Cough-counting

Board any bus or train. You will hear people cough and sneeze incessantly and unmasked even sitting under a warning sign at the height of a pandemic. The biggest issue that has been overlooked has been oral transmission. A necessary solution is ‘cough-monitoring’. Early school films had topics on how to avoid spreading germs in classrooms. Children were advised to stay home if sick and cover their mouths if they couldn’t avoid a sneeze or cough. These are the same warnings posted in buildings and on buses half a century later. Yet the warnings go unheeded. Masks, contact tracing, hand-washing, and disinfecting solutions are undermined if people continue to cough and sneeze in public. Monitoring these events and drawing media attention to the counts can begin to make people re-aware of this basic conservative etiquette.

Coughing and sneezing are central to the entire pandemic. Normal expiration requires some proximity whereas these cover a much longer range.Where infection rates are high, a persistent cougher is a lethal threat. All the preventive check-ins, distancing, contact tracing, hand-washing and aerosol spraying by space-suited health workers come to nothing if an infected population walks around blithely coughing and sneezing in public places – almost always completely oblivious to what they are doing. The biggest challenge is that they are usually argumentative if called out. It would be risky to launch a direct cough-shaming campaign as based on the mask history it would be certain to attract cynical often violent resistance. Some people would then deliberately cough and spit to make a point. This has already been observed among adults even without such a campaign, let alone children. So the psychological solution is termed 'extinction', a non-rewarding indirect feedback to the cougher, rather than direct aversive reinforcement via shaming.

Monitoring and neutral feedback are a subtle but effective way of
conditioning behaviour. Contemporary mobile phones, data loggers, and
freeware audio editing apps are sufficient to start a monitoring
campaign. The research is easily conducted by merely boarding a bus with
a monitor. Additional campaign resources, such as 'teacher kits' can develop at no cost on social media and through existing teacher-sharing sites. Merely subtly making it 'uncool' to publicly cough or sneeze can have an impact. Extremely immature children and even adults might rebel at first but in the long run the message would sink in that coughs and sneezes are rude and somewhat predictable. If one is going to cough there may be time and opportunity to do it elsewhere, rather than to nearby persons. Mere awareness could have an impact, given the current low level. Social media discussion could quickly build momentum with no financial outlay merely because of the millions of people who daily now observe these cough events without it registering.

The main beneficiaries of any preventive campaign are those vulnerable to the illness. Some countries have low levels of refrigeration and car ownership, forcing them to mingle daily in close proximity in public places. They can’t avoid going to crowded markets. Even with masks and sanitizers, coughs and sneezes can affect all those nearby. Those targeted for monitoring are the spreaders who are oblivious to their coughs and sneezes. Mere awareness might prevent some spread.

Coughs and sneezes are a main means of virus transmission.Cough-counting is a low-cost universal information and behavioralcampaign strategy. It is scalable to impact on subsequent pandemics by changing behavioral norms and accepted etiquette.Many people seem to think they are exempt from the etiquette as they have some other cause for the cough such as allergy or smoking. This bad habit becomes lethal to others if they contract the virus. Cough-counting could become an index of community vulnerability and awareness. Simple data-logging with electronic devices can keep count as these are distinctive sounds. The mere presence of surveillance can affect behavior if people feel they may be monitored.It helps "Prevent the spread of misinformation and inspire individuals to protect themselves and their communities, including through information campaigns and behavioral nudges" Some seem to think it is acceptable to cough in public. Sneezes are somewhat less predictable but can at least be covered. The perpetrators are least likely to wear masks. Such responses are oblivious to their potential as spreaders and also as role models for their families and colleagues. These patterns of etiquette will be helpful in the next pandemic.

MCA has been active since 1976 with these educational campaigns. We routinely submit to government inquiries. The cough-counting has been done informally thus far. We haven't made results public because of potential backlash such as has dogged the mask-wearing campaigns.

Without promotion such as a link with Solve we will never carry it further. It is not a question of finance but rather of time. We are volunteers. We run on a minimal budget to cover our registration cost only. That frees us from the dependence on corporate funding all too common in our sector.

We could run a no-cost campaign tomorrow but without promotion and follow-up it could backfire by breeding cynical immature cough-daring behavior. It needs a media and social media gradual build.  This cough-counting approach runs far lower risks than our usual campaigns as there is no well-funded central opposition to it and no one defamed.

It combines behavioral and electronic concepts. We have not seen any such campaign elsewhere focusing on the coughing as an issue in its own right. Most public notices pay lip service with warnings 'do not board if unwell' and 'cover with your arm' if you must cough, but they are portrayed in a secondary light compared to distancing, hand-sanitizing, and masks. Coughs are a key as they override these other precautions. If an infected serial cougher boards a bus or enters a shop they can leave a trail of risk that lingers even after they leave. This can undo the precautions of check-in procedures and hand-sanitizing. Our state of South Australia has thus far avoided the high infections overseas through onerous early lockdown of state borders. However our research shows us that our population is as reckless as anywhere else in personal habits. Plenty wear masks but those who cough and sneeze are never seen to wear masks and rarely to even cover themselves. They become abusive if challenged.These bad habits could haunt us if we encountered an even more contagious and lethal strain.

We mainly write submissions to government to inform policy rather than service provision so have no such numbers.

Social media could exponentially grow a campaign.

The main impact for MCA has been some early legislative changes. It is an uphill battle against well-funded interest groups. A cough-monitoring campaign would meet no entrenched resistence as unlike the mental health sector there is no financial incentive or organization pushing against it.

Social media platforms are self-counting and usually open to the public. So if the campaign spawns offshoots around the globe these can usually be monitored by social media joins and likes. Rigorous cough measurement would be more difficult and the aim would be to call for health departments to become involved if the idea takes off.

3 volunteers, part time

We have a number of social media outlets via our non-profit and university links. I have accounts with teacher-resource sites. We could get media attention. We need the 'hook' for a news angle and to minimize backlash from a too-confrontational campaign.

Make it a decentralized idea-based movement so that no formal roles or paid positions are needed. All demographics are involved. No one is exempt. Social media platforms tend to attract like-minded groups so we would build out from some local groups starting with things like community group and school projects. These can then be linked and very simple teacher kits created.

I was contacted by email from Solve based on interest from an earlier proposal. COVID and looming further pandemics are a matter of
great public importance. We had been toying with a cough-monitoring
campaign and Solve provides an opportunity to implement it. We otherwise would be unlikely to undertake it.

Our existing resources could set up basic videos, and information pages and blogs for interactions but if it grew we would be in no position as unpaid volunteers with other duties to monitor and feed these. Rather we would promote a social media group and encourage school and community projects.

We could approach news media ourselves but an international link such as with Solve works wonders with Australian media and the rest of the world. So it would self-promote. Any SEO expert will agree that inbound .gov and .edu links are among the highest search endorsements.

As a medical school academic I usually keep arm's length rather than publishing as an academic because our usual 'critical/ethical' work (sometimes involving $multi-billion US lawsuits) is adversarial. This cough campaign is neutral and I should be able to get some university backing.

If Solve or any MIT showed interest in writing that I could take to my medical school supervisors I could get the resources of the university behind me. It is a neutral topic without funded or organised adversaries and should speak for itself as cough warnings are an age-old public health, school and household strategy.

It needs no research 'breakthrough' to get a news hook.The mere public mention of an affiliation, prize or mere international 'interest' can generate a small news story. This then amplifies. Youth groups and schools are good at promoting worthy ‘causes’. I was involved with a $multi-million online school eco-murder-mystery game and presented papers on how to do such gamification 'on a shoe-string budget'.

Aged care and vulnerable groups could add their voice. The media then follows the ‘human interest’ angles from these.