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Alison Stewart: Respiratory viruses are surging in our area, and if you're coughing, you're not alone. It's causing a lot of concern, not to mention a lot of side-eye on the subway. For at least the second year in a row, the word tripledemic is being used. We're going to clear our throats and talk about it. The author of a recent New York Magazine article titled The Cough That Doesn't End joins us, journalist Rachel Sklar. Hi, Rachel.

Rachel Sklar: Hi.

Alison Stewart: Also joining us is Dr. Mark Horowitz, a board-certified family physician in New York. Dr. Horowitz, nice to meet you.

Dr. Mark Horowitz: Nice to meet you, Alison. Thank you for having me on for this relevant and important discussion.

Alison Stewart: Listeners, we want to let you know. This segment is about information. Dr. Horowitz obviously can't diagnose you over the radio, and his advice on air should not take place of visiting your own doctor if you're not feeling great. Rachel, your article is dated January 2nd of this year. It dropped over the holidays, but you obviously started working on this much earlier. What made you write about coughing?

Rachel Sklar: It was an assignment, actually. Initially, from the parenting perspective, my editor, Julia Edelstein, wanted to know if I was interested in taking a fun chase down to figure out how to cure that lingering pesky cough that we all seem to have. It was initially assigned as a fun quest. As I began reporting it and diving down deep into all of our lungs, or postnasal drip, or acid reflux, or whatever may be causing the cough, I figured out that it was a huge, huge topic, and then we adjusted accordingly.

It still had the quest frame, and I know that there's a lot of people out there who don't feel like it solved their problem, but I do also know that there are a lot of people out there who did find that it had helpful information. The goal was to just break it down a little bit and also to put a name to the lingering cough that people have because a lot of people think that they're just stuck with it and they're not.

Alison Stewart: Listeners, let's get you in on this conversation. Do you have a lingering cough? How have you been coping? What's your cough in public technique, or maybe you have a question for our guests? Our phone lines are open. 212-433-WNYC. That's 212-433-9692. You can join us on air, or you can text to us at that number always. 212-433-9692. You can reach out to us on social media @allofitwnyc. Maybe you have a family recipe for a cough, something you do to help with the cough. You can feel free to share that with your fellow public radio listeners. 212-433-9692. 212433-WNYC. Dr. Horowitz, people are obviously aware of COVID, but in addition, what else is spreading in our area that's causing coughing?

Dr. Mark Horowitz: Alison, you used the term tripledemic as was coined last year for the confluence of COVID, flu, and RSV that we went through last winter. I would like to substitute the word pentademic for what we're going through now. Acute cough, and I want to compliment Rachel on her very fine article, and in particular, highlight the section of her article that distinguished how doctors approach patients with cough by the duration of cough. A cough that is of three weeks duration or less, Rachel correctly pointed out, we call that an acute cough. Whereas three to eight weeks is more of a subacute cough, and longer than eight weeks is a chronic cough. Each of those categories have different causes and a different medical approach.

I'm going to be talking predominantly about adults. However, as a family physician, I see children as well. Our approach to kids with cough is slightly different, and I want to highlight that at the outset. When I use the term pentademic, I'm referring not only to COVID, which is still the predominant virus causing cough in the New York area right now, but we're also seeing RSV, which stands for respiratory syncytial virus, and we're seeing influenza. The other pathogens that are causing cough right now include strep and other bacteria, and then good old fashioned garden variety colds caused by viruses that go by the name of rhinovirus, adenovirus, or even coronavirus, but pre-COVID coronaviruses.

Alison Stewart: Rachel, and this is anecdotal, but I'm curious. Since you spent a lot of time thinking and writing and interviewing people about coughing, is there more coughing, or are we just more aware of coughing because of COVID?

Rachel Sklar: The two chronic cough experts I spoke with, Dr. Peter Dicpinigaitis from the Montefiore Chronic Cough Center, who was very clear to me about when I accidentally used the word acute to talk about a generalized cough, and he was like, "No, no, no. There are categories," and also Dr. Thomas Carroll, who's the author of a book called Chronic Cough, both of them said that there is a heightened awareness of coughing post-COVID, and both of them expressed real empathy for chronic cough sufferers who are not contagious but are already self-conscious of their coughing situation in public, and that this reaction in public has shifted a lot more towards shaming and feeling bad and feeling guilty.

Just anecdotally, most people I spoke to all spoke to the general horror of people thinking that they were contagious, but the flip side of that is I am not a doctor. I don't know when you're contagious, when I'm contagious, when my child is contagious. I have a general idea. I take COVID tests when there's a need for them, and I take precautions, but being a good cough citizen and being careful about how you cough in public is also important. I think that it's all wrapped up into it. There's a lot of how we feel about coughing wrapped up in this issue as well as the straight, "I have a cough. What's happening? Why is this reflex happening in my throat?"

Alison Stewart: Dr. Horowitz, can one have a cough and not be technically sick?

Dr. Mark Horowitz: Sure. Absolutely. As Rachel points out, there are causes of chronic cough that are not related to acute illness. We have asthma, allergy, acid reflux, postnasal drip. Of course, we also have more serious causes of cough. When someone has a cough of eight weeks or longer, we need to be really meticulous in the evaluation of that patient and not assume that they have something that's not contagious or not serious.

Alison Stewart: Let's take a call. Philip is calling in from Astoria, Queens. Hi, Philip. Thanks for calling WNYC. You're on the air.

Philip: Thank you. I had a holiday party on the 14th of December. Shortly thereafter, on Tuesday, they told us that several people had COVID. I was testing for days to see if I developed COVID, and I felt something developing on my throat. It was always negative. I eventually went into the doctors on the 21st or 22nd, and they got back to me on New Year's Eve saying I had RSV and not strep, not COVID, not influenza, luckily.

I was terribly sick on Christmas, and I still pushed myself to see my family with a mask and everything, but I completely lost my voice trying to talk through it. I'm much better now. I'm in complete recovery, except I have this very long lingering cough that comes up every so often. I've been coughing into the inside of my shirt whenever it comes up, but I'm actually very worried that people are going to judge me or are thinking that I should be wearing a mask all the time or that I shouldn't be working in my office or taking the subway.

I also have a little bit of fluid still in my sinuses and whatnot, but I don't think I'm contagious anymore. I've been told that the RSV cough can linger for four to eight weeks afterwards, potentially. At least that's what the doctor at the urgent care said, and that's what the government website on RSV has said. I'm curious about that, but also very worried that people are going to think poorly of me on this front.

Alison Stewart: Philip, thank you for calling in. Dr. Horowitz, do you want to take that question about how contagious he might be at this point?

Dr. Mark Horowitz: I sure do. RSV is not the only cause of cough that lingers. Listeners who have had COVID know that long after they test negative, they may still have cough. RSV and COVID are both tremendously inflammatory viruses. Fortunately, COVID has evolved to a less lethal state and causes minor symptoms, but there still are tremendous number of patients who have cough for weeks after recovery from COVID. This should be distinguished from long COVID. This isn't long COVID. This is just post-COVID inflammation, and RSV can indeed cause the same thing, and the patient is not contagious to others.

Alison Stewart: Rachel, I want to bring you into the conversation something that Philip mentioned, the social aspect of this. When you were talking to people about this idea of the minute you cough, everyone just stares at you. Tell us a little bit about people you talk to and how they deal with the fact that there's a social element to this now, too. Once upon a time, you cough, people said, "Oh, are you okay?" Now people look at you like, why are you on the subway? Why are you in this office?

Rachel Sklar: The entry point for the article, actually, I got the assignment and was like, all right, I guess I have to find someone coughing. Then that evening, I went to a panel with Senator Gillibrand and two women's health experts, including one named Alessandra Henderson, who is the founder of Elektra Health woman's health company. She was turning her head to cough every so often on the panel. I was like, "I think I might have my lead."

I went up to her. I'm friendly with her. I went up to her after, and I said, "Is it okay to talk about this for this article?" She said, "Yes, but I'm not contagious. I tested this morning. Absolutely. I would not have done this if I had COVID. This is a chronic condition. I've had it since I was a kid. I just cough sometimes." One of the things that I also noticed about this, because I'm watching this panel for a while, is how unflappable Senator Gillibrand was during it all. We all operate in our lives. We sometimes cannot react to a cougher.

I also think there's extending a little bit of grace and good faith in the workplace or in a professional space or just in a trusted space, that people are aware on a public health level that if they're sick, they should stay home. Now, I cannot, obviously, paint with a broad brush here, given a very vocal segment of the population that does not feel that they should mask or whatever. That was not part of the exploration of this article. It was more about what people generally expressed, which was always trying to walk the line between looking after their health, going about their business.

Also, the guidelines that we receive, which are when to keep your kids home from school, when to keep yourself home. Those have shifted. We're all trying to do our best, I think, is where I came down in this article, and with the understanding that not everybody feels that way, particularly when they are in the presence of someone who may or may not be coughing a lot and not covering their mouth.

Alison Stewart: My guests are Dr. Mark Horowitz as well as Rachel Sklar. She wrote the piece, The Cough That Doesn't End. Listeners, we can take your calls about your lingering cough. How long have you been coughing? How have you been coping? Maybe you have a family recipe that helps with a cough, something you do to help, help out your fellow public radio listeners. Our phone lines are open 212-433-9692, 212-433-WNYC. You can call in and join us on air. You can also text to us at that number. Joyce is calling in from Troy, New York. Hi, Joyce. Thanks for holding. You're on the air now.

Joyce: Hi. I've had this cough since December of 2022. I cough all day. I was proactive in going to the doctors. I went and had an endoscopy because I have a history of acid reflux that came out negative. I went to an ENT doctor. They did a scope down the nose, and then they sent me for a CAT scan. The CAT scan came back with nodules in the lung. I figured maybe it was something lung-related.

I followed with a pulmonologist, but long story short, they're saying that the cough is not related to my lung. Nobody knows why I have this cough, what it's related to. I'm just assuming at this point that it could be post-nasal drip. Does post-nasal drip just come on all of a sudden like that and cause you to cough all day, all night? Well, the funny thing is, when I'm laying down in bed at night, I don't cough.

Alison Stewart: Joyce, I hope you feel better. I hope you're feeling okay in that. Dr. Horowitz, I wanted to bring up one more subject before we go on to etiquette and to kids is, the Suffolk County Health Department recently reported it's tracking a growing number of whooping cough cases. When we think about whooping cough, something people have probably thought about in a long time, how does it differ from what we've been discussing, COVID, RSV, and flu?

Dr. Mark Horowitz: Every couple of years, we see a surge in pertussis, which is the scientific name for whooping cough, formerly a childhood disease in this era of vaccination. I say that emphatically because whooping cough vaccine is part of routine childhood vaccination, so it's almost universally administered. In the era of vaccination, the age range of pertussis has shifted to an older age range.

Listeners who have a family member who is pregnant are often encouraged by that family member or that family member's obstetrician to get a booster vaccine for pertussis if they're going to come in contact with the baby before the baby is fully vaccinated. Whooping cough is characterized by a noisy cough, hence the name whooping cough. It goes through several different stages, and I'm thinking back to my board exam to remember the various stages because we see it so infrequently now, but every couple of years, there's a recurrence, a surge in the number of cases, and we have to think about that when we see either a child or an adult with a noisy cough.

Alison Stewart: Rachel, I want to circle back to how this article first started when you started talking about kids because I remember when my son was little, we used to call a elementary school, a germ farm. Just, there was always a parent. You always had a cold. They were always bringing on something. Is that still the case? Is it that parents have greater exposure because of kids?

Rachel Sklar: I think that definitely the more people you have wandering through your home, bringing in germs from the outside, of course, any parent who's just brought their kid into daycare for the first time can probably attest it. I remember bringing my daughter in, and then she was out for, like, the first two weeks and then gave me pink eye. That was delightful, so it is what it is.

What I will say is that was one of the questions that I asked Dr. Deepa Rastogi, who's a pediatric pulmonologist that I spoke to for the piece. She's also at Montefiore, and she did say that it felt like things had leveled off post-pandemic, in terms of initially, kids weren't at school and they weren't at daycare, and then afterwards, there was a surge of exposure. She did say that it had seemed to have leveled off. That didn't make it into the piece. A lot of stuff didn't make it into the piece, but what was relevant did and what was relevant for coughs did.

I just want to speak to what Joyce had said for a moment. Again, not a doctor, but one thing that I was sent on this quest as a detective. What's very clear is that we all have to be our own detectives when it comes to our health. It sounded like Joyce was being an excellent cough detective, and that those were all really important data points, particularly the one about it not happening when lying down.

I hope that she's able to find relief soon and a doctor who can help her decipher that information, but just the framework that the doctors helped me lay out for the piece, I think it's very helpful just thinking about what your condition is and what happens under what circumstances so that you can communicate effectively to your healthcare professional. That, to me, felt like the most important takeaway from the piece.

Alison Stewart: Dr. Horowitz, I don't know if this is apocryphal or not, but there's this idea that we haven't been exposed to each other, we haven't been in big settings, and our bodies are more vulnerable now. Is there any truth to that, or is that just sort of one of those things people say to each other?

Dr. Mark Horowitz: No, I think there's truth to that. I think it's particularly true when we think about kids who were out of school for a period of time during the early part of the pandemic. They were deprived of the rich childhood experience of getting sick multiple times. There truly is less immunity to certain viruses among children. It's probably the same with adults who were working from home or not working or isolating for a period of time.

Alison Stewart: Allison from Greenwich, Connecticut, has a very interesting question. Hi, Allison. You are on the air.

Allison: I thank you. I was wondering, what is the difference between a productive cough and an unproductive cough, which I guess should be obvious, and when should you take medicine to stop yourself from coughing?

Alison Stewart: Doctor, I'll let you start, and then we'll go to Rachel's findings.

Dr. Mark Horowitz: What a terrific and challenging question. When we say productive versus non-productive, we're talking about whether or not an individual is bringing up sputum mucus when they cough. That's often a clue to the origin of the cough. Cough that produces mucus tends to come from lower down in the airway, the bronchial tubes or the lungs itself. Very often, the color of the sputum gives us a clue as to whether it's viral or bacterial or something else completely.

If you have a productive cough and it doesn't go away after a few days, you need to call your healthcare provider and discuss it with him or her. That's extremely important. As for treating cough, again, Rachel made some excellent points in her article about this, and that is that we shouldn't treat cough unless we know the cause of that cough. Not every cough needs to be treated because it's our body's protective mechanism for getting rid of pathogens in our lungs and in our airways, but sometimes a cough can be disruptive. It can keep you up at night. It can be socially embarrassing, it can be painful, and those are circumstances where suppressing a cough might be a consideration.

Alison Stewart: You wrote, Rachel, "It's a crapshoot as to what cough medicine actually works." Tell us what you found.

Rachel Sklar: First of all, I will say that all the doctors I spoke to regarding children said that it's not like over-the-counter cough medications are not recommended in pediatric circumstances. I even pressed Dr. Rastogi and was like, "A 16-year-old kid can't have a Halls?" She did laugh, but she also said, "These are the guidelines. Go accordingly."

This didn't make it into the piece, but I subsequently learned a lot of people who are Drake fans knew it a lot longer than me, but codeine cough syrup mixed with soda can be something that people enjoy taking for a high. Don't do that. Don't do that. Don't do that. Again, not a doctor, but I feel confident that I--

Alison Stewart: One more time, don't do that.

Rachel Sklar: Obviously, there are products that do work. Again, your healthcare provider can advise you accordingly. For example, in Robitussin, there is the active ingredient actually goes to the coughing center in your brain and inhibits that. There was a finding recently on an FDA advisory panel that phenylephrine. You Google it.

Dr. Mark Horowitz: Phenylephrine.

Rachel Sklar: Thank you very much. I'm a much more of a writer than a talker, particularly on medical matters. Regardless, that this is a decongestion and that was found to not be basically efficacious in the way that medications were suggesting it was. These cough and cold medications, they're all bundled. Everybody swears by what works for them for what they want it to work for. I want to return to what Dr. Horowitz says, which is, "It's very important to know what the cause is before you treat it."

Alison Stewart: Let's talk to Martha from Westchester. Hi, Martha. Thanks for calling in.

Martha: Yes, thanks for taking my call. Yes, I use my grandmother's old recipe. I finally started doing it because everything else failed. It's a simple steaming little bit of boiling water in a bowl and in the sink and a towel over your head and just steam for a minute or so. It just helps so much. It's symptom, but, boy, it helps a lot. I've tried everything.

Alison Stewart: Martha, thank you for calling in. Doctor, of all of those stories we hear from our moms and our grandmoms and our grandpas, which of the family remedies really can at least help you feel better?

Dr. Mark Horowitz: The answer is, whatever works for you is right. I can't choose one among them. The steam treatment is definitely what we would call in New York, bubbameisterism, but it's accurate bubbameisterism. It's based on sound scientific principles. The steam helps break up the mucus and loosen it, so you can get rid of it.

Alison Stewart: Doctor, are there some coughs you should just not treat, you just let it run its course.

Dr. Mark Horowitz: As I said before, if a cough is disruptive, painful, socially embarrassing, then it's worth considering treatment once you know the cause. However, if someone has COVID or RSV or the flu, treating the cough, I think, to some extent, prolongs the illness. It keeps the organisms in your lungs and interferes with your body's natural mechanism of getting rid of infection.

The overwhelming majority of acute infections don't need cough medicine. If I may launch into just a 32nd PSA at this point for your listeners, COVID is still with us. As much as we would like to forget about it, put it behind us, it is the predominant cause of acute respiratory illness in the New York area right now. I've had approximately 40 patients in my practice since Christmas test positive, and many of them call me with the same complaints, minor cold-like or flu-like symptoms. Because their experience with COVID previously is a more severe illness they don't think about testing themselves.

Again, this is a very, very smart virus. In a Darwinian sense, it realizes it can't survive if it continues to be lethal. It's mutated into, thankfully, a much milder form. I encourage listeners to think about COVID if they have trivial respiratory symptoms and test and test again. Many of us have a very high level of immunity based on several doses of the vaccine and/or exposure to COVID and previous infections. The minute our body comes in contact with the virus, we start fighting it off and the symptoms can be very mild.

Rachel used a community model before, and I use the same model when we test ourselves, when we take the vaccine and boosters, we're not only taking care of ourselves, but we're taking care of our community. If you have trivial symptoms and don't test and you have COVID, and you go to work, or you go to a store, you go to a gathering and someone there is elderly or otherwise vulnerable, you can do them some harm.

I really want to encourage people to remember that COVID, albeit very mild these days, thankfully, not in all cases, but in most cases, should be thought of when you have trivial respiratory symptoms. If you test positive either on the first test or the second test, to call your healthcare provider because I'm a big advocate of antiviral treatment. It is a game changer. It has really relieved symptoms quickly, resulted in negative tests more quickly, and allowed people to get back to work and life much more quickly.

Alison Stewart: Dr. Mark Horowitz and Rachel Sklar. Rachel, thank you for sharing your reporting. Dr. Horowitz, thank you for sharing your expertise. We really appreciate your time today.

Rachel Sklar: Thank you so much.

Dr. Mark Horowitz: Thank you, Alison, and thank your listeners.

[MUSIC - The Stape Singers:Respect Yourself]

Alison Stewart: Staple Singers have it right. Hey, we're talking all things post-apocalyptic sci-fi with our friend, Clyde Folley, from the Criterion Channel. We're breaking down his new film series and taking your calls. That's next.

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