Health Inequalities and Capitalism in Canada

Public Goods  •  July 22, 2025  •  Arnel M. Borras

Drawing inspiration from Engels (1845), Marx and Engels ([1848] 1964), and Marx (1867), and extending my own previous work (Borras 2021, 2022, 2023), this piece explores health inequities – those preventable and unjust differences in health outcomes – through a critical political economy lens.

This approach understands health inequities not as isolated problems or unfortunate outcomes, but as structural expressions of a capitalist system that organizes society through class rule and exploitative social relations. Human beings, it argues, are inherently social; our lives are shaped by the relations of production – relations that form the basis of broader structures like the economy, politics, and the law. These structures shape consciousness and reproduce inequality unless transformed through collective struggle.

Health, then, is political. The critical political economy approach scrutinizes how capitalism – deeply entangled with colonialism, racism, and sexism – produces and sustains unequal health outcomes. It centers ideology, interests, and power as key forces that determine whose lives are valued, whose health is prioritized, and who is left behind.

This approach pays close attention to the ways class, race, gender, and other social relations affect the production, distribution, and consumption of resources necessary for health. It maps the terrain of conflict among states, capital, and civil society organizations – especially workers’ and people’s movements – as they contest the direction of health policy and the allocation of life-sustaining goods and services.

By examining how human-to-human and human-to-nature relations are organized under capitalism, this perspective insists that health cannot be separated from questions of wealth, power, and ecological sustainability. Importantly, it not only reveals the deep roots of health inequities – it offers tools for transformation. It calls on scholars, advocates, practitioners, and movements to confront root causes and struggle toward a society where all can live healthy, dignified lives.

Capitalism and Its Impact on Health

Capitalism commodifies even the most essential human needs. In this system, workers are compelled to sell their labour, while capital relentlessly pursues profit and wealth accumulation. This dynamic entrenches inequality and inflicts lasting harm on both people and the planet.

As Sam Gindin explains in our interview, capitalism subjects workers to precarious, high-pressure environments that wear down mental and physical health. Disempowered and fragmented, workers are left with little collective capacity to resist structural harms. As he puts it, “Capitalism… means they live in permanent insecurity… and the working class… has been defeated.”

The late Leo Panitch similarly emphasized that health inequities are not anomalies, but systemic features of capitalism. While governments may mitigate or exacerbate these harms through policy, the underlying engine remain the same: the imperative of capital accumulation, which consistently takes precedence over public well-being. As Panitch observed: “The fundamental parameters of inequalities… are given by capitalist social relations and the requirements of reproducing favourable conditions for capital accumulation and reproducing the class relations that are necessary for a capitalist society.”

This analysis continues a longstanding tradition – from Marx and Engels’ vivid accounts of working-class life in the 19th century to 20th-century research documenting how workers disproportionately suffered from exhaustion, mental disorders, and exposure to toxins, leading to high rates of injury and early death (Navarro 1986, 106–40). These harms have never disappeared. In the 21st century, coal miners still contract black lung disease, which cuts life expectancy by over twelve years (Mazurek et al. 2018, 820). Across generations, capitalist class relations have produced – and continue to produce – devastating health outcomes for workers.

Today, billions of workers and low-income families lack sufficient access to nutritious food, safe housing, or adequate medical care. In this system, profit comes before life – capital kills on a mass scale. Confronting these injustices requires not just policy reform, but systemic transformation.

Neoliberalism, Work, and Health

Neoliberalism has expanded the global precariat, trapping hundreds of millions in informal, insecure, and low-wage work. Gig platforms like Uber and Care.com, along with the rise of temporary contracts, have normalized job instability, stagnant wages, and the erosion of benefits (De Stefano 2016). These exploitative conditions disproportionately impact manual labourers, children, women, immigrants, and racialized groups – exposing them to chronic financial stress and heightened health risks (Benach et al. 2016; Borras et al. 2021; Muntaner et al. 2010). Neoliberalism has not only intensified exploitation – it has deepened health inequities.

As wealth concentrates further at the top, the gap between capital and labour grows wider. In 2023, the CEOs of the “Low-Wage 100” earned 603 times more than the average worker (Anderson 2023, 1–3). Amazon’s injury rate – 80% higher than the industry average – is emblematic of how profit-making and capital accumulation are consistently prioritized over worker well-being (Strategic Organizing Center 2023, 3–5).

In Canada, the pattern is no different. Neoliberal restructuring has eroded union density and fueled the rise of part-time and contract-based jobs. Real wages have stagnated, while poverty rates have climbed. By 2016, the country’s 87 wealthiest families held as much wealth as 12 million of its poorest residents – equivalent to the combined wealth of Prince Edward Island, Newfoundland and Labrador, and New Brunswick (Macdonald 2018, 5–10). By 2024, the top 20% of Canadians controlled 67.6% of national wealth, while the bottom 40% held just 2.8% (Statistics Canada 2024, 4). These disparities are not only economic – they are embodied. Low-income men live 8.1 years less, and low-income women 3.6 years less, than their high-income counterparts (Milligan and Schirle 2018, 19).

Neoliberal capitalism entrenches class divisions and systematically produces health inequities. These outcomes are not accidental – they are structural, predictable, and enduring.

The Capitalism–Imperialism–Colonialism–Racism Nexus

Colonialism, dating back to the 1500s, was defined by violent expropriation – land seizures, slavery, and genocide. While national liberation movements intensified after World War II and many formal colonial regimes dissolved, settler colonialism and neocolonialism persist – most visibly through global finance, international trade agreements, and the military dominance of imperial powers like the United States. Colonialism, imperialism, and capitalism have long operated as interlocking systems of domination, shaping global economies, politics, cultures, and institutions, while systematically producing and maintaining health inequities.

Modern capitalism emerged between 1500 and 1800 through imperial and colonial expansion. European powers accumulated capital through the violent extraction of natural resources and commodities such as sugar and cotton – produced through the enslavement of African peoples (Veltmeyer 2020, 3–8). By the 19th century, capitalism was deeply fused with international markets, accelerating labour exploitation and environmental destruction, particularly in colonized regions. In the Americas, capitalist development was built on Indigenous dispossession and the forced labour of enslaved people (Marx 1867, 164, 533). Enslaved women, in particular, were valued not only for their labour but also for their reproductive capacity – generating intergenerational wealth for slaveholders. White women were not passive observers – they actively participated, managing nearly one-third of all transactions and 40% of the trade in enslaved women (Logan 2024).

Health inequities, therefore, are not simply about race or gender in isolation – they are produced through systems of domination rooted in capitalism and colonialism.

Nancy Fraser (2023) outlines four historical phases of capitalism – mercantile, liberal-colonial, state-managed, and financialized – each defined by new forms of exploitation and expropriation. Capitalism, she argues, is not just an economic system but an “institutionalized societal order.” In the mercantile phase, wealth was amassed through slavery and land theft. The liberal-colonial phase entrenched racial hierarchies: white workers gained rights and protections while racialized populations were subjected to dispossession and brutality. The state-managed phase brought welfare and security for white citizens, even as racialized labour remained hyper-exploited. In today’s financialized phase, domination is exercised through debt, precarious work, and transnational financial instruments that disproportionately target the poor and racialized (Fraser 2023, 14–48).

These overlapping systems continue to shape health outcomes across the globe. From environmental racism to coerced labour, colonized and racialized communities bear the brunt of capitalism’s harms. As Frantz Fanon (1963) warned, the violence of imperialism leaves not only material depravation but deep psychological wounds. Across all phases of capitalist development, it is the exploited and expropriated who suffer most – and their suffering is etched into their bodies, their communities, and their lifespans.

Capitalism–Colonialism Nexus and the Health Divide

Bryan Palmer (2023) writes: “Capitalism and colonialism are the undeniable foundations of modern Canada.” Settler colonialism and capitalism were not parallel forces – they were co-constitutive systems that fueled the dispossession, forced assimilation and disruption of Indigenous ways of life. The residential school system, for instance, was explicitly designed to erase Indigenous cultural identities. Meanwhile, the Indian Act of 1876 authorized land seizures and dismantled traditional economic and social structures. Colonial policies also forcibly relocated Inuit communities into permanent settlements, resulting in devastating health consequences (Ontario Human Rights Commission 2005; Smylie and Firestone 2016).

These structural violences persist into the twenty-first century. Indigenous Peoples continue to face stark socioeconomic and health inequities – chronic poverty, limited access to care, and disproportionately high rates of mental health challenges. Food insecurity, housing instability, and homelessness are far more acute among Indigenous communities than in the broader population. These are not isolated problems, but symptoms of systemic marginalization rooted in settler-colonial capitalism.

The intertwining of capitalism, imperialism, and colonialism has produced a profound health divide. Life expectancy among Indigenous Peoples remains significantly lower than that of non-Indigenous populations, with gaps exceeding ten years between residents of Nunavut and those in British Columbia (Statistics Canada 2018, 1). These are not mere disparities in outcomes – they are material expressions of entrenched domination.

Addressing these inequities requires more than acknowledgment or reform. It demands a transformative struggle for social justice – one that directly confronts and dismantles the entwined logics of capitalism, imperialism, and colonialism. Though analytically distinct, these systems are materially entangled – and must be resisted together.

Capitalism–Racism Nexus and the Health Divide

Racism, deeply rooted in the historical foundations of colonialism and capitalism, continues to shape cultural, political, and economic inequalities – and, in turn, drives profound health inequities (Borras 2021). Structural racism, embedded within settler colonialism and white supremacy, operates through institutions that systematically disadvantage racialized communities (National Collaborating Centre for Determinants of Health, NCCDH 2018). These inequities are not incidental to capitalism’s function – they are essential to its reproduction.

Colonized and racialized populations – particularly Indigenous, Black, Hispanic, and Asian communities – face disproportionately high rates of poverty, chronic illness, stress-related diseases, and premature death (Bailey et al. 2017). These outcomes are the result of interlocking forces: displacement from ancestral lands; barriers to employment, housing, and education; limited access to culturally safe healthcare; constant exposure to interpersonal and institutional racism; chronic stress that erodes the body; intergenerational trauma; and heightened exposure to environmental toxins (NCCDH 2018).

The COVID-19 pandemic laid bare – and deepened – these structural inequalities. Racialized groups, often concentrated in overcrowded, low-income housing, suffered significantly higher rates of infection and mortality (Chung et al. 2020). Migrant workers – many from formerly colonized nations – were especially vulnerable under exploitative labour regimes. At Alberta’s Cargill meat plant, nearly 1,000 temporary foreign workers contracted COVID-19. Yet just two weeks after the outbreak, the facility was reopened (Dryden and Rieger 2020). The precarity of these workers’ legal status and the absence of basic protections reveal how racialized labour is routinely sacrificed for profit.

Environmental racism compounds these harms. Racialized and low-income communities are disproportionately situated near toxic industrial zones, exposed to unsafe air and water, and subjected to hazardous land-use policies (Taylor 2014). From Silicon Valley to Chemical Valley, capitalist expansion has produced sacrifice zones – spaces where racialized bodies disproportionately absorb the costs of economic growth. These harms are not unintentional – they are engineered by systems that consistently prioritize capital over life.

Health inequities are not caused by individual behaviours or cultural deficits. They are produced by structural power relations. Racism is not a relic of the past – it is a constitutive feature of capitalism. Addressing racialized health inequities requires more than policy reform. It demands rupture: the dismantling of capitalism and the colonial and imperial systems that uphold racial hierarchies. Only by confronting these root structures can we move toward health justice.

Capitalism–Sexism Nexus and the Health Divide

Heteropatriarchy is fundamentally entangled with capitalism, exploiting sex and gender identities in the service of profit and capital accumulation. Reflecting on the brutal consequences of industrial capitalism in the nineteenth century, Friedrich Engels observed: “Women made unfit for child-bearing, children deformed, men enfeebled, limbs crushed, whole generations wrecked, afflicted with disease and infirmity, purely to fill the purses of the bourgeoisie!” (Engels 1845, 123). As industrial technology advanced and machines replaced manual labour, capitalists increasingly turned to cheaper sources of labour – namely women and children. In some cases, men became complicit, even acting as slave traders by selling family members to capitalists. As Marx noted, working-class families themselves were commodified under capital (Marx 1867, 272). Today, capitalism – amplified by persistent sexist structures – continues to shape family life and social reproduction, reinforcing inequality.

The fusion of capitalism and sexism, anchored in traditional gender roles, sustains deep and persistent economic inequalities. Globally, women earn 28% less than men across 104 countries (Boniol et al. 2019, 1). Despite decades of advocacy, progress toward pay equity remains painfully slow. At the current pace, it will take 136 years to close the gender wage gap (Oxfam 2022, 4). The capitalist class and the capitalist state continue to profit from this systemic devaluation of women’s labour.

In Canada, gender discrimination remains entrenched. As of 2023, women earned 8.5% less than men – even after adjusting for age, marital status, education, job type, occupation, immigration status, and unionization (Macdonald 2024, 4). Recent immigrants face further wage discrimination, earning 8% less than Canadian-born workers. While public and private sector wages may appear comparable on average, substantial gender disparities persist: in the private sector, men earn 10% more than women; in the public sector, the gap narrows to 5%. Public sector employment offers modest but meaningful gains – women earn 4% more than in the private sector, while men earn slightly less, narrowing the overall gender wage gap (Macdonald 2024, 4–6).

The “motherhood penalty” further entrenches inequality. Women experience wage reductions for having children, while men receive a “fatherhood premium” – 15% in the private sector and 7% in the public sector. Public sector gains are most significant for middle- and lower-income earners, achieving near parity around $20 per hour. However, at higher income levels, the gap widens again, with public sector wages falling below those of the private sector. The public sector also reduces the wage gap for newcomers, with a differential of 3% compared to 8% in the private sector (Macdonald 2024, 4–6). Parenthood, income, and immigration status intersect to shape wage differentials, with public sector employment offering important – though limited – gains for marginalized groups.

Although average hourly wages may appear similar across sectors, the public sector more effectively addresses discriminatory gaps by raising wages for women, mothers, and new Canadians, while slightly compressing top-end salaries for men, executives, and medical professionals. The private sector, by contrast, exacerbates inequality through inflated executive pay and the maintenance of structural wage disparities (Macdonald 2024, 4–6). While imperfect, public sector employment provides a more promising avenue for reducing poverty and economic inequality than its private counterpart.

Sexism within capitalist workplaces also compounds financial, physical, and psychosocial stress for women. Long before COVID-19, neoliberal restructuring had already intensified gendered and class-based inequities. As Morrow et al. (2004) show, neoliberal reforms dismantled public supports, disproportionately harming women – particularly those already burdened by caregiving responsibilities, workplace discrimination, and economic precarity.

The pandemic only deepened these inequities. Women experienced steeper income losses than men, largely due to their overrepresentation in health and social work services – sectors marked by low wages and significant gender pay gaps. These were among the hardest hit industries. The closure of schools and care services increased unpaid care giving, which overwhelmingly fell on women (International Labour Organization 2020). Lockdowns saw a sharp rise in domestic violence, as women – isolated from support networks – were confined with abusers. At the same time, access to reproductive health services and legal assistance declined dramatically (World Health Organization 2020). The pandemic did not just reveal gendered inequities – it intensified them, particularly in the domains of employment, caregiving, and exposure to violence.

Just as race, ethnicity, and Indigeneity shape health outcomes, so too do gender and class. These forces are embedded within social systems that structure every aspect of life and health. Capitalism, in privileging dominant norms and gender roles, systematically exploits women and girls in the relentless pursuit of profit.

To meaningfully advance health equity, we must confront not only sexism but also capitalism itself. These systems are not merely intersecting – they are co-constitutive. Capitalism is a core driver of gendered health inequities. It reproduces heteropatriarchal structures and thrives on the exploitation of marginalized gender identities. Addressing one without the other leaves the foundations of inequality intact.

The Intricate Web of Capitalism–Colonialism–Racism–Sexism

Capitalism, integrally imbricated with colonialism, racism, and sexism, constitutes a complex social system that entrenches and reproduces health inequities. In capitalist societies, categories such as race, ethnicity, Indigeneity, sex, and gender are not incidental – they are strategically mobilized to maximize profit extraction. Nowhere is this more evident than in the organization of the labour market.

In 2019, Canada’s unemployment rate for racialized groups stood at 9.2%, compared to 7.3% for non-racialized populations (Block, Galabuzi, and Tranjan 2019, 4). These disparities reveal more than unequal access to jobs – they reflect a capitalist labour market that privileges non-racialized workers while extracting value from the precarity of racialized ones. Employers exploit this vulnerability by offering lower wages and circumventing labour standards, particularly in informal or “under-the-table” arrangements. Such conditions disproportionately affect workers living paycheck to paycheck, reinforcing both racial and class inequality.

The scale of exploitation is staggering. In 2021, Filipino workers earned just 74 cents for every dollar earned by non-Indigenous, non-racialized workers – a 26% wage gap (Statistics Canada 2022, 2). When race and gender entwine, the disparity widens: racialized women earned only 59 cents for every dollar earned by non-racialized men (Block et al. 2019, 5). These wage differentials reflect a capitalist system that uses race and gender to sort workers into insecure, low-paid, and low-status jobs. Yet ample evidence shows that secure, fairly paid work is a critical determinant of health; its absence directly contributes to adverse health outcomes.

Even within the healthcare sector – where care should be central – capitalist hierarchies reproduce systemic inequality. In Canada, the UK, and the US, the organization of healthcare mirrors broader social stratification. At the top are physicians – disproportionately white men from affluent backgrounds. Nurses often come from working- or middle-class families. Support staff are frequently racialized and economically marginalized. These occupational hierarchies affect not only recognition and career mobility but also health and well-being (Navarro 1977, 446). Even within Canada’s public, not-for-profit system, these divisions remain deeply entrenched.

As a racialized immigrant working in Canadian healthcare, I have witnessed these dynamics firsthand. Workers from formerly colonized nations are often deskilled – their education and credentials deemed invalid by Canadian institutions. This is not a question of merit; it reflects colonial and capitalist logics that devalue knowledge and labour from the Global South. In long-term care settings, where racialized women are overrepresented, low wages often compel workers to hold multiple jobs. Chronic understaffing, excessive workloads, verbal abuse, and physical violence are routine – and yet these conditions are normalized by those in power.

Public discourse – shaped by government, media, academia, and industry – tends to frame problems in long-term care as the failures of individual care workers. Rarely are these issues attributed to structural exploitation, institutional neglect, or systemic abuse by residents, families, managers, administrators, employers, and the state. This narrative erasure renders invisible the safety and well-being of healthcare workers especially those who are racialized, females, and non-heterosexual males.

The COVID-19 pandemic exposed and intensified these long-standing systemic injustices. Racialized health workers bore disproportionate risks – many of the first to die were front-line staff and physicians from racialized communities. This is not a coincidence – it is built into the system. In Western capitalist systems, racialized workers are concentrated in patient-facing roles, while non-racialized individuals dominate administrative and supervisory positions. These occupational divisions reflect broader hierarchies of race, gender, and class.

The pandemic also laid bare the fragility of Canada’s long-term care system. In our interview, then President of SEIU Healthcare, Sharleen Stewart reflected on the convergence of race, gender, and class: “Our personal support workers who died, they were all women of colour… very low-paid, very little benefits, very little retirement security.” Though she did not explicitly name capitalism, racism, or sexism, her testimony reflects their cumulative effects.

Interlocking systems of capitalism, (neo)colonialism, racism, and patriarchy continue to shape access to health, safety, and material resources – ultimately determining who lives and who is left behind. These systems disproportionately burden Indigenous Peoples, racialized groups, women, gender-diverse communities, and the working class.

The COVID-19 crisis deepened existing barriers to health care, food, housing, and employment, exposing the Canadian state’s failure to protect those most exploited and oppressed. These are not the by-products of a broken system – they are the predictable outcomes of one functioning exactly as designed.

Toward Social Justice and Health Equity

Despite decades of research and growing awareness, state responses to health and care inequities remain inadequate. What is needed is not just acknowledgment, but action: the dismantling of capitalism and the colonial, racial, and gendered logics it produces and sustains.

Real transformation depends on the collective agency of workers, scholars, activists, and communities. We must fight for redistributive policies, close racial and gender pay gaps, and confront the entrenched power of both state and capital. This is not merely a matter of reform – it is a matter of mobilization. Public education, grassroots organizing, and collective resistance are essential to disrupting the capital–state alliance and forging a path toward structural justice.

That path – rooted in equity, solidarity, and shared emancipation – points us toward a fundamentally different societal horizon. This is the project of socialism. But what does socialism mean in the twenty-first century? •

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