Medical social work is a field of professional social work, the concept of which had originated in England in the 1880’s. It got acceptance in the United States in early 1900’s. Service to the sick has been a part of Indian tradition. However, its scientific orientation is of recent origin (GOI, 1987, 175). Around 1945, some Indian doctors who had been abroad had observed the functioning of "almoners" in Britain and medical social workers in the USA, as part of the health team. They felt the need to have a similar pattern of team work in India as well.
The Bhore Committee Report (GOI, 1946) had strongly recommended the appointment of medical social workers in hospitals. Probably by the influence of these recommendations the first medical social worker was appointed in J.J. Hospital, Bombay, in 1946.

The Evolution of the Concept of Medical Social Work
Historically medical social work with a scientific basis started in hospitals. However, gradually it has spread to clinics, dispensaries, rehabilitation centres, public welfare agencies and community health programmes. Over a period of time, with the changes in approaches towards health, the roles and functions of medical social workers also have changed tremendously. In the light of the above discussions, the present paper attempts to analyse the concept of medical social work, its changing functions and the present status of medical social workers in India.
In the late 19th century Dr. Richard Cabot’s insights into the "shortsightedness" of hospital-based treatment inspired him to introduce a new staff member, whom he termed as `medical social worker’. Initially medical social workers had a limited purpose of reviewing the applicants for admission to the dispensary and to exclude those unsuitable for free care. Soon they were able to understand and respond to the varied needs and problems of the patients, and thus gained greater acceptance from the people as well as from the medical team. Thus at the curative and rehabilitative levels of health care, the medical social worker helps the patients to cope up with the psycho-social problems that arise out of ill-health and disability and enable them to lead a productive and satisfactory life.

The medical social worker with his/her knowledge of the dynamics of human behaviour as well as skills in establishing purposeful relationships, tries to know the patient as a ‘person’, his socio-economic conditions, his attitude towards health problems, his relationship with the family, taps community resources and acts as a liaison between the patient and the community.

At the preventive and promotive phases of health, the medical social worker studies the socio-cultural pattern and the health needs of the families and the community, interprets the same to the team and derives maximum participation of the people, so as to raise their health status. Thus the existence of the medical social worker in a health settings can in itself be a recognition of the psycho-social aspects of health.
The Bhore Committee had opined that ‘the hospital social service brings to the care of the sick in institutions such knowledge of their social conditions as well as hasten and safeguard their recovery and help to prevent any recurrence’. Such knowledge enables those responsible for their treatment to understand and treat the patient’s illness more effectively. In the carrying out of her duties, the medical social worker has become in fact an assistant to the physician in the diagnosis treatment and rehabilitations of the patient.

Role of the Medical Social Worker
In the modern era of varied and complex diseases for which the medical science is unable to find out remedies, the functions of a medical social worker attains much importance. One such example in recent times is the emergence of Acquired Immuno Deficiency Syndrome (AIDS) as a major threat to community health, for which there is no effective medicine or vaccines till date. The disease has already created panic among the planners, medical professionals as well as the social workers. The reported cases of irrational and inhuman treatment of AIDS patients by the medical professionals, their family members and the society are clear-cut evidences to such irrational panic or, to coin a term "AIDS Phobia". Lack of awareness regarding various issues related to AIDS such as how the disease is transmitted, what are the major precautions to be taken for prevention and besides, the belief that AIDS is transmitted only through sexual promiscuity especially that of homo-sexuality, are the underlying causes for such a panic. Here the role of medical social worker varies from clarifying the doubts of the people to the myriad social, psychological and economic problems related to AIDS. Rehabilitation of the patient to his/her own family and the society is one of the major concerns of medical social work. At the preventive level the medical social worker can help the people by giving counselling to reduce high risk behaviour such as prostitution, intravenous drug use, homosexuality etc. The social worker can create awareness regarding the need for use of only HIV negative blood for transfusions, safe sex practices etc.
The same functions of medical social workers are applicable to all other serious diseases in India such as TB, Leprosy, Cancer etc. Except in case of AIDS, there is effective treatments available for them in modern medicine especially if diagnosed early. The medical social worker with the skills in understanding the person in his ‘totality’ and with the application of various social work methods such as case work, group work, community organisation, social work research and social welfare administration can influence the treatment and rehabilitation process. By using social case work methods, which is an enabling process of one-to-one relationship. The medical social worker can interpret the nature of the disease and its implication to the patients and their families, and can study the socio-economic conditions of the patient to provide necessary emotional support during the crisis situation, use the technique of environmental modification, if necessary, so as to enable the patient to benefit from the prescribed treatment. He/she can also interpret the patients psycho-social problems to the other members of the family.

Medical Social Interactions
Group work is another method of social work through which the social worker helps the individuals in group. Using group work, the medical social worker enables the patients with similar problems to come together so that they feel less isolated and lonely. This could bring about a feeling of belonging. Medical social worker can use this group as a therapeutic agent for emotional growth and attitudinal changes among the group members. Thus the group can be used as a major vehicle for mutual sharing and helping. Presently group work method is widely used in the West among AIDS patients.
Community resources are tremendous in terms of health care practices. Positive aspects of indigenous medicines have to be popularised, especially when modern medicine is inaccessible and unaffordable to the majority of the population. Also we understand that there are limitations for modern medicines. Thus using the skill in organising the community the medical social worker can promote the use of community resources with regard to health care.
People-oriented research is a neglected part in health care systems in India. The majority of the social science researchers look for cause-effect, as well as cost-benefit analysis, whereas the need of the hour is inter-disciplinary research which takes into account the varied social, psychological, economic and cultural aspects of the life of the people. Thus the "people" are pushed backward while the `disease’ and `medicine’ take the front seat in planning. Social work research has the potential to conceive the idea of "people-centred" research in health, and the medical social worker has an important role in promoting social work research so as to enable the health care planning in the country.

Status of Medical Social Workers
The status of medical social workers is directly related to the recognition by the people, the health team, the planners, the government, the non-governmental organisations, the social workers and social work education institutions. The role of medical social worker in India is not well recognised.
The Medical Council of India’s report in 1973 on the minimum standard requirements for medical colleges for 100 admissions, had recommended that there should be six medical social workers in each of the Preventive and Social Medicine Departments, two at the College, two at the Rural Health Centre and two at Urban Training Health Centre. If these recommendations are implemented by all States, there would be requirements of more than 1000 medical social workers only for the Preventive and Social Medicine Departments of Medical Colleges all over the country. But development in this regard is meagre. Response from the planners is also not encouraging as in many of the committee reports after Bhore Committee (GOI, 1946) such as Mudaliar Committee (GOI, 1961), Srivastava Committee (GOI, 1975) etc., the role and importance of medical social worker was neglected. However the medical colleges and big hospitals in the metropolitan cities and other big cities have already started taking initiative in appointing medical social workers. Thus the number of medical social workers are increasing slowly but steadily.
In hospital settings in India, the qualifications, functions and duties of a doctor, nurse and other auxiliary personnel have been defined. But for the medical social workers, no function are identified nor qualifications recognised as yet by the health team. Even the social workers themselves and the medical team are not able to identify various roles of social workers in a medical setting. As a result in many cases they get low acceptance and they enjoy only low status in the medical team. Since in hospital settings, tangible results are of paramount importance and the results of the work of the medical social workers are often invisible as they deal with social and psychological aspects of the patients, often their contributions are not perceived properly by the administrators and the medical team. Thus in many of the hospitals the medical social worker functions as a single worker. Very often the medical social workers are engaged in routine and monotonous non-professional duties which hampers their motivation to function effectively. Also the salary of the medical social workers is very low among the members of the medical team.

Unhealthy Proliferation
According to Association of School of Social Work in India (ASSWI) there are more than 60 schools of social work, which offers Masters Degree in Social work. However, recently there is a mushrooming of social work education institutions in all parts of the country. Many of these institutions do not have adequate professionally qualified faculties. As the quality of social work education itself is low in many of these institutions, one can imagine the practical difficulties in the growth of the profession in a very important field of social work i.e., Medical Social work, which demands much input from the profession. Also many of the schools of social work in India are based in urban centres, and the rural areas are totally neglected. One cannot simply blame the medical profession or hospitals in rural areas for not appointing medical social workers in their team. In many cases they are not aware of even the profession called social work and its importance in the treatment and rehabilitation of the patients.
The response of the non-governmental organisations to the importance of medical social worker is encouraging. Many of the NGOs are giving importance to community-based health care services in which medical social workers have important roles to play. However, the development in this regard is also very slow.

Conclusions and Suggestions
The approach to health care has been changing over the years from the focus on ‘cure’ through the wonders of ‘modern medicine’ to the patient in his ‘totality’. The time has arrived to accept that modern medicine has its own limitations, as the problems of human-beings are complex in nature, the solution for which cannot be searched within the frame work of medicine alone. The causes of physical problems can be traced back to psychological, social and economic history of the patient. Thus the understanding of health from the focus of ‘medicine’ needs to be shifted to the "people’.
The recognition should include people’s acceptance of medical social worker and his roles, identification and analysis of the roles of social workers by the social worker themselves, recognition by the health team in terms of accepting the importance of the medical social worker for the health team, sharing views, mutual help etc. It also needs recognition by the planners in terms of bringing out issues related to medical social work. From the Government side recognition should include opening new avenues for medical social workers to be part of the health team, fixing adequate and decent salary scale on par with the other professionals, improving promotion facilities etc. Recognitions of medical social workers by the non-governmental organisation involved in health care is another important aspect of status of medical social workers. The recognition by the social work education institutions should include giving importance to field based practical experience in medical social work to students of social work, identifying and strengthening the theoretical aspect of social work methods. This will help the students to apply the same in practical situation and encourage social work students to build up their career in the field. The rural areas where more than 74 per cent of our population lives should be given much more importance by the social workers and the social work education institutions.

Reference

1. Government of India. (1987), ‘Encyclopaedia of Social Work in India’ Vol. III, Publication Division, Ministry of Information & Broadcasting, New Delhi.
2. Government of India (1975), ‘Health Services and Medical Education - A programme for Immediate Action’, Report of the Group on Medical Education and Support Manpower, Ministry of Health & Family Welfare, New Delhi.
3. Government of India (1961), Report of the Health Survey and Planning Committee, Miknistry of Health, New Delhi.
4. Government of India (1946) Report of the Health Survey and Development (Bhore Committee) Committee Publication Division, New Delhi.
5. Medical Council of India (1973), Report New Delhi.
6. Nadkarni, Vimla V (1985), A Model of Community Health for Medical Social Workers’, Indian Journal of Social Work, Oct. 1985, Issue - 3.

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