male unemployment ushered women into the new health care workforce by necessity, transmuting their unpaid work in the home into low-paid work in hospitals, home care agencies and nursing homes. Through archival research, Winant unearths the intimate, everyday lives, experiences and work of white women during this dramatic shift. Despite lacking archival material covering Black women from Pittsburgh, who had been far more likely to work than white women before this shift, Winant pieced together a similar process: from the domestic work to which segregation had confined them, Black women took their garnered skills into new health care positions.

Hospitals and the rest of the health care system effectively absorbed the ballooning surplus population of laid-off workers. But this emergent industry, countercyclically booming in the ‘80s, depended on the exploitation of these women’s labor. (The other such absorber, Winant points out, was the then-burgeoning prison industrial complex.) He terms this process a “decomposition and recomposition” of the working class, the receding of the relatively privileged industrial union man and the emergence of a care worker army.

Meanwhile, Dowling’s text concisely yet thoroughly presents the wider hellscape that is the care economy.

Her book is set in the United Kingdom in the decade of Tory-led austerity after the global financial crisis of 2008, but before the COVID-19 pandemic. Britain’s health care system has a very different history, but as in the U.S., care workers are similarly concentrated in deindustrialized regions. An accessible read that pairs well with Winant’s text, The Care Crisis maps how that austerity and deindustrialization, compounded by a fast-aging population, has led to a growing crisis of care.

“In the wake of austerity and against the backdrop of the failures of privatization, overstretched and underfunded public services have left people in the lurch,” Dowling writes. In other words, more and more people are not getting the care they need and their caregivers are not getting the support they need to care — or the chance to live dignified lives in their own right.

The Care Crisis weaves together theory and sociological analysis with firsthand stories of care workers, but begins by asking “What is care?” Dowling describes it “as all the supporting activities that take place to make, remake, maintain, contain and repair the world we live in and the physical, emotional and intellectual capacities required to do so.” In this sense, care work is “an ethical social relationship based on both feelings of affection and a sense of service.”

Indeed, that quality of care work, as Winant remarks in his book, too, is what makes carers more exploitable. Where care work is not properly funded or paid, carers’ caring, employers know, will lead them to fill in the gaps.

Who does the work of caring? Much like in the United States, Dowling notes, the UK relies on “global care chains” through which care work is offloaded, often by the increasing number of middle-class women in the workforce, onto immigrant women from the Caribbean, Africa, Asia and increasingly, Eastern Europe. The cuts in funding to key pillars of care provision in the UK have also offloaded the work onto children, informal caregivers, family members, charity and an emergent self-care industry.

Dowling calls these cuts and the schemes to uphold profit through the crises that result — via privatization and financialization — “care fixes.” Threading through them is a Thatcherite ideology of “personal responsibility,” which, she says, dangerously elides care’s structural dimensions. Winant’s book is riddled with examples of such care fixes, chief among them was a major 1983 change in how Medicare reimbursed hospitals for their treatments: on behalf of capital, the shift fueled the rise of large, money hungry hospitals; the destruction of small, poorer ones; greater inequality of care among patients and within hospitals among workers and as seen in full view since the pandemic began, the intensifying working conditions for health care workers.

Perhaps unsurprisingly, given the politically unignorable horrors care workers have endured during the pandemic, the Biden administration has made small but significant steps in valuing care, as welfare rights activists have been demanding for decades. The American Recovery Plan Act, passed earlier this year, expanded the child tax credit, putting thousands of poverty-relieving dollars into the pockets of families. And Congress is now considering funding for home and community care, among debates over what constitutes “infrastructure.”

Such public investment is critical, so Biden’s moves should be applauded. But any system where those subsidies go to privately run and for-profit care is bound to value profit over the needs of people. Both Dowling and Winant convincingly identify the public-private configuration of the care economy, not just austerity, as fatal for any world that truly wishes to treat care and its practitioners as “essential.”

To end the care crisis, Dowling concludes, “we must reclaim the means to care from the prerogatives of profitability and put better ways of valuing care into practice.”

It’s a system-shifting ask, but necessary. After all, Winant writes, “we all need care.”

•••

The Next Shift: The Fall of Industry and the Rise of Healthcare in Rust Belt America
By Gabriel Winant
Harvard University Press; March 2021

The Care Crisis: What Caused It and How Can We End It?
By Emma Dowling
Verso; January 2021

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