‘I’ve trained my whole life for this’

In the eye of the pandemic, viral disease expert Bonnie Maldonado still has hope

In the 2011 movie Contagion, a viral outbreak begins with glitz. After a business trip, Gwyneth Paltrow’s character, Beth, is gambling in a Macau casino. It’s brightly lit; spirits are high; Beth looks luminous. She shakes hands with a chef who — spoilers ahead — transmits a lethal new virus to her. (The chef’s hands carry a virus picked up from an infected pig he prepared for a pork dish; the pig had gotten the virus from a wild bat.)

Following Beth’s dramatic death from the new virus, a World Health Organization epidemiologist uses casino security-camera footage to identify Beth as the index case in a pandemic that kills millions. The epidemiologist is one of several scientists whose actions drive the plot.

“I love it because it’s not real,” said Stanford infectious disease epidemiologist (and sci-fi fan) Yvonne Maldonado, MD, who recently watched the movie during a rare break in the 14-18 hour days she’s been working on COVID-19.

“People say, ‘How could you watch Contagion?’” Maldonado said, laughing. “But why wouldn’t I?”

In spite of its unrealistic Hollywood touches — for instance, a vaccine that’s ready in just four months — Contagion reflects one piece of reality: A global pandemic can put scientists in the spotlight.

That’s where Maldonado is now. Across Stanford, California and the nation, people are relying on her acumen as an infectious-disease detective, epidemiologist, collaborator and leader.

“She’s said many times, ‘I’ve trained my whole life for this,’” said Clea Sarnquist, DrPH, clinical associate professor of pediatrics and a longtime research collaborator. Maldonado, who goes by Bonnie, is adept at meshing new data with knowledge built during decades fighting other viruses, including HIV, polio and measles, her colleagues said.

Bonnie Maldonado's leadership in shaping Stanford Medicine's pandemic response and explaining COVID-19 to the public is the culmination of a lifetime of learning. (Photography by Timothy Archibald)

“Bonnie has stepped up to fill an undefined leadership role that only a crisis like this could demand,” said Lloyd Minor, MD, dean of the School of Medicine.

Maldonado has been a key player in shaping the response of Stanford’s medical facilities and guiding its COVID-19 research efforts, and she has worked closely with infection control leaders at county, state and national levels to connect Stanford with the larger pandemic response. She also has been the university’s primary scientific spokesperson, responding to hundreds of COVID-related media queries.

Stanford Medicine’s response to COVID-19 has been very much a team effort, with hundreds of individuals playing essential roles,” Minor said. “But Bonnie has become an axis around which all of this spins.”

A passion for viruses

A Southern California native and daughter of Mexican immigrants, Maldonado spent childhood summers with her paternal grandparents in the city of Chihuahua in northern Mexico.

Seeing the vast socioeconomic disparities between her own family living in Chihuahua and others there who were not so fortunate, she felt a duty to help, which planted the seed for a career in global health. Her parents, a butcher and a legal secretary, were frequent volunteers at community events such as food and clothing drives. They encouraged Maldonado and her sister — now a chemical engineer — to pursue both science and community engagement as the first members of their family to attend college.

After medical school at Stanford and further training in pediatrics and infectious disease at Johns Hopkins, Maldonado spent two years in Berkeley, California, with the Centers for Disease Control and Prevention’s Epidemic Intelligence Service program. Her first task upon arriving in 1986 was to find the source for what turned out to be the biggest U.S. malaria outbreak in more than 30 years. (She linked malarial mosquitoes in the ponds on a San Diego golf course with changes in Mexico’s malaria control program and poor health care for undocumented immigrants who were crossing the U.S.-Mexico border.)

But AIDS is the disease that most shaped Maldonado’s career. At the beginning of the AIDS crisis, she was the only epidemiologist in the Bay Area to study the disease in children, who can become infected during birth. “I was familiar with a horrible, virtually untreatable pandemic where we watched children die,” she said.

“The kids [with HIV/AIDS] were just horribly ill. By then, in the early 1990s, I had my oldest daughter and son as well. It was hard to see these little kids who were the same age as my children getting sick and dying.”

Starting in 1987, while still at the CDC, Maldonado ran Northern California’s HIV surveillance program, which she started a few weeks after her older daughter was born.

She helped develop the criteria defining pediatric HIV, as well as treatments and strategies to prevent mother-to-child transmission, work that continued when she was hired at Stanford in 1988.

“The kids [with HIV/AIDS] were just horribly ill,” she said. “By then, in the early 1990s, I had my oldest daughter and son as well. It was hard to see these little kids who were the same age as my children getting sick and dying.”

Health care providers’ fears were another challenge. HIV is not transmitted through casual contact, but many medical professionals were initially reluctant to treat HIV-positive children.

“I spent a lot of time teaching the nurses, doctors and other staff not to be afraid of the kids, to be willing to provide them with clinical care and not treat them like pariahs,” Maldonado said.

Maldonado has also extensively studied such viral diseases as polio, measles and Ebola in developing countries. She’s adept at tackling nitty-gritty problems that can leave research projects hamstrung, said Sarnquist. Once, her team ran out of dry ice for a study in Mexico, threatening their ability to keep doses of polio vaccine cold.

“Bonnie said, ‘How about the local Coca-Cola factory? They have dry ice. Can we buy some from them?’” Sarnquist recalled. (The idea to call the factory came from a team member in Mexico, Maldonado said, adding, “If you listen to people in the community, they almost always have a good answer to a problem.”)

Full-bore COVID-19

In February, as it became clear that the novel coronavirus was spreading globally and Stanford Medicine leaders ramped up their response, Maldonado’s expertise was in high demand.

“All of a sudden, I was on calls with her and others six or more hours a day,” said Andra Blomkalns, MD, chair of Stanford’s Department of Emergency Medicine. “And people were asking, over and over, ‘Bonnie, what are your thoughts?’”

Norman Rizk, MD, then co-chair of the hospitals’ joint clinical operations resource team, said, “Bonnie has been very involved in everything, from how we manage access to the hospital buildings, to what drugs we might use to treat the disorder, to whether it would be prudent to take in a lot of patients with COVID from other hospitals.”

Maldonado began working 18 or more hours per day. As the chief of infection prevention and control at Stanford Children’s Health, she consulted closely with her counterpart, Lucy Tompkins, MD, PhD, chief of infection prevention and control at Stanford Health Care, to ensure that infection control and pandemic response measures at the pediatric and adult hospitals were aligned.

She coordinated with Rizk and Sara Cody, MD, chief public health officer for Santa Clara County, to ensure that Stanford’s resources — such as the virus test developed by Benjamin Pinsky, MD, PhD, in March — were available to people in hard-hit parts of the county. And Maldonado was instrumental in securing funding from local philanthropists for some of the first pandemic-related research projects.

“She’s able to distill a lot of information into what’s immediately important for the conversation,” said Blomkalns. “And she’s not at all afraid to say things if she’s in conflict with people in the room; she says what needs to be said.”

These skills have helped guide common-sense decisions in an environment where things aren’t perfect, Blomkalns said. Maldonado set policy for how to put contagious COVID-19 patients on respirators and for utilizing the limited number of negative-pressure rooms, which have ventilation systems that prevent unfiltered air from leaving the room.

“We needed to innovate and create solutions for many possible situations. Bonnie was able to translate her scientific knowledge into what was most feasible given the constantly evolving situation,” said Blomkalns.

“I had a hard time that week. As a person of color myself, I know this happens all the time. The fact that people thought this was new made me really sad; it hasn’t ever gone away.”

For months, Maldonado was immersed in pandemic-related work without losing momentum. But when George Floyd, a Black man, was killed May 25 in Minneapolis by a white police officer kneeling on his neck, she says she hit a very low point.

“I just couldn’t believe one more thing was happening in this world to make us less human,” she said. “I had a hard time that week. As a person of color myself, I know this happens all the time. The fact that people thought this was new made me really sad; it hasn’t ever gone away.”

Maldonado, who is also the School of Medicine’s senior associate dean for faculty development and diversity, helped organize online town hall meetings for the Stanford Medicine community that focused on the Black Lives Matter movement.

Her team solicited and funded applications for grants that would address disparities around COVID-19, which has disproportionately affected people of color. They also assembled diversity-related resources from throughout the school.

“I felt a need to keep going, to do something to support people who were feeling vulnerable,” she said. “I wanted to be out there protesting, but I realized my time is better spent here.”

Maldonado has also been a key scientific spokesperson on all things COVID-19, communicating with the news media and the broader Stanford community.

“She can craft her message in a way that is understandable to each audience,” said media relations specialist Lisa Kim, who has triaged media requests related to COVID-19 throughout the pandemic. Maldonado stays patient with reporters driven by breaking COVID developments, and she’s available almost constantly, said Kim: “I’ve received emails from her as early as 5 a.m. and after midnight.”

(Midway through reporting this story, I took a break to eat lunch and read the news. I opened a New York Times parenting story about letting kids use public restrooms during the pandemic — something I was vaguely worried about for my young kids. Maldonado was the first expert quoted, giving her usual sensible advice: “Most people aren’t sitting in public bathrooms for hours and hours,” her quote began. I burst out laughing.)

Generating new knowledge

Early in the pandemic, several Stanford scientists began discussing how to study the novel coronavirus. So little was known about COVID-19, the disease it causes, that even the symptom list was incomplete.

“We recognized we would need to see COVID-positive patients in an outpatient setting because 80% of patients aren’t admitted to the hospital, and we needed to figure out new medications and ways to manage the disease in patients with less severe illness,” said infectious disease expert Upinder Singh, MD, professor of medicine.

The team also hoped to investigate the immune responses of these individuals, which could hold clues to why some people become much sicker than others.

“But bringing them into the main hospital or clinics for research was problematic for the safety of our other patients,” Singh said. A member of Singh’s team had an idea: Why not set up tents to house research facilities? Researchers could see COVID-19 patients separately from uninfected people, and could easily keep everything clean and well-ventilated. Maldonado was among the first to support the plan.

“She got it,” Singh said. Maldonado and Minor brought others on board and quickly assembled a funding proposal for a local donor who wanted to help.

Blomkalns helped the team plan research that compared COVID-19 test samples taken from the front of the nostril with those taken deep in the back of the nose, a step toward building self-testing for the disease.

Even in the teeth of a pandemic, the scientists were excited to be generating new knowledge. “It was really fun,” Blomkalns said, sounding a little surprised at herself. “Bonnie’s really good at encouraging her team.”

Now, two tents house a COVID-19 clinical and translational research unit co-led by Singh and Maldonado. The tents are outfitted with air conditioning and heat, WiFi, electricity and research equipment, and they are close to the hospital’s emergency department in case a COVID-19 patient participating in the trials is sick enough to need hospitalization. Other academic medical centers have struggled or failed to open similar research facilities, Singh said.

“I really love seeing patients because all the other stuff I’m doing takes a back seat and I can just focus on one person. I really think it helps ground me. It’s the kind of thing that makes me really understand the meaning of what I’m doing.”

Maldonado is involved in two large epidemiological studies of the disease, as well as vaccine and treatment trials. Each Sunday, she sees participants in a placebo-controlled trial of a drug called favipiravir, an antiviral that researchers hope may reduce disease severity and make infected people less likely to spread the SARS-CoV-2 virus.

“I really love seeing patients because all the other stuff I’m doing takes a back seat and I can just focus on one person,” Maldonado said. The experience reminds her of working with pregnant women in Zimbabwe, who often walked for hours to reach a clinic where they could get an HIV test and, if it was positive, medication to prevent viral transmission to their babies.

“I really think it helps ground me. It’s the kind of thing that makes me really understand the meaning of what I’m doing.”

It’s an enormous workload, but Maldonado has some help. On weekdays, she’s up between 5 and 6 to get ready for many hours of online meetings — a challenge because “anyone who knows me knows I am not a morning person,” she said, laughing.

She relies on assistants for scheduling and has become more efficient at everything: firing off emails during long meetings; using a 7-minute phone app workout to squeeze in exercise; and relying on her husband, Ramiro, a lawyer, to make dinner.

“I don’t do this at all by myself. There are dozens and dozens of people who are working along with me,” she said. “What I can do is bring people together. For every hour that I put in, I’m probably amplifying that by 100 hours of other people’s work.”

She gets a lift by walking or running on the Stanford campus, where she and her husband live. They both keeps tabs on their three adult children — who visit occasionally — and her 87-year-old father, who lives in Los Angeles and whom they have seen only once since the pandemic began.

More than six months into the pandemic, her optimism has not waned. “I was always hopeful, and I still have hope,” she said. “We can conquer this disease. We’ve conquered other diseases like this or worse.

“It’s scary and horrifying that we have to learn about this virus through this living experiment that we are undergoing. But I really think that, in the end, I’ve learned more in the past seven months than I’ve learned about anything else over my lifetime. It’s really moved very quickly.”

Erin Digitale is the pediatrics science writer in the Office of Communications. Email her at digitale@stanford.edu.

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