 Thanks, Ashkan. Hey everybody, good to be back. Where do I start? I just want to say thanks. We'll get the volume figured out hopefully. Thanks to everybody for having me. I know I'm sort of the outsider around here. There might be a couple of other health officials around, but I'm here and I was drawn to the community, your community because of the problems you might encounter in dealing with health departments. And my goal is to sort of make that a better experience for you and work with my peers in health to sort of help them understand what you're about. Basically what's happened is you sort of get lumped into the swimming pool category and I honestly believe you don't belong there. So the last three years I've sort of spent working with your community to help you help me sort of thing. Our interests are aligned. So what I wanted to do today was cover a little bit about what's a hazard and what's a risk and inform you about that distinction because I think that's really important for you to be able to engage with me, Public Health Inspector. I wanted to give you a lay of the land of where things are at from a regulatory perspective throughout North America. And then maybe finally finish with some advice for you to consider as you go forward and meet with health inspectors and things like that. But before I start into that, I wanted to use an analogy to your industry that came to my mind, take you through a similar experience with a different industry and show you potentially how interaction with the health department and how perhaps even the health department made the wrong decisions. So this is going back a while and you may or may not have heard about this. There were three university trained graduates who had this idea for a company and the company would serve the public in the sense that they would offer physical and psychological benefit to the public if you needed the service. So these three graduates, they take out second mortgages on their home and they get a commercial space in this location in eastern U.S. and they eventually grow their business. They're able to hire a fourth person who's sort of an admin role and then another person who is helping with the technical side. So they're growing business and popular. And lo and behold, that got the attention of local officials, namely the health department. The health department came to their business and they had a discussion around like, what are you about? What do you do? And like flotation, there wasn't a lot of evidence to show that the service that they provide is safe or not. And that's kind of where you're at. There's this discussion right now about the safety. And so what happened was that that relationship didn't go very well at first and eventually the health department showed up with a court order saying, shut this down. So again, actually some footage, I think the footage you could describe it is catastrophic actually, the impact on the community. And this is sort of what happened here. Health department orders to shut it down. This happens and I'm glad you're all laughing because if you weren't, I'd be in trouble. All these ghosts sort of leave the building and destroy essentially the city of New York. And okay, good. I'm glad I got a few chuckles because what's going to follow is pretty dry perhaps. But I wanted to talk about this particular moment in time and reflect on who you are and who I am and the long arm of the law, if you will. So you've got this sort of clear divide between the operators who are sort of going like, we offer this service that's good and we need our service and you get the sort of the law enforcement angle and you've got this utility worker. You've got the man or the city official saying, we need to do something about this. And then you've got Walter Peck, if you've ever seen this movie. Walter Peck, can they officially refer to him as Pecker? Sort of saying shut it down. I don't know anything about this, shut it down to prevent some bad things from happening. So that's sort of where health officials are at. We're a very risk averse community, sometimes to a fault. And we operate, you might hear something, we might hear us tell you something called the precautionary principle. So we, precautionary principle is, to summarize it as basically we don't want to wait around for something bad to happen when we could have put an intervention in place to prevent it. The other side of the precautionary principle is you as the industry are responsible for describing to us why you are safe. So it's not, the burden is on you to prove that you're safe, not for me to prove that you're unsafe. So that's very similar to what happened here and it's very similar to what goes on in a lot of float centers in certain jurisdictions. We really struggle with the idea that you let people float naked in water and there's no chlorine in there. That's just where our heads are at. We're used to swimming pools and that's sort of an issue. So in the last few years, I'm not a words on slide this guy, so I apologize there's a few in this one. But basically I've been coming to the conference and a lot of other health officials and auxiliary health officials have been coming to the conference and building a relationship with your community over the last few years. There's also a lot of organizations with acronyms, so that's never a good sign. You've got obviously know the FTA and if you didn't know, the Flotation Tech Association has a set of standards, multiple pages of standards and guidelines on how to operate your centers in a safe, effective way and I personally believe that those standards put you in a position to keep the public safe sufficiently. There's also all these other acronyms, the National Collaborating Centre for Environmental Health and PHO, that's Public Health Ontario. They've done some work in looking into the literature and evidence into flotation and maybe some auxiliary sort of recreational water activities and looked at evidence and risk. The National Sanitation Foundation has come out with, at one time they were using your community to sort of inform this document called a Component Specific Certification CCS and that process sort of ended recently. They sort of gave up, I guess you could say and that work has sort of been taken over by the Centre for Disease Control, the CDC which I'm sure you've heard about. If you haven't heard about them, just watch the first episode of Walking Dead. The CDC sort of gets taken over. They play a huge role in keeping the public safe, the CDC and I would never say anything untoward about them. They birthed this arms-length community called the Council for the Model Aquatic Health Code and we'll talk about that later. So there's all these outside interests, I guess, sort of in the health community, showing an interest in your community and lots of different perspectives. Last year the Flotation Tech Association hosted a workshop and I was part of it. This is just an example of the things we're coming up with. Achieving health and safety outcomes in Flotation. There's lots of different reasons why you're different than pools. This is an abbreviated version of the resource we created and I do believe this is available on the FTA website. But what it is, it just sort of breaks down why you're different than pools and why you're a little bit safer. And we'll talk about that when we talk about risk assessment. I also want to touch on the term regulation and then regulate. What do I mean when I say regulate things? I'm just talking in the general sense today. So the general idea that we as a society, health officials in your industry are going to establish this agreed-upon set of rules or norms that govern sort of how you should operate. So I don't mean the great development of an act or a regulation or a code or a guideline or a standard or best practices. I don't really mean that today. What I mean is just regulate. Somebody wants to put a set of rules in front of you that you should follow. And there's lots of different agencies saying our rules are the best. So that's sort of happening right now. So when is the right time to regulate? We generally, in Canada, where I come from and we're in the States here where we're gathered here today, we live in a free democratic society and liberty prevails and you should be able to pursue your rights and freedoms. Sometimes, if you do that in a way, you could affect the public. You could harm the public. And so we have these impetus to put rules in place to keep people safe. And that's a good thing. But right now, when's the right time to do that? Well, maybe there's some harms or some unsafe outcomes happening. Evidence has come forward to say that actually the way we used to do things is wrong. And you put these measures in place to keep people safe. So why don't we just regulate everything? Why don't we just regulate flotation and get it over with? Why don't we let all the state departments come up with their rules? You don't need to regulate to get a positive outcome. I want to make that point clear. There's no shirt, no shoes, no service. That's not some health rule where I'm going to get some chest germs on the food or something. It's there as a societal norm and if you show up to the restaurant with no shirt on, it's more of a policy and more of a... But it's very effective. If you walk into a restaurant with a shirt on, you sort of consciously go, this isn't right. And then self-regulation can work. And this is sort of something that came up in some of the workshops we had yesterday. And I've got the picture of the fawns giving a thumbs up. But if you can picture a float center with something like a thumbs up and maybe the FTA logo or something similar that sort of told the public, we got this. And then the association and this facility belongs to the association and the people within are educated and competent workers and we follow this established set of guidelines. That would give the public a lot more sense of assurance. So you don't need a province or a state or a country to say you must follow these rules. Perhaps even just self-regulation could work. So why don't we just regulate everything? Another example is unintended consequences. It can happen that you didn't think about. So you sort of rushed to put out these rules and then all of a sudden you go, okay we're using the rules and there's things happening that we didn't think would happen. And this, here's maybe a better example. So we want to prevent people from falling downstairs. So we're going to warn them that every step you take, you could fall. And then eventually you trip over all the things. It becomes an impediment to safety when you put these rules in place. And in your context the unintended consequences that I'm observing are requirements for chlorine. And the unintended consequence could be that once you get into an enclosed space what's the air quality issue? So you think you're putting in this great measure with chlorine or bromine to disinfect the water if it's needed and then you're creating this unintended consequence to health. And then again, why don't we regulate everything? Well regulations need to be proportional and I talked about this when I described earlier that we live in a free society you can't just make rules, they have to make sense. There has to be this need for the rule. There has to be evidence to show that if the rule isn't there harms would occur. And you have to be balanced and sensible to the population. So one example I was just talking with some operators last night one example is there's still states that don't require you to wear a helmet when you ride a motorcycle and in Canada we all have to and why is that different in California than it is here or in Canada where I come from? It's because the people of California decided we're good with that. We don't want that rule imposed on us or our freedom is more important than that rule. So health officials can't just hide behind the cautionary principle and say we're going to put rules in place because we think something might happen one day but those rules have to make sense. And that's sort of what I need to remind my peers when they have these discussions. So again, terribly wordy slide. If I were to stand up here and have an argument with one of my peers or a discussion these are some of the reasons why I would say we should consider not regulating flotation. I do believe the flotation tank standards are sufficient to keep people safe. There's no really evidence of injury, there's no real illness right now. I mean that's not the end all be ill of the reason but that definitely should be considered. I think things are safe right now as practiced under the FDA standard and so there's no real need right now to make things safer. We haven't identified the risks properly, we haven't identified the hazards and I want to get into that next and then is it proportional? Do the benefits create an undue harm to your community as small business owners? I don't know if that question has been answered. So in short, the precautionary principle doesn't override your, it doesn't always automatically override your constitutional rights or in Canada our charter rights and freedoms. So the current landscape, lots of players, lots of acronyms out there. Everyone feels their right, everyone feels that they're doing their part to keep people safe. But who's right and who's wrong? I do want to take a second to talk about this process that's undergoing right now, a little bit of a call for a sense of urgency and I think at the end of my presentation, Ash kind of might fill in any blanks I leave here, but you should all know that the Center for Disease Control and the Council for the Model Aquatic Health Code, it was introduced this year that they were proposing to put rules for flotation tanks into something called the Model Aquatic Health Code. The Model Aquatic Health Code is a set of rules, suggested rules if you will, that health departments can adopt in full or in part to support their swimming pool legislation. There's many jurisdictions that don't have legislation so they can take this code and call it the rules or if you're in a province or state that has rules and you're going to update them, you might look to the code to guide you in what the rule should be. So there's this process going on and we're sort of halfway through the process. I know this is extremely pixelated, so we've got this idea that there's been this proposal and we're about here where we could vote. So this proposal is going to go forward to a vote in October and you need to be a member of the Model Aquatic Health Code Association to vote and I would encourage you all to get to know what's being proposed. Consider joining this. There's a nominal fee to join this group and then you get to first provide comment on the proposed rules and you get to have your own vote. I think we could get, we could probably spend a full 25-minute presentation on this process and where it's gone wrong in a lot of our opinions, but suffice it to say that this is how we feel. This is Mr. Pecker sort of saying, yeah, please send in your comments and then to hear on a phone call, yeah, we didn't listen to those is sort of where we're at so we're sort of putting out this, want to make you aware that this is an issue. Some of the proposed things, if adopted, would propose measures that they're adopted could affect your business and they will affect your business if adopted by the local health department, so I'll leave you with that positive thing and we'll move on. If you want to talk about that more, I'm around to the end of the day, go to the Float Tank Association table, they can give you more information. Dr. Feinstein, Ashkan Graham, all can get you pointed in the right direction, you can start by maybe just visiting, just Google those five letters and become a member and get to know the process, but I'll leave you with that. Let's talk about risk assessment. How is risk assessed? So I think sometimes where public health officials go wrong is they, anytime something could go wrong, they call it a risk, but that's not right. There's hazards that become risks and so pianos tend to be pretty safe. It's not a risky activity to play the piano, but where pianos can become risky is sort of, oh, I just pulled this random picture off the internet, anybody, and then if someone is dangling a piano over somebody, you might think, okay, the likelihood of a potential negative outcome increases if that piano is dangling over somebody's head and I sort of look up at these thousand pounds of Epsom salt up here going, what better way to demonstrate hazard versus risk? So if a 50-pound bag is beside me, I'm likely not going to be crushed, but the likelihood increases as I sort of walk over here and so I'm hoping, I'm assuming there's lots of good safety measures in place to prevent that hazard from becoming reality as I stand here. So we don't really deal in pianos in public health, but we do deal with infectious organisms. Here's one called norovirus, and norovirus is a gastrointestinal virus that's very virulent. One to 10 viral particles can make you sick, and what I've got here is that, luckily, you have to get into your mouth and swallow it to make you sick, and so we've got this much more risky because the mouth is open, the mouth is closed here. We could get further into it and know how much gets caught up in the facial hair, but for now, suffice it to say, hazards aren't, we don't regulate to prevent hazards, we regulate to prevent risks, and we struggle. I think we quickly, too quickly jump in public health to that is risky when we haven't done a full hazard assessment first. So if we break down, and again, I'm going to just tell you that the why of why I'm going to call these things unlikely has been covered in other presentations and in the podcast I did with Ashkahn. So if you want to sort of know more about why these, I would describe these potential hazards as unlikely, we can get into that, but the growth of pathogens has been demonstrated to be a low likelihood in your float solution. Ingestion of pathogens because you don't swallow that water, low likelihood of infection because you need to drink those or eat those germs to make you sick. Likelihood of drowning, low, so a couple cases of people drowning, more related in my opinion to the use of drugs, in particular horse tranquilizer, but that's not going to inform risk. That's sort of like explainable for other reasons. Skin infections, there's a little bit of information to show that likelihood of sort of accumulating germs on your skin is low in these settings. We need to do more work there but right now I would describe the likelihood of low. Plus if you have a cut, you're going to cover that because it stings, that's a safety measure that helps. Likelihood of not showering, so pools, we know people don't shower before they jump in. In your environments, we suspect that that rate of showering is much higher before and certainly after because you're going to get that salt off. That's all protective from a public health standpoint. Acquiring a sexually transmitted infection, no documented cases, tell me how that could happen, I don't know, but these are the things public health officials go, that's a risk. And I go, no, you're dreaming about potential hazards here. Let's describe how likely that is, very low. Urinary tract infection, same thing. You might go, well, there's a potential chance for something to crawl up you in that region. Show me some evidence and then we can talk about risk before we jump to that conclusion. Harms of peroxide, public health inspectors aren't really comfortable or all that familiar with the use of hydrogen peroxide in aquatic environments. But think about what we can do with peroxide, we can put it on our cuts, we can put it on our teeth and shine UV light on it to make our teeth brighter. It's a safe compound, safe chemical, especially at the low parts per million concentration you're using. Contrast, that was swimming pools. The likelihood of growth of pathogens, I see it all the time, it's the ideal breeding ground. Even in the presence of chlorine, germs can exist. High likelihood of growth of pathogens in a swimming pool environment. Ingestion of pathogens, we know that you swallow water when you swim. In the amount of milliliters of water ingested per swimming, higher likelihood of that potential hazard happening means better chance of a risk. Drowning. Not all pools are associated with drowning, but definitely the evidence shows that people drown in swimming pools. Skin infection, same thing, likelihood of not showering very high and there's all kinds of studies to show that. You're different than swimming pools at the fundamental level and what's happening is you're being compared at this level and I think that's unfair. Pardon me. So this phrase, risk to risk aversion is something we talk about in public health and we talk about it all over, like constitutional law talks about this as well. I've got the spin bikes. Has anybody here go to spin class at all? You've ever been to one? You've heard about these classes where you spin? So they have that out there and it's like the societal norm to wipe down your bike with a disinfectant wipe after. They show that the inappropriate use of those disinfectant wipes on environmental surfaces actually increases the chance of growth of that germ you're trying to kill. And also because these germs transmit their genetic information to each other, increases the likelihood of antibiotic resistance. So if you try to have to take a drug to treat an infection, we're creating in our environment these super bugs and so there's risks to risk aversion. We might think it's, you know, I should wipe this down, but in fact maybe just clean it. You know, you don't need the disinfectant part. Another way to look at risk assessment and this is called a natural swimming pond. We're opening one, not we, but in Alberta, we're opening one of these. It's an outdoor swimming pool. It looks like a swimming pool, but instead of a filter and instead of chlorine in the water, this is a wetland that it's filtered through. So the wetlands are aquatic bacteria, the pathogen is out of the water, and then it passes by UV light and goes back into the water. So this is a non-chlorinated swimming pool and that's going to blow the minds of some health regulators, but how is this made possible? And again, this is present in Alberta. It's present in Minneapolis as well and throughout Europe. And what you can do this, if you do your own risk assessment on these particular situations, and this is what they look at. They have a quantitative microbial risk assessment and what they do is they look at the hazards, like what could go wrong here? What are we concerned about? What organisms are out there? How many organisms? So let me move down to dose response. How many organisms are needed to make me sick in a typical Baylor? And then you talk about exposure. So yeah, there's these organisms in the water, but can they get into the body to make you sick? You need to do that particular assessment. And from there, you characterize risk and you start to put in different measures to keep it safe. So there's another way to look at flotation, I think, and this might be the way to do it. What can you do? You know, we're here to help you. What can we do? What can you do for me? Play a role in the precautionary principle. So you need to do your part as an industry to tell us at Public Health that you're safe and then I think you need to support a unified voice. There was this article that came out in eastern Canada. 25% of people reported that they shower before they go into swimming pool. Only 25%. So 75% of visitors to this public swimming pool don't shower before they go in. I have this feeling that your rate of showering is much higher. And I'm encouraged to hear that some facilities are looking at that. You could do a simple, you don't need a scientific study design other than maybe a survey of your clients, maybe through the FDA that says that did you shower today? Yes or no? But a compliance rate that's, I suspect to be 85% or higher that people shower before and after, that's all protective. And you know what it does? It differentiates you from the swimming discussion. Another one is, and we've heard about it today, is I think your industry needs to get the health benefits of your service in front of us in a better way. So we don't, I've talked to my colleagues and I'll say, you know, there's a lot of evidence emerging that this is a healthy activity. It keeps people out of hospitals, keeps people away from prescription drugs. That's all part of the health discussion too. And we don't really know about that. So I encourage that sort of work and I'm excited to hear what's happening there. And then I think suppliers can step up by saying, you know, before you buy a tank, you should ask the question, does this kill germs? I know it's got a UV lamp and an ozone and a filter, but do germs live in here and what's the germ reduction? I think we could start to market our materials better to people like me so that I know that if I'm going to buy any piece of equipment, it's going to do what I hope it does. Another example of that might be ultraviolet light. So a lot of systems have ultraviolet light, but we don't really know is it transmitting any light through the tubes where the water is passing through. So there's some work to do there. Unified voice. And we're going to cross the streams, right? We're going to, if you want to deal with the CDC and the NSF, you need a unified voice. I do believe that and you've got a very committed board at the FDA and voices at the Folk Collective and other organizations that can help with that, and I think we should support that. It helps me as a regulator knowing what the community is and who represents it. And finally, I want to leave you with this, is to understand hazards and risks and don't be afraid to challenge the assumptions that I might make about your industry. I just want to say thank you again. I know I'm sort of the outsider here, but it's a common vision and that is healthy people. And we have to keep in mind that we're not on dissimilar paths here. Thank you so much for having me again. Thank you.