I was at a long-awaited panel discussion at my friends’ private home, listening to Senator Kristen Gillibrand speak about paid leave and reproductive rights with women’s health entrepreneurs Priyanka Jain and Alessandra Henderson, when I first heard it: The Cough.
Henderson, the founder of a women’s health company called Elektra Health, coughed discreetly from the makeshift stage. Then she coughed again. It was dry and quick and frequent. Every so often, she would turn her head, raise her hands, and behind the swishy curtain of her chic blonde bob, cough. A woman stole over and slipped her a cough drop. Gillibrand had warmed up and was on a tear about TikTok. (Not a fan, by the way.) And still, discreetly but certainly not imperceptibly, coughing. Henderson did not otherwise seem sick. She was a power woman on a panel with a Senator, in peak form, but what can I say: these days, you notice the cough.
Who among us has not walked the streets of New York beset by the scourge of the season, the persistent hacking cough? Maybe you currently have one yourself, or the person in the subway seat next to you is coughing, or you’ve narrowly escaped catching a cold from your throat-clearing cubicle neighbor. Even if you’re been personally spared, you’ve likely noticed that the entire city is hacking away right now, or maybe in this endless Covid era, it’s all just harder to ignore. Respiratory virus season is in full swing, COVID is still here, and the CDC sent an alert out last week that vaccinations are low. The cough-industrial complex is booming, but despite the fact that we now have CRISPR gene editing and a postpartum depression pill, it’s a crapshoot as to what cough medicine actually works. In September, an FDA advisory panel ruled that phenylephrine, the main ingredient in many decongestants, doesn’t actually do anything. Phenylephrine is for stuffy noses but it’s bundled in a bunch of the top cough medicines to treat a cross-section of cold symptoms.
After the talk, I asked Henderson about her cough. “I’m not contagious. I would never be here. I tested myself again this morning,” she said immediately. “I get this many times a year, and so no matter how I’m sick, or what I’m sick with, it always manifests in my chest. I just have very weak lungs.” It turned out that Henderson had fluid in her lungs as a newborn, and a childhood with frequent bouts of whooping cough. I also have very weak lungs, so I get it. Mine trace back to a bout of asthmatic bronchitis that sent me to the hospital for a week in third grade and again in my teens after finding out the hard way that I had a cat allergy. I have an inhaler, but when I get sick, I, too, feel it in my chest. And when it gets bad, there is the cough.
When I asked friends if they’re noticing coughs more or suffering themselves, they regaled and horrified me with their coughing fits. One had COVID-triggered asthma and an eight-month cough (under control now, thanks to two inhalers and a trip to the pulmonologist). Another was a lifelong mucous-heavy cougher whose tips included “Chest Physical Therapy” which uses gravity and chest/back percussion to get phlegm to loosen and drain (she lies prone hanging over her bed while “banging her back”). I talked to a big-time media executive who travels with a hepa filter and humidifier mini, and swears by her AirTamer, an on-the-go travel air purifier that you wear around your neck. I also have an asthmatic friend who uses a nebulizer and hasn’t fully recovered from COVID a year and a half ago: “Still have shortness of breath constantly!!!” she wrote to me in an email.
I embarked on a quest for answers that I hoped could help us all.
Interrogating the Cough Specialists
First up, I called Dr. Benjamin Tweel, an otolaryngologist, or an Ear, Nose & Throat doctor (ENT) at Mount Sinai Hospital on the Upper East Side. He explained coughing almost defensively: “Coughing is a protective reflex. Some people argue that it’s the most important function of the throat.” He went on to share that the throat and voice box have three functions: speaking, swallowing, and coughing, and that people cough either to dislodge something that is physically present, like mucous, or to prevent something from going down into their lungs. “When we have these pathologic coughs or these coughs where we’re doubled over because we have a coughing fit, I like to think that the calibration of the cough reflex is a little bit off or oversensitive,” he said.
Tweel, and every other doctor with whom I spoke, emphasized that there are three kinds of coughs: “acute” which lasts for less than three weeks; “subacute,” which lingers for three to eight weeks, and “chronic,” which persists for more than eight weeks. “The cough is the single most common complaint for which people in the United States seek medical attention,” said Dr. Peter Dicpinigaitis, who has the ultimate credentials for this story—director of the Montefiore Cough Center in the Bronx and the Editor-in-Chief of a journal called LUNG.
Part of why coughing confounds so many of us is that there are myriad causes for it. Cold and flu season (or in medical terms, rhinovirus and influenza virus, respectively) and RSV and COVID are big culprits. There are also environmental triggers like cigarette smoke, air pollution, dust, pet dander, mold, terrible overpowering perfume, and cold air. And when a cough persists more than eight weeks, the potential causes expand even further. At that point, “it becomes much more likely that it isn’t simply due to a residual cold, and it’s instead due to one or more treatable, reversible causes,” said Dicpinigaitis The three most common underlying issues: upper airway cough syndrome (which used to be known as “post-nasal drip”), asthma and asthma-like entities, and gastroesophageal reflux disease (GERD). “When a patient goes to the doctor with a chronic cough, the doctor’s first job isn’t to give you a cough suppressant, it’s to evaluate whether you have one or more of those three things, treat those three things, and then make the cough go away,” said Dicpinigaitis.
Dr. Thomas Carroll, a surgeon at Brigham and Women’s Hospital and an assistant professor of Otolaryngology at Harvard Medical School, is the author of the book Chronic Cough, which was published in 2019. I asked him if Long Covid has made coughing more prevalent. “Yes and no,” he answered. He told me that chronic cough can be a “post-viral problem” in which a nerve becomes hyperstimulated and won’t relax after a virus. “If you get a cold or COVID, you can get neuropathy of the 10th cranial nerve, which is the vagus nerve,” he said. “And when the vagus nerve doesn’t work, we get everything from tickles in our throat to stomach emptying issues and reflux. So, when I think about a post viral cough, I’m thinking, how has it affected this vagus nerve, and what are the downstream effects of that?”
I also spoke to Dr. Deepa Rastogi, a pediatric pulmonologist and the chief of Pediatric Respiratory and Sleep Medicine at the Children’s Hospital at Montefiore in the Bronx, to get some perspective on kids. “The most important thing to recognize is that cough is a symptom,” she said. “It’s something that the child is experiencing and there can be many, many different reasons that could be underlying the cough.”
Learning the Etiquette
I wanted to talk to someone about the public health aspects of coughing — about how to be a better cough citizen. Post-COVID, it feels like the coughers are getting all the shame. It can be hard to remember that all of us are just a gross handshake or crowded subway ride away from joining their ranks. When I asked my 8-year-old daughter what she does when she encounters someone coughing, she answered: “I like, move away without them knowing. I do the moonwalk away.”
Cover your cough and then wash your hands. I had to go get three graduate degrees to be able to tell you that.
Kevin Hook is the director of the Adult-Gerontology Primary Care Nurse Practitioner program at the NYU Rory Meyers College of Nursing, which makes him a public health expert. He also commutes to the city regularly from Philadelphia by train. “I’ve noticed when anybody coughs more than once on the train, people start getting very angry. I can see people looking and they’re looking annoyed, like, why are you on this train?” He said he frequently sees fellow passengers’ heads pop up, looking around for the culprit. “I always sit in my quiet car, but even those people are coughing.” He has simple advice for being a good cough citizen: “Cover your cough and then wash your hands. I had to go get three graduate degrees to be able to tell you that.”
Carroll and Dicpinigaitis felt for their patients and the awkwardness they encounter in our cough-averse, COVID-phobic world. “The typical patient who previously had a cough could go on the subway or the bus or go to a store and have a cough here or there, now they’re looked at as a pariah,” Carroll said, noting that they likely “just have an irritative” that is a symptom of another, non-contagious problem. “It’s hard for them to deal with it now that we’ve had COVID. People look at them like they’re going to contaminate the world.” Said Dicpinigaitis: “It’s been difficult for them.”
Exploring Current Cough Theories
While it seems like kids are always the ones with the cough (or maybe just mine, coughing on me) I was stunned to learn that chronic cough is most prevalent in women. “In adults, chronic cough is very much a female specific problem,” Dicpinigaitis told me. “Two thirds of patients that come to chronic cough centers are women, and we and others have shown in the lab that women have a more sensitive cough reflex than do men.” In a study at the Montefiore Cough Center, Dicpinigaitis told me that 62 percent of the women with treatment-resistant chronic cough (what Dicpinigaitis called “refractory chronic cough”) reported having “cough induced stress urinary incontinence,” meaning that coughing was making them pee.
I’m a mom, so obviously I asked if there was correlation with having had a child through vaginal delivery. Nope. “These are people who had absolutely no history of urinary incontinence until they got the chronic cough,” he said.
Dicpinigaitis said that women didn’t tell him about their incontinence until he asked them specifically. “They won’t speak about it. They think that they’re unique and with this terrible problem that, as you can imagine, leads to even more anxiety, more depression, more social isolation. And then when I tell them it’s a common problem that will probably get better as we get the cough better, they’re very relieved.”
I fumed a little when he told me about this. We have dozens of variations on cough drops yet somehow no one has yet noticed that coughing manifests in women’s bodies differently. After the call I emailed Alessandra Henderson, the OG cougher from the panel, and shared Dr. Dicpinigaitis’ observations. She had told me that one of her reasons for starting a women’s health company (Elektra focuses on menopause and women’s hormonal health) was her own coughing journey, and now lo and behold, it turned out that coughing was a woman’s health issue.
Getting Rid of It
Natalie Wachen plays KT in Broadway’s Merrily We Roll Along and professionally not-coughs on stage for eight shows per week. I asked her for her secrets. “For me, instead of trying to get rid of a cough, which is what I did all winter last year, I’m just really trying to not get one,” she tells me. (Bette Midler’s show-stopping coughing fit in Hello, Dolly! is still a cautionary tale in these parts.) “I do a lot of supplements. I have a really expensive air purifier, and I mask if anyone around me has got a cough.”
Keeping the cast healthy is a communal goal at the Hudson Theatre. “We have tons of air purifiers backstage, which is fantastic…they’re in the dressing rooms, they’re in the wig room, they’re in the hallways,” Wachen said. Cast members also stock “whatever our favorite go-to potion or supplement is” in their dressing rooms. “If somebody coughs or sneezes, there’s always somebody who offers up a cough drop or whatever, a supplement or a swig of something.” Her supplements of choice? “Right now I’m doing the elderberry and lots of vitamin C and D. I also have Emergen-C packets.” Her advice was helpful from a prevention standpoint, but what if it’s too late for that?
I posed my treatment question to Dr. Mikhail Varshavski, aka “Dr. Mike,” a popular doctor on TikTok and Instagram, with 2.1M and 4.4 M followers respectively. Dr. Mike lives in Manhattan and is a primary care physician in New Jersey, and said he sees mostly acute and subacute coughs in his practice, and generally recommends letting the cough run its course, at least at first. “I like to stay away from medications, even over the counter medications,” he told me. “I would say in 90 percent of those cases, I’m not recommending an over the counter cough suppressant. These actually have very limited evidence to work when compared against even simple things like taking honey.” He also emphasized the importance of non-medicinal supportive care, like “making sure a child is well-hydrated, because when a child is not well hydrated, their mucous actually thickens and becomes more difficult to clear, therefore it gets sticky in the lungs and the upper airways.” He recommends a nasal rinse or spray because “it clears out the nasal passageways of mucus and allergens and bacteria and remnants of inflammatory cells.”
“Pediatrics overall has moved away from using cough suppressants,” concurred Dr. Rastogi, adding that the word “pediatric” applies to people as old as 18 or even 21, in some contexts. I asked: Does this mean a teenager shouldn’t have a Halls? She laughed. “Again, you know, it’s hard for me to give you a cut off age. But yes, we try to avoid doing over the counter cough suppressants.”
Dicpinigaitis said that steroids—inhaled or oral—can sometimes help ease a subacute cough or treat a cough related to asthma. “When you get a cold, and the cold goes away, and the cough lingers for two, three, four, or five weeks, and the cough is very severe and disruptive, I might give a short course of oral steroids to really hit the inflammation hard. But most of the discussion on steroids is in the realm of chronic cough,” he told me.
I posted in a private listserv of professional women asking what they took for a cough—home remedies welcome. No clear winner emerged but I got a fusillade of tips, many of which included Kentucky bourbon. (Grandmothers swore by it, I was told and told again.) Honey, ginger, and lemon figured prominently. A friend advised me to zen out and switch to edibles.
There were also votes for humidifiers, and leaving the shower running (I already do this when my kid is sick. We call it a “steamy”). Zinc. Sea moss. Saline spray, just like Dr. Mike. Another friend swore by eating honey hot, and with your head flipped upside down. “As if you are trying to touch your toes,” she instructed helpfully. “This allows the mixture to coat the back of your throat, the part that always hurts and never gets touched with cough drops.” She is from New Jersey.
At a party, I was asking everyone about their coughs, and a Swedish woman in fabulous pants recommended boiling pears with cinnamon sticks and cardamom bolts for 45 minutes to an hour. “Then you eat the pears. They’re delicious. And then you drink the water.” It turns out both pears and cardamom are imbued with phlegm-reducing qualities, according to numerous yoga sites and, for pears, a Scottish study from 2003.
Finally, I went to Walgreens and browsed the cough and cold section. I scoped out the Robitussins (elderberry and honey), and the knock-off Tussins (Walgreen’s brand), the Quils (Day & Ny) and the knock-off Quils, Theraflu, Mucinex, Tylenol Cold & Flu, and Coricidin, which I’d never noticed but is for people with high blood pressure, plus the drops — Halls, knock-off Halls, Vicks Vapo-Cool, and Ricola. Many of these products had versions which added the word “SEVERE” in all caps, which I now understood to be mostly typography.
I looked at them all differently now.
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