It’s one of those awkward situations we’ve all been in.
Sitting in a meeting, or on crowded city transit, or at the dinner table, you desperately try to stifle it, but you can’t.
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You turn red. Your eyes start to water. The veins on your forehead may even bulge a little as you try to prevent the unleashing of some otherworldly beast from the depths of your throat, chest and lungs.
In the wake of COVID-19’s worst days, which left us all too keenly aware of the spread of respiratory viruses, the nagging, terrible-sounding cough has become the new social faux pas, a viral scarlet letter quick to leave you scorned by those around you.
And even though our friends, colleagues or family members with these lingering coughs are otherwise healthy, the instinct to escape, to move away, to cover our own faces, and think to ourselves “Eww, what’s wrong with them?” is for many of us simply too strong to resist.
Like the passing of wind or burping, the cough is the next biological function, however necessary, to avoid in public.
“Nowadays, it’s more appropriate to fart than to cough,” says Oakville resident Rouba Boushnak.
Boushnak was hoping to talk to me on a Tuesday. But she couldn’t. She had a coughing fit, one of so many she’s had of late. The next day when we finally connect, she tells me she’s been dealing with a nagging cough since November after contracting a respiratory virus.
While she has fully recovered from her illness and is back to being active, for Boushnak, a former tennis pro who now owns a Pilates studio with her partner, the cough remains.
“It’s embarrassing, especially if you have phlegm to get rid of,” says Boushnak, 54. “Some people are grossed out by the sound.
“People think, ‘Oh, you’re coughing. Why are you here?’ “
Gillian Wilner, a first-year justice and legal studies student at the University of Guelph and whose father, Mike Wilner, writes for the Star, knows all about that reaction.
Since November, she has also been nursing a lingering cough that came out of nowhere, she says. No illness. No fever. No loss of energy. Nothing.
“It just has not gone away,” she says.
Wilner recounts running late to a recent seminar, comprising about 10 students.
“When I came into the room, it was dead silent and then I just started hacking up a lung,” she says. “Everyone was staring at me.”
Why we cough
Indeed, there is perhaps no more unnerving sound produced by the human body than the guttural, raspy and sometimes eyebrow-raising cough.
But while it might sound like we’ve transformed into an angry donkey or a goat with a painful hernia, respiratory experts note that such coughs do not necessarily mean we are ill or contagious.
In fact, says Dr. Samir Gupta, a respirologist at Unity Health Toronto, coughs are caused by a number of reasons and don’t necessarily indicate that the person experiencing them is sick.
When it comes to the common respiratory viruses circulating this time of year — COVID, influenza, RSV and others — the cough, often called a post-viral cough, is often the last thing to get better, he says, and can last an average of three weeks post-infection.
“This is not a problem, this is actually expected and you will get better,” Gupta says.
Then there are coughs that last longer, known as sub-acute or chronic coughs, the majority of which have three causes, he explains.
The first is asthma, and in particular, cough-variant asthma, in which a cough is usually the only symptom. Many people may not even know they are suffering from this because the other asthma symptoms are subtle or non-existent, he says.
The second common cause of chronic cough is post-nasal drip, in which mucus from the nose drips down the back of the throat. Sometimes the mucus will land on the larynx, or voice box, resulting in that raspy sound when we talk.
“Your lungs don’t want mucus there, so they’ll tell your brain to reflexively clear your throat,” Gupta explains. “The body will trigger a cough.”
The third culprit is acid reflux, in which acid from the stomach makes its way up into the swallowing tube. As soon as the nerves there feel the acid coming up, they want to protect the lungs, Gupta says.
“So what do they do? They send a signal to the brain, saying ‘protect the lungs.’ How does the brain protect the lungs? You cough, because when you cough, you’re closing off your airway, and you’re forcefully breathing out. So anything in that area gets expelled.”
He adds that scientists are learning that in some cases, prolonged coughs for which the most common causes aren’t responsible could be symptoms of long COVID.
Gupta notes that a cough can spread germs through respiratory droplets.
If the person coughing near to you is in fact sick, it’s very hard to tell simply by the sound of their cough, says Gupta. The reality is that if the person has an active infection, and you are in close proximity to them, he says, there is certainly a chance you will become infected.
“It is very difficult to quantify that chance, because it depends on many factors, the most important of which is what exactly that infection is,” Gupta says.
The science of coughs is one thing, but even if we understand why we cough, it doesn’t explain why we still want to run out into the cold weather when someone during an office meeting starts hacking away.
You’re not just being paranoid. It turns out the way our brains have developed over time informs this instinct, says Dr. Melanie Badali, a Vancouver-based psychologist.
She explains that everyone has a “behavioural immune system” that helps us automatically detect cues that may indicate the presence of pathogens and prompt a reaction to avoid threats.
The problem, she says, is that it can be overly sensitive at times.
“It’s like a smoke detector going off when we burn some toast,” Badali says. “The alarm is warning us and we feel uncomfortable even though we are not actually in danger.
“The same goes for our response to coughs that are not actually a reliable signal for bacteria, viruses or other microorganisms that can cause disease.”
That instant revulsion or anxiety we might feel when someone coughs, and the associated actions, such as recoiling, are part of humans’ “first line of defence” against infection, she says.
But those initial reactions may not fit the facts.
“We may recoil in response to a cough but that does not mean we need to get off the bus, leave the office or ditch school,” says Badali.
So what is the appropriate reaction if you find yourself sitting next to someone unleashing a paroxysm of coughing? Before jumping to conclusions and giving that “why are you here?” look, start with empathy, says Susy Fossati, founder of Avignon Etiquette, a Toronto-based etiquette consultancy.
“Put yourself in their shoes,” she says, noting that we’ve all been in a situation where we just can’t suppress a cough. “If we’re truly uncomfortable in this situation, we would just get up and move away. To try to address anything would be considered bad manners.”
If you find you’re the cougher, aside from taking the obvious steps of turning your face into your elbow or a tissue, consider moving away from people to a less crowded area, Fossati advises, “not because we have to but because it’s considerate.
And if you’re fretting about going to that dinner party out of fear that a hacking fit might dampen the mood, Fossati says it’s good idea to let the host know about your stubborn cough and that you’re not contagious.
“That way you’re doing that part, and, you’re politely leaving it up to them to decide how they feel both for themselves, or other guests,” she says.
As the American poet Anne Sexton once wrote, “Love and a cough cannot be concealed.”
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