When Walking Fails

Iezzoni, L.I. When Walking Fails: Mobility Problems of Adults with Chronic Conditions . Berkeley : University of California Press , 2003 £40 (hbk) £13.95 (pbk) xxii + 355pp . ISNB 0-520-23742-0 (hbk) ISBN 0-520-23819-2 (pbk) Lisa Iezzoni is a physician who has had multiple schlerosis for over 20 years and uses a battery powered scooter to enable her to be mobile. This has allowed her to continue her career, although as an academic rather than a clinical doctor, becoming Professor of Medicine at the Harvard Medical School. This book tells Iezzoni's own story of problems with mobility, and along the way reminds us of the uncaring attitudes of the caring professions towards their own, but for the most part other people's stories. These were gathered by interviews with 56 people who live with failing mobility and who spoke about the issues that arise and the problems they face. These people are all of working age or active older people, who have progressive chronic conditions, who therefore have had full mobility in the past and are experiencing deterioration to a greater or lesser degree. Interviews and focus groups were also conducted with physicians, physical therapists, medical directors of health insurance plans, and disability rights campaigners. Data were also collected from Federal surveys carried out in the USA in 1994 and 95. The book aims to be an advocate for those 10% of Americans living in the community with problems of mobility, and to inform policy makers of the way in which public policy and health insurance are counterproductive in enabling people to become more mobile and independent. As such it is very much focused on the health care services in the USA, although some of the tensions and mismatch between the needs of individuals and health policy will be very familiar to British health and social professionals. This is not a sociological account but it encompasses epidemiological data, a brief sociological account of disability, and an analysis of disability policy in the USA, all used to explain the difficulties that are apparent within the stories told by people with mobility problems and their families. By also gathering data from physicians and therapists about their experience of treating these people a wider perspective is obtained than would be from individual stories alone. For example, one primary care physician speaks of his ‘blindness’ (sic) to the rules of prescribing set by the health insurers, but also of his worry that one of his patients, most of whom are poor, would be sent a large bill by the provider because the insurance company will not fund the drug he has prescribed. The book begins with the epidemiology of mobility difficulty, followed by a discussion of some physiological facets, such as gait and pain. The next chapter considers some of the sociological work on disability, including that by Oliver, and Goffman's work on stigma. Interesting here is a discussion on the reaction of Roosevelt to his own loss of mobility and use of a wheelchair, and his continued silence about his inability to walk. Chapters using empirical data on the effects of living with some degree of immobility are interspersed with chapters using the research with physicians and therapists, all of which graphically describe the difficulties that people with impaired mobility face, and the views of health professionals to treating or caring for them. The final two chapters focus on the experience of people within the health insurance system and what this will pay for, which is specific to an American reader. This does, however, provide an insight into the additional problems that people in a private health insurance market face, and the diversity and perversity in the entitlement of people to reimbursement for mobility aids. For example, one woman was told by her home nurse that she could no longer attend her after the nurse spotted an electric wheelchair in her home. Medicare policy is to pay solely for nursing the housebound, and so the patient stopped using the chair and stayed in her home to make herself eligible for dressings to her leg ulcers. The final chapter of the book highlights what has improved for people with limited mobility over the years, and what is unchanged. Technology and medical interventions have improved argues Iezzoni, but health care policy has not. She points to contradictory policies, such as the fact that ‘extras’ like special wheelchair cushions to prevent decubitus ulcers are not reimbursed by insurers, but surgical treatment when ulcers occur is. How useful is this book for a non-American audience? This is an insightful exploration of the problems that limited mobility causes. The biomedical focus on disease processes means that this commonly occurring problem is often not approached except as part of the symptomology of specific disease states. By treating mobility as a health and quality of life issue in its own right, with a number of common problems being experienced regardless of the cause of the limited mobility Iezzioni has provided a useful analysis for social scientists and health professionals researching or working in the field

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