Pneumoconiosis is one of the most significant occupational diseases in China. We argue the key driver behind pneumoconiosis prevalence and consequent limited treatment is a balance of power significantly favoring capital over labor. The political and economic history of China has included a systematic weakening of the position of labor through unfettered marketization and weak trade unions. This is especially true for the mining sector, where pneumoconiosis is an occupational risk. The changed structure of the mining industry, the lowering standards of labor protection, the decentralization of taxation and associated inequalities between provinces, and the generation of surplus labor associated with the household responsibility system have all played their part in the pneumoconiosis outbreak. Several policy issues have exacerbated the sufferings of pneumoconiosis-stricken workers that we explore in this article. On a grassroots political level, the absence of effective unions in China, including in the mining industry, provides a compelling explanation for why these policy issues have not been addressed.