‘I was seeing people dying every day – healthcare workers who were fit and well. That was worrying’
As incident director for Public Health Wales, Dr Giri Shankar has seen first-hand the effect of the virus on our nation and has been at the forefront of the pandemic response, advising the Welsh Government. But, as he tells LAURA CLEMENTS, he’s never felt
FOR someone in charge of the coronavirus pandemic response in Wales, Dr Giri Shankar is remarkably serene.
In fact, Dr Shankar, the incident director for the coronavirus outbreak for Public Health Wales (PHW), admits that at no point in the past 12 months has he felt stressed. Sad, yes, disturbed even, and exhausted too, but never stressed.
In the early days, when he and most of us barely knew what was coming, he was putting in 18-hour days – up at 5am to sort the daily press briefing and still in meetings after midnight to discuss the next moves.
“When the pandemic was declared, nobody expected it would run this long,” said Dr Shankar, with an ironic chuckle.
“We thought it would be a few weeks, a few months perhaps, so I took on the role of incident director first and there was only me. I did it for 56 days – I worked in the role without a single day’s break and then I realised it’s not going to be possible to be just me.”
First they drafted in Dr Robin Howe, a microbiologist, and then Chris Williams, an epidemiologist. Finally, as the second wave took hold and the workload continued to ramp up, Dr Eleri Davies, a microbiologist, joined the PHW incident director team in October.
Throughout the pandemic, PHW has provided expert public health advice to the Welsh Government, various multi-agency partners and the people of Wales on how to respond to coronavirus.
While it is up to government ministers to make the final decisions on things like lockdown measures, PPE stocks and how to roll out the mass vaccination programme, PHW’S role in a pandemic is to protect the public from infection and to provide advice on epidemiology (the incidence and prevalence of disease). Perhaps it’s bestknown for reporting the daily cases, deaths and vaccination updates on the PHW dashboard.
Although operationally independent of the Welsh Government, it acts at the Welsh Government’s direction and is a designated “category one responder” under the Civil Contingencies Act.
Dr Shankar, who joined PHW in 2016, can still remember the very first meeting he attended with his equivalents from all four UK nations to discuss what was happening in China. It was January 9, 2020, and even then the 44-year-old knew there would be cases arriving on UK and Welsh soil imminently.
“We set up our own incident management on January 21,” he recalled easily, a date etched in his memory forever and which will probably come to define his career.
“From January 21 to March 23, when we went into lockdown, it was horrendous. It was 16, 17, 18 hours some days. We could finish off a press conference at midnight and be ready for another one at five in the morning. So that period was really, really long hours.
“I was certainly convinced that we would get cases here and we would get the impact of it because international travel is such that it brings movement of people. But what I hadn’t appreciated was the rate of growth.
“We had our first case towards the end of February then the exponential growth was something that I hadn’t appreciated because most of the focus at that time was in China, which was the hotspot of the pandemic. But when we analysed it in retrospect, a lot of the imported cases from March were mainly from Europe – travellers from ski resorts in Italy and France as well.
“That was when we thought that something that was far away was actually right next door and the level of incursions that happened was quite unprecedented.”
Dr Shankar wasn’t the only one unprepared for the scale of what the virus would unleash. Working with colleagues in England, he was trying to set up a system that would assign a unique identity to each new confirmed case of coronavirus and settled on a six-digit identifier.
“One of my colleagues in England said, ‘Do we really need six digits? Do you think we’ll go over 10,000 cases?,’” Dr Shankar said. “And here we are with millions of cases afterwards.”
In fact, as of March 23 this year, a year on from the start of the first lockdown, the exact number stood at 4,307,304. In total, more than 148,000 people have so far died in the UK with Covid-19 on the death certificate.
In March 2020, scientists, health officials and ministers were still trying to play catch-up with the fast-moving virus and a national lockdown was seen as the only solution.
“It came to a point that we had no choice because people were dying every day,” said Dr Shankar, who has worked since day one of the pandemic from a tiny desk squeezed into a corner of his home in Llandaff in Cardiff. It’s stayed that way for more than a year and he swivels his camera round to prove it.
“And the level of mortality, especially in the elderly population, was quite disturbing actually,” he added. “One of the jobs I have as incident director, which I absolutely hate, is to sign off the daily death numbers.
“That’s one of the most painful aspects of this role. I was seeing people dying every day – even healthcare workers who were fit and well. That was worrying. That realisation was when the penny dropped, I think. I thought, ‘We can’t go on like this, we need to lock down.’”
That was probably the lowest point in the pandemic for him personally, he said.
“We had no idea about what treatment worked in March and April,” he added. “We were trying a cocktail of everything – ventilation beds were filling up, we didn’t know what was the right PPE kit to use and that started to worry me a lot.
“Any death is sad, but seeing health professionals who were previously fit and well individuals succumbing to this infection – that was quite a low point. I was quite disturbed about it.”
He shrugs and gives a resigned smile, adding: “It’s just that curve you go down then you go up.”
Married and with two young children of primary school age, Dr Shankar says he’s not stepped out of Cardiff since March 14 last year. He puts his serenity down to daily morning yoga and meditation, catching up on his beloved Formula One and cricket and spending as much time as possible playing board games with his family.
“In a pandemic situation you have to take actions very quickly, therefore your thinking also should be very clear,” he said. “And all that comes from being able to maintain a balanced equilibrium between work, life and general outlook.”
But there’s more to his demeanour than simply yoga – Dr Shankar is quite simply a genuine and kind man who believes passionately in doing good. He’s spent more than a decade training for an unimaginable pandemic, so does he relish the opportunity to put these skills to good use?
“I see it more of an opportunity to serve,” he said resolutely. “You don’t have to make a special effort to say that I wish a pandemic happens so I can show my skills. You should more be interested in doing good things and, by doing good things, it will take you on and draw some attention and recognition.
“But if your sole purpose is to seek attention then you will lose what you need to do. I’ve always been a firm believer that whatever you do, you do with sincerity, devotion and dedication. And the results will take care of themselves.”
Dr Shankar has worked his entire career in infectious diseases, which is unusual among his colleagues at PHW. Growing up in a large family in India, he was the youngest student at medical school aged just 17 and went on to become an infectious disease specialist in his home country.
Working in a tropical climate, he enjoyed the variety of what would come through his door every day. “One day I
‘‘ In a pandemic situation you have to take actions very quickly, therefore your thinking also should be very clear. And all that comes from being able to maintain a balanced equilibrium between work, life and general outlook - Public Health Wales’s
Dr Giri Shankar
would see a patient with polio, the next would be a patient with tuberculosis, the third day I would see someone with chikungunya or malaria, so it’s that variety that keeps me going,” he said.
He speaks passionately about public health and he has a clear sense of duty to make a difference to “a large chunk of the population”. But medicine wasn’t his first passion and, growing up, the young Giri was more into fast cars.
“I am a bit of a petrolhead and I always wanted to be an automobile engineer,” he said, although he’s never regretted pursuing medicine.
A turning point in his decision to solely pursue infectious diseases in public health was running a polio eradication camp in India as a second-year medical student in 1997.
“After smallpox, polio is the only other infection that has been eliminated,” he said. “So you’ve got this real prospect of mass intervention – powerful tools such as vaccination, hygiene, clean water – all those make real impact on quality of life and life expectancy.”
After moving to the UK to gain experience in a developed nation, he worked first as a consultant in infectious disease control and then joined Public Health England, where he stayed for 10 years until moving to Cardiff in 2016.
Although pandemics don’t happen that often, coronavirus is not the first Dr Shankar has worked on.
He was instrumental in containing the swine flu outbreak in 2009, then working for Public Health England. So he knew what he was talking about in the meetings he was having with his own team and colleagues in the Welsh Government and they drew heavily on that experience.
“Although we did experience and record a level of excess mortality because we had experience of influenza and the development of vaccines against it, that pandemic was contained reasonably okay,” he said. “But this time it was nothing like that.”
He knew that a national lockdown would help slow the spread of the virus and, while there have been criticisms that the Government didn’t act fast enough, it was facing a reality it had never really faced before.
“Most importantly, when society is confronted and faced with such a challenge, people don’t want to take drastic measures first,” said Dr Shankar, in his measured and calming voice. It’s easy to imagine he must have been a comforting presence in those fraught meetings about what to do next.
“People want to say, ‘Shall we do some other measures first in the hope that it will work? Therefore why do we want to unnecessarily curb our freedom and our lives because all that has negative consequences, like closing schools, et cetera.’
“But once you realise those initial measures are not really working, then you have to go to those drastic measures.
“Just imagine if this was not a pandemic but a prepandemic planning phase. If we had been training and said, ‘For a future pandemic we’ll lock down the country and nothing will be allowed to happen’, nobody would have accepted it as an intervention because we are not used to feeling that way.
“In hundreds and hundreds of years one thing we love is freedom and if that is taken away it’s not a thing that will be easily acceptable. Therefore, when China introduced what was widely called ‘draconian measures’ by the media here, we were thinking, ‘We can’t possibly do that here.’ But six weeks later we did exactly that.”
He does not criticise the decisions made – his role is to advise – but he does think there are lessons to be learned.
“What this pandemic will certainly do is to open a large part of society and a large group of key movers and shakers in society to the seriousness of planning for a potential pandemic,” he said with his characteristic objectivity.
“I’m not saying there wasn’t seriousness before, but what this has brought to the fore is the scale of the pandemic. Previously we had pandemic plans but not for pandemics that would last years. We had pandemic plans that lasted weeks or months, so I think that has definitely put a new lens on planning.”
Perhaps the fact we’d already had one lockdown meant it was easier to implement a second in the autumn as case numbers started to rise again – we had already come around to the idea of having our freedom curbed. But the “firebreak” lockdown and then the subsequent local lockdowns had little impact on the infection rate, in part because the virus had another surprise in store – new and emerging variants. They were playing catch-up again.
“We did expect a second wave, there’s no doubt about it,” said Dr Shankar. “In the period between September and October we did notice there were lots of cases going up in some parts of Wales more than others. Places like Cwm Taf Morgannwg, Merthyr Tydfil and Blaenau Gwent.
“But what caught everybody by surprise was, again, the rate of growth. We were nearly less than 10 per 100,000 towards the end of summer, but in September, one week after schools reopened, cases numbers started to go up.”
Pressed further,
Dr
Shankar doesn’t mean that the return to classrooms was to blame for a rise in cases. Rather, it was due to returning international travellers and increased mixing following the relaxation of restrictions, he said.
“Within two or three weeks numbers were so high that already by the beginning of October we were thinking about another lockdown and that’s when the discussions started and we had the firebreak which got the case numbers down, which was good,” he continued.
“After seemingly going in the right direction, this new dimension got added to the pandemic which was the emergence of variants. We expected variants to happen, but we didn’t expect them to emerge with such a high level of transmissibility.”
What followed was a period of confusion, said Dr Shankar, who was trying to work out if the rise in cases was because of people having pandemic fatigue and not following the guidance.
“Now, in hindsight, we know there was a more transmissible virus,” he said. “And a more transmissible virus and people mixing more had an additive effect and therefore the rates we saw just before Christmas were staggering. We were 630 cases per 100,000.
“It takes only four weeks for cases to go up to that level, but takes three months of lockdown to bring it down. I think the population has still not grasped the seriousness and we can let it slip very quickly, but to take back control is really incredibly hard.”
For Dr Shankar, the second wave was frustrating – not so much because people weren’t following the rules but because he was trying to work out what was the “deficiency in our risk communication methods”.
“I thought, ‘Are we not able to communicate this better to the public in a way they understand it?’,” he explained.
“You see the comments on our social media and some people completely get it and there are some other comments you see where people have just got the wrong end of the stick completely.”
He is remarkably understanding and fair, saying that he can forgive the sometimes aggressive tone or the language used because they are “clearly from frustration”.
“That’s where I get frustrated,” he continued. “Have we failed in our risk communication method? Or what is it that makes people take that risk?”
He is refreshingly open and honest about the evolution of the pandemic and how he personally has coped with the demands that came with it.
“I do work long hours,” he said without a hint of bitterness. “And I don’t mean just me – everybody in my team and everybody in public service has done a phenomenal job – but never once in all these years, and especially in the last 12 months, have I felt that I can’t cope with this or that this is too stressful.
“That thought has never occurred to me. Because I do manage my time and I do manage my mind really differently. I’m tired because of long working hours, but I’ve never felt stressed.”
The effect of the pandemic on the Valleys has been particularly concerning for Dr Shankar and has uncovered some of the stark realities of life in those communities.
For example in Rhondda Cynon Taf, which has the highest Covid death rate in the UK (361.8 per 100,000), more than three in five people work in jobs that cannot usually be done from home such as health and social care, education, retail and manufacturing. Lower levels of car ownership in the Valleys mean more people rely on public transport for work – risking further spread of the disease.
“One of the things that I’ve come to realise is that we’re seeing it from a public health point of view, but in a lot of families, especially in deprived communities, people experience poverty and it can only drive up risk,” said Dr Shankar.
“So if it’s a choice between going to work and getting Covid versus putting food on your table for your family, there are some families who can’t afford not to go to work.
“I consider myself to be incredibly privileged – I had a really good middleclass upbringing, was able to go to private school and I have a good education, and have a decent job with really decent pay. But a large majority of the population don’t have that.
“And I think that we, as health professionals, need to understand a bit more because we can’t see the whole world with the rose-tinted glasses of a medic or a NHS professional.
“That has been quite staggering. We know that 28% of children live in poverty in Cwm Taf Morgannwg and in today’s modern society that is quite worrying.”
With case rates now heading firmly in the right direction and an overall infection rate in Wales at its lowest since early September, there is some hope that life can begin to return to normal. The vaccination rollout is also cause for optimism – although Dr Shankar is cautiously optimistic only.
“Before the emergence of the variants, we would have been more confident in saying vaccination is the way out,” he said carefully.
It’s thanks to Dr Shankar that Wales was designated as one of the sites of the trial of the first Oxford/astrazeneca vaccine. That was simply based on Wales’s track record of successful vaccine trials for the meningococcal vaccination, he said.
“But with the emergence of variants that potentially have blunting effects on the effectiveness of the vaccine, I would just like to say that the vaccines will play a crucial role but vaccination is not the only answer and can’t be the only answer,” he continued.
“We still have to be diligent about ways of working, ways of interacting, surveillance, risk associated with travel and, more importantly, to pursue the ongoing work to find effective treatments.”
He is optimistic about the future, though, when coronavirus doesn’t dominate the daily headlines and life has gone back to some form of normality.
“I think people who think deep about it will also appreciate what you enjoy when you are not in a pandemic situation,” he said with a hopeful smile.
“People will start to value those more now going forward because a lot of the things we took for granted as things that will remain forever with us – the pandemic has shown that’s just not the case.
“I do think respect between humans, respect for bilateral ties with countries and interacting with people will change a little bit for the better.”