Author Archives: Janet Miller

Freedom Through Interdependence

Photo: Personal Archive, Used with Permission

By Janet von Konsky Miller, MPH


In recent years, my husband and I have often sought out community firework displays on the 4th of July. Whether we find a lookout spot to view the glittering sky show from afar or seek the crowds to experience the soundwaves as each explosive blast bursts a spray of colorful shapes overhead, we have enjoyed contributing to the “oohs” and “ahs” that invariably accompany the annual pyrotechnic shows. Last year we even ventured outside of our local festivities to experience renowned firework displays surrounded by Tahoe’s scenic grandeur. Amidst pandemic conditions, however, the 4th of July festivities this year will look much different. This year’s local firework shows are cancelled to discourage transmission-prone crowds from gathering.

News reports of COVID-19 spikes in cases throughout the US have been reported the week before the Independence Day holiday. As of July 2, the US has 2,732,531 cases1 and those numbers are increasing by an average of over 40,000 cases daily.2 Nine percent of all COVID-19 tests are currently positive in the US.3 California along with Arizona, Texas, and Florida comprise half of the nation’s new COVID 19 cases.2 As of July 2, 6.4% of California COVID-19 tests are positive, which has increased from 4.5% positivity on June 4.4 While Santa Clara County fares better than the state-wide positivity rates, these county rates are increasing as well (2.62% positive tests on July 2 up from 1.39% on June 4 in Santa Clara Couny).5

This July 4th marks 244 years since the Declaration of Independence was signed, a document declaring colonial independence from Great Britain. This document symbolizes the values of freedom and independence deeply rooted in American culture. This year’s anniversary calls Americans to conceptualize their freedom and independence from a pandemic perspective.

To explore freedom and independence within a pandemic, we must first understand the virus behind the pandemic. The SARS coV 2 virus causing COVID-19 is a new virus in humans. Over the past 6 months, scientists have examined past viruses that are similar to SARS coV 2 and have studied how this new virus affects human physiology. If we as community members better understand its effects, we might be better able to embrace the importance of following recommendations meant to slow transmission.

When exposed to the SARS coV 2 virus, the virus binds ACE2 receptors.6 These receptors are found in many places throughout the body, including the lungs. While over 40% of those exposed may not experience symptoms,7 symptoms will occur 4 to 5 days after exposure on average in symptomatic individuals.8 In more moderate forms of the disease, local inflammation will resolve as healthy immune systems attack and kill the virus. In severe disease, however, an inflammatory response called a “cytokine storm” ensues.8, 9, 10 A dysfunctional immune system that is unable to conquer the virus coupled with inflammation may lead to lung tissue damage, low oxygen levels, risk of opportunistic infection such as pneumonia, organ failure, and possible death.6, 8 Those who suffer severe disease and recover may be inflicted with post recovery health issues from lung damage.23, 25

An immune dysfunction associated with the severe COVID-19 cases is characterized by low levels of an immune cell called “T cells.”10, 11, 12, 13, 14 T cell levels decline with age and may contribute to the increased risk of severe COVID-19 with advancing age.8, 14 In Santa Clara County, only 12.5% of the COVID-19 cases but 68% of the deaths have occurred in individuals who are 70 years of age or older.15 In the same county, 34.5% of cases and 2.5% of deaths occur in individuals who are between 20 and 39 years of age.15

T cell levels also decline with malnutrition.16,17 Therefore, it may be possible that those who do not have access to adequate nutrition could be at risk of severe COVID 19 disease. National food insecurity rates are estimated to be twice the pre-pandemic rates.18 California food bank demands have soared 73% in 1 year.18

Obesity may promote T cell dysfunction and this may not be reversible with weight loss.19 The Centers for Disease Control and Prevention (CDC) report that over 42 out of every 100 US adults are obese.20 Factors influencing obesity include diet, exercise, and sedentary lifestyles, and obesity risk may increase with chemical exposures and gut dysbiosis.21 Obesity is a risk factor for severe COVID-19 disease.22

Personal freedom and community responsibility are not mutually exclusive. It is estimated that masks may cut SARS coV 2 transmission in half.24 It may save someone from severe disease, post recovery health issues, and death. If we all cooperate with transmission mitigation efforts, businesses will open sooner, lasting health effects will be reduced, the pandemic health care impact will be eased, and loved ones will be able to hug again. It only takes properly wearing a mask when in public. It only takes a 6-foot distance when in contact with others. It only takes regular hand washing and cleaning of frequently touched surfaces. By embracing these behavior choices, we help each other and we commit to end this global pandemic. This is freedom. This is community. Through interdependence we may experience independence.


1CDC. (2020). Cases in the US. July 3. Retrieved from

2NBC News. (2020). Fauci: COVID-19 cases could swell to 100,000 a day if U.S. doesn’t control virus. June 30. Retrieved from

3CDC. (2020). Testing Data in the US. July 2. Retrieved from

4California State Government. (2020). COVID-19 State-wide Update: How are COVID-19 cases progressing? July 3. Retrieved from

5Santa Clara County Public Health Department. (2020). Novel Coronavirus (COVID-19): COVID-19 Testing Dashboard. July 2. Retrieved from

6 Zabetakis, I., Lordan, R., Norton, C., Tsoupras, A. (2020). COVID-19: The inflammation link and the role of nutrition in potential mitigation. Nutrients. 12(5): 1466. doi: 10.3390/nu12051466

7 Lavezzo, E., Franchin, E., Ciavarella, C., Cuomo-Dannenberg, G., Barzon, L, Del Vecchio, C., Rossi, L., Manganelli, R., Loregian, A., Navarin, N., Abate, D., Sciro, M., Merigliano, S., De Canale, E., Vanuzzo, M.C., Besutti, V., Saluzzo, F., Onelia, F., Pacenti, M., Parisi, S., Carretta, G., Donato, D., Flor, L., Cocchio, S., Masi, G., Sperduti, A., Cattarino, L., Salvador, R., Nicoletti, M., Caldart, F., Castelli, G., Nieddu E., Labella, B., Fava, L., Drigo, M., Gaythorpe, K.A.M., Imperial College COVID-19 Response Team, Brazzale, A.R., Toppo, S., Trevisan, M., Baldo, V., Donnelly, C.A., Ferguson, N.M., Dorigatti, I., & Crisant, A. (2020). Suppression of a SARS-CoV-2 outbreak in the Italian municipality of Vo’. Nature. Jun 30. doi: 10.1038/s41586-020-2488-1

8 Tay, M.Z., Poh, Z.M., Renia, L., MacAry, P.A., & Ng, L.F.P. (2020). The trinity of COVID-19: immunity, inflammation and intervention. Nature Reviews Immunology. 20: 363–374. doi: 10.1038/s41577-020-0311-8

9 Ye, Q., Wang, B., & Mao, J. (2020). The pathogenesis and treatment of the ‘Cytokine Storm’ in COVID-19. Journal of Infection. 80: 607-613. doi: 10.1016/j.jinf.2020.03.037

10Diao, B., Wang, C., Tan, Y., Chen, X., Liu, Y., Ning, L., Chen, L., Li, M., Liu, Y., Wang, G., Yuan, Z., Feng, Z., Wu, Y., & Chen, Y. (2020). Reduction and functional exhaustion of T cells in patients with coronavirus disease 2019 (COVID-19). Front. Immunol. May 1.

11Ganjia, A., Farahania, I., Khansarinejada, B., Ghazavib, A., Mosayebia, G. (2020). Increased expression of CD8 marker on T-cells in COVID-19 patients. Blood, Cells, Molecules and Diseases. 83: 102437. doi: 10.1016/j.bcmd.2020.102437

12Qin, C., Zhou, L., Hu, Z., Zhang, S., Yang, S., Tao, Y., Xie, C., Ma, K., Shang, K., Wang, W., & Tian, D.S. (2020). Dysregulation of immune response in patients with COVID-19 in Wuhan, China.  Clin Infect Dis. ciaa248. doi: 10.1093/cid/ciaa248

13Wang, F., Hou, H., Lui, Y., Tank, G., Wu, S., Huang, M., Liu, W., Zhu, Y., Lin, Q., Mao, L, Fang, M., Zhang, H., Sun, Z. (2020). The laboratory tests and host immunity of COVID-19 patients with different severity of illness. JCI Insight. 5(10):e137799. Doi:10.1172/jck.insight.137799

14Liu, Y., Pang, Y., Hu, Z., Wu, M., Wang, C., Feng, Z., Mao, C., Tan, Y., Liu, Y., Chen, L., Wang, G., Yuan, Z., Diao, B., Wu, Y., & Chen, Y. (2020). Thymosin alpha 1 (Tα1) reduces the mortality of severe COVID-19 by restoration of lymphocytopenia and reversion of exhausted T cells. Clin Infect Dis. ciaa630. doi: 10.1093/cid/ciaa630

15Santa Clara County Public Health Department. (2020). Novel Coronavirus (COVID-19): Demographics of Cases and Deaths. July 3. Retrieved from

16Alwarawrah, Y., Kiernan, K., MacIver, N.J. (2018). Changes in nutritional status impact immune cell metabolism and function. Front Immunol. 9:1055. doi: 10.3389/fimmu.2018.01055

17Cohen, S., Danzaki, K., & MacIver N.J. (2017). Nutritional effects on T-cell immunometabolism. Eur J Immunol. 47(2): 225–235. doi:10.1002/eji.201646423

18 NY Times. (2020). As Hunger Spreads with Pandemic, Government Takes Timid Steps. May 13. Retrieved from

19Rebeles, J., Green, W.D., Alwarawrah, Y., Nichols, A.G., Eisner, W., Danzaki, K., MacIver, N.J., Beck, M.A. (2019). Obesity-induced changes in T-cell metabolism are associated with impaired memory T-cell response to influenza and are not reversed with weight loss. J Infect Dis. 219(10): 1652–1661. doi: 10.1093/infdis/jiy700

20CDC. (2020). Adult Obesity Facts. June 29. Retrieved from

21CDC. (2020). Adult Obesity Causes and Consequences. June 11. Retrieved from

22CDC. (2020). CDC Updates, Expands List of People at Risk of Severe COVID-19 Illness . June 25. Retrieved from

23Science News. (2020). Some Patients Who Survive COVID-19 May Suffer Lasting Lung Damage. April 27. Retrieved from

24CNN. (2020). Pelosi Says Federal Mandate on Masks Is ‘Long Overdue.’ June 28. Retrieved from

25Spagnolo, P., Balestro, E., Aliberti, S., Cocconcelli, E., Biondini, D., Della Casa, G., Sverzellati, N., Maher, T.M. (2020). Pulmonary fibrosis secondary to COVID-19: a call to arms? The Lancet. May 15. doi: 10.1016/ S2213-2600(20)30222-8

Pandemic Coping Tool Box

By Janet von Konsky Miller, MPH


I took a virtual yoga class a week ago. In the week before this class, I had noticed that maintaining my lockdown morale had become more of an effort. As lockdown wore on, I had noticed others expressing likewise morale challenge. During class, the virtual yoga instructor voiced these same observations. As we begin week 6 of social distancing and SCC’s shelter in place mandate, we might fill the pandemic-coping tool box with healthy strategies to maintain morale and weather this traumatic storm.

I have attended many webinars while social distancing, especially in the first few weeks of the SCC shelter in place mandate. One of the webinars presented by the National Academy of Medicine (NAM) and the American Public Health Association (APHA) was a 2-part webinar on Social Distancing. One presenter, Dr. Sandro Galea, identified the COVID-19 pandemic as meeting the criteria for a traumatic event. He said that traumatic events are associated with increased stress behaviors and mental health issues. Experiencing multiple stressors can exacerbate the consequences of trauma on mental health. Some examples of multiple stressors people may be experiencing during the pandemic may include care of a high-risk loved one, economic burdens, among others. The more stressors, the greater the trauma’s effect, especially if these added stressors endure over time.1

While the presenter suggested solutions at a system-wide level, what can we do ourselves to mitigate the stress from the pandemic and subsequent isolation during lockdown? One article suggests that connection with others, healthy eating, adequate sleep, and exercise, in addition to other coping tools, may benefit mental health during this pandemic.2 A Harvard Medical School article suggests that through physical activity we can reduce anxiety and depression and increase well-being.  When working out with others, even if it is remote, the synchronized movement may contribute to increased self-esteem and cooperation.3 Laughter,4 gardening,5, 6 viewing nature,7 and music8, 9, 10 are other strategies that have been shown to impact the stress response.

Including emotional “normalcy” as a tool to remember during this anything-but-normal time may go a long way in coping with the trauma of the pandemic.1 Anxious? Sad? Grief-stricken? Irritable? Perhaps it may be comforting to know that experiencing a myriad of feelings during this crisis may be “normal.” Remember to be kind and compassionate to self as well as others during this crisis. Include reaching out to each other in that coping tool box because together we will get through this traumatic event.*

(*Note: If experiencing overwhelming emotional and mental distress, reach out to a mental health professional)


1NAM & APHA. (2020). The Science of Social Distancing, Part 2 [webinar]. COVID-19 Conversations. April 1. Retrieved from

2Psycology Today. (2020). Trauma of Pandemic Proportions. March 14. Retrieved from

3Harvard Health Publishing. (2016). How simply moving benefits your mental health. March 28. Retrieved from

4Yim, J.E. (2016). Therapeutic Benefits of Laughter in Mental Health: A Theoretical Review [abstract]. Tohoku J Exp Med. 239(3):243-9. doi: 10.1620/tjem.239.243

5University of Colorado Boulder. (2018). Why Dirt May Be Nature’s Original Stress Buster. Retrieved from

6Soga, et al. (2017). Gardening is beneficial for health: A meta-analysis. Preventive Medicine Reports. 5: 92-99. doi:

7Van den Berg, et al. (2015). Autonomic nervous system responses to viewing green and built settings: Differentiating between sympathetic and parasympathetic activity. Int J Environ Res Public Health. 12(12):15680-15874. doi: 10.3390/ijerph121215026

8Jolij, J. & Meurs, M. (2011). Music Alters Visual Perception. PLoSONE. 6(4): e18861. 

9Harvard Medical School. (2011). Music and Health. Retrieved from…/music-and-health

10UC Berkeley, Greater Good Science Center. (2015). Five Ways Music Can Make You Healthier.  Retrieved from

Face Masks

By Janet von Konsky Miller, MPH


As the week-3 SIP closes amidst changing guidelines for wearing face masks during essential outings, it was delightful to see my SIP-mate dive into the art and craft of face mask making yesterday. He experimented with scarfs and shop towels.

While he was busy creating, I dove into learning more about the science behind effective face masks. Here is what I found:

N95 masks are 95% effective as a barrier against particles that are 0.3 microns in size.1, 2  This compares to surgical masks which are effective only up to 65%.3  Whereas the surgical masks are a loosely worn barrier, the NIOSH certified N95 masks fit snugly against the face.1 As we reserve the N95 and surgical masks for the health care work force, we must turn to creatively repurposing home items for home-made face masks.

For the home-made face mask, different fabrics offer different amounts of protection. While T-shirt type fabric may be too thin to be very helpful, two layers of tightly woven fabric offers pretty good protection, according to a North Carolina anesthesiologist who tested different fabrics for effectiveness. The report suggests that if you don’t have fabric with a 180-thread count, use a less tightly woven fabric along with a flannel layer.3

A Los Angeles based clothing manufacturer (Suay Sew Shop) experimented with fabric masks lined with shop towels. This organization tested masks against 0.3 micron sized particles and found that cotton masks were up to 60% effective at blocking particles, and cotton masks lined with shop towels were 93% effective.4, 5 

When studying the effectiveness of 2-layer cotton face masks compared to medical masks in a healthcare setting, researchers found that cloth masks were less effective than the medical masks in preventing rhinovirus infection when worn continuously. Though there were challenges with the control group in the study design, the researchers hypothesized that moisture content and tightness of weave may be factors influencing the effectiveness of cloth masks.6

It is important to remember that the face mask recommendation does not diminish the importance of social distancing during this pandemic, but may be helpful in reducing transmission when participating in essential outside activity. 

It is also important to understand how to properly use the face masks:7

  • Wash hands before putting on a face mask
  • Make sure both the nose and mouth are covered (I saw someone yesterday who just covered the mouth!)
  • Don’t touch the mask
  • If it is wet, replace it
  • Remove a mask from the straps, not the body of the mask
  • Wash hands after removing the mask

Home-made fabric masks may be laundered after use, but adding harsh chemicals to the wash is not recommended.3

Guidelines are updated as more is learned about the SARS Cov 2 virus that causes COVID-19. The virus is currently believed to be airborne which means it can remain in the air even if the infected person is not close by.8 It can take up to 2 weeks for symptoms to appear after exposure.9  Not only are asymptomatic infected people contagious, those who have had the virus may continue to be contagious from 8 days to 37 days after recovery.10, 11  Wearing a face mask may reduce viral transmission when worn by infected individuals.12 Due to asymptomatic transmissions, wearing a face mask during essential activity away from home may help stop the spread of the virus.

So much has changed in the last month for everyone, and while it may be difficult to embrace ever-changing guidelines, it can be an opportunity for some creative SIP mask-making activity!


1FDA. (2020). N95 Respirators and Surgical Masks (Face Masks). Retrieved from

2CDC. (2009). N95 Respirators and Surgical Masks. Retrieved from

3NBC News. (2020). Making your own face mask? Some fabrics work better than others, study finds. Retrieved from

4Business Insider. (n.d.). Using blue shop towels in homemade face masks can filter particles 2x to 3x better than cotton, 3 clothing designers discover after testing dozens of fabrics. Retrieved from

5Daily Mail. (2020). Designers find that layering two blue shop towels inside cotton face masks makes the most effective homemade PPEs. Retrieved from

6 MacIntyre, C.R., Seale, H., Dung, T.C., Hien, N.T., Nga, P.T., Chughtai, A.A., Rahman, B., Dwyer, D.E., & Wang, Q. (2015). A cluster randomised trial of cloth masks compared with medical masks in healthcare workers. BMJOpen. 5:e006577. doi:10.1136/bmjopen-2014-006577

7WHO. (n.d.) Coronavirus disease (COVID-19) advice for the public: When and how to use masks. Retrieved from

8Johns Hopkins Medicine. (n.d.). Coronavirus Disease 2019 vs. the Flu. Retrieved from

9Yale Medicine. (2020). 5 Things Everyone Should Know About the Coronavirus Outbreak. Retrieved from

10Chang et al. (2020). Time Kinetics of Viral Clearance and Resolution of Symptoms in Novel Coronavirus Infection. American Thoracic Society. March 23: 1-12. doi: 10.1164/rccm.202003-0524LE.

11Zhou, et al. (2020). Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. The Lancet. 395( 10229):P1054-1062. doi:

12Leung, N.H.L., Chu, D.K.W., Shiu, E.Y.C., Chan, K.H., McDevitt, J.J., Hau, B.J.P., Yen, H.L., Li, Y., Ip, D.K.M., Peiris, J.S.M., Seto, W.H., Leung, G.M., Milton, D.K., & Cowling, B.J. (2020). Respiratory virus  shedding in exhaled breath and efficacy of face masks. Nature Medicine. 26: 676–680.

Last Updated 5/21/20

To Hike or Not to Hike

By Janet von Konsky Miller, MPH


Today begins week 2 of the COVID-19 shelter in place mandate in Santa Clara County. When I started week 1, I was grateful that the mandate allowed me to hike. Getting out into nature using local trails was a welcome coping strategy to all of the changes the mandate influenced: work, social contact, economics, habits and routines. It is my happy place.

I quickly found that social distancing was difficult to commit to on the trail, however. Many other residents were also taking advantage of the ability to hike the local trails and staying 6 feet apart from other hikers on a narrow trail is at times impossible. What is an avid hiker to do?!

I heard some people are traveling to remote wilderness locations to get their nature and physical activity fix. While tempting, it warrants caution. Hikers who don’t know they have the virus risk exposing rural areas to the virus. Keep in mind the rural population tends to be older and has a reduced access to hospitals (seven percent of rural hospitals have closed in the past decade).1

While California open space and many parks remain open, this is subject to change.2 Traveling distances to get a nature fix may cause further closures of nature access. For instance, hikers have been urged to get off the PCT (access to supplies has been interrupted and risk of contaminating rural areas is a concern).3 Taking cue from other states, Montana locals are requesting Yellowstone be closed.4

“ ‘Ultimately, social distancing doesn’t mean traveling all over the place while making sure you’re six feet away from people.’ “.3

Remember, infected droplets from respiration can stay in the air for 3 hours. Smaller droplets stay in the air longer than large droplets, and smaller droplets are more likely to gain access to lung tissue. The larger droplets may dehydrate and become smaller droplets. Don’t forget that eyes are also a virus access point. And staying 6 feet away doesn’t mean you haven’t come into contact with the virus, but that there is less concentrations of the virus in the air which influences infection.5

Though remote hiking may pose less of a risk to hikers due to fewer people on the trail, it potentially brings the virus in to rural communities. Let’s take the “stay home” motto to heart. Find nature’s beauty in small things – the trees are beginning to blossom, and the bulbs are blooming. Get exercise at home. Stay active, stay local. Just for now. We can do this.


1Forbes. (2020). How The COVID-19 Coronavirus Pandemic Is Impacting Rural America. Retrieved from

2Mercury News. (2020). Coronavirus parks closures in the Bay Area: Five things to know. Mar 23. Retrieved from

3LAist. (2020). Coronavirus Is Forcing Hikers To Quit The Pacific Crest Trail. Retrieved from

4Montana Free Press. (2020). Neighboring counties ask Yellowstone National Park to close. Retrieved from

5UMN, Center for Infectious Disease Research and Policy. (2020). COVID-19 transmission messages should hinge on science. Retrieved from