Applied Science, Faculty of
Community and Regional Planning (SCARP), School of
DSpace
UBCV
Crandall, Robert A.
Master of Science in Planning - MSc (Plan)
University of British Columbia
Increasing numbers of deaths, injuries, and disease outbreaks associated with the use of spas and hot tubs have created increasing concern about the effectiveness of existing spa management policies and procedures. The problem of devising appropriate public spa policies is complicated by the high degree of uncertainty related to spa management. In examining this problem, the thesis evaluates policy for public spas and hot tubs and proposes a set of policies for the Province of British Columbia which would provide reasonable public health and safety protection. The potential hazards associated with spa use are examined in order to identify the risks and uncertainties which pose difficulties for spa management. The difficulties illuminate several basic issues which policy evaluation must address. A framework is developed for evaluating spa management policies based upon public policy and public health literature. Using criteria established by the evaluative framework, spa policies and practices in selected jurisdictions of the United States and Canada are evaluated. Literature and interviews obtained from government agencies, the industry, spa operators and others are used as a basis of information for the evaluation. A set of spa policies for British Columbia is then proposed which is designed to meet the evaluative criteria and overcome existing deficiencies evidenced by the U.S.-Canadian experience. The results of the study indicate that potential hazards associated with public spas and hot tubs justify government regulation of spa management in a manner different from regulation of swimming pool and other public bathing activities. Spa policies in British Columbia which provide reasonable public health protection should be developed to accomplish the following; (1) precisely define spa hazards, (2) provide an acceptable level of "safe" conditions for spa users and the public, (3) actively involve spa users and operators in policy development, (4) provide policy implementation measures which effectively deal with the variable conditions of spas, and (5) organize a social learning process to reduce uncertainties and improve spa management practices. Specific recommendations for attaining these objectives are suggested.
AN EVALUATION OF POLICY FOR PUBLIC SPAS AND HOT TUBS IN BRITISH COLUMBIA by Robert A. C r a n d a l l B.A. S t a n f o r d U n i v e r s i t y 1972 A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE i n THE FACULTY OF GRADUATE STUDIES School of Community & Regional Planning We accept t h i s t h e s i s as conforming to the r e q u i r e d standards THE UNIVERSITY OF BRITISH COLUMBIA A p r i l , 1983 © Robert A. C r a n d a l l , 1983 In p r e s e n t i n g t h i s t h e s i s i n p a r t i a l f u l f i l m e n t of the requirements f o r an advanced degree at the U n i v e r s i t y of B r i t i s h Columbia, I agree t h a t the L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e f o r r e f e r e n c e and study. I f u r t h e r agree t h a t p e r m i s s i o n f o r e x t e n s i v e copying of t h i s t h e s i s f o r s c h o l a r l y purposes may be granted by the head o f my department or by h i s or her r e p r e s e n t a t i v e s . I t i s understood t h a t copying or p u b l i c a t i o n of t h i s t h e s i s f o r f i n a n c i a l g a i n s h a l l not be allowed without my w r i t t e n p e r m i s s i o n . Department of COMKu'fxJ Try j P^o/UAC ft^WHUfe-The U n i v e r s i t y of B r i t i s h Columbia 1956 Main Mall Vancouver, Canada V6T 1Y3 Date (Lfu\0 .St. DE-6 (3/81) i i ABSTRACT I n c r e a s i n g numbers of deaths, i n j u r i e s , and d i s e a s e outbreaks a s s o c i a t e d with the use of spas and hot tubs have c r e a t e d i n c r e a s i n g concern about the e f f e c t i v e n e s s of e x i s t i n g spa management p o l i c i e s and procedures. The problem of d e v i s i n g a p p r o p r i a t e p u b l i c spa p o l i c i e s i s complicated by the high degree of u n c e r t a i n t y r e l a t e d to spa management. In examining t h i s problem, the t h e s i s e v a l u a t e s p o l i c y f o r p u b l i c spas and hot tubs and proposes a set of p o l i c i e s f o r the Province of B r i t i s h Columbia which would pr o v i d e reasonable p u b l i c h e a l t h and s a f e t y p r o t e c t i o n . The p o t e n t i a l hazards a s s o c i a t e d with spa use are examined i n order to i d e n t i f y the r i s k s and u n c e r t a i n t i e s which pose d i f f i c u l t i e s f o r spa management. The d i f f i c u l t i e s i l l u m i n a t e s e v e r a l b a s i c i s s u e s which p o l i c y e v a l u a t i o n must address. A framework i s developed f o r e v a l u a t i n g spa management p o l i c i e s based upon p u b l i c p o l i c y and p u b l i c h e a l t h l i t e r a t u r e . Using c r i t e r i a e s t a b l i s h e d by the e v a l u a t i v e framework, spa p o l i c i e s and p r a c t i c e s i n s e l e c t e d j u r i s d i c t i o n s of the Un i t e d S t a t e s and Canada are e v a l u a t e d . L i t e r a t u r e and i n t e r v i e w s obtained from government a g e n c i e s , the i n d u s t r y , spa o p e r a t o r s and ot h e r s are used as a b a s i s of i n f o r m a t i o n f o r the e v a l u a t i o n . A set of spa p o l i c i e s f o r B r i t i s h Columbia i s then proposed which i s designed to meet the e v a l u a t i v e c r i t e r i a and overcome e x i s t i n g d e f i c i e n c i e s evidenced by the U.S.-Canadian experience. The r e s u l t s of the study i n d i c a t e that p o t e n t i a l hazards a s s o c i a t e d w i t h p u b l i c spas and hot tubs j u s t i f y government r e g u l a t i o n of spa management i n a manner d i f f e r e n t from r e g u l a t i o n of swimming p o o l and o t h e r p u b l i c b a t h i n g a c t i v i t i e s . Spa p o l i c i e s i n B r i t i s h Columbia which p r o v i d e r e a s o n a b l e p u b l i c h e a l t h p r o t e c t i o n s h o u l d be d e v e l o p e d t o a c c o m p l i s h the f o l l o w i n g ; (1) p r e c i s e l y d e f i n e spa h a z a r d s , (2) p r o v i d e an a c c e p t a b l e l e v e l of " s a f e " c o n d i t i o n s f o r spa u s e r s and t h e p u b l i c , (3) a c t i v e l y i n v o l v e spa u s e r s and o p e r a t o r s i n p o l i c y development, (4) p r o v i d e p o l i c y i m p l e m e n t a t i o n measures which e f f e c t i v e l y d e a l w i t h the v a r i a b l e c o n d i t i o n s of spas, and (5) o r g a n i z e a s o c i a l l e a r n i n g p r o c e s s t o reduce u n c e r t a i n t i e s and improve spa management p r a c t i c e s . S p e c i f i c recommendations f o r a t t a i n i n g t h e s e o b j e c t i v e s a r e su g g e s t e d . TABLE OF CONTENTS A b s t r a c t i i L i s t Of F i g u r e s And Tables v i Acknowledgements . . v i i I. INTRODUCTION i x 11 . CHAPTER 1 The Development Of The Spa And Hot Tub Market And I t s I m p l i c a t i o n s For The Establishment Of P o l i c y 1 What Are Spas And Hot Tubs? 1 The Emergence Of Spas And Hot Tubs As A P u b l i c Concern . 2 The Development Of The Spa And Hot Tub Market And I t s Economic And S o c i a l Impacts 3 An E x p l a n a t i o n For The Rapid Growth Of The Spa And Hot Tub Market 8 I m p l i c a t i o n s Of The Spa And Hot Tub Market Development For The Establishment Of P o l i c y 11 Summary 12 I I I . CHAPTER 2 The C h a r a c t e r i s t i c s Of Ri s k s And U n c e r t a i n t i e s In Reg u l a t i o n Of P u b l i c Health Hazards A s s o c i a t e d With Spas And Hot Tubs 16 D e f i n i t i o n s Of "Risks" And " U n c e r t a i n t i e s " 16 Spas And Hot Tubs: P u b l i c Health Concerns 18 P o t e n t i a l Hazard Areas 22 Pathogenic Hazards 22 Managing Spa Water Q u a l i t y To C o n t r o l Pathogens .. 22 C o n t r o l l i n g S p e c i f i c Pathogens 30 Hyperthermia Hazards 37 V i s u a l Hazards From Poor Water C l a r i t y 40 Drowning Hazards R e l a t e d To The Spa A e r a t i o n Systems 41 I d e n t i f i c a t i o n Of S p e c i f i c Risks And U n c e r t a i n t i e s Within The P o t e n t i a l Hazard Areas 43 Major P o l i c y D i f f i c u l t i e s A r i s i n g From Spa Management U n c e r t a i n t i e s 50 F. Basic Issues Involved In The Re g u l a t i o n Of Spas 59 IV. CHAPTER 3 How Should P u b l i c Spa And Hot Tub P o l i c y Be Designed? .. 65 Governmental R e s p o n s i b i l i t y For P r o t e c t i n g Users Of Spa F a c i l i t i e s 65 Governmental R e s p o n s i b i l i t y For P r o t e c t i n g The P u b l i c From E x t e r n a l E f f e c t s Of Spa Operations 68 D e c i s i o n Processes For Determining Spa Regulat i o n And P r o v i s i o n Of Information To The P u b l i c 70 Development Of E f f e c t i v e Implementation Measures 72 Establishment Of A S o c i a l L e a r n i n g Process To Reduce U n c e r t a i n t y 75 C r i t e r i a For E v a l u a t i n g A l t e r n a t i v e Spa P o l i c i e s 78 V. CHAPTER 4 Experience In The U.S. and Canada 85 A. Background Of The U.S. Experience 85 Scope Of Study 85 A B r i e f D e s c r i p t i o n Of The U.S. Experience 88 V B. The U.S. S t r u c t u r e Of O r g a n i z a t i o n a l Involvement With P u b l i c Spas ". 93 C. The A c t o r s And T h e i r R e l a t i o n To The System 94 A n a l y s i s Of The U.S. Experience 96 Governmental Roles And R e s p o n s i b i l i t i e s 96 Decision-Making Processes For E s t a b l i s h i n g C o n d i t i o n s Of "Safe" Use 103 Implementation P r a c t i c e s 107 P r o v i s i o n For S o c i a l L e a r n i n g 112 D e f i c i e n c i e s In U.S. Spa P o l i c i e s And P r a c t i c e s : Lessons For Design Of Model P o l i c y 114 The Canadian Experience With Spas 115 Scope Of Study 115 D e s c r i p t i o n Of The B.C. P u b l i c H e a l t h System And I t s R e l a t i o n To P u b l i c Spas 116 The B r i t i s h Columbia E x p e r i e n c e With Spas 118 The Case For Spa P o l i c y Change In B r i t i s h Columbia ..120 VI CHAPTER 5 Recommendations For A Spa P o l i c y Framework For B r i t i s h Columbia 124 Development Of Approved Standards And Procedures For P u b l i c Spas And Hot Tubs 125 D e t e r m i n a t i o n Of P r o v i n c i a l P u b l i c Spa/Hot Tub Standards And Management P o l i c i e s 127 Measures For Implementing Spa Standards And Management P o l i c i e s In B.C 1 29 P o l i c i e s To Reduce U n c e r t a i n t i e s And Improve Spa Management And Enforcement Procedures 134 E. Notes On P r o v i s i o n s For Funding 137 Summary And Expected R e s u l t s : How The Model P o l i c y Can C o r r e c t Present D e f i c i e n c i e s 139 APPENDIX A Pathogenic Hazards And P u b l i c Spa/Hot Tub F a c i l t i e s ....146 APPENDIX B Cu r r e n t Knowledge & G u i d e l i n e s For Spa Management 167 APPENDIX C B e h a v i o u r a l C o n s i d e r a t i o n s Of Spa A c t o r s 174 APPENDIX D A D e t a i l e d D e s c r i p t i o n Of The U.S. E x p e r i e n c e 190 APPENDIX E The B.C. H e a l t h Act And I t s P r o v i s i o n s For Spas 224 APPENDIX F A Sample Spa Operator T r a i n i n g Program 235 APPENDIX G A Sample 'Plan Of Op e r a t i o n ' 241 v i LIST OF FIGURES AND TABLES FIGURE PAGE 1 Pool S a l e s vs Spa/Hot Tub S a l e s 1976-1980 7 TABLE PAGE I CPSC Cases I n v o l v i n g Spa F a t a l i t i e s January 1, 1979 - June 14, 1981 19 II The U.S. S t r u c t u r e of O r g a n i z a t i o n a l Involvement With P u b l i c Spas and Hot Tubs 93 III The Canadian S t r u c t u r e of O r g a n i z a t i o n a l Involvement With P u b l i c Spas and Hot Tubs ....... 115 IV Current Knowledge and G u i d e l i n e s f o r Spa Management 170 v i i Acknowledgements I wish to express my s i n c e r e s t g r a t i t u d e t o the many people whose encouragement and a s s i s t a n c e c o n t r i b u t e d to t h i s t h e s i s . I a p p r e c i a t e the i n f o r m a t i o n and i n t e r e s t which was pro v i d e d by numerous i n d i v i d u a l s from p u b l i c h e a l t h and s a f e t y agencies, the pool and spa i n d u s t r y , and personnel a s s o c i a t e d with spa f a c i l i t i e s . I am indebted to Dr. C.J.G. Mackenzie ( P r o f e s s o r , Dept. of H e a l t h Care and Epidemiology, U.B.C.) f o r h i s h e l p i n f u r t h e r i n g my understanding about pathogenic hazards and p u b l i c h e a l t h p r o t e c t i o n . P r o f e s s o r Anthony Dorcey ( t h e s i s s u p e r v i s o r ) deserves my s p e c i a l thanks f o r h i s guidance, comments, and sugg e s t i o n s . His i n s i g h t s and a t t e n t i o n to d e t a i l c o n s i d e r a b l y strengthened the f i n a l product. Of a l l those who c o n t r i b u t e d , I owe the l a r g e s t debt of g r a t i t u d e to P r o f e s s o r I r v i n g Fox whose wisdom, moral support, and pa t i e n c e with me was ins t r u m e n t a l to the development of t h i s t h e s i s . Through my a s s o c i a t i o n with P r o f e s s o r Fox i n h i s r o l e as both an academic and a t h e s i s a d v i s o r , I was extremely f o r t u n a t e having the op p o r t u n i t y to l e a r n , f o r myself, why many other people c o n s i d e r him an e x c e l l e n t a d v i s o r and a great man. I a l s o wish to acknowledge the hard work and d e d i c a t e d e f f o r t s of my t y p i s t s , Sharon and Margaret. F i n a l l y , I thank my fa m i l y and f r i e n d s whose love and support was a source of s t r e n g t h . To a very s p e c i a l f r i e n d , I v i i i express a warm and h e a r t f e l t thank you. Th i s t h e s i s i s d e d i c a t e d i n memory of Dr. James T. Watkins IV, my former mentor at S t a n f o r d U n i v e r s i t y , who passed away i n October 1982. His support, encouragement, and s p i r i t remain with me and I g r a t e f u l l y acknowledge h i s c o n t r i b u t i o n . ix INTRODUCTION The purpose of t h i s t h e s i s i s twofold: ( 1 ) to develop a • framework f o r e v a l u a t i n g p o l i c i e s governing the o p e r a t i o n and use of p u b l i c spas and hot tubs; ( 2 ) to apply t h i s framework to recommend a set of p o l i c i e s f o r B r i t i s h Columbia which w i l l assure reasonable p r o t e c t i o n of p u b l i c h e a l t h and s a f e t y i n p u b l i c spa and hot tub use. To achieve these o b j e c t i v e s , t h e problems and u n c e r t a i n t i e s faced i n spa management w i l l be i d e n t i f i e d and these w i l l be r e l a t e d to a number of normative c o n s i d e r a t i o n s to e s t a b l i s h a framework for e v a l u a t i n g p u b l i c p o l i c y . To p r o v i d e a p r a c t i c a l i n s i g h t i n t o the s t a t u s and l i m i t a t i o n s of c u r r e n t p o l i c i e s , e x i s t i n g p o l i c i e s i n s e l e c t e d p a r t s of the U n i t e d S t a t e s and Canada w i l l be d e s c r i b e d and e v a l u a t e d . Using the e v a l u a t i v e framework and a n a l y s i s of e x i s t i n g p o l i c i e s as a guide, a set of p o l i c i e s f o r r e g u l a t i n g p u b l i c spa and hot tubs in B r i t i s h Columbia w i l l be recommended. The reason f o r t h i s study i s the i n c r e a s i n g concern about the occurrence of deaths, i n j u r i e s , and d i s e a s e outbreaks a s s o c i a t e d with spa* use and the p o s s i b i l i t y t h a t present p o l i c y i n B r i t i s h Columbia may be inadequate for p r o t e c t i n g p u b l i c h e a l t h and s a f e t y . The p r o t e c t i o n of p u b l i c h e a l t h and s a f e t y *Note: Spas and hot tubs are v i r t u a l l y i d e n t i c a l i n f u n c t i o n and purpose. The only s i g n i f i c a n t d i f f e r e n c e i s t h a t "hot tubs" r e f e r to u n i t s where the m a t e r i a l c o n s t r u c t i o n of the s h e l l i s wooden. T h i s d i f f e r e n c e has some p o s s i b l e r a m i f i c a t i o n s f o r spa management. The reader should be aware of the d i s t i n c t i o n , but f o r the sake of b r e v i t y , the word "spas" w i l l f r e q u e n t l y be used to mean both spas and hot tubs. X i n the r e l a t e d a c t i v i t y of swimming in p u b l i c f a c i l i t i e s has t r a d i t i o n a l l y been a r e g u l a t o r y concern of government. F u r t h e r , i t has a l s o been suggested, by some e x p e r t s , that p u b l i c spas pose a g r e a t e r h e a l t h and s a f e t y r i s k than p u b l i c swimming p o o l s . In view of these c o n s i d e r a t i o n s , an examination of the p o t e n t i a l hazards a s s o c i a t e d with p u b l i c spas, and the c o s t s and b e n e f i t s of a l t e r n a t i v e p o l i c i e s to p r o t e c t p u b l i c h e a l t h and s a f e t y would appear to be needed. Current p u b l i c spa p o l i c y i n the U.S. and Canada i s i n c o n s i s t e n t and i n some areas, confused. Standards, r e g u l a t i o n s , and g u i d e l i n e s , where they do e x i s t , vary g r e a t l y w i t h i n each c o u n t r y . In some j u r i s d i c t i o n s , p o l i c y i s non-e x i s t e n t and i n other j u r i s d i c t i o n s , the e x i s t i n g p o l i c i e s are q u e s t i o n a b l e when con s i d e r e d i n l i g h t of spa management problems and u n c e r t a i n t i e s . In view of the evident c o n f u s i o n and l i m i t a t i o n s of e x i s t i n g p o l i c i e s , t h i s t h e s i s endeavors to determine how e x i s t i n g p o l i c i e s should be designed. The t h e s i s i s organized as f o l l o w s : 1. The f i r s t chapter d e s c r i b e s the h i s t o r i c a l development of p u b l i c spas i n order to p r o v i d e the reader with a background on spas and the growing importance of the spa i n d u s t r y . 2. The second chapter w i l l i d e n t i f y the nature of the p u b l i c h e a l t h r i s k s and u n c e r t a i n t i e s a s s o c i a t e d with spa management i n order to determine the b a s i c i s s u e s i n v o l v e d i n the r e g u l a t i o n of spas. 3. By drawing upon the l i t e r a t u r e d e a l i n g with the design of x i p u b l i c p o l i c i e s and the p r o t e c t i o n of p u b l i c h e a l t h , the t h i r d chapter develops a framework f o r e v a l u a t i n g p u b l i c p o l i c i e s governing spa management. 4. The f o u r t h chapter d e s c r i b e s and e v a l u a t e s e x i s t i n g spa management p o l i c i e s i n s e l e c t e d p a r t s of the Un i t e d S t a t e s and Canada, based upon the framework developed i n chapter t h r e e . 5. The f i n a l chapter u t i l i z e s the e v a l u a t i v e framework developed i n chapter three and draws upon the U.S. and Canadian experience d e s c r i b e d i n chapter four to s p e c i f y a proposed set of spa management p o l i c i e s f o r B r i t i s h Columbia which w i l l assure a reasonable p r o t e c t i o n of p u b l i c h e a l t h and s a f e t y . 1 CHAPTER 1 The Development of the Spa and Hot Tub Market and I t s I m p l i c a t i o n s f o r the Establishment of P o l i c y What are Spas and Hot Tubs? Spas and hot tubs conjure up many d i f f e r e n t images. I n d i v i d u a l p e r c e p t i o n s range from ideas of a r t h r i t i c therapy to sexual s t i m u l a t i o n . Some people c a l l them " J a c u z z i s " (a brand name misnomer which has captured s u b s t a n t i a l g e n e r i c s t a t u s ) ; some c a l l them " w h i r l p o o l s " ( p r i m a r i l y d e r i v e d from the s w i r l i n g a c t i o n of the water); others r e f e r to them as " c e s s p o o l s " (a term r e f l e c t i n g negative b i a s e s toward spas as a r e s u l t of q u e s t i o n i n g t h e i r c l e a n l i n e s s and water q u a l i t y ) ; and some people tag them "baby p o o l s " (a term i l l u s t r a t i n g a s u b t l e , but s i g n i f i c a n t f a c t o r f o r much misuse and misunderstanding of spas and hot t u b s ) . In any case, i t is. true that there are many v a r i e t i e s , s i z e s , shapes, and uses f o r spas and hot tubs, p r o v i d i n g a b a s i s f o r t h e i r d i v e r s e d e s c r i p t i o n s and t h e i r p e r c e i v e d a t t r i b u t e s . An e x c e l l e n t formal and g e n e r a l d e f i n i t i o n of spas and hot tubs i s p r o v i d e d i n the U.S. H e a l t h and Human S e r v i c e s p u b l i c a t i o n , "Suggested H e a l t h and Sa f e t y G u i d e l i n e s f o r P u b l i c Spas and Hot Tubs". 1 Spas and hot tubs are pools designed f o r r e c r e a t i o n a l and t h e r a p e u t i c use and f o r p h y s i o l o g i c a l and p s y c h o l o g i c a l r e l a x a t i o n . These pools are not d r a i n e d , cleaned and 2 r e f i l l e d a f t e r each use and may i n c l u d e , but are not l i m i t e d to these types: h y d r o j e t c i r c u l a t i o n , hot water, c o l d water, mineral baths, a i r i n d u c t i o n systems or some combination of these. Spas and hot tubs are shallow i n depth and not meant f o r swimming or d i v i n g . However, these f a c i l i t i e s , l i k e swimming p o o l s , are c l o s e d c y c l e water systems and may be designed with complete water c i r c u l a t i o n , f i l t r a t i o n , h e a t i n g and i n some cases d i s i n f e c t a n t and overflow systems i n t e g r a t e d with the water c i r c u l a t i o n system. In most cases, both spas and hot tubs equipped with heaters have automatic water temperature c o n t r o l s . A p u b l i c spa and hot tub, depending on i t s s i z e , l o c a t i o n and support equipment c a p a c i t y , can accommodate from one to many bath e r s . The Emergence of Spas and Hot Tubs as a P u b l i c Concern In the mid 1970's a phenomenon known as "hot tubbing" took h o l d on the West Coast, r e i n f o r c i n g the image of C a l i f o r n i a as "the land of nuts and f r u i t s bent on moral d e s t r u c t i o n through i t s h e d o n i s t i c and l i b e r t i n e p u r s u i t s " . While t h i s phenomenon was r e g r e t t a b l e to some and welcome to o t h e r s , spas and hot tubs d i d not s u f f e r the s h o r t - l i v e d f a t e of many fads, but i n s t e a d they became e s t a b l i s h e d as a v i a b l e and growing i n d u s t r y throughout North America. Although the f i r s t e a r l y model spas f o r consumer purchase date back to 1970 and a number of spas i n p u b l i c f a c i l i t i e s were i n o p e r a t i o n even e a r l i e r , no r e a l market e x i s t e d u n t i l 1 973, 2 and i t i s g e n e r a l l y r e c o g n i z e d that 1977 was the t u r n i n g p o i n t when spas began to have a major impact upon our s o c i a l m i l i e u . 3 The emergence of the spa and hot tub market has produced s i g n i f i c a n t economic and s o c i e t a l impacts d e s p i t e i t s r e l a t i v e l y s m a l l d i s t r i b u t i o n thus f a r . Along with these impacts, the 3 nature of the product and i t s use a l s o gave r i s e to p u b l i c h e a l t h and s a f e t y concerns i n a number of ways. The sub j e c t of spas and hot tubs i s not only an example of t r a d i t i o n a l problems faced i n d e a l i n g with p u b l i c h e a l t h hazards i n water p l a n n i n g and management, but i t i s a l s o i l l u s t r a t i v e of the growing importance of d e a l i n g with u n c e r t a i n t y i n p u b l i c p o l i c y development. Greater complexity and r a p i d change i n our s o c i e t y i n c r e a s i n g l y and a b r u p t l y exposes us to p u b l i c h e a l t h hazards o f t e n w e l l before our s c i e n t i f i c and i n s t i t u t i o n a l knowledge i s s u f f i c i e n t to manage the s i t u a t i o n p r o p e r l y . In choosing spas and hot tubs as an example, t h i s case study aims at developing a s t r a t e g y and design which i s r e l e v a n t to t h i s g e n e r a l problem. The Development of the Spa and Hot Tub Market and I t s Economic and S o c i a l Impacts De s p i t e our modern view of spas and hot tubs, we are reminded that t h e i r c u l t u r a l use and acceptance has long precedence. As one spa chemical manufacturer's maintenance manual a p t l y d e s c r i b e s the h i s t o r i c a l r o l e : C o n g r a t u l a t i o n s on becoming p a r t of h i s t o r y . As the owner of a spa/hot tub, you are now p a r t of a s o c i a l phenomenon that i s t r a c e a b l e back to a n c i e n t Egypt, t o the p r e h i s t o r i c c i t i e s of the Indus V a l l e y , to the e a r l y c i v i l i z a t i o n s around the Aegean Sea and the O r i e n t as w e l l . The a n c i e n t Greeks d e v i s e d l u x u r i o u s b a t h i n g p r o v i s i o n s with heated water, plunges, and showers. The Romans developed bathing as a p u b l i c d i v e r s i o n to a unique and e l a b o r a t e degree. The Japanese t r a d i t i o n a l l y use the bath as a d i s c i p l i n e d , s p i r i t u a l r i t u a l . The c l e a n s i n g comes f i r s t and the bath i s r e s t r a i n e d , simple, and s u i t a b l e f o r q u i e t contemplation. I t ' s up to you to use your spa/hot tub i n any way or i n many ways f o r your b e n e f i t and p l e a s u r e . You have a b e a u t i f u l a d d i t i o n to your way of 4 l i f e and we want to he l p you keep i t that way." Today, spas and hot tubs are found j u s t about everywhere, i n p r i v a t e r e s i d e n t i a l use and p u b l i c or commercial f a c i l i t i e s . Spas and hot tubs are here to stay, and to some people t h e i r presence means a myriad of new p u b l i c h e a l t h problems. According to Cranf o r d K. Gibbs, an engineer with the O n t a r i o M i n i s t r y of Hea l t h : "The w h i r l p o o l spa/hot tub problem i s with us now, and i s a f f e c t i n g the l i v e s of hundreds of people . . . a d v e r s e l y , i n my view." 5 North American t r a d i t i o n has g e n e r a l l y accepted v a r y i n g degrees of l i m i t a t i o n s upon government i n t e r v e n t i o n i n t o the p r i v a t e use of products and s e r v i c e s , depending upon t h e i r p e r c e i v e d e f f e c t s . The p e r c e i v e d e f f e c t s of pools and spas upon p u b l i c h e a l t h has been a major r a t i o n a l e f o r government involvement i n t h i s i n d u s t r y . 6 T h i s i s p a r t i c u l a r l y t r u e where such f a c i l i t i e s are p u b l i c l y used. T h i s study i s focused on the p u b l i c spa and hot tub se c t o r of the pool and spa i n d u s t r y . D e s p i t e the b r i e f h i s t o r y of spas and hot tubs, they have become a s u b s t a n t i a l p o r t i o n of the c u r r e n t l y estimated t o t a l pool/spa market of $3-$4 b i l l i o n a n n u a l l y . With approximately 100,000 spas/hot tubs s o l d per year at an average r e t a i l p r i c e ranging between $2,500 and $5,000 (modest f i g u r e s ) , new s a l e s of spas/hot tubs and necessary support equipment alone account f o r $250 to $500 m i l l i o n a n n u a l l y . On the b a s i s of experience with p o o l s , after-market items such as chemicals, replacement 5 equipment/parts, and s e r v i c e s would probably double t h i s f i g u r e . T h e r e f o r e , i t i s reasonable to p l a c e the estimated t o t a l spa market s a l e s somewhere i n the neighbourhood of $1 b i l l i o n a n n u a l l y . Thus, i t would c o n s t i t u t e approximately 1/4 to 1/3 of the t o t a l pool/spa market. The percentage of d o l l a r market share c o n t r i b u t e d by spas to the t o t a l i s remarkable c o n s i d e r i n g t h e i r r e l a t i v e newness and the f a c t that p r i c e s f o r spas/hot tubs are g e n e r a l l y 1/3 to 1/2 the p r i c e of an average p o o l . (Note: a l l f i g u r e s are merely approximations based upon market survey and they represent the U.S. market only.) An even more i n t e r e s t i n g comparison i s , as shown i n the graph below, the number of u n i t s of pools and spas/hot tubs s o l d per year. As one can see, i n only four y e a r s , s a l e s of spas and hot tubs have almost e q u a l l e d pool s a l e s a n n u a l l y . 6 Pool Sales vs. Spa/Hot Tub S a l e s 1976-1980 1 20 1 10 1 00 90 Number of 80 U n i t s S o l d 70 ( i n 60 thousands) 50 40 30 20 1 0 0 Pools 108 (No a c t u a l s t a t i s t i c was a v a i l a b l e f o r t h i s year) 1976 1977 1978 1979 1980 (Source of s t a t i s t i c s : "Swimming Pool Industry Market Reports", Hoffman P u b l i c a t i o n s ) 7 Although s a l e s dipped s l i g h t l y i n 1980, t h i s r e f l e c t s the downturn i n the g e n e r a l economy at t h a t time, not the t r u e growth t r e n d s . Future s a l e s p r e d i c t i o n s are o p t i m i s t i c f o r spas/hot tubs except under e x c e p t i o n a l l y poor ge n e r a l economic c o n d i t i o n s . The f i g u r e s s t i l l r e v e a l an astounding growth p a t t e r n , and t h i s has had a s u b s t a n t i a l i n f l u e n c e on i n d u s t r y and consumer behaviour. Over 2/3 of the swimming pool c o n t r a c t o r s now a l s o s e l l spas, averaging 13 s a l e s per year per c o n t r a c t o r . 7 Manufacturers of p o o l and spa products have t a r g e t e d the spa market f o r e x t e n s i v e a d v e r t i s i n g and promotion ef f o r t s . Consumers have c l e a r l y adopted spas as a r e c r e a t i o n a l a l t e r n a t i v e . A c t u a l s t a t i s t i c s of spa use are not a v a i l a b l e . However, on the b a s i s of i n f o r m a t i o n on p u b l i c swimming po o l use and a general idea of the s i z e of the spa market, i t i s reasonable to assume that spa users number in the m i l l i o n s and that a good d e a l of spa a c t i v i t y occurs i n p u b l i c f a c i l i t i e s . 8 U n l i k e p u b l i c p o o l s , u n f o r t u n a t e l y , there are no r e l i a b l e f i g u r e s on the number of p u b l i c spas i n o p e r a t i o n . Q ueries d i r e c t e d to p u b l i c o f f i c i a l s about the number of u n i t s i n e x i s t e n c e r e c e i v e vague and unsure r e p l i e s . T h i s i s due to the f a c t that permits f o r spa/hot tub i n s t a l l a t i o n s ( u n l i k e pools) are not g e n e r a l l y r e q u i r e d ; and where they are r e q u i r e d , p r o v i s i o n s are d i f f i c u l t to enforce ( f o r the obvious reason that spas can be i n s t a l l e d without easy d e t e c t i o n ) . However, to p r o v i d e an idea of the numbers of p u b l i c spas we may be d e a l i n g with, the I l l i n o i s Dept. of P u b l i c H e a l t h estimates that there 8 are a minimum of 2,200 u n i t s i n o p e r a t i o n i n I l l i n o i s . 9 In comparison, B r i t i s h Columbia (which does r e q u i r e permits) approved 75 permits f o r " t h e r a p e u t i c p o o l s " i n 1980 and 92 permits i n 1981. T h i s r e p r e s e n t s a l a r g e i n c r e a s e over the number i n 1977 of 23 permits. I t i s conceded that permitted " t h e r a p e u t i c p o o l s " are a c o n s e r v a t i v e estimate of a c t u a l p u b l i c spas and hot tubs i n o p e r a t i o n i n the p r o v i n c e . 1 0 Spa market i n f o r m a t i o n l i k e l y w i l l improve i n the f u t u r e , yet the s t a t i s t i c s so f a r are s u f f i c i e n t to demonstrate the magnitude of t h e i r sudden growth. E d i t o r i a l m a t e r i a l by v a r i o u s magazines and newspapers support t h i s o b s e r v a t i o n and i n d i c a t e some of the s o c i a l changes r e s u l t i n g from the gr o w t h . 1 1 1 2 S t o r i e s and a r t i c l e s abound with regard to the v a r i o u s uses and s o c i a l i n f l u e n c e spas and hot tubs have had. The v a r i e t y and number of s o c i a l behaviours i n v o l v e d with spas and hot tubs are f a r too e x t e n s i v e to document here. But i t i s evident that the o v e r a l l s o c i a l impacts are c o n s i s t e n t with and have c o n t r i b u t e d to the g e n e r a l l y i n c r e a s e d s o c i e t a l emphasis on val u e s r e l a t e d to h e a l t h , f i t n e s s , r e c r e a t i o n , and r e l a x a t i o n . An E x p l a n a t i o n f o r the Rapid Growth of the Spa and Hot Tub Market What are the reasons f o r t h i s r a p i d growth and sudden i n t e r e s t i n spas as a r e c r e a t i o n a l amenity? The tremendous 9 growth r a t e i s a t t r i b u t a b l e to a strong demand f o r spas and, ap p a r e n t l y , a s u f f i c i e n t supply. Industry/spa operator i n t e r e s t s on the supply s i d e and consumers on the demand side p e r c e i v e l a r g e b e n e f i t s through growth of the spa market. The i n d u s t r y ' s m o t i v a t i o n f o r promoting growth i s o b v i o u s l y economic, both i n i t s e f f o r t s to s t i m u l a t e consumer demand and to meet the response. S p e c i f i c a l l y , f o r the i n d u s t r y , the spa market means: 1. A vast new market o p p o r t u n i t y , as spas do not d i s t r a c t from pool s a l e s and sometimes may promote pool purchases. 2 . A p o t e n t i a l l y g r e a t e r market i n the long term, f o r the reason above and a l s o because of the tremendous a f t e r -market, p a r t i c u l a r l y i n chemica l s . 3 . The r e l a t i v e ease and speed of i n s t a l l a t i o n a l l o w s freedom from t r a d i t i o n a l p o o l c o n s t r u c t i o n drawbacks such as: weather c o n s t r a i n t s (causing d e l a y s , inconvenience, and seasonal slow-downs), high c a p i t a l investment, e x t e n s i v e l a b o r requirements and problems, and cash flow problems. In some i n s t a n c e s , r e t a i l e r s simply s e l l " d o - i t - y o u r s e l f " spa packages, f r e e i n g themselves even more from p o t e n t i a l p r o f i t - d r a i n i n g problems. The owners of p u b l i c spa o p e r a t i o n s s i m i l a r l y are motivated by the market's p r o f i t p o t e n t i a l . To some, i t o f f e r s a brand 10 new area of business endeavor, and to ot h e r s , spas may serve to enhance the o v e r a l l f a c i l i t i e s of a r e c r e a t i o n a l o p e r a t i o n . The growth of the market i s both a t t r a c t i v e to spa operat o r s and a l s o a c t s as a f o r c e f o r meeting competition i n the r e c r e a t i o n a l f i e l d . Operators, too, both s t i m u l a t e and meet consumer demand. What are the roo t s of the consumer demand f o r spas? We may c a t e g o r i z e spa "consumer demand as being based on two broad i n c e n t i v e s ; ( 1 ) s o c i a l - r e c r e a t i o n a l and ( 2 ) t h e r a p e u t i c . The s o c i a l - r e c r e a t i o n a l i n c e n t i v e i s q u i t e apparent, and i t re p r e s e n t s a c h o i c e by consumers amongst a l a r g e number of a l t e r n a t i v e a c t i v i t i e s . Such a demand i s sub j e c t to c o n s i d e r a b l e f l u c t u a t i o n s over time, and thus, i t may be d i f f i c u l t t o p r e d i c t usage as a r e s u l t of t h i s m o t i v a t i o n . The t h e r a p e u t i c i n c e n t i v e , however, i s the i n t e r e s t i n g one, p a r t i c u l a r l y to t h i s case study. I n c r e a s i n g l y , consumers and p h y s i c i a n s are l o o k i n g at spas f o r t h e r a p e u t i c reasons, not j u s t f o r a r t h r i t i s and s t i f f n e s s , but f o r many other h e a l t h s u f f e r e r s , i n c l u d i n g p a r a p l e g i c s and m u l t i p l e s c l e r o s i s p a t i e n t s . 1 3 One doctor d e s c r i b e s the b e n e f i t s t h i s way; "the heat i n c r e a s e s blood c i r c u l a t i o n while the water p r o v i d e s buoyancy, which makes movement e a s i e r . The hydrotherapy reduces s t i f f n e s s and s o r e n e s s . " 1 " The p o s i t i v e h e a l t h e f f e c t s of spas are s t i l l a matter of d i s p u t e , however. 1 5 On a s c a l e ranging from extreme (and perhaps unfounded) t h e r a p e u t i c c l a i m s to a r b i t r a r y d i s m i s s a l of any b e n e f i t s and to a l l p o i n t s i n between, medical and h e a l t h 11 experts have no s o l i d agreement on t h i s i s s u e . I f anything, the m a j o r i t y of experts seem to b e l i e v e that there are b e n e f i c i a l e f f e c t s ; but as to the exact b e n e f i t s , t h e i r purpose, t h e i r extent and under what c o n d i t i o n s may be anybody's guess. The U.S. I n t e r n a l Revenue S e r v i c e supports the case f o r spas as a t h e r a p e u t i c d e v i c e . Under S e c t i o n 213 of the I n t e r n a l Revenue Code, the e n t i r e c o s t s of i n s t a l l i n g and m a i n t a i n i n g spas are tax d e d u c t i b l e where the use i s e s s e n t i a l to the treatment of a d i s a b i l i t y . 1 6 F u r t h e r , i n i n t e r v i e w s with spa p e r s o n n e l , o p e r a t o r s and managers f e l t , based upon t h e i r experience and comments from t h e i r customers, that spas do d e f i n i t e l y have very b e n e f i c i a l h e a l t h r e s u l t s . 1 7 I t may be a while before spa t h e r a p e u t i c b e n e f i t s are f u l l y understood, but the p e r c e p t i o n s of t h e i r t h e r a p e u t i c worth have gained a f o o t h o l d . I f that f o o t h o l d becomes f i r m l y p l a n t e d , e i t h e r as a p e r c e p t u a l r e a l i t y or as a proven medical f a c t , we can s a f e l y p r e d i c t t h at spas w i l l become a very major h e a l t h c o n s i d e r a t i o n — no longer j u s t simply a " f a d " or a s u b s t a n t i a l p o r t i o n of the r e l a t i v e l y small pool/spa t o t a l market. I t p r e s e n t s a troublesome c o n f l i c t f o r policy-makers, i n v o l v i n g d e l i c a t e b a l a n c i n g between p r o t e c t i n g the p u b l i c from h e a l t h hazards i n one d i r e c t i o n , while simultaneously seeking to improve p u b l i c h e a l t h i n another d i r e c t i o n . I m p l i c a t i o n s of the Spa and Hot Tub Market Development fo r the Establishment of P o l i c y 12 An understanding of the h i s t o r i c a l development of the spa market may e x p l a i n government delay i n e s t a b l i s h i n g spa p o l i c i e s and c u r r e n t p o l i c y d i f f i c u l t i e s i n d e a l i n g with p o t e n t i a l hazards and u n c e r t a i n t i e s a s s o c i a t e d with spas. The f o l l o w i n g i m p l i c a t i o n s may be reasonably drawn: 1. The s t r o n g p e r c e p t i o n of spa b e n e f i t s by i n d u s t r y , spa o p e r a t o r s , and consumers may have d i v e r t e d a t t e n t i o n away from c o n s i d e r a t i o n of p o t e n t i a l hazards a s s o c i a t e d with spa use. 2 . The development of the spa market from the e x i s t i n g swimming pool i n d u s t r y l e d many people to assume that spas were s i m i l a r to swimming pools with respect to e n g i n e e r i n g c o n s t r u c t i o n , maintenance, and management standards. Since p u b l i c swimming pool p o l i c y has been a c c e p t a b l e and s t a b l e f o r many years, the need to examine p o t e n t i a l spa use hazards was not i n i t i a l l y p e r c e i v e d . Thus, the manner i n which the spa market developed obscured the need f o r p o l i c y c o n s i d e r a t i o n s of p o t e n t i a l hazards and u n c e r t a i n t i e s . Issues r e l a t i n g to the p u b l i c h e a l t h and w e l l -being of spa users and the general p u b l i c were not r a i s e d to any s i g n i f i c a n t e xtent. As a r e s u l t , present p o l i c y to p r o t e c t p u b l i c h e a l t h should begin with a thorough examination of the p o t e n t i a l hazards. Summary 13 We can draw s e v e r a l c o n c l u s i o n s from examining the emergence of the spa market: F i r s t , the growing demand and supply of p u b l i c spas has been f i r m l y e s t a b l i s h e d and may l i k e l y i n c r e a s e i n the f u t u r e . Yet, even i f not one more p u b l i c spa were c o n s t r u c t e d , there are enough a l r e a d y i n o p e r a t i o n to merit c o n s i d e r a t i o n . Hence, as p r e v i o u s l y s t a t e d , spas, as p u b l i c matters, are here to s t a y . Second, there i s much vested i n t e r e s t i n the p r e s e r v a t i o n and growth of the p u b l i c spa market and t h i s i s d i s t r i b u t e d among the i n d u s t r y , spa o p e r a t o r s , and spa u s e r s . Consequently, a good d e a l of p o t e n t i a l c o n f l i c t e x i s t s i f a c t i o n i s taken which i n c r e a s e s the p e r c e i v e d c o s t s imposed on any of these groups (but a l s o , on the other hand, proper and e f f e c t i v e p o l i c i e s and management are advantageous to a l l concerned). T h i r d , should a f a i l u r e to r e g u l a t e spas to p r o v i d e reasonable p u b l i c h e a l t h and s a f e t y p r o t e c t i o n r e s u l t i n major p u b l i c h e a l t h problems, st r o n g p u b l i c p r e s s u r e s f o r government a c t i o n c o u l d develop. Fourth, the sudden emergence of spas as a p u b l i c h e a l t h concern c r e a t e s new c h a l l e n g e s to s c i e n t i f i c and p o l i t i c a l communities to f i n d ways of p r o t e c t i n g p u b l i c h e a l t h and s a f e t y . Information on p u b l i c h e a l t h e f f e c t s of spas i s sketchy (and i n some areas, n o n - e x i s t e n t ) . But d e s p i t e the u n c e r t a i n t i e s that now e x i s t , government may be r e q u i r e d to a c t before a s o l i d s c i e n t i f i c b a s i s develops f o r managing spas i n a manner that w i l l assure reasonable p r o t e c t i o n of p u b l i c h e a l t h and s a f e t y . In order to a p p r e c i a t e the d i f f i c u l t i e s faced by those who 14 must d e a l with spas, we need to examine the nature of the r i s k s and u n c e r t a i n t i e s which may be c o n f r o n t e d by e f f o r t s to r e g u l a t e p u b l i c spas i n the p u b l i c i n t e r e s t . 1 5 Footnotes - Chapter 1 1U.S. Dept. of H e a l t h and Human S e r v i c e s , Suggested H e a l t h and Safety G u i d e l i n e s f o r P u b l i c Spas and Hot Tubs, Report of the P u b l i c H e a l t h S e r v i c e , Centers f o r Disease C o n t r o l ( A t l a n t a : Centers f o r Disease C o n t r o l , 1981), p. 1. 2Diane Newton, " E v o l u t i o n of the Spa Industry", Pool & Spa News, September 21, 1982, pp. 41-42. 3Hoffman P u b l i c a t i o n s , Inc. Swimming Pool Industry Market Report, ( F t . Lauderdale, F l a . , 1980), p. 8. "Great Lakes Biochemical Co., Inc., Spa & Hot Tub Water Maintenance, (Milwaukee, Wis., 1979), p. 3. 5 C r a n f o r d K. Gibbs, " L e t t e r s to the E d i t o r " , Pool & Spa News, February 9, 1 9 8 1 , pp. 6-7. 6Robert J a n i s , "SPEC Meets on Governmental A f f a i r s " , Pool & Spa News, A p r i l 5, 1982, p. 16. 7Hoffman P u b l i c a t i o n s , op. c i t . , 1981, p. 3. 8"RAB Inst a n t Background: Swimming Pool D e a l e r s " , Survey s u p p l i e d by WGN Radio, Chicago, I l l i n o i s , 1979, pp. 187-188. i n t e r v i e w with Dave A n t o n a c c i , I l l i n o i s Dept. of P u b l i c H ealth, E n g i n e e r i n g and S a n i t a t i o n D i v i s i o n , S p r i n g f i e l d , 111., J u l y 7, 1982. 1 0 I n t e r v i e w with W i l l i a m Withers, B r i t i s h Columbia M i n i s t r y of H ealth, P r e v e n t i v e S e r v i c e s , V i c t o r i a , B.C., August 27, 1982. 1 1 " H o t Tubs & Spas — The Joys of Tubbing", B e t t e r Homes and Gardens, Remodeling Ideas, Winter 1980/81, p. 118. 1 2 " G e t t i n g Y o u r s e l f Into Hot Water", Sunset Magazine, Sunset Ideas f o r Hot Tubs, Spas, & Home Saunas, August, 1979, p. 5. 1 3 H e l e n Donigan, "Spas Mean Hydrotherapy", Pool & Spa News, September 21, 1981, p. 58. 1 t t I b i d . 1 5 C l a r e F l e i g , "Hot Water: I t ' s Time Tested Cure, Doctor Claims." Pool & Spa News, February 23, 1981, p. 29-30. 1 6MacKenzie Canter I I I , "Uncle Sam May Help S e l l Pools and Spas", PS Magazine, (Washington, D . C ) , October/November 1980, p. 6. 1 i n t e r v i e w s with v a r i o u s o p e r a t o r s i n Chicagoland area, June-July 1982. 16 CHAPTER 2 The C h a r a c t e r i s t i c s of R i s k s and U n c e r t a i n t i e s i n R e g u l a t i o n of P u b l i c H e a l t h Hazards A s s o c i a t e d with Spas and Hot Tubs D e f i n i t i o n s of " R i s k s " and " U n c e r t a i n t i e s " P o t e n t i a l h e a l t h hazards r e l a t e d to spa use may be c l a s s i f i e d i n t o four broad c a t e g o r i e s : pathogenic, hyperthermia ( r e l a t e d to water temperature), v i s u a l ( r e l a t e d to water c l a r i t y ) , and drowning ( r e l a t e d to h a i r and body entrapment from the spa a e r a t i o n system). Managers face numerous u n c e r t a i n t i e s i n d e a l i n g with these hazards. To e x p l o r e the u n c e r t a i n t i e s i n spa management, we need to d i s t i n g u i s h between the terms " r i s k " and " u n c e r t a i n t y " and c l a r i f y the d i s t i n c t i o n between them. For the purposes of t h i s t h e s i s , a framework pr o v i d e d by Quade 1 i s used. A s i t u a t i o n of r i s k i s d e f i n e d as "one i n which a l l p o s s i b l e outcomes are known, together with the odds of each o c c u r r i n g . What i s not known i s the p a r t i c u l a r outcome that w i l l o c c u r . " 2 A s i t u a t i o n of u n c e r t a i n t y i s d e f i n e d as "one where the u n d e r l y i n g p r o b a b i l i t y d i s t r i b u t i o n i s unknown." 3 The d i s t i n c t i o n between r i s k and u n c e r t a i n t y i s that " i n a r i s k y s i t u a t i o n the random event comes from a known p r o b a b i l i t y d i s t r i b u t i o n , whereas i n a s i t u a t i o n of u n c e r t a i n t y the p r o b a b i l i t y d i s t r i b u t i o n i s unknown and must be chosen 17 s u b j e c t i v e l y . " 4 By use of the terms "chosen s u b j e c t i v e l y " , i t i s meant that experts can be c a l l e d upon i n some cases to evaluate a s i t u a t i o n and make judgements based upon t h e i r knowledge. Both of these types of u n c e r t a i n t i e s are co n s i d e r e d " s t o c h a s t i c u n c e r t a i n t i e s " because p r o b a b i l i t i e s a t t a c h e d t o t h e i r p o s s i b l e occurrence have some l o g i c a l b a s i s . There i s another c l a s s of u n c e r t a i n t i e s which may be c a l l e d " r e a l u n c e r t a i n t i e s " . Real u n c e r t a i n t i e s have no l o g i c a l b a s i s f o r an assignment of p r o b a b i l i t i e s to a p o t e n t i a l s i t u a t i o n of r i s k . U n c e r t a i n t i e s which depend on the d e l i b e r a t e a c t i o n s of people or changes i n i n d i v i d u a l and s o c i a l p r e f e r e n c e s ( i . e . , human behaviour and val u e s ) and p r e d i c t i o n s about f u t u r e s t a t e s of the world f a l l w i t h i n t h i s c a t egory. U n c e r t a i n t i e s which c o u l d be e l i m i n a t e d by g a t h e r i n g of a d d i t i o n a l i n f o r m a t i o n , but where doing so would be e x c e s s i v e i n co s t or time, might f o r a l l p r a c t i c a l purposes a l s o be c o n s i d e r e d r e a l u n c e r t a i n t i e s . We can c l a s s i f y the v a r i o u s u n c e r t a i n t i e s i n t o these a r e a s : 1. U n c e r t a i n t i e s which can be e l i m i n a t e d and/or reduced to r i s k s by ga t h e r i n g a d d i t i o n a l i n f o r m a t i o n . 2. U n c e r t a i n t i e s which c o u l d l i k e l y be reduced t o r i s k s by judgement. 3. U n c e r t a i n t i e s which are r e a l and cannot be e l i m i n a t e d or reduced to r i s k s . For f a c i l i t y , we w i l l l a b e l and r e f e r to these u n c e r t a i n t i e s as: (1) i n f o r m a t i o n a l u n c e r t a i n t i e s , (2) judgement u n c e r t a i n t i e s , and (3) r e a l u n c e r t a i n t i e s . A f t e r examining the 18 p u b l i c h e a l t h concerns and p o t e n t i a l hazards of spas and hot tubs, we w i l l s p e c i f y p e r t i n e n t r i s k s and u n c e r t a i n t i e s i n accord with the above d e f i n i t i o n s and d i s t i n c t i o n s . Spas and Hot Tubs; P u b l i c Health Concerns In acknowledging spas and hot tubs as a v i a b l e h e a l t h and r e c r e a t i o n a l a l t e r n a t i v e , we must then address the q u e s t i o n : are they t r u l y a p u b l i c h e a l t h concern? The answer i s u n e q u i v o c a l l y "yes". Spa users are, without doubt, exposed to hazards as a d i r e c t consequence of p u b l i c spa and hot tub o p e r a t i o n . T h i s c o n c l u s i o n i s supported by the Center f o r Disease C o n t r o l (a d i v i s i o n of the U.S. Dept. of H e a l t h and Human S e r v i c e s , h e r e a f t e r r e f e r r e d to as "CDC"), which s t a t e s t h a t : The spa and hot tub i n d u s t r y i s c u r r e n t l y expanding i n t o s t a t e s which do not have adequate r e g u l a t i o n s to c o n t r o l the h e a l t h and s a f e t y f e a t u r e s of these f a c i l i t i e s . E p i d e m i o l o g i c evidence has shown that spas and hot tubs can be of s i g n i f i c a n t p u b l i c h e a l t h concern i f they are not p r o p e r l y designed, operated, and m a i n t a i n e d . 5 Even the business and i n d u s t r y i n t e r e s t s who p r o f i t from encouraging spa use do not deny the e x i s t e n c e of p o t e n t i a l hazard to some degree. The U.S. Consumer Product S a f e t y Commission (CPSC) i s s u e d a press r e l e a s e i n December, 1979 warning of the hazards of drowning i n spas from exposure to water 19 exceeding 104°F, and a l s o i n combination with use of a l c o h o l . 6 The r e p o r t s t a t e s : There were an estimated 200 emergency room-treated i n j u r i e s i n 1979, and 1,100 i n 1980 which were a s s o c i a t e d with spas. The CPSC has on f i l e , records of 30 r e s i d e n t i a l spa-a s s o c i a t e d deaths, 22 o c c u r r i n g i n 1979, 6 i n 1980 and 2 i n the f i r s t h a l f of 1981. Heat and a l c o h o l were c i t e d as c o n t r i b u t o r y or c a u s a l f a c t o r s i n 12 of these cases; drowning with no s p e c i f i c c a u s a l f a c t o r was c i t e d i n 13 cases; 2 drownings were s a i d t o have r e s u l t e d from the v i c t i m s being rendered unconscious as a r e s u l t of a f a l l and head i n j u r y p r i o r to drowning; and one death was caused by e l e c t r o c u t i o n . There are 2 deaths and 2 cases of near drownings r e s u l t i n g from h a i r entanglements i n spa d r a i n s . There are 6 deaths and one i n j u r y r e p o r t e d which oc c u r r e d in a commercial or p u b l i c l o c a t i o n . These 7 cases have been determined to be out of scope f o r t h i s r e p o r t . 7 CPSC Cases I n v o l v i n g Spa F a t a l i t i e s January 1, 1979 - June 14, 1981 Hazard P a t t e r n Number Drowning - Heat and A l c o h o l C o n t r i b u t i n g F a c t o r s 12 Drowning - Cause Not S p e c i f i e d 13 Drowning - Hair Entanglement 2 Drowning - Rendered Unconscious from F a l l / H e a d I n j u r y 2 E l e c t r o c u t i o n 1 Drowning - Commercial/Public L o c a t i o n 6 T o t a l 36 (U.S. Consumer Product S a f e t y Commission/HIEH) Since the time of t h i s r e p o r t an a d d i t i o n a l 41 (as of August, 1982) deaths have o c c u r r e d . In June, 1982, a r e c a l l was made of 125,000 d r a i n cover f i t t i n g s s o l d nationwide by one manufacturer, as a r e s u l t of two drownings and a t h i r d near-drowning. 8 S i g n i f i c a n t l y , the CPSC r e p o r t shows a l a r g e 20 i n c r e a s e i n emergency room-treated i n j u r i e s and c o n t i n u i n g deaths from 1979 to 1980. Some s t a t e s a l s o view the problems q u i t e s e r i o u s l y . For example, the s t a t e of Oregon has banned p u b l i c hot tubs* (not spas) o u t r i g h t . T h e i r own r e s e a r c h and experience with hot tubs has l e d them to conclude that the b a c t e r i a l organism, Pseudomonas aeruginosa which p r i m a r i l y causes s k i n rashes, i s u n c o n t r o l l a b l e i n these u n i t s and can be extremely d e l e t e r i o u s . (Note: although the reader should be aware that there are other s t r a i n s of Pseudomonas, t h i s study w i l l use "Pseudomonas" s o l e l y i n r e f e r e n c e to Pseudomonas aeruginosa; any other s t r a i n s r e f e r r e d to w i l l be s p e c i f i c a l l y named). M u n i c i p a l i t i e s , such as a group of v i l l a g e s i n the Chicago land area which compose the Northwest M u n i c i p a l Conference, have begun to devise r e g u l a t i o n s s p e c i f i c to p u b l i c spas. Although no s e r i o u s a c c i d e n t has yet o c c u r r e d i n t h e i r p a r t i c u l a r j u r i s d i c t i o n , those h e a l t h o f f i c i a l s are aware of problems elsewhere and see p o t e n t i a l dangers. As s t a t e d by one member, "We don't want to have to w r i t e an ordinance a f t e r a drowning or s e r i o u s d i s e a s e problem has o c c u r r e d . " 9 In f i e l d r e s e a r c h , every i n d i v i d u a l i n t e r v i e w e d , r e g a r d l e s s of background, expressed some measure of concern over the h e a l t h and s a f e t y hazards. There i s no d i s p u t e as to whether or not *The d i s t i n c t i o n between spas and hot tubs i s important here because p o r o s i t y of the wood c o n s t r u c t i o n m a t e r i a l s of hot tubs was c o n s i d e r e d more of a hazard than other spa c o n s t r u c t i o n m a t e r i a l s (e.g., f i b e r g l a s s and c o n c r e t e ) . 21 hazards e x i s t . Divergence of o p i n i o n begins with i s s u e s such as the degree of hazard, the p r o b a b i l i t y of occurrence, the l i k e l i h o o d of reducing or e l i m i n a t i n g the hazard, the amount of hazard which should be allowed, and q u e s t i o n s regarding spas as being merely a s s o c i a t e d with the hazards i n c o n t r a s t to being the cause. There appears to be v i r t u a l l y unanimous agreement that maintenance, management, and o p e r a t i o n a l f a c t o r s are the p r i n c i p a l elements that determine hazard exposure and outcomes. Although a few people view proper spa management as a hopeless task, the vast m a j o r i t y of experts t h i n k that the h e a l t h hazards can be brought under c o n t r o l through c a r e f u l o p e r a t i o n . However, spa management e n t a i l s d e a l i n g with complex t e c h n i c a l and s c i e n t i f i c matters i n which s i g n i f i c a n t u n c e r t a i n t y appears to e x i s t . In order to i d e n t i f y the u n c e r t a i n t i e s and demonstrate how they complicate t e c h n i c a l and normative aspects of p o l i c y development, an understanding of the r e l a t i o n s h i p between spa water q u a l i t y c h a r a c t e r i s t i c s and the p o t e n t i a l hazards i s important. The f o l l o w i n g s e c t i o n s d e s c r i b e these t e c h n i c a l and s c i e n t i f i c areas and i l l u s t r a t e the key weaknesses where u n c e r t a i n t y has f r u s t r a t e d establishment of p o l i c y . 22 P o t e n t i a l Hazard Areas The s a f e t y and h e a l t h hazards i n v o l v e d i n spa usage can be examined by c l a s s i f y i n g the problems i n t o four a r e a s : 1. d i s i n f e c t i o n and c o n t r o l of pathogenic hazards 2 . hyperthermia hazards 3 . v i s u a l hazards from poor water c l a r i t y 4 . drowning hazards from the spa a e r a t i o n system In each area, there are a number of s p e c i f i c hazards of v a r y i n g degrees and p r o b a b i l i t y of occurrence. However, a l l three areas are l e g i t i m a t e concerns that have been documented as problems by p u b l i c and/or p r i v a t e sources. 1 . Pathogenic Hazards The growth of b a c t e r i a , v i r u s e s , and fun g i i n the spa environment c o n s t i t u t e one of the major sources of h e a l t h hazards. T h i s p o t e n t i a l hazard area i s one of the most important p u b l i c h e a l t h concerns, and i t a l s o poses the most d i f f i c u l t i e s f o r spa management. Managing Spa Water Q u a l i t y to C o n t r o l Pathogens The main concern i n water q u a l i t y management f o r spas ( l i k e p o ols) i s to prevent growth of b a c t e r i a , v i r u s e s , and f u n g i , and the spread of i n f e c t i o u s d i s e a s e s . These pathogens can be 2 3 introduced from the source of water supply, the a i r , or by b athers. The higher temperatures of spa water are conducive to the growth of many of these pathogens. In order to achieve the water q u a l i t y o b j e c t i v e s , i n d i c a t o r s f o r d i s i n f e c t a n t l e v e l s , pH, t o t a l a l k a l i n i t y , hardness, t o t a l d i s s o l v e d s o l i d s , and t r a c e metals are used. These parameters, as with any body of water, have b e a r i n g upon the a b i l i t y of the d i s i n f e c t a n t ( u s u a l l y c h l o r i n e or bromine) to act upon the pathogens. The f a c t o r s which a f f e c t pool and spa water q u a l i t y i n c l u d e : I. P h y s i c a l F a c t o r s A. F i l t r a t i o n B. C i r c u l a t i o n C. Temperature I I . Chemical F a c t o r s A. pH B. T o t a l A l k a l i n i t y C. Calcium Hardness D. T o t a l S o l i d s E. L a n g e l i e r S a t u r a t i o n Index of C o r r o s i t i v i t y or S c a l i n g Tendencies F. Trace Elements I I I . B i o l o g i c a l F a c t o r s A. D i s i n f e c t i o n B. Shock Treatment f o r removal of chloramine ammonias, and o r g a n i c m a t e r i a l s C. Algae c o n t r o l Standards f o r these f a c t o r s have worked reasonably w e l l f o r p o o l s , but even pools have problems. One study has i n d i c a t e d that of 193 pools i n v e s t i g a t e d , "105 f a i l e d to meet s t a t e requirements f o r r e s i d u a l c h l o r i n e l e v e l s , and 106 of these f a i l e d to have proper pH r a n g e s . " 1 0 However, i t i s g e n e r a l l y recognized that a p r o p e r l y t r a i n e d and c o n s c i e n t i o u s i n d i v i d u a l 24 can f a i r l y e a s i l y maintain proper water q u a l i t y i n p o o l s . "Pseudomonas b a c t e r i a probably would not be a problem i n pool environments i f proper maintenance requirements are not v i o l a t e d , or unless the inherent c h a r a c t e r i s t i c s of the pool make i t d i f f i c u l t to maintain those r e q u i r e m e n t s . " 1 1 T h i s has not proven so f o r spas. Due to the high temperatures maintained i n w h i r l p o o l s , and the frequent high i n t e n s i t y a c t i v a t i o n of the water, proper f r e e d i s i n f e c t a n t r e s i d u a l s are d i f f i c u l t to m a i n t a i n . Frequent monitoring of these p o o l s throughout the day i s necessary to assure that the proper f r e e d i s i n f e c t a n t and pH i s maintained. Since frequent monitoring i s d i f f i c u l t to achieve, the p o t e n t i a l f o r Pseudomonas and other pathogenic contamination i s always pre s e n t . I t i s our c o n t e n t i o n that heated w h i r l p o o l s w i l l continue to be marginal o p e r a t i o n s from the s t a n d p o i n t of swimmer h e a l t h , and perhaps p u b l i c h e a l t h agencies should run exhaustive water q u a l i t y t e s t s on these types of pools to determine i f they can continue to be allowed as safe to u s e . 1 2 I t was f i r s t thought by most people that spa water q u a l i t y management would not be a problem, because we have had a good "t r a c k r e c o r d " with swimming pool water q u a l i t y . I t was thought that spas would simply be an e x t e n s i o n of p o o l s , and that they c o u l d be t r e a t e d as "baby p o o l s " . The emergence of spas i n l a r g e numbers has proved t h i s f a l s e . There i s a l a c k of experience with the h i g h l y v a r i a b l e c o n d i t i o n s of spas as a r e s u l t of these important d i f f e r e n c e s : 1. High Water Temperatures cause r a p i d e v a p o r a t i o n of water and i n c r e a s e the c o n c e n t r a t i o n of d i s s o l v e d s o l i d s . 2. Heavy Bather Loads (a f u n c t i o n of spas' small s i z e ) and hot water r e s u l t s i n high c o n c e n t r a t i o n s of body o i l s , s k i n f l a k e s , 25 and other organic wastes which contaminate the water. 3. A e r a t i o n E f f e c t s , r e s u l t i n g from i n c r e a s e d v e l o c i t y and heat, r a p i d l y change the chemical c h a r a c t e r of water, which i n turn a c c e l e r a t e s c h l o r i n e l o s s , a f f e c t s pH, and i n c r e a s e s the p o s s i b i l i t y of e x c e s s i v e foaming. Depending on l o c a l a i r q u a l i t y c o n d i t i o n s , a e r a t i o n may a l s o i ntroduce more d i r t i n t o the w a t e r . 1 3 What d i f f i c u l t i e s do these unique spa f a c t o r s present f o r the maintenance of water q u a l i t y ? F i r s t , d i f f i c u l t i e s i n p r e d i c t i n g water q u a l i t y stem from the wide v a r i a t i o n i n the c o n d i t i o n s that a f f e c t spa water q u a l i t y . The p r i n c i p a l v a r i a t i o n s are found i n (a) the p h y s i c a l and chemical c h a r a c t e r i s t i c s of the spa water, (b) the presence of b i o l o g i c a l and organic m a t e r i a l s i n the spa water, and (c) the numbers and kinds of i n d i v i d u a l s u sing spas. These c o n d i t i o n s can vary from spa to spa or with one spa over time. High v a r i a b i l i t y i n spa water q u a l i t y i s caused by four main f a c t o r s : 1. V a r i a t i o n s i n the numbers and kinds of spa bathers and the consequent d i f f e r e n c e s i n the amount of b i o l o g i c a l and orga n i c m a t e r i a l i n t r o d u c e d to the spa and d i f f e r e n c e s i n the amount of exposure they b r i n g to d i s e a s e organisms. 2. V a r i a t i o n s from time to time i n the extent to which d i s e a s e organisms e x i s t i n a given l o c a l environment, apart from being c a r r i e d i n t o spas by b a t h e r s . 3. D i f f e r e n c e s i n l o c a l water s u p p l i e s and the p h y s i c a l 26 environment ( i . e . , a i r , s u n l i g h t , e t c .) 4. V a r i a t i o n s caused by spa operator manipulation of p h y s i c a l and chemical f a c t o r s (e.g., chemical treatment, o p e r a t i o n of spa f i l t r a t i o n equipment, water l e v e l , e tc.) Spa water q u a l i t y may respond d r a m a t i c a l l y to each of these f a c t o r s because of the high water temperature, heavy bather loads, and a e r a t i o n i n spas. The indoor pool and spa at the UBC Aquatic Center i l l u s t r a t e s the e f f e c t s of bather loads i n c r e a t i n g h i g h l y v a r y i n g c o n d i t i o n s . The pool c o n t a i n s approximately 800,000 g a l l o n s (U.S.) of water and the spa has roughly 2,000 g a l l o n s . "Bather l o a d " , d e f i n e d as the number of persons per volume of water over time, would by comparison be as f o l l o w s : - each person i n the spa would be e q u i v a l e n t to 400 people i n the p o o l . - thus, 10 people in the spa (a common occurrence) would be equal to 4,000 people i n the p o o l ! By r e g u l a t i o n , the pool i s not allowed to have t h a t many people i n at one time. But i f such a bather l o a d were permitt e d , the e f f e c t s of the b i o l o g i c a l and organic m a t e r i a l s upon the water chemistry would be tremendous and make maintenance d i f f i c u l t . For h e a l t h and s a f e t y reasons, we would not t o l e r a t e (and probably c o u l d not d e a l with) the number of pool users suggested by our i l l u s t r a t i o n . Yet with spas, our p e r c e p t i o n s are deceived by l o o k i n g at the ab s o l u t e number of people, r a t h e r than the more important p r o p o r t i o n of users to 2 7 the volume of water. The s i g n i f i c a n c e of t h i s i s the important e f f e c t of bather lo a d upon spa water q u a l i t y and that the r a t i o of users to water q u a l i t y i s h i g h l y v a r i a b l e . The r e l a t i o n s h i p s amongst spa water q u a l i t y parameters are complex in themselves, but as the above example shows, an a d d i t i o n a l or "marginal" user i n the small volume of spa water can have tremendous e f f e c t on the parameters. C a l c u l a t i n g the proper chemical water balance a l s o becomes extremely d i f f i c u l t , because the number of users, time spent i n the spa by each user, and the p o r t i o n of the users' bodies immersed i n the water a l l f l u c t u a t e g r e a t l y . The p o s s i b l e combination of f a c t o r s and use i s not only i n f i n i t e , but attempts to develop a r t i f i c i a l l i m i t s are complicated by the t i g h t t o l e r a n c e s imposed by the r e l a t i v e l y small volume of water. Casual, broad, or c a r e l e s s d i v i s i o n of f a c t o r s and use can l e a d to s i g n i f i c a n t e r r o r s which might be f a r l e s s n o t i c e a b l e i n p o o l s . Second, the r e l a t i o n s h i p between water q u a l i t y c o n d i t i o n s and number of spa users i s not r e a d i l y p r e d i c t a b l e and r e q u i r e s c l o s e monitoring and o b s e r v a t i o n in order to maintain " s a f e " c o n d i t i o n s . Water q u a l i t y parameters, such as pH, t o t a l a l k a l i n i t y , t o t a l d i s s o l v e d s o l i d s , and d i s i n f e c t a n t l e v e l s , are s u b j e c t to dramatic changes, which may be n o n - l i n e a r and a l s o l e a d to r a p i d d e t e r i o r a t i o n i n water q u a l i t y . There i s evidence to show that even under seemingly s t a b l e pH and c h l o r i n e ranges in pools (ranges which meet normal s t a n d a r d s ) , that extreme f l u c t u a t i o n s occur i n the hypochlorous a c i d ( i . e . the 28 b a c t e r i c i d e agent) curve and that c l o s e r m o nitoring of c h l o r i n e and pH l e v e l s i s e s s e n t i a l f o r m a i n t a i n i n g the d e s i r e d water q u a l i t y . 1 4 The e f f e c t s of d i f f e r e n t i n d i v i d u a l s upon the water q u a l i t y parameters can sometimes be more s i g n i f i c a n t than the number of u s e r s . Spa temperatures i n c r e a s e s e c r e t i o n of body o i l s . F u r t h e r , people b r i n g many "foreign'' m a t e r i a l s (e.g. d i r t , deodorants, e t c.) i n t o the spa. The amounts of b o d i l y and " f o r e i g n " m a t e r i a l s d i f f e r from i n d i v i d u a l to i n d i v i d u a l . I t cannot be r e a d i l y p r e d i c t e d when the e f f e c t s of d i f f e r e n t users w i l l cause parameter t h r e s h o l d s to be exceeded and water c o n d i t i o n s d r a s t i c a l l y a l t e r e d . An i l l u s t r a t i o n of t h i s i s an a c t u a l i n c i d e n t which i n v o l v e d two separate spas with s i m i l a r c o n d i t i o n s , management, and number of u s e r s . In one spa, d i s i n f e c t a n t l e v e l s were d i f f i c u l t to maintain and gen e r a l water q u a l i t y was poor. An e x t e n s i v e i n v e s t i g a t i o n r e v e a l e d that the problem was r e l a t e d to hi g h amounts of s k i n p a r t i c l e s i n the water from a group of frequent users who a l s o o f t e n s u n t a n n e d . 1 5 T h e r e f o r e , management p r a c t i c e s cannot be simply based on t h e o r e t i c a l c o r r e l a t i o n s between number of spa users and water q u a l i t y parameters. I t i s d i f f i c u l t to d e f i n e what i s an "average" user or group of users f o r purposes of a d j u s t i n g parameters to meet c e r t a i n c o n d i t i o n s . I f i n c o r r e c t judgements are made with respect to the p o s s i b l e e f f e c t s of d i f f e r e n t u s e r s , i t becomes c o n s i d e r a b l y more d i f f i c u l t t o determine what management procedures are needed to r e s t o r e water q u a l i t y . 29 Thus, i t i s c r i t i c a l l y i m p o r t a n t t h a t f r e q u e n t and e f f e c t i v e m o n i t o r i n g systems a r e used i n spa o p e r a t i o n s so t h a t " s u r p r i s e s " may be a v o i d e d . T h i r d , spa water q u a l i t y i s c o m p l i c a t e d by the f a c t t h a t c o r r e c t i v e measures f o r a d j u s t i n g the water c h e m i s t r y a r e h i n d e r e d by the s m a l l volume of water and i t s c o n s e q u e n t i a l r a p i d , dynamic n a t u r e . N o r m a l l y w i t h p o o l s , c h e m i c a l s ( e . g . , c h l o r i n e f o r d i s i n f e c t i o n and h y d r o c h l o r i c a c i d f o r l o w e r i n g pH) a r e metered or o t h e r w i s e a d m i n i s t e r e d t o the p o o l so as t o b u i l d up a "bank" of d i s i n f e c t i o n (as i n the case of c h l o r i n e ) or t o g r a d u a l l y reduce the pH ( i n the case of a c i d ) . W i t h spas, t i g h t t o l e r a n c e s make g r a d u a l a d j u s t m e n t s n e c e s s a r y , but they a r e a l s o d i f f i c u l t t o a d m i n i s t e r a c c u r a t e l y , more prone t o e r r o r , and l e a v e l i t t l e room f o r s a f e t y m a r g i n s . Thus, a t t e m p t s t o compensate, and e s p e c i a l l y over-compensate, f o r water q u a l i t y problems can c r e a t e worse problems. We know, f o r i n s t a n c e t h a t e x c e s s i v e a d d i t i o n of a c i d can lower pH too r a p i d l y under c e r t a i n c o n d i t i o n s , hence a f f e c t i n g b a t h e r s , d i s i n f e c t i o n c a p a b i l i t y and spa equipment. E x t r a o r d i n a r i l y h i g h l e v e l s of c h l o r i n e or bromine may be hazardous i n the spa i t s e l f or i n waste water d i s c h a r g e s e l s e w h e r e . In each c a s e , we must ask ; can the " c u r e " be worse than the " d i s e a s e " ? We can summarize the t h r e e main d i f f i c u l t i e s of m a i n t a i n i n g spa water q u a l i t y : 1. Wide v a r i a t i o n s from l o c a t i o n t o l o c a t i o n and from time t o time - which c r e a t e problems i n m a i n t a i n i n g a c c e p t a b l e 30 water q u a l i t y c o n d i t i o n s . 2. N o n - l i n e a r i t y between water q u a l i t y parameters and number of users - which c r e a t e s the problem of p r e d i c t i n g spa water q u a l i t y trends and p r e s c r i b i n g remedial measures. 3. P o t e n t i a l dangers of c o r r e c t i v e measures - which p r e c l u d e s the p o s s i b i l i t y of over-compensating to b u i l d a wide margin of s a f e t y . These problems c o u l d c o n c e i v a b l y be s u b s t a n t i a l l y reduced by very e x t e n s i v e human or mechanical m o n i t o r i n g . However, such monitoring i s an expensive and/or d i f f i c u l t p r ocess which so f a r has not been widely c o n s i d e r e d worthwhile or f e a s i b l e . The c o n c l u s i o n i s inescapable that spa management i s a d i f f i c u l t t ask, p a r t i c u l a r l y f o r u n t r a i n e d or p o o r l y - t r a i n e d spa o p e r a t o r s . C o n t r o l l i n g S p e c i f i c Pathogens* The concern with t h i s problem r e l a t e s to the i d e n t i f i c a t i o n of the pathogenic organisms which a l r e a d y appear to be a s s o c i a t e d with spas or are p o t e n t i a l r e c o g n i z a b l e hazards. In spas, i n d i v i d u a l s are p a r t i c u l a r l y s u s c e p t i b l e to pathogens, not only because of the temperature and water chemistry f a c t o r s d i s c u s s e d e a r l y , but a l s o because the body i s s t r i p p e d of i t s normal " d e b r i s " . D i l a t i o n of pores and pounding from w h i r l p o o l a c t i o n r e l e a s e p r o t e c t i v e o i l s and dead s k i n . T h i s has two *Note: See Appendix A f o r a more comprehensive d i s c u s s i o n of pathogenic hazards. 31 e f f e c t s ; f i r s t , i t p r o v i d e s a n u t r i t i o n a l source f o r organisms and second, i t p r o v i d e s an entry pathway i n t o the s k i n (but not the body). The body, upon c o o l i n g down a f t e r spa use, can t r a p the organisms i n the s k i n pores. F e s t e r i n g or i r r i t a t i o n may then occur on the body. T h i s sequence i s f a i r l y t y p i c a l of pathogenic problems r e l a t i n g to s k i n rashes and minor i n f e c t i o n s — a r e l a t i v e l y common problem from spas. Pseudomonas aeruginosa - T h i s organism has so f a r been given the most a t t e n t i o n . Known as c a u s i n g what i s commonly c a l l e d "swimmer's ear" i n p o o l s and l a k e s , t h i s b a c t e r i a has been i d e n t i f i e d as a major source of s k i n rashes r e s u l t i n g from spa use. Outbreaks of the d i s e a s e appear i n 8 to 48 hours a f t e r exposure and u s u a l l y disappear i n three to seven d a y s . 1 6 Symptoms i n c l u d e : i t c h i n g , ear p a i n , weakness, headache, sore t h r o a t , a u x i l i a r y lymphadenopathy, and p a i n f u l b r e a s t s . 1 7 These c h a r a c t e r i s t i c s are well-agreed upon, but there i s disagreement over other a s p e c t s , such as other hazards from Pseudomonas. From one h e a l t h o f f i c i a l : I f these were the only p o t e n t i a l h e a l t h problems, we wouldn't be as concerned about i t as we are. But there are other p o t e n t i a l problems i t can cause. I f i t becomes a systemic i n f e c t i o n i n v o l v i n g the blood stream, then there i s a f a i r l y h igh p r o b a b i l i t y of m o r t a l i t y . Systemic Pseudomonas i n f e c t i o n s u s u a l l y occur i n people who have primary h e a l t h impairment, such as burn v i c t i m s , or people who have gunshot or puncture wounds. A r t h r i t i c i n d i v i d u a l s are s u s c e p t i b l e too, because they are u s u a l l y put on immuno-suppressant drugs, and a l o t of p h y s i c i a n s are p r e s c r i b i n g spa pools as therapy f o r a r t h r i t i s . 1 8 The m o r t a l i t y r a t e r e f e r r e d to i s estimated at 40 percent 32 i f Pseudomonas enters the bloodstream. 1 9 However, th i s p o s i t i v e statement about the danger of death from Pseudomonas in a spa i s disputed by an industry researcher who c a l l s i t "supposition" and that a more accurate answer would be "It's impossible to say." 2 0 A number of other controversial questions surround the Pseudomonas bacteria. Among them i s the question of the a b i l i t y to k i l l the organism by chlorination and also the chemical parameters favorable for growth. 2 1 Studies seem to indicate that chlorine does k i l l Pseudomonas, but that many other factors, such as pH, temperature, organic material, and other chemicals can s i g n i f i c a n t l y influence the effectiveness of chlorine as a b a c t e r i c i d e . 2 2 Compounding the problem i s the fact that Pseudomonas has the c a p a b i l i t y of producing a slime coating around i t s e l f i f i t can fi n d some porous opening in a material which allows attachment. Hence, wood tubs or poorly maintained spas with scale build-up may permit Pseudomonas to attach i t s e l f , rendering chlorine less viable as a d i s i n f e c t a n t . Another question relates to the associative factors of Pseudomonas with spas. Research by members of the Recreational Water Quality C r i t e r i a Program (U.S. Environmental Protection Agency), suggests that the presence of the organism i s more d i r e c t l y linked to certain individuals and other environments, and that there is no conclusive evidence of a cause and effect relationship between densities of the bacteria in water and incidence of i n f e c t i o n s . 2 3 Additional research on Pseudomonas is continuing, but at the present, there are s t i l l many serious, 3 3 unanswered q u e s t i o n s . D e s p i t e the ambiguity, the consensus i s that Pseudomonas does pose some measure of h e a l t h hazard f o r spa users -- f o r what reasons and under what c o n d i t i o n s , we are not sure. As noted by one h e a l t h o f f i c i a l ; "You don't have outbreaks i n scummy water n e c e s s a r i l y . One of the c l e a n e s t tubs I've ever seen was loaded with Pseudomonas." 2 4 The l a r g e s t outbreak to date occurred i n A t l a n t a , Georgia in March, 1981, i n v o l v i n g 75 p e o p l e . 2 5 Other v a r i o u s s t a t e s , i n c l u d i n g Colorado, New York, Oregon, Minnesota, Alabama, and North C a r o l i n a have a l s o r e p o r t e d s i g n i f i c a n t i n c i d e n t s . Many other s t a t e and l o c a l h e a l t h o f f i c i a l s have i s o l a t e d Pseudomonas c u l t u r e s i n p u b l i c spas, even i f they experienced no outbreaks. Thus, t h i s p a r t i c u l a r b a c t e r i a l organism may deserve c a r e f u l m onitoring and perhaps f u r t h e r study. S p e c i a l work on t h i s problem i s , i n f a c t , c u r r e n t l y being conducted by one of the world's l e a d i n g experts on Pseudomonas. 2 6 From the i n d u s t r y , two chemical companies have run t e s t i n g . Bio-Lab, Inc. of Decatur, Georgia has done l a b o r a t o r y t e s t i n g and O l i n Corp. of New Haven, Conn, has conducted i n - f i e l d t e s t i n g . Both t e s t s showed c h l o r i n e was e f f e c t i v e a g a i n s t Pseudomonas, but the c o n d i t i o n s and c h l o r i n e l e v e l s d i f f e r e d between the two s t u d i e s . The most s i g n i f i c a n t and c o n s i s t e n t r e s u l t s of the two t e s t s appear to be that c o n s t a n t l y maintained f r e e c h l o r i n e l e v e l s are important to prevent the establishment of Pseudomonas i n the spa water. The d i r e c t o r of one of the t e s t s underscores the n e c e s s i t y of proper spa water q u a l i t y management; " I t i s my o p i n i o n that these outbreaks occur because of poor or no attempt to maintain 3 4 s a n i t i z e d w a t e r . " 2 7 L e g i o n e l l a pneumophilia - T h i s organism produces " L e g i o n n a i r e ' s Disease" -- a d i s e a s e d i s c o v e r e d s e v e r a l years ago and diagnosed as r e s p o n s i b l e f o r the deaths of many American Legion conventioneers who stayed at one h o t e l i n P h i l a d e l p h i a . In the past year, p u b l i c h e a l t h o f f i c i a l s i n M o n t p e l i e r , Vermont re p o r t e d i s o l a t i o n of L. pneumophilia i n hot t u b s . 2 8 T h i s has been s u b s t a n t i a t e d by o t h e r s , and resea r c h i n New York has i n d i c a t e d t hat people using spas have 10 times the chance of c o n t a c t i n g the d i s e a s e . 2 9 The CDC L e g i o n e l l a Branch i s a c t i v e l y i n v o l v e d i n f u r t h e r work on t h i s . However, some experts do not think that the Vermont i n c i d e n t i s good e p i d e m i o l o g i c a l evidence because L e g i o n e l l a appears to be a u b i q u i t o u s water organism. The CDC a f f i r m s t h i s c a u t i o n a r y note; "there are 50,000-70,000 i n s t a n c e s of L e g i o n e l l a per year. Being an a q u a t i c organism, i t i s a l s o found i n l a k e s , streams, moist e a r t h , and even shower heads i n h o s p i t a l s . " 3 0 Far l e s s i s known about t h i s d i s e a s e than Pseudomonas, and c u r r e n t l y , the focus i s on determining c a u s a t i o n - a s s o c i a t i o n f a c t o r s . Although the geographic l o c a t i o n s and temporal r e l a t i o n s h i p s of these f i n d i n g s are of i n t e r e s t and suggest that environmental i s o l a t e s may be somehow a s s o c i a t e d with the outbreaks, they must be i n t e r p r e t e d c a u t i o u s l y . T h i s i s because i n v e s t i g a t o r s have recovered LDB from l o c a t i o n s i n which cases had r e c e n t l y occurred, but treatment on removal of the p u t a t i v e environmental source of LDB d i d not prevent the continued occurrence of human i n f e c t i o n and d i s e a s e . 3 1 35 Thus i t i s h i g h l y u n f a i r to s i n g l e out spas i n a s s o c i a t i o n with the d i s e a s e . Regardless, the s e r i o u s nature of L e g i o n e l l a r e q u i r e s us to c o n s i d e r i t a p o s s i b l e p u b l i c h e a l t h hazard with spas and to p r o t e c t a g a i n s t i t s occurrence i n the same degree as in any other a q u a t i c environment. Pontiac Fever - The CDC has r e c e n t l y d i s c o v e r e d p o s s i b l e evidence of a l i n k between t h i s d i s e a s e and s p a s . 3 2 I t i s d e r i v e d from the L e g i o n e l l a organism, but i t produces d i f f e r e n t symptoms. I n d i v i d u a l s s u f f e r i n f l u e n z a - t y p e r e a c t i o n s , which, f o r our case of spas, d e f i n i t e l y c o mplicates source i d e n t i f i c a t i o n . Information i n any s i g n i f i c a n t d e t a i l on t h i s d i s e a s e i s not c u r r e n t l y a v a i l a b l e and l i t t l e can be s a i d about i t except to note i t s p o s s i b i l i t y as another p u b l i c h e a l t h hazard with spas. Other Pathogenic Hazards - T r a d i t i o n a l water q u a l i t y concerns of S t a p h y l o c o c c i and S t r e p t o c o c c i a l s o f i g u r e as p o s s i b l e hazards of spas, but only i n a minor way. Some h e a l t h o f f i c i a l s have re p o r t e d the i s o l a t i o n of s t r e p i n spas, yet i t should be noted that s t r e p v i r t u a l l y has to be i n g e s t e d or maintain entry through an open wound to be a problem. In reasonably c a r e f u l use of spas, t h i s i s r a r e l y a concern. Herpes and other s o c i a l d i s e a s e s have been r a i s e d as p o s s i b l e hazards, but f o r the most par t d i s m i s s e d . Although such d i s e a s e s are not impossible to contact i n spas, they are not c o n s i d e r e d hazards r e l a t e d to spas because they r e q u i r e p h y s i c a l c o n t a c t , which c l e a r l y c o u l d take 36 p l a c e anywhere. L a s t l y , v i r u s e s such as p o l i o and h e p a t i t i s are l i k e w i s e d i s m i s s e d as spa concerns. V i r u s e s g e n e r a l l y r e q u i r e i n g e s t i o n and t h e i r presence r e l a t e s to our o v e r a l l environment. These other pathogens cannot be c h a r a c t e r i z e d as s p e c i a l p u b l i c h e a l t h hazards r e l a t e d to spas, but n e i t h e r can they be t o t a l l y ignored, e s p e c i a l l y i n the cases of staph and s t r e p . Spa water q u a l i t y management does have to f o l l o w normal s a n i t a t i o n procedures p r a c t i c e d elsewhere as p r e v e n t i o n from these pathogens. F u r t h e r , as noted by one biochemist, "mutation of b a c t e r i a occurs a l l the t i m e . " 3 3 New, p r e v i o u s l y unknown pathogens ( L e g i o n e l l a being a prime example) can appear, so we cannot f e e l too secure about our c u r r e n t l e v e l of knowledge. We need to be on guard. Perhaps the b a c t e r i o l o g i c a l h e a l t h hazards of spas can best be viewed and summarized from a statement by an o f f i c i a l from the I l l i n o i s Dept. of P u b l i c H e a l t h . To paraphrase h i s comments: "Pools and spas should be c o n s i d e r e d as p l a c e s where people congregate. Those who have d i s e a s e s can spread them there and t h i s c o u l d happen i n any p u b l i c area of g a t h e r i n g . " 3 4 Regardless of our knowledge (or lack o f ) , t h i s statement makes a good d e a l of sense. Spas i n p u b l i c f a c i l i t i e s w i l l always i n c r e a s e h e a l t h hazards to some extent. A d d i t i o n a l i n f o r m a t i o n about these p o t e n t i a l hazards should h e l p us to make b e t t e r d e c i s i o n s , but r e c o g n i t i o n of t h i s broad statement p r o v i d e s reason to remain a l e r t to p o t e n t i a l hazards without n e c e s s a r i l y condemning any s p e c i f i c f a c i l i t y prematurely or 3 7 without j u s t cause. U n t i l we develop c l e a r documentation and accepted evidence of any of the pathogenic hazards, a c a u t i o u s yet aware approach might be our best at t h i s time. P u b l i c h e a l t h p r o t e c t i o n a g a i n s t pathogenic hazards would i n v o l v e : 1. Development of spa water q u a l i t y management standards and g u i d e l i n e s which e l i m i n a t e or c o n t r o l pathogenic organisms in spas. 2 . Spa operator understanding of spa water q u a l i t y c h a r a c t e r i s t i c s and procedures f o r p r e v e n t i n g degradation of water q u a l i t y and adherence to the standards. 3 . Spa user understanding of p o t e n t i a l pathogenic hazards, r e c o g n i t i o n of poor water q u a l i t y c o n d i t i o n s , and avoidance of unsafe spa environments. 4. R e s o l u t i o n of u n c e r t a i n t i e s i n regard to both the p o t e n t i a l pathogenic hazards and spa management procedures f o r reducing the hazards. 2 . Hyperthermia Hazards Other h e a l t h and s a f e t y f a c t o r s should be c o n s i d e r e d apart from the chemical and b i o l o g i c a l concerns. The f i r s t of these f a c t o r s i s high water temperature which can c r e a t e problems of hyperthermia. Spa o p e r a t o r s must be aware that the spa water q u a l i t y c h a r a c t e r i s t i c of temperature may r e q u i r e s p e c i a l management p r e c a u t i o n s to p r o t e c t c e r t a i n users from harm. Hyperthermia occurs when deep body temperature i s higher 38 than the thermoregulatory " s e t p o i n t " . The human t o l e r a n c e i s w i t h i n ±4° of the normal 98.6°F. In g e n e r a l women are l e s s heat t o l e r a n t than men and small persons of e i t h e r sex are at a disadvantage when exposed to thermal extremes. Heat (hyperthermia) can cause drowsiness, l e t h a r g y , v a s o d i l a t i o n , c a r d i o d e p r e s s i o n , decreased myocardial c o n t r a c t i b i l i t y , hypoglycemia, h y p e r t e n s i o n , r e s p i r a t o r y d e p r e s s i o n , decreased c e r e b r a l blood flow and a l t e r e d c e r e b r a l t i s s u e c o m p l i a n c e . 3 5 The p o t e n t i a l h e a l t h hazards from h i g h temperatures are r e l a t i v e l y well-understood, and the suggested maximum l i m i t of 104°F (40°C) i s commonly accepted now. T h i s g u i d e l i n e i s based on knowledge that the human body begins to l o s e i t s a b i l i t y to c o o l i t s e l f at temperatures above 104°. I t i s f u r t h e r recommended that a maximum l i m i t of 10 to 15 minutes i n a spa, at one time, should be observed. Some people are more s u b j e c t to hazard, and the g e n e r a l recommended g u i d e l i n e s may be unsafe to them. Determining a c c e p t a b l e l e v e l s f o r these cases i s d i f f i c u l t , and the problem of users being unaware of t h e i r p e r s o n a l h e a l t h d e f e c t s can a l s o e x i s t . Prolonged spa usage can be dangerous f o r the "average" person, but any l e n g t h of use by e l d e r l y people, people with medical problems (e.g., high blood p r e s s u r e , d i a b e t e s , c a r d i o v a s c u l a r , c i r c u l a t o r y impairments, e t c . ) , and anyone under the i n f l u e n c e of a l c o h o l or other drugs, even i n moderate amounts, i s l i k e l y to be d a n g e r o u s . 3 6 Research and experimentation at the U n i v e r s i t y of Washington School of Medicine a l s o i n d i c a t e s that pregnant women must take s p e c i a l p r e c a u t i o n s , as temperatures g r e a t e r than 102°F f o r more than 15 minutes can endanger the d e v e l o p i n g embryo or 39 f e t u s . 3 7 E s t a b l i s h i n g other g u i d e l i n e s f o r who may use spas, at what temperatures, and f o r what l e n g t h of time i s an important, but a l s o ambiguous, matter. The work of the CPSC and the U n i v e r s i t y of Washington medical school i s h e l p f u l f o r developing h e a l t h and s a f e t y g u i d e l i n e s . However, shortcomings s t i l l remain. One of these i s the lac k of i n f o r m a t i o n about changes in b l o o d pressure or heart r a t e s i n r e l a t i o n to spa water temperatures. Such i n d i c a t o r s c o u l d be h e l p f u l i n d e v i s i n g o p e r a t i o n a l standards. The t e s t s on pregnant women at the U n i v e r s i t y of Washington used v a g i n a l and r e c t a l temperatures as i n d i c a t o r s , but these are o b v i o u s l y i m p r a c t i c a l f o r normal o p e r a t i o n a l purposes. Another shortcoming i s the absence of i n f o r m a t i o n about the kinds and numbers of "near-misses" — cases where people have f e l t d i z z y or l e t h a r g i c i n spas, but got out before an a c c i d e n t o c c u r r e d . As suggested by V i c t o r i a Brown of the CPSC, t h i s type of i n f o r m a t i o n would g r e a t l y a i d i n e s t a b l i s h i n g b e t t e r p r e v e n t a t i v e measures. 3 8 The l a r g e s t s i n g l e drawback i s our i n a b i l i t y (due to e t h i c a l , p r a c t i c a l and other c o n s i d e r a t i o n s ) to conduct e x t e n s i v e t e s t i n g on humans. As a r e s u l t , we have to accept estimates and ranges which leave open hyperthermia hazards f o r s u s c e p t i b l e i n d i v i d u a l s . There i s r e a l l y not much that can be done to improve t h i s area of knowledge, but c e r t a i n l y i n d i v i d u a l s who have the s l i g h t e s t doubt of t h e i r a b i l i t y t o withstand the h i g h temperatures are s t r o n g l y recommended to c o n s u l t t h e i r p h y s i c i a n beforehand. 40 3. V i s u a l Hazards from Poor Water C l a r i t y T h i s problem area i s not as s e r i o u s as pathogenic and hyperthermia concerns, but i t s t i l l deserves water q u a l i t y c o n s i d e r a t i o n beyond mere a e s t h e t i c reasons. F i r s t , i t i s a f a c t o r which can a f f e c t d i s i n f e c t i o n c o n s i d e r a b l y . Lack of c l a r i t y can be a t t r i b u t e d to a number of parameters such as d i s s o l v e d s o l i d s , high pH, e x c e s s i v e foaming, and an abundance of the " f o r e i g n " substances mentioned e a r l i e r . Inadequately s i z e d or p o o r l y maintained f i l t r a t i o n systems can a l s o be a f a c t o r . A l l of these a f f e c t the a b i l i t y of the d i s i n f e c t a n t to work e f f e c t i v e l y . For example, "as the t o t a l d i s s o l v e d s o l i d s b u i l d up i n the water, the s a n i t i z e r (whether c h l o r i n e or bromine) becomes surrounded by these d i s s o l v e d s o l i d s and cannot a t t a c k and k i l l b a c t e r i a and a l g a e . A high l e v e l of t o t a l d i s s o l v e d s o l i d s a l s o a f f e c t s pH. There i s yet no agreed upon general standard, but i t appears that a l e v e l of about 1,500 ppm i s the maximum l e v e l of t o t a l d i s s o l v e d s o l i d s that should be t o l e r a t e d i n a s p a . " 3 9 The other parameters important to a c h i e v i n g c l a r i t y l i m i t d i s i n f e c t i o n d i f f e r e n t l y , but t h e i r e f f e c t s on c l a r i t y can be as e x t e n s i v e as the e f f e c t s from high l e v e l s of d i s s o l v e d s o l i d s . Second, poor water c l a r i t y can be an o b s e r v a t i o n a l problem obscu r i n g the presence of broken g l a s s or other dangerous o b j e c t s t h a t may be i n a spa. Conceivably, i t c o u l d a l s o prevent us from n o t i c i n g a drowning person, e s p e c i a l l y a small c h i l d . A l s o , users and o p e r a t o r s might be unaware of m i s s i n g or 41 broken g r a t e s or o u t l e t s -- c o n d i t i o n s which e n g i n e e r i n g s t u d i e s show i n c r e a s e the chance of h a i r or body entrapment. 4 0 The i n s t a n c e s of water c l a r i t y problems with p u b l i c spas seem to be q u i t e high, mostly i n h e a v i l y - u s e d f a c i l i t i e s . Since t h i s i s e a s i l y n o t i c e d as a problem, i t i s f r e q u e n t l y r e p o r t e d and, u n l i k e pathogenic hazards, i t i s not d i f f i c u l t to i d e n t i f y . Water c l a r i t y problems in spas r e l a t e p r i m a r i l y to bather l o a d , and a f t e r a time, i t becomes v i r t u a l l y impossible to c l e a r the water through f i l t r a t i o n and chemical treatments. The only s o l u t i o n then i s to d r a i n the u n i t completely, c l e a n i t thoroughly, and r e f i l l with f r e s h water. T h i s r e q u i r e s c o n s c i e n t i o u s maintenance, v a r y i n g with each spa o p e r a t i o n . Thus, g u i d e l i n e s recommending i n t e r v a l s f o r d r a i n i n g are d i f f i c u l t to e s t a b l i s h on a uniform b a s i s . N e v e r t h e l e s s , t h i s problem must be addressed to accomplish proper spa water q u a l i t y management. 4. Drowning Hazards R e l a t e d to the Spa A e r a t i o n Systems A f i n a l h e a l t h and s a f e t y hazard r e l a t e s to the a e r a t i o n systems i n spas. For i n order to generate the water pressure necessary f o r a e r a t i o n , c i r c u l a t i o n or booster pumps must be s u f f i c i e n t l y s i z e d to produce flow r a t e s which are much g r e a t e r than normally r e q u i r e d without a e r a t i o n . V e l o c i t i e s generated by these pumps tend to p u l l people or p o r t i o n s of a person's body toward d r a i n s u r f a c e s or other spa water o u t l e t s . 4 1 T h i s leads to p o s s i b l e h a i r or body entrapment whereby i n d i v i d u a l s 42 cannot r e l e a s e themselves from the o u t l e t . I f entrapment occurs underwater (where o u t l e t s are g e n e r a l l y located) the person may drown. If an i n d i v i d u a l ' s head i s not submerged but entrapment prevents l e a v i n g the spa and h e l p i s u n a v a i l a b l e , the p o s s i b i l i t y of hyperthermia danger a r i s e s . F a c t o r s such as: (a) Improperly designed c i r c u l a t i o n systems; (b) swimming pool-designed o u t l e t s (note: there are o u t l e t s f o r spas with s p e c i a l g r a te c o v e r s ) ; and (c) broken o u t l e t g r a te covers a l l can i n c r e a s e the p o s s i b i l i t y of entrapment o c c u r r i n g . Thus, spa o p e r a t o r s must be aware that the spa water q u a l i t y c h a r a c t e r i s t i c of c i r c u l a t i o n has an e f f e c t on s a f e t y measures f o r p r e v e n t i n g entrapment. F i l t r a t i o n i s a l s o an important aspect of spa management i n regard to entrapment, as water c l a r i t y a l l o w s e a s i e r d e t e c t i o n of improper or broken o u t l e t grates and v i c t i m s of entrapment ( t h i s i s e s p e c i a l l y r e l e v a n t to very young c h i l d r e n ; the CPSC's r e p o r t s show drownings from entrapment are h i g h e s t i n the age bracket of c h i l d r e n under 3 years o l d ) . Although the a e r a t i o n system i s not a "pure" water q u a l i t y c o n s i d e r a t i o n , i t i s important to d e a l with simultaneously i n spa management p o l i c y , as i t i s part of the t o t a l spa system which c o n t r o l s water q u a l i t y . Along with heat, a e r a t i o n produces the p r i n c i p a l t h e r a p e u t i c b e n e f i t s of spas, and thus i t s c o n s i d e r a t i o n cannot be ignored. The examination of the four main p o t e n t i a l hazard areas serve as a background f o r i d e n t i f y i n g the s p e c i f i c r i s k s and 43 u n c e r t a i n t i e s a s s o c i a t e d with spa use and f o r then understanding the d i f f i c u l t i e s faced i n d e v i s i n g spa management p o l i c i e s . I d e n t i f i c a t i o n of S p e c i f i c R i s k s and U n c e r t a i n t i e s Within the P o t e n t i a l Hazard Areas In p r e c e d i n g s e c t i o n s , p o t e n t i a l spa hazards areas were i d e n t i f i e d , and w i t h i n those areas, i t may be p o s s i b l e to i t e m i z e s p e c i f i c s i t u a t i o n s of r i s k . However, i f we apply the s t r i c t d e f i n i t i o n of " r i s k " as s t a t e d above, we would f i n d very few a c t u a l s i t u a t i o n s of r i s k s with spas. The a v a i l a b l e data base i s e i t h e r i n s u f f i c i e n t i n many areas or i t has not been s y n t h e s i z e d so that we c o u l d reasonably say that p r o b a b i l i t y d i s t r i b u t i o n s are known. For i n s t a n c e , i t might appear reasonable to designate c e r t a i n pathogenic hazards, such as Pseudomonas aeruginosa, i n the category of r i s k . But there i s inadequate i n f o r m a t i o n about the a c t u a l number of cases, both rep o r t e d and unreported. The most l o g i c a l candidate f o r accumulating t h i s i n f o r m a t i o n on a n a t i o n a l b a s i s i n the U.S. would be the CDC. Yet, to date, they have not accumulated a re c o r d of d i s e a s e - r e l a t e d deaths or i l l n e s s e s a s s o c i a t e d with s p a s . " 2 F u r t h e r , there i s no data a v a i l a b l e on a c t u a l numbers of spa u s e r s . Hence, an assessment of the p r o b a b i l i t y of a spa user becoming i n f e c t e d by Pseudomonas from spa use does not have s t a t i s t i c a l v a l i d i t y at t h i s time. There appear to be only two p o t e n t i a l hazard areas where we c u r r e n t l y c o u l d s p e c i f y r i s k s c o n s i s t e n t with our d e f i n i t i o n . These a r e : 44 1. Hyperthermia hazards - P r e v i o u s l y c i t e d s t u d i e s and l i t e r a t u r e on the e f f e c t s of h e a t / a l c o h o l provide us with a reasonably sound b a s i s f o r determining r i s k s i n t h i s a r e a . Spa use by pregnant women, and i n d i v i d u a l s who are under the i n f l u e n c e of a l c o h o l or drugs, e x e m p l i f i e s s i t u a t i o n s which can be i d e n t i f i e d as r i s k s . 2. Drowning hazards from spa a e r a t i o n systems - The e f f e c t s of h a i r and body entrapment are well-documented. And the r i s k s of drowning from entrapment c o u l d be s p e c i f i e d , p a r t i c u l a r l y i f v i s u a l hazards e x i s t . T h i s i s not meant to imply that we have a c t u a l l y gone to the e f f o r t of s p e c i f y i n g these r i s k s . However, the evidence f o r l a b e l l i n g these items as r i s k s seems to be overwhelmingly agreed upon and acknowledged. Beyond these acknowledged spa r i s k s , we enter s i t u a t i o n s of u n c e r t a i n t y . I n f o r m a t i o n a l U n c e r t a i n t i e s In spa management, there are a number of u n c e r t a i n t i e s which c o u l d be e l i m i n a t e d , reduced, or changed to s t o c h a s t i c u n c e r t a i n t i e s by a d d i t i o n a l i n f o r m a t i o n . For example: A. In r e l a t i o n to pathogenic hazards 1. The range of pathogens which c o u l d e x i s t i n spas and under v a r i o u s c o n d i t i o n s i s not known, but an assembly of a v a i l a b l e knowledge c o u l d c h a n g e the c u r r e n t s i t u a t i o n of u n c e r t a i n t y . 45 2. For any one spa, we do not know the a c t u a l types and numbers of pathogens present or being i n t r o d u c e d by bathers , but c o n c e i v a b l y t e s t i n g or monitoring methods c o u l d provide i n f o r m a t i o n to change the u n c e r t a i n t y . 3 . The range and e f f e c t i v e n e s s of p o s s i b l e p r e v e n t a t i v e measures a g a i n s t v a r i o u s pathogens i n spas i s not s u f f i c i e n t l y known. 4. The s p e c i f i c e f f e c t s of p h y s i c a l and chemical f a c t o r s upon d i s i n f e c t i o n e f f i c a c y in hot water chemistry i s not f u l l y known. (Note: most f a c t o r s are known, but a few are s t i l l open to question.) B. .In r e l a t i o n to hyperthermia hazards 1. The e f f e c t s of spa temperatures upon blood pressure and heart r a t e s c o u l d be determined through assembly of e x i s t i n g medical knowledge. 2. S t a t i s t i c s about the kinds and numbers of "near-miss" hyperthermia cases o c c u r r i n g i n spas are not a v a i l a b l e . C. In r e l a t i o n to poor water c l a r i t y hazards 1. The s p e c i f i c e f f e c t s of p h y s i c a l and chemical f a c t o r s upon water c l a r i t y i n hot water chemistry i s not f u l l y known. (The same a p p l i e s here as f o r d i s i n f e c t i o n e f f i c a c y . ) 2. The r e l a t i o n s h i p between b i o l o g i c a l f a c t o r s and water c l a r i t y i n hot water chemistry have not been f u l l y i d e n t i f i e d . 46 Judgement U n c e r t a i n t i e s These u n c e r t a i n t i e s tend to have some r e l a t i o n s h i p to i n f o r m a t i o n a l u n c e r t a i n t i e s , i n that judgements can be a s s i s t e d by i n c r e a s i n g i n f o r m a t i o n . Judgement u n c e r t a i n t i e s , however, i n v o l v e i n t e r p r e t a t i o n of data where attachment of p r o b a b i l i t i e s to outcomes s t r o n g l y depends upon the weight a t t a c h e d to v a r i o u s inputs of a v a i l a b l e knowledge. T h i s i s d i f f e r e n t i a t e d from i n f o r m a t i o n a l u n c e r t a i n t i e s which can be reduced through accumulation of data and a p p l i c a t i o n of l i n e a r a n a l y s i s . A. In r e l a t i o n to pathogenic hazards 1. The p r o b a b i l i t y of v a r i o u s pathogens e n t e r i n g the spa environment r e q u i r e s judgements about which p o t e n t i a l pathogens should be c o n s i d e r e d f o r a p a r t i c u l a r geographic or socio-economic area (e.g. i s c h o l e r a s t i l l a concern i n North America? How much?) 2. The p r o b a b i l i t y of v a r i o u s pathogens i n f e c t i n g i n d i v i d u a l s and c a u s i n g d i s e a s e depends on judgements about i n d i v i d u a l s ' r e s i s t a n c e to a d i s e a s e . 3 . The probable r e s u l t s of p r e v e n t a t i v e and c o n t r o l measures (e.g., with the use of d i s i n f e c t a n t s ) r e q u i r e judgements re g a r d i n g the " c o r r e c t " combination of other f a c t o r s such as the f o l l o w i n g ; i ) the a p p r o p r i a t e l e v e l of d i s i n f e c t a n t to maintain at a l l times i i ) a p p r o p r i a t e methods and i n t e r v a l s f o r t e s t i n g / m o n i t o r i n g d i s i n f e c t i o n r e s i d u a l s and pathogenic organisms 4 7 i i i ) the q u a n t i t y or dosage of d i s i n f e c t a n t s r e q u i r e d per bather or per g a l l o n ( s ) of spa water over time. i v ) a p p r o p r i a t e i n t e r v a l s and q u a n t i t i e s r e q u i r e d f o r e f f e c t i v e s u p e r c h l o r i n a t i o n . (Note: i t may be that t a k i n g these u n c e r t a i n t i e s together and t r y i n g to a s s i g n a p r o b a b i l i t y r i s k to one s p e c i f i c i n d i v i d u a l in a s p e c i f i c spa at a s p e c i f i c time i s too much of an a n a l y t i c a l task, and t h e r e f o r e becomes a r e a l u n c e r t a i n t y . ) B. In r e l a t i o n to hyperthermia hazards 1. In a d v i s i n g i n d i v i d u a l s having s p e c i a l p h y s i c a l c h a r a c t e r i s t i c s , the probable " s a f e " d e l i n e a t i o n of spa temperature s e t t i n g s r e q u i r e s medical judgements. 2. The management procedure(s) which would be most l i k e l y e f f e c t i v e i n d e t e c t i n g users whose p r i o r p h y s i c a l c o n d i t i o n make t h e i r exposure to spa temperatures unsafe r e q u i r e s both medical and p r a c t i c a l judgements. C. In r e l a t i o n to poor water c l a r i t y hazards 1. The estimated r i s k of d i s e a s e a s s o c i a t e d with v a r i o u s time i n t e r v a l s f o r d r a i n i n g spa waters f o r s p e c i f i e d bather load/water q u a l i t y r a t i o s . 2. The probable amounts of water l o s s from evaporation and splash-out and the r e s u l t i n g e f f e c t s upon the spa water chemi s t r y . 3 . The probable bather and e x t e r n a l environmental e f f e c t s (e.g., d i r t , s u n l i g h t ) upon key i n t e r r e l a t e d chemical 48 parameters. 4. The estimated r i s k of d i s e a s e a s s o c i a t e d with d i f f e r e n t i n t e r v a l s f o r t e s t i n g / m o n i t o r i n g water c l a r i t y . Real U n c e r t a i n t i e s A. In r e l a t i o n to pathogenic hazards 1. The a c t i o n s of spa op e r a t o r s and p u b l i c h e a l t h o f f i c i a l s toward implementing recommended c o n t r o l and p r e v e n t a t i v e measures i s not determinable i n any t r u e p r o b a b i l i s t i c sense. A c t u a l behaviour can only be estimated i n p r a c t i c a l terms as a b a s i s f o r e s t a b l i s h i n g management p o l i c i e s , and such e s t i m a t i o n s would i n v o l v e judgement. However, u n t i l i n f o r m a t i o n about spa a c t o r behaviour i s developed and judgements made, b e h a v i o u r a l f a c t o r s i n spa use remain r e a l u n c e r t a i n t i e s . 2. The a c t i o n s of spa users which might c o n t r i b u t e to the spread of i n f e c t i o u s d i s e a s e both i n t e r n a l and e x t e r n a l t o the spa environment i s a l s o not determinable i n any t r u e p r o b a b i l i s t i c sense. 3. The a c c e p t a b l e l e v e l of pathogenic r i s k f o r spa users, e s p e c i a l l y f u t u r e spa us e r s , depends on i n d i v i d u a l and s o c i a l v a l u e s which can s h i f t over time. Thus, ac c e p t a b l e l e v e l s cannot be p r e d i c t e d f o r the f u t u r e . 4. Our a b i l i t y through d e s i g n , e n g i n e e r i n g , or s a n i t a t i o n p r a c t i c e s to e l i m i n a t e or v i r t u a l l y e l i m i n a t e pathogenic hazards can never be s p e c i f i e d as i t would invoke 49 p r e d i c t i n g a " f u t u r e s t a t e of the world." 5. The p r o b a b i l i t y of emergence of p r e v i o u s l y unknown pathogens immune to n o r m a l l y - p r a c t i c e d s a n i t a t i o n procedures a l s o cannot be p r e d i c t e d . B. In r e l a t i o n to poor water c l a r i t y hazards 1. The behaviour of spa u s e r s , o p e r a t o r s , and h e a l t h o f f i c i a l s toward implementing recommended procedures and norms. 2. The a c c e p t a b l e l e v e l of r i s k from poor water c l a r i t y f o r spa users, e s p e c i a l l y f u t u r e spa u s e r s . C. In r e l a t i o n to hyperthermia hazards 1. The behaviour of the v a r i o u s spa users toward o b s e r v i n g and e n f o r c i n g p r e c a u t i o n a r y temperature warnings 2. The a c c e p t a b l e l e v e l of r i s k from temperature f o r spa users, p a r t i c u l a r l y f o r those i n d i v i d u a l s most s u s c e p t i b l e to problems. I t i s important to note that when i n f o r m a t i o n and judgement u n c e r t a i n t i e s e x i s t , they remain r e a l u n c e r t a i n t i e s f o r management purposes u n t i l the i n f o r m a t i o n i s generated or u n t i l steps are taken to apply expert judgement to convert u n c e r t a i n t i e s to r i s k s . As an a d d i t i o n a l note to our d i s c u s s i o n of u n c e r t a i n t y , we must be c a r e f u l not to take " f a c t s " r e l a t e d to hazards f o r granted. Areas where u n c e r t a i n t i e s have been e l i m i n a t e d or reduced to r i s k s may be s t i l l s u b j e c t to r e a l u n c e r t a i n t y both 50 i n a t e c h n i c a l and b e h a v i o u r a l sense. Advances or d i s c o v e r i e s in the medical, b i o l o g i c a l , and ge n e t i c f i e l d s can be r e v o l u t i o n a r y and yeste r d a y ' s " f a c t s " may become today's myths. For example, recent s t u d i e s i n d i c a t i n g the a b i l i t y of the Pseudomonas organism to produce a p r o t e c t i v e slime c o a t i n g a g a i n s t c h l o r i n e has r a i s e d q u e s t i o n s about the " f a c t s " i n v o l v e d i n k i l l i n g t h i s organism. A l s o , we always need to q u e s t i o n the r e a l a b i l i t y of i n d i v i d u a l s to understand and r e t a i n a v a i l a b l e i n f o r m a t i o n intended to reduce hazards. Real u n c e r t a i n t y i s not l i m i t e d merely to d e l i b e r a t e behaviour. We can never p r e d i c t when i n d i v i d u a l s w i l l f a i l to comprehend communications. The assumption that "everyone c e r t a i n l y understands something" can be dangerous. These types of " v e i l e d " r e a l u n c e r t a i n t i e s suggest that we should a v o i d o v e r - r e l i a n c e upon any one " f a c t " f o r o v e r a l l p o l i c y success or f o r c r i t i c a l outcomes to an i n d i v i d u a l ' s h e a l t h . Major P o l i c y D i f f i c u l t i e s A r i s i n g from Spa Management U n c e r t a i n t i e s The u n c e r t a i n t i e s i n v o l v e d with spa water q u a l i t y management are manifested i n four major areas of d i f f i c u l t y . These d i f f i c u l t i e s cannot be r e s o l v e d , except normatively, because of t h e i r s t r o n g t i e to the judgement and r e a l u n c e r t a i n t i e s . Examining each d i f f i c u l t y s e p a r a t e l y : 1. The d i f f i c u l t y of d e f i n i n g (a) the extent to which spas c r e a t e p u b l i c h e a l t h and s a f e t y hazards and, (b) the p r e c i s e 51 nature of the hazards they c r e a t e . How do we d e f i n e the p r e c i s e nature of spa hazards so that p o l i c i e s can be designed to d e a l e f f e c t i v e l y with the hazards that e x i s t ? With v i s u a l hazards from poor water c l a r i t y and drowning hazards from entrapment, r e l a t i o n s h i p between h e a l t h hazards and spas has been reasonably w e l l determined and no r e a l d i f f i c u l t y e x i s t s . Hyperthermia i s s l i g h t l y more d i f f i c u l t . Medical evidence has p r o v i d e d reasonably good i n f o r m a t i o n about hyperthermia, yet doubts do remain s i n c e temperature and d u r a t i o n t h r e s h o l d s are not t o t a l l y d e f i n e d . D i s i n f e c t i o n and c o n t r o l of pathogenic hazards pose a major d i f f i c u l t y . One h e a l t h o f f i c i a l i n t e r v i e w e d i n d i c a t e d that there are only remote chances of s e c u r e l y l i n k i n g a d i s e a s e problem to a s p e c i f i c source, as doing so r e q u i r e s prompt i n v e s t i g a t i o n , c a r e f u l and a c c u r a t e a n a l y s i s of very complicated r e l a t i o n s h i p s — and a good d e a l of l u c k . 4 3 The dynamic and v a r i a b l e nature of spa water compounds the d i f f i c u l t y of determining cause. E p i d e m i o l o g i c a l s t u d i e s are commonly used as an attempt to overcome the d i f f i c u l t y , but t h i s method i s o f t e n s u b j e c t to s t r o n g c r i t i c i s m . 4 4 T h i s d i f f i c u l t y i s important to our p o l i c y c o n s i d e r a t i o n s because i t "cuts both ways" in a f f e c t i n g our a b i l i t y to judge h e a l t h hazards. In the d i r e c t i o n of t r y i n g to p r o t e c t p u b l i c h e a l t h , i t becomes d i f f i c u l t to document cases c o n v i n c i n g l y 52 enough to s t i m u l a t e and i n i t i a t e a c t i o n . D e s p i t e r e p o r t s of d i s e a s e outbreaks, many p u b l i c h e a l t h o f f i c i a l s have had no problems i n t h e i r j u r i s d i c t i o n . Is the l a c k of r e p o r t e d i n c i d e n t s i n a j u r i s d i c t i o n due to a true absence of problems or the p u b l i c ' s i n a b i l i t y (or l a c k of awareness) f o r r e l a t i n g problems to spa usage? Some of the d i s e a s e s such as rashes are q u i t e common and may not show up f o r s e v e r a l days a f t e r spa exposure. Thus, i n d i v i d u a l s may not see the l i n k between the d i s e a s e and spa use. An example i s Pontiac Fever, where i t i s u n l i k e l y that i n d i v i d u a l s would r e l a t e f l u - l i k e symptoms to t h e i r use of a spa. Conversely, f o r much the same reasons, spas may r e c e i v e i n c o r r e c t blame f o r a d i s e a s e . The Pseudomonas b a c t e r i a l problem may be an example. Research i n d i c a t e s that i t i s normal to f i n d l a r g e numbers of Pseudomonas i n many environments and that i n f e c t i o n may be more predominantly r e l a t e d to f a c t o r s other than human exposure to the organism.* 5 Even i f Pseudomonas i s p r e v a l e n t i n other environments and t h e i r presence i n spas i s unimportant, are spas s t i l l the cause because t h e i r h i g h temperature d i l a t e s pores a l l o w i n g entry? Or would the cause be r e l a t e d to the d e c i s i o n of a user to remove a bandage on a wound while i n the spa, thus choosing t h i s p a r t i c u l a r environment f o r exposure to Pseudomonas? T h e r e f o r e , we a l s o have the p o s s i b i l i t y r a i s e d that although spas may be the a c t u a l l o c a t i o n a l source of a problem, the wrong f a c t o r may be i d e n t i f i e d . Hence, we might e r r o n e o u s l y emphasize d i s i n f e c t i o n i n our p o l i c y c o n s i d e r a t i o n s at p o i n t s where other management 53 c o n s i d e r a t i o n s may be more important. The f o r e g o i n g d i s c u s s i o n i n d i c a t e s that the d i f f i c u l t y of d e f i n i n g the hazards a s s o c i a t e d with spas c r e a t e s two types of problems f o r p o l i c y development. F i r s t , i t may not be easy to d e f i n e the hazards c o n v i n c i n g l y enough to s t i m u l a t e a c t i o n by policy-making o f f i c i a l s . Second, because of h i g h l y v a r i a b l e c o n d i t i o n s of use and intake water, and the u n c e r t a i n t i e s faced i n d e f i n i n g c a u s e - e f f e c t r e l a t i o n s , i t i s d i f f i c u l t to p r e s c r i b e p r e v e n t a t i v e measures that w i l l reduce or e l i m i n a t e the hazard. 2 . The d i f f i c u l t y of b a l a n c i n g h e a l t h b e n e f i t s a g a i n s t h e a l t h hazards i n choosing amongst a p p r o p r i a t e p o l i c i e s . T h i s i s a c e n t r a l q u e s t i o n r a i s e d by h e a l t h o f f i c i a l s and the i n d u s t r y . Many people who use spas f o r h e a l t h reasons are those who are a l s o most prone to the p o t e n t i a l hazards. A person who f e e l s i l l and under medication may go i n t o a spa to f e e l b e t t e r , but a l s o s u b j e c t s himself to hyperthermia or pathogenic dangers (the example of a r t h r i t i s p a t i e n t s has been c i t e d e a r l i e r ) . Tense and s t r e s s f u l persons l o o k i n g to r e l a x may encounter high blood p r e s s u r e problems. And people aching from c o l d s or the f l u may use a spa whereby t h e i r i l l n e s s not only reduces t h e i r r e s i s t a n c e to other d i s e a s e s but a l s o exposes other users to germs. T h i s d i f f i c u l t y stems from s e v e r a l problems. F i r s t , the b e n e f i t s from spa use and the importance att a c h e d to the hazards of spa use v a r i e s among i n d i v i d u a l s i n accord with t h e i r values 54 which cannot be p r e c i s e l y measured. Second, the u n c e r t a i n t i e s in d e f i n i n g hazards and the u n c e r t a i n t i e s about the p h y s i c a l and p s y c h o l o g i c a l e f f e c t s of spa use make i t d i f f i c u l t f o r an i n d i v i d u a l to compare b e n e f i t s and adverse e f f e c t s i n a l o g i c a l f a s h i o n . T h i r d , s o c i e t y has not made a c l e a r d e t e r m i n a t i o n of the extent to which an i n d i v i d u a l i s e n t i t l e d to endanger h i s own h e a l t h and to endanger the w e l l - b e i n g of other members of s o c i e t y . Yet, p o l i c i e s must be developed i n the absence of a c l e a r r e s o l u t i o n of these problems. 3 . The d i f f i c u l t y of e s t a b l i s h i n g standards i n the face of wide v a r i a b i l i t y among c o n d i t i o n s at d i f f e r e n t spas and over time. The three p r i n c i p a l v a r i a b l e s (spa water p h y s i c a l / c h e m i c a l c h a r a c t e r i s t i c s , presence of b i o l o g i c a l / o r g a n i c m a t e r i a l s , and spa usage by i n d i v i d u a l s ) c r e a t e a d i f f i c u l t y i n d e v i s i n g standards which cover the range of c o n d i t i o n s without being vague. I f standards are too narrowly formulated, they may be i n a p p r o p r i a t e or i n a p p l i c a b l e to some spa f a c i l i t i e s or to a s p e c i f i c spa f a c i l i t y at c e r t a i n times. I f standards are devi s e d too broadly, they may f a i l to guide o p e r a t o r s i n spa management and f a i l to provide users and h e a l t h o f f i c i a l s with a s u f f i c i e n t l y p r e c i s e c r i t e r i o n f o r e v a l u a t i n g c o n d i t i o n s of a spa f a c i l i t y . An example of t h i s with spas i s the g u i d e l i n e f o r p e r i o d i c a l l y d r a i n i n g the u n i t s . An i n t e r v i e w with the d i r e c t o r of the U n i v e r s i t y of B r i t i s h Columbia Aquatic Centre w e l l 55 i l l u s t r a t e s the dilemma. Upon l o o k i n g over the CDC spa g u i d e l i n e s , h i s f i r s t remark was "This i s n i c e , but i f I fol l o w e d t h e i r recommendation on d r a i n i n g , I would have a l l kinds of problems.'" 1 6 The reason f o r h i s comment was that UBC's spa has an e x c e p t i o n a l l y high bather l o a d , and the CDC's vague g u i d e l i n e of " c o n t i n u o u s l y or at l e a s t once a month" i s not very h e l p f u l . The word " c o n t i n u o u s l y " i s uncl e a r and "once a month" would be d e f i c i e n t f o r that spa. By experience, he t h i n k s that i t needs to be dr a i n e d at l e a s t 2-3 times a week. The CDC g u i d e l i n e makes l i t t l e sense, as an e f f e c t i v e s o l u t i o n u l t i m a t e l y r e s t s on the operator's process of t r i a l - a n d - e r r o r and judgement with a s p e c i f i c spa — and even those s o l u t i o n s may be temporary due to v a r i a b i l i t y f a c t o r s . I t might be suggested that the drainage q u e s t i o n c o u l d be so l v e d by choosing a more a p p r o p r i a t e parameter, such as number of bathers. The problem with t h i s i s that even i f we assumed a l l other c o n d i t i o n s c o u l d be h e l d constant (not a good assumption), one bather i s not the same as the next. Each i n d i v i d u a l w i l l i n t r o d u c e wide v a r i a t i o n s of b i o l o g i c a l and organic m a t e r i a l i n t o the spa. Furthermore, simply d r a i n i n g a spa does l i t t l e good i f i t i s not clea n e d p r o p e r l y p r i o r to r e f i l l i n g . The d i f f i c u l t y r e s t s i n the b a s i c c h a r a c t e r i s t i c s of spas e a r l i e r d e s c r i b e d and a p p l i e s to many other problems besides the que s t i o n of d r a i n i n g . The h i g h l y v a r i a b l e and v o l a t i l e r e a c t i o n s of spa water dooms r i g i d l y - f o r m e d standards to 56 f a i l u r e . I n e v i t a b l y , e x c e p t i o n s w i l l a r i s e — and most f r u s t r a t i n g of a l l , there w i l l be many exce p t i o n s of a l l types we cannot even make a r u l e of except i o n s ! T h i s dilemma h a r d l y eases our worries about developing guidance and a s s u r i n g some measure of c o n t r o l over hazards, but the e x i s t e n c e of high v a r i a b i l i t y i s a r e a l i t y . Consequently, we may be f o r c e d to develop ranges which are f l e x i b l e enough to a n t i c i p a t e v a r i a t i o n s so that c o u n t e r i n g a c t i o n s can be taken. T h i s i s reasonable and can s t i l l a l low standards to be more e f f e c t i v e d e s p i t e the d i f f i c u l t i e s . For p o l i c y to be e f f e c t i v e , however, i n f o r m a t i o n about the types and sources of v a r i a b i l i t y must be adequately disseminated and o p e r a t o r s have to be t r a i n e d to respond to the v a r y i n g water q u a l i t y c o n d i t i o n s . 4. The d i f f i c u l t y of p r e d i c t i n g or a n t i c i p a t i n g the behaviour of spa users, spa o p e r a t o r s , p u b l i c h e a l t h o f f i c i a l s and i n d u s t r y r e p r e s e n t a t i v e s . In working toward d e v e l o p i n g a framework and e v a l u a t i o n of p o l i c y a l t e r n a t i v e s f o r p u b l i c spa management i n B r i t i s h Columbia, a background of the case study problems would be incomplete without c o n s i d e r i n g matters of behaviour. The behaviour of spa o p e r a t o r s , government agenci e s , spa u s e r s , and the i n d u s t r y i s important to e s t a b l i s h i n g a p p r o p r i a t e spa management p o l i c i e s . There i s a s u b s t a n t i a l body of knowledge about i n d i v i d u a l and o r g a n i z a t i o n a l behaviour, and where u n c e r t a i n t i e s e x i s t , 57 experimentation can i n c r e a s e knowledge of spa a c t o r behaviour. Thus, spa a c t o r behaviour i s a d i f f i c u l t y which p o l i c y must address, but i t i s not an insurmountable one. For p o l i c y purposes, p r e d i c t i n g "average" behaviour of spa a c t o r s i s important even though i t i s impossible to p r e d i c t how a s p e c i f i c operator or user w i l l behave. The key group f o r purposes of implementation c o n s i s t s of the spa o p e r a t o r s because of t h e i r a c t u a l day-to-day c o n t r o l over spa water c o n d i t i o n s . C e r t a i n l y , the others have an i n f l u e n c e i n the process, but spa o p e r a t o r s have the most independence and d i r e c t involvement. Speaking f o r many of the v a r i o u s people i n t e r e s t e d i n spa water q u a l i t y management, one i n d u s t r y researcher has w r i t t e n , "Keep i n mind, r e g a r d l e s s of standards developed, chemicals used, or how good the support equipment, unless the operator i s knowledgeable on how to maintain the spa, the problems w i l l s t i l l e x i s t . To summarize then, the development of standards i s not what i s important here, i t ' s how those standards are used."" 7 Within t h i s statement, the problems r e l a t e d to b e h a v i o u r a l c o n s i d e r a t i o n s are w e l l encapsulated. The main spa a c t o r s can be d e f i n e d as f o l l o w s : The term "spa o p e r a t o r " i s d e f i n e d as: an i n d i v i d u a l ( e i t h e r an owner, manager or other employee of a spa f a c i l i t y ) , who i s i n charge of the spa o p e r a t i o n s on a d a i l y or p e r i o d i c b a s i s . Operation of spas e n t a i l s maintenance, m o n i t o r i n g , and management of the spa u n i t s . 58 "Spa Users" are d e f i n e d as i n d i v i d u a l s who p a r t i c i p a t e i n the use of p u b l i c spa f a c i l i t i e s . Frequency of use i s not a determinant f o r d e s i g n a t i n g i n d i v i d u a l s as spa u s e r s . Spa users do not c o n s t i t u t e the general p u b l i c , per se; the term "non-u s e r s " may l a t e r be a p p l i e d to the p o p u l a t i o n which never uses p u b l i c spas. " P u b l i c H e a l t h O f f i c i a l s ' ' i n c l u d e a l l the i n d i v i d u a l s who d i r e c t l y work f o r p u b l i c h e a l t h agencies w i t h i n any j u r i s d i c t i o n . These people are i n v o l v e d i n the d a i l y a d m i n i s t r a t i o n of p u b l i c h e a l t h l e g i s l a t i o n . L e g i s l a t o r s , o u t s i d e s c i e n t i s t s , c o n s u l t a n t s , or others who i n d i r e c t l y d e a l with p u b l i c h e a l t h agencies are not i n c l u d e d i n t h i s category. "Industry r e p r e s e n t a t i v e s " are i n d i v i d u a l s employed by p r o f i t and n o t - f o r - p r o f i t o r g a n i z a t i o n s i n v o l v e d i n the pool and spa i n d u s t r y . These people may d i r e c t l y i n t e r a c t with the spa o p e r a t o r s or they may have i n d i r e c t l i n k s through the manufacturing i n d u s t r y to consumer business c h a i n s . A d e t a i l e d c h a r a c t e r i z a t i o n of these a c t o r s i s provided i n Appendix C along with suggestions about how to account f o r t h e i r behaviour i n p o l i c y development and implementation. As both a s i g n i f i c a n t r e a l u n c e r t a i n t y and a s t r o n g f a c t o r i n i n f l u e n c i n g the eventual outcome of spa management p o l i c y , behaviour i s an important c o n s i d e r a t i o n , yet our i n s t i t u t i o n a l a b i l i t i e s to d e a l with i t are o f t e n inadequate. The importance of the behaviour of spa a c t o r s f o r p o l i c y design i s i l l u s t r a t e d by the f o l l o w i n g l i s t of q u e s t i o n s . 59 1. What i n c e n t i v e s can be provided to induce spa operat o r s to manage t h e i r f a c i l i t i e s so as to minimize h e a l t h hazards? 2 . How can users be motivated to take s u i t a b l e p r e c a u t i o n s to p r o t e c t t h e i r own h e a l t h and he l p to minimize hazards to other users and non-users? 3 . How can p u b l i c h e a l t h o f f i c i a l s be motivated to f u n c t i o n i n a c o n s t r u c t i v e way to upgrade spa ope r a t i o n s ? S c i e n t i f i c s t u d i e s of o r g a n i z a t i o n a l and i n d i v i d u a l behaviour can provide a b a s i s f o r c o n s t r u c t i v e experimentation with p o l i c i e s that are responsive to human b e h a v i o u r a l c h a r a c t e r i s t i c s . B a s i c Issues Involved i n the Regulation of Spas The i d e n t i f i c a t i o n of u n c e r t a i n t i e s a s s o c i a t e d with spa management and the r e s u l t i n g d i f f i c u l t i e s these u n c e r t a i n t i e s pose f o r p o l i c y development serve to c l a r i f y the b a s i c i s s u e s which p o l i c y design must address. These b a s i c i s s u e s a re: 1. How are users of spas to " p r o t e c t " themselves or be " p r o t e c t e d " from p o t e n t i a l impairment of t h e i r h e a l t h r e s u l t i n g from spa use? F u r t h e r : - What i s the r e s p o n s i b i l i t y of government? - What i s the r e s p o n s i b i l i t y of the user? - What i s the r e s p o n s i b i l i t y of spa oper a t o r s ? 2 . How are non-users of spas to p r o t e c t themselves or be p r o t e c t e d from p o t e n t i a l impairment of t h e i r h e a l t h r e s u l t i n g from spa o p e r a t i o n s ? How do users p r o t e c t 60 themselves or be p r o t e c t e d from other users? Again, what i s the r e s p o n s i b i l i t y of government, of o p e r a t o r s , and of users? 3. I f government does r e g u l a t e , c o n t r o l , or i n f l u e n c e (e.g., by i n c e n t i v e s ) spa o p e r a t i o n s , how should i t go about d e c i d i n g what measures to i n s t i t u t e ? - What should be the r o l e of s c i e n t i s t s and other experts? - What should be the r o l e of the bureaucracy? - What should be the r o l e of o p e r a t o r s , users, and non-users (the general p u b l i c ) ? - What should be the r o l e of e l e c t e d o f f i c i a l s ? 4. I f government i s i n v o l v e d in " i n f o r m i n g " users and non-users about r i s k s , u n c e r t a i n t i e s , and a p p r o p r i a t e spa use, how does i t proceed i n developing " r e l i a b l e " or " a c c u r a t e " information? What should be the r o l e of s c i e n t i s t s , government pers o n n e l , o p e r a t o r s , i n d u s t r y , the general p u b l i c and e l e c t e d o f f i c i a l s i n d e c i d i n g upon the content and procedures f o r such communication? 5. How should government r e g u l a t i o n s or i n c e n t i v e s be implemented so as to be e f f e c t i v e ? 6. In view of u n c e r t a i n t i e s , advances must emerge from experiment and e x p e r i e n c e . How can c r e a t i v e advance and l e a r n i n g be f o s t e r e d and f a c i l i t a t e d ? The i s s u e s thus emerge from examination of the r i s k s , u n c e r t a i n t i e s , and d i f f i c u l t i e s a s s o c i a t e d with spa management. To s e l e c t any form of p o l i c y f o r p u b l i c spas these i s s u e s must 61 be addressed w i t h i n the context of whatever premises our design of p o l i c y i s based. In the next chapter, a framework i s developed as a b a s i s f o r e v a l u a t i n g design of p o l i c y f o r B r i t i s h Columbia. 62 Footnotes - Chapter 2 'E.S. Quade, A n a l y s i s f o r P u b l i c D e c i s i o n s , 2nd e d i t i o n (North H o l l a n d ; New York, Amsterdam, O x f o r d ) : E l s e v i e r Science P u b l i s h i n g Co., I n c . ) , 1982. 2 I b i d . 3 I b i d . " I b i d . 5U.S. Dept. of Health and Human S e r v i c e s , op. c i t . , p r e f a c e . 6 V i c t o r i a R. Brown, Spa A s s o c i a t e d Hazards - An Update and Summary, U.S. Consumer Product Safety Commission, Washington, D.C, D i r e c t o r a t e f o r Hazard I d e n t i f i c a t i o n and A n a l y s i s D i v i s i o n of Human F a c t o r s , May, 1981, p. 1. 7 I b i d . , p. 3. 8"Drownings Spur R e c a l l of Spa P a r t , " Chicago Tribune, June 26, 1982, S e c t i o n 1, p. 17. 9 I n t e r v i e w with D a n i e l T a r r y , Environmental H e a l t h O f f i c e , V i l l a g e of A r l i n g t o n Heights, I l l i n o i s , J u l y 13, 1982. 1 0 M a j . W i l l i a m J . Sausker et a l . , Pseudomonas F o l l i c u l i t i s A c q u i r e d from a Hea l t h Spa W h i r l p o o l , J o u r n a l of the American Me d i c a l A s s o c i a t i o n , June 2, 1978, p. 2364. 1 1 W i l l i a m J . McCausland and Paul J . Cox, "Pseudomonas I n f e c t i o n Traced to Motel W h i r l p o o l " , J o u r n a l of Environmental H e a l t h , M a r c h / A p r i l 1975, p. 458. 1 2 I b i d . 1 3 G r e a t Lakes Bi o c h e m i c a l , op. c i t . , pp. 5-6. 1 4Rand Green, Pool & Spa News, "Water Chemistry Workshop; Part I I " , August 17, 1981, p. 59. 1 i n t e r v i e w with George Watson, Great Lakes Bi o c h e m i c a l , June 28, 1982. 1 6 J o h n Washburn et a l . , "Pseudomonas aeruginosa Rash A s s o c i a t e d With a W h i r l p o o l , " J o u r n a l of the American Medical A s s o c i a t i o n , May 17, 1976, pp. 2205-2207. 1 7U.S. Dept. of Health & Human S e r v i c e s / P u b l i c Health S e r v i c e , "Outbreak of Pseudomonas aeruginosa Serotype 0:9 A s s o c i a t e d With a W h i r l p o o l , " M o r b i d i t y and M o r t a l i t y Weekly Report, Centers f o r Disease C o n t r o l , J u l y 17, 1981, p. 324. 63 1 8 P o o l & Spa News, "ISTI Backs Pseudomonas Study; Causes, Prevention Sought," February 9, 1981, p. 148. 1 9 R o b e r t J a n i s , op. c i t . , p. 16. 2 0 I n t e r v i e w with John Puetz, Head of Research, Great Lakes Biochemical Co., Inc., Milwaukee, Wis., J u l y 13, 1982. 2 1 T e s t samples of the pseudomonas b a c t e r i a were c u l t u r e d out of H e a l t h Dept., but when sent to Bio-Lab, Inc. the organisms d i e d i n 30 seconds at 1.0 ppm. Pool & Spa News, op. c i t . , Feb. 9, 1981, p. 148. A l s o confirmed i n l e t t e r and memo from James M i l l e r , D i r e c t o r of M i c r o b i o l o g y , Bio-Lab, Inc., J u l y 28, 1982. 2 2G.P. F i t z g e r a l d and M.E. Der V a r t a n i a n , "Pseudomonas aeurigonosa f o r the E v a l u a t i o n of Swimming Pool C h l o r i n a t i o n and A l g i c i d e s , " A p p l i e d M i c r o b i o l o g y , March, 1969, pp. 415-421. 2 3 V i c t o r J . C a b e l l i , H a r r i e t Kennedy, and M o r r i s A. L e v i n , "Pseudomonas a e r u g i n o s a - f e c a l C o l i f o r m R e l a t i o n s h i p s i n E s t u a r i n e and Fresh R e c r e a t i o n a l Waters," J o u r n a l of Water P o l l u t i o n C o n t r o l F e d e r a t i o n , February 1976, pp. 367-376. 2 f t P o o l & Spa News, op. c i t . , February 9, 1981, p. 148. 2 5CDC, M o r b i d i t y and M o r t a l i t y Report Weekly Report, op. c i t . , J u l y 17, 1981. 2 6 P o o l & Spa News, op. c i t . , February 9, 1981, p. 148. 2 7 L e t t e r from James J . M i l l e r , D i r e c t o r of M i c r o b i o l o g y , Bio-Lab, Inc., Decatur, Ga., J u l y 28, 1982. 2 8 J o r i a n C l a i r , E d i t o r , " R e f l e c t i o n s , " Pool & Spa News, Feburary 8, 1982, p. 6. 2 9 R o b e r t J a n i s , Pool & Spa News, op. c i t . , A p r i l 5, 1982, p. 1 6. 3 0 J o r i a n C l a i r , op. c i t . 3 1 G a r y L. Latimer and R i c h a r d A. Ormsbee, L e g i o n n a i r e ' s Disease, Marcel Dekker, Inc., New York. 3 2 I n t e r v i e w with Dr. E l l e n E. Jones, CDC, A t l a n t a , Ga., August 11, 1982. 3 3 I n t e r v i e w with John Puetz, op. c i t . 3 " I n t e r v i e w w i t h Dave A n t o n a c c i , op. c i t . 3 5 V i c t o r i a R. Brown, U.S.CP.S.C. , op. c i t . 64 3 6 V i c t o r i a " R. Brown U.S.C.P.S.C., op. c i t . p. 9. 3 7Mary Ann S. Harvey, M a r c e l l a M. McRorie, and David W. Smith, "Suggested L i m i t s of Exposure in the Hot Tub and Sauna f o r the Pregnant Woman," From the Dysmorphology U n i t , Dept. of P e d i a t r i c s , C h i l d Development and Mental R e t a r d a t i o n Center, and the Center f o r I n h e r i t e d Diseases, U n i v e r s i t y of Washington School of Medicine, S e a t t l e , Wash., 1980. 3 8 I n t e r v i e w with V i c t o r i a Brown, CPSC, Washington, D.C, August 10, 1982. 3 9 B o b Lowry, "Hot Water Chemistry," Pool & Spa News, February 8, 1982, p. 96. "°William N. Rowley, D i r e c t o r of E n g i n e e r i n g and Gordon F. E h r e t , Chief Engineer, Swimquip, a D i v i s i o n of Wylain, Inc., "Primer on S u c t i o n Entrapment i n Swimming Pools or Therapeutic P o o l s " . 4 ' W i l l i a m N. Rowley and Gordon F. Ehret, i b i d . " i n t e r v i e w with Dr. Steve C o c h i , R e s p i r a t o r y and S p e c i a l Pathogens Branch, CDC, A t l a n t a , Ga., January 27, 1983. " i n t e r v i e w with D a n i e l T a r r y , op. c i t . " " W i l l i a m W. Lawrance, Of Acceptable Risk, Science and the Determination of S a f e t y , (Los A l t o s , Ca.: W i l l i a m Kaufman, Inc., 1976), pp. 13-14. " i n t e r v i e w with Dave A n t o n a c c i , op. c i t . ( a l s o may be r e f e r e n c e d to the s t u d i e s by F i t z g e r a l d , et a l . and C a b e l l , et a l . ) . " i n t e r v i e w with Jim Bremner, D i r e c t o r , UBC Aquatic Centre, Vancouver, B.C., J u l y 26, 1982. " 7 L e t t e r from John Puetz, Head of Research, Great Lakes Biochemical Co., Inc., Milwaukee, Wis., A p r i l 22, 1982. 65 CHAPTER 3 How Should P u b l i c Spa and Hot Tub P o l i c y Be Designed? One method of addr e s s i n g the i s s u e s r a i s e d i n the preceding chapter i s to develop a t h e o r e t i c a l framework based on l i t e r a t u r e i n the sub j e c t area which can then be used to eval u a t e a l t e r n a t i v e p o l i c i e s . U n f o r t u n a t e l y , i n p u b l i c h e a l t h areas where s i t u a t i o n s of r i s k and u n c e r t a i n t y are complicated by complex t e c h n i c a l and s c i e n t i f i c matters, the development of a con c e p t u a l framework i s d i f f i c u l t . Debate i n the l i t e r a t u r e and i n p r a c t i c e continues to rage over the best approach to p u b l i c h e a l t h hazard problems such as our case study problem e x e m p l i f i e s . The premises c o n t a i n e d below are s u r e l y s u b j e c t to disagreement depending on one's p e r s p e c t i v e . However, they do represent an organized approach based upon widely-accepted views which can be a p p l i e d to p o l i c y e v a l u a t i o n . 1 . What i s the r e s p o n s i b i l i t y of government to p r o t e c t the h e a l t h and w e l l - b e i n g of users of spa f a c i l i t i e s when complex t e c h n i c a l and s c i e n t i f i c i n f o r m a t i o n determine s a f e t y ? Economic theory t e l l s us that an e f f i c i e n t market r e q u i r e s t h a t users be informed about the consequences of a c q u i r i n g a good or s e r v i c e . 1 2 3 Although spa users c o u l d inform themselves about spas, the t e c h n i c a l i n f o r m a t i o n i s so complex that a c q u i s i t i o n of info r m a t i o n would be too c o s t l y and i m p r a c t i c a l f o r most u s e r s . Because the t e c h n i c a l i n f o r m a t i o n i s so 66 complex, i t seems that n e i t h e r government nor p r i v a t e groups can communicate to a spa user a l l the in f o r m a t i o n he r e q u i r e s to make an informed c h o i c e . " 5 6 T h e r e f o r e , some process i n which i n d i v i d u a l s have confidence must be organized to e s t a b l i s h what c o n s t i t u t e s reasonably " s a f e " c o n d i t i o n s of use. U n c e r t a i n t i e s a l s o need to be s p e c i f i e d . F i n a l l y , there must be a means to t r a n s f e r a v a i l a b l e i n f o r m a t i o n i n t o the development and implementation of procedures which assure that " s a f e " c o n d i t i o n s of use are being f o l l o w e d . 7 8 Thus, i f we assume that a l i b e r a l democratic system r e q u i r e s that an i n d i v i d u a l i s e n t i t l e d to "good" i n f o r m a t i o n on which to deci d e whether i t i s d e s i r e a b l e to use a given spa, i t i s p r a c t i c a b l e to supply the o r d i n a r y user with two items of in f o r m a t i o n : The f i r s t item i s whether c o n d i t i o n s of " s a f e " use have been e s t a b l i s h e d by a l e g i t i m a t e l y recognized body and second, whether reasonable p r e c a u t i o n s have been taken to meet those c o n d i t i o n s i n a spa that a user might u t i l i z e . There appears to be no reasonable a l t e r n a t e way f o r government to supply t h i s k i nd of i n f o r m a t i o n . Users who wish to examine inf o r m a t i o n u t i l i z e d i n determining what c o n s t i t u t e s " s a f e " c o n d i t i o n s should have access to i t , i n c l u d i n g i n f o r m a t i o n about any u n c e r t a i n t i e s that have been c o n s i d e r e d . The system, however, must be geared to the l a r g e body of users who cannot a f f o r d the c o s t s or employ the s k i l l s to make an independent judgement of what c o n s t i t u t e s " s a f e " c o n d i t i o n s and to determine 6 7 whether such c o n d i t i o n s are being met. I t must be r e c o g n i z e d that some i n d i v i d u a l s w i l l r e q u i r e a d d i t i o n a l i n f o r m a t i o n beyond what i s r e f e r r e d to above. These are i n d i v i d u a l s who may be unable to t o l e r a t e c o n d i t i o n s that are reasonably " s a f e " f o r most people. These i n d i v i d u a l s are e n t i t l e d to i n f o r m a t i o n about: a) I n d i v i d u a l c h a r a c t e r i s t i c s (e.g., heart c o n d i t i o n , age, pregnancy) which r e q u i r e that s p e c i a l p r e c a u t i o n s be taken to ensure " s a f e " use. b) The types of s p e c i a l p r e c a u t i o n s which should be taken f o r each c h a r a c t e r i s t i c . I t i s the r e s p o n s i b i l i t y of government to see that reasonable steps are taken to inform p r o s p e c t i v e users as to what these c h a r a c t e r i s t i c s are and what s p e c i a l p r e c a u t i o n s are r e q u i r e d f o r each. I t should be r e c o g n i z e d that the development and communication of i n f o r m a t i o n has c o s t s which may be s i g n i f i c a n t . Industry i s g e n e r a l l y r e l u c t a n t to absorb these c o s t s unless d e v e l o p i n g and communicating i n f o r m a t i o n serves t h e i r i n t e r e s t s . Operators and users, on an i n d i v i d u a l b a s i s , do not have the a b i l i t y or resources f o r developing and communicating i n f o r m a t i o n . Thus, government must e i t h e r p r o v i d e necessary funds or e s t a b l i s h a process f o r c o l l e c t i n g funds from i n d u s t r y , o p e r a t o r s , and u s e r s . •> In s h o r t , i t i s the r e s p o n s i b i l i t y of government to 6 8 p r o s p e c t i v e spa users t o : - e s t a b l i s h the c o n d i t i o n s under which spas can be used with reasonable s a f e t y by the average member of the gen e r a l p u b l i c . - provide reasonable assurance t h a t a given spa meets these c o n d i t i o n s . - see that the p u b l i c has r e l i a b l e access to i n f o r m a t i o n about i n d i v i d u a l c h a r a c t e r i s t i c s which r e q u i r e that s p e c i a l p r e c a u t i o n s be taken. - see that the p u b l i c has r e l i a b l e access to i n f o r m a t i o n about the s p e c i a l p r e c a u t i o n s that should be taken f o r each c h a r a c t e r i s t i c m e r i t i n g s p e c i a l a t t e n t i o n . - p r o v i d e p u b l i c funding or e s t a b l i s h a process of c o l l e c t i n g funds from the spa a c t o r s f o r development and communication of necessary i n f o r m a t i o n . 2 . What i s the r e s p o n s i b i l i t y of government to those who may s u f f e r from the e x t e r n a l e f f e c t s of spa op e r a t i o n s ? " E x t e r n a l i t i e s " or " t h i r d p a r t y e f f e c t s " may be d e f i n e d as those p o s i t i v e or negative e f f e c t s caused by the a c t i o n s of one i n d i v i d u a l (or group, f i r m , e t c . ) upon the welfar e of another without some l e g a l l y r e c o g n i z a b l e mechanism f o r compensation or red r e s s being a v a i l a b l e . 9 " T h i r d - p a r t y c o s t s " can be imposed upon the general p u b l i c from spa o p e r a t i o n s i f a spa user c o n t r a c t s an i n f e c t i o u s d i s e a s e from a spa and l a t e r i n f e c t s non-users. Such c o s t s can 69 a l s o be imposed on spa users by another user i n a s i t u a t i o n where an i n d i v i d u a l n e g l i g e n t l y e n t e r s a spa with an i l l n e s s or open wound and t r a n s m i t s a d i s e a s e to other u s e r s . In both of these cases, a user b e n e f i t s from spa o p e r a t i o n s but imposes c o s t s on others without p r o v i d i n g compensation (and u s u a l l y without consent of the harmed p a r t y ) . In a sense, such e f f e c t s amount to s u b s i d i e s f o r the users who b e n e f i t but do not bear the f u l l c o s t s of t h e i r a c t i v i t i e s . Government i s the re c o g n i z e d i n s t i t u t i o n f o r r e p r e s e n t i n g the i n t e r e s t s of those who may be v u l n e r a b l e to adverse e x t e r n a l e f f e c t s . 1 0 In the case of spa o p e r a t i o n s these adverse e f f e c t s take the form of some type of i n f e c t i o n or d i s e a s e . I t i s i m p r a c t i c a l to compensate the a d v e r s e l y a f f e c t e d p a r t y f o r s u f f e r i n g these c o s t s because one's h e a l t h i s g e n e r a l l y regarded as being beyond monetary va l u e . T h e r e f o r e , i t i s the r e s p o n s i b i l i t y of government to see that users of p u b l i c spas and the general p u b l i c have reasonable assurance that the o p e r a t i o n of spas w i l l not impose e f f e c t s adverse to the h e a l t h of both users and non-users. I t i s recog n i z e d that governments cannot provide absolute assurance of such p r o t e c t i o n . T h i s i s p a r t l y due to u n c e r t a i n t i e s and p a r t l y due to the i m p o s s i b i l i t y of m a i n t a i n i n g a b s o l u t e c o n t r o l over the performance of spa operat o r s and us e r s . Government r e s p o n s i b i l i t y t h e r e f o r e c o n s i s t s of e s t a b l i s h i n g the c o n d i t i o n s of sa f e use and t a k i n g steps to 7 0 enforce such c o n d i t i o n s . Nonetheless, the l i a b i l i t y of the n e g l i g e n t operator and of the n e g l i g e n t user must s t i l l e x i s t , as i t does under our system of laws for other human a c t i v i t i e s , such as d r i v i n g an automobile. 3 . In view of the t e c h n i c a l and s c i e n t i f i c nature of spa management, how should government d e c i s i o n s be made which r e l a t e to r e g u l a t i o n of spa d e s i g n / o p e r a t i n g procedures and to d e t e r m i n a t i o n of the kinds of i n f o r m a t i o n t h a t should be communicated to the p u b l i c ? What should be the r o l e of s c i e n t i s t s , government a d m i n i s t r a t o r s , spa o p e r a t o r s , i n d u s t r y r e p r e s e n t a t i v e s , and concerned members of the p u b l i c i n such decision-making? In a c c o r d with l i b e r a l democratic theory, a "good" p u b l i c d e c i s i o n process takes i n t o account the p r e f e r e n c e s of the a f f e c t e d p a r t i e s , which are determined by t h e i r values and i n t e r e s t s . When pre f e r e n c e s d i f f e r , e l e c t e d r e p r e s e n t a t i v e s are r e s p o n s i b l e f o r weighing these d i f f e r e n c e s and d e c i d i n g what course to pursue. In order f o r the a f f e c t e d p a r t i e s u sers, o p e r a t o r s , i n d u s t r y r e p r e s e n t a t i v e s , and members of the g e n e r a l p u b l i c -- to decide upon t h e i r p o l i c y p r e f e r e n c e s , they need to be w e l l informed about how a l t e r n a t i v e management p o l i c i e s w i l l a f f e c t t h e i r i n d i v i d u a l o b j e c t i v e s and what r i s k s and u n c e r t a i n t i e s are a s s o c i a t e d with a l t e r n a t i v e p o l i c i e s . 1 1 1 2 Since e f f e c t s and the means of modifying them are determined by such complex methods as the e n g i n e e r i n g design of spas, the 71 chemistry of water and d i s i n f e c t a n t s , microorganism growth and human ph y s i o l o g y , s c i e n t i s t s must be employed to generate most of the f a c t u a l i n f o r m a t i o n that a f f e c t e d p a r t i e s r e q u i r e to determine t h e i r p r e f e r e n c e s . Securing e f f e c t i v e p a r t i c i p a t i o n and understanding of a l t e r n a t i v e management p o l i c i e s by a l l the a f f e c t e d p a r t i e s i n v o l v e s c o s t s (e.g., f o r p u b l i c awareness seminars, pamphlets, etc.) These c o s t s must be accounted f o r i n order f o r the decision-making to f u n c t i o n p r o p e r l y . The decision-making system must, t h e r e f o r e , have the f o l l o w i n g key f e a t u r e s : 1. A l t e r n a t i v e management p o l i c i e s should be c o n c e p t u a l i z e d by a l l of the a f f e c t e d p a r t i e s on the b a s i s of i n f o r m a t i o n s u p p l i e d by s c i e n t i s t s with a p p r o p r i a t e s p e c i a l t i e s . 2 . Government a d m i n i s t r a t o r s should f a c i l i t a t e the d e c i s i o n process, but not engage i n the r o l e of d e c i s i o n makers. They should f a c i l i t a t e (a) the u t i l i z a t i o n of q u a l i f i e d s c i e n t i s t s , (b) the communication of s c i e n t i f i c i n f o r m a t i o n to the q u a l i f i e d p a r t i e s , and (c) n e g o t i a t i o n among i n t e r e s t e d p a r t i e s to achieve consensus. 3 . Where agreement cannot be reached, e l e c t e d r e p r e s e n t a t i v e s or i n d i v i d u a l s accountable to them should have the r e s p o n s i b i l i t y f o r d e c i d i n g ; where i t i s necessary f o r d e c i s i o n s to be a u t h o r i t a t i v e , e l e c t e d r e p r e s e n t a t i v e s or i n d i v i d u a l s accountable to them must have r e s p o n s i b i l i t y f o r (a) e n a c t i n g necessary l e g i s l a t i o n , (b) f o r e s t a b l i s h i n g a p p r o p r i a t e r e g u l a t i o n s , and (c) f o r c a r r y i n g out implementation programs. 72 4. In order f o r the decision-making process to p r o p e r l y f u n c t i o n i n accord with l i b e r a l democratic p r i n c i p l e s , there must be funding p r o v i s i o n s f o r c o s t s i n c u r r e d to encourage the p a r t i c i p a t i o n and understanding of a l t e r n a t i v e p o l i c i e s by a l l a f f e c t e d i n t e r e s t s . F u r t h e r , there should be channels e s t a b l i s h e d which a l l o w a l l of the other a c t o r s to appeal d e c i s i o n s to e l e c t e d o f f i c i a l s or i n d i v i d u a l s accountable to them. In summary, government d e c i s i o n s r e s p e c t i n g l e g i s l a t i o n and/or r e g u l a t o r y p o l i c y toward spa management should use the expert judgements of s c i e n t i s t s , h e a l t h o f f i c i a l s , and i n d u s t r y wherever p o s s i b l e . However, the e n t i r e d e c i s i o n process and development of i n f o r m a t i o n should be open, a c c e s s i b l e , and c o m p e t i t i v e with a l l a f f e c t e d i n t e r e s t s being represented throughout a l l stages of the p r o c e s s . Government d e c i s i o n s should a l s o provide mechanisms f o r r e p r e s e n t a t i v e groups to c h a l l e n g e the d e c i s i o n s i n the f u t u r e . An on-going i n t e r a c t i v e d e c i s i o n process amongst a l l a f f e c t e d i n t e r e s t s i s v i t a l f o r d e a l i n g with the spa i s s u e s laden with r i s k and u n c e r t a i n t y . 4. What determines the e f f e c t i v e n e s s of implementation measures? Government implementation measures are g e n e r a l l y c l a s s i f i e d i n t o two c a t e g o r i e s : (1) r e g u l a t o r y c o n t r o l s (or d i r e c t i v e s ) which are monitored through enforcement procedures, and (2) i n c e n t i v e s which are aimed to induce b e h a v i o u r a l changes i n 7 3 those people t a r g e t e d by p o l i c y o b j e c t i v e s . 1 3 1 4 I t i s u n l i k e l y that r e g u l a t i o n through enforcement o f f i c i a l s would be f u l l y e f f e c t i v e . 1 5 F i r s t of a l l , o f f i c i a l s cannot be present i n spa o p e r a t i o n s at a l l times to ensure compliance. Second, problems can occur i f enforcement o f f i c i a l s are o v e r l y p e r m i s s i v e or n e g l i g e n t . T h i r d , spa operat o r s may f i n d ways to circumvent r e g u l a t o r y c o n t r o l s . F ourth, monitoring and enforcement procedures may i n v o l v e c o s t s which are beyond p u b l i c h e a l t h budgetary c o n s t r a i n t s . F i n a l l y , r e g u l a t i o n through enforcement o f f i c i a l s does nothing toward reducing u n c e r t a i n t i e s or m o t i v a t i n g spa operat o r s to go beyond minimum compliance. Although some p o t e n t i a l hazards a s s o c i a t e d with spas can be reasonably d e f i n e d as " r i s k s " (e.g., drowning from entrapment, c e r t a i n known e f f e c t s from hyperthermia) and c o n d i t i o n s f o r c o n t r o l l i n g these hazards can be e a s i l y s p e c i f i e d and enforced, a broader base of implementation measures i s necessary to assure " s a f e " c o n d i t i o n s i n p u b l i c spas. E f f e c t i v e implementation of spa management a c t i v i t i e s would r e q u i r e : (a) w e l l - t r a i n e d o p e r a t o r s , (b) educated users and a b a s i s f o r users to have some degree of checking on the adherence to " s a f e " c o n d i t i o n s , (c) p e r i o d i c monitoring of spa f a c i l i t i e s and a p p r o p r i a t e p e n a l t i e s f o r f a i l u r e s to comply with the standards determining c o n d i t i o n s of " s a f e " use, and (d) p r o v i s i o n s f o r funding m o n i t o r i n g and enforcement procedures. 7 4 An e f f e c t i v e system of implementation measures should make p r o v i s i o n s f o r the f o l l o w i n g : 1. Educating o p e r a t o r s to understand: (a) how the spa system f u n c t i o n s , i n c l u d i n g i t s e n g i n e e r i n g , chemical and b i o l o g i c a l a s p e c t s . (b) the r a t i o n a l e s f o r any standards or c o n d i t i o n s the spa system i s expected to meet. (c) the techniques to u t i l i z e under changing c o n d i t i o n s i n order to adhere to standards. 2. P r o v i d i n g each user with r e a d i l y understandable i n f o r m a t i o n on the standards or c o n d i t i o n s that a spa i s expected to meet and p r o v i d i n g , to the extent p r a c t i c a b l e , simple means whereby users can check to see i f standards are being met. 3 . P r o v i d i n g users with r e a d i l y understandable i n f o r m a t i o n about i n d i v i d u a l c h a r a c t e r i s t i c s that r e q u i r e s p e c i a l p r e c a u t i o n a r y measures and i n s t r u c t i o n s about how to take such p r e c a u t i o n s . 4 . R e q u i r i n g p e r i o d i c monitoring by an a p p r o p r i a t e government agency and having p r o v i s i o n s f o r f i n e s and c l o s u r e s when standards are being v i o l a t e d . 5. E s t a b l i s h i n g monitoring/enforcement procedures which are e i t h e r w i t h i n p u b l i c h e a l t h budgetary c o n s t r a i n t s or o b t a i n i n g funds from other sources. Thus, the e x i s t e n c e of continuous v a r i a b l e c o n d i t i o n s and our d e s i r e to see operators exceed minimum compliance c r e a t e p r a c t i c a l l i m i t a t i o n s to e f f e c t i v e implementation of approved standards through t y p i c a l r e g u l a t o r y p r o c e d u r e s . 1 6 More 7 5 e f f e c t i v e measures appear to be best i n s t i t u t e d through developing procedures f o r users to act as a check on o p e r a t o r s and then to use i n c e n t i v e s f o r m o t i v a t i n g o p e r a t o r s toward higher spa management norms. 1 7 To accomplish e i t h e r of these g o a l s , i t i s necessary to e s t a b l i s h an environment fo r a s o c i a l l e a r n i n g process to take p l a c e , so that both o p e r a t o r s and users can develop the c a p a b i l i t y to e f f e c t i v e l y i n t e r a c t with each. 5. What f a c t o r s i n f l u e n c e the r a t e of s o c i a l l e a r n i n g ? T h i s i s a very c r i t i c a l p o l i c y area f o r both e f f e c t i v e implementation and the attainment of higher spa management norms under c o n d i t i o n s of u n c e r t a i n t y . U n c e r t a i n t i e s w i l l always leave doubts about: (a) whether our approved standards are adequate, and ( 2 ) whether attempts to exceed these approved steps are " a p p r o p r i a t e " or " s a f e " . 1 8 Thus, a process f o r s o c i a l l e a r n i n g i s necessary to provide guidance and to d e a l with u n c e r t a i n t y . A s o c i a l l e a r n i n g process can be d e s c r i b e d i n d e t a i l u s i n g s o c i o l o g i c a l and p s y c h o l o g i c a l p r i n c i p l e s . For s i m p l i f i c a t i o n purposes, the d e f i n i t i o n of a s o c i a l l e a r n i n g process w i l l be l i m i t e d to mean "a r e c u r s i v e or i t e r a t i v e process" whereby feedback mechanisms al l o w e v a l u a t i o n of r e s u l t s from which c o r r e c t i v e a c t i o n s can then be taken to a d j u s t c o n d i t i o n s . T h i s process i s ongoing. More complete d e s c r i p t i o n s of a s o c i a l l e a r n i n g process are p r o v i d e d by Mack, 1 9 Dunn, 2 0 and o t h e r s . However, the important element to p o l i c y c o n s i d e r a t i o n s i s the 76 r e c o g n i t i o n that c r e a t i v e e f f o r t s are v i t a l to d e a l i n g with u n c e r t a i n t y and r a i s i n g standards i n spa management. U n c e r t a i n t y i s a dominant c h a r a c t e r i s t i c of the spa r management problem. The primary u n c e r t a i n t i e s I r e l a t e t o : (a) the nature of pathogens i n the spa environment and ways of c o n t r o l l i n g the spread of d i s e a s e , (b) the p h y s i c a l e f f e c t s (e.g., water temperature, d i s i n f e c t a n t s , e t c . ) of the spa environment on c e r t a i n users, and (c) the way us e r s , o p e r a t o r s , and p u b l i c o f f i c i a l s w i l l respond to v a r i o u s p u b l i c h e a l t h arrangements i n a c t u a l spa management p r a c t i c e s . A conscious and determined e f f o r t i s needed to p r o f i t from experience so as to reduce the f o r e g o i n g three c a t e g o r i e s of u n c e r t a i n t y and thus improve the c a p a b i l i t y of spa management p r a c t i c e s to p r o t e c t p u b l i c h e a l t h . T h i s r e c o g n i t i o n a p p l i e s e s p e c i a l l y to areas of r e a l u n c e r t a i n t y which pose the g r e a t e s t t h r e a t to d i s r u p t i n g p o l i c y o b j e c t i v e s s i n c e we may be l e a s t prepared to handle u n p r e d i c t a b l e events or behaviour (e.g., appearance of a new pathogenic organism i n spa environments, m a l i c i o u s or extremely c a r e l e s s a c t i o n s by o p e r a t o r s , e t c . ) Previou s d i s c u s s i o n of the d i f f i c u l t i e s of e f f e c t i v e l y e n f o r c i n g r e g u l a t o r y c o n t r o l measures i n d i c a t e s that u s e r s , o p e r a t o r s , and p u b l i c h e a l t h o f f i c i a l s need to be s t i m u l a t e d to p a r t i c i p a t e i n the e f f o r t to reduce a l l three c a t e g o r i e s of u n c e r t a i n t y and apply the knowledge gained t o improving spa management p r a c t i c e s . E x i s t i n g u n c e r t a i n t i e s and expected c o n t i n u a t i o n of v a r i a b l e c o n d i t i o n s i n spa environments r e q u i r e 7 7 g r e a t e r knowledge to be gained about pathogens, p h y s i c a l e f f e c t s , and spa a c t o r s ' behaviour and stronger assurance that spa o p e r a t o r s can d e a l with v a r i a b l e c o n d i t i o n s where guidance from standards i s u n a v a i l a b l e (e.g., the e a r l i e r s t a t e d problem of determining i n t e r v a l s f o r d r a i n i n g s p a s ) . Although p e n a l t i e s may be necessary to enforce r e g u l a t i o n s and standards, they are u n s u i t e d to s o c i a l l e a r n i n g . P s y c h o l o g i c a l and s o c i o l o g i c a l l i t e r a t u r e emphasizes p o s i t i v e m o t i v a t i o n and reinforcement as being the most s u c c e s s f u l f a c t o r s i n areas where p o s i t i v e l e a r n i n g i s important to the outcome of s i t u a t i o n s . 2 1 S t u d i e s of comparative h e a l t h care s i t u a t i o n s a l s o i n d i c a t e that p o s i t i v e i n c e n t i v e s are r e q u i r e d f o r groups to i d e n t i f y and r e p o r t r e l e v a n t experience and to design improved management p r a c t i c e s based t h e r e o n . 2 2 F i n a l l y , i t should be noted that i n c e n t i v e s should not be thought of s o l e l y i n economic terms. F a c t o r s of p r i d e , a l t r u i s m , and l e a r n i n g c u r i o u s i t y can a l s o be used to advantage i n developing i n c e n t i v e measures. 2 3 P o s i t i v e i n c e n t i v e s may r e q u i r e c u r r e n t and f u t u r e e x p e n d i t u r e s . These c o s t s should be a n t i c i p a t e d and planned f o r as best p o s s i b l e w i t h i n c u r r e n t understanding of spa management needs to r e s o l v e u n c e r t a i n t y . The above c o n s i d e r a t i o n s l e a d to the c o n c l u s i o n that a "good" system of spa management r e q u i r e s t h a t : - P u b l i c h e a l t h o f f i c i a l s and o p e r a t o r s are made keenly aware that the r e d u c t i o n of u n c e r t a i n t i e s and the 7 8 c a p a b i l i t y to deal with s u r p r i s e s i s the most c h a l l e n g i n g task faced i n spa management. - P o s i t i v e i n c e n t i v e s are pro v i d e d to s t i m u l a t e p u b l i c h e a l t h o f f i c i a l s , o p e r a t o r s , and users to engage i n a con c e n t r a t e d e f f o r t to reduce the three c a t e g o r i e s of u n c e r t a i n t i e s . - A system f o r funding the s o c i a l l e a r n i n g aspects to c r e a t e awareness of u n c e r t a i n t y and to pro v i d e p o s i t i v e i n c e n t i v e s must be e s t a b l i s h e d to meet c u r r e n t spa management needs and to a n t i c i p a t e f u t u r e needs. T h i s concludes the d i s c u s s i o n of t h e o r e t i c a l premises f o r c o n s i d e r a t i o n of spa p o l i c y d e s i g n . Although any one of the areas are worthy of exhaustive d i s c u s s i o n , i t i s hoped that the reader has been able to c o n c e p t u a l i z e the main t h r u s t of these premises and t h e i r r e l a t i o n to the p o l i c y d e s i g n . The f i n a l s e c t i o n of t h i s chapter d i s t i l l s from these premises e v a l u a t i v e c r i t e r i a which can be a p p l i e d to a l t e r n a t i v e p o l i c i e s . C r i t e r i a f o r E v a l u a t i n g A l t e r n a t i v e Spa P o l i c i e s From the preceding d i s c u s s i o n of the t h e o r e t i c a l premises needed f o r ad d r e s s i n g spa management p o l i c y i s s u e s , a v a r i e t y of areas have been covered to provide a b a s i s f o r judging the me r i t s of e x i s t i n g and proposed p o l i c i e s . These premises can be reduced to e v a l u a t i v e c r i t e r i a a p p l i c a b l e to spa management experience i n the U.S. and Canada and to d e s i g n i n g a model p o l i c y f o r B r i t i s h Columbia. These are as f o l l o w s : 79 C r i t e r i o n 1 - Has government acted to e s t a b l i s h c o n d i t i o n s that p r o v i d e reasonable assurance of " s a f e " use of p u b l i c spas and hot tubs? a) Government must take p o s i t i v e a c t i o n to i d e n t i f y c o n d i t i o n s (governing standards) which, i f f o l l o w e d , provide reasonable assurance that a spa i s " s a f e " to use by most members of the general p u b l i c and that the h e a l t h of non-users w i l l be p r o t e c t e d . b) Government must take p o s i t i v e a c t i o n to i d e n t i f y the c h a r a c t e r i s t i c s that some people may have which r e q u i r e that s p e c i a l p r e c a u t i o n s be taken to a v o i d h e a l t h hazards from spa use. c) Government must e s t a b l i s h procedures f o r i d e n t i f y i n g p u b l i c spas that adhere to standards f o r " s a f e " use by most members of the general p u b l i c . d) Government must e s t a b l i s h procedures that assure members of the p u b l i c r e l i a b l e access to i n f o r m a t i o n about i n d i v i d u a l c h a r a c t e r i s t i c s that r e q u i r e s p e c i a l p r e c a u t i o n s be taken, as w e l l as i n s t r u c t i o n s about how to take such p r e c a u t i o n s . e) Funds necessary to achieve the above s u b - c r i t e r i a should be pr o v i d e d . C r i t e r i o n 2 - Are " s a f e " c o n d i t i o n s of use e s t a b l i s h e d through processes i n which users, o p e r a t o r s , and the p u b l i c have conf idence? a) A l t e r n a t i v e government management p o l i c i e s f o r spas must be c o n c e p t u a l i z e d by a l l a f f e c t e d p a r t i e s (users, o p e r a t o r s , 80 i n d u s t r y r e p r e s e n t a t i v e s , and the general p u b l i c ) on the b a s i s of i n f o r m a t i o n s u p p l i e d to them by q u a l i f i e d s c i e n t i s t s . b) Procedures should e x i s t through which an e f f o r t i s made to r e c o n c i l e d i f f e r e n c e s of p r e f e r e n c e s among a f f e c t e d p a r t i e s with regard to government management p o l i c i e s f o r spas. c) Where agreement cannot be reached, procedures should e x i s t f o r d e c i s i o n s to be made by e l e c t e d r e p r e s e n t a t i v e s or i n d i v i d u a l s accountable to them. d) Funds should be p r o v i d e d to see that d e c i s i o n processes f o r e s t a b l i s h i n g " s a f e " c o n d i t i o n s can be undertaken i n conformance with the above s u b - c r i t e r i a . C r i t e r i o n 3 - Are e f f e c t i v e processes u t i l i z e d to implement c o n d i t i o n s which assure " s a f e " use of p u b l i c spas? a) P r o v i s i o n s must be made to educate o p e r a t o r s to understand the f u n c t i o n i n g of spa systems, the r a t i o n a l e f o r approved standards, and techniques to u t i l i z e (under changing c o n d i t i o n s ) to adhere to standards. b) Procedures must e x i s t f o r informing users about standards and c o n d i t i o n s of " s a f e " use and, to the extent p r a c t i c a b l e , provide simple means f o r users to check on whether standards are being met. c) Procedures must e x i s t f o r seeing that i n d i v i d u a l s are informed of i n d i v i d u a l c h a r a c t e r i s t i c s that r e q u i r e p r e c a u t i o n a r y measures be taken and that i n d i v i d u a l s are i n s t r u c t e d as to how to f o l l o w such p r e c a u t i o n s . 81 d) An a p p r o p r i a t e government agency must p e r i o d i c a l l y monitor spa o p e r a t i o n s and a d m i n i s t e r p e n a l t i e s of f i n e s and p o s s i b l y c l o s u r e s when standards are v i o l a t e d . e) Funds should be provided to enact implementation measures, and f u t u r e needs should be c o n s i d e r e d . Funding obtained from u s e r s , o p e r a t o r s , or the i n d u s t r y should be c o n s i d e r e d as an a l t e r n a t i v e . C r i t e r i o n 4 - Do spa management processes s t i m u l a t e the p r o g r e s s i v e advancement of knowledge i n order to reduce u n c e r t a i n t y and thus provide a b a s i s f o r improved spa management? a) P u b l i c h e a l t h o f f i c i a l s and o p e r a t o r s must be keenly aware that the r e d u c t i o n of u n c e r t a i n t i e s and the c a p a b i l i t y to d e a l with s u r p r i s e s i s the most c h a l l e n g i n g task faced i n spa management. b) P o s i t i v e i n c e n t i v e s must be provided to s t i m u l a t e p u b l i c h e a l t h o f f i c i a l s , o p e r a t o r s , and users to engage i n a c o n c e n t r a t e d e f f o r t to reduce the three c a t e g o r i e s of u n c e r t a i n t i e s by an on-going s o c i a l l e a r n i n g process. T h i s process should i n v o l v e r e c o g n i t i o n of key i n d i c a t o r s of spa problems from experience and adjustment of management p r a c t i c e s i n accordance with t h i s new knowledge. c) Funds to p r o v i d e p o s i t i v e i n c e n t i v e s and e s t a b l i s h a s o c i a l l e a r n i n g process should be p r o v i d e d . These c r i t e r i a can be used to q u a l i t a t i v e l y e valuate the U.S.-Canadian experience with spas, as w e l l as to guide the 82 design of a model spa p o l i c y f o r B r i t i s h Columbia. The c r i t e r i a a l s o become a means f o r judging the e f f e c t i v e n e s s of f u t u r e implemented p o l i c y . The next chapter uses the t h e o r e t i c a l premises to t e s t the a c t u a l experience to date with spa management i n the U.S. and Canada. By comparing the t h e o r e t i c a l premises with a c t u a l experience, a range of reasonable a l t e r n a t i v e s f o r p o l i c y i s examined, and d e f i c i e n c i e s are i d e n t i f i e d . 8 3 Footnotes - Chapter 3 1 E d i t h Stokey and Ric h a r d Zeckhauser, A Primer f o r P o l i c y A n a l y s i s , (New York: W.W. Norton & Co., 197QT. 2Economic C o u n c i l of Canada, Reforming R e g u l a t i o n s , (Ottawa, 1981). 3 " T o x i c Substance P o l i c y and the P r o t e c t i o n of Human H e a l t h " by Paul R. Portney, Paul R. Portney, ed., Current Issues i n U.S. Environmental P o l i c y , Resources f o r the Future, ( B a l t i m o r e : John Hopkins Press, 1978), pp. 105-143. "J.H. Dales, P o l l u t i o n , Property, & P r i c e s , (Toronto and B u f f a l o : U n i v e r s i t y of Toronto Press, 1968). 5 R i c h a r d Zeckhauser and C h r i s t o p h e r Zook, " F a i l u r e s to C o n t r o l H e a l t h C o s t s : Departures from F i r s t P r i n c i p l e s " , pp. 87-116, A New Approach to the Economics of Hea l t h Care, Mancur Olson, e d ~ (Washington, D.C. and London: American E n t e r p r i s e I n s t i t u t e f o r P u b l i c P o l i c y Research, 1981). 6Robert G. Evans, P r i c e Formation i n the Market f o r P h y s i c i a n S e r v i c e s , (Ottawa: Information Canada, 1973). 7Baruch F i s c h o f f , Sarah L i c h t e n s t e i n , Paul S l o v i c , Stephen L. Derby, and Ralph L. Keeney, Acceptable Risk, (Cambridge: Cambridge U n i v e r s i t y Press, 1981). 8G. Bruce Doern, The P e r i p h e r a l Nature of S c i e n t i f i c and T e c h n o l o g i c a l C o n t r o v e r s y " i n F e d e r a l P o l i c y Formation, ( H u l l , Quebec: Canadian Government P u b l i s h i n g Centre, 1981 ). 9 J a c k H i r s c h l e i f e r , P r i c e Theory and A p p l i c a t i o n s , second e d i t i o n (Englewood C l i f f s , N.J.: P r e n t i c e - H a l l Inc., 1980). 1 0 S t o k e y and Zeckhauser, op. c i t . 1 1 John Okay, "Economic For c e s " , pp. 78-100, Renewable Na t u r a l Resources: A Management Handbook f o r the 1980's, Dennis L. L i t t l e , Robert E. D i l s , and John Gray, ed., (Boulder, Colorado: Westview P r e s s , 1982). 1 2 I r v i n g K. Fox, " I n s t i t u t i o n f o r Water Management i n a Changing World", N a t u r a l Resources J o u r n a l , 16: 743-758, October, 1976. 1 3 Zeckhauser and Zook, op. c i t . 1"Economic C o u n c i l of Canada, op. c i t . 1 5Andrew R. Thompson, Environmental R e g u l a t i o n i n Canada: An Assessment of the Regulatory Process, (Vancouver, B.C.: 84 Westwater Research Centre, 1980). 1 6 Zeckhauser and Zook, op. c i t . 1 7Graham Atkinson and Jack Cook, " R e g u l a t i o n : I n c e n t i v e s Rather Than Command and C o n t r o l " , pp. 211-218, Mancur Olson, op. c i t . 1 8 F i s c h o f f , e t . a l . , op. c i t . 1 9 R u t h P. Mack, Planning On U n c e r t a i n t y , (New York: John Wiley & Sons, 1971). 2 0 E d g a r S. Dunn, J r . , Economic and S o c i a l Development: A Process of S o c i a l L e a r n i n g , ( B a l t i m o r e : John Hopkins Press, 1971 ) . 2 1 J o h n a t h a n L. Freedman, J . M e r r i l l C a r l s m i t h , and David 0. Sears, S o c i a l Psychology, (Englewood C l i f f s , N.J.: P r e n t i c e -H a l l , Inc., 1970). 2 2 Zeckhauser and Zook, op. c i t . 2 3 R u t h Mack, op. c i t . 85 CHAPTER 4 Experience i n the U.S. and Canada There has been a d i f f e r e n t response i n each country to the emergence of spas and hot tubs as a p u b l i c h e a l t h and s a f e t y concern. We need to look at experiences i n both and then, by using the c r i t e r i a of the pr e v i o u s chapter, e x i s t i n g p r a c t i c e s can be eva l u a t e d as a guide to s t r u c t u r i n g set of p o l i c i e s f o r B r i t i s h Columbia. Background of the U.S. Experience Scope of Study I n v e s t i g a t i o n of the U.S. experience with spas c o n s i s t e d of a review of the l i t e r a t u r e and i n t e r v i e w s with the v a r i o u s spa a c t o r s (a l i s t of main sources are pro v i d e d i n the footnotes at the end of t h i s c h a p t e r ) . The kinds of l i t e r a t u r e which were examined i n c l u d e ; (1) pool and spa trade j o u r n a l s , (2) newspaper a r t i c l e s , (3) magazine a r t i c l e s , (4) pool and spa standards, codes, and g u i d e l i n e s , (5) manufacturers' product l i t e r a t u r e , s p e c i f i c a t i o n s , and i n s t r u c t i o n s , (6) government agency r e p o r t s , (7) s c i e n t i f i c s t u d i e s , (8) p u b l i c h e a l t h j o u r n a l s , and (9) correspondence. Personal and phone i n t e r v i e w s were conducted with; ( 1 ) f e d e r a l , s t a t e , and l o c a l p u b l i c h e a l t h and s a f e t y o f f i c i a l s , (2) members of the N a t i o n a l Spa and Pool I n s t i t u t e , (3) i n d u s t r y 86 s c i e n t i s t s and other r e p r e s e n t a t i v e s , (4) spa o p e r a t i o n owners, managers, and maintenance people, (5) independent s c i e n t i s t s and r e s e a r c h e r s , and (6) spa users and non-users. F e d e r a l , s t a t e , and l o c a l j u r i s d i c t i o n s were examined to v a r y i n g degrees. The r e s e a r c h focused on the f o l l o w i n g j u r i s d i c t i o n s : 1. F e d e r a l (the two main agencies i n v o l v e d ; CDC and CPSC) 2 . The State of I l l i n o i s 3 . The State of Oregon 4 . Cook and DuPage Counties i n I l l i n o i s 5. The C i t y of Chicago 6. V a r i o u s suburban m u n i c i p a l i t i e s o u t s i d e Chicago (e.g. A r l i n g t o n Hts., Mt. Prospect, Schaumberg, Downers Grove, P a l o s ) . The s t a t e s of I l l i n o i s and Oregon were chosen because they represented the two extremes of r e g u l a t o r y a c t i v i t y with spas. I l l i n o i s has not r e g u l a t e d p u b l i c spas (with the minor exception of i s s u i n g c o n s t r u c t i o n permits when spas are b u i l t with new p u b l i c p o o l s ) . Oregon has been one of the most a c t i v e s t a t e s with spas and has d e v i s e d separate standards and codes f o r spas. The l o c a l j u r i s d i c t i o n s a l s o represented a range of r e g u l a t o r y a c t i v i t y with spas. The survey of the l i t e r a t u r e and i n f o r m a t i o n from i n t e r v i e w s provided f u r t h e r knowledge about other s t a t e and l o c a l j u r i s d i c t i o n s . T h i s i n f o r m a t i o n supplements and helps s u b s t a n t i a t e the i n f o r m a t i o n obtained from I l l i n o i s and Oregon. 8 7 I n i t i a l r e s e a r c h i n d i c a t e d that spa r e g u l a t i o n , based upon the a p p l i c a t i o n of swimming pool standards and codes, was a d e f i c i e n t p r a c t i c e , and hence j u r i s d i c t i o n s which have continued i n t h i s p r a c t i c e were not examined. The reasons f o r t h i s c o n c l u s i o n are as f o l l o w s : 1. The CDC g u i d e l i n e s and CPSC r e p o r t s c l e a r l y show that f e d e r a l o f f i c i a l s have recognized the n e c e s s i t y of t r e a t i n g spas separate from p o o l s . 2. Quotes i n trade j o u r n a l s and through i n t e r v i e w s i n d i c a t e d i n d u s t r y r e p r e s e n t a t i v e s a l s o agreed that separate spa standards were necessary. 3 . The s t a t e of Oregon, which has r e g u l a t e d spas f o r s e v e r a l y e a r s , chose to adopt separate spa standards and codes a f t e r r e a l i z i n g the problems i n t r y i n g to c o n t r o l spa hazards by the use of pool c r i t e r i a . 4. P u b l i c h e a l t h o f f i c i a l s i n I l l i n o i s i n d i c a t e d they would adopt separate spa r e g u l a t i o n i f funding were a v a i l a b l e to permit r e g u l a t i o n of spas by the s t a t e . 5. The l o c a l j u r i s d i c t i o n s s t u d i e d a l s o concurred with t h i s c o n c l u s i o n and some are i n the process of i n i t i a t i n g separate spa standards and codes. In reviewing the l i t e r a t u r e and i n t e r v i e w i n g spa a c t o r s , emphasis was p l a c e d upon the f o l l o w i n g c a t e g o r i e s of i n f o r m a t i o n : 1. As p e r c e i v e d by the v a r i o u s spa a c t o r s , what are the h e a l t h hazards a s s o c i a t e d with spa use and to what extent are spa users and the p u b l i c exposed to these hazards? 88 2 . What e f f o r t s a re b e i n g taken by government a g e n c i e s , i n d u s t r y , and spa o p e r a t o r s t o i n f o r m spa u s e r s and the p u b l i c of the p o t e n t i a l h a z a r d s and about p r o c e d u r e s f o r a v o i d i n g c o n d i t i o n s of p o t e n t i a l hazard? 3 . Who d e t e r m i n e s spa s t a n d a r d s and o t h e r i n s t r u m e n t s of r e g u l a t i o n ? What do the s e p o l i c i e s c o n s i s t of and how a r e they developed? 4. How a r e e x i s t i n g s t a n d a r d s and o t h e r p o l i c i e s b e i n g implemented by p u b l i c h e a l t h a g e n c i e s and do spa u s e r s u n d e r s t a n d how t o e v a l u a t e the c o n d i t i o n s of p a r t i c u l a r spa f a c i l i t i e s ? 5. Do the v a r i o u s spa a c t o r s u n d e r s t a n d what u n c e r t a i n t i e s a r e i n v o l v e d i n spa management and the importance of d e a l i n g w i t h u n c e r t a i n t y i n o r d e r t o improve spa management? What i s b e i n g done t o reduce u n c e r t a i n t i e s and improve spa management? A B r i e f D e s c r i p t i o n of the U.S. E x p e r i e n c e A d e t a i l e d d e s c r i p t i o n of the U.S. e x p e r i e n c e i s p r o v i d e d i n Appendix D. The f o l l o w i n g summary i s merely i n t e n d e d as a background f o r the e v a l u a t i o n of the U.S. e x p e r i e n c e . As d e s c r i b e d i n e a r l i e r c h a p t e r s , the U.S. i n i t i a l l y responded t o spas i n one of two ways: ( 1 ) t r e a t i n g them as s m a l l p o o l s or ( 2 ) i g n o r i n g and a v o i d i n g them (due t o l a c k of knowledge and co n c e r n about h a z a r d s ) . There were e x c e p t i o n s t o t h i s g e n e r a l a t t i t u d e , m o s t l y i n the i n d u s t r y s e c t o r , where 89 a n t i c i p a t i o n of spa d i f f e r e n c e s s t i m u l a t e d r e s e a r c h and product changes/innovations. As i n f o r m a t i o n developed, i n d u s t r y e x p e r t s began to communicate knowledge of spas' c h a r a c t e r i s t i c d i f f e r e n c e s throughout the i n d u s t r y and, where p o s s i b l e , to spa o p e r a t o r s . Although p u b l i c h e a l t h o f f i c i a l s may have been aware of the d i f f e r e n c e s at an e a r l y date, o f f i c i a l a c t i o n ( i n terms of l e g i s l a t i o n , codes, standards, warnings, e d u c a t i o n a l programs, e t c . ) have been slow i n developing and not uniform a c r o s s the country. In the past year, c o n s i d e r a b l e a c t i o n has taken p l a c e , and thus, a major s h i f t has o c c u r r e d i n the U.S. outlook on spas. T h i s s h i f t can be d e s c r i b e d as an acknowledgement that spas are s i g n i f i c a n t l y d i f f e r e n t than p o o l s , and hence a l l matters r e l a t i n g to spa water q u a l i t y management must be c o r r e s p o n d i n g l y a d j u s t e d . T h i s r e c o g n i t i o n , seemingly l o g i c a l and s t r a i g h t f o r w a r d , was not q u i c k l y gained. Since i t s acceptance, though, a t u r n i n g p o i n t f o r a c t i v i t y was reached. The U.S. approach to spa management can be c a t e g o r i z e d i n t o t hree main kinds of p o l i c i e s : 1) No r e g u l a t i o n of spas 2) R e g u l a t i o n of spas using e x i s t i n g swimming pool standards and r e g u l a t o r y c o n t r o l s ( t h i s k i n d of p o l i c y i s sometimes s l i g h t l y m o d i f i e d to i n c l u d e a few s p e c i a l p r o v i s i o n s f o r spas, e.g., maximum temperature l i m i t s ) . 3 ) R e g u l a t i o n of spas using standards s p e c i f i c a l l y designed to s u i t the unique c h a r a c t e r i s t i c s of spas. T r a d i t i o n a l swimming pool r e g u l a t o r y c o n t r o l s are o f t e n used i n 90 c o n j u n c t i o n with these s p e c i f i c spa standards. Some e f f o r t s are u s u a l l y made to inform users about p o t e n t i a l spa hazards and s p e c i a l p r e c a u t i o n s r e q u i r e d and to t r a i n / e d u c a t e operators about standards, r a t i o n a l e s , and procedures f o r adhering to the s p e c i f i c spa standards. In the j u r i s d i c t i o n s s t u d i e d ( e i t h e r b r i e f l y or i n depth), the major p o l i c y trend appears to be toward the t h i r d type of p o l i c y where spas are t r e a t e d d i f f e r e n t l y than p o o l s . Some j u r i s d i c t i o n s s t i l l use swimming pool standards, but they are i n the process of changing to s p e c i f i c spa standards. Fewer j u r i s d i c t i o n s f a i l to r e g u l a t e spas or continue to use swimming pool c r i t e r i a , but they s t i l l r epresent s i g n i f i c a n t numbers. These b a s i c p o l i c y approaches form a gen e r a l b a s i s f o r e v a l u a t i n g the U.S. experience with spas. For the reasons below, the f i r s t two approaches may be g e n e r a l l y c o n s i d e r e d d e f i c i e n t and incapable of meeting the e v a l u a t i v e c r i t e r i a . The t h i r d approach i s of most i n t e r e s t to the o b j e c t i v e of recommending a set of spa p o l i c i e s f o r B r i t i s h Columbia. Although s e r i o u s weaknesses a l s o e x i s t i n t h i s approach, i t i s most i n s t r u c t i v e to examine the stren g t h s and weaknesses of p o l i c i e s i n j u r i s d i c t i o n s where c o n s i d e r a b l e e f f o r t s have a l r e a d y been d i r e c t e d toward r e g u l a t i n g spas. 1) No r e g u l a t i o n of spas The f i r s t kind of p o l i c y (or more p r e c i s e l y , l a c k of 91 p o l i c y ) i s s o r e l y d e f i c i e n t because i t denies the r o l e and r e s p o n s i b i l i t y of government with p u b l i c spas. The p o t e n t i a l hazards and u n c e r t a i n t i e s a s s o c i a t e d with spas are not acknowledged, and hence users and the p u b l i c are both unprotected and p o o r l y informed about p o t e n t i a l p u b l i c h e a l t h hazards. As a r e s u l t , the other three c r i t e r i a cannot be s a t i s f i e d . 2 ) R e g u l a t i o n of spas using e x i s t i n g swimming pool standards and r e g u l a t i o n s The second kind of p o l i c y , used i n some j u r i s d i c t i o n s , f a i l s to meet the c r i t e r i a f o r much the same reasons. T h i s kind of p o l i c y f a i l s to meet the c r i t e r i a because i t l a r g e l y ignores c u r r e n t t e c h n i c a l and s c i e n t i f i c knowledge about spa management. Although swimming pool standards and r e g u l a t i o n s may p o s s i b l y a f f o r d b e t t e r p r o t e c t i o n f o r users and the p u b l i c than no r e g u l a t i o n at a l l , f a i l u r e of t h i s p o l i c y to adequately recognize the p o t e n t i a l hazards and u n c e r t a i n t i e s a s s o c i a t e d with spas c r e a t e s d e f i c i e n c i e s with regard to a l l of the c r i t e r i a . 3 ) R e g u l a t i o n of spas using standards s p e c i f i c a l l y designed f o r spas The t h i r d kind of p o l i c y r e c o g n i z e s the p o t e n t i a l hazards a s s o c i a t e d with spas and tends to meet a l l of the c r i t e r i a , except the d e c i s i o n process c r i t e r i o n , where i t f a i l s 92 completely. With the other c r i t e r i a , i t has weaknesses which examination of the s u b - c r i t e r i a exposes. The c h i e f f a i l u r e of t h i s kind of p o l i c y i s i t s lack of f u l l r e c o g n i t i o n of the p r i n c i p a l u n c e r t a i n t i e s and a l a c k of s t r a t e g y to d e a l with them. F a i l u r e to f u l l y r ecognize u n c e r t a i n t i e s i n v o l v i n g the nature of pathogenic standards, p h y s i c a l c h a r a c t e r i s t i c s of spas and spa a c t o r behaviour a f f e c t s a l l of the c r i t e r i a so that t h i s kind of p o l i c y i s d e f i c i e n t i n a l l areas. We can c o n s i d e r the development of response to spas by l o o k i n g at the' c a t e g o r i e s of p a r t i c i p a n t s . The c h a r t below d e p i c t s most of the a c t o r s who are i n v o l v e d i n the o v e r a l l spa management p i c t u r e . C e r t a i n l y , there may be o t h e r s , but these are the main i n t e r e s t e d groups. 93 The U.S. S t r u c t u r e Of O r g a n i z a t i o n a l Involvement with P u b l i c Spas & Hot Tubs F e d e r a l Agencies CDC CPSC P u b l i c Health J o i n t Committee on Swimming & Bathing EPA State Agencies L o c a l V a r i o u s s t a t e P u b l i c H e a l t h Departments St a t e Envi ronmental Agenc i e s County He a l t h Departments M u n i c i p a l H e a l t h Departments M u n i c i p a l O f f i c i a l s O r g a n i z a t i o n s Industry Operators NSPI (Wash.) NSPI ( L o c a l Chapters) ISTI ( L o c a l & N a t i o n a l ) I n d i v i d u a l Firms Other A s s o c i a -t i o n s (such as ASPI) High Use P u b l i c F a c i l i t i e s Low use P u b l i c F a c i l i t i e s High Use Commerc i a l / P r i v a t e Low Use Commerc i a l / P r i v a t e Code & Approval O r g a n i z a t i o n s UL IBOC IAMPO Others N o t - F o r - P r o f i t Users - Am. Publ i c H e a l t h Assoc i a t ion - NSF - Conf. of S t a t e S a n i t a r y Eng. - Others S o c i a l / R e c r e a t i o n a l T h e r a p e u t i c O c c a s i o n a l Users Research U n i v e r s i t i e s Foundations I n d i v i d u a l Researchers Media - Trade P u b l i c a t i o n s - Radio, TV - Newspapers 94 The A c t o r s And T h e i r R e l a t i o n To The System The key a c t o r s i n the U.S. spa system are (a) i n d u s t r y , (b) spa o p e r a t o r s , (c) spa users, and (d) the v a r i o u s f e d e r a l , s t a t e , and l o c a l a gencies. Each of these a c t o r s have an important r o l e i n e s t a b l i s h i n g " s a f e " c o n d i t i o n s of use i n p u b l i c spas through implementation . of c u r r e n t knowledge of a p p r o p r i a t e spa management and development of improved p r a c t i c e s . Industry has dominated the s i t u a t i o n to date. I t has been a l e a d i n g a c t o r i n a l l areas, i n c l u d i n g (a) p r o v i s i o n of i n f o r m a t i o n , (b) development of standards, g u i d e l i n e s and r e g u l a t i o n s , (c) educat i o n , and (d) r e s e a r c h / s t u d i e s . In the development and pr o d u c t i o n of spa products, i n d u s t r y has a strong i n t e r e s t i n seeing that spa o p e r a t i n g c o n d i t i o n s are c o n s i d e r e d " s a f e " by the p u b l i c . Growth and s t a b i l i t y of the spa market are h i g h l y dependent on the p u b l i c ' s p e r c e p t i o n s of the r e c r e a t i o n a l / t h e r a p e u t i c b e n e f i t s of spas weighed a g a i n s t the p o t e n t i a l hazards of use. A l s o , i n d u s t r y ' s r o l e as the developer and producer of spa products causes other a c t o r s to r e l y upon i t f o r c u r r e n t knowledge and new i n f o r m a t i o n about spa management. Spa o p e r a t o r s and users are "the h e a r t " of the spa system. In t h e i r r e s p e c t i v e r o l e s as p r o v i d e r s and consumers of spa f a c i l i t i e s , they are the most important a c t o r s i n e s t a b l i s h i n g " s a f e " c o n d i t i o n s and r e s o l v i n g u n c e r t a i n t i e s . The va l u e s and 95 behaviour of operat o r s and users determine the a c t u a l outcomes of spa use c o n d i t i o n s and the f u r t h e r i n g of knowledge. The r o l e s of operat o r s and users serve both to " t e s t " the e f f o r t s of other a c t o r s and to g r e a t l y i n f l u e n c e the performance of the spa management system. P u b l i c h e a l t h o f f i c i a l s serve as i n t e r m e d i a r i e s between i n d u s t r y and o p e r a t o r s / u s e r s in t r y i n g to communicate knowledge and i n a d m i n i s t e r i n g procedures which are c o n s i d e r e d e s s e n t i a l f o r establishment of " s a f e " c o n d i t i o n s and r e s o l u t i o n of u n c e r t a i n t i e s . In the event that c o n f l i c t occurs among the other a c t o r s with respect to d e c i s i o n s that determine and e s t a b l i s h " s a f e " c o n d i t i o n s , p u b l i c h e a l t h o f f i c i a l s e i t h e r seek to mediate the c o n f l i c t or ad v i s e e l e c t e d o f f i c i a l s when agreements cannot be reached. V a r i o u s government j u r i s d i c t i o n s i n the U.S. allow c e r t a i n l a t i t u d e f o r p u b l i c h e a l t h o f f i c i a l s to make d e c i s i o n s and act on t h e i r own, but h e a l t h o f f i c i a l s remain accountable to e l e c t e d o f f i c i a l s . The above d e s c r i p t i o n summarizes the spa management system s t r u c t u r e i n the U.S. To eval u a t e the a c t u a l performance of the system, the a c t i o n s taken by U.S. spa a c t o r s are weighed w i t h i n the framework provided by the c r i t e r i a of t h i s t h e s i s . 96 A n a l y s i s of the U.S. Experience 1. Governmental Roles and R e s p o n s i b i l i t i e s a) Have U.S. p u b l i c h e a l t h and s a f e t y agencies taken p o s i t i v e a c t i o n to i d e n t i f y c o n d i t i o n s (governing standards) which, i f f o l l o w e d , p r o v i d e reasonable assurance that a spa i s " s a f e " to use by most members of the general p u b l i c and that the h e a l t h of non-users w i l l be p r o t e c t e d ? On a f e d e r a l l e v e l , the CPSC has i d e n t i f i e d hazardous c o n d i t i o n s with regard to drownings from entrapment and hyperthermia. The CDC has developed spa management g u i d e l i n e s , which cover c r i t e r i a f o r design, c o n s t r u c t i o n , i n s t a l l a t i o n and o p e r a t i o n of spas, and has a l s o undertaken r e s e a r c h on d i s e a s e outbreaks i n v o l v i n g Pseudomonas and L e g i o n e l l a b a c t e r i a . The comprehensiveness of the CDC g u i d e l i n e s and i t s r e s e a r c h program are q u e s t i o n a b l e , though, f o r the f o l l o w i n g reasons. 1) The g u i d e l i n e s were developed with c o n s i d e r a b l e r e l i a n c e upon i n f o r m a t i o n s u p p l i e d by i n d u s t r y through NSPI. The i n f o r m a t i o n and recommendations s u p p l i e d by NSPI c o u l d p o s s i b l y be b i a s e d or f a i l to c o n s i d e r a l l a v a i l a b l e , reasonable o p t i o n s . 2 ) Because of innumerable other p u b l i c h e a l t h concerns and c o n s t r a i n t s , the CDC has not examined a range of p o t e n t i a l spa pathogenic hazards. Research a c t i v i t i e s are o r i e n t e d toward examining p o t e n t i a l pathogenic hazards a f t e r they 97 occur and are r e p o r t e d -- and only i f such outbreaks are c o n s i d e r e d s i g n i f i c a n t . 3 ) The CDC has not attempted to compile s t a t i s t i c s on cases i n v o l v i n g d i s e a s e , i l l n e s s or deaths a s s o c i a t e d with spas. Although p o s i t i v e a c t i o n s have c l e a r l y been taken by f e d e r a l agencies to i d e n t i f y c o n d i t i o n s f o r "safe use", the adequacy of the steps that have been taken are open to q u e s t i o n p a r t i c u l a r l y with regard to pathogenic hazards. Some o r i g i n a l r e s e a r c h work has been undertaken by s t a t e and l o c a l p u b l i c h e a l t h agencies (e.g., the s t a t e of Oregon's work r e l a t i n g to Pseudomonas problems and s t u d i e s on spa management by Alameda County i n C a l i f o r n i a ) . State and l o c a l e f f o r t s , however, have been l i m i t e d and not e f f e c t i v e l y c o o r d i n a t e d among j u r i s d i c t i o n s a c c o r d i n g to r e p o r t s i n the trade j o u r n a l s and statements made by h e a l t h o f f i c i a l s and i n d u s t r y r e p r e s e n t a t i v e s . 1 2 3 4 5 By p r i m a r i l y u s i n g the work of f e d e r a l agencies ( c o n t a i n i n g s t r o n g input from i n d u s t r y ) , some s t a t e , county, and m u n i c i p a l j u r i s d i c t i o n s have taken r e s p o n s i b i l i t y f o r e s t a b l i s h i n g spa p o l i c i e s which i d e n t i f y c o n d i t i o n s of " s a f e " use (e.g. C a l i f o r n i a , Oregon, Utah, Dade County i n F l o r i d a , S e a t t l e -King County i n Washington). These j u r i s d i c t i o n s appear to have used the CDC g u i d e l i n e s i n whole or i n p a r t , making m o d i f i c a t i o n s as necessary to s u i t l o c a l c o n d i t i o n s . Others such as Chicago, have merely t r a n s f e r r e d swimming pool p o l i c i e s and standards to the area of spas (although such j u r i s d i c t i o n s 98 may be i n the process of e l i m i n a t i n g use of pool standards f o r spas and adopting s p e c i f i c spa s t a n d a r d s ) . Some j u r i s d i c t i o n s have not attempted to d e a l with spas at a l l (e.g. I l l i n o i s , Michigan, and Wi s c o n s i n ) . I n c o n s i s t e n c i e s a l s o e x i s t i n o v e r l a p p i n g j u r i s d i c t i o n s . For i n s t a n c e , the s t a t e of I l l i n o i s has not taken any a c t i o n , but subordinate j u r i s d i c t i o n s such as Chicago and other m u n i c i p a l i t i e s have i n i t i a t e d a process of dev e l o p i n g spa standards. O v e r a l l , the U.S. experience i n d i c a t e s a mixed answer to the q u e s t i o n of whether p u b l i c h e a l t h agencies have taken a c t i o n to i d e n t i f y c o n d i t i o n s of " s a f e " use. F i r s t , the s i t u a t i o n v a r i e s among the j u r i s d i c t i o n s and l e v e l s of government which are examined. Second, c o n d i t i o n s f o r pr e v e n t i n g hazards of entrapment and hyperthermia seem to be much more c l e a r l y d e f i n e d than pathogenic hazards (note, see Appendix D: a means f o r e v a l u a t i n g the e f f i c a c y of d i s i n f e c t a n t s i n spas has only r e c e n t l y been developed, i n d i c a t i n g the need fo r a d d i t i o n a l work). T h i r d , s a f e t y measures r e q u i r e d of op e r a t o r s and users to meet the s p e c i f i c c o n d i t i o n s that r e l a t e to spas have not been w e l l developed. Although, c o n d i t i o n s governing a p p r o p r i a t e user behaviour d e r i v e d from swimming pool experience (e.g., showering p r i o r to use, not e n t e r i n g spas when i n d i v i d u a l s have open wounds, e t c . ) can be r e a d i l y a p p l i e d to spas, the s p e c i a l operator management p r a c t i c e s r e q u i r e d because of the widely v a r y i n g c o n d i t i o n s found i n spas have not been w e l l d e f i n e d and a p p r o p r i a t e p r a c t i c e s s p e c i f i e d . 99 b) Have p u b l i c h e a l t h and s a f e t y agencies taken p o s i t i v e a c t i o n to i d e n t i f y c h a r a c t e r i s t i c s of i n d i v i d u a l s which may r e q u i r e that s p e c i a l p r e c a u t i o n s be taken to a v o i d h e a l t h hazards from spa use? Much of t h i s type of i n f o r m a t i o n , e s p e c i a l l y r e l a t e d to high temperature e f f e c t s and i n c r e a s e d v u l n e r a b i l i t y of some i n d i v i d u a l s to c e r t a i n d i s e a s e s , i s a v a i l a b l e w i t h i n e x i s t i n g medical and p u b l i c h e a l t h knowledge. The extent to which t h i s knowledge has been s p e c i f i c a l l y r e l a t e d to spa c o n d i t i o n s and spa users again depends on which j u r i s d i c t i o n i s examined. Some j u r i s d i c t i o n s (e.g. Oregon, S e a t t l e - K i n g County, A r l i n g t o n Hts., II.) have i d e n t i f i e d these concerns, while others have not. Although b e t t e r i n f o r m a t i o n about s p e c i a l p r e c a u t i o n s might seem d e s i r a b l e o v e r a l l , j u r i s d i c t i o n s which have s p e c i f i c a l l y addressed spa problems can be c o n s i d e r e d as having taken reasonable p o s i t i v e a c t i o n . c) Have p u b l i c h e a l t h and s a f e t y agencies e s t a b l i s h e d procedures f o r i d e n t i f y i n g spas that adhere to standards f o r " s a f e " use? Beyond the i d e n t i f i c a t i o n of design, c o n s t r u c t i o n , i n s t a l l a t i o n and o p e r a t i o n c r i t e r i a f o r " s a f e " spa c o n d i t i o n s , the CDC g u i d e l i n e s a l s o recommend procedures f o r : (1) M o n i t o r i n g p u b l i c spas. ( 2 ) I d e n t i f y i n g and t r o u b l e s h o o t i n g h e a l t h and s a f e t y problems durin g the o p e r a t i o n of p u b l i c spas. 100 As noted above, some j u r i s d i c t i o n s have adopted CDC or s i m i l a r g u i d e l i n e s . Often i n these cases, the design, c o n s t r u c t i o n and i n s t a l l a t i o n c r i t e r i a are used as a b a s i s f o r permit or l i c e n s i n g procedures i n order to i d e n t i f y a spa adhering to standards. In j u r i s d i c t i o n s where these c r i t e r i a are based upon swimming pool standards, permits or l i c e n s e s f o r spa o p e r a t i o n s are a l s o f a i r l y common. The a p p r o p r i a t e n e s s , however, of a p p l y i n g swimming pool standards to spas seems to be s t r o n g l y d e f i c i e n t i n l i g h t of recent knowledge. Thus, permits or l i c e n s e s i s s u e d i n t h i s context are inadequate as means f o r a l l o w i n g i n d i v i d u a l s to i d e n t i f y a spa that adheres to c o n d i t i o n s f o r " s a f e " use. Procedures f o r i d e n t i f y i n g spas that adhere to o p e r a t i o n a l standards f o r " s a f e " use d i f f e r among j u r i s d i c t i o n s . Some j u r i s d i c t i o n s , u s ing CDC or s i m i l a r g u i d e l i n e s , have adopted procedures f o r operator c e r t i f i c a t i o n . Other j u r i s d i c t i o n s simply employ monitoring procedures and i d e n t i f y a spa i n v i o l a t i o n of standards by c l o s u r e of the f a c i l i t y u n t i l c o n d i t i o n s are c o r r e c t e d . Some j u r i s d i c t i o n s use both procedures. The j u r i s d i c t i o n s using swimming pool standards as a b a s i s f o r spa o p e r a t i o n c r i t e r i a u t i l i z e s i m i l a r procedures, but again, swimming pool standards are not adequate. d) Have p u b l i c h e a l t h agencies e s t a b l i s h e d procedures that assure members of the p u b l i c r e l i a b l e access to in f o r m a t i o n about i n d i v i d u a l c h a r a c t e r i s t i c s that r e q u i r e that s p e c i a l p r e c a u t i o n s be taken, as w e l l as 101 i n s t r u c t i o n s about how to take such p r e c a u t i o n s ? The CDC g u i d e l i n e s recommend that warnings be posted to p r o v i d e t h i s kind of i n f o r m a t i o n to i n d i v i d u a l s . Acceptance of t h i s recommendation v a r i e s by j u r i s d i c t i o n i n a c c o r d with the p r e v i o u s d i s c u s s i o n . However, i t may be q u e s t i o n a b l e whether posted warnings are s u f f i c i e n t f o r a s s u r i n g r e l i a b l e access to t h i s i n f o r m a t i o n . Signs can be i n c o n s p i c u o u s l y posted or may be i n s u f f i c i e n t , i n themselves, f o r adequately communicating the c h a r a c t e r i s t i c s and i n s t r u c t i o n s about s p e c i a l p r e c a u t i o n s . S e a t t l e - K i n g County i s an example of a j u r i s d i c t i o n which has attempted to remedy t h i s p o s s i b l e weakness. The county has made pamphlets, c o n t a i n i n g important i n f o r m a t i o n about s p e c i a l p r e c a u t i o n s , a v a i l a b l e to i n d i v i d u a l s . Procedures have t h e r e f o r e been established' - i n some j u r i s d i c t i o n s , and some j u r i s d i c t i o n s have p r o v i d e d more r e l i a b l e access than o t h e r s . e) Has adequate funding been provided by government f o r developing i n f o r m a t i o n to i d e n t i f y " s a f e " c o n d i t i o n s of use and matters r e l a t e d to s p e c i a l p r e c a u t i o n s which need to be taken? To the extent taken toward p o s i t i v e a c t i o n s , funding has, of course, been pr o v i d e d f o r the a c t i v i t i e s d e s c r i b e d above. However, inadequate funding has r e s t r i c t e d development and 102 p r o v i s i o n of in f o r m a t i o n i n two ways. F i r s t , some j u r i s d i c t i o n s (e.g., the s t a t e of I l l i n o i s ) have f a i l e d to meet i n f o r m a t i o n a l needs due to lack of funding and not because of lack of concern about spa hazards. Second, "gaps" of i n f o r m a t i o n s t i l l e x i s t even in j u r i s d i c t i o n s which have been a c t i v e with spas. These "gaps" (mostly r e l a t e d to pathogenic hazards) can sometimes be a t t r i b u t e d to funding problems. In a s s e s s i n g the U.S. experience f o r meeting our f i r s t c r i t e r i o n , e x i s t i n g p o l i c y and p r a c t i c e s have been shown d e f i c i e n t w i t h i n c e r t a i n j u r i s d i c t i o n s and with respect to some of the s u b - c r i t e r i a . These f a i l u r e s may be c a t e g o r i z e d as f o l l o w s : - J u r i s d i c t i o n s which have ignored p u b l i c spas have f a i l e d to assume necessary r e s p o n s i b i l i t y f o r e s t a b l i s h i n g c o n d i t i o n s f o r " s a f e " use. - J u r i s d i c t i o n s which have attempted to d e a l with spas through a p p l i c a t i o n of e x i s t i n g p u b l i c swimming pool standards and p o l i c i e s have not adequately addressed p o t e n t i a l hyperthermia and pathogenic hazards p e c u l i a r to spas. Thus, users and the general p u b l i c have not been p r o v i d e d reasonable assurance of " s a f e " c o n d i t i o n s f o r spas i n these j u r i s d i c t i o n s . - The three main u n c e r t a i n t i e s i n spa management (nature of pathogens i n the spa environment, p h y s i c a l c h a r a c t e r i s t i c s of the spa environment, and behaviour of spa a c t o r s ) c r e a t e "gaps" of i n f o r m a t i o n which have prevented a l l j u r i s d i c t i o n s from completely meeting t h i s c r i t e r i o n . 103 - Lack of adequate funding has prevented some j u r i s d i c t i o n s from e n t i r e l y meeting t h i s c r i t e r i o n and weakened the a b i l i t y of other j u r i s d i c t i o n s . 2 . Decision-Making Processes f o r E s t a b l i s h i n g C o n d i t i o n s of "Safe" Use a) Have a l t e r n a t i v e government management p o l i c i e s f o r spas been c o n c e p t u a l i z e d by a l l a f f e c t e d p a r t i e s on the b a s i s of i n f o r m a t i o n s u p p l i e d by q u a l i f i e d s c i e n t i s t s ? J u r i s d i c t i o n s which have t o t a l l y ignored p u b l i c spas can be e l i m i n a t e d from c o n s i d e r a t i o n i n regard to meeting t h i s c r i t e r i o n . J u r i s d i c t i o n s which have a p p l i e d swimming pool p o l i c i e s to spas f a i l to meet the c r i t e r i o n because a t t e n t i o n to c u r r e n t t e c h n i c a l and s c i e n t i f i c knowledge has been n e g l e c t e d . In f e d e r a l , s t a t e and l o c a l d e c i s i o n processes where c u r r e n t knowledge has been u t i l i z e d , the c r i t e r i o n i s not met because a l l a f f e c t e d p a r t i e s have not been i n v o l v e d . Industry, p u b l i c h e a l t h o f f i c i a l s and s c i e n t i s t s have been i n v o l v e d , but u s e r s , o p e r a t o r s , and the g e n e r a l p u b l i c have not taken p a r t . The assumption behind t h i s process i s that p u b l i c h e a l t h o f f i c i a l s serve as a p p r o p r i a t e r e p r e s e n t a t i v e s of u s e r s , o p e r a t o r s and the general p u b l i c . T h i s assumption i s u n j u s t i f i e d , p a r t i c u l a r l y i n regard to user and operator r e p r e s e n t a t i o n . As key a c t o r s whose p r e f e r e n c e s and behaviour are c r i t i c a l 104 determinants of a c t u a l spa management outcomes, users and operato r s should be more d i r e c t l y represented. Two reasons f o r more d i r e c t u ser/operator r e p r e s e n t a t i o n a r e : (1) I d e n t i f i c a t i o n and establishment of procedures f o r informing i n d i v i d u a l s about " s a f e " c o n d i t i o n s of use imply value judgements r e l a t i n g t o i n d i v i d u a l p r e f e r e n c e s f o r a v e r s i o n to r i s k s . Since users are the primary spa a c t o r s exposed to spa hazards, i t i s d i f f i c u l t to determine whether our f i r s t c r i t e r i o n i s e f f e c t i v e l y met without having s i g n i f i c a n t input from u s e r s . (2) In p r e s e n t i n g necessary i n f o r m a t i o n about " s a f e " c o n d i t i o n s and, l a t e r , seeking to implement measures designed to assure such c o n d i t i o n s , i t i s important that p o l i c y concepts and language are understandable to users and o p e r a t o r s . (3) Operators can provide p r a c t i c a l i n s i g h t i n t o management p r a c t i c e s which can be done e f f e c t i v e l y . The lack of user/operator p a r t i c i p a t i o n i n the development of the CDC and other s i m i l a r g u i d e l i n e s and i n a number of p u b l i c h e a l t h agency/industry conferences demonstrates the weakness of the c u r r e n t d e c i s i o n - p r o c e s s i n r e l a t i o n to the above c o n s i d e r a t i o n s . Moreover, i n d u s t r y , by s u p p l y i n g the bulk of i n f o r m a t i o n about "safe 1 1 c o n d i t i o n s , has tended to dominate the d e c i s i o n p r o c e s s . Thus, the a b i l i t y of p u b l i c h e a l t h o f f i c i a l s to represent u s e r s / o p e r a t o r s has been f u r t h e r eroded. In using 105 g u i d e l i n e s s u b s t a n t i a l l y d e v i s e d by i n d u s t r y without c o n s u l t i n g users and o p e r a t o r s , the U.S. experience has f a i l e d to take i n t o account the p r e f e r e n c e s and knowledge of two key spa a c t o r s . b) Do procedures e x i s t through which e f f o r t s are made to r e c o n c i l e d i f f e r e n c e s of p r e f e r e n c e s with regard to spa management p o l i c i e s ? There appear to be adequate procedures among i n d u s t r y and p u b l i c h e a l t h o f f i c i a l s f o r r e c o n c i l i n g d i f f e r e n c e s (e.g., conferences, b a r g a i n i n g s e s s i o n s , use of independent standards-s e t t i n g groups such as UL). However, as the above d i s c u s s i o n i n d i c a t e s , procedures f o r r e c o n c i l i n g d i f f e r e n c e s of p r e f e r e n c e s are inadequate due to lack of r e p r e s e n t a t i o n of a l l a f f e c t e d i n t e r e s t s . c) Do procedures e x i s t f o r d e c i s i o n s to be made by e l e c t e d r e p r e s e n t a t i v e s or i n d i v i d u a l s accountable t o them where agreement cannot be reached? Yes, p u b l i c h e a l t h agencies can recommend l e g i s l a t i o n / o r d i n a n c e s to e l e c t e d o f f i c i a l s , or i n some cases they have a u t h o r i t y d e l e g a t e d to them by e l e c t e d o f f i c i a l s to make such d e c i s i o n s . d) Has funding been e s t a b l i s h e d to allow d e c i s i o n processes f o r e s t a b l i s h i n g " s a f e " c o n d i t i o n s to be undertaken i n conformance with a l l of the above sub-c r i t e r i a ? There i s no c l e a r evidence which i n d i c a t e s whether t h i s 106 s u b - c r i t e r i o n i s met. However, i t i s reasonable, to assume that j u r i s d i c t i o n s (e.g. I l l i n o i s ) without b a s i c spa r e g u l a t o r y funding probably would not meet t h i s s u b - c r i t e r i o n . In b r i e f , the U.S. experience f a i l s to meet the c r i t e r i o n of p r o v i d i n g decision-making processes f o r e s t a b l i s h i n g c o n d i t i o n s of " s a f e " use i n which a l l a f f e c t e d i n t e r e s t s have co n f i d e n c e because of the f o l l o w i n g weaknesses: - Some j u r i s d i c t i o n s have ignored c u r r e n t t e c h n i c a l and s c i e n t i f i c i n f o r m a t i o n about spas so that p o t e n t i a l hazards and u n c e r t a i n t i e s have not been c o n s i d e r e d -- thus, d e c i s i o n s r e l a t i n g s p e c i f i c a l l y to spas have not been made. - Those j u r i s d i c t i o n s which have p a i d a t t e n t i o n to c u r r e n t t e c h n i c a l and s c i e n t i f i c i n f o r m a t i o n and adopted s p e c i f i c spa p o l i c i e s have f a i l e d to allow r e p r e s e n t a t i o n of users, o p e r a t o r s and the p u b l i c . T h i s l e a v e s two q u e s t i o n s unanswered which are important to assurance of c o n f i d e n c e i n the d e c i s i o n process; (1) do users, o p e r a t o r s and the p u b l i c i n these j u r i s d i c t i o n s agree that these p o l i c i e s , i f f o l l o w e d , w i l l produce " s a f e " c o n d i t i o n s (or do these a c t o r s simply l a c k the knowledge necessary to r a i s e i s s u e s and express disagreement)? and (2) do users and o p e r a t o r s s u f f i c i e n t l y understand why these p o l i c i e s are important and how they should be e f f e c t i v e l y implemented? I f these q u e s t i o n s cannot be answered a f f i r m a t i v e l y , there i s a l o g i c a l b a s i s f o r a l a c k of c o n f i d e n c e i n the e x i s t i n g d e c i s i o n p r o c e s s . The nature of the e x i s t i n g u n c e r t a i n t i e s i n spa management, as d e s c r i b e d i n chapter two, tend to 107 i n d i c a t e that these q u e s t i o n s would be answered n e g a t i v e l y . 3 . Implementation P r a c t i c e s a) Have p r o v i s i o n s been made to educate oper a t o r s to understand the f u n c t i o n i n g of spa systems, the r a t i o n a l e f o r approved standards, and techniques f o r adhering to standards (under v a r i a b l e spa c o n d i t i o n s ) ? Some e f f o r t s have been made by both i n d u s t r y and h e a l t h departments to educate o p e r a t o r s . Industry, under the auspices of NSPI and ISTI, have arranged seminars and d i s t r i b u t e d w r i t t e n m a t e r i a l s . Some s t a t e s (e.g., Oregon) have developed t r a i n i n g programs f o r o p e r a t o r s . Where implemented, e d u c a t i o n a l programs appear t o be e f f e c t i v e i n te a c h i n g o p e r a t o r s how spa systems f u n c t i o n and i n teac h i n g the r a t i o n a l e s f o r approved standards. The e f f e c t i v e n e s s of the techniques being taught f o r handl i n g v a r i a b l e spa c o n d i t i o n s may be q u e s t i o n a b l e though, because experts are s t i l l i n disagreement about a p p r o p r i a t e spa management procedures (e.g., methods f o r d i s i n f e c t i o n and i n t e r v a l s f o r d r a i n i n g s p a s ) . Disagreements among experts on these and other important spa management procedures have caused c o n s i d e r a b l e c o n f u s i o n f o r o p e r a t o r s (see Appendix D). b) Do procedures e x i s t to inform users about standards and 108 c o n d i t i o n s of " s a f e " use and to provide simple means for users to check on whether standards are being met? The CDC g u i d e l i n e s recommend that s i g n s be posted which ad v i s e users to a v o i d use of spas exceeding 104° F and that reasonable time l i m i t s (e.g. 10 minutes) should be observed i n use. The g u i d e l i n e s a l s o recommend that warnings be posted which advise users of proper behaviour and i n d i v i d u a l c h a r a c t e r i s t i c s which r e q u i r e that s p e c i a l p r e c a u t i o n s be taken. The m u n i c i p a l i t i e s of A r l i n g t o n Hts., Schaumberg, Mt. Prospect, B u f f a l o Grove, P a l a t i n e , and Hoffman E s t a t e s i n I l l i n o i s have adopted these CDC recommendations and r e q u i r e o p e r a t o r s to post these warnings. The s t a t e of Oregon and the proposed C i t y of Chicago codes simply r e q u i r e that warnings be posted which ad v i s e users not to exceed a time l i m i t of 15 minutes. None of the above j u r i s d i c t i o n s r e q u i r e or recommend p o s t i n g of i n f o r m a t i o n r e l a t e d to p o t e n t i a l v i s u a l hazards from poor water c l a r i t y , drowning hazards from entrapment, or pathogenic hazards. In these hazard areas, users seem to be s e r i o u s l y uninformed about standards and c o n d i t i o n s of " s a f e " use. Simple means f o r users to check on spa c o n d i t i o n s seem to be l i m i t e d to the p r o v i s i o n of thermometers f o r gauging water temperature and w a l l c l o c k s f o r gauging d u r a t i o n of spa use. Means f o r checking other spa water q u a l i t y parameters (e.g., d i s i n f e c t a n t l e v e l s , pH, b a c t e r i a l counts, e t c . ) are not o r d i n a r i l y p r o v i d e d i n spa f a c i l i t i e s or by spa p o l i c i e s . Procedures f o r informi n g users of a p p r o p r i a t e spa use 109 behaviour, as noted above, have been implemented i n a number of ways and to v a r y i n g degrees. However, operator and h e a l t h o f f i c i a l f r u s t r a t i o n s i n g a i n i n g user compliance with these b e h a v i o u r a l standards have caused t h i s area of concern to become de-emphasized and sometimes t o t a l l y n e g l e c t e d . As a r e s u l t , many users are unaware of the importance of checking on the behaviour of other users (see Appendix D). c) Do procedures e x i s t f o r seeing that i n d i v i d u a l s are informed about c h a r a c t e r i s t i c s and i n s t r u c t i o n s r e q u i r i n g s p e c i a l p r e c a u t i o n s be taken i n spa use? There do not appear to be any measures beyond those p r e v i o u s l y d e s c r i b e d ( s i g n s , pamphlets) which would assure that users are informed i n the j u r i s d i c t i o n s s t u d i e d i n depth. d) Do a p p r o p r i a t e government agencies p e r i o d i c a l l y monitor spa o p e r a t i o n s and administer p e n a l t i e s when standards are v i o l a t e d ? In the j u r i s d i c t i o n s focused upon i n t h i s study where spas are being r e g u l a t e d , t h i s s u b - c r i t e r i o n i s being reasonably met. Other U.S. j u r i s d i c t i o n s which f o l l o w the CDC g u i d e l i n e s would a l s o probably meet t h i s s u b - c r i t e r i o n . These j u r i s d i c t i o n s check f a c i l i t y records, i n s p e c t f a c i l i t i e s on a p e r i o d i c b a s i s , t e s t water samples f o r parameter l e v e l s and b a c t e r i a l counts, and advise o p e r a t o r s on management procedures. The h e a l t h departments p r i m a r i l y check d i s i n f e c t a n t l e v e l s , 110 pH, and c o l i f o r m counts (Oregon has a l s o run s u r v e i l l a n c e on Pseudomonas counts) d u r i n g on-premise i n s p e c t i o n s . However, some i n s p e c t o r s may a l s o t e s t the parameters of t o t a l a l k a l i n i t y , t u r b i d i t y , c y a n u r i c a c i d , and c a l c i u m hardness. As an example of records which o p e r a t o r s are r e q u i r e d to maintain, the Oregon spa code r e q u i r e s the f o l l o w i n g : a) r e s u l t s of operator t e s t s (as s p e c i f i e d by the code) of the parameters l i s t e d above b) dates and times of f i l t e r backwashing ( i . e . c l e a n i n g ) c) dates that spas were emptied and/or cleaned d) p e r i o d s of r e c i r c u l a t i o n equipment o p e r a t i o n and/or m a l f u n c t i o n and r e p a i r However some experts q u e s t i o n whether a p p r o p r i a t e parameters are being monitored i n determining presence of pathogenic organisms and e f f i c a c y of d i s i n f e c t a n t s ( t e s t i n g f o r Pseudomonas and organic matter are two common suggestions f o r improved m o n i t o r i n g ) . The b i g g e s t weakness i n the c u r r e n t monitoring system i s the r e l i a n c e upon p u b l i c h e a l t h o f f i c i a l s ' c a p a c i t i e s t o : (1) check records of f a c i l i t i e s , ( 2 ) d i s c u s s problems with o p e r a t o r s , and (3) conduct p e r s o n a l on-premise i n s p e c t i o n s . As noted by s e v e r a l h e a l t h o f f i c i a l s , time and budgetary c o n s t r a i n t s s e v e r e l y l i m i t t h e i r a b i l i t y to a c t i v e l y monitor spas as f r e q u e n t l y as necessary to see that standards are not v i o l a t e d . CDC's recommendation of once a week i s o f t e n u n r e a l i s t i c compared to the c o n s t r a i n t s of many j u r i s d i c t i o n s , 111 and f u r t h e r , the high v a r i a b i l i t y of spas c a s t s doubt upon the e f f e c t i v e n e s s of once-a-week procedures. e) Have p r o v i s i o n s f o r funding of implementation measures been e s t a b l i s h e d to provide f o r c u r r e n t and f u t u r e spa needs? As d e s c r i b e d i n Appendix D, Oregon and I l l i n o i s s t a t e and l o c a l o f f i c i a l s b e l i e v e that funding has been g e n e r a l l y inadequate because of p r e s s u r e s to r e s t r a i n or reduce government budgets i n the past few years. The c o s t s of implementation measures are s i g n i f i c a n t and these c o s t s u s u a l l y tend to i n c r e a s e over the long term. In r e c o g n i z i n g the v a r i a b i l i t y problems of spas, some o f f i c i a l s have questioned the worth of d i r e c t i n g major expenditures toward measures such as i n s p e c t i o n s of spa o p e r a t i o n s . Outside of p u b l i c h e a l t h agency budgets, there does not appear to be any e x i s t i n g schemes to o b t a i n funds from other sources such as i n d u s t r y , o p e r a t o r s , or u s e r s . The above c o n c l u s i o n s cannot be broadly accepted as a p p l i c a b l e to a l l U.S. j u r i s d i c t i o n s . However, in view of recent economic c o n d i t i o n s i t i s reasonable to assume, that other j u r i s d i c t i o n s , b esides Oregon and I l l i n o i s , have had s i m i l a r funding problems. The t h i r d c r i t e r i o n has not been met i n the U.S. experience because of the f o l l o w i n g main weaknesses; - V a r i a b i l i t y of spa c o n d i t i o n s have made implementation measures both d i f f i c u l t and i n e f f e c t i v e . - Users are p o o r l y informed about standards f o r " s a f e " 112 c o n d i t i o n s of use and have l i t t l e means of checking c o n d i t i o n s . Users are over-dependent upon the behaviour of op e r a t o r s and p u b l i c h e a l t h o f f i c i a l s . In view of the v a r i a b l e nature of spa c o n d i t i o n s and i t s r e l a t i o n to p o t e n t i a l hazards, t h i s over-dependence i s not sound p o l i c y f o r p r o t e c t i n g p u b l i c h e a l t h . - Funding i s p r e s e n t l y inadequate, and i t may always be, i n l i g h t of the problems of v a r i a b l e c o n d i t i o n s . New monitoring/enforcement methods which are l e s s expensive to implement or schemes to secure funding from users, o p e r a t o r s , or i n d u s t r y were not found i n t h i s study's r e s e a r c h of U.S. j u r i s d i c t i o n s . 4. P r o v i s i o n f o r S o c i a l L e a r n i n g a) Have p u b l i c h e a l t h o f f i c i a l s and o p e r a t o r s been made keenly aware that r e d u c t i o n of u n c e r t a i n t i e s and c a p a b i l i t y to d e a l with s u r p r i s e s i s the most c h a l l e n g i n g task faced i n spa management? Up u n t i l the l a s t few y e a r s , the answer was c l e a r l y "no". Awareness has s t a r t e d to develop s i n c e then, but the number of j u r i s d i c t i o n s which f a i l to r e g u l a t e spas or t r e a t them s i m i l a r to swimming pools i n d i c a t e s t h a t awareness i s s t i l l i n s u f f i c i e n t (see q u o t a t i o n i n Appendix D, p. 208). Operators, as a whole, a l s o appear to be unaware. 113 b) Have p o s i t i v e i n c e n t i v e s been p r o v i d e d to s t i m u l a t e spa a c t o r s to engage i n a c oncentrated e f f o r t to reduce u n c e r t a i n t i e s ? During t h i s study, a few i s o l a t e d cases of p o s i t i v e i n c e n t i v e s being u t i l i z e d were found, and i t i s reasonable to think that o t hers probably e x i s t (see Appendix D, pp. 216-218). However, p o l i c i e s and p r a c t i c e s showed no strong evidence of p o s i t i v e i n c e n t i v e s being used i n a c o n c e n t r a t e d e f f o r t to reduce u n c e r t a i n t i e s . F a i l u r e to acknowledge u n c e r t a i n t i e s , as noted s e v e r a l times, i s one reason for t h i s d e f i c i e n c y . Other reasons may i n c l u d e t r a d i t i o n a l r e l i a n c e upon r e g u l a t o r y c o n t r o l s r a t h e r than p o s i t i v e i n c e n t i v e s , and the l a c k of a w e l l - o r g a n i z e d attempt to d e a l with spas among the v a r i o u s j u r i s d i c t i o n s and spa a c t o r s . Because of wide v a r y i n g degrees of awareness, the need f o r p o s i t i v e i n c e n t i v e s and s o c i a l l e a r n i n g i s not yet f u l l y r e a l i z e d . The U.S. experience i n e s t a b l i s h i n g p r o v i s i o n s f o r s o c i a l l e a r n i n g shows these weaknesses: - R e c o g n i t i o n of the u n c e r t a i n t i e s i n spa management has developed only r e c e n t l y , and t h i s awareness v a r i e s c o n s i d e r a b l y among j u r i s d i c t i o n s and from one spa a c t o r to the next. Hence, the need f o r p o s i t i v e i n c e n t i v e s and s o c i a l l e a r n i n g i s not f u l l y r e a l i z e d . - The n o t i o n of i n v o l v i n g o p e r a t o r s and users i n a c o n c e n t r a t e d e f f o r t to reduce u n c e r t a i n t i e s may be unthought of by other spa a c t o r s . E a r l i e r d i s c u s s i o n 1 14 r e l a t i n g to d e c i s i o n processes f o r e s t a b l i s h i n g " s a f e " c o n d i t i o n s would tend to support t h i s s p e c u l a t i o n . D e f i c i e n c i e s i n U.S. Spa P o l i c i e s and P r a c t i c e s : Lessons f o r Design of Model P o l i c y The d e f i c i e n c i e s observed i n the- U.S. experience can be used as a guide f o r a v o i d i n g s i m i l a r problems i n spa p o l i c y f o r B r i t i s h Columbia. These d e f i c i e n c i e s can be summarized as f o l l o w s : 1. The f a i l u r e to recognize p o t e n t i a l hazards a s s o c i a t e d with spa use, i n some U.S. j u r i s d i c t i o n s , has prevented users and the p u b l i c from being adequately informed about c o n d i t i o n s of " s a f e " use and about requirements f o r c e r t a i n i n d i v i d u a l s to take s p e c i a l p r e c a u t i o n s i n use. 2. Within j u r i s d i c t i o n s where p o t e n t i a l hazards have been recognized, the f a i l u r e to allow or encourage adequate r e p r e s e n t a t i o n of the key a c t o r s i n spa management operato r s and users — c r e a t e s s e r i o u s problems i n determining a p p r o p r i a t e l e v e l s of " s a f e t y " and e f f e c t i v e implementation measures. 3. The f a i l u r e to d e v i s e a p p r o p r i a t e techniques f o r h a n d l i n g the h i g h l y v a r i a b l e c o n d i t i o n s of spas h i n d e r s the design of e f f e c t i v e implementation measures and leaves users o v e r l y dependent upon the a b i l i t i e s of o p e r a t o r s and h e a l t h o f f i c i a l s to e s t a b l i s h " s a f e " c o n d i t i o n s i n spas. 1 15 4. The f a i l u r e on a widespread b a s i s to recognize the importance of reducing u n c e r t a i n t i e s i n spa management has re t a r d e d or prevented the development of p o s i t i v e i n c e n t i v e s and a s o c i a l l e a r n i n g process i n which co-o p e r a t i v e and concentrated e f f o r t s by o p e r a t o r s , users and h e a l t h o f f i c i a l s c o u l d improve spa management p r a c t i c e s . The Canadian Experience With Spas Scope of Study The study of Canadian spa management system was l i m i t e d p r i m a r i l y to the Province of B r i t i s h Columbia. The only s i g n i f i c a n t d i f f e r e n c e s between the U.S. and Canadian experience appear to be: (a) fewer numbers of spas and users i n Canada, and (b) a l a t e r development of the spa market i n Canada. The s t r u c t u r e of the spa management system i n Canada i s d e p i c t e d i n the c h a r t below. 1 1 6 Industry F e d e r a l P r o v i n c i a l M u n i c i p a l Agenc i e s Agenc i e s & L o c a l - Canadian - Dept. of - M i n i s t r y - M u n i c i p a l Swimming Health & of Health Health Pool Welfare - P r o v i n c i a l Depts. Assoc. Medical - Medical - I n d i v i d u a l H e a l t h Health Firms O f f i c e r O f f i c e r s - L o c a l H e a l t h Boards - Union He a l t h Boards Spa Operators - High use p u b l i c F a c i l i t i e s - Low use p u b l i c f a c i l i t i e s - High use p r i v a t e f a c i l i t i e s - Low use p r i v a t e f a c i l i t i e s Spa Users Outside I n f l u e n c e s S o c i a l / R e c r e a t i o n a l T h e r a p e u t i c O c c a s i o n a l Users U.S. Industry U.S. Research U.S. Experience D e s c r i p t i o n of The B.C. P u b l i c H e a l t h System and I t s R e l a t i o n to Spas The f e d e r a l r o l e with regard to spas and pools i s l i m i t e d l a r g e l y to e d u c a t i o n a l matters. P o l i c i e s governing the o p e r a t i o n of spas are, t h e r e f o r e , the r e s p o n s i b i l i t y of p r o v i n c i a l and m u n i c i p a l j u r i s d i c t i o n s . Although the o r g a n i z a t i o n of i n s t i t u t i o n s i s f a i r l y complicated and sometimes o v e r l a p p i n g , the i n s t i t u t i o n a l s t r u c t u r e i n B r i t i s h Columbia can be b r i e f l y d e s c r i b e d as f o l l o w s : 1 17 Under the B.C. Health Act of 1972, the M i n i s t e r of H e a l t h and the p r o v i n c i a l M edical Health O f f i c e r are charged with the r e s p o n s i b i l i t y of overseeing the r e g u l a t i o n s p e r t a i n i n g to swimming p o o l s , spray p o o l s , and wading p o o l s . They may delegate d u t i e s to v a r i o u s engineers and i n s p e c t o r s w i t h i n t h e i r r e s p e c t i v e departments. In p r a c t i c e the M i n i s t r y of H e a l t h has primary r e s p o n s i b i l i t y f o r issuance of permits, making i n s p e c t i o n s , and i n i t i a t i n g programs r e l a t e d to p o o l s . They a l s o d r a f t l e g i s l a t i o n , monitor and keep t r a c k of the general s i t u a t i o n . The Medical H e a l t h O f f i c e r c a r r i e s out the l a b t e s t i n g of samples and serves to advise (and a l s o provide j o i n t approval) on matters p e r t a i n i n g to issuance of permits and s e t t i n g of standards f o r s a n i t a t i o n , water q u a l i t y , and p u b l i c s a f e t y . At the m u n i c i p a l l e v e l , a number of m u n i c i p a l i t i e s i n c l u d i n g Vancouver, Burnaby, Richmond, North Vancouver, West Vancouver, and V i c t o r i a have t h e i r own separate h e a l t h departments and they a l s o are i n v o l v e d i n pool and spa r e g u l a t i o n , p r i m a r i l y i n monitoring and enforcement r o l e s . Employees of these departments are p a i d by t h e i r r e s p e c t i v e m u n i c i p a l i t y . Other areas i n the p r o v i n c e , where separate h e a l t h departments do not e x i s t , are handled by the p r o v i n c i a l M i n i s t r y of H e a l t h . In areas without separate M e d i c a l H e a l t h O f f i c e r s the p r o v i n c i a l MHO has r e s p o n s i b i l i t y f o r d u t i e s r e l a t e d to pools and spas. Other i n s t i t u t i o n s a l s o can get i n v o l v e d with pool and spa 118 p o l i c y d e c i s i o n s at the l o c a l l e v e l . L o c a l Boards of Health have d i s c r e t i o n i n matters and they can have i n f l u e n c e on what the MHO does or says. There are a l s o Union Boards of H e a l t h , composed of r e p r e s e n t a t i v e s from m u n i c i p a l i t i e s and school boards. They can provide input i n t o d e c i s i o n s f o r areas o u t s i d e the j u r i s d i c t i o n of l o c a l h e a l t h departments. As a general g u i d e l i n e , the l e g i s l a t i v e domain of the p r o v i n c e supercedes m u n i c i p a l and l o c a l o rdinances. M u n i c i p a l and l o c a l i n s t i t u t i o n s can pass l e g i s l a t i o n d i f f e r e n t from the p r o v i n c e , but only i f the standards are h i g h e r . The p r o v i n c i a l standards thus serve as the b a s e l i n e . The B r i t i s h Columbia Experience With Spas B r i t i s h Columbia has p r i m a r i l y followed the approach of r e g u l a t i n g p u b l i c spas under i t s e x i s t i n g p o l i c y f o r p u b l i c swimming p o o l s . With the one e x c e p t i o n of maximum temperature requirements, water q u a l i t y standards are based upon pr e v i o u s pool standards. As i n d i c a t e d i n Appendix E, the few p r o v i s i o n s in the H e a l t h Act which s p e c i f i c a l l y r e l a t e to spas are u n n e c e s s a r i l y vague and do not p r o v i d e adequate guidance f o r o p e r a t o r s and u s e r s . More s i g n i f i c a n t l y , the e x i s t i n g p r o v i s i o n s are i n a c c u r a t e and incomplete i n l i g h t of c u r r e n t t e c h n i c a l and s c i e n t i f i c i n f o r m a t i o n . V i s u a l , drowning, and hyperthermia hazards are addressed, but only to a minor degree compared to j u r i s d i c t i o n s which have a c t i v e l y d e a l t with spas. 119 P r o v i s i o n s f o r p u b l i c h e a l t h p r o t e c t i o n from the s p e c i a l pathogenic hazards posed by spas are completely n e g l e c t e d . O v e r a l l , spa p o l i c y i n B.C. resembles the second kind of p o l i c y seen i n the U.S. j u r i s d i c t i o n s where spas are p r i n c i p a l l y t r e a t e d as small swimming p o o l s . Since t h i s type of p o l i c y has been e x t e n s i v e l y covered i n the e v a l u a t i o n of the U.S. experience, a d e t a i l e d a n a l y s i s i s unnecessary here. A c r i t i q u e , based upon c u r r e n t t e c h n i c a l and s c i e n t i f i c knowledge, of e x i s t i n g standards and r e g u l a t i o n s f o r spas i n B.C. i s c o n t a i n e d i n Appendix E. T h i s c r i t i q u e reviews e x i s t i n g p r o v i s i o n s and d e s c r i b e s t h e i r weaknesses. I t should be evident from the U.S. experience that t h i s approach i s s e r i o u s l y d e f i c i e n t . B r i e f examination of experience elsewhere i n Canada s u b s t a n t i a t e s t h i s argument. The Provinces of Saskatchewan and O n t a r i o have experienced growing p u b l i c h e a l t h problems with spas and recognized the need to take steps to develop p o l i c i e s s p e c i f i c a l l y aimed at h a n d l i n g the p o t e n t i a l hazards a s s o c i a t e d with s p a s . 6 The Canadian Swimming Pool A s s o c i a t i o n i s i n the process of d e v i s i n g s p e c i f i c spa s t a n d a r d s . 7 Thus, i t seems evident that e x i s t i n g spa p o l i c y i n B.C. i_s l a g g i n g behind the times, and a new p o l i c y should be c o n s i d e r e d . 120 The Case For Spa P o l i c y Change in B r i t i s h Columbia Using the f i g u r e s s u p p l i e d by the p r o v i n c e f o r the number of spas pe r m i t t e d j u s t i n the years 1977, 1980, and 1981, we can assume that there are at l e a s t 200 p u b l i c spas o p e r a t i n g i n the pro v i n c e ( f i g u r e s as s u p p l i e d i n Chaper 1). I f we then assume that there are at l e a s t an average of 10 people a day who use each spa (not at a l l unreasonable as there are o f t e n 10 people an hour using the UBC spa), then we c o u l d conclude that there are a minimum of 2000 people using p u b l i c spas d a i l y w i t h i n B.C. Taken over a p e r i o d of time, even c o n s i d e r i n g m u l t i p l e exposures by users, a s u b s t a n t i a l number of people are undoubtedly a f f e c t e d by p u b l i c spas. In view of the number of people i n v o l v e d and the hazards a s s o c i a t e d with spa use, i t i s evident that government a c t i o n to p r o t e c t p u b l i c h e a l t h i s r e q u i r e d . Spas are now being e x t e n s i v e l y used i n B.C. and as i n d i c a t e d e a r l i e r i n t h i s t h e s i s , p u b l i c h e a l t h hazards a s s o c i a t e d with spas r e q u i r e government a c t i o n to e s t a b l i s h and implement c o n d i t i o n s of safe use. New p o l i c i e s which a c c u r a t e l y account for spa management problems and u n c e r t a i n t i e s should be developed i n B.C. i n accord with the e v a l u a t i v e framework e s t a b l i s h e d i n chapter three and the l e s s o n s gained from o b s e r v a t i o n of the U.S. expe r i e n c e . 121 Footnotes - Chapter 4 1Robert J a n i s , Pool & Spa News, "SPEC Meets on Governmental A f f a i r s " , A p r i l 5, 1982, p. 16. 2 J o r i a n C l a i r , Pool & Spa News, "Spa H e a l t h Code A c t i o n Planned: ISTI to Meet with NSF i n October", September 21, 1981, p. 98. i n t e r v i e w with Dave A n t o n a c c i , op. c i t . "Interview with Jim Brown, October 1 8 , 1982. i n t e r v i e w with L a r r y P a u l i c k , V i c e P r e s i d e n t , NSPI, Washington D.C, August 10, 1982. 6 L e t t e r from L. J . Corkery, Consultant P u b l i c Health I n s p e c t i o n , Saskatchewan He a l t h , Regina, Saskatchewan, February 14, 1983. L e t t e r from Peter J . Block, Senior Consultant Swimming Pools, P u b l i c H e a l t h Branch, O n t a r i o M i n i s t r y of Hea l t h , Toronto, O n t a r i o , February 7, 1983. i b i d . Main Sources of Information U.S. Center f o r Disease C o n t r o l ; A t l a n t a , Georgia Consumer Products Safety Commission; Washington, D.C. St a t e of I l l i n o i s , Dept. of P u b l i c H e a l t h ; S p r i n g f i e l d , II Cook County P u b l i c Health Dept.; Maywood, I I . DuPage County H e a l t h Dept; Wheaton, I I . Northwest M u n i c i p a l Conference; Mt. Prospect, I I . St a t e of Oregon, P u b l i c H e a l t h D i v i s i o n ; P o r t l a n d , Oregon N a t i o n a l Spa & Pool I n s t i t u t e ; Washington, D.C. N a t i o n a l Spa & Pool I n s t i t u t e Midwest Chapter; Chicago, II Great Lakes Biochemical Co., Inc.; Milwaukee, Wis. Bio-Lab, Inc.; Decatur, Ga. The Meadow Club; R o l l i n g Meadows, I I . Chicago H e a l t h Club; Maywood, I I . C o n t i n t e n t a l Club; R o l l i n g Meadows, I I . Spa P e t i t e ; Schaumberg, I I . H e a l t h F i t n e s s ; Westmont, I I . Pool & Spa News; Los Angeles, Ca. Swimming Pool Age; F t . Lauderdale, F l a . Pool Scope; Washington, D.C. Chicago Tribune; Chicago, I I . 123 Canada B.C. M i n i s t r y of Heal t h ; V i c t o r i a , B.C. Vancouver P u b l i c Health Dept.; Vancouver, B.C. Vancouver Medical Health O f f i c e r ; Vancouver, B.C. Richmond Medical Health O f f i c e r ; Richmond, B.C. Burnaby Medical Health O f f i c e r ; Burnaby, B.C. Saskatchewan Health; Regina, Saskatchewan O n t a r i o M i n i s t r y of H e a l t h ; Toronto, O n t a r i o U.B.C. Aquatic Centre; Vancouver, B.C. Brentwood Racquet Club; Burnaby, B.C. Vancouver YMCA; Vancouver, B.C. H a r r i s o n Hot Springs Community Centre; H a r r i s o n , B.C. Vancouver Sun; Vancouver, B.C. 124 CHAPTER 5 Recommendations For a Spa P o l i c y Framework f o r B r i t i s h Columbia Since there i s not a set of p o l i c i e s i n B r i t i s h Columbia which s p e c i f i c a l l y d e a l with spas i n accord with the e v a l u a t i v e framework, a complete set of new p o l i c i e s needs to be designed (with the exception of maximum temperature l e v e l s ) . The f o l l o w i n g proposed p o l i c y framework i s designed (a) to meet the e v a l u a t i v e c r i t e r i a which have been developed, and (b) to de a l with the d e f i c i e n c i e s found i n those j u r i s d i c t i o n s which have endeavored to r e g u l a t e p u b l i c spas and hot tubs. In the recommended set of p o l i c i e s , no attempt w i l l be made to i n d i c a t e which p a r t i c u l a r p u b l i c h e a l t h agency should be r e s p o n s i b l e f o r the v a r i o u s p o l i c i e s . The term " a p p r o p r i a t e h e a l t h agency" w i l l r e f e r to whatever p r o v i n c i a l or l o c a l government agencies might be i n v o l v e d i n spa management. F u r t h e r , no attempt i s made to judge the extent to which new l e g i s l a t i o n i s r e q u i r e d to e s t a b l i s h the proposed p o l i c i e s , standards, r e g u l a t i o n s , or procedures. S p e c i f i c t e c h n i c a l and s c i e n t i f i c recommendations are p u r p o s e f u l l y not i n c l u d e d , as t h i s i s c o n s i d e r e d best l e f t to decision-makers and the a f f e c t e d i n t e r e s t s w i t h i n B r i t i s h Columbia. The reader may wish to c o n s u l t the appendices ( e s p e c i a l l y appendix B) and r e f e r e n c e s c i t e d i n t h i s t h e s i s as a guide to t e c h n i c a l and s c i e n t i f i c concerns. F i n a l l y , i t i s assumed that a m i n i s t e r , committee of m i n i s t e r s , or the l e g i s l a t u r e , i f necessary, w i l l have f i n a l r e s p o n s i b i l i t y f o r any p o l i c i e s adopted. The recommendations are as f o l l o w s : 1 25 1. Development of Approved Standards and Procedures f o r P u b l i c Spas and Hot Tubs The P r o v i n c e , under the a p p r o p r i a t e h e a l t h agency, should immediately i n i t i a t e a process to develop "Approved Standards and Procedures f o r P u b l i c Spas and Hot Tubs in B r i t i s h Columbia", which would separate p u b l i c spa standards from p u b l i c swimming pool standards. The most recent s c i e n t i f i c and t e c h n i c a l knowledge about p o t e n t i a l spa hazards and c o n d i t i o n s should be u t i l i z e d to devise standards which provide reasonable assurance f o r " s a f e " use. The standards should cover the f o l l o w i n g a s p e c t s : a) p u b l i c spa and hot tub design, c o n s t r u c t i o n and i n s t a l l a t i o n c r i t e r i a b) p u b l i c spa and hot tub o p e r a t i o n and management c r i t e r i a , and key parameters (e.g., d i s i n f e c t a n t l e v e l s , pH, temperature, b a c t e r i a l counts, e t c . ) f o r " s a f e " spa c o n d i t i o n s should be i d e n t i f i e d . c) s p e c i f i c warnings of hazards to spa users and s p e c i f i c i n f o r m a t i o n about i n d i v i d u a l c h a r a c t e r i s t i c s r e q u i r i n g s p e c i a l p r e c a u t i o n s d u r i n g spa use and i n s t r u c t i o n s on how to take such p r e c a u t i o n s d) s a f e t y and emergency procedures e) a p p r o p r i a t e spa user behaviour c r i t e r i a f ) record-keeping and monitoring procedures Standards which cover these aspects serve to meet our sub-c r i t e r i a of p o s i t i v e a c t i o n to i d e n t i f y c o n d i t i o n s of " s a f e " use 1 26 which w i l l p r o t e c t users, non-users, and those i n d i v i d u a l s r e q u i r i n g s p e c i a l p r e c a u t i o n s . In a d d i t i o n , i t would be necessary that the f o l l o w i n g procedures be e s t a b l i s h e d : a.) Spa f a c i l i t i e s should be r e q u i r e d to o b t a i n i n i t i a l o p e r a t i n g permits based upon compliance with design, c o n s t r u c t i o n , and i n s t a l l a t i o n c r i t e r i a e s t a b l i s h e d by the approved standards. Permits should be c o n s p i c u o u s l y posted. b) Spa f a c i l i t i e s should be r e q u i r e d to p e r i o d i c a l l y renew permits based upon compliance with the o p e r a t i o n and management c r i t e r i a e s t a b l i s h e d by the approved standards and other requirements s p e c i f i e d by e s t a b l i s h e d p o l i c y . c) Spa f a c i l i t i e s should be r e q u i r e d to post conspicuous warnings in accord with the approved standards which cover: ( i ) warnings of p o t e n t i a l hazards f o r the average user. ( i i ) i n s t r u c t i o n s of a p p r o p r i a t e spa use behaviour to prevent occurrence of spa hazards. ( i i i ) i n d i v i d u a l c h a r a c t e r i s t i c s which r e q u i r e c e r t a i n people to take s p e c i a l p r e c a u t i o n s d u r i n g spa use. ( i v ) i n s t r u c t i o n s on how s p e c i a l p r e c a u t i o n s should be taken. d) The a p p r o p r i a t e h e a l t h agency should develop a pamphlet on "Safe Use of P u b l i c Spas and Hot Tubs" to be made a v a i l a b l e to the p u b l i c through spa f a c i l i t i e s and through p u b l i c h e a l t h a g e n c i e s . T h i s pamphlet should i n c l u d e the warnings and i n s t r u c t i o n s d e s c r i b e d above. These p r o v i s i o n s meet the other two s u b - c r i t e r i a f o r 1 27 e s t a b l i s h i n g procedures which (1) i d e n t i f y spas adhering to standards and (2) a s s u r i n g r e l i a b l e access to i n f o r m a t i o n r e g a r d i n g s p e c i a l p r e c a u t i o n s f o r c e r t a i n i n d i v i d u a l s . Thus, development of approved standards w i t h i n the above format f u l l y meets the f i r s t c r i t e r i a f o r a "good" spa p o l i c y . 2. Determination of P r o v i n c i a l P u b l i c Spa/Hot Tub Standards and Management P o l i c i e s In order that standards and management p o l i c i e s f o r p u b l i c spas meet the c r i t e r i o n of having been e s t a b l i s h e d through processes i n which users, o p e r a t o r s , and the p u b l i c have c o n f i d e n c e , the f o l l o w i n g p r o v i s i o n s should be made: a) The a p p r o p r i a t e h e a l t h agency should arrange a s e r i e s of " P u b l i c Awareness Seminars" which are open to a l l i n t e r e s t e d u sers, o p e r a t o r s , and members of the p u b l i c . These seminars should serve t o i l l u m i n a t e and c l a r i f y the b a s i c i s s u e s i n v o l v e d i n the r e g u l a t i o n of p u b l i c spas. b) The a p p r o p r i a t e h e a l t h agency should e s t a b l i s h a committee e q u a l l y composed of r e p r e s e n t a t i v e s from a l l a f f e c t e d i n t e r e s t s ( p u b l i c h e a l t h o f f i c i a l s , members of the p u b l i c , i n d u s t r y , spa o p e r a t o r s , and spa u s e r s ) . T h i s committee should be a i d e d by i n f o r m a t i o n s u p p l i e d by q u a l i f i e d s c i e n t i s t s . The purpose of the committee should be to review proposed standards and management p o l i c i e s and to make f i n a l recommendations f o r adoption of standards and p o l i c i e s . c) P r i o r to making f i n a l recommendations, the committee should 1 28 i n v i t e , r e c e i v e , and review comments about the proposed p o l i c y from the general p u b l i c and s p e c i a l i n t e r e s t s by n o t i f y i n g the p u b l i c of the e x i s t e n c e of the p r o p o s a l s and a l l o w i n g complete access to t h e i r c ontent. d) The recommendations f o r standards and management p o l i c i e s should be decided, a f t e r weighing arguments and o u t s i d e comments, by m a j o r i t y vote of the committee. I f a m i n o r i t y of the committee has strong o b j e c t i o n s to the spa p o l i c y or to s p e c i f i c p r o v i s i o n s of the p o l i c y , a m i n o r i t y r e p o r t o u t l i n i n g the o b j e c t i o n s and reasons f o r the o b j e c t i o n s should a l s o be submitted to the a p p r o p r i a t e body with the a u t h o r i t y to r e g u l a t e spas. e) The a p p r o p r i a t e h e a l t h agency should a u t h o r i t a t i v e l y decide on acceptance of the model p o l i c y and i s s u e whatever d i r e c t i v e s necessary f o r e n a c t i n g the p o l i c y or d e l e g a t i n g a u t h o r i t y . I f m i n o r i t y o b j e c t i o n s e x i s t , i t should be the r e s p o n s i b i l i t y of the a p p r o p r i a t e body having the a u t h o r i t y to r e g u l a t e spas to make f i n a l d e t e r m i n a t i o n . In e s t a b l i s h i n g the above-suggested process f o r the det e r m i n a t i o n of p u b l i c spa standards and management p o l i c i e s , the second c r i t e r i o n i s f u l l y met by: a l l o w i n g a l l a f f e c t e d i n t e r e s t s to p a r t i c i p a t e i n c o n c e p t u a l i z i n g the p o l i c y ; p r o v i d i n g means f o r d i f f e r e n c e s i n p r e f e r e n c e s to be r e c o n c i l e d ; and p r o v i d i n g a means f o r f i n a l d e t e r m i n a t i o n where agreements cannot be reached. 3. Measures f o r Implementing Spa Standards and Management 1 29 P o l i c i e s i n B.C. The e s t a b l i s h e d spa p o l i c y must have e f f e c t i v e procedures f o r implementation. The recommended measures i n c l u d e : a) Part V I I , s e c t i o n 81 of the B.C. H e a l t h Act p r o v i d e s that "Every swimming-pool s h a l l be operated and maintained by a competent operator and manager. The Department of Health may r e q u i r e a c e r t i f i c a t e of competency obtained through attendance and s u c c e s s f u l completion of an approved swimming-pool o p e r a t o r ' s t r a i n i n g course as evidence of compliance with t h i s s e c t i o n . " T h i s p r o v i s i o n should be a c t i v a t e d i n regard to spas and t h e r a p e u t i c pools so that a l l spa o p e r a t o r s p a r t i c i p a t e i n a p r o v i n c i a l l y - s p o n s o r e d t r a i n i n g program. The t r a i n i n g program should i n c o r p o r a t e the best c u r r e n t knowledge on the f u n c t i o n i n g of spa systems, r a t i o n a l e s f o r approved standards, and techniques f o r o p e r a t o r s to deal with v a r i a b l e spa c o n d i t i o n s . A sample t r a i n i n g program i s p r o v i d e d i n Appendix F. b) Spa owners should be r e q u i r e d to f o r m a l i z e the approved standards and management p o l i c i e s i n t o "Plans of O p e r a t i o n " . The purpose of t h i s p r o v i s i o n i s twofold: (1) to encourage o p e r a t o r s to c o n s c i o u s l y t h i n k of spa water q u a l i t y management as a primary goal i n the d a i l y , on-going o p e r a t i o n of a f a c i l i t y as opposed to viewing compliance with standards and r e g u l a t i o n s simply as an o b l i g a t o r y task f o r p a s s i n g h e a l t h department i n s p e c t i o n s . 130 ( 2 ) to provide users with an a d d i t i o n a l means to evaluate on a r e g u l a r b a s i s spa f a c i l i t i e s ' c o n d i t i o n s , s e r v i c e s , and performance. The "Plans of Operation" f o r any f a c i l i t y should be f l e x i b l e i n a l l o w i n g an operator to design o p e r a t i n g plans a c c o r d i n g to i n d i v i d u a l needs, purposes, and c r e a t i v e a b i l i t i e s . However, each plan would have t o , i n some way, co n s i d e r and provide f o r : a) s a t i s f a c t i o n of the approved standards and procedures b) t r a i n i n g of f a c i l i t y personnel c) n o t i f y i n g users of hazards and proper behaviour (as w e l l as p r o v i s i o n s f o r e n f o r c i n g t h i s ) d) water q u a l i t y and equipment maintenance procedures e) m o n i t o r i n g , t e s t i n g , and record-keeping procedures f) s a f e t y and emergency procedures E v a l u a t i o n and approval of plans should be based on these p r o v i s i o n s being met w i t h i n the l i m i t s of c u r r e n t knowledge. Approval f o r unusual methods would r e q u i r e p r i o r s u b s t a n t i a t i o n and be fo l l o w e d through a set t r i a l p e r i o d of experimentation c l o s e l y monitored by h e a l t h o f f i c i a l s . A l s o , a n t i c i p a t e d bather load of each f a c i l i t y should be weighed i n judging a p p r o v a l . Users and the general p u b l i c should have access to a f a c i l i t y ' s p l a n s , c) Spa o p e r a t o r s should be r e q u i r e d to post i n f o r m a t i o n , e a s i l y observable near the spa u n i t , about key parameters a f f e c t i n g " s a f e " c o n d i t i o n s . T h i s i n f o r m a t i o n should i n c l u d e i n simple terms, the f o l l o w i n g : 131 ( i ) the parameter and a simple d e f i n i t i o n of the parameter ( i i ) a simple e x p l a n a t i o n of what the parameter and p o s s i b l e consequences i f the parameter standard i s not f o l l o w e d (e.g., " c h l o r i n e l e v e l s - f o r d i s i n f e c t i o n - prevents b a c t e r i a l growth i n the spa"). ( i i i ) the range of values f o r the parameter which adhere to the approved standards ( i v ) a simple means of d i s p l a y i n g the parameter values of a c t u a l spa c o n d i t i o n s on a continuous or p e r i o d i c (no gr e a t e r than hourly) b a s i s . c) Spa operators should be ad v i s e d to take measures which assure that users are informed of s p e c i a l p r e c a u t i o n s i n use and r e q u i r e d to provide adequate means of compensation should i n j u r i e s or deaths occur. ( i ) Spa op e r a t o r s should advise spa users to o b t a i n a p h y s i c i a n ' s approval f o r spa use, p a r t i c u l a r l y those i n d i v i d u a l s who have a medical h i s t o r y which would warrant s p e c i a l p r e c a u t i o n s to be taken. The approval should be updated on a y e a r l y b a s i s . ( i i ) Spa o p e r a t o r s should be r e q u i r e d to o b t a i n product l i a b i l i t y insurance amounts c o n s i s t e n t with the c u r r e n t recommended coverage f o r s i m i l a r r i s k a reas. e) The a p p r o p r i a t e h e a l t h agency should e s t a b l i s h procedures f o r monitoring and record-keeping to be administered by a p p r o p r i a t e a g e n c i e s . These procedures should i n c l u d e : 132 ( i ) S u b m ittal by spa o p e r a t o r s of records of key parameters (recorded p e r i o d i c a l l y , e.g. hourly) and submitted on a weekly b a s i s . These records should be reviewed p e r i o d i c a l l y by the p u b l i c h e a l t h agency and the records should be maintained on f i l e . ( i i ) The p u b l i c h e a l t h agency should conduct o n - s i t e i n s p e c t i o n s of spa f a c i l i t y premises on a p e r i o d i c b a s i s to a s c e r t a i n whether spa f a c i l i t i e s are adhering to approved standards and management p o l i c i e s . ( i i i ) P u b l i c h e a l t h agencies should e s t a b l i s h channels of communication between users and the agency. For example, phone numbers and addresses of a p p r o p r i a t e h e a l t h agencies c o u l d be posted i n spa f a c i l i t i e s and personnel be made a v a i l a b l e in h e a l t h agencies to handle phone c a l l s or l e t t e r s from users and the p u b l i c . User and non-user complaints, i n q u i r i e s or problems should be addressed through these channels, and procedures should be developed by agencies to r e s o l v e s e r i o u s or r e c u r r i n g problems. ( i v ) A p p r o p r i a t e h e a l t h agencies should e s t a b l i s h a system of f i n e s and c l o s u r e s as a means to enforce operator compliance with the approved standards and management p o l i c i e s . (v) A p p r o p r i a t e h e a l t h agencies should e s t a b l i s h a procedure f o r a r b i t r a t i o n to r e s o l v e any problems between users and o p e r a t o r s or o p e r a t o r s and agencies 133 which are not c l e a r l y d e f i n e d and r e s o l v e a b l e through e i t h e r a p p l i c a t i o n of the approved standards and management p o l i c i e s or the e s t a b l i s h e d normal channels of communication. I t i s envisaged that problems may a r i s e as a r e s u l t of such f a c t o r s as; (1) i n t e r p r e t a t i o n of approved standards and procedures, (2) changing p e r c e p t i o n s of " s a f e " c o n d i t i o n s due to s h i f t s i n spa a c t o r s ' v a l u e s and behaviour or s c i e n t i f i c advances, and (3) i s s u e s r e l a t i n g to q u e s t i o n s of " f a i r n e s s " . Since p o l i c y cannot be expected to f u l l y a n t i c i p a t e such f a c t o r s in r e a d i l y c o d i f i a b l e terms, a r b i t r a t i o n procedures are important f o r r e s o l v i n g f u t u r e problems i n s p e c i f i c i n s t a n c e s which do not j u s t i f y o v e r a l l changes i n spa p o l i c y . The procedures f o r a r b i t r a t i o n should r e c e i v e p r i o r approval by the a p p r o p r i a t e body having a u t h o r i t y to r e g u l a t e spas. The above p r o v i s i o n s f u l l y meet the t h i r d c r i t e r i o n by: (1) p r o v i d i n g education and t r a i n i n g to o p e r a t o r s , (2) p r o v i d i n g users with a means f o r checking a c t u a l spa c o n d i t i o n s a g a i n s t the approved standards, (3) p r o v i d i n g a mechanism which assures that i n d i v i d u a l s r e q u i r i n g s p e c i a l p r e c a u t i o n s are informed, (4) p r o v i d i n g p u b l i c h e a l t h agency monitoring and enforcement procedures, and (5) p r o v i d i n g procedures f o r r e s o l v i n g f u t u r e problems i n s p e c i f i c cases not warranting o v e r a l l changes i n p o l i c y . 134 4. P o l i c i e s to Reduce U n c e r t a i n t i e s and Improve Spa Management and Enforcement Procedures Because of the e x i s t e n c e of s i g n i f i c a n t u n c e r t a i n t i e s r e l a t e d t o : (1) the nature of pathogenic hazards, (2) the p h y s i c a l c h a r a c t e r i s t i c s of spas, and (3) the behaviour of spa a c t o r s , P r o v i n c i a l spa p o l i c y should i n c l u d e p o s i t i v e i n c e n t i v e s and a process f o r s o c i a l l e a r n i n g i n order to improve spa management p r a c t i c e s beyond i t s c u r r e n t s t a t e . Recommendations of t h i s kind are as f o l l o w s : a) The a p p r o p r i a t e h e a l t h agency with c o - o p e r a t i o n from s c i e n t i s t s and i n d u s t r y should c l e a r l y i d e n t i f y the e x i s t i n g u n c e r t a i n t i e s in spa management; by p r i o r i t y , the u n c e r t a i n t i e s should be i d e n t i f i e d i n a w r i t t e n r e p o r t along with suggestions on how these u n c e r t a i n t i e s might be reduced. The r e p o r t should be d i s t r i b u t e d to a l l p u b l i c h e a l t h o f f i c i a l s i n the Province and spa o p e r a t o r s . b) "Plans of O p e r a t i o n " should serve to f u r t h e r s o c i a l l e a r n i n g and improve spa management. I d e n t i f i e d u n c e r t a i n t i e s and problems of top p r i o r i t y c o u l d be d e a l t with through u t i l i z a t i o n of "Plans of Operation". Operators should be encouraged to i n c l u d e i n t h e i r p l a n s : ( i ) a c t i o n s which might h e l p reduce u n c e r t a i n t i e s (e.g. data c o l l e c t i o n of bather use and behaviour) ( i i ) experimental techniques f o r ha n d l i n g v a r i a b l e c o n d i t i o n s (e.g. methods to determine a p p r o p r i a t e i n t e r v a l s f o r d r a i n i n g spas) ( i i i ) development and implementation of s p e c i a l 135 r e c r e a t i o n a l and t h e r a p e u t i c programs f o r users which i n c r e a s e user b e n e f i t s and which promote user p a r t i c i p a t i o n i n understanding and being r e s p o n s i b l e f o r establishment of " s a f e " c o n d i t i o n s . T h i s may improve p u b l i c h e a l t h p r o t e c t i o n and a l s o s t i m u l a t e o p e r a t o r s to compete on l e v e l s r e l a t e d to water q u a l i t y c o n d i t i o n s , ( i v ) the use of t r a i n e d r e c r e a t i o n a l and t h e r a p e u t i c p r o f e s s i o n a l s who may b r i n g a d d i t i o n a l knowledge and p e r s p e c t i v e s to the " s a f e " and " b e n e f i c i a l " use of spas. c) The a p p r o p r i a t e h e a l t h agency, in c o n j u n c t i o n with other p u b l i c h e a l t h agencies, should develop p o s i t i v e i n c e n t i v e s to encourage opera t o r s to improve the l e v e l of spa management. Examples of such i n c e n t i v e s might i n c l u d e : ( i ) r a t i n g systems f o r spa f a c i l i t i e s which are posted or p u b l i s h e d f o r p u b l i c i n s p e c t i o n . ( i i ) p r e s e n t a t i o n of awards f o r well-managed o p e r a t i o n s ( i i i ) f i n a n c i a l i n c e n t i v e s f o r operat o r s who exceed approved standards or who make an outstanding c o n t r i b u t i o n to e l e v a t e spa management knowledge and p r a c t i c e s d) The a p p r o p r i a t e h e a l t h agency should commission s t u d i e s and re s e a r c h f o r reducing u n c e r t a i n t i e s and improving spa management as funding a l l o w s . S t u d i e s and r e s e a r c h should be conducted by i n d i v i d u a l s or groups o u t s i d e of the r e p r e s e n t a t i v e body which recommends or approves standards 1 36 (e.g. u n i v e r s i t i e s , p r i v a t e c o n s u l t a n t s ) . Examples of r e l e v a n t s t u d i e s might i n c l u d e : ( i ) the range of pathogenic hazards and p r e v e n t a t i v e measures which can most e f f e c t i v e l y reduce these hazards ( i i ) methods which o p e r a t o r s can u t i l i z e to more e f f e c t i v e l y d eal with v a r i a b l e c o n d i t i o n s (e.g., a p p r o p r i a t e i n t e r v a l s f o r d r a i n i n g spas, gauging a p p l i c a t i o n of d i s i n f e c t a n t s , e t c.) ( i i i ) b e h a v i o u r a l s t u d i e s r e l a t i n g to spa management (e.g., how to achieve user compliance with spa use r u l e s , how to e f f e c t i v e l y teach o p e r a t o r s to handle spa management t a s k s , e t c . ) Many other s t u d i e s that might be worthwhile c o u l d be undertaken, but these are the primary areas which should be examined f i r s t . e) The P r o v i n c i a l Spa P o l i c y should be reviewed by the a p p r o p r i a t e h e a l t h agency at a minimum of every two years (or i f s i g n i f i c a n t problems become apparent before then) and a d j u s t e d a c c o r d i n g l y . The type of d e c i s i o n process, e a r l i e r d e s c r i b e d , which i n c l u d e s input from a l l a f f e c t e d i n t e r e s t s and f i n a l a u t h o r i t y r e s t e d i n the l e g i s l a t u r e should be fo l l o w e d . Communications and meetings with p u b l i c h e a l t h j u r i s d i c t i o n s o u t s i d e of B.C., i n Canada and the U.S. should be developed i n order to exchange i n f o r m a t i o n and remain c u r r e n t on spa management p o l i c i e s and p r a c t i c e s . 1 37 T h i s f i n a l set of p r o v i s i o n s f u l l y meets the f o u r t h c r i t e r i o n , as they provide f o r : (a) acknowledgement and i d e n t i f i c a t i o n of spa management u n c e r t a i n t i e s ; ' (2) a t o o l (the "plans of o p e r a t i o n " ) f o r o p e r a t o r s to develop a l e a r n i n g process and f o r improving spa management performance; (3) p o s i t i v e i n c e n t i v e s to motivate operator l e a r n i n g ; (4) new s t u d i e s which may reduce u n c e r t a i n t i e s ; and (5) a process f o r p o l i c y review and g a t h e r i n g knowledge from experience elsewhere i n order to allow l e a r n i n g w i t h i n the whole spa management system. Notes on P r o v i s i o n s f o r Funding A d e t a i l e d d i s c u s s i o n of funding and other economic matters r e l a t e d to development of a B.C. model spa p o l i c y were c o n s i d e r e d o u t s i d e the scope of t h i s t h e s i s , and there w i l l not be an attempt to provide d e t a i l here. However, the obvious importance of funding to the success of the model p o l i c y deserves mention of a few g e n e r a l comments and suggestions, which are based on o b s e r v a t i o n s gained through r e s e a r c h on t h i s t h e s i s . F i r s t , the economic c l i m a t e of the past few years has c r e a t e d p r e s s u r e s on a l l government agencies to r e s t r a i n or reduce budgets — p u b l i c h e a l t h agencies are no e x c e p t i o n . Costs i n v o l v e d i n d e v e l o p i n g and a d m i n i s t e r i n g programs such as the above spa p o l i c y can become s u b s t a n t i a l . They a l s o g e n e r a l l y r e q u i r e on-going expenditures which can o f t e n i n c r e a s e 138 over time. But p u b l i c h e a l t h p r o t e c t i o n i s c o n s i d e r e d one of the primary concerns of government and v i t a l to a l l i n d i v i d u a l s i n s o c i e t y . P u b l i c spas and hot tubs, r e g a r d l e s s of one's view toward them, are here to stay; and as matters of p u b l i c h e a l t h concern, p u b l i c budgets should adequately account f o r spa r e g u l a t i o n . Second, i t appears that spa r e g u l a t o r y e f f o r t s act as a kind of subsidy f o r those i n d i v i d u a l s who use spas, p a r t i c u l a r l y on a r e g u l a r b a s i s . So f a r , i t a l s o appears that spa r e g u l a t o r y e f f o r t s ( i f undertaken p r o p e r l y ) r e q u i r e g r e a t e r expenditures than with other s i m i l a r a c t i v i t i e s , such as p u b l i c swimming. F u r t h e r , i t appears that spa users, e s p e c i a l l y r e g u l a r u s e r s , c o n s t i t u t e a m i n o r i t y of the p o p u l a t i o n , and hence they can be c o n s i d e r e d a " s p e c i a l i n t e r e s t " . Although i t would be u n f a i r to deny any a l l o c a t i o n of p u b l i c funds toward p u b l i c spa r e g u l a t i o n , i t i s reasonable to r a i s e the q u e s t i o n of whether spa users should bear more of the c o s t s i n v o l v e d . T h e r e f o r e , the f o l l o w i n g two suggestions are made: (1) P u b l i c h e a l t h agencies should c a r e f u l l y analyze funding requirements f o r r e g u l a t i n g spas both f o r the short-term and, as n e a r l y as p o s s i b l e , f o r the long-term. I f i t appears that budgets w i l l be inadequate, ( e i t h e r now or i n the f u t u r e ) , to implement spa p o l i c y e f f e c t i v e l y , h e a l t h o f f i c i a l s should a l e r t l e g i s l a t o r s and the p u b l i c as soon as p o s s i b l e , rather than wait u n t i l problems a r i s e . (2) An economic study should be immediately undertaken which 139 c o n s i d e r s a l t e r n a t i v e methods f o r o b t a i n i n g necessary funds for spa r e g u l a t i o n . Taxes or s p e c i a l assessments l e v i e d on spa users (and a p p l i e d through o p e r a t o r s or i n d u s t r y ) should be c o n s i d e r e d as one of the a l t e r n a t i v e s . Perhaps a " r e g u l a t o r y tax" c o u l d be d e v i s e d which uses c o s t s of r e g u l a t i o n , over and above comparative p u b l i c h e a l t h programs, as a b a s i s f o r computing tax amounts. Such a system might serve the added purpose of p r o v i d i n g o p e r a t o r s and users with an i n c e n t i v e to manage spa f a c i l i t i e s more e f f e c t i v e l y so as to incur the l e a s t needs f o r government r e g u a l t i o n . Although these comments and suggestions are o u t s i d e a d e t a i l e d a n a l y s i s i n t h i s t h e s i s , they r e f l e c t e x p e r i ences, o p t i o n s , and o b s e r v a t i o n s d e r i v e d through work on t h i s case study. These comments and suggestions should at l e a s t be c o n s i d e r e d by policy-makers i n t e r e s t e d i n spas and pursued i f deemed worthy of f u r t h e r i n v e s t i g a t i o n . Summary and Expected R e s u l t s : How the Model P o l i c y Can C o r r e c t Present D e f i c i e n c i e s The main weakness i n present B.C. spa p o l i c y i s i t s f a i l u r e to i n c o r p o r a t e recent t e c h n i c a l and s c i e n t i f i c knowledge about p o t e n t i a l spa hazards and spa management. As a r e s u l t , p o t e n t i a l spa hazards are not being adequately d e a l t with by p o l i c y , and the Province i s f a i l i n g to f u l f i l l i t s r o l e and r e s p o n s i b i l i t y i n p r o t e c t i n g the h e a l t h of users and non-users 140 of spas. Although some j u r i s d i c t i o n s elsewhere i n Canada and the U n i t e d S t a t e s have reco g n i z e d the p o t e n t i a l hazards and taken p o s i t i v e steps to d e a l with these hazards, t h e i r a c t i o n s should only be p a r t i a l l y used as a model f o r B.C. p o l i c y . These j u r i s d i c t i o n s have p r i m a r i l y f a i l e d t o : (1) i n c l u d e o p e r a t o r s and users i n the d e c i s i o n process f o r deve l o p i n g spa standards and management p o l i c i e s (2) s u f f i c i e n t l y acknowledge spa management u n c e r t a i n t i e s and d e v i s e a s t r a t e g y f o r reducing the u n c e r t a i n t i e s (problems i n h a n d l i n g the v a r i a b l e spa c o n d i t i o n s are l i n k e d to t h i s matter of u n c e r t a i n t y ) . Some j u r i s d i c t i o n s i n the U.S. and Canada have taken the c r u c i a l f i r s t s tep of r e c o g n i z i n g the problems a s s o c i a t e d with spas and attempting to d e a l with these problems. However, i n order f o r spa management p o l i c i e s to be e f f e c t i v e and provide users and the p u b l i c with c o n f i d e n c e that t h e i r h e a l t h i s being reasonably p r o t e c t e d i n the use of spas, a d d i t i o n a l steps must be taken. I t i s a l s o c r u c i a l t h a t policy-makers recognize that o p e r a t o r s and users are key a c t o r s and that t h e i r a c t i v e p a r t i c i p a t i o n i n p o l i c y development i s e s s e n t i a l . F u r t h e r , spa p o l i c i e s must recognize and account f o r d e f i c i e n c i e s i n present spa management knowledge r e s u l t i n g from the elements of u n c e r t a i n t y . A change i n B.C. spa p o l i c y which re c o g n i z e s p o t e n t i a l spa hazards and then takes the a d d i t i o n a l steps w i l l serve to reasonably p r o t e c t p u b l i c h e a l t h and s a f e t y . Recommendations have been presented which c o r r e c t e x i s t i n g d e f i c i e n c i e s by meeting a l l of the c r i t e r i a set f o r t h i n t h i s 141 study. If these recommendations are accepted, what r e s u l t s can be expected and how would they a c t u a l l y overcome present d e f i c i e n c i e s ? 1. R e c o g n i t i o n of p u b l i c h e a l t h hazards by the M i n i s t r y of Health and e f f o r t s to develop more a p p r o p r i a t e spa standards and management p o l i c i e s w i l l cause a l l spa a c t o r s to r e a l i s t i c a l l y examine the p o t e n t i a l problems which may a r i s e from p u b l i c spa and hot tub use. T h i s w i l l a llow spa a c t o r s to be prepared and to develop p r e v e n t a t i v e measures before s e r i o u s problems do occur as they have in p l a c e s with a h i s t o r y of heavy spa market development. 2. The model p o l i c y recommendations emphasize communication of necessary i n f o r m a t i o n about spa hazards and p r e v e n t a t i v e measures to users, non-users and o p e r a t o r s so that spa market mechanisms w i l l be more e f f i c i e n t and l e a d to " s a f e " use of p u b l i c spas and hot tubs. T h i s w i l l serve to f u l f i l l government's r e s p o n s i b i l i t y to p r o t e c t the h e a l t h of users i n spa use and the general p u b l i c from e x t e r n a l e f f e c t s due to spa use. 3. I n c l u s i o n of users, non-users and o p e r a t o r s i n the d e c i s i o n process f o r e s t a b l i s h i n g spa standards and management p o l i c i e s w i l l assure, as w e l l as p o s s i b l e , that i n d i v i d u a l p r e f e r e n c e s about " s a f e " spa c o n d i t i o n s w i l l be adequately accounted f o r i n spa p o l i c y d e c i s o n s . T h i s not only p r o v i d e s a l l spa a c t o r s with confidence i n the d e c i s i o n process, i t a l s o w i l l produce a more e f f e c t i v e o v e r a l l spa system by u t i l i z i n g more f u l l y the c a p a b i l i t i e s of u s e r s , 1 42 operators and h e a l t h o f f i c i a l s i n implementation of the p o l i c y . The proposed implementation measures r e a l i s t i c a l l y c o n s i d e r the spa a c t o r s ' c a p a b i l i t i e s and the d i f f i c u l t i e s c r e a t e d by v a r i a b l e spa c o n d i t i o n s . Adoption of the recommendations w i l l encourage a c t i v e p a r t i c i p a t i o n and i n t e r a c t i o n among users, o p e r a t o r s , and h e a l t h o f f i c i a l s . T h i s w i l l spread the r e s p o n s i b i l i t y f o r e s t a b l i s h i n g " s a f e " c o n d i t i o n s of use and i t w i l l enhance the prospect of s u c c e s s f u l spa management by p r o v i d i n g : (a) a means f o r spa c o n d i t i o n s to be monitored and c o r r e c t e d , i f necessary, on a more frequent b a s i s which v a r i a b i l i t y r e q u i r e s , and (b) a means f o r a l l the v a r i o u s spa a c t o r s to check on spa c o n d i t i o n s so that hazardous c o n d i t i o n s are not ignored because of d e l i b e r a t e or u n i n t e n t i o n a l n e g l e c t by any one spa a c t o r . The model p o l i c y recommendations acknowledge both the importance of reducing u n c e r t a i n t i e s i n spa management and the need f o r spa a c t o r s to be able to cope with s u r p r i s e s i n order to p r o t e c t p u b l i c h e a l t h e f f e c t i v e l y now and i n the f u t u r e . P o s i t i v e i n c e n t i v e s and s o c i a l l e a r n i n g t o o l s p r o v i d e d by "plans of o p e r a t i o n s " and s t u d i e s are recommended as ways to encourage and allow spa a c t o r s to improve spa management beyond i t s c u r r e n t s t a t e . Improved spa management w i l l p r o v i d e users and the general p u b l i c with g r e a t e r confidence that spa r e c r e a t i o n a l and t h e r a p e u t i c b e n e f i t s can be enjoyed without endangering 143 p u b l i c h e a l t h and s a f e t y . In c o n c l u s i o n , the p o t e n t i a l h e a l t h hazards a s s o c i a t e d with p u b l i c spas and hot tubs are very r e a l and they are probably underestimated by many people. Most e x p e r t s , however, agree that sound spa management p o l i c i e s and p r a c t i c e s can s i g n i f i c a n t l y reduce the hazards so that p u b l i c h e a l t h and s a f e t y p r o t e c t i o n can be reasonably assured to spa users and the general p u b l i c . Government p u b l i c p o l i c y can e f f e c t i v e l y serve t h i s o b j e c t i v e through the r e g u l a t i o n of p u b l i c spas and hot tubs. Yet, the c o n d i t i o n s of u n c e r t a i n t y i n v o l v e d i n spa management weaken the a b i l i t y of government to provide e f f e c t i v e c o n t r o l of problems r e s u l t i n g from spa use. E f f e c t i v e spa p o l i c i e s should accept t h i s r e a l i t y and d e v i s e s o l u t i o n s best s u i t e d to d e a l i n g with u n c e r t a i n t y . Adaptive and f l e x i b l e spa p o l i c i e s complement the framework f o r spa management pro v i d e d by b a s i c r e g u l a t o r y requirements r e l a t e d to the e s t a b l i s h m e n t , m o n i t o r i n g , and enforcement of spa standards. The P r o v i n c e of B r i t i s h Columbia can p r o v i d e a reasonable l e v e l of p u b l i c h e a l t h and s a f e t y p r o t e c t i o n i n the use of spas which would be c o n s i s t e n t with both theory and experience by f o l l o w i n g the recommendations o u t l i n e d i n t h i s t h e s i s . T h i s n e c e s s i t a t e s a w i l l i n g n e s s to change from e x i s t i n g p o l i c i e s and an understanding of how l e s s o n s gained elsewhere can be used as a guide f o r a b e t t e r system. C r e a t i n g a w i l l i n g n e s s to change p u b l i c d i r e c t i o n i s , as noted by Downs 1, Kaspersons 2, and o t h e r s , i s o f t e n a d i f f i c u l t 144 task u n t i l a c r i s i s o ccurs. Overcoming t h i s d i f f i c u l t y i s the p r e r e q u i s i t e f o r a c h i e v i n g " s a f e r " c o n d i t i o n s of use f o r p u b l i c spas and hot tubs i n B.C. I t i s hoped that t h i s t h e s i s and s i m i l a r e f f o r t s w i l l c r e a t e awareness about the problem with p u b l i c spas, encourage others to take a c t i o n , and p rovide d i r e c t i o n f o r t a k i n g a c t i o n . 1 45 Footnotes - Chapter 5 1 Anthony Downs, "Up and Down with Ecology: The Issue-A t t e n t i o n C y c l e " , The P u b l i c I n t e r e s t 29 (Summer 1972), pp. 38-50. 2Roger E. Kasperson, "Environmental S t r e s s and the M u n i c i p a l P o l i t i c a l System", i n R. E. Kasperson and J . V. Minghi, eds., The S t r u c t u r e of P o l i t i c a l Geography, (Chicago: A l d i n e Press, 1971) , pp. 481-96. 1 4 6 APPENDIX A Pathogenic Hazards and P u b l i c Spa/Hot Tub F a c i l i t i e s : New Challenges to P u b l i c H e a l t h Robert A. C r a n d a l l 1 and C.J.G. MacKenzie, M.D.2 Hot-water bathing as a r e c r e a t i o n a l and t h e r a p e u t i c a c t i v i t y has r a p i d l y gained p o p u l a r i t y w i t h i n the l a s t s i x y e a r s . Along with t h i s i n c r e a s e d p o p u l a r i t y , the i n c i d e n c e of d i s e a s e a s s o c i a t e d with spa and hot tub use has a l s o tended to i n c r e a s e . U n i t e d S t a t e s o f f i c i a l s from both f e d e r a l and s t a t e h e a l t h agencies (e.g., Centre f o r Disease C o n t r o l and Oregon St a t e P u b l i c H e a l t h Department) have expressed s e r i o u s concerns about p u b l i c h e a l t h problems with p u b l i c spa and hot tub f a c i l i t i e s , p a r t i c u l a r l y where f a c i l i t i e s are p o o r l y or only m a r g i n a l l y maintained. Numerous cases i n v o l v i n g s k i n i n f e c t i o n from the organism Pseudomonas aeruginosa have been w e l l -documented, and s t u d i e s i n d i c a t e that there i s a higher r i s k of d i s e a s e from t h i s organism when i n d i v i d u a l s are exposed to spas/hot tubs compared to swimming p o o l s . 1 " 6 Although aeruginosa has long been a s s o c i a t e d with 1Robert A. C r a n d a l l , M.A., Dept. of Community and Regional P l a n n i n g , U n i v e r s i t y of B r i t i s h Columbia. 2C.J.G. MacKenzie, M.D., CM., D.P.H., FRCP(C), P r o f e s s o r , Dept. of Health Care and Epidemiology, U n i v e r s i t y of B r i t i s h Columbia. 147 swimming p o o l s , the i n c r e a s e d r a t e of occurrence as a problem with spas and hot tubs r a i s e s q u e s t i o n s about these new environmental c o n d i t i o n s as sources of i n f e c t i o u s d i s e a s e . Comparison of the d i f f e r i n g c h a r a c t e r i s t i c s between pools and spas shows that the spa/hot tub environment i s more conducive f o r the establishment and growth of microorganisms. The warmer temperature range (35°-43°C), pH range (7.0-8.0), a e r a t i o n , and i n c r e a s e d presence of organic m a t e r i a l s due to high bather l o a d * * are common c o n d i t i o n s f o r spas/hot tubs and a l l f o s t e r a s u i t a b l e medium f o r the growth of a v a r i e t y of p o t e n t i a l l y pathogenic organisms. As the experience with aeruginosa demonstrates, assumptions u n d e r l y i n g swimming pool water q u a l i t y p r a c t i c e s may be m i s l e a d i n g when a p p l i e d to recommending proper d e s i g n , e n g i n e e r i n g , s a n i t a t i o n , management, and r e g u l a t o r y methods f o r spas and hot tubs. R e l i a n c e upon swimming pool experience as a precedence f o r spa water q u a l i t y may be g r o s s l y i n e f f e c t i v e , and perhaps i n some i n s t a n c e s , expose p u b l i c users to g r e a t e r r i s k from pathogenic organisms. The purpose of t h i s paper i s to c r e a t e i n c r e a s e d awareness of t h i s p o s s i b l i l i t y , s t i m u l a t e thought toward more a p p r o p r i a t e and comprehensive s o l u t i o n s , and suggest g e n e r a l a l t e r n a t i v e s f o r f u t u r e d i r e c t i o n . **Defined as "the number of users per volume of water over time." 148 Research Background and Methods Th i s r e s e a r c h was motivated by work r e l a t i n g to recommendations f o r spa and hot tub p u b l i c p o l i c y i n B r i t i s h Columbia, whereby concerns were r a i s e d about the extent of knowledge r e l a t i n g to pathogenic h a z a r d s . 7 P r i o r p e r s o n a l experience i n the pool and spa i n d u s t r y and the p r e v i o u s r e s e a r c h c i t e d above a l s o served as a b a s i s f o r the study. The spa and hot tub environment was modelled to e s t a b l i s h t y p i c a l o p e r a t i o n a l parameters. A reasonably wide range of microorganisms were s e l e c t i v e l y chosen on the b a s i s of t h e i r p o t e n t i a l f o r s u r v i v a l and/or growth w i t h i n the spa/hot tub environment. M i c r o b i o l o g i c a l data was then obtained by a search of the l i t e r a t u r e . Using the c a t e g o r i e s shown i n Table 1, c h a r a c t e r i s t i c s of the v a r i o u s organisms were compared to those of the spa/hot tub model. A d d i t i o n a l l y , m i c r o b i o l o g i c a l s t u d i e s r e l a t i n g to hot s p r i n g s was b r i e f l y examined. An e x t e n s i v e examination of e p i d e m i o l o g i c a l s t u d i e s f o r i n f e c t i o u s d i s e a s e problems i n swimming p o o l s , spas, hot tubs, and other water r e c r e a t i o n r e l a t e d areas was a l s o undertaken. F i n a l l y , the f i n d i n g s of these i n v e s t i g a t i o n s were analyzed from the p e r s p e c t i v e of b a s i c p u b l i c h e a l t h and e p i d e m i o l o g i c p r i n c i p l e s . F i n d i n g s The r e s u l t s are i n c o n c l u s i v e due to i n s u f f i c i e n t data and e m p i r i c a l s t u d i e s . Although there i s a p o s i t i v e c o r r e l a t i o n between the c h a r a c t e r i s t i c s of the spa/hot tub environment and 1 49 those which favor the growth of a number of p o t e n t i a l pathogenic organisms, other important i n t e r c o n n e c t i n g f a c t o r s ( e f f i c a c y of d i s i n f e c t i o n , o r i g i n and t r a n s m i s s i o n of the organism, and i n d i v i d u a l s u s c e p t i b i l i t y to i n f e c t i o n ) which l e a d to d i s e a s e outbreaks are not s u f f i c i e n t l y known. T h i s complicates the det e r m i n a t i o n of p o t e n t i a l hazard. The r e s u l t s from the comparison of the environment and p o t e n t i a l pathogens are co n t a i n e d i n Table 2. The review of p e r t i n e n t e p i d e m i o l o g i c a l s t u d i e s and experimental r e s e a r c h r a i s e d s e v e r a l q u e s t i o n s of p a r t i c u l a r i n t e r e s t about p o t e n t i a l hazards which, to date, have been given l i t t l e or no p u b l i c a t t e n t i o n . These s p e c u l a t i v e f i n d i n g s might be worth c o n s i d e r i n g as pa r t of an o v e r a l l e f f o r t to reduce pathogenic r i s k s i n correspondence with the environmental c o n d i t i o n s . 1. Are the environmental c o n d i t i o n s of spas and hot tubs a l l o w i n g a wider range of pathogenic s p e c i e s and a c t i v i t i e s to occur? Besides the more evident f a c t o r s of temperature and organic matter, spas/hot tub environments may a l s o i n c r e a s e hazards as a r e s u l t of pH, a e r a t i o n , and d i s i n f e c t a n t e f f i c a c y . Research by Brock 8 on t h e r m o p h i l i c organisms i n hot s p r i n g s at Yellowstone Park suggests that many of these organisms a l s o have an a f f i n i t y f o r a l k a l i n e pH and d i e under a c i d pH. T h i s p a t t e r n i s q u i t e c o n s i s t e n t with the organisms examined i n t h i s study. The s l i g h t l y a l k a l i n e pH range, 7.2-7.8, c u r r e n t l y recommended as 150 the i d e a l range f o r spas and hot tubs, i s a l s o f r e q u e n t l y i d e a l for the growth of the i d e n t i f i e d pathogens. Moreover, i n c r e a s e d ammonia loads from bather use c o n s i s t e n t l y d r i v e pH i n the a l k a l i n e d i r e c t i o n . Blanchard and Syzdek 9 d e s c r i b e the r o l e of bubbles in t r a n s f e r r i n g pathogens from water to the a i r and a l s o i n p r o t e c t i n g the organisms from d i s i n f e c t i o n . The a e r a t i o n process may reduce d i s i n f e c t a n t e f f i c a c y , but more s i g n i f i c a n t l y i t i n t r o d u c e s o p p o r t u n i t i e s f o r i n f e c t i o n from organisms which are normally t r a n s m i t t e d through the a i r and i n f e c t areas of the body not u s u a l l y immersed i n spa water (e.g., nose, mouth, and e a r s ) . There may be some t r a d e - o f f i n v o l v i n g the d i r e c t e f f e c t s of a e r a t i o n upon organisms; on one hand some may be k i l l e d , while on the other hand h i g h l y a e r o b i c ones f l o u r i s h . Rapid b u i l d - u p of t o t a l d i s s o l v e d s o l i d s reduce the e f f i c a c y of commonly-used halogenated d i s i n f e c t a n t s . Ammonias forming with c h l o r i n e to produce chloramines f u r t h e r l i m i t d i s i n f e c t i o n e f f i c a c y . F i n a l l y , the p o r o s i t y of spa/hot tub s t r u c t u r e s ( p a r t i c u l a r l y wooden u n i t s ) a l l o w s organisms to a t t a c h themselves and develop p r o t e c t i v e mechanisms a g a i n s t d i s i n f e c t a n t s . For example, Brown 1 0 c i t e s evidence of P. aeruginosa forming a p r o t e c t i v e slime c o a t i n g as an e x p l a n a t i o n f o r the organism's apparent r e s i s t a n c e to c h l o r i n e under c e r t a i n c o n d i t i o n s . 2. Are c u r r e n t p r a c t i c e s s u f f i c i e n t to p r o t e c t spa/hot tub 151 users from l e s s l i k e l y , but p o t e n t i a l l y severe or f a t a l disease? Two organisms emerge as h i g h l y dangerous pathogens capable of withstanding c u r r e n t p r e v e n t a t i v e p r a c t i c e s . The f i r s t i s L e g i o n e l l a pneumophilia. The U.S. Center f o r Disease C o n t r o l i s c u r r e n t l y i n v e s t i g a t i n g the p o s s i b l e l i n k to spas/hot tubs, a f t e r r e p o r t s from the Vermont P u b l i c H e a l t h Department e t i o l o g i c a l l y i m p l i c a t e d 2 deaths from L e g i o n n a i r e ' s Disease with s p a s . 1 1 The environmental c o n d i t i o n s of spas/hot tubs appear s u i t a b l e f o r L^ _ pneumophilia. "The r e l a t i o n s h i p between L. pneumophilia and a l g a l p h o t o s y n t h e s i s suggests that warm h a b i t a t s which are open to a l g a l c o l o n i z a t i o n or a l g a l products may be environments f o r L_j_ p n e u m o p h i l i a . " 1 2 There has been s p e c u l a t i o n that Pontiac Fever (a n o n - l e t h a l d i s e a s e which o r i g i n a t e s from L^ pneumophilia and produces i n f l u e n z a - t y p e symptoms) i s a s s o c i a t e d with spas and hot tubs. Caution i s urged i n regard to premature i m p l i c a t i o n of spas/hot tubs and L^ pneumophilia d e s p i t e acknowledged environmental b a c t e r i a l presence. L^ pneumophilia outbreaks have continued d e s p i t e e l i m i n a t i o n of the environmental s o u r c e . 1 3 1 4 One e x p l a n a t i o n f o r the e p i d e m i o l o g i c u n c e r t a i n t i e s may be found i n work by Rowbotham 1 5 1 6 and Nagington and S m i t h 1 7 . They suggest t h a t ameoba feed on L_;_ pneumophilia and that the l e g i o n e l l a s sometimes s u r v i v e as a r e s u l t of p r o t e c t i o n a f f o r d e d by the amoeba. As s t a t e d i n a Lancet e d i t o r i a l , 1 8 "This might p o s s i b l y be a mechanism by which l e g i o n e l l a s c o u l d s u r v i v e i n 152 water, but more importantly i t i s a way i n which l a r g e numbers of l e g i o n e l l a s could be d e l i v e r e d to a p o t e n t i a l h ost. I n h a l a t i o n of only one v e s i c l e or an amoeba c o u l d l e t 50-1000 pathogens i n t o the r e s p i r a t o r y system, and i t would be s u r p r i s i n g i f there were not more than one amoeba i n an a e r o s o l coming from a c o o l i n g tower, an e v a p o r a t i v e condensor, or a shower." Limax amoeba have been r o u t i n e l y i s o l a t e d from swimming p o o l s , 1 9 and spa c o n d i t i o n s appear more f a v o r a b l e to amoebic growth. The second organism of i n t e r e s t i s N a e g l a e r i a f o w l e r i , an amoeba commonly found i n s o i l s and w a t e r . 2 0 I t has been i d e n t i f i e d as the cause of f a t a l m e n i n g o e n c e p h a l i t i s i n over 100 cases from such d i v e r s e areas as C z e c h o s l o v a k i a , England, East A f r i c a , A u s t r a l i a , New Zealand, the U.S. ( F l o r i d a , Texas, V i r g i n i a , G eorgia, C a l i f o r n i a , and New York), Belgium, and I n d i a . 2 1 2 2 Indoor swimming p o o l s , thermal s p r i n g s , heated p o o l s , and waters used to c o o l manufacturing processes have been i n c r i m i n a t e d as sources of the f a t a l i n f e c t i o n s . . . . In nature, i t feeds p r i m a r i l y on b a c t e r i a . Thus, contamination of warm water with b a c t e r i a s u b s t r a t e p r o v i d e s an e x c e l l e n t environment f o r r a p i d growth. . . . Water i n swimming p o o l s should be c i r c u l a t e d f r e q u e n t l y enough to reduce organic contamination and to c o n t r o l temperature e l e v a t i o n . The value of c h l o r i n e has not been demonstrated." 2 3 ** N. f o w l e r i grows r e a d i l y at body temperature and above, and **Anderson & Jamieson (1972) c o u l d not e l i m i n a t e N a e g l e r i a i n a swimming pool using s u p e r c h l o r i n a t i o n up to 10 ppm. 153 may grow best at ±45°C. I t s most f a v o r a b l e pH range i s 7.6 to 9.1. Being a h i g h l y a e r o b i c organism, the a e r a t i o n process i s a l s o f a v o r a b l e to i t s s u r v i v a l . Pool f i l t e r s can provide an e x c e l l e n t medium of growth f o r N_;_ f o w l e r i and other amoeba. To date, f o w l e r i has not been i s o l a t e d i n a spa/hot tub. The organism i s f r e e - l i v i n g i n the environment. Limax amoeba have been i s o l a t e d from human t h r o a t s and n a s a l mucosa, 2' 2 5 Moreover, the organism does form c y s t s , a l l o w i n g movement and entry i n t o other environments. At 37°C, f o w l e r i are e a s i l y transformed i n t o f l a g e l l a t e s , f a c i l i t a t i n g i n f e c t i o n through the n a s a l p a s s a g e s . 2 6 The p o s s i b i l i t y of t r a n s m i s s i o n i n a e r o s o l form has been mentioned e a r l i e r and f u r t h e r , the p o s s i b i l i t y of an i n d i v i d u a l submerging h i s head below water i n a spa or hot tub always e x i s t s . The l a r g e s t r e p o r t e d outbreak of the d i s e a s e o c c u r r e d i n a Czechoslovakian indoor swimming pool r e s u l t i n g i n 16 deaths between 1962 and 1965. 2 7 K a d l e c 2 8 i s o l a t e d t h i r t y - t h r e e s t r a i n s of v i r u l e n t and n o n - v i r u l e n t N_;_ f o w l e r i from that same pool 12 years l a t e r . The organism would appear to be more hazardous i n warm, spa waters. De J o n c k h e e r e 2 9 concludes that warm or t h e r m a l l y p o l l u t e d waters enhance the growth of the pathogenic s t r a i n s of N_j_ f o w l e r i . S i n g h 3 0 a l s o c i t e s temperature as the dominant f a c t o r i n f l u e n c i n g i n c i d e n t s of f a t a l m e n i n goencephalitis from f o w l e r i i n water. A d d i t i o n a l work by C a r t e r , 3 1 De J o n c k h e e r e , 3 2 W i l l a e r t et a l . , 3 3 , De Jonckheere, 3" De Jonckheere and van de V o o r d e , 3 5 1 54 Kadlec et a l . , 3 6 Lawande et a l . , 3 7 Singh and D a s 3 8 N e v a , 3 9 Chang, 4 0 and others s u b s t a n t i a t e the f i n d i n g s presented above. F i n a l l y , S i n g h 4 1 s t a t e s that more cases of N_j_ f o w l e r i have c o n t r i b u t e d to m e n i n g o e n c e p h a l i t i s than have been diagnosed and r e p o r t e d . Since m e n i n g i t i s and e n c e p h a l i t i s are commonly a t t r i b u t e d to b a c t e r i a l and v i r a l agents, i t i s c o n c e i v a b l e that amoebic sources have been overlooked i n d i a g n o s i s . F u r t h e r i n v e s t i g a t i o n may be needed to determine the r e l a t i o n s h i p between amoeba and other microorganisms. Groscop and B r e n t 4 2 s t u d i e d the e f f e c t s of twenty-four s t r a i n s of chromogenic b a c t e r i a on f i v e s t r a i n s of amoeba (N.gruberi was i n c l u d e d , but not N^ f o w l e r i ) . Three of the b a c t e r i a , i n c l u d i n g P. aeruginosa, were found to be t o x i c to the amoeba. I t may a l s o t o x i c to f o w l e r i . I f so, the high occurrence of P. aeruginosa r e p o r t e d i n spas and hot tubs c o u l d l i m i t N. f o w l e r i . Thus, e f f e c t i v e c o n t r o l of P^ aeruginosa might enhance the o p p o r t u n i t i e s f o r establishment of N_j_ f o w l e r i i n spas and hot tubs. 3 . Are d i s e a s e outbreaks going undetected because of m i s d i a g n o s i s or f a i l u r e of i n d i v i d u a l s to f o r m a l l y r e p o r t problems? I n t u i t i v e l y , i t seems q u i t e reasonable t h a t both p h y s i c i a n s and p a t i e n t s would have d i f f i c u l t y determining the source of many of the d i s e a s e s which c o u l d p o t e n t i a l l y d e r i v e from spas. These c o u l d i n c l u d e : P. aeruginosa (rash symptoms), Pontiac fever ( f l u - l i k e symptoms), G i a r d i a l a m b a l i ( d i a r r h e a ) , 1 55 Trichamonas ( v a g i n i t i s ) , E. floccosum ( a t h l e t e ' s f o o t ) , N. f o w l e r i (headaches and backaches, i f not f a t a l ) , and Candida A l b i c a n s ( v u l v o v a g i n i t i s ) . E m p i r i c a l s t u d i e s conducted i n Oregon have shown evidence of undetected and unreported c a s e s . * 3 In one study, n i n e t y - t h r e e cases of Pseudomonas f o l l i c u l i t i s were f o r m a l l y r e p o r t e d i n Oregon between 1980 and 1982. An a d d i t i o n a l 74 cases a s s o c i a t e d with these outbreaks were d i s c o v e r e d by follow-up i n v e s t i g a t i o n . Other i n v e s t i g a t i o n e f f o r t s produced s i m i l a r i n f o r m a t i o n , and i n one s u r v e i l l a n c e program, 75% of a f f e c t e d persons f a i l e d to seek medical c a r e . The study a l s o noted s e v e r a l i n s t a n c e s of m i s d i a g n o s i s by p h y s i c i a n s and t h e i r f a i l u r e to r e p o r t cases to the P u b l i c H e a l t h Department. Summary and Recommendations The f i n d i n g s presented here do not p r o v i d e a b a s i s f o r determining the pathogenic r i s k s of spas and hot tubs, nor do they, adequately conclude that the p o t e n t i a l hazards c o n s t i t u t e s i g n i f i c a n t p u b l i c h e a l t h concerns. However, the r e s u l t s do show that spas and hot tubs p r o v i d e e x c e l l e n t environments f o r c u l t u r i n g a wide range of pathogenic microorganisms and that the e f f e c t i v e n e s s of present p r e v e n t a t i v e measures i s q u e s t i o n a b l e and u n c e r t a i n . The p o t e n t i a l f o r hazard i s i n c r e a s e d by two major weaknesses which o f t e n occur i n v a r i o u s p u b l i c f a c i l i t i e s ; (1) the treatment of u n i t s as "small swimming p o o l s " and (2) 156 poor maintenance and o p e r a t i o n . 4 4 Thus, i t would seem wise to d i r e c t a t t e n t i o n to more a p p r o p r i a t e s o l u t i o n s which can reduce r i s k s on a more comprehensive b a s i s - before major problems develop which do pr o v i d e c l e a r c u t evidence of hazards. There are numerous a l t e r n a t i v e s which may be c o n s i d e r e d to improve management and r e g u l a t o r y a s p e c t s , but they are beyond the scope of t h i s paper. The purpose here i s to urge c o n s i d e r a t i o n and development of new ideas and d e v i c e s r e l a t i n g to de s i g n / e n g i n e e r i n g of the systems, water p u r i f i c a t i o n , and t e s t i n g / m o n i t o r i n g . These g e n e r a l g u i d e l i n e s are recommended: 1. S o l u t i o n s should be broadly-designed to encompass the wide range of p o t e n t i a l pathogenic microorganisms r a t h e r than j u s t the most common ones. 2. So f a r , the s i n g u l a r e f f o r t s to c o r r e c t problems a l l appear to share the common f a c t o r of f r e q u e n t l y and s t r o n g l y d i s r u p t i n g the spa/hot tub environment. Such methods i n c l u d e : frequent d r a i n i n g and thorough c l e a n i n g of the u n i t , frequent and thorough c l e a n i n g of the f i l t r a t i o n system, and frequent s u p e r c h l o r i n a t i o n or shock treatment of the water. Thus, new s o l u t i o n s might be d i r e c t e d toward c o n s t a n t l y d e - s t a b i l i z i n g the spa/hot tub environment, thereby p l a c i n g c o n s i d e r a b l e s t r e s s upon p o s s i b l e organisms. 3. The b a s i c p r i n c i p l e s of epidemiology and p u b l i c h e a l t h of host, agent and environment should be used as a guide, and a 157 minimum of two out of three areas should be s u f f i c i e n t l y covered in a l l s i t u a t i o n s . 4. Regional c o n s i d e r a t i o n s should be i n c o r p o r a t e d i n t o s o l u t i o n s , t a k i n g i n t o account s o c i a l , economic, and resource f a c t o r s . B r i e f examples of a l t e r n a t i v e t e c h n i c a l s o l u t i o n s might i n c l u d e : - Flow-through water systems coupled with a heat exchanger. T h i s system might be a p p r o p r i a t e f o r w a t e r - r i c h areas such as the P a c i f i c Northwest. - A heat s t e r i l i z a t i o n process f o r supply water w i t h i n the c i r c u l a t i o n system with a cooling-down process to the d e s i r e d temperature j u s t p r i o r to r e - e n t r y i n t o the spa/hot tub u n i t . Areas with p l e n t i f u l supply of energy (perhaps even s o l a r ) might c o n s i d e r t h i s approach. - Combination schemes i n v o l v i n g m u l t i p l e use of d i s i n f e c t a n t s (e.g., c h l o r i n e / b r o m i n e and ozone or UV) and improved f i l t r a t i o n : Development of dev i c e s which monitor organic m a t e r i a l l e v e l s and a u t o m a t i c a l l y shock t r e a t the water when necessary. (Japanese standards . f o r heated baths r e q u i r e permanganate val u e s f a r l e s s than 25 m g / l i t r e and change of water d a i l y ) . 4 5 T h i s approach might apply to areas which are d e f i c i e n t i n both water and energy r e s o u r c e s . - Development of dev i c e s which sense c r i t i c a l parameters (e.g., organic m a t e r i a l , d i s i n f e c t a n t f r e e r e s i d u a l , pH, 158 t o t a l d i s s o l v e d s o l i d s ) and a u t o m a t i c a l l y shut-down the system and prevent r e - s t a r t i n g u n t i l proper adjustments are made. T h i s c o u l d be used in any a r e a . The above suggestions are not meant to supplant nor ignore the other important s o c i a l , b e h a v i o u r a l , economic, p o l i t i c a l and l e g a l aspects which surround the s i t u a t i o n . However, any t e c h n i c a l advances which e f f e c t i v e l y reduce both hazards and o p e r a t i o n a l c o s t s can be extremely h e l p f u l f o r the c o n f i d e n t and enjoyable hot-water b a t h i n g . E f f o r t s which d i r e c t l y c o n f r o n t the d i f f i c u l t i e s of spa water q u a l i t y management may not only be p r o d u c t i v e i n t h i s i n s t a n c e , but c o n c e i v a b l y they c o u l d p r o v i d e v a l u a b l e i n f o r m a t i o n and/or products u s e f u l to other areas concerned with water q u a l i t y . 159 References C i t e d 1Center f o r Disease C o n t r o l , " M o r b idity and M o r t a l i t y Weekly Report", 24(41): 349-350, October 17, 1975. 2 C e n t e r f o r Disease C o n t r o l , " M o r b i d i t y and M o r t a l i t y Weekly Report", 30(27): 392-330, J u l y 17, 1981. 3Sausker, Maj. 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" 5Hoadley, A.W., " P o t e n t i a l H e a l t h Hazards A s s o c i a t e d with Pseudomonas aeruginosa i n Water", American Soc. f o r T e s t i n g M a t e r i a l s , STP 635, 1977, pp. 80-114. 163 A d d i t i o n a l References Consulted 4 6 D u B o i s , Rene J . , and H i r s c h , James G. (ed)., B a c t e r i a l and Mycotic I n f e c t i o n s of Man, 4th e d i t i o n , J.B. L i p p i n c o t t Co.: P h i l a d e p h i a and Montreal, 1965. " 7 C h r i s t i e , A.B., I n f e c t i o u s D i s e a s e s : Epidemiology and C l i n i c a l P r a c t i c e , 3rd e d i t i o n , C h u r c h i l l L i v i n g s t o n , Edinburgh, London, Melbourne, and New York, 1980. fl8Cerva, L. et a l . , " N a e g l e r i a F o w l e r i i n C o o l i n g Waters of Power P l a n t s , " J . Hyg. E p i d . , M i c r o b i o l . and Immun., 2:152-161, 1982. tt9Wadowsky, Robert M. et a l . , "Hot Water Systems as Sources of L e g i o n e l l a pneumophilia i n H o s p i t a l and N o n h o s p i t a l Plumbing F i x t u r e s " , A p p l i e d and Env. M i c r o b i o l . , 43(5):1104-1110, May 1982. 5 0Donders, D.J., "An Outbreak of L e g i o n n a i r e ' s Disease A s s o c i a t e d With a Contaminated A i r - C o n d i t i o n i n g C o o l i n g Tower", New England J . Medicine, 302:365-370, 1980. 5 1 B a y l o r , "Water-to-Air T r a n s f e r of V i r u s " , Science 197 :763-764, 1977. 5 2 B e e c h , J.A. "Estimated Worst Care Trihalomethane Body Burden of a C h i l d Using a Swimming Po o l " , Med. Hypotheses, 28(2):97-103, March 1980. 5 3 B e e c h , J.A. et a l . , " N i t r a t e s , C h l o r a t e s and Trihalomethanes i n Swimming Pool Water", Am. J . P u b l i c H e a l t h , 70(1):79-82, January 1980. 5 " H o e p r i c h , Paul D., ed., I n f e c t i o u s D i s e a s e s , 2nd e d i t i o n , Harper & Row P u b l i s h e r s , Inc.: Hagerstown, Md., 1977. 1 64 TABLE I A Comparison of Spa Environment C h a r a c t e r i s t i c s With C h a r a c t e r i s t i c s of S e l e c t e d Pathogens PATHOGENS A B C D E F G H I * 1 . B r u c e l l a e NO YES NO NO YES NO NO YES (I) 3 2. Candida a l b i c a n s NO YES YES YES YES ? YES YES (DC) 6 3. Coxsacki YES YES YES YES YES YES YES NO (I) 7 4. Cryptococcus NO YES YES ? YES 7 NO YES (DC) 4 5. E. c o l i YES YES YES YES YES NO YES YES (I) 7 6. E. floccosum YES YES YES YES YES YES YES YES (DC) 8 7. G i a r d i a lambali YES YES YES YES NO 7 YES NO (I) 5 8. Gonococcus NO YES YES YES YES NO YES YES (DC) 6 9. Herpes simplex NO YES ? YES YES NO YES YES (DC) 5 10. H. i n f l u e n z a e NO YES YES YES YES YES YES NO (R) 6 1 1 . L e g i o n e l l a pneumophilia YES YES YES YES YES NO YES NO (R) 6 12. L e p t o s p i r o s i s YES YES YES YES YES NO YES YES (I) 7 13. Mycobacterium b a l n e i YES YES YES YES YES 7 7 YES (DC) 6 14. N a e g l e r i a fowler i YES YES YES YES NO YES NO NO (I) 5 15. N a e g l e r i a g r u b e r i YES YES YES YES NO YES NO NO (I) 5 16. Penumococc i NO YES YES YES YES YES YES NO (R) 6 17. Pseudomonas aeruginosa YES YES YES YES YES NO YES YES (DC) 7 18. Salmonella YES YES YES YES YES NO YES NO (I) 6 19. S h i g e l l a YES YES YES YES YES NO YES YES (I) 7 20. Staphlococc i YES YES YES YES YES NO YES YES (DC) 7 21 . Streptococc i YES YES YES YES YES NO YES YES (R) 7 22. Trichamonas NO YES YES YES YES YES YES YES (DC) 7 23. T. tonsurans YES YES YES YES YES YES YES YES (DC) 8 24. V i b r i o s c h o l e r a YES YES NO YES YES NO YES NO (I) 5 25. V i r a l h e p a t i t u s YES YES YES YES YES YES YES NO (R) 7 26. Actinomycetes NO YES YES ? YES 7 NO YES (I) 4 * T o t a l © of Matched C h a r a c t e r i s t i c s Sources: 9,1 8 ,19,23,38,39,46,47,54 A. Waterborne B. Can s u r v i v e a e r a t i o n C. S u r v i v a l at spa temperature (35°-43° C) D. S u r v i v a l at spa pH range (7.2-7.8) E. S u r v i v a l through spa f i l t r a t i o n (Note: e f f e c t i v e f i l t r a t i o n f o r v a r i o u s media i s : sand 18-20 microns, c a r t r i d g e 8-10 microns, diatomaceous e a r t h 4-6 microns. Some organisms may be abl e to s u r v i v e i n the f i l t e r u n i t s . ) F. S u r v i v e s c h l o r i n e or bromine (.225 - 3.0 ppm) G. Transmission between people i n spa environment p o s s i b l e H. Capable of i n f e c t i n g p a r t s of body t y p i c a l l y immersed i n spa I. T y p i c a l mode of t r a n s m i s s i o n : (D) D i r e c t c o n t a c t ; (I) In g e s t i o n ; (R) R e s p i r a t o r y 165 TABLE II C l a s s i f i c a t i o n of Pathogens by t h e i r E s t a b l i s h e d Or P o t e n t i a l Hazards i n Spa/Hot Tub Environments Known & I d e n t i f i e d Problems 1 . Coxsacki 2. E. c o l i 3. E. floccosum 4. Mycobacterium b a l n e i 5. Pseudomonas aeruginosa 6. S t a p h l o c o c c i 7. S t e p t o c o c c i Known but Rare Problems 1. L e p t o s p i r o s i s 2. Salmonella 3. S h i g e l l a 4. V i b r i o s P o t e n t i a l Problems 1. Candida a l b i c a n s 2. G i a r d i a lambali 3. L e g i o n e l l a pneumophilia 4. N a e g l e r i a f o w l e r i 5. N a e g l e r i a g r u b e r i 6. Trichomonas 7. T. tonsurans P o t e n t i a l but Found Commonly in other Environments 1. Gonococcus 2. Herpes simplex 3. H. i n f l u e n z a e 4. Pneumococci 5. V i r a l h e p a t i t u s U n l i k e l y Problems 1. Actinomycetes 2. B r u c e l l a e s 3. Cryptococcus ( C a t e g o r i z a t i o n of pathogens based on number of matched c h a r a c t e r i s t i c s i n Table I.) ) 166 TABLE III Cumulative T o t a l s of Matching C h a r a c t e r i s t i c s Between Spa/Hot Tub Environments and S e l e c t e d Pathogens Spa Environment C h a r a c t e r i s t i c s © of Pathogens With Corresponding C h a r a c t e r i s t i c s % of Pathogens Which May Be Hazardous Under Spa Environment C h a r a c t e r i s t i c s © Found/Total © A. Water B. A e r a t i o n C. Temperature D. pH E. F i l t r a t i o n F. D i s i n f e c t i o n G. Human Transmission H. Region of I n f e c t i o n 1 7/26 26/26 23/26 23/26 23/26 9/26 20/26 16/26 65% 1 00% 88% 88% 88% 35% 80% 64% Comments A. Non-waterborne pathogens, p a r t i c u l a r l y v i r u s e s , can be t r a n s m i t t e d from one spa user to another. E. The amoeba examined are the only pathogens capable of being f i l t e r e d . However, poor f i l t r a t i o n or c i r c u l a t i o n c o u l d allow these organisms to pose a hazard. A l s o , these organisms may be capable of s u r v i v i n g and growing i n s i d e the f i l t e r . F. A high degree of u n c e r t a i n t y e x i s t s as to d i s i n f e c t i o n e f f i c a c y . G. Some of the pathogens which are not t r a n s m i t t e d from human to human may nonetheless enter the spa environment as H. A l l of the pathogens can i n f e c t the human host i n circumstances where i n d i v i d u a l s submerge t h e i r heads under water and where a e r o s o l c o n d i t i o n s allow spread of the organisms through the a i r . c y s t s . 167 APPENDIX B Current Knowledge & G u i d e l i n e s f o r Spa Management There i s disagreement over v a r i o u s spa water q u a l i t y management procedures, parameters, and a c c e p t a b l e l e v e l s . Experts d i s a g r e e about matters which i n c l u d e (but are not l i m i t e d t o ) : c h l o r i n e or bromine l e v e l s , pH v a l u e s , s u p e r c h l o r i n a t i o n i n t e r v a l s , maximum l e v e l of t o t a l d i s s o l v e d s o l i d s , and i n t e r v a l s f o r d r a i n i n g spas and tubs. Progress has been made toward d e v e l o p i n g uniform standards, but g u i d e l i n e s are s t i l l not f i r m . The cha r t below i s not meant to be comprehensive, but i t does p r o v i d e a comparison of recommendations from s e v e r a l g e n e r a l l y r e c o g n i z e d sources of e x p e r t i s e . F o l l o w i n g the c h a r t s , a l i s t of recommended procedures has been compiled and s y n t h e s i z e d from the same sources. These procedures apply to p u b l i c spas and hot tubs. Sources ( i n order as they appear on the c h a r t s ) : - The Center f o r Disease C o n t r o l , U.S. Dept. of Health and Human S e r v i c e s - J a c u z z i W h i r l p o o l Bath, S u b s i d i a r y of Kidde, Inc. - Great Lakes Biochemical Co., Inc. - Robert Lowry, V i c e P r e s i d e n t and T e c h n i c a l D i r e c t o r , L e i s u r e Time Chemical Corp., member NSPI Chemical Standards Committee 168 OPERATIONAL PARAMETERS P u b l i c Spas & Hot Tubs MINIMUM IDEAL MAXIMUM A. DISINFECTANT LEVELS 1 . Free C h l o r i n e (ppm) 1.0 1.0-1.5 3.0 1 .5 3.0 5.0 2. Combined C h l o r i n e None None 0.2 (ppm) None None 0.2 3. Bromine 0.8 1 .5 3.0 1 .0 2.0 -B. CHEMICAL VALUES 1 . pH 7.2 7.5 7.8 7.2 7.2-7.6 7.6 7.2 7.4-7.8 7.8 7.2 7.2-7.8 7.8 2. T o t a l A l k a l i n i t y 60 100 200 (ppm as CaCo ) 80 80-125 175 P l a s t e r , T i l e 125-150 V i n y l , FG 75 - 150 — 80-140 — 3. D i s s o l v e d s o l i d s 300 - 1500 (ppm) - - 1500 - - 1500 — — 1500 4. Hardness 50 125 500 (ppm as CaCo ) 175 200-275 275 100 100-400 400 100 150-400 400 5. Trace Metals (ppm) - 0 -(Iron, Copper) — — — - - .2 169 C. BIOLOGICAL VALUES 1. Algae 2. B a c t e r i a None No v i s i b l e algae None Refer to l o c a l h e a l t h code or APHA standard D. STABILIZER 1 . Cynanuric A c i d (ppm) 30 30 — 1 50, except where 100 by l o c a l h e a l t h dept. 1 50 E. ALGICIDES Follow d i r e c t i o n s of EPA r e g i s t e r e d products F. REMEDIAL PRACTICES 1. D a i l y Shock Treatment C h l o r i n e (ppm) 5 10 - -2. A d d i t i o n a l S u p e r c h l o r i n a t i o n C h l o r i n e (ppm) 10 _ -3. Water Replacement Water i n spas which have high bather use should be r e p l a c e d c o n t i n u o u s l y or at l e a s t once a month. At l e a s t once very 30 days. Frequent replacement of 1/4 or 1/2 of water; or completely p e r i o d i c a l l y (1-2 months). Every two months or more o f t e n i f needed. 170 G. TEMPERATURE 1. Temperature - Bather 1 04°F p r e f e r e n c e (40°C) - - 1 04°F - - 104°F H. WATER CLARITY 1. Water T u r b i d i t y 0 0.5 or l e s s 1.0 (Jackson T u r b i d i t y 0 0-0.5 1 .0 U n i t s ) - - -171 PUBLIC SPA/HOT TUB OPERATOR'S GUIDELINES I n i t i a l Start-Up or R e f i l l 1. Clean & p o l i s h spa. 2. P r e - f i l t e r water duri n g f i l l ; do not use d e i o n i z e d or softened water. 3. Add se q u e s t e r i n g and c h e l a t i n g chemicals. 4. Test and balance water f o r pH, t o t a l a l k a l i n i t y and hardness. 5. Add s a n i t i z e r and begin c i r c u l a t i o n . 6. Shock t r e a t . 7. Turn on a e r a t i o n pump or blower. 8. S t a r t up chemical feed pump & begin adding s a n i t i z e r c o n t i n u o u s l y . 9. Turn o f f a e r a t i o n and use only as needed, but run c i r c u l a t i o n system 24 hours/day. Check Hourly 1. C h l o r i n e (or Bromine) 2. pH 3. Temperature below. D a i l y 1. Shock t r e a t to 10 ppm. 2. Test and c o r r e c t i f necessary t o t a l a l k a l i n i t y , t u r b i d i t y . Weekly 1. Test and a d j u s t hardness, c y a n u r i c a c i d ( i f a p p l i c a b l e ) 2. Clean f i l t e r s or f i l t e r elements Monthly - M a i n t a i n 1-3 ppm - M a i n t a i n 7.2-7.8 Mai n t a i n at 1 r e s i d u a l . 04°F (40°F) or 1. D r a i n , c l e a n and r e f i l l u n i t . 172 P e r i o d i c a l l y 1. Add s e q u e s t e r i n g and c h e l a t i n g chemicals. 2. Add defoaming agent as necessary. 3. Clean areas adjacent to spa/hot tub. 4. Check and maintain support equipment. 5. Add make-up supply water as necessary. A d d i t i o n a l Procedures 1. Provide t r a i n i n g to a l l employees a c t i v e l y i n v o l v e d i n spa management with regard to equipment, chemical h a n d l i n g , water treatment, and s a f e t y & emergency procedures. 2. Provide a c c e s s i b i l i t y to i n s t r u c t i o n a l m a t e r i a l s , f i r s t a i d equipment, and s a f e t y & emergency procedures. 3. M a i n t a i n records on d a i l y b a s i s f o r : - Amounts of chemicals added. - Amounts of f r e s h water added. - R e s u l t s of a l l water t e s t s . - Date and time of f i l t e r backwash or c l e a n i n g . Periods of r e c i r c u l a t i o n equipment o p e r a t i o n and/or m a l f u n c t i o n and r e p a i r . 4. Enf o r c e the f o l l o w i n g r u l e s and post a c a u t i o n s i g n . - No person s h a l l use the spa alone C h i l d r e n under 14 s h a l l not use unless a r e s p o n s i b l e observer i s p r e s e n t . - Bathers s h a l l take a c l e a n s i n g shower. - Swimwear s h a l l be c l e a n . No person s u f f e r i n g from a communicable d i s e a s e t r a n s m i s s a b l e v i a water or under the i n f l u e n c e of a l c h o h o l or drugs s h a l l use the spa. - No person s h a l l engage i n horse p l a y i n or around a p u b l i c spa. Persons u s i n g medications such as a n t i c o a g u l e n t s , a n t i h i s t a m i n e s , v a s c o c o n s t r i c t o r s , v a s o d i l a t o r s , s t i m u l a n t s , h y p n o t i c s , n a r c o t i c s , or t r a n q u i l i z e r s s h a l l use the spa. - E l d e r l y persons, pregnant women, and those s u f f e r i n g from heart d i s e a s e , d i a b e t e s , or high blood pressure should c o n s u l t t h e i r p h y s i c i a n before using the spa. - Observe a reasonable time p e r i o d (e.g., 10 minutes). Shower, c o o l down, and i f you wish, r e t u r n f o r another b r i e f s t a y . I f f e e l i n g s of d i z z i n e s s , nausea, or f a i n t n e s s occur, leave spa immediately. - Do not use spa at temperatures above 104°F. 173 The above g u i d e l i n e s are merely intended to represent a c r o s s - s e c t i o n of spa management recommendations, and they are not n e c e s s a r i l y a u t h o r i t a t i v e or i r r e f u t a b l e . However, they do represent the c u r r e n t s t a t e - o f - t h e - a r t knowledge as w e l l as demonstrating some of the d i s c r e p a n c i e s . I t should be noted that these g u i d e l i n e s have changed over the past few years, e v o l v i n g from swimming pool standards which were determined i n a p p r o p r i a t e f o r spas. F i n a l l y , the parameters and g u i d e l i n e s represent a c o l l e c t i o n of work and they are o f t e n d u p l i c a t i o n s of recommendations from other sources. 174 APPENDIX C Be h a v i o u r a l C h a r a c t e r i z a t i o n s f o r Spa Operators, Spa Users, Health O f f i c i a l s and Industry R e p r e s e n t a t i v e s Spa Operators I t i s u s e f u l to c a t e g o r i z e the types of spa o p e r a t o r s commonly found managing spas, bearing i n mind that any g e n e r a l i z a t i o n i s never complete, f u l l y a c c u r a t e , or without e x c e p t i o n . 1. The F a s t i d i o u s Operator T h i s type of person takes a great d e a l of p r i d e i n both the c o n d i t i o n s of the spa and h i s own a b i l i t y and knowledge of the o p e r a t i o n s . Compliments, p u b l i c a p p r o v a l , and general r e c o g n i t i o n are h i g h l y m o t i v a t i n g f a c t o r s as w e l l as the i n d i v i d u a l ' s own p e r s o n a l p r i d e . U s u a l l y t h i s type of person i s an eager l e a r n e r and t r i e s to keep abreast of new developments and i n f o r m a t i o n . Although f i n a n c i a l i n c e n t i v e s and/or t h r e a t of p u n i t i v e a c t i o n may have i n f l u e n c e upon t h i s type of i n d i v i d u a l , the dominant f a c t o r remains i n the realm of s e l f - p r i d e and o u t s i d e a p p r o v a l . 2. The "Know-It-All" Operator The "Know-It-All" c h a r a c t e r i s t i c a l l y assumes that he has a l l the answers; what he does i s always c o r r e c t ; and t h i n g s must be done h i s way or not at a l l . T h i s i s probably the most d i f f i c u l t person to d e a l with, because he w i l l defy r e g u l a t o r y 175 e f f o r t s ( o v e r t l y and c o v e r t l y ) , d i s r e g a r d economic i n c e n t i v e s to prove a p o i n t (even at h i s own expense), and p l a c e l i t t l e s i g n i f i c a n c e on p r i d e and approval f a c t o r s ( f o r the reason that he assumes an i n i t i a l l e v e l of e x p e r t i s e and needs no f u r t h e r r e i n f o r c e m e n t ) . O c c a s i o n a l l y , t h i s kind of i n d i v i d u a l w i l l be d e c e p t i v e by p r e t e n d i n g to l i s t e n to advice and suggestions or to weigh a l t e r n a t i v e s , but then in p r a c t i c e , he w i l l proceed i n h i s own d i r e c t i o n anyhow. In rar e i n s t a n c e s , l o g i c and common sense work to motivate t h i s i n d i v i d u a l , but most o f t e n the best approach i s to apply chosen m o t i v a t i o n techniques i n such a way as to allow f o r expected d i s c r e p a n t behaviour. 3 . The Greedy Operator T h i s operator adheres q u i t e c l o s e l y to the p r i n c i p l e s of p r o f i t maximization. The "bottom l i n e " s t r o n g l y determines h i s d e c i s i o n s and a c t i o n s , both i n p o s i t i v e and negative d i r e c t i o n s . He e x h i b i t s no s p e c i a l b i a s e s toward m a i n t a i n i n g spa water q u a l i t y or p u b l i c s a f e t y and h e a l t h . He i s as l i k e l y to show stro n g concern f o r these matters as to show weak concern, depending on h i s c o n v i c t i o n and a n a l y s i s of what i s f i n a n c i a l l y best f o r him. To a l a r g e degree, t h i s type of person i s f a i r l y easy to d e a l with because h i s m o t i v a t i o n s are c l e a r and d i r e c t . Sometimes r e g u l a t i o n s which thr e a t e n to impose c o s t s can modify h i s behaviour, but o f t e n t h i s type of person q u i c k l y l e a r n s ways to work around the r e g u l a t i o n s or to exert i n f l u e n c e to h i s advantage. Economic i n c e n t i v e s work best because they make the most sense to h i s framework of understanding the world. 176 4 . The F e a r f u l or S e c u r i t y - S e e k i n g Operator T h i s type of person w i l l do whatever he deems to be the best o v e r a l l course of d i r e c t i o n to p r o t e c t h i s f a c i l i t y , h i s job, h i s r e p u t a t i o n , and s i m i l a r concerns of others d i r e c t l y r e l a t e d to h i s p u r s u i t s . Although each of the c a t e g o r i e s share t h i s c h a r a c t e r i s t i c to some degree and i n v a r i o u s forms, the " f e a r f u l or s e c u r i t y - s e e k i n g " operator i s d i s t i n g u i s h e d by h i s i n o r d i n a t e a t t e n t i o n to o b t a i n i n g and ma i n t a i n i n g s e c u r i t y f o r the sake of s e c u r i t y i t s e l f . As a r e s u l t , h i s h a n d l i n g of any p a r t i c u l a r phase of the o p e r a t i o n i s never p r e d i c t a b l e , because t h i s i n d i v i d u a l i s c o n t i n u o u s l y engaged i n making t r a d e - o f f s amongst h i s v a r i o u s concerns r e g a r d i n g s e c u r i t y , f o r which he tends to co n c e a l h i s i n t e n t and purpose. Combinations of mo t i v a t i o n s work w e l l with him, but g e n e r a l l y p o s i t i v e reinforcement and encouragement of l a t i t u d e and e x p r e s s i o n are best, so long as there e x i s t s p r o v i s i o n s f o r c o n t r o l l i n g e x c e s s i v e and extreme behaviour which might be h i g h l y advantageous to h i s sense of s e c u r i t y , but j e o p a r d i z e o t h e r s . 5. The "Easy-Going Operator T h i s l a s t kind of i n d i v i d u a l , because of f i n a n c i a l w e l l -being, m a t u r i t y , or other s e l f secure t r a i t s , almost always i s i n d i f f e r e n t to the types of p o l i c i e s and requirements i n v o l v e d i n o p e r a t i n g the spa so long as they are reasonably f a i r and c o n s i s t e n t . T h i s operator i s p r i m a r i l y concerned with a v o i d i n g needless h a s s l e s and entanglements, and o f t e n he i s most concerned with " p l a y i n g by the r u l e s " , having t h i n g s run 177 smoothly, and doing what i s " r i g h t " f o r a l l p a r t i e s concerned. T h i s type of person i s by f a r the e a s i e s t to deal with because of h i s f l e x i b i l i t y , open-mindedness, sense of f a i r n e s s , and w i l l i n g n e s s to cooperate. However, i f p o l i c i e s or requirements are implemented which g r e a t l y take advantage of those a t t r i b u t e s , such a person can become a very d i f f i c u l t and formidable opponent to any process. In summary, these c a t e g o r i e s of o p e r a t o r s c e r t a i n l y cannot be c o n s i d e r e d e i t h e r comprehensive or s i n g u l a r l y t r u e f o r each spa o p e r a t o r . C e r t a i n l y i t i s p o s s i b l e to c o n s t r u c t other c h a r a c t e r i z a t i o n s or v a r i a t i o n s of ones above. And undoubtedly, each spa operator possesses p o r t i o n s of more than one of the c h a r a c t e r i s t i c s . However, these c a t e g o r i e s do represent the most common c h a r a c t e r i z a t i o n s and cover a s i g n i f i c a n t l y wide range of probable behaviour i n spa o p e r a t i o n s . The most important c o n s i d e r a t i o n i s to i d e n t i f y these p o s s i b l e c h a r a c t e r i s t i c s , e v a l u a t e the key m o t i v a t i n g f a c t o r s , and assess the r e l a t i v e extent of each type of behaviour w i t h i n the spectrum of spa o p e r a t o r s as a whole i n order to develop some reasonable idea of what i n c e n t i v e s and/or d i s i n c e n t i v e s w i l l be most e f f e c t i v e and e f f i c i e n t i n d i f f e r e n t s i t u a t i o n s . There are o b v i o u s l y no patent answers, but c o n s i d e r a t i o n of these b e h a v i o u r a l c h a r a c t e r i s t i c s , along with c a r e f u l thought, judgement, and experience are necessary. Although the behaviour of spa o p e r a t o r s i s key to sound spa management i n B.C., i t i s h e l p f u l to c h a r a c t e r i z e the other 178 a c t o r s who are p a r t i c i p a n t s i n the s i t u a t i o n . In order to f a m i l i a r i z e the reader with v a r i o u s ranges of p e r s o n a l i t i e s , the f o l l o w i n g b r i e f d e s c r i p t i o n s are p r o v i d e d . Spa Users The Uninformed User T h i s covers the vast m a j o r i t y of c u r r e n t spa u s e r s . They assume e i t h e r that there i s no danger or that the danger i s remote. They assume, for i n s t a n c e , that " a l l those chemicals being poured i n t o spas" a u t o m a t i c a l l y p r o t e c t them from i n f e c t i o u s d i s e a s e . Instead, they worry m i s l e a d i n g l y about c o n t r a c t i n g d i s e a s e s p o p u l a r i z e d by the media, such as Herpes. The b i g g e s t f a l l a c i e s which uninformed users are prone to b e l i e v e are that s c i e n t i s t s r e a l l y know the answers to " s a f e " spa management and that p u b l i c h e a l t h o f f i c i a l s are c o n s c i e n t i o u s l y and c o n s i s t e n t l y safeguarding the p u b l i c w e l f a r e . An uninformed spa user becomes informed through exposure to both a d d i t i o n a l i n f o r m a t i o n and experience. The C a r e l e s s User A spa user can be informed about spa r i s k s and have a d e s i r e to a v o i d them, but some users w i l l s t i l l be c a r e l e s s i n t h e i r use. I n d i v i d u a l s , e i t h e r through pr e o c c u p a t i o n with other t h i n g s or by simply f a i l i n g t o stop and t h i n k , can e a s i l y n e g l e c t to shower before use or proceed to enter a spa with an 179 open wound. Reminders of some s o r t , p a r t i c u l a r l y ones which c a r e l e s s users cannot a v o i d n o t i c i n g or obeying, are the best means f o r i n s u r i n g more c a r e f u l use. Another c l a s s of users w i l l tend to ignore warnings which they f e e l are u n n e c e s s a r i l y p r o t e c t i v e . These type of people may think that p r e c a u t i o n a r y warnings and measures are wise f o r most people, but that they are exaggerated f o r them. Because of the m i s p e r c e p t i o n that they are somehow beyond being a f f e c t e d by hazards posed to the "average person", i t i s necessary to present the dangers to them i n an immediate context and to c h a l l e n g e t h e i r assumptions by s t r a i g h t f o r w a r d l o g i c . The Risk-Taker I n d i v i d u a l s do e x i s t who maintain a f a s c i n a t i o n with f a c i n g r i s k y , and even o u t r i g h t dangerous, s i t u a t i o n s . They may be w e l l aware that heavy a l c o h o l consumption or smoking marijuana immediately p r i o r to using a spa has a h i g h element of r i s k . Yet, t h i s k i nd of person f i n d s a sense of excitement or a " t h r i l l i n l i v i n g " by a c t i n g c l o s e to the border of i n j u r y or death. One method f o r d e a l i n g with t h i s behaviour i s simply to p r o h i b i t these types of users or c e r t a i n behaviours of these u s e r s . Another a l t e r n a t i v e method, where f e a s i b l e , i s to develop some way to remove or d i l u t e the p e r c e p t i o n of danger f o r t h i s i n d i v i d u a l . The "Picky" User Some spa users w i l l f i n d f a u l t with spa o p e r a t i o n s or 180 p u b l i c h e a l t h e f f o r t s no matter what attempts are made with spa management. T h i s i n d i v i d u a l would be unhappy even i f p o l i c y followed h i s own recommendations. T h i s kind of behaviour i s r e a l l y a form of seeking a t t e n t i o n . Since a " p i c k y " user wants a t t e n t i o n and to have h i s views expressed, i t i s worthwhile to i n v o l v e him as a p a r t i c i p a n t , but not at the expense of e x c l u d i n g or d e t r a c t i n g from the i n t e r e s t s of other people. P o l i c y should c l e a r l y and u n e q u i v o c a l l y f o r c e the " p i c k y " user to r e a l i z e t h a t h i s i s not the only i n t e r e s t which must be s a t i s f i e d . The " W i l l y - N i l l y " User T h i s i s a very d i f f i c u l t type of user to deal with, because f e a r s are g e n e r a l l y i r r a t i o n a l and u n r e l a t e d to the a c t u a l spa o p e r a t i o n . I t i s not l i k e l y t h a t o p e r a t o r s w i l l r e g u l a r l y encounter s i t u a t i o n s of use by these people, due to t h e i r obvious presence of f e a r . However, i t i s c o n c e i v a b l e that f o r medical reasons or peer p r e s s u r e s to engage in spa use that a " w i l l y - n i l l y " user may be a concern. The only e f f e c t i v e way to deal with t h i s p o t e n t i a l behaviour i s to recognize that such people e x i s t and to p r o v i d e s p e c i a l circumstances, arranged by t r a i n e d p e r s o n n e l , to work with t h i s user. T h i s probably w i l l be a r a r e s i t u a t i o n , but one which should be a n t i c i p a t e d . The Informed and I n t e l l i g e n t User At f i r s t glance, the b e h a v i o u r a l c h a r a c t e r i s t i c s of t h i s user might appear " i d e a l " f o r spa management. However, an 181 informed and i n t e l l i g e n t approach by such a user may only be wise f o r that person's own s e l f i s h i n t e r e s t s -- i t i m p l i e s nothing of h i s views toward imposing hazards or c o s t s on o t h e r s . In c e r t a i n cases, an " i n t e l l i g e n t " d e c i s i o n f o r one person may even i n v o l v e r a i s i n g r i s k s f o r other u s e r s . For example, i t i s not i n c o n c e i v a b l e that i n a crowded f a c i l i t y an i n d i v i d u a l might d e l i b e r a t e l y appear at "spa s i d e " with an ugly body rash or evidence of i l l n e s s i n order to c r e a t e more room i n the spa f o r h i m s e l f . Furthermore, t h i s type of user can s t i l l be l u l l e d i n t o i g n o r i n g the r e a l u n c e r t a i n t i e s a s s o c i a t e d with spas. P o l i c y should c o n s i d e r means both i n acc o u n t i n g f o r " t h i r d - p a r t y " e f f e c t s and i n acknowledging the r e a l u n c e r t a i n t i e s i n d e a l i n g with t h i s type of user. P u b l i c H e a l t h O f f i c i a l s The S t r i c t E n f o r c e r Some o f f i c i a l s w i l l demonstrate an "eng i n e e r i n g p e r s p e c t i v e " i n which spa management i s viewed as a formula of standards or g u i d e l i n e s which can be r e a d i l y e v a l u a t e d and then c o r r e c t e d through some enforcement p r o v i s i o n . R i g i d p o s i t i o n s may be taken which s t i r a n imosity w i t h i n o p e r a t o r s toward h e a l t h o f f i c i a l s and r e g u l a t i o n s , and t h i s can produce outward or c o v e r t operator d e f i a n c e , r e s u l t i n g i n i n c r e a s e d r i s k s to u s e r s . R i g i d p o s i t i o n s can a l s o cause o f f i c i a l s to overlook the 182 weaknesses of recommended spa management and ignore new and b e t t e r ideas. T h i s i s p a r t i c u l a r l y a p p l i c a b l e i n our s i t u a t i o n of high u n c e r t a i n t y and v a r i a b i l i t y . To allow f o r t h i s form of behaviour, p o l i c y should seek to motivate these o f f i c i a l s by emphasizing spa management o b j e c t i v e s , which lead to success i n o v e r a l l g o a l s of r i s k r e d u c t i o n ; and not focus too narrowly on success merely with methods of spa management. F u r t h e r , p o l i c y should not encourage such o f f i c i a l s i n t o entrenched p o s i t i o n s where judgements of t h e i r performance are based upon success i n e n f o r c i n g methods r a t h e r than success i n r i s k r e d u c t i o n , (e.g., i t would be more p r e f e r a b l e to evaluate the o f f i c i a l s ' performance based upon r e d u c t i o n of d i s e a s e outbreaks r a t h e r than upon the number of f a c i l i t y c l o s i n g s from f a i l u r e of o p e r a t o r s to meet standards.) The Zealot T h i s o f f i c i a l has the tendency to f i n d dangers l u r k i n g everywhere w i t h i n spa environments and develop a cause to "root out a l l the e v i l s " . The z e a l o t may d i r e c t a t t e n t i o n at spas g e n e r a l l y or at operators and u s e r s . T h i s i n d i v i d u a l w i l l demonstrably (and sometimes b l i n d l y ) pursue avenues of c r i t i c i s m and a c t i o n s designed to c o r r e c t what he views as s e r i o u s problems. T h i s behaviour can sometimes be h e l p f u l , but i t can a l s o be s h o r t - s i g h t e d . Moreover, i t may take a d e s t r u c t i v e form which p o l a r i z e s other p a r t i c i p a n t s and c r e a t e s stalemate s i t u a t i o n s i n important areas f o r r e s o l v i n g spa management problems. 183 O f f i c i a l s of t h i s type can perhaps best be motivated i n more p o s i t i v e d i r e c t i o n s by exposing them to other p a r t i c i p a n t s ' q u e s t i o n i n g . S i m i l a r to the r i g i d p o s i t i o n s a s s o c i a t e d with the " s t r i c t e n f o r c e r " , behaviour can a l s o be l a r g e l y m o d i f i e d through developing more f l e x i b l e and c l e a r p o l i c y o b j e c t i v e s . The Clockwatcher He has a job to do. And that job i s l a r g e l y d e f i n e d i n terms of m a i n t a i n i n g a p h y s i c a l presence d u r i n g s p e c i f i e d time p e r i o d s . Although t h i s person may c a r r y a semblance of p r o f e s s i o n a l r e s p o n s i b i l i t y d u r i n g work hours, t h i s sense does not guide h i s a c t i o n s . Anything i n h i s r o l e as a p u b l i c h e a l t h o f f i c i a l which appears to extend beyond h i s "job d e s c r i p t i o n " w i l l be ignored or done s u p e r f i c i a l l y . T h i s kind of o f f i c i a l i s a l s o prone to becoming a "buddy" of spa o p e r a t o r s and to allow unreasonable leeway i n r e g u l a t o r y enforcement. The "I'm too busy fo r that now" O f f i c i a l T h i s i s a r e l a t i v e l y common type of p u b l i c h e a l t h o f f i c i a l with respect to p u b l i c spas. Besieged (or p e r c e i v e d as being besieged) by numerous p u b l i c h e a l t h concerns and p r o j e c t s , t h i s o f f i c i a l s sees spas as a nuisance and t r i e s to a v o i d having to d e a l with them. He r a t i o n a l i z e s spa problems as being minor and he w i l l p r o c r a s t i n a t e on t a k i n g a c t i o n u n t i l p r e s s u r e s f o r doing so mount. The i n d i v i d u a l i s motivated p a r t i a l l l y by education about the problems, but p u b l i c or l e g i s l a t i v e p r e s s u r e s are necessary 184 to r e a l l y s t i m u l a t e t h i s o f f i c i a l . The Guardian or Steward of P u b l i c H e a l t h An o f f i c i a l of t h i s type t r u l y does t r y to p r o t e c t the p u b l i c i n t e r e s t . While being concerned about reducing r i s k s i n spa management he i s a l s o w e l l aware of the c o - o p e r a t i o n needed from o p e r a t o r s , users and i n d u s t r y to o b t a i n s u c c e s s f u l r e s u l t s . T h i s i n d i v i d u a l w i l l h o l d f i r m to m a i n t a i n i n g sound p u b l i c h e a l t h p r i n c i p l e s , but he can a l s o c a r e f u l l y weigh economic and b e h a v i o u r a l f a c t o r s i n t o spa management p o l i c i e s . Thus, t h i s o f f i c i a l o f t e n i s h i g h l y e f f e c t i v e i n p o l i c y implementation. P o l i c y can g r e a t l y b e n e f i t by promoting these types of o f f i c i a l s i n t o l e a d e r s h i p r o l e s . Industry Order-Takers An i n d u s t r y o r d e r - t a k e r merely attempts to meet the requests and demands of o p e r a t o r s and consumers without ever q u e s t i o n i n g the products being purchased or t h e i r intended use. The u n d e r l y i n g a t t i t u d e i s that t h e i r job i s merely to p r o v i d e the s e r v i c e s or goods and t h e i r r e s p o n s i b i l i t y ends at that p o i n t . U n f o r t u n a t e l y , the nature of spas makes t h i s behaviour u n d e s i r a b l e . Through ignorance or attempts to cut purchasing c o s t s , o p e r a t o r s may use spa products which j e o p a r d i z e the s a f e t y of u s e r s . 185 Order-takers can be d e a l t with by making them s u f f i c i e n t l y aware of t h e i r a f t e r - s a l e r e s p o n s i b i l i t i e s . They are a l s o motivated to assume more r e s p o n s i b i l i t y whenever co m p e t i t i o n f o r c e s comparison of product q u a l i t y as a f a c t o r i n operator and spa user buying d e c i s i o n s . E v a n g e l i s t s C e r t a i n members i n the spa i n d u s t r y attempt to i n c r e a s e t h e i r revenues or s t a t u s through o r g a n i z i n g committees and campaigns to develop good spa management g u i d e l i n e s . T h i s type of person w i l l f r e q u e n t l y appear on codes and standards committees. His motive i s u s u a l l y s e l f i s h , which, i n some cases, w i l l serve the p u b l i c i n t e r e s t v i a the " i n v i s i b l e hand" p r i n c i p l e . However, when the behaviour of t h i s i n d i v i d u a l becomes f i x e d i n a p a t t e r n of "evangelism", the r i g i d f e a t u r e s d e s c r i b e d with c e r t a i n h e a l t h o f f i c i a l s become a p p l i c a b l e here. Options become overlooked and the l a r g e r p i c t u r e of spa management o b j e c t i v e s can be l o s t . P o l i c y should c o n s i d e r approaches f o r d e a l i n g with i n d u s t r y " e v a n g e l i s t s " i n much the same way as zealous p u b l i c h e a l t h o f f i c i a l s . Gypsies There i s an i n d u s t r y joke about people who buy a t r u c k , p a i n t t h e i r name on backwards, and suddenly c a l l themselves " q u a l i f i e d pool and spa s e r v i c e people". The sad t r u t h i s that such c h a r a c t e r s do i n f a c t e x i s t -- and sometimes i n l a r g e numbers. They can go i n and out of business as q u i c k l y as a i t 186 takes them to f i n i s h a p a r t i c u l a r job and get p a i d . T h e i r l a c k of knowledge of t h e i r trade and u n d e r l y i n g l a c k of concern f o r t h e i r customers can le a d to haphazard work, s a l e s of unnecessary or dangerous products, bad advice to o p e r a t o r s , and angry customers who then d i s t r u s t i n d u s t r y members i n g e n e r a l . L i c e n s i n g and c e r t i f i c a t i o n requirements can perhaps e l i m i n a t e " g y p s i e s " or f o r c e them to "cl e a n up t h e i r a c t " . More e f f e c t i v e l y , customers with b e t t e r i n f o r m a t i o n about these c h a r a c t e r s and other a l t e r n a t i v e s e r v i c e s may decrease the e f f e c t s of " g y p s i e s " upon spa o p e r a t i o n s . Sharks These people have the same e f f e c t s upon spa management and op e r a t i o n s as "g y p s i e s " , except that "sharks" i n t e n t i o n a l l y and knowingly pursue s e l f i s h i n t e r e s t s without concern f o r t h e i r customers or the p u b l i c . There i s no r e a l element of conscience i n t h e i r a c t i o n s and the o l d e x p r e s s i o n "they would s e l l t h e i r grandmother to cut a d e a l " a p t l y a p p l i e s to the behaviour of these i n d u s t r y types. Although t h e i r e f f e c t s on spa management are a k i n to those of g y p s i e s , the "sharks'" m o t i v a t i o n of e x c e s s i v e greed p r e s e n t s a d i f f e r e n t c h a l l e n g e to p o l i c y . Consumer i n f o r m a t i o n i s h e l p f u l i n c o n t r o l l i n g the behaviour of these i n d u s t r y types, but i t i s a l s o necessary to have p r o v i s i o n s which provide consumer p r o t e c t i o n and means f o r recourse. 187 T e c h n i c i a n s and Engineers T h i s group of people i n the i n d u s t r y u s u a l l y operates "behind the scenes" yet they can have a powerful i n f l u e n c e on products, s e r v i c e s , and i n f o r m a t i o n developed by the i n d u s t r y . T e c h n i c i a n s and engineers not only produce t e c h n i c a l s o l u t i o n s to spa management problems, but they a l s o can h e l p c l a r i f y and analyze s i t u a t i o n s f o r other i n d u s t r y people. However, t e c h n i c i a n s and engineers tend to e x h i b i t l i t t l e u nderstanding of the a b i l i t i e s and w i l l i n g n e s s of o p e r a t o r s and users to comprehend spa management. T h i s a t t i t u d e can l e a d to design of products and output of i n f o r m a t i o n which confuse ope r a t o r s and users or which does not match the r e a l i t y of spa management s i t u a t i o n s . I t i s important that these kinds of i n d i v i d u a l s are exposed to a wide range of other people as w e l l as to what might be c o n s i d e r e d " i r r a t i o n a l behaviour" of ope r a t o r s and u s e r s . Seminar p r e s e n t a t i o n s to o p e r a t o r s or users and i n - f i e l d c o n s u l t i n g are e x c e l l e n t v e h i c l e s f o r e n l a r g i n g the p e r s p e c t i v e of the t e c h n i c i a n s and e n g i n e e r s . Honest Businessmen The use of the word "honest" with t h i s category of i n d u s t r y people does not n e c e s s a r i l y r e f e r to moral q u a l i t i e s ; but r a t h e r i t r e f e r s to a behaviour c o n s i s t e n t with s o l i d business p r i n c i p l e s . Honest businessmen l i v e up to t h e i r s t a t e d commitments i n t r a n s a c t i o n s . In t h e i r b e l i e f i n the maxim " i t ' s good f o r b u s i n e s s " , they w i l l be f a c i l i t a t i n g with customers beyond what normally might be expected. The behaviour of honest 188 businessmen i s motivated by t h e i r a t t i t u d e that l i f e f u n c t i o n s best on a r e c i p r o c a l b a s i s . These i n d u s t r y people u s u a l l y make strong c o n t r i b u t i o n s to spa management problems, as they are aware that s a f e , happy opera t o r s and users w i l l produce f u t u r e p r o f i t s . Honest businessmen are g e n e r a l l y q u i t e easy to deal with, but i t cannot be a u t o m a t i c a l l y assumed that these i n d i v i d u a l s w i l l be aware of s i t u a t i o n s where r e c i p r o c i t y i s important. I t i s necessary f o r others to draw a t t e n t i o n to problems. Marketers Such i n d i v i d u a l s are a v e r s i o n of honest businessmen, with an important d i f f e r e n c e . Marketers have a l a r g e r and longer-term p e r s p e c t i v e and concentrate on concepts r a t h e r than j u s t s p e c i f i c t r a n s a c t i o n s . T h e i r behaviour can be i n v a l u a b l e to spa management, as these i n d i v i d u a l s w i l l take i n i t i a t i v e to f i n d s o l u t i o n s . F r e q u e n t l y , the most c r e a t i v e and i n n o v a t i v e ideas w i l l emerge from t h i s group of people. P o l i c y can p a r t i c u l a r l y b e n e f i t by u t i l i z i n g marketers' t a l e n t s toward r e s t r u c t u r i n g p o t e n t i a l l y n e g ative s i t u a t i o n s i n t o p o s i t i v e d i r e c t i o n s . The above d e s c r i p t i o n s conclude an overview of the behaviour which can be expected from the other main a c t o r s i n v o l v e d with spa management. As with the c h a r a c t e r i z a t i o n of spa o p e r a t o r s , no c l a i m of t o t a l accuracy or comprehensiveness i s made. However, i f policy-makers are a l e r t to the p o t e n t i a l f o r other p o s s i b l e behaviour, i t i s reasonable to use these 189 c h a r a c t e r i z a t i o n s as a foundation f o r b e h a v i o u r a l assumptions. 190 APPENDIX D A D e t a i l e d D e s c r i p t i o n of the U.S. Experience As a guide to understanding the r o l e s of each p a r t i c i p a n t , i t i s h e l p f u l to c l a r i f y the c a t e g o r i e s and i n d i c a t e some of t h e i r important c o n t r i b u t i o n s to spa management progress thus f a r . The I n d u s t r y ' s Role The spa i n d u s t r y o r i g i n a t e d from the pool i n d u s t r y , l a t e r s p l i n t e r e d o f f on i t s own, and more r e c e n t l y , the two groups moved c l o s e r together. The e a r l i e r f r a c t u r e of the two s e c t o r s was a d i r e c t r e s u l t of d i f f e r i n g needs and i n t e r e s t s as seen by the people whose business was predominantly spas. T h i s s p l i n t e r i n g was h i g h l y s i g n i f i c a n t because i t f o r c e d the pool i n d u s t r y i n t o r e c o g n i z i n g and accommodating the d i f f e r e n c e s ; thus adding impetus to the spread of i n f o r m a t i o n about spa c h a r a c t e r i s t i c s . By the term " i n d u s t r y " , we r e f e r to the business firms which are engaged i n the manufacturing, d i s t r i b u t i o n , r e t a i l i n g , and s e r v i c i n g of spa and s p a - r e l a t e d p r o d u c t s . These f i r m s represent a very wide scope of o r g a n i z a t i o n a l types i n s i z e and s t r u c t u r e . The trade a s s o c i a t i o n groups have been c l a s s i f i e d here d e s p i t e t h e i r n o t - f o r - p r o f i t s t a t u s and s t a t e d p u b l i c - i n t e r e s t o b j e c t i v e s . The N a t i o n a l Spa & Pool I n s t i t u t e (formerly the N a t i o n a l Swimming Pool I n s t i t u t e ) , l o c a t e d i n Washington, D.C, 191 i s the dominant trade a s s o c i a t i o n , and as a trade a s s o c i a t i o n , i t i s unique. I t i s a completely v e r t i c a l l y i n t e g r a t e d i n t e r n a t i o n a l a s s o c i a t i o n of more than 2 0 0 0 member fi r m s i n the U.S., Canada, and over 2 0 other f o r e i g n c o u n t r i e s . The a s s o c i a t i o n r e p r e s e n t s firms which range from g i a n t c o r p o r a t i o n s to "ma & pa o p e r a t i o n s " . I t i n c l u d e s d i v e r s e members such as independent s a l e s r e p r e s e n t a t i v e s , c o n s u l t a n t s , p u b l i c h e a l t h o f f i c i a l s , a r c h i t e c t s , f i n a n c i a l i n s t i t u t i o n s , and o t h e r s . In s p i t e of i t s r e l a t i v e l y small s i z e as a trade a s s o c i a t i o n , NSPI i s very e f f e c t i v e and a c t i v e , p a r t i c u l a r l y i n t e c h n i c a l and government r e l a t i o n s e f f o r t s . I t i s h i g h l y regarded with respect to i t s e f f e c t i v e n e s s and a c t i v i t y . What makes the a s s o c i a t i o n unique i s i t s dual s t a t u s as both a p u b l i c s e r v i c e o r g a n i z a t i o n and as an arm of the i n d u s t r y . In regard to i t s p u b l i c s e r v i c e r o l e , the NSPI c h a r t e r l i s t s one of i t s o b j e c t i v e s as; "to d i g n i f y and e l e v a t e the standards of the swimming pool and spa i n d u s t r y ; to conduct a program of p u b l i c education with re s p e c t to swimming pools and spas; and to e s t a b l i s h uniform standards f o r the de s i g n , c o n s t r u c t i o n , and equipping of swimming pools and spas." In t h i s f u n c t i o n the NSPI works c l o s e l y with a p p r o p r i a t e government agencies, u n i v e r s i t i e s , code a s s o c i a t i o n s , and other p u b l i c s e r v i c e agencies such as the American Red Cross and the N a t i o n a l S a n i t a t i o n Foundation. With these groups, NSPI shares i n f o r m a t i o n and s e r v i c e s r e c i p r o c a l l y , conducts r e s e a r c h , and develops programs. On the other hand, the a s s o c i a t i o n a l s o c l e a r l y r e p r e s e n t s " i n d u s t r y " i n t e r e s t s . I t s p e c i f i c a l l y develops and implements 192 promotional and marketing programs designed to s t i m u l a t e consumer demand and i n f l u e n c e p u b l i c p r e f e r e n c e s and o p i n i o n s . I t s annual convention, though p a r t l y e d u c a t i o n a l , serves p r i m a r i l y as a showcase f o r manufacturers' p r o d u c t s . The importance of t h i s background i n f o r m a t i o n to t h i s study i s t w o - f o l d . F i r s t , NSPI has s u b s t a n t i a l i n f l u e n c e on the p o l i c y process n a t i o n a l l y and l o c a l l y . Secondly, i t s dual f u n c t i o n r a i s e s q u e s t i o n s r e g a r d i n g c o n f l i c t s of i n t e r e s t . For example, i n 1979 NSPI r e c e i v e d a $9,000 c o n t r a c t from the Center f o r Disease C o n t r o l f o r work r e l a t i n g to the development of spa management g u i d e l i n e s ( r e f e r r e d to s e v e r a l times i n t h i s study) and the CDC openly acknowledges NSPI as a major c o n t r i b u t o r to the g u i d e l i n e s . T h i s has both value and f a c t u a l r a m i f i c a t i o n s . F i r s t , as a matter of c o n t r o v e r s y , not e s t a b l i s h e d f a c t , some people have charged that NSPI i s dominated by the l a r g e manufacturing f i r m s whose dues and other c o n t r i b u t i o n s a l s o represent the l a r g e s t source of revenue to the a s s o c i a t i o n . I f t h i s i s t r u e , then the p o s s i b i l i t y e x i s t s that these manufacturers may i n f l u e n c e p u b l i c p o l i c y to t h e i r b e n e f i t . There i s , i n f a c t , a Manufacturers' C o u n c i l , which does p r o v i d e some evidence of t h i s . As an example of t h i s , the C o u n c i l r e c e n t l y a c ted to t r y and prevent the N a t i o n a l S a n i t a t i o n Foundation (NSF) from making changes to the present pool f i l t r a t i o n standard and adding requirements f o r spa equipment t e s t i n g and l i s t i n g . 1 The b a r g a i n i n g i s not concluded, but i t looks as i f a compromise w i l l be reached whereby the standard w i l l be m o d i f i e d r a t h e r than having a new code w r i t t e n f o r 193 s p a s . 2 The s i g n i f i c a n c e of p o s s i b l e manufacturer c o n t r o l i s that these firms have a stake i n s e l l i n g s p e c i f i c products; whereas other types of firms ( i . e . , w holesalers and r e t a i l e r s ) do not — t h e i r i n t e r e s t i s to s e l l any products. T h i s d i s t i n c t i o n can p o s s i b l y be both b e n e f i c i a l and d e t r i m e n t a l f o r the p u b l i c i n t e r e s t . A manufacturer (or group of manufacturers) may i n f l u e n c e p u b l i c p o l i c y toward acceptance of u n d e s i r a b l e or unnecessary products. Conversely, they may have a b e n e f i c i a l e f f e c t at times by being more d i s c e r n a b l e and knowledgeable about products. Regardless of the a c t u a l amount of i n f l u e n c e of manufacturers, though, i t i s reasonable to suggest that c l o s e NSPI involvement i n p u b l i c p o l i c y formation i s to some degree b i a s e d toward i n d u s t r y i n t e r e s t s , p o s s i b l y at the expense of o t h e r s . A second r a m i f i c a t i o n i s that (as in many o r g a n i z a t i o n s ) important p o l i c i e s can o f t e n be dominated by the same i n d i v i d u a l s or companies, time a f t e r time. From a standpoint of f a c t u a l concerns, t h i s c r e a t e s the p o s s i b i l i t y of good i n f o r m a t i o n or a l t e r n a t i v e s being overlooked, a c c i d e n t a l l y or otherwise. A l s o , there i s frequent d u p l i c a t i o n of recommendations in g u i d e l i n e s and standards. The danger of t h i s i s t h a t s e p a r a t e l y p u b l i s h e d m a t e r i a l s can be d e c e p t i v e l y accepted as having gone through a process of separate i n v e s t i g a t i o n , q u e s t i o n i n g , and a n a l y s i s . Thus, a s i d e from normal value q u e s t i o n s , the dominance of the same groups can a l s o l e a d to a tendency to ignore important o u t s i d e a c t i o n s or e m p i r i c a l knowledge. 194 Against these c r i t i c i s m s about p o t e n t i a l NSPI c o n f l i c t , other c o n s i d e r a t i o n s must be weighed. F i r s t of a l l , NSPI has, i n a c t u a l i t y , accomplished i t s dual r o l e q u i t e s u c c e s s f u l l y and r e t a i n e d an a c c e p t a b l e l e v e l of c r e d i b i l i t y and o b j e c t i v i t y i n the minds of many people. A l l of the other s e c t o r s shown i n the char t do reco g n i z e (to v a r y i n g , but s i g n i f i c a n t degrees) NSPI as a l e g i t i m a t e p u b l i c s e r v i c e o r g a n i z a t i o n . There are reasons f o r t h i s : (1) i n order to remain " l e g i t i m a t e " i n the eyes of government, other o r g a n i z a t i o n s , and the p u b l i c , NSPI must always c o n s c i o u s l y endeavour to s t r i v e f o r f a i r n e s s , o b j e c t i v i t y , and the p u b l i c i n t e r e s t . I t would be s u i c i d a l f o r NSPI to do otherwise and perhaps at times the a s s o c i a t i o n may have to a c t c o n t r a r y to i t s own i n t e r e s t s i n order to "prove" i t s p osture; (2) the l a r g e d i v e r s i t y of members i n the a s s o c i a t i o n almost i n e v i t a b l y guarantees that no one s p e c i f i c i n t e r e s t can dominate, i . e . , u n f a i r or unreasonable a c t i o n s i n one d i r e c t i o n can n e g a t i v e l y a f f e c t o t h e r s and provoke s e r i o u s d i s p u t e s . As an example, a c h l o r i n e manufacturer who t r i e s to i n f l u e n c e standards toward acceptance of c h l o r i n e as the "proper" spa d i s i n f e c t a n t w i l l s u r e l y draw the wrath of the bromine (or other d i s i n f e c t a n t ) manufacturers. T h i s a c t s as an e f f e c t i v e check a g a i n s t abuses, but i r o n i c a l l y , i t can a l s o be d e t r i m e n t a l to f a c t u a l concerns. C e r t a i n products, which may be i n f e r i o r , c o u l d be t o l e r a t e d i n standards as an e f f o r t to appease those i n t e r e s t s . (3) NSPI i s c o n s i s t e n t l y the t a r g e t f o r c r i t i c i s m by the trade p u b l i c a t i o n s , d i s a f f e c t e d NSPI members, and non-NSPI i n d u s t r y people. As to be expected, c r i t i c i s m 195 u s u a l l y aims at e x p l o i t i n g whatever appears to be b i a s e d , improper, or done in poor judgement. In i t s goal to i n c r e a s e and r e t a i n membership, NSPI must always c o n s t a n t l y be a l e r t to that p o t e n t i a l c r i t i c i s m and t r y to a v o i d i t by seeking o b j e c t i v i t y . T h i s , too, forms an e f f e c t i v e check a g a i n s t abuses. A second c o n s i d e r a t i o n i s the p o s t u l a t i o n of what the o v e r a l l s i t u a t i o n f o r pools and spas would be without NSPI. Many of i t s recognized c o n t r i b u t i o n s might not otherwise occur, and i t i s u n l i k e l y t h a t government or other o r g a n i z a t i o n s would have the wherewithal and/or the i n t e r e s t i n a c t i n g as a s u b s t i t u t e f o r NSPI f u n c t i o n s . Moreover, i n d i v i d u a l f i r m s would have l i t t l e reason to r e s t r a i n t h e i r s e l f i s h and p o t e n t i a l l y d e s t r u c t i v e e f f o r t s , as the checks a g a i n s t t h i s would be n o n - e x i s t e n t . T h i s c o n s i d e r a t i o n i s an e x c e e d i n g l y important j u s t i f i c a t i o n f o r NSPI's r o l e . A f i n a l c o n s i d e r a t i o n i s whether i t t r u l y matters i f a c o n f i c t of i n t e r e s t e x i s t s or not. S t u d i e s of other i n d u s t r i e s i n d i c a t e that i n d u s t r y o f t e n "captures" the r e g u l a t o r y process anyhow. 3 I f t h i s i s true and we are unable to d e v i s e b e t t e r systems in g e n e r a l , then what d i f f e r e n c e does i t make whether the i n d u s t r y i n f l u e n c e i s e x e r t e d i n an organized or unorganized manner? Some might argue that when i n f l u e n c e i s e x e r t e d through an a s s o c i a t i o n , at l e a s t i t i s done i n an o r d e r l y , organized way, whereby d e c i s i o n s and a c t i o n s can be more r e a d i l y i d e n t i f i e d and t r a c e d i f q u e s t i o n a b l e s i t u a t i o n s a r i s e . In summary, NSPI, both on a n a t i o n a l and l o c a l l e v e l , has 196 the p o t e n t i a l f o r demonstrating c o n f l i c t s of i n t e r e s t which a f f e c t p u b l i c p o l i c y and may be counter to the p u b l i c i n t e r e s t . However, experience shows that t h i s i s l a r g e l y not the case and that where p o s s i b l e abuses may occur, those abuses are perhaps more t o l e r a b l e than the a l t e r n a t i v e of not having the a s s o c i a t i o n . The q u e s t i o n then might be r a i s e d ; why doesn't the NSPI simply d i s c a r d the r o l e of being the arm of the i n d u s t r y and s o l e l y c o n c e n t r a t e on p u b l i c s e r v i c e matters? The qu e s t i o n has been r a i s e d and w i t h i n the i n d u s t r y i t s e l f . The answer i s q u i t e b a s i c — i t r e a l l y does not matter i f the a s s o c i a t i o n does pursue promotional and marketing a c t i v i t i e s . For i n order to o b t a i n the funding, i n f o r m a t i o n , and co o p e r a t i o n of the v a r i o u s f i r m s , NSPI would s t i l l be sub j e c t to p o t e n t i a l b i a s and lack of o b j e c t i v i t y — that aspect would not change. I f promotional and marketing a c t i v i t i e s o f f e r m o t i v a t i o n s f o r f i r m s to j o i n and support the a s s o c i a t i o n , then so be i t . The b e n e f i t s from t h i s support and s e l f - i n d u c e d checks a g a i n s t business abuses f a r outweigh the p o s s i b l e negative e f f e c t s which would be beyond any ones present i n a p u r e l y p u b l i c s e r v i c e r o l e . T h i s lengthy d i s c u s s i o n of NSPI i s more p e r t i n e n t than f o r the other a c t o r s i n v o l v e d , because i t i s the f o c a l p o i n t f o r the U.S. experience with spas. Of a l l the a c t o r s , i t i s the one which has had the most d i r e c t i n t e r a c t i o n with every other group. As a r e s u l t , i t serves as a "weathervane" f o r what i s t a k i n g p l a c e on a r e g u l a r b a s i s and a l s o as a c u l m i n a t i o n p o i n t f o r what has taken p l a c e through the e f f o r t s of o t h e r s . 197 F e d e r a l , S t a t e , and L o c a l Government Agencies These a c t o r s have been lumped together f o r convenience, but t h e i r r o l e s i n the U.S. experience have been q u i t e v a r i e d both with regard to d i f f e r e n t responses from each l e v e l of government and w i t h i n each l e v e l i t s e l f . There have been some very a c t i v e and v o c a l p u b l i c o f f i c i a l s who have urged and taken p u b l i c a c t i o n with spas. But there are a l s o a l a r g e number of o f f i c i a l s who have not wanted to take steps or c o u l d not. The reasons f o r t h i s are i n t e r e s t i n g . I n - f i e l d i n t e r v i e w s r e v e a l e d that there are o f f i c i a l s who p r e f e r to a v o i d involvement with spas. T h i s runs c o n t r a r y to p o s s i b l e s t e r e o t y p e s of p u b l i c h e a l t h o f f i c i a l s such as "they are always d e d i c a t e d to p r o t e c t i n g p u b l i c h e a l t h " or somewhat op p o s i t e , " p u b l i c agencies w i l l jump at any o p p o r t u n i t y to s t i c k t h e i r nose i n t o a s i t u a t i o n and attempt to garner p o s i t i o n s of a u t h o r i t y or power". The r e l u c t a n c e i s , as p r e v i o u s l y mentioned, due to both lac k of knowledge and l a c k of concern, but i t goes deeper and i s q u i t e understandable. P u b l i c h e a l t h o f f i c i a l s have innumerable e x i s t i n g and p o t e n t i a l h e a l t h concerns, a l l of which c o u l d c o n c e i v a b l y p l a c e high demands on t h e i r departments' manpower, budgets, and time. Some f e e l that they a l r e a d y are not s a t i s f a c t o r i l y coping with present r e s p o n s i b i l i t i e s , so that the prospect of new ones are not d e s i r a b l e . T h i s a t t i t u d e has been exacerbated by the recent rash of government cut-backs. I t i s a s i t u a t i o n of being asked to do more with l e s s . Thus, i f i t i s at a l l p o s s i b l e to a v o i d the added a d m i n i s t r a t i o n c o s t s and 198 problems of spas, some p u b l i c o f f i c i a l s would j u s t as soon "look the other way". Some departments simply cannot a f f o r d to do what they view as necessary. The combination of r i s i n g c o s t s and s h r i n k i n g budgets has c o n s t r a i n e d p u b l i c a c t i v i t y i n some j u r i s d i c t i o n s . The s t a t e of I l l i n o i s i s one example. With t h e i r normal pool program, the department has been f o r c e d to e l i m i n a t e sampling, l a b t e s t s , and reduced the number of i n s p e c t i o n s . A new program f o r spas — estimated at a c o s t of $ 2 0 0 , 0 0 0 / y e a r f o r one s i m i l a r to pool r e g u l a t i o n — i s not f e a s i b l e . In f a c t , the department d i d d r a f t proposed l e g i s l a t i o n which f a i l e d to get l e g i s l a t i v e support. So d e s p i t e the agency's b e l i e f that spa r e g u l a t i o n i s important and more of a h e a l t h problem than p o o l s , nothing i s being done at t h i s time. Wisconsin and Michigan are i n worse shape, as they were f o r c e d to t o t a l l y e l i m i n a t e t h e i r pool programs. f t The d i f f e r i n g a b i l i t i e s and w i l l i n g n e s s of the v a r i o u s j u r i s d i c t i o n s i n g e t t i n g i n v o l v e d with spas has three main e f f e c t s . The f i r s t e f f e c t i s the obvious lac k of u n i f o r m i t y i n spa r e g u l a t o r y treatment which has added c o n f u s i o n to the process of t r y i n g to d e a l with spas. The second e f f e c t i s t h a t i t a l l o w s p o t e n t i a l squabbling amongst the l e v e l s of government. In the U.S., d i r e c t i o n may be given by the f e d e r a l government, but i t i s o f t e n l e f t to the d i r e c t i o n of each s t a t e , p a r t i c u l a r l y i n d a i l y a d m i n i s t r a t i o n t a s k s . The s t a t e s , having primary a u t h o r i t y , may delegate (or c o n t r a c t ) the d u t i e s to 199 county governments. The s t a t e and county then work c o o p e r a t i v e l y . L o c a l and m u n i c i p a l governments may a l s o get i n v o l v e d on t h e i r own or i n c o o p e r a t i o n with s t a t e s and c o u n t i e s to whom they are subordinate. Where no a c t i o n i s taken by s t a t e s or c o u n t i e s , there i s the l i k e l i h o o d that m u n i c i p a l governments may begin imposing standards or r e g u l a t i o n s which run counter to p r i n c i p l e s of other government l e v e l s , hence c r e a t i n g c o n f l i c t s . A t h i r d e f f e c t i s that the j u r i s d i c t i o n s with more severe budgetary c o n s t r a i n t s are more s u s c e p t i b l e to seeking s h o r t - c u t s or a c c e p t i n g o u t s i d e i n f o r m a t i o n which i s weak or d e t r i m e n t a l . A l l of the above c o n s i d e r a t i o n s represent r e a l occurrences and they demonstrate some of the c u r r e n t weaknesses. Another very important p o t e n t i a l weakness e x i s t s which, as of y e t , appears u n r e s o l v a b l e . T h i s i s the aspect of e f f e c t i v e enforcement of r e g u l a t i o n s . Besides t y p i c a l enforcement problems, spas present an a d d i t i o n a l problem. In r e f e r e n c e to the v a r i a b i l i t y of spas d i s c u s s e d i n Chapter 2 , we have a s i t u a t i o n where spa water c o n d i t i o n s can l i t e r a l l y change i n minutes, and thus the c o s t s f o r e f f e c t i v e monitoring and enforcement may become e x c e s s i v e and the e f f o r t s f r u s t r a t i n g . T h i s , i n p a r t , i s r e f l e c t e d i n the ex p r e s s i o n of some h e a l t h o f f i c i a l s t h a t r e g u l a t i o n may be c o u n t e r - p r o d u c t i v e . A f i n a l major weakness i s that p u b l i c h e a l t h departments have to show care to a v o i d l i a b i l i t y i f s e r i o u s problems a r i s e . In l i g h t of budgetary and enforcement problems, a dilemma re g a r d i n g l i a b i l i t y i s c r e a t e d . The u n c e r t a i n t i e s i n v o l v e d p l a c e 2 0 0 a great d e a l of burden on a l l p a r t i e s concerned i f a q u e s t i o n of l i a b i l i t y does a r i s e . Because c l e a r and c o n s i s t e n t p o l i c y d i r e c t i o n s are l a c k i n g , i t w i l l be more complicated and messy to s o r t through a problem case. The q u e s t i o n i s ; has a norm of s a t i s f a c t o r y government r e s p o n s i b i l i t y toward p u b l i c spas been reasonably e s t a b l i s h e d to o f f e r guidance? The Operators There i s a b s o l u t e l y no c l e a r p a t t e r n of o p e r a t i o n or behaviour on the part of the o p e r a t o r s . In v i r t u a l l y every aspect of o p e r a t i o n , with the p o s s i b l e exception of observing the 104°F temperature l i m i t , there i s e x t r a o r d i n a r y i n c o n s i s t e n c y from o p e r a t i o n to o p e r a t i o n and even w i t h i n the same o p e r a t i o n from day to day. Operators are o f t e n p o o r l y informed of proper procedures, and where they have been informed, they have been confused from r e c e i v i n g d i f f e r e n t i n f o r m a t i o n from a l l kinds of sources. They p i c k up i n f o r m a t i o n from: vendors they d e a l with, p r e v i o u s pool o p e r a t i o n experience, w r i t t e n m a t e r i a l s , manufacturer product i n s t r u c t i o n s , e d u c a t i o n a l programs p r o v i d e d by both i n d u s t r y and p u b l i c a g e n c i e s , and by comparing notes with other o p e r a t o r s . I n v a r i a b l y , management has become a t r i a l and e r r o r process based on d i f f e r i n g b i a s e s which may or may not be j u s t i f i e d These b i a s e s are so v a r i e d that i t i s impossible to disaggregate them. 201 The absence of any systematic or l o g i c a l p a t t e r n of c u r r e n t spa o p e r a t i o n makes i t f u t i l e to c h a r a c t e r i z e a c t u a l p r a c t i c e s . The only r e l i a b l e c h a r a c t e r i z a t i o n i s that a l a r g e m a j o r i t y of o p e r a t o r s seem to want some a u t h o r i t a t i v e g u i d e l i n e s f o r o p e r a t i o n -- with the o p p o r t u n i t y f o r f l e x i b i l i t y a c c o r d i n g to i n d i v i d u a l circumstances. A l l want the s i m p l e s t , l e a s t time-consuming, and l e a s t c o s t l y method of o p e r a t i o n . The u n c e r t a i n t i e s and c o n f u s i o n s experienced by i n d u s t r y and government are f a r more evident by the time they reach the l e v e l of the o p e r a t o r . T h i s has overwhelmingly been the o u t s t a n d i n g weakness found i n the U.S. experience. The Spa Users The l e v e l of awareness of spa h e a l t h r i s k s and proper spa water q u a l i t y i s e x c e p t i o n a l l y poor among the general p u b l i c . As one county h e a l t h o f f i c i a l suggested; "The best t h i n g that c o u l d be done with spas now would be to take out f u l l page ads t e l l i n g the p u b l i c not to get i n any w h i r l p o o l which i s d i r t y , e x c e s s i v e l y foamy, d i s c o l o r e d , or you can't see the bottom!" 5 T h i s h e a l t h o f f i c i a l was being somewhat dramatic at the time and r e a l i z e s that there are a l s o other problems, but h i s meaning was c l e a r : the p u b l i c s o r e l y needs education about spa use and they have no idea of what r i s k s they are exposed t o . As shown i n Chapter 2 , there i s a r e a l weakness with the p u b l i c understanding of h e a l t h hazards and with being able to c o r r e l a t e a problem to spa usage. T h e r e f o r e , complaints to h e a l t h agencies 2 0 2 or to spa operato r s which might a l e r t us to a problem are l i k e l y going undetected i n many i n s t a n c e s . F u r t h e r , spa users are n e g l i g e n t and/or ignorant of the consequences of t h e i r behaviour. S p e c i f i c problems of horseplay, i n g e s t i o n of drugs p r i o r or du r i n g use, and f a i l u r e to observe reasonable d u r a t i o n s of use are a l l f a i r l y common. Complaints of unusual behaviour have been made to h e a l t h departments by other u s e r s . Among them; a woman washing her h a i r i n spa and another case where a woman was shaving her le g s and armpits i n the sp a . 6 However, the most common b e h a v i o u r a l problems are with standard hygiene p r a c t i c e s being v i o l a t e d : f a i l u r e to take showers p r i o r to use (which i s even worse a f t e r a person i s sweaty from e x e r c i s e ) , entry i n t o the spa with exposed c u t s or wounds, and e x c e s s i v e o i l , cosmetics, deodorant, or other subtances on the user's body. These have long been p r o h i b i t e d by r e g u l a t i o n with p o o l use and probably v i o l a t e d the vast m a j o r i t y of time. Although f a i l u r e to observe these r e g u l a t i o n s with pools i s u n d e s i r a b l e , f a i l u r e with spas can be c a t a s t r o p h i c to e f f o r t s f o r p r o p e r l y m a i n t a i n i n g water q u a l i t y . Operators are at a l o s s as to how they can e f f e c t i v e l y e n f o r c e these p r o v i s i o n s without employing i m p r a c t i c a l procedures. S t i l l , e i t h e r users must be s u f f i c i e n t l y convinced of the importance of these t h i n g s so as to act r e s p o n s i b l y on t h e i r own, or operato r s must devise some method f o r enforcement. Good spa management otherwise may be s e v e r e l y l i m t e d by these b e h a v i o u r a l abuses. 203 The above d i s c u s s i o n c h a r a c t e r i z e s the experience and weaknesses of the four p r i n c i p a l a c t o r s . The other p a r t i c i p a n t s can be c o n s i d e r e d p e r i p h e r a l to the o v e r a l l spa s i t u a t i o n i n the U.S. By t h i s , i t i s meant that they have not been c o n s t a n t l y i n v o l v e d or made a focus of p a r t i c u l a r o b j e c t i v e s . Even though they should not be d i s r e g a r d e d , they are not c e n t r a l to our c o n s i d e r a t i o n s . Steps Toward Spa Water Q u a l i t y Management i n the U.S. Since the t u r n i n g p o i n t of acknowledging the uniqueness of spas, concrete a c t i o n s have been taken by the v a r i o u s a c t o r s i n an e f f o r t to a l l e v i a t e spa p u b l i c h e a l t h hazards. The e f f o r t s f a l l i n t o these c a t e g o r i e s : (1) G u i d e l i n e and r e g u l a t o r y standards development, (2) S t u d i e s / r e s e a r c h , (3) Education, (4) I n c e n t i v e s , and other measures. 1. G u i d e l i n e , Standards and Regulatory Developments T h i s area has r e c e i v e d the most a t t e n t i o n by everyone concerned. For spas, g u i d e l i n e s and standards have been developed to d e a l with three aspects which a f f e c t s a f e t y and h e a l t h . They a r e : a. Design and C o n s t r u c t i o n C r i t e r i a b. I n s t a l l a t i o n C r i t e r i a c. Operation and Maintenance C r i t e r i a 2 0 4 Design, c o n s t r u c t i o n (and m a t e r i a l s ) , and i n s t a l l a t i o n are not d i r e c t concerns of water q u a l i t y management, as i n the op e r a t i o n s phase. However, o p e r a t i o n s can be s e v e r e l y hampered by f a i l i n g to give thorough and c a r e f u l a t t e n t i o n to the pre-o p e r a t i o n a l concerns. F u r t h e r , standards f o r design, c o n s t r u c t i o n , and i n s t a l l a t i o n can act as a scre e n i n g process to s o r t out p u b l i c l y d e s i r a b l e and u n d e s i r a b l e o p e r a t o r s . The i n f e r e n c e can be drawn that an operator who i s i n i t i a l l y r e l u c t a n t , u n w i l l i n g or unable to provide proper f a c i l i t i e s , f i n a n c e s , and a t t i t u d e might a l s o c o n s i s t e n t l y "cut c o r n e r s " i n the o p e r a t i o n a l phase. Of course, t h i s i n f e r e n c e does not always h o l d t r u e . Nor can i t be assumed that an i n i t i a l l y "unworthy" operator w i l l p r o p e r l y c a r r y on i n the o p e r a t i o n a l phase. What can be l o g i c a l l y s a i d i s t h i s ; f i r s t , the purpose of standards fo r d e s i g n , c o n s t r u c t i o n , and i n s t a l l a t i o n i s to promote a c o n s i s t e n t l e v e l of q u a l i t y (the l e v e l being dependent on the standards, and the adherence to and enforcement of them) i n the p r e - o p e r a t i o n a l areas which have an e f f e c t on the a b i l i t y to e f f e c t i v e l y operate and manage spa water q u a l i t y . Second, such standards can be used to discourage o p e r a t o r s , who, f o r reasons of e i t h e r l a c k of a b i l i t y or w i l l i n g n e s s , may g i v e inadequate a t t e n t i o n or completely d i s r e g a r d concern f o r p u b l i c h e a l t h and s a f e t y . T h i r d , i m p o s i t i o n of standards i n the p r e - o p e r a t i o n a l phase w i l l mean a d d i t i o n a l c o s t s f o r some or a l l of the f o l l o w i n g groups -- users, o p e r a t o r s , consumers i n g e n e r a l , p u b l i c agencies and taxpayers. And f o u r t h , the use of standards i n these areas i m p l i e s a r e s t r i c t i o n of ch o i c e f o r p o t e n t i a l 2 0 5 p u b l i c users, i . e . , those i n d i v i d u a l s who might be w i l l i n g to assume the r i s k of a "lower" q u a l i t y f a c i l i t y a t a reduced user fee would not have the ch o i c e to do so. I d e a l l y , we would want the spa operator to choose m a t e r i a l s of c o n s t r u c t i o n and design which are s t r u c t u r a l l y sound, take s a f e t y c o n s i d e r a t i o n s i n t o account and allow f o r proper o p e r a t i o n (both f o r equipment and chemical treatment). We would a l s o i d e a l l y want the operator to make such c h o i c e s c o n s i s t e n t with p o t e n t i a l p u b l i c users' w i l l i n g n e s s to pay f o r a c e r t a i n q u a l i t y of f a c i l i t i e s . T h i s b r i n g s up the common i s s u e s of the market versus i n t e r v e n t i o n . For the moment, l e t us j u s t recognize the d i f f i c u l t y of composing p r e - o p e r a t i o n a l standards. I t i s important to understand that there i s a c l o s e r e l a t i o n s h i p between p r e - o p e r a t i o n a l and o p e r a t i o n a l standards, and that a s o l i d argument can be made f o r c o n s i d e r i n g both phases t o g e t h e r . T h i s has been the approach by most o r g a n i z a t i o n s who have developed g u i d e l i n e s and standards. The i n d u s t r y , s p e c i f i c a l l y NSPI, was the f i r s t to recommend and develop standards. In A p r i l , 1978 they p u b l i s h e d a set of g u i d e l i n e s c o v e r i n g p r e -o p e r a t i o n a l and o p e r a t i o n a l phases, "Minimum Standards f o r P u b l i c Spas and Hot Tubs". 7 As c i t e d e a r l i e r , the f e d e r a l government working i n c o n j u n c t i o n with NSPI and s t a t e p u b l i c h e a l t h departments i s s u e d "Suggested H e a l t h and S a f e t y G u i d e l i n e s f o r P u b l i c Spas and Hot Tubs" i n A p r i l , 1981. 8 Both of these p u b l i c a t i o n s are s t r i c t l y recommendations and have no bi n d i n g or l e g i s l a t e d p r o v i s i o n s upon operat o r s or u s e r s . At the 206 s t a t e and l o c a l l e v e l , there are d i s a r r a y e d e f f o r t s . Some s t a t e s a c t i v e l y use swimming pool standards f o r spas, some do not use any standards. Even i f s t a t e s have not developed spa standards, some m u n i c i p a l i t i e s have gone ahead on t h e i r own. I l l i n o i s i s an example. The s t a t e has done nothing with regard to spa standards and n e i t h e r have the c o u n t i e s . However, there are misc e l l a n e o u s r e g u l a t o r y a c t i v i t i e s t a k i n g p l a c e , the ha n d l i n g of which v a r i e s by l o c a l e . The s t a t e does approve permits f o r new spas, but only i n the case where a spa i s b u i l t i n c o n j u n c t i o n with a p u b l i c p o o l — then, a spa i s c o n s i d e r e d an "appurtenance" of the po o l and covered under the s t a t e act f o r swimming pools and bathing beaches. 9 Otherwise, spas are not r e q u i r e d to o b t a i n a permit. Cook County handles the permit approval process f o r the s t a t e f o r spas i n that county. A c c o r d i n g to the head of that department, he uses the CDC g u i d e l i n e s as a b a s i s f o r approval and he i s mainly i n t e r e s t e d i n the f i l t r a t i o n , d i s i n f e c t i o n , and a n t i - v o r t e x main d r a i n c o n s t r u c t i o n p r o v i s i o n s . 1 0 In neighbouring Du Page County, the s t a t e d i r e c t l y handles permits but the county may take care of o p e r a t i o n a l matters. To date, Du Page County does not undertake s p e c i f i c spa i n s p e c t i o n or r e g u l a t i o n a c t i v i t i e s . In the s m a l l e r c o u n t i e s , the s t a t e would d i r e c t l y be i n v o l v e d , but other than the p e r m i t t i n g d e s c r i b e d above, no s i g n i f i c a n t a c t i o n s appear to have taken p l a c e . In the Northwest suburbs of Chicago, the group e a r l i e r mentioned, the Northwest M u n i c i p a l Conference has developed standards which w i l l be implemented i n t h e i r r e s p e c t i v e communities i n F a l l 1982. T h i s work was done with the h e l p of l o c a l members of the 207 NSPI, Midwest Chapter and drew p r i m a r i l y upon the suggestions p r o v i d e d by the NSPI Minimum Standards and the CDC g u i d e l i n e s . The group added a few more s t r i n g e n t p r o v i s i o n s , notably with regard to f i l t r a t i o n and as of l a s t word, they "are reviewing the code with a view toward r e v i s i n g some of the d e f i n i t i o n s and c o n s i d e r i n g p r o h i b i t i n g wood tubs. (They) a l s o p l a n to add a paragraph to the c a u t i o n s i g n regarding the hazard to pregnant women."11 The c i t y of Chicago i s a l s o c l o s e to e n a c t i n g a spa code and has r e l i e d upon r e p r e s e n t a t i v e s from J a c u z z i W h i r l p o o l Bath Inc. and Kohler C o . 1 2 The major input seems to be from J a c u z z i and from t h e i r t e s t / s t a n d a r d s c o o r d i n a t o r Perry Meikle, l o c a t e d i n C a l i f o r n i a . 1 3 Other e f f o r t s are being made throughout the n a t i o n i n v a r i o u s ways. For example i n Dade County F l o r i d a , the A s s o c i a t e d Swimming Pool I n d u s t r i e s a s s o c i a t i o n (a small r e g i o n a l pool trade group separate from NSPI) has formed a j o i n t committee with NSPI to e s t a b l i s h standards f o r t h e i r c o u n t y . 1 " P e r i p h e r a l a c t o r s have a l s o a c t e d . The I n t e r n a t i o n a l A s s o c i a t i o n of Plumbing and Mechanical O f f i c i a l s (IAMPCO) has p u b l i s h e d "Uniform Swimming P o o l , Spa, and Hot Tub Code" f o r p l u m b i n g . 1 5 T h i s document paved the way f o r the I n t e r n a t i o n a l Congress of B u i l d i n g O f f i c i a l s to agree on phasing out t h e i r separate code i n the next three y e a r s . 1 6 Underwriters L a b o r a t o r i e s has been a l s o working on standards f o r spa e l e c t r i c a l requirements s i n c e 1979 and r e c e n t l y p u b l i s h e d g u i d e l i n e s UL-1563. 1 7 Other e f f o r t s have taken p l a c e on a smaller s c a l e , but major e f f o r t s at d e v e l o p i n g standards and r e g u l a t i o n s are underway and w i l l 208 continue through 1983. I t i s i n t e r e s t i n g to note that i n d u s t r y has been the prime mover in t h i s d i r e c t i o n . One i n d u s t r y member s t a t e d i n September 1981; The grace p e r i o d i s up. Codes are coming. I t i s now j u s t a matter of d e c i d i n g whether we want to have the codes f o r c e d on us, or whether we w i l l p a r t i c i p a t e i n f o r m u l a t i n g these r e g u l a t i o n s . Do we want to a c t , or r e a c t ? I t ' s taken us e i g h t months to i s o l a t e the course of a c t i o n — now we need to move q u i c k l y . Morrow observed that there are 10 s t a t e s a c t i v e l y i n v o l v e d i n i n i t i a t i n g codes that w i l l a f f e c t the spa i n d u s t r y . He added that many s t a t e s a l r e a d y have codes, most of which are based upon i n a c c u r a t e data and lack b u i l t - i n updating mechanisms. 1 8 The most s i g n i f i c a n t a c t i o n , however, i s being undertaken by a group composed of i n d u s t r y members, r e g u l a t o r y agencies, p u b l i c h e a l t h o f f i c i a l s , other s a f e t y / h e a l t h o r g a n i z a t i o n s and sponsored by the N a t i o n a l S a n i t a t i o n Foundation. E f f o r t s were i n i t i a t e d i n September 1981 and are c o n t i n u i n g . R e s u l t s may be a v a i l a b l e sometime during F a l l 1982. The purpose of t h i s conference u n d e r l i e s the s i g n i f i c a n c e of u n c e r t a i n t y i n spa water q u a l i t y management. T h i s s e l e c t group of people from many s e c t o r s has been working on d e v e l o p i n g spa h e a l t h code s t a n d a r d s . 1 9 Thus, d e s p i t e a l l p r i o r a c t i v i t y i n t h i s area, i t i s evident that a number of experts t h i n k that the present g u i d e l i n e s are i n s u f f i c i e n t . T h i s committee i s a d d r e s s i n g f i v e p r i o r i t i e s : 1) D e f i n i n g the areas of r e s e a r c h which w i l l g ive i n s i g h t to the s o l u t i o n of problems of the i n d u s t r y groups. 2) B i o c i d e s and how they r e l a t e to the hot tub rash as w e l l as hot water m i c r o b i o l o g y of organisms i n the hot water, as 2 0 9 compared with the c o o l e r swimming pool water. 3) Hot water chemistry as i t r e l a t e s to the f l u c t u a t i o n of temperatures. 4) Hyperthermia and the r e a c t i o n of the human body to temperatures above 104°F. 5) the general s a f e t y of spas and hot tubs as i t r e l a t e s to h a i r and body entrapment. 2 0 As a means f o r addr e s s i n g spa water q u a l i t y , the committee has developed a format f o r s t a n d a r d i z i n g water samples used to evaluate s a n i t i z i n g products and p r o c e d u r e s . 2 1 I t i s as f o l l o w s ; - a pH f a c t o r of 7.2 to 7.8 - t o t a l organic carbon as 200 ppm glucose - t o t a l K j e l d a h l n i t r o g e n as 100 ppm urea - t o t a l d i s s o l v e d s o l i d s as 300 ppm sodium c h l o r i d e (Na C I ) ; 50 ppm potassium sulphate (k SO ) - hardness as 200 ppm calcium c h l o r i d e (Ca CI ); 200 ppm magnesium c h l o r i d e (Mg CI ) - a l k a l i n i t y as 100 ppm sodium bicar b o n a t e (Na Co ) - o i l and grease as 50 ppm Johnson & Johnson Baby O i l - a d d i t i o n a l chemical measures i n c l u d e ; (1) e l e c t r i c c o n d u c t i v i t y , (2) o x i d a t i o n r e d u c t i o n p o t e n t i a l ; and f o r i n n o c u l a t i o n t e s t s : (1) 10 5 per ml each of E C o l i , Pseudomonas aeruginosa, and Staph aureus. - samples are to be s t i r r e d d u r i n g the t e s t p e r i o d , and once p l a c e d i n the media, they are to be removed at uniform time p e r i o d s — 1, 5, 10, 15, 30, and 60 minutes — to assess d i s i n f e c t i o n e f f i c a c y of the chemical or d i s i n f e c t i o n 210 d e v i c e . The e f f o r t s by t h i s committee sponsored by NSF may represent a major breakthrough i n the t e c h n i c a l area of spa water q u a l i t y . I t i s s i g n i f i c a n t to observe that the awareness and acceptance of the uniqueness of spa water i s the key to making progress with the problems. I t i s much e a s i e r to understand a l l the c o n f u s i o n , i n c o n s i s t e n c y and l a c k of major p u b l i c a c t i o n with spas when the work of t h i s group i s c o n s i d e r e d . A s o l i d consensus (of o p i n i o n ) about gauging the e f f i c a c y of d i s i n f e c t i o n does not e x i s t up to t h i s p o i n t t e l l s us a great d e a l about the d i f f i c u l t y of u n c e r t a i n t y i n spa management so f a r . The U.S. has experienced a r a p i d growth i n p u b l i c spa use with p o t e n t i a l l y s i g n i f i c a n t h e a l t h r i s k s a t t a c h e d , and we have had no c l e a r understanding of how to e v a l u a t e the primary aspect of d i s i n f e c t i o n . Whether or not t h i s group produces worthwhile r e s u l t s f o r spa management p o l i c y use, two c o n c l u s i o n s emerge. 1. The a p p l i c a t i o n of swimming pool standards to spas i s not only i n a p p r o p r i a t e , but i t may be extremely m i s l e a d i n g , and e f f o r t s to remedy t h i s s i t u a t i o n are imperative f o r reducing r i s k s . 2. Standards and r e g u l a t i o n s developed up u n t i l now are s u b j e c t to r e v i s i o n and p o s s i b l e e x t e n s i v e r e v i s i o n . For i f we have only r e c e n t l y begun to formulate an accepted means f o r e v a l u a t i n g the e f f e c t i v e n e s s of d i s i n f e c t i o n s p e c i f i c a l l y f o r spa water 21 1 c o n d i t i o n s , i t w i l l take time to e s t a b l i s h those methods and determine our a c t u a l spa water q u a l i t y s t a t u s i n p u b l i c f a c i l i t i e s . T h i s c o u l d l e a d to major changes i n s e v e r a l areas i n c l u d i n g equipment, management techniques and user g u i d e l i n e s . F i n a l l y , a recent survey by NSPI, r e p o r t e d January 1982, seems to i n d i c a t e that the m a j o r i t y of p u b l i c h e a l t h o f f i c i a l s r e l y on NSPI standards f o r pools and spas. Sixty-one percent of the respondents s a i d that they used a l l or pa r t of those standards. Of 95 responses, 90 were u s i n g codes f o r p u b l i c p o o l s ; of t h i s number, 36 used part of NSPI 1s standards and 14 used them e n t i r e l y . 2 2 I t i s i n t e r e s t i n g to observe that almost 50% more o f f i c i a l s used codes f o r p o o l s , but not spas, and on l y about 10% more r e l i e d on NSPI f o r pools but not spas. F u r t h e r , the response of NSPI s e n i o r v i c e p r e s i d e n t L a r r y P a u l i c k i l l u s t r a t e s the m o t i v a t i o n f o r i n d u s t r y involvement with standards; . . . wide spread use of NSPI standards ensures a more uniform set of codes among separate geographic a r e a s . T h i s , i n t u r n , p r o v i d e s a more u n i f i e d method f o r i n d u s t r y p r o d u c t s . The more p u b l i c o f f i c i a l s who use NSPI standards, the b e t t e r i t i s f o r our members. When a b u i l d e r can use i d e n t i c a l s p e c i f i c a t i o n s from one j u r i s d i c t i o n to another i t saves time, money, and g r e a t l y reduces the chance f o r m i s c a l c u l a t i o n s . U n i f i e d use of standards simply p r o v i d e s a b e t t e r m a r k e t . 2 3 I t i s n e i t h e r a c c i d e n t a l nor a matter of a l t r u i s m that the i n d u s t r y has been the major i n i t i a t o r of standards f o r spas. As the above statement demonstrates, i n d u s t r y i s w e l l aware of the b e n e f i t s of t h e i r p a r t i c i p a t i o n and i n i t i a t i v e . 212 Studies/Research A number of e f f o r t s i n t h i s area have been p r e v i o u s l y r e f e r r e d to i n other chapters and d u p l i c a t e mention i s unnecessary here. However, two other e f f o r t s do deserve mention. The f i r s t i s a $41,000 study on Pseudomonas backed by the I n t e r n a t i o n a l Spa & Tub I n s t i t u t e (ISTI) (1977). T h i s work, conducted by an Oregon m i c r o b i o l o g i s t , noted f o r e x p e r t i s e on Pseudomonas, w i l l study the r e l a t i o n s h i p of the organism to spas and hot tubs. R e s u l t s of t h i s work so f a r may have had i n f l u e n c e on the s t a t e of Oregon's o p p o s i t i o n to wooden hot tubs and a l s o upon the l a t e r organized NSF Conference d e s c r i b e d i n the preceding s e c t i o n . ISTI has plans to promote f u r t h e r s t u d i e s on the whole area of "Hot Water and the Human Body", c o v e r i n g p h y s i o l o g i c a l and p s y c h o l o g i c a l a s p e c t s , among o t h e r s . The U n i v e r s i t y of Southern C a l i f o r n i a and UCLA have been t e m p o r a r i l y de s i g n a t e d as the i n s t i t u t i o n s who w i l l conduct the r e s e a r c h . 2 " A second study of note was conducted a few years ago under the auspices of the D i v i s i o n of Environmental H e a l t h i n Alameda County, Ca. with a s s i s t a n c e from u n i v e r s i t y and other p u b l i c h e a l t h o f f i c i a l s . 2 5 The study developed from a permit request of an operator to i n s t a l l a redwood hot tub. I t was run f o r a p e r i o d of one year and i t produced these immensely important r e s u l t s : F i r s t , The c o n c l u s i o n of the study "showed that i f proper measures were taken, a redwood hot tub spa c o u l d be operated i n a safe and s a n i t a r y manner." 2 6 213 Second, a number of suggested o p e r a t i o n a l g u i d e l i n e s developed from the study are more s t r i n g e n t than o t h e r s formulated elsewhere. Of s p e c i a l i n t e r e s t i s the recommendation of 2.5 ppm minimum f r e e c h l o r i n e r e s i d u a l . T h i r d , the study p l a c e s strong emphasis on c o n s i s t e n t and c o n s c i e n t i o u s monitoring and maintenance. The maintenance of chemical parameter l e v e l s was c o n s i d e r e d a h i g h l y important f a c t o r f o r c o n t r o l l i n g pathogens. Fourth, i t was shown that the operat o r s given proper and thorough i n s t r u c t i o n s c o u l d operate the spa c o r r e c t l y , and even more i m p o r t a n t l y , they had the a b i l i t y to conduct frequent and c o n s i s t e n t monitoring and water a n a l y s i s over a p e r i o d of time. These e f f o r t s i n c l u d e d b a c t e r i o l o g i c a l sampling and t e s t i n g , procedures normally c o n s i d e r e d too d i f f i c u l t f o r o p e r a t o r s . F u r t h e r , the operators' e f f o r t s were good — d i f f e r i n g only s l i g h t l y from the r e s u l t s o b tained by the D i v i s i o n of Environmental Health's sampling. In view of the f a c t that t h i s study was conducted f o r a reasonably long time on one of the toughest spas to operate (a redwood tub) with high demands on the operator, i t i s s u r p r i s i n g that more a t t e n t i o n i s not p a i d to t h i s work. By t h i s , i t i s meant that the study, at an e a r l y stage of the U.S. experience, proved that operators with guidance and c o o p e r a t i o n from knowledgeable spa and h e a l t h a u t h o r i t i e s c o u l d handle spa water q u a l i t y management. T h e r e f o r e , i t would seem l o g i c a l to e x p l o i t knowledge of how t h i s l e a r n i n g process was achieved and why i t was e f f e c t i v e . F u r t h e r , i t would seem reasonable to pursue 214 a d d i t i o n a l s i m i l a r e f f o r t s i n other p l a c e s . Education Attempts to educate both o p e r a t o r s and spa users have been made to v a r y i n g degrees and by d i f f e r i n g sources. The i n d u s t r y , both w i t h i n and o u t s i d e NSPI, has sponsored seminars, p r i n t e d m a t e r i a l s , and run s p e c i a l e d u c a t i o n a l programs at consumer product shows such as one h e l d i n Long Beach, Ca. i n 1981. NSPI has gone to the l e n g t h of p r i n t i n g s p e c i f i c spa s a f e t y p r e c a u t i o n s i g n s which are a v a i l a b l e f o r u s e . 2 7 On the governmental f r o n t , education attempts have been r e l a t i v e l y minor on the whole. In b e l i e v i n g that 80 percent of spa problems are due to a l a c k of operator knowledge of proper maintenance, P a u l i c k of NSPI i s quoted on the s u b j e c t of governmental education e f f o r t s ; We r e a l i z e that p u b l i c o f f i c i a l s are u n d e r s t a f f e d and underbudgeted and so they can't be depended upon to get the i n f o r m a t i o n to the owner/operator. Thus, we r e a l i z e the need f o r d e v e l o p i n g i n f o r m a t i o n and d i s s e m i n a t i n g i t to the owner/operator, a l s o p o i n t i n g out to him that t h i s w i l l i n c r e a s e h i s r e t u r n on h i s i n v e s t m e n t . 2 8 Our e a r l i e r d i s c u s s i o n r e g a r d i n g the c u r r e n t c o n s t r a i n t s on government agencies i s c o n s i s t e n t with t h i s e x p l a n a t i o n f o r the r e l a t i v e l y modest e f f o r t s by p u b l i c h e a l t h agencies. However, i t i s evident from both c o n t i n u i n g spa problems and f i e l d r e s e a r c h i n t e r v i e w s with o p e r a t o r s that e d u c a t i o n a l e f f o r t s are s t i l l 215 d e f i c i e n t . Part of the reason f o r t h i s i s the l i m i t a t i o n of i n d u s t r y to "do i t a l l " . But two other c o n s i d e r a t i o n s may be important. One i s the seeming f a i l u r e to n o t i f y the p u b l i c of the r i s k s i n v o l v e d i n spa use. Perhaps g r e a t e r emphasis i n t h i s d i r e c t i o n would spur more a t t e n t i o n being given to proper maintenance. And secondly, the e d u c a t i o n a l e f f o r t s have been spora d i c without having any organized approach or b u i l t - i n i n s t i t u t i o n a l mechanism. T h i s i s probably the biggest weakness because our s i t u a t i o n with spas must deal with a high turnover of people — both spa users and operator p e r s o n n e l . As a r e s u l t , e d u c a t i o n a l e f f o r t s may be l o s t through inadequate procedures for t r a n s m i t t i n g knowledge and experience. However, i t i s noteworthy that attempts to educate the consumer are beginning to take p l a c e . King County, Washington (where S e a t t l e i s located) r e c e n t l y p u b l i s h e d a consumer pamphlet e n t i t l e d , "Staying Happy & Healthy i n Your Spa & Hot T u b " . 2 9 Reports are that the i n i t i a l 8,000 c o p i e s r a p i d l y s o l d out and a second p r i n t i n g was r e q u i r e d . And even Vogue Magazine has moved to warn consumers, p u b l i s h i n g i n i t s January 1983 i s s u e a short a r t i c l e on rash problems in spas and hot t u b s . 3 0 I n c e n t i v e s and Other Measures I t appears that there has not yet been any type of f i n a n c i a l i n c e n t i v e a c t i o n s taken i n the U.S., but there i s evidence of non-monetary i n c e n t i v e s through p r a i s e , r e c o g n i t i o n , 216 and c o o p e r a t i o n from p u b l i c h e a l t h o f f i c i a l s to o p e r a t o r s . These e f f o r t s seem to be f a i r l y s u c c e s s f u l . The Seminole County He a l t h Department i n F l o r i d a has begun a program of awarding o p e r a t o r s fo r o u t s t a n d i n g maintenance of water q u a l i t y and appearance. The department's philosophy has been "to come down hard on those f a c i l i t i e s or i n d i v i d u a l s i n v i o l a t i o n of the S a n i t a r y Code but a l s o to o f f e r a s s i s t a n c e i n the p r e v e n t i o n of problems with pools and s p a s . " 3 1 And they b e l i e v e i t i s important to recognize those people who c o n s c i e n t i o u s l y work hard to p r o t e c t p u b l i c h e a l t h . Another type of c o o p e r a t i v e approach was d e s c r i b e d i n an i n t e r v i e w with one m u n i c i p a l h e a l t h o f f i c i a l i n I l l i n o i s . 3 2 He b e l i e v e s that i t i s important to work with owners of f a c i l i t i e s on more than j u s t simply a l e v e l of meeting standards and e n f o r c i n g r e g u l a t i o n s . Many of the owners of f a c i l i t i e s he d e a l s with are small business people who have l i m i t e d f i n a n c i a l resources or f o r reasons of ignorance, p r e s s u r e s , or time c o n s t r a i n t s g e n e r a l l y manage t h e i r business p o o r l y . T h i s h e a l t h o f f i c i a l , when encountering v i o l a t i o n s , has found i t s u c c e s s f u l to r e q u i r e the operator to make changes on a staged p r i o r i t y method based on the element of hazard and the owner's f i n a n c i a l c a p a b i l i t i e s . Thus, rather than demand compliance a l l at once, the operator i s given the o p p o r t u n i t y to s t r e t c h the c o s t s over time. F u r t h e r , where i t i s a p p r o p r i a t e , the h e a l t h o f f i c e r w i l l o f f e r suggestions on general business and management p r a c t i c e s which an operator may be o v e r l o o k i n g . In t h i s i n s t a n c e , i t i s viewed that an o p e r a t o r ' s i n a b i l i t y to p r o p e r l y maintain the 217 f a c i l i t i e s may be the r e s u l t of not r e c o g n i z i n g the need f o r making management adjustments i n areas u n r e l a t e d to maintenance. These e f f o r t s are i n t e r e s t i n g and perhaps c o u l d be a p p l i e d i n other p l a c e s . The reason f o r t h e i r mention i s not to s p e c i f i c a l l y recommend those approaches, but merely to p o i n t out that methods other than the t y p i c a l ones have been t r i e d i n c o n j u n c t i o n with spas and proven at l e a s t moderately s u c c e s s f u l . T h i s suggests that i n c o n s i d e r i n g p u b l i c p o l i c y formation, i t i s worthwhile to p o s t u l a t e such a l t e r n a t i v e s or even p o s s i b l y more c r e a t i v e ones. Summary of the U.S. Experience I t i s apparent that the d r i v i n g f o r c e f o r seeking spa water q u a l i t y s o l u t i o n s has o r i g i n a t e d from the spa i n d u s t r y with l e s s e r impetus from government. E f f o r t s by the i n d u s t r y have been g e n e r a l l y h e l p f u l and i n the p u b l i c i n t e r e s t . However, i t should be recognized that these e f f o r t s are based on s e l f i s h i n t e r e s t s foremost. The t h r e a t s of u n d e s i r a b l e government i n t e r v e n t i o n have been a strong m o t i v a t i o n f o r i n d u s t r y a c t i o n . More im p o r t a n t l y , the r e a l i t y i s that i f spa water q u a l i t y i s not s o l v e d and s e r i o u s problems c o n t i n u e to r i s e i n p u b l i c awareness, users of spas would probably d e c l i n e and the spa market would l e s s e n and maybe even c o l l a p s e . T h e r e f o r e , there i s sound reason to t h i n k that the i n d u s t r y can be counted upon to pursue spa water q u a l i t y o b j e c t i v e s with as much, or p o s s i b l y 218 more, enthusiasm than government agencies. The dominance of the i n d u s t r y r a i s e s a couple of s e r i o u s q u e s t i o n s though. The f i r s t i s ; are users and non-users being p r o p e r l y and adequately informed of the hazards? -- i . e . i s there a "process f o r approved standards"? That q u e s t i o n c o u l d only be answered a u t h o r i t a t i v e l y through an e x t e n s i v e p u b l i c survey, beyond the scope of t h i s study. Yet, i t i s c l e a r t h at i n d u s t r y has a tendency to discourage, downplay, and minimize the p u b l i c r e p o r t i n g of r i s k s f o r the obvious reason of not wanting to scare people away from u s i n g spas. In f a i r n e s s to the i n d u s t r y , t h i s a t t i t u d e can be present without c a s t i n g any disparagements on t h e i r i n t e n t i o n s or a c t i o n s . For i t i s q u i t e normal f o r any group or i n d i v i d u a l to muffle r e p o r t s about t h e i r products and s e r v i c e s u n t i l the r e p o r t s are w e l l s u b s t a n t i a t e d . There i s normal concern about p e r m i t t i n g f a l s e alarms or unwarranted s l a n d e r . Regardless, t h i s s t i l l l eaves a v o i d of in f o r m a t i o n with the p u b l i c i n the gray areas of hazard. Even i f hazards d i d not warrant e x p l i c i t warning at a p a r t i c u l a r stage, a weakness e x i s t s because users and non-users might not have the means of judging the hazards f o r themselves. I t i s not j u s t a qu e s t i o n of user and non-user ignorance, but a l s o that users and non-users are i n the p o s i t i o n of having to almost e x c l u s i v e l y depend on operator competence and d i s p o s i t i o n f o r t h e i r h e a l t h and s a f e t y . T h i s r a i s e s doubts about the e x i s t e n c e of a "process f o r operator a c c o u n t a b i l i t y " . The second q u e s t i o n r a i s e d by i n d u s t r y dominance concerns 219 the a b i l i t y and r i g h t of t h i s group t o e x e r c i s e such i n f l u e n c e on the o v e r a l l p r o c e s s . There i s l i t t l e , i f any a t a l l , i n p u t from o p e r a t o r s and spa u s e r s apparent i n the development of spa management p o l i c i e s and d i r e c t i o n . T h i s not o n l y r a i s e s o b v i o u s v a l u e q u e s t i o n s , but doubts r e g a r d i n g the e f f e c t i v e n e s s of p o l i c y w i t h o u t the a c t i v e i n v o l v e m e n t of the two major p a r t i c i p a n t s s h o u l d a l s o be r a i s e d . E a r l i e r d i s c u s s i o n of the management and b e h a v i o u r a l problems h i g h l i g h t s t h i s p o i n t . I f i t i s so w e l l - r e c o g n i z e d by the e x p e r t s t h a t maintenance i s the overwhelming key t o spa water q u a l i t y s o l u t i o n s , i t would seem n a t u r a l t o p l a c e g r e a t e r emphasis on the i n v o l v e m e n t of o p e r a t o r s and u s e r s i n the p o l i c y p r o c e s s or a t l e a s t t o devote much more e f f o r t and i n s t i t u t i o n a l s t r u c t u r i n g toward b r i n g i n g the l e a r n i n g and e x p e r i e n c e of t h e s e p a r t i c i p a n t s t o the f o r e f r o n t . T h i s q u e s t i o n c r e a t e s c o n c e r n s about the a v a i l a b i l i t y of a " p r o c e s s f o r s o c i a l l e a r n i n g " . I t does seem e v i d e n t t h a t the t e c h n i c a l approach, s p e c i f i c a l l y t he r o u t e of s t a n d a r d s and r e g u l a t i o n ( a l s o e d u c a t i o n where p o s s i b l e ) , has p r e v a i l e d i n the U.S. e x p e r i e n c e f o r d e v e l o p i n g spa water q u a l i t y management p o l i c y . The c r i t i c i s m here r e l a t e s t o our e a r l i e r c o n s i d e r a t i o n of s t a n d a r d s and the problems of u n c e r t a i n t y s t a t e d i n Chapter 2. There i s the r e a l p o s s i b i l i t y t h a t t h i s t e c h n i c a l approach w i l l l e a d t o our " t o o l s becoming our o b j e c t i v e s . " By d e s i g n i n g a system f o r d e a l i n g w i t h the h e a l t h and s a f e t y h a z a r d s which f o c u s e s on o p e r a t o r s m e e t i n g c e r t a i n c r i t e r i a e s t a b l i s h e d by the e x p e r t s , the U.S. e x p e r i e n c e i s l a r g e l y i g n o r i n g the v i t a l i n t e r a c t i v e 2 2 0 f a c t o r s concerned with the user-operator sphere. T h i s i s not to c r i t i c i z e the work which has taken p l a c e -- i t may very w e l l prove e x c e l l e n t f o r the short term. The q u e s t i o n i s ; can i t be made to work i n the c u r r e n t context of p o l i c y design f o r the long term? What Is M i s s i n g From the U.S. Experience to Make Spa Management Safer and More E f f e c t i v e ? The i n c o n s i s t e n c y or complete absence of spa standards w i t h i n s t a t e and l o c a l j u r i s d i c t i o n s i s a f a i l i n g i n p r o v i d i n g spa users (and operators) a s o l i d base of i n f o r m a t i o n necessary f o r e v a l u a t i n g and reducing hazards. Interviews with o p e r a t o r s i n d i c a t e d t h at they wanted t h i s type of a u t h o r i t a t i v e guidance. Industry and other p r i v a t e i n i t i a t i v e s have been h e l p f u l , but these e f f o r t s have been d i f f u s e d and not always c o n s i s t e n t themselves. F u r t h e r , i n d u s t r y e f f o r t s are always subject to c r e d i b i l i t y q u e s t i o n s because o p e r a t o r s , users, and the p u b l i c may suspect those e f f o r t s to be s e l f - s e r v i n g to i n d u s t r y . Without any form of organized p o l i c y toward spas, the l a c k of p r o v i s i o n s to account f o r e x t e r n a l i t i e s i s very d i s t u r b i n g . I t only takes one poorly-managed spa o p e r a t i o n to s t a r t an epidemic of d i s e a s e amongst the p o p u l a t i o n at l a r g e , and once s t a r t e d , the problem may be d i f f i c u l t to c o n t a i n as recent experiences with Herpes and AIDS d i s e a s e have shown. T h i s i s a s e r i o u s d e f i c i e n c y i n the U.S. s i t u a t i o n with p u b l i c spas. No t r u l y r e p r e s e n t a t i v e process f o r decision-making with 221 spas has yet been undertaken. With the p o s s i b l e e x c e p t i o n of a few l o c a l areas (and t h i s i s q u e s t i o n a b l e ) , no d e c i s i o n process has allowed f o r user or p u b l i c p a r t i c i p a t i o n , and o p e r a t o r s have r a r e l y been i n v o l v e d . Thus f a r , a l l d e c i s i o n s have been dominated by the p u b l i c h e a l t h and i n d u s t r y i n t e r e s t s e c t o r s . There does not appear to be any "process f o r approved standards" c o n s i s t e n t with our c r i t e r i o n . L i t t l e , i f any, a t t e n t i o n has been p a i d to measures f o r d e a l i n g with u n c e r t a i n t i e s i n spa management. No s t u d i e s have r e a l l y examined the extent of hazards and c l e a r l y i d e n t i f i e d what are r i s k s and what are u n c e r t a i n t i e s . Although, most spa experts i n t u i t i v e l y recognize the importance of operator and user behaviour to o v e r a l l spa s a f e t y , l i t t l e has been d i r e c t e d at d e a l i n g with the problem except f o r s c a t t e r e d and minor e d u c a t i o n a l programs. P u b l i c and p r i v a t e e f f o r t s , where they have been undertaken, have focused more on p r o v i d i n g i n s t r u c t i o n s or warnings with l i t t l e or no e f f o r t toward t r a i n i n g o p e r a t o r s , d e v i s i n g r i s k i n d i c a t o r s f o r u s e r s , or i n s t a l l i n g a l e a r n i n g process f o r d e a l i n g with spa hazard problems. P o s i t i v e i n c e n t i v e s and an environment f o r a s o c i a l l e a r n i n g process are non-existent because of f a c t o r s l i s t e d above and because no r e a l s i g n i f i c a n c e has been a t t a c h e d to t h e i r need as of y e t . In b r i e f , the U.S. experience f a i l s to meet a l l of our c r i t e r i a f o r spa p o l i c y d e s i g n . T h i s i s not s u r p r i s i n g , though, ecause spa p o l i c y has not been given adequate a t t e n t i o n o v e r a l l . 222 Footnotes - Appendix D '"Manufacturers C o u n c i l Takes Stand on NSF Issues," Pool & Spa News, February 22, 1982, pp. 8 & 108. 2Nancy Iran P h i l l i p s , "Hot Water Industry P u l l s Together on Skin Rash Problems," Swimming Pool Age, A p r i l , 1982, pp. 11 & 36. 3 A l l e n V. Kneese and Ch a r l e s L. S c h u l t z e , P o l l u t i o n , P r i c e s , and P u b l i c P o l i c y Resources f o r the Future and The Brookings I n s t i t u t i o n , (Washington, D.C: The Brookings I n s t i t u t i o n ) , 1975, p. 7. "Interview with Dave A n t o n a c c i , op. c i t . i n t e r v i e w with Roy Dzieranowski, Cook County H e a l t h Department, J u l y 12, 1982. 6 I n t e r v i e w with D a n i e l T a r r y , op. c i t . ' N a t i o n a l Spa & Pool I n s t i t u t e , "Minimum Standards f o r P u b l i c Spas & Hot Tubs," Washington, D.C, 1978. 8U.S. Department of Hea l t h and Human S e r v i c e s , Suggested He a l t h and Safety G u i d e l i n e s f o r P u b l i c Spas and Hot Tubs, P u b l i c H e a l t h S e r v i c e , Centers f o r Disease C o n t r o l , A t l a n t a , Ga., A p r i l 1981. 9 I l l i n o i s , Minimum S a n i t a r y Requirements f o r the Design and Operation of Swimming Pools and Bathing Beaches, Department of P u b l i c Health, D i v i s i o n of Swimming, Pools and R e c r e a t i o n , S p r i n g f i e l d , I l l i n o i s , February 1976. (Note: these r e g u l a t i o n s have been r e v i s e d somewhat s i n c e t h a t time, but p u b l i s h e d c o p i e s are not a v a i l a b l e . ) 1 0 I n t e r v i e w with Roy Dzieranowski, op. c i t . 1 1 l e t t e r from D a n i e l T a r r y , Enironmental H e a l t h O f f i c e r , V i l l a g e of A r l i n g t o n Heights, August 3, 1982. 1 2 J o h n F r a n t z , "Midwest News," Pool & Spa News, Feb. 8, 1982, p. 128. 1 3 C i t y of Chicago, Proposed P u b l i c Spa Code, Revised March 8, 1982, Perry M e i k l e , J a c u z z i W h i r l p o o l Bath, Walnut Creek, Ca. ' " " F l o r i d a News," Pool & Spa News, September 21, 1981, p. 86. 1 5"IAPMO, ICBO Agree on Code", Pool & Spa News, A p r i l 5, 1982, pp. 1 and 114. 223 1 6 I b i d 1 7"UL Looks at Spa Safety Hazards", Pool & Spa News, A p r i l 5, 1982, pp. 40 & 42. 1 8 J o r i a n C l a i r , "Spa Hea l t h Code A c t i o n Planned; ISTI to Meet with NSF i n October", Pool & Spa News, September 21, 1981, p. 98. 1 9 I b i d 2 0Nancy Iran P h i l l i p s , op. c i t . 2 1 J o r i a n C l a i r , "Spa Health Code A c t i o n Planned; ISTI to Meet with NSF i n October", op. c i t . 2 2"New Awareness Shown For Pool/Spa Safety Needs", Pool & Spa News, January 25, 1982, pp. 146 & 148. 2 3 I b i d 2 " " I S T I Backs Pseudomonas Study; Causes, Pr e v e n t i o n Sought," Pool & Spa News, February 9, 1981, pp. 1 & 148. 2 5 J o u r n a l of Environmental H e a l t h , January/February, 1979, pp. 189-193. 2 6 I b i d , p. 192. 2 7 " S p a Sp e c t a c u l a r A t t r a c t s 13,000 Consumers," Pool & Spa News, August 17, 1981, pp. 8 & 96. 2 8Nancy Iran P h i l l i p s , op. c i t . , pp. 11 & 36. 2 9 S e a t t l e - King County Dept. of P u b l i c H e a l t h , S e a t t l e , Washington, March, 1981. 3 0 Vogue Magazine, January, 1983, p. 84. 3 1 H e l e n Donigan, "Industry News," Pool & Spa News, February 23, 1981, p. 14. 224 APPENDIX E The B.C. Health Act And I t s P r o v i s i o n s f o r Spas The f o l l o w i n g s p e c i a l p r o v i s i o n s f o r t h e r a p e u t i c pools are cont a i n e d i n the B.C. Hea l t h Act i n the s e c t i o n s p e r t a i n i n g to r e g u l a t i o n of p u b l i c swimming p o o l s , spray pools, and wading p o o l s . Part IX--Therapeutic Pools 84. (a) Pa r t s X and XI of these r e g u l a t i o n s s h a l l not apply to t h e r a p e u t i c p o o l s . (b) P r o v i s i o n s of Part IX of these r e g u l a t i o n s s h a l l govern the c o n s t r u c t i o n , o p e r a t i o n , and maintenance of the t h e r a p e u t i c p o o l , n o t w i t h s t a n d i n g any c o n f l i c t i n g p r o v i s i o n s elsewhere i n these r e g u l a t i o n s . 85. The r e c i r c u l a t i o n r a t e through the f i l t e r system s h a l l be s u f f i c i e n t to pass the e n t i r e volume of the pool i n one hour or l e s s . 86. I f a t h e r a p e u t i c pool i s operated \as a h e a l t h e s t a b l i s h m e n t , the manager s h a l l be r e s p o n s i b l e f o r the continuous s u p e r v i s i o n of ba t h e r s . At a l l other e s t a b l i s h m e n t s where a t h e r a p e u t i c pool i s operated, the manager may be r e q u i r e d by the Med i c a l Health O f f i c e r to employ a person to be r e s p o n s i b l e f o r the continuous s u p e r v i s i o n of bath e r s . 87. Seats and benches s h a l l have a n o n s l i p s u r f a c e and the edges s h a l l be marked i n a c o n t r a s t i n g c o l o u r . 88. Pool w a l l s s h a l l have a smooth f i n i s h to f a c i l i t a t e c l e a n i n g . 89. A maximum v e l o c i t y of water through the d r a i n s of any of the r e c i r c u l a t i o n systems s h a l l be 1 1/2 f e e t per second. 90. A minimum of one t o i l e t and one shower s h a l l be pro v i d e d c o n v e n i e n t l y near the pool f o r each sex. 91. Pools l e s s than 100 square f e e t i n area may have a reduced walkway width of 2 f e e t f o r up to 75 percent of the pool perimeter. The access to the pool s h a l l be from a walkway 4 f e e t or g r e a t e r i n width. 92. A c l e a r l y v i s i b l e n o t i c e or warning s i g n s h a l l be posted at a l l entrances to the p o o l , s t a t i n g such d i r e c t i o n s necessary f o r the s a f e t y of the patro n s . 93. A c l o c k of s u f f i c i e n t s i z e and design s h a l l be l o c a t e d to be seen by those i n the p o o l . 1 In a d d i t i o n to these p r o v i s i o n s , a maximum temperature l i m i t of 104°F i s now recommended and n o t i c e s to t h i s e f f e c t have been given to spa f a c i l i t i e s by a p p r o p r i a t e h e a l t h agenc i e s . 225 An examination of the above p r o v i s i o n s r e v e a l s the f o l l o w i n g weaknesses i n e x i s t i n g spa p o l i c y : (a) S e c t i o n 85 addresses the need f o r improved spa f i l t r a t i o n systems. However, the requirement of a one hour turnover rate may be inadequate. The CDC g u i d e l i n e s recommend a turnover r a t e of every 30 minutes, and the proposed g u i d e l i n e s of the Canadian Swimming Pool A s s o c i a t i o n recommend a r a t e of every 15 minutes. T h i s s e c t i o n f a i l s to address other important spa f i l t r a t i o n matters such as the types of f i l t e r s and r e q u i r e d c l e a n i n g of f i l t e r s . (b) S e c t i o n 86 i s a h e l p f u l g u i d e l i n e p a r t i c u l a r l y i n regard to pr e v e n t i o n of hyperthermia and drowning hazards i f t h i s p r o v i s i o n i s adhered to by o p e r a t o r s and enforced by h e a l t h o f f i c i a l s . However, i t assumes t h a t spa f a c i l i t y personnel are adequately t r a i n e d to a s s i s t bathers and to take a p p r o p r i a t e measures i f necessary. Without such assurance, t h i s s e c t i o n i s c o n s i d e r a b l y weakened. (c) S e c t i o n 87 i s a t y p i c a l s a f e t y p r o v i s i o n which may h e l p reduce a c c i d e n t s caused by v i s u a l hazards. (d) S e c t i o n 88 appears to be a p r o v i s i o n designed to improve s a n i t a t i o n . However, i f spas are not r e q u i r e d t o be d r a i n e d and c l e a n e d at p e r i o d i c i n t e r v a l s , t h i s s e c t i o n i s meaningless. (e) S e c t i o n 89 appears to be a p r o v i s i o n intended to reduce drowning hazards from entrapment. However, the v e l o c i t y of water i s only one pa r t of the problem. The s i z e of d r a i n and other o u t l e t openings and the type of o u t l e t g r a te covers i s 226 e q u a l l y important e s p e c i a l l y i n the case of c h i l d r e n who are prone to p u t t i n g p a r t s of t h e i r bodies i n t o openings. ( f ) S e c t i o n s 90 & 91 do not provide added h e a l t h and s a f e t y p r o t e c t i o n from hazards a s s o c i a t e d with spas. (g) S e c t i o n 92 i s u n n e c e s s a r i l y vague by f a i l i n g to s p e c i f y what warnings and d i r e c t i o n s should be posted. Interviews with two o p e r a t o r s of separate f a c i l i t i e s demonstrated the weakness of t h i s p r o v i s i o n . One operator i n d i c a t e d that two warnings are r e q u i r e d ; (1) that users be advised that a maximum time l i m i t of 10 minutes i n a spa be observed and (2) i n d i v i d u a l s with heart problems should not use a spa without a p h y s i c i a n ' s a p p r o v a l . 2 Another operator was aware of the H e a l t h Act's g e n e r a l p r o v i s i o n , but he knew of no s p e c i f i c r e q u i r e d warnings. His f a c i l i t y posts a number of warnings and d i r e c t i o n s based upon h i s knowledge and judgement. 3 I t i s evident from the vagueness of S e c t i o n 92 and the i n c o n s i s t e n t p r a c t i c e s f o l l o w e d by operators that a s e r i o u s weakness e x i s t s i n informing users of hazards and a p p r o p r i a t e behaviour. I t appears that e x i s t i n g spa p o l i c y i n t h i s regard r e l i e s upon the d i s c r e t i o n of e i t h e r l o c a l h e a l t h i n s p e c t o r s or o p e r a t o r s . In l i g h t of the numerous s p e c i a l p r e c a u t i o n s a d v i s e d i n other j u r i s d i c t i o n s and by most e x p e r t s , the vagueness of S e c t i o n 92 i s a s e r i o u s d e f i c i e n c y . (h) S e c t i o n 93 p r o v i d e s users a means f o r judging t h e i r d u r a t i o n of spa use. However, no p r o v i s i o n s are made f o r p r o v i d i n g 2 2 7 means f o r users to judge other c o n d i t i o n s , such as temperature, d i s i n f e c t a n t l e v e l s , pH, or b a c t e r i a l presence. In summary, the e x i s t i n g p r o v i s i o n s f o r t h e r a p e u t i c pools i n B.C. are i n a c c u r a t e , incomplete, and vague i n view of c u r r e n t t e c h n i c a l and s c i e n t i f i c knowledge. The one e x c e p t i o n i s the r e c e n t l y recommended maximum temperature l i m i t . V i s u a l , drowning, and hyperthermia hazards are addressed only to a minor degree. Pathogenic hazards, as s p e c i f i c a l l y r e l a t e d to spas, are not addressed. The present l e g i s l a t i v e set-up i n B.C. leaves our study j u r i s d i c t i o n v u l n e r a b l e to problems. As r e p e a t e d l y p o i n t e d out, i t i s not only inadequate to t r e a t spas l i k e pools — i t can a l s o be q u i t e dangerous to do so. Examination of s p e c i f i c key parameter requirements i n the B.C. H e a l t h Act underscore some of the major t e c h n i c a l and s c i e n t i f i c weaknesses i n the four p o t e n t i a l hazard areas. D i s i n f e c t i o n / c o n t r o l of pathogens -One of the c r i t i c a l f a c t o r s which has emerged from the U.S. experience i s that l e v e l s of d i s i n f e c t i o n must be maintained on a s i g n i f i c a n t l y h igher and more c o n s i s t e n t b a s i s than with p o o l s . Standards f o r pool c h l o r i n a t i o n were o r i g i n a l l y designed to allow f o r a f r e e r e s i d u a l bank capable of meeting expected c h l o r i n e demand in p o o l s . The v a r i a b l e and v o l a t i l e nature of spa water has proved t h i s g u i d e l i n e to be t e r r i b l y i n s u f f i c i e n t f o r p u b l i c spas. Where changes and r e s u l t a n t 2 2 8 pathogenic hazards can so r a p i d l y occur, a temporary let-down i n d i s i n f e c t i o n c a p a b i l i t y can be dangerous. Thus, i t i s not s u r p r i s i n g that many U.S. experts have recommended much higher c h l o r i n e and bromine l e v e l s (as high as 3.0 ppm) and s t r e s s e d the importance of automatic c h l o r i n a t i o n and bromination equipment. F u r t h e r , a number of experts now suggest that s u p e r c h l o r i n a t i o n procedures be taken a f t e r each bather use to destroy organic m a t e r i a l which otherwise nourishes microorganisms. Great Lakes Biochemical Co. has s p e c i f i c a l l y made t h i s change i n t h e i r user i n s t r u c t i o n s . Under c u r r e n t pool r e g u l a t i o n s here i n B.C., op e r a t o r s are allowed to maintain c h l o r i n e r e s i d u a l s as low as 0.5 ppm, although the h e a l t h department does recommend higher l e v e l s up to 1.0 ppm. However, even the l e v e l of 1.0 ppm does not g i v e an adequate margin of s a f e t y f o r spas, p a r t i c u l a r l y as bather load i n c r e a s e s . The use of t h i s standard, by d e f a u l t , a c t u a l l y encourages poor spa management. The one advantage of the a p p l i c a t i o n of swimming pool standards i n B.C., compared to many U.S. j u r i s d i c t i o n s , i s that spas are r e q u i r e d to have automatic chemical f e e d e r s . However, s i n c e these feeders are capable of breaking down or o p e r a t i n g improperly, they must be p e r i o d i c a l l y monitored and maintained. F u r t h e r , they w i l l not maintain s u f f i c i e n t l e v e l s unless i n i t i a l l y a d j u s t e d to do so. As f o r s u p e r c h l o r i n a t i o n , there i s no mention of i t i n the B.C. He a l t h Act — t h i s i s a very s e r i o u s d e f i c i e n c y . The c r u c i a l chemical parameter of pH has a l s o not been 229 a p p r o p r i a t e l y addressed w i t h i n e x i s t i n g standards. B.C. op e r a t o r s must maintain a l e v e l of at l e a s t 7.4 roughly s i m i l a r to the U.S. " i d e a l " range of 7.2-7.6. However, B.C. o p e r a t o r s are allowed to exceed 7.8, a l e v e l c o n s i d e r e d unacceptable i n the U.S. f o r both pools and spas. At l e v e l s above 7.8, i t i s w e l l understood that c h l o r i n e d i s i n f e c t i o n e f f i c a c y i s c o n s i d e r a b l y reduced. The Hea l t h Act compensates f o r t h i s by r e q u i r i n g c h l o r i n e l e v e l s of 1.0 ppm at pH higher than 7.8." Again, with the case of spas, the r a t e of d i s i n f e c t i o n c a p a b i l i t y at t h i s a l l o w a b l e l e v e l of pH i s l i k e l y i n s u f f i c i e n t , e s p e c i a l l y as bather l o a d i n c r e a s e s . To make the p o i n t , spa op e r a t o r s i n B.C. t e c h n i c a l l y c o u l d run at r i d i c u l o u s l y high pH l e v e l s and s t i l l conform to the standards — the spa water c o u l d c o n c e i v a b l y be c l e a r , show ac c e p t a b l e c h l o r i n e l e v e l s , but the c h l o r i n e may be v i r t u a l l y i n e f f e c t i v e as a b a c t e r i c i d e . Furthermore, as pH i n c r e a s e s s c a l i n g and c a l c i f i c a t i o n a l s o i n c r e a s e . S cale can serve as a medium f o r organism growth and c r e a t e c a l c i f i c a t i o n i n equipment such as f i l t e r s , pumps, he a t e r s , and automatic c h l o r i n a t o r s . I f these items are not p r o p e r l y and f r e q u e n t l y cleaned, the s c a l e b u i l d - u p w i l l not only damage the equipment but le a d to reduced flow and inadequate supply of d i s i n f e c t a n t p rovided by automatic f e e d e r s . Water C l a r i t y -With t h i s concern, the a p p l i c a t i o n of the Health Act to spas i s a l s o d e t r i m e n t a l . The c h e m i c a l - d i s i n f e c t a n t parameters, as i n d i c a t e d above, would e v e n t u a l l y hinder c l a r i t y . Another 230 important f a c t o r a f f e c t e d i s f i l t r a t i o n . The c u r r e n t requirement i s that f i l t r a t i o n equipment be s i z e d f o r a maximum turnover r a t e of one hour. T h i s may be inadequate f o r spas, as some experts have advised r a t e s as s t r i c t as a maximum of once every 15 minutes. If so, other f a c t o r s i n v o l v i n g the h y d r a u l i c s of the system such as p i p i n g , i n l e t s , o u t l e t s , e t c . would a l s o have to be a d j u s t e d a c c o r d i n g l y . Backwashing or c l e a n i n g requirements of f i l t e r media a l s o should be examined. F u r t h e r , some experts b e l i e v e that sand f i l t r a t i o n i s inadequate f o r spas and that only diatamaceous e a r t h or c a r t r i d g e f i l t e r s are capable of c a p t u r i n g the f i n e r p a r t i c l e s and amounts of o i l present i n spa water. The H e a l t h Act allows use of sand f i l t e r s , a s do the U.S. codes. T h i s p o s s i b l e weakness r e f e r s to e a r l i e r mention of a weakness r e s u l t i n g from i n d u s t r y involvement with standards. F i n a l l y , the eventual b u i l d - u p of t o t a l d i s s o l v e d s o l i d s i n spas r e q u i r e s p e r i o d i c spa d r a i n i n g as a c r i t i c a l f a c t o r f o r proper management. T h i s i s completely d i s r e g a r d e d i n the H e a l t h Act. D e s p i t e c o n t r o v e r s y over recommended drainage i n t e r v a l s , experts do concur that t h i s f a c t o r i s h i g h l y important to c l a r i t y and d i s i n f e c t i o n . Hyperthermia -Although B.C. now recommends a maximum l i m i t of 104°F, t h i s study d i d not determine how r i g o r o u s l y t h i s i s e n f o r c e d . Moreover, c u r r e n t r e g u l a t i o n s s u f f e r the same drawbacks faced i n the U.S. as to user awareness of r i s k s , i n d i v i d u a l t h r e s h o l d s fo r time and temperature, and other u n c e r t a i n t i e s . Though t h i s 231 hazard has been addressed i n B.C., there are s t i l l weaknesses i n the c u r r e n t p o l i c i e s . Drowning hazards from entrapment The obvious and most important weakness in e x i s t i n g p o l i c y i s the absence of requirements fo r s p e c i a l l y - d e s i g n e d spa d r a i n and o u t l e t covers ( i . e . a n t i - v o r t e x ) . These items should be i n c l u d e d i n spa c o n s t r u c t i o n and i n s t a l l a t i o n c r i t e r i a . M o n i t o r i n g and E d u a t i o n a l E f f o r t s M o n i t o r i n g and enforcement of spa r e g u l a t i o n s are s i m i l a r to those used f o r p o o l s . Each f a c i l i t y i s i n s p e c t e d at l e a s t once a year as p a r t of a procedure f o r issuance of annual o p e r a t i o n permits. From i n t e r v i e w s with h e a l t h o f f i c i a l and o p e r a t o r s , i t appears that p e r i o d i c i n s p e c t i o n s are conducted much more f r e q u e n t l y , i n some j u r i s d i c t i o n s as o f t e n as once a week. T h i s i s a p o s i t i v e f e a t u r e of the e x i s t i n g management system, and i t may be s e r v i n g to overcome some of the p o l i c y d e f i c i e n c i e s . E d u c a t i o n a l e f f o r t s p r i m a r i l y seem to be d i r e c t e d only toward pool o p e r a t i o n . The M i n i s t r y of H e a l t h has p u b l i s h e d a w e l l - w r i t t e n booklet f o r o p e r a t o r s , e n t i t l e d "Commercial Swimming Pool Operator's Guide". 5 T h i s study d i d not f i n d any e d u c a t i o n a l m a t e r i a l s on programs which were s p e c i f i c a l l y concerned with spa management or with educating users and the p u b l i c about spa hazards, recommended spa use behaviour, or 2 3 2 necessary s p e c i a l p r e c a u t i o n s . Through comparison to spa standards and r e g u l a t i o n s formed elsewhere i n Canada and the U.S., other weaknesses in the e x i s t i n g p r o v i n c i a l p o l i c y can be shown. The above c o n s i d e r a t i o n s only d e s c r i b e the major ones. I t i s important to understand that use of the Health Act f o r spas i s s e r i o u s l y d e f i c i e n t — and n o t simply a matter of " s p l i t t i n g h a i r s " or of some experts recommending u n n e c e s s a r i l y h i g h standards. Experts may d i s a g r e e about the "best" spa water q u a l i t y parameters, yet i t i s obvious that the requirements under the B.C. H e a l t h Act are f a r a f i e l d from c u r r e n t t e c h n i c a l and s c i e n t i f i c knowledge. The continued a p p l i c a t i o n of these f l a g r a n t l y i n a p p r o p r i a t e p o l i c i e s i s p o t e n t i a l l y hazardous to p u b l i c h e a l t h -- t h i s p o i n t cannot be o v e r s t a t e d . The longer these p o l i c i e s remain in e f f e c t , the more d i f f i c u l t , too, i t w i l l be to a l t e r the behaviour of o p e r a t o r s . Increased r e s i s t a n c e and lessened a b i l i t y to change may become r e a l o b s t a c l e s f o r a c h i e v i n g spa water q u a l i t y . Of g r e a t e r concern, p u b l i c h e a l t h may be u n n e c e s s a r i l y s u b j e c t to p o t e n t i a l hazards. If e x i s t i n g p o l i c i e s c o ntinue and spas i n c r e a s e i n numbers and usage, the p o s s i b i l i t i e s of s e r i o u s d i s e a s e or death may a l s o i n c r e a s e . Lessons from the U.S. experience should be c o n v i n c i n g enough to arouse concern. The Importance of P u b l i c Awareness About Spa Hazards The present s i t u a t i o n i s d e f i c i e n t and p u b l i c values are 233 p o o r l y represented due to lack of p u b l i c awareness about spa management and hazards. The c u r r e n t use of swimming pool standards and r e g u l a t i o n s c o n t a i n e d i n the B.C. H e a l t h Act have alre a d y been i d e n t i f i e d as i n a p p r o p r i a t e to spas. U n t i l the government acknowledges c u r r e n t p o l i c y as being d e f i c i e n t , i t i s d o u b t f u l that the g e n e r a l p u b l i c w i l l develop an accurate awareness of spa hazards. Instead, the p u b l i c i s s u b j e c t to m i s l e a d i n g i n f o r m a t i o n about spas, as e x e m p l i f i e d by a "herpes s c a r e " report which o c c u r r e d i n 1982. T h i s r e f e r s to r e p o r t s which were made i n the l o c a l media about hot tubs being sources f o r t r a n s m i t t i n g h e r p e s . 6 Although the r e p o r t was s t i l l e d by subsequent statements from medical and h e a l t h experts, i t r a i s e d s i g n i f i c a n t a t t e n t i o n -- to the extent that the news d i r e c t o r of CFOX Radio was beseiged with over two dozen c a l l s w i t h i n a few hours immediately a f t e r the newscast. 7 Another example o c c u r r e d i n a November i s s u e of Ubyssey. 8 In t h i s case, an a r t i c l e , intended as a " c o l l e g e prank", claimed that the UBC Aquatic Centre (pool & spa) was being c l o s e d because of a herpes epidemic. Although the ruse was f a i r l y soon uncovered, a number of people i n i t i a l l y b e l i e v e d the r e p o r t s and were q u i t e upset, as subsequent l e t t e r s to the e d i t o r r e v e a l e d . More important, though, f a l s e r e p o r t s such as these tend to c r e a t e a "cry wolf" syndrome which may l e a d to l a x i t y with s e r i o u s and r e a l p o t e n t i a l hazards. 234 Footnotes - Appendix E 1B.C. Health Act, B.C. Reg. 289/72, December 1, 1972, "Swimming-Pool, Spray P o o l , and Wading-Pool R e g u l a t i o n s " , p. 14. 2 I n t e r v i e w with Lorenzo Lepore, Manager, Brentwood Racquet Club, Burnaby, March 21, 1983. 3 I n t e r v i e w with Jim Bremner, D i r e c t o r U.B.C. Aquatic Centre, March 21, 1983. ""B.C. Hea l t h A c t , " B.C. Reg. 289/72, December 1, 1972, p. 13. (At pH higher than 7.8, f r e e a v a i l a b l e c h l o r i n e l e v e l s must be at 1.0 ppm, f r e e a v a i l a b l e cyanurate c h l o r i n e and bromine l e v e l s must be at 1.5 ppm.) 5 B r i t i s h Columbia, "Commercial Swimming Pool Operator's Guide," M i n i s t r y of Health, D i v i s i o n of Environmental E n g i n e e r i n g , V i c t o r i a , B.C. 6CFOX Radio, morning newscast, Vancouver, B.C., September 9, 1982. 'Interview with Gary M a r s h a l l , News D i r e c t o r , CFOX Radio, Vancouver, B.C., September 9, 1982. 8 The Ubyssey, U n i v e r s i t y of B r i t i s h Columbia, Vancouver, B.C., November 16, 1982, pp. 1 and 3. 235 APPENDIX F A Sample Spa Operator T r a i n i n g Program A 5-day program c o u l d be e s t a b l i s h e d with t h i s o u t l i n e as f o l l o w s : Day 1: I n t r o d u c t i o n to spa o p e r a t i o n s ; t h e i r b e n e f i t s and problems a) T h e r a p e u t i c / r e c r e a t i o n a l b e n e f i t s and p u b l i c h e a l t h p r o t e c t i o n b) Equipment and f a c i l i t y o p e r a t i o n and maintenance. Day 2: Water Chemistry and D i s i n f e c t i o n a) Water balance and the e f f e c t s of v a r i o u s parameters. b) D i s i n f e c t i o n procedures and r e l a t i o n s h i p s to other parameters. Day 3: Spa Water Q u a l i t y Management S k i l l s a) o b s e r v i n g parameters and v a r i a b l e s ; t e s t i n g and m o nitoring b) drawing r e l a t i o n s h i p s from o b s e r v a t i o n c) a n t i c i p a t i n g problems d) methods for adjustments and e v a l u a t i n g c o r r e c t i o n s Day 4: D e a l i n g with Others a) t r a i n i n g of spa management personnel b) modifying spa user behaviour c) s a f e t y and emergency p r e p a r a t i o n s and procedures 236 Day 5: Designing Spa Operation Plans a) general requirements b) creating alternatives and developing plans c) detecting needs for adjustments and incorporating the changes. Certainly, t h i s program could be modified or made more extensive, but i t represents the basic areas which we would want to cover with operators. Advanced and refresher programs could be devised i f the need and demand developed. Such programs should be carr i e d out at actual spa f a c i l i t i e s and r e g i s t r a t i o n fees should be charged to cover costs. S p e c i f i c a l l y , we want to provide an understandable framework for operators; With Public health: the importance of sound spa management and rationales for standards With equipment: i t s interrelatedness to spa water qua l i t y and subsequent safety/health concerns. With water chemistry and d i s i n f e c t i o n : a) Teach operators to f i r s t understand their i n i t i a l water quality conditions; i . e . , their water supply and i t s parameter components of pH, t o t a l a l k a l i n i t y , hardness, trace elements, etc. b) Teach operators how to adjust the least variable parameters f i r s t and how to eliminate undesired chemical elements(e.g.copper,iron). 237 c) Teach operators how to focus on the three main f a c t o r s of d i s i n f e c t a n t l e v e l s , c l a r i t y , and temperature. Use as guides the f o l l o w i n g : 1) c h l o r i n e or bromine f r e e r e s i d u a l / d i s i n f e c t i o n high l o a d spas: 3.0 ppm med. to low load spas: 1.5 ppm pH f o r both: 7.2-7.6 s u p e r c h l o r i n a t i o n : high load - 10 ppm d a i l y a f t e r spa shut-down low load - 5 ppm d a i l y a f t e r spa shut-down pathogenic c o n t r o l : Pseudomonas should be used as an i n d i c a t o r . 2) water c l a r i t y h i g h load - l e s s than .5 (JTU's) low l o a d - .5 to 1.0 (JTU's) T o t a l D i s s o l v e d S o l i d s : high l o a d - r e p l a c e 1/3 of water when 500 ppm i s reached - 2/3 when 1000 ppm i s reached - a l l water when 1500 ppm i s reached low l o a d - r e p l a c e 1/2 of water when 1000 ppm i s reached - r e p l a c e a l l water when 1500 ppm i s reached 3) temperature hig h l o a d - maintain temperature at 102°F or l e s s low l o a d - maintain temperature at 104°F or l e s s 238 The above g u i d e l i n e s merely r e f l e c t person o p i n i o n as to proper l e v e l s which might be used as s t a r t i n g p o i n t s . I t t r i e s to account f o r the t w o - t i e r e d d i f f e r e n c e of spa bather loads and uses c o n s e r v a t i v e recommended parameters. L o c a l a c t o r s might want to adopt d i f f e r e n t i n i t i a l standards and a l s o provide g u i d e l i n e s f o r other parameters and o p e r a t i o n a l methods, such as shown i n Appendix B. The important p o i n t s , though., are; (1) that these i n i t i a l g u i d e l i n e s should be f l e x i b l e and o p e r a t o r s encouraged to experiment ( w i t h i n reason) with v a r y i n g them, and (2) o p e r a t o r s should be taught to maintain the l e s s v a r i a b l e parameters (e.g. t o t a l a l k a l i n i t y , hardness) on a g e n e r a l b a s i s and to c a r e f u l l y monitor the changes and e f f e c t s of the three main areas, and (3) methods should be taught f o r h a n d l i n g the most v a r i a b l e c o n d i t i o n s . d) Operators should then be taught how to observe and a s s o c i a t e e x t e r n a l e f f e c t s on spa water q u a l i t y ; such as number of bathers, types of bathers, the environment o u t s i d e the spa, e t c . These again should be r e l a t e d to our three main f a c t o r s . With Management S k i l l s T h i s area of t r a i n i n g should i n t e g r a t e the l e a r n i n g process from the f i r s t two days, and then t h i s should be p l a c e d i n t o the context of p r a c t i c a l c o n s i d e r a t i o n s , e.g., i f d i s i n f e c t a n t l e v e l s appear inadequate, the operator should i n c r e m e n t a l l y i n c r e a s e the dosage u n t i l the problems seem r e c t i f i e d — then perhaps to decrease the dosage i n c r e m e n t a l l y i n order to l e a r n 239 the proper range f o r h i s o p e r a t i o n . With D e a l i n g with Others Spa o p e r a t o r s should be taugh thow to d e a l with other people i n v o l v e d i n the spa system and that c o n t r o l or good management of spa water q u a l i t y i s dependent on these other people. T h e o r e t i c a l c h a r a c t e r i z a t i o n of behaviour and m o t i v a t i o n s and p r a c t i c a l methods f o r a c h i e v i n g c o o p e r a t i v e behaviour should be taught. Operators should a l s o be prepared and have p r o v i s i o n s f o r handling emergencies. With Designing Spa Operation Plans The f i n a l s e c t i o n of t r a i n i n g would attempt to p u l l together the p r e v i o u s four days of l e a r n i n g . Spa management u n c e r t a i n t i e s should be h i g h l i g h t e d and o p e r a t o r s should be made keenly aware of the importance of reducing u n c e r t a i n t y and d e a l i n g with s u r p r i s e s . I t should inform o p e r a t o r s of the b a s i c f e a t u r e s which must be i n c l u d e d i n a p l a n f o r a p p r o v a l , and then s t i m u l a t e thought on a l t e r n a t i v e s . E x i s t i n g plans can be used as examples; and operators should be encouraged to t h i n k c r e a t i v e l y and design plans a p p r o p r i a t e to t h e i r f a c i l i t i e s and patrons. Plans should be d e v i s e d using both b e h a v i o u r a l and t e c h n i c a l p e r s p e c t i v e s . Ideas c o u l d be suggested as to how to o b t a i n p r o f e s s i o n a l c o n s u l t a t i v e s e r v i c e s , r e f e r e n c e s , or monitoring arrangements. F i n a l l y , the operator should be taught how to use h i s plan as a guide f o r o p e r a t i o n — 240 i . e . , u s i n g i t i n c o o r d i n a t i o n with implementation. Thus, the operator would want to understand how to e v a l u a t e problems with the p l a n and then how to make adjustments. Changes should be submitted to the h e a l t h department f o r a p p r o v a l . O v e r a l l , we want to provide a g e n e r a l format f o r o p e r a t o r s and i d e a l l y we would want to present t h i s i n an i n t e r e s t i n g , and even fun, way so as to c r e a t e a w i l l i n g and c o o p e r a t i v e atmosphere which h o p e f u l l y would f o s t e r operator c r e a t i v i t y and c o n s c i e n t i o u s n e s s toward spa o p e r a t i o n . Using the b a s i c format as a s t a r t i n g p o i n t , operators c o u l d then n e g o t i a t e the remainder of o p e r a t i o n a l matters with the h e a l t h department. 241 APPENDIX G A Sample "Plan of O p e r a t i o n " * Safe & Healthy Spa F i t n e s s Centre 1 23 S. Ma i n Vancouver, B.C. F a c i l i t i e s ; 10 r a c q u e t b a l l / s q u a s h c o u r t s , 10 t e n n i s c o u r t s , 75 m. x 25 m. swimming p o o l , 4 hydrotherapy spas. 2 saunas, jogging t r a c k , e x e r c i s e and weight room, mens' and l a d i e s ' change rooms, r e s t a u r a n t , snack bar, lounge, and merchandise room. Membership i n f o r m a t i o n : 1000 member enrollment, monthly dues of $100.00; c o u r t time, food, d r i n k s and merchandise e x t r a . Hours of O p e r a t i o n : M-F, 6:00 a.m.-11:00 p.m.; Saturdays 7:00 a.m.-9:00 p.m.; Sundays Noon-6:00 p.m.; c l o s e d h o l i d a y s . Information r e g a r d i n g the hydrotherapy spas D e s c r i p t i o n of Spas & Equipment: The Centre i s equipped with 4 separate spas, 110 sq. f t . each with volumes of 2000 U.S. g a l . 2 spas are g e n e r a l purpose, 1 spa i s f o r s p e c i a l t h e r a p e u t i c purposes only, 1 spa i s f o r s p e c i a l r e c r e a t i o n a l purposes o n l y . Equipment s p e c i f i c a t i o n s , s i z i n g , and layout per a r c h i t e c t u r a l * T h i s i s used s o l e l y as an example and i t i s not intended to be r e p r e s e n t a t i v e of any p a r t i c u l a r spa f a c i l i t y . 242 and e n g i n e e r i n g b l u e p r i n t s . Expected Bather Load R a t i o Per Spa: Not to exceed 1 person per 200 g a l . of water (10 people allowed i n at a t i m e ) . Methods of Water Q u a l i t y C o n t r o l and S a n i t a t i o n : 1. Bromine and o x i d i z e r } d i s i n f e c t i o n & } shock treatment 2. Ozone } 3. Sodium b i s u l p h a t e (acid) or sodium carbonate (soda ash) as necessary to c o n t r o l pH and t o t a l a l k a l i n i t y . S t a f f 1 - Manager (on duty at a l l times) 1 - P h y s i o t h e r a p i s t ( r e g u l a r l y scheduled to conduct t h e r a p e u t i c programs) 1 - R e c r e a t i o n a l / F i t n e s s S p e c i a l i s t ( r e g u l a r l y scheduled to conduct r e c r e a t i o n a l programs) 16 - Part-time Attendants (scheduled on a staggered b a s i s with 1 attendant per spa on duty at a l l times) 1 - C o n s u l t i n g P h y s i c i a n (as necessary) 2 - Maintenance People ( a l t e r n a t e schedules) I. T r a i n i n g of Spa F a c i l i t y Personnel - Managers w i l l have a d m i n i s t r a t i v e background and t r a i n i n g and they w i l l be f a m i l i a r with a l l o p e r a t i o n s of the f a c i l i t y . They w i l l a t t e n d P r o v i n c e t r a i n i n g s e s s i o n and 243 a l s o h o l d a recognized l i f e s a v i n g c e r t i f i c a t i o n . - P h y s i o t h e r a p i s t s w i l l h o l d an a c c r e d i t e d degree i n Physiotherapy and a background i n water t h e r a p e u t i c techniques. - R e c r e a t i o n a l / F i t n e s s s p e c i a l i s t w i l l h o l d an a c c r e d i t e d degree in r e c r e a t i o n / p h y s i c a l education and a p p r o p r i a t e background, - Attendant w i l l h o l d a r e c o g n i z e d l i f e s a v i n g c e r t i f i c a t i o n and be t r a i n e d in-house on spa water chemistry, spa equipment, procedures, and i n t e r a c t i o n s with spa u s e r s . - C o n s u l t i n g p h y s i c i a n w i l l be l i c e n s e d i n B.C. and be a v a i l a b l e f o r c o n s u l t a t i o n on programs, s a f e t y and h e a l t h recommendations and i n d i v i d u a l user c o n s u l t a t i o n as requested. P h y s i c i a n w i l l be f a m i l i a r i z e d with p h y s i c a l and chemical spa o p e r a t i o n s . - Maintenance people w i l l be thoroughly t r a i n e d on spa water chemistry and maintenance of spa equipment in-house and through a v a i l a b l e t r a i n i n g programs elsewhere. 11. P r o v i s i o n s ' f o r N o t i f y i n g Users of Hazards 1. Each member w i l l be p r o v i d e d a copy of the pamphlet "Safe Use of P u b l i c Spas". 2. Warning sig n s posted per the "B.C. Approved Standards f o r P u b l i c Spas". 3. Requirement of a p h y s i c i a n ' s approval and any r e s t r i c t i o n s f o r each spa user; to be maintained on f i l e . 244 4. P r i n t i n g and d i s t r i b u t i o n of any a d d i t i o n a l i n f o r m a t i o n as necessary. I I I . User Behaviour Requirements and Methods of Enforcement 1. A l l users w i l l be r e q u i r e d to take showers. 2. No person with an open wound, l e s i o n or observable sig n of e x t e r n a l d i s e a s e problem w i l l be allowed to use the spas. 3. No person with s e r i o u s i l l n e s s w i l l be allowed to use the spas. 4. No c h i l d r e n under 3 years of age and no pregnant women w i l l be allowed to use the spa (unless approved by the Centre's c o n s u l t i n g p h y s i c i a n ) . 5. No i n d i v i d u a l under the i n f l u e n c e of a l c o h o l or drugs w i l l be allowed to use the spas. 6. No horse p l a y or other dangerous a c t i v i t i e s w i l l be allowed. 7. No food, d r i n k s , tobacco or any o b j e c t s w i l l be allowed i n the spas or i n the immediate v i c i n i t y . 8. No user w i l l be allowed to remain i n a spa f o r longer than 15 minutes at a time u n l e s s given p r i o r approval by c o n s u l t i n g p h y s i c i a n and/or p h y s i o t h e r a p i s t s . A l l members w i l l be p r o v i d e d with these r u l e s (and others i f necessary) i n t h e i r membership packet. Showers w i l l be assured through design of a s p e c i a l "shower c u r t a i n " which a l l users w i l l have to pass through to use spas. Attendants w i l l be t r a i n e d to see that these r u l e s are observed by the patrons and request any v i o l a t o r to e i t h e r r e f r a i n from the v i o l a t i o n or 245 leave the f a c i l i t y . Any problems with compliance w i l l be r e f e r r e d to the manager. An i n d i v i d u a l who r e f u s e s to comply w i l l be e x p e l l e d from membership. IV. Equipment and Spa Unit Maintenance Procedures Per the "B.C. Approved Standards f o r P u b l i c Spas". (The Centre re s e r v e s the r i g h t to changes and m o d i f i c a t i o n s subject to h e a l t h department a p p r o v a l ) . V. Water Q u a l i t y and S a n i t a t i o n Procedures Per the "B.C. Approved Standards f o r P u b l i c Spas". (The Centre re s e r v e s the r i g h t to changes and m o d i f i c a t i o n s s u b j e c t to h e a l t h department a p p r o v a l ) . VI. M o n i t o r i n g , T e s t i n g and Record-Keeping Per the "B.C. Approved Standards f o r P u b l i c Spas". (The Centre re s e r v e s the r i g h t to changes and m o d i f i c a t i o n s s u b j e c t to h e a l t h department a p p r o v a l ) . V i s i b l e N o t i f i c a t i o n of Water C o n d i t i o n s to Users a) 1 temperature w a l l c l o c k and 1 thermometer per spa. b) d i g i t a l w a l l d i s p l a y of bromine and pH l e v e l s . c) d i s k f o r judging water c l a r i t y w i l l be embedded on bottom of spa which must be observable to users at a l l times. 2 4 6 d) one time c l o c k f o r users to observe d u r a t i o n of spa use. Users w i l l be provided as a guide, "Safe Use of P u b l i c Spas", which i n d i c a t e s recommended parameter l e v e l s and p o t e n t i a l consequences from i n s u f f i c i e n t l e v e l s . Signs w i l l be posted near each w a l l d i s p l a y of c o n d i t i o n s to i n d i c a t e recommended l e v e l s a c c o r d i n g to standards. Parameter readings w i l l be wired i n t o the Centre's o f f i c e and an alarm w i l l i n d i c a t e i f parameters reach minimum l e v e l s . Attendants w i l l maintain records of usage and t h i s i n f o r m a t i o n w i l l be c o o r d i n a t e d with other p h y s i c a l , chemical and b i o l o g i c a l data as the b a s i s f o r f u t u r e management adjustments. V I I . S a fety and Emergency Procedures Per the "B.C. Approved Standards f o r P u b l i c Spas". (The Centre r e s e r v e s the r i g h t to changes and m o d i f i c a t i o n s subject to h e a l t h department a p p r o v a l ) . S p e c i a l Programs I. T herapeutic and I I . R e c r e a t i o n a l Note; I t i s beyond the scope of t h i s t h e s i s to suggest a p p r o p r i a t e programs i n d e t a i l . P r o f e s s i o n a l s with e x p e r t i s e i n these areas should be c o n s u l t e d . I t i s recommended that programs 2 4 7 be d e v i s e d with f u r t h e r implementation and s o c i a l l e a r n i n g o b j e c t i v e s as d e s c r i b e d i n Chapter 5. General program areas might i n c l u d e : a) programs to t r e a t a r t h r i t i c or other s p e c i f i c h e a l t h problems of i n d i v i d u a l s b) programs f o r s t r e s s r e d u c t i o n and r e l a x a t i o n c) programs f o r t r e a t i n g and r e l a x i n g s p e c i f i c muscle and j o i n t areas which are s t r e s s e d by p a r t i c u l a r a t h l e t i c a c t i v i t i e s ( i . e . f o r joggers, s k i e r s , e t c . ) d) s o c i a l programs f o r o r g a n i z a t i o n s or g a t h e r i n g of f r i e n d s on s p e c i a l o c c a s i o n s . Other programs are p o s s i b l e and c r e a t i v e ideas can be developed i n t o e f f e c t i v e measures which p r o t e c t p u b l i c h e a l t h while enhancing spa b e n e f i t s .
Thesis/Dissertation
eng
Planning
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An evaluation of policy for public spas and hot tubs in British Columbia
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