Andrew Fraser: Sickening inequalities blight our society They are a seemingly inevitable consequence of life in a society where there are winners and losers, and these differences are as great in Scotland as anywhere in the Western world. But health inequalities are not inevitable. There are ways to lessen the gap - where there is the will. Some blame the lifestyle of people in more deprived circumstances - they made choices and the results are poorer health and shorter life. However, there is plenty of evidence telling us that early life experiences - the society and economic circumstances where we begin to grow - add or subtract years to healthy life expectancy. Even before we are born, our foetal life influences our prospects. We cannot choose our parents; but growing up with major challenges means the quality of life which can be expected as an adult has already been influenced. Is this fair? How does it feel to be at the top, or the bottom, of an inequality? A recent report on alcohol consumption painted a stark picture of how the same lifestyle can yield very different results. All communities broadly appear to drink alcohol at the same, excessive levels across Scotland. But the death rates from alcohol-related diseases of men living in the most deprived areas is five times higher than the least deprived group. Consider the following scenarios; a wealthy man goes out to drink in company and with food. He becomes very drunk and his companions ensure he gets a taxi home - he has the money. He reaches home, and tries to eat but he is sick; there is someone there to ensure that he doesn't come to harm overnight. The next morning, he is late to work, almost incapable of making a contribution but his colleagues cover up for him, knowing that his better days will allow him to catch up. Meanwhile, a man from a deprived area goes drinking with his friends. He doesn't eat and has no money for a taxi. He avoids a fight outside a fish and chip shop on the way home, but slips and falls, bruising his head. His house is unheated and there is no food in the fridge, and no-one with the basic knowledge to check on him if he takes ill during the night. He is late for work the next day, is incapable of work through danger to himself or others. He risks discipline or the sack. Both have drunk the same amount of alcohol but one cannot afford anything else and has little protection in terms of personal safety or employment. His circumstances are entirely different and it is little wonder that his risks to life directly from alcohol and other hazards are many times higher. A study of healthy life expectancy has revealed that the lives of one fifth of Scotsmen in the poorest communities will be blighted by ill health before they even reach the age of 48. Women in deprived groups don't fare much better, reaching only 51.5 years of age before poor health sets in. This means they can expect to live out the next 21 years - the rest of their lives - in poor health. These statistics should matter to everyone - those who have the longest lives to live will feel fortunate. They are likely to be enjoying a higher standard of living, to occupy positions of responsibility, perhaps employ people less fortunate than themselves, and pay more tax. The implications of their good fortune, though are more complex. People who can expect to live a healthy life only until their late forties are less likely to hold down a job, to be a breadwinner, and more likely to use health services, social welfare support and whatever the State can offer in supporting their failing health and wellbeing. This fifth of the country struggles through their fifties and sixties, less productive and sicker, making a dwindling contribution to their families, communities and the rest of society. Inequalities matter, to individuals, communities and society. The Audit Scotland report published earlier this month calculated that health inequalities cost the country £10 billion. That sum hurts everyone, in economic and social terms. But the incalculable waste is human potential, with many Scots leading lives of poor quality, and lives cut short. A fairer Scotland, with reduced inequalities, would be a healthier Scotland. Health inequalities may be hard to fathom, but they are deep and steep and worth tackling. Dr Andrew Fraser is director of public health science at NHS Health Scotland