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World Water Day 2001: Water for positive health: Previous page | 1,2,3,4

Springs and spas: the long tradition of using water for pleasure and health

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Waters with a reputation for health giving properties are found all over the world. The word ‘spa’, meaning mineral water, comes from Belgian resort of Spa. The term now includes hot tubs, whirlpools and mineral baths drawn from natural springs. Hydrotherapy pools, and other warm pools used primarily for medical purposes, draw on long established experience of the beneficial effects of water treatment. Since ancient times, drinking or bathing in mineral waters has been reputed to cure a variety of illnesses, including heart diseases, joint disorders, respiratory inflammation and kidney stones. While there have been few scientific studies of these postulated effects, there is no doubt of the benefits of warm water therapy in pain relief, joint mobility and relaxation. Naturally occurring hot springs were particularly valued in colder climates, for example the springs developed by the ancient Romans in Europe. The Baden-Baden springs in Germany, developed by the Romans as Aquae Aureliae, are the hottest in Europe and like most other thermal springs, are slightly radioactive. In many of the springs in Central and Eastern Europe, the ritual of combining cold, warm and hot baths for health has survived almost unchanged. In North America, native Americans believed in the curative effects of hot springs: one spring that became a famous spa, Saratoga, derives from the Mohawk word meaning “the place of the medicine waters of the great spirit.” Religion played a part in establishing the use of spas. The thermal baths in Budapest were developed during the Ottaman rule of Hungary: the inspiration was the Islamic tradition of cleanliness.

The health hazards of spas

Spas, hot tubs and whirlpools may not be drained, cleaned or refilled after each use. The health hazards associated with their use include those associated with swimming pools, although the high temperatures in some types of spas exacerbate the effects of alcohol or drugs and the risk of drowning may be enhanced by the lack of transparency in coloured or turbid spa waters. While deaths are rare, most have been associated with the combination of high water temperature and use of alcohol or drugs. The resulting drowsiness increases the risk of drowning. In the USA, 67% of all drownings occur in spas, hot tubs and back yard pools (WHO, 2000 (a)). Of 700 deaths in spas and hot tubs recorded in the USA since 1980, a third were children under five years of age, emphasising the importance of supervision of children playing with water. The high bather load and high turnover rate of users in many spas and whirlpools pose an infection risk, including microorganisms from the bathers and those present in the water. The warm, nutrient containing, aerobic water provides an ideal environment for many organisms, such as Legionella pneumophila, the cause of legionellosis (legionnaires’ disease) and Pseudomonas aerugionosa, which causes folliculitis, an infection of the hair follicles associated with an itchy rash. Natural hot spas may contain a species of amoeba that can cause meningitis (Acanthamoeba): cases have been reported after swimming in natural spas or exposure to fountains in warm climates. Infections of the ear (otitis externa), urinary tract, respiratory tract, eye and wounds have also been linked to spas. These infections are difficult to control and require frequent monitoring of the pH (degree of acidity/ alkalinity) of the water, disinfection and filtration. Water treatment may present chemical hazards unless the chemical disinfection is well managed. There is also a risk of accidents around spas due to slips, trips and falls: bathers may also pick up fungal and other infections from the wet surfaces.

WHO activities and safe recreational environments

Water has been used for positive health for millennia, and recreational use is not just a luxury. It provides opportunities for physical exercise, rest and pleasure, all fundamental components of the well being essential to health. Health aspects of the recreational use of the water environment have attracted increasing attention by members of the public, concerned professionals and regulatory agencies. The WHO programme on water, sanitation and health includes development of guidelines for safe recreational water environments for coastal, freshwaters, swimming pools and spas (WHO 1998, 2000 (a)); and a manual on the monitoring and assessment of bathing waters, including a code of good practice agreed with the European Commission (Bartram and Rees 1999). In 1998, a meeting between the WHO and USEPA (United States Environmental Protection Agency) produced the Annapolis Protocol (WHO 1999 (b)). This acknowledged the limitations in establishing ways of monitoring recreational water quality and the need to agree possible alternative approaches, with particular emphasis on the control of microbiological hazards.

The mineral content of ‘spa’ water and its effects

Natural mineral and spa waters collect their constituents as they filter through rock strata, such as calcium from limestone strata or magnesium from dolomites. Iron may be present in suspension. Minor elements include fluoride and several other trace elements. The mineral content is usually higher in warmer waters. Waters from volcanic sources may contain high concentrations of sodium and bicarbonates, giving them a natural effervescence.

The main difference between ‘mineral’ and ‘spring’ water is that no therapeutic claims are made for the latter, although a water does not have to have a therapeutic claim to be described as ‘mineral’. Microbiological quality control is required for both. The standards for microbiological purity and frequency of testing are usually less strict than for mains supplied water. The waters may be alkaline (pH above 7) or acid. Mineral waters are, by definition, bottled at source without treatment, except filtration, but their production is strictly regulated. Some mineral waters have marked effects on the gastrointestinal tract, often acting like a laxative. Bottled mineral water may be preferred for taste and supposed health benefits. This links back to the spa/mineral-water tradition, but is also determined by fashion. Bottled water consumption is rapidly increasing in many countries, for example reported as up by 35% in Thailand in 2001 (Watertech Online 2001). This has raised concerns, not least for the environment and cost: tap water is often as good as bottled water and costs up to 1,000 times less (Ferrier, 2001): domestic treatment of water (for example by chlorinating, boiling or Sodis) is the recommended option where supplies are unreliable and for people on low incomes.

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