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City Questions Circumcision Ritual After Baby Dies

Published: August 26, 2005 in the New York Times

A circumcision ritual practiced by some Orthodox Jews has alarmed city health officials, who say it may have led to three cases of herpes – one of them fatal – in infants. But after months of meetings with Orthodox leaders, city officials have been unable to persuade them to abandon the practice.

The city’s intervention has angered many Orthodox leaders, and the issue has left the city struggling to balance its mandate to protect public health with the constitutional guarantee of religious freedom.

“This is a very delicate area, so to speak,” said Health Commissioner Thomas R. Frieden.

The practice is known as oral suction, or in Hebrew, metzitzah b’peh: after removing the foreskin of the penis, the practitioner, or mohel, sucks the blood from the wound to clean it.

It became a health issue after a boy in Staten Island and twins in Brooklyn, circumcised by the same mohel in 2003 and 2004, contracted Type-1 herpes. Most adults carry the disease, which causes the common cold sore, but it can be life-threatening for infants. One of the twins died.

Since February, the mohel, Rabbi Yitzchok Fischer, 57, has been under court order not to perform the ritual in New York City while the health department is investigating whether he spread the infection to the infants.

Pressure from Orthodox leaders on the issue led Mayor Michael R. Bloomberg and health officials to meet with them on Aug. 11. The mayor’s comments on his radio program the next day seemed meant to soothe all parties and not upset a group that can be a formidable voting bloc: “We’re going to do a study, and make sure that everybody is safe and at the same time, it is not the government’s business to tell people how to practice their religion.”

The health department, after the meeting, reiterated that it did not intend to ban or regulate oral suction. But Dr. Frieden has said that the city is taking this approach partly because any broad rule would be virtually unenforceable. Circumcision generally takes place in private homes.

Dr. Frieden said the department regarded herpes transmission via oral suction as “somewhat inevitable to occur as long as this practice continues, if at a very low rate.”

The use of suction to stop bleeding dates back centuries and is mentioned in the Talmud. The safety of direct oral contact has been questioned since the 19th century, and many Orthodox and nearly all non-Orthodox Jews have abandoned it. Dr. Frieden said he hoped the rabbis would voluntarily switch to suctioning the blood through a tube, an alternative endorsed by the Rabbinical Council of America, the largest group of Orthodox rabbis.

But the most traditionalist groups, including many Hasidic sects in New York, consider oral suction integral to God’s covenant with the Jews requiring circumcision, and they have no intention of stopping.

“The Orthodox Jewish community will continue the practice that has been practiced for over 5,000 years,” said Rabbi David Niederman of the United Jewish Organization in Williamsburg, Brooklyn, after the meeting with the mayor. “We do not change. And we will not change.”

David Zwiebel, executive vice president of Agudath Israel, an umbrella organization of Orthodox Jews, said that metzitzah b’peh is probably performed more than 2,000 times a year in New York City.

The potential risks of oral suction, however, are not confined to Orthodox communities. Dr. Frieden said in March that the health department had fielded several calls from panicked non-Orthodox parents who had hired Hasidic mohels unaware of what their services entailed.

Defenders of oral suction say there is no proof that it spreads herpes at all. They say that mohels use antiseptic mouthwash before performing oral suction, and that the known incidence of herpes among infants who have undergone it is minuscule. (The city’s health department recorded cases in 1988 and 1998, though doctors in New York, as in most states, are not required to report neonatal herpes.)

Dr. Kenneth I. Glassberg, past president of the New York section of the American Urological Association and director of pediatric urology at Morgan Stanley Children’s Hospital of New York-Presbyterian, said that while he found oral suction “personally displeasing,” he did not recommend that rabbis stop using it.

“If I knew something caused a problem from a medical point of view,” said Dr. Glassberg, whose private practice includes many Hasidic families, “I would recommend against it.”

But Rabbi Moshe Tendler, a microbiologist and professor of Talmud and medical ethics at Yeshiva University, said that metzitzah b’peh violates Jewish law.

“The rule that’s above all rules in the Torah is that you cannot expose or accept a risk to health unless there is true justification for it,” said Dr. Tendler, co-author of a 2004 article in the journal Pediatrics that said direct contact posed a serious risk of infection.

“Now there have been several cases of herpes in the metro area,” he said. “Whether it can be directly associated with this mohel nobody knows. All we’re talking about now is presumptive evidence, and on that alone it would be improper according to Jewish law to do oral suction.”

The inconsistent treatment of Rabbi Fischer himself indicates the confusion metzitzah b’peh has sown among health authorities, who typically regulate circumcisions by doctors but not religious practitioners.

In Rockland County, where Rabbi Fischer lives in the Hasidic community of Monsey, he has been barred from performing oral suction. But the state health department retracted a request it had made to Rabbi Fischer to stop the practice. And in New Jersey, where Rabbi Fischer has done some of his 12,000 circumcisions, the health authorities have been silent.

Rabbi Fischer’s lawyer, Mark J. Kurzmann, said that absent conclusive proof that the rabbi had spread herpes, he should be allowed to continue the practice. Rabbi Fischer said through Mr. Kurzmann that the twin who died and the Staten Island boy both had herpes-like rashes before they were circumcised and were seen by a pediatrician who approved their circumcision. The health department declined to comment on its investigation.

City Risking Babies’ Lives With Brit Policy: Health Experts

Published: October 14, 2005 in The Jewish Week

A renowned expert on sexually transmitted disease denounced as “outrageous” this week the Bloomberg administration’s failure to ban New York City mohels from suctioning blood with their mouths from a baby’s penis in the circumcision rite.

“[It] is a major public health hazard,” declared Dr. Jonathan Zenilman, a professor of epidemiology at the Bloomberg School of Public Health — the Johns Hopkins University education and research center named for New York’s philanthropist mayor, its biggest financial supporter.

Zenilman, who grew up in an Orthodox family in Woodmere, L.I., warned that allowing the practice known as metzitzah b’peh “is actually crazy” due to the potentially fatal danger of transmitting herpes to vulnerable newborns.

A prominent colleague, Dr. John Santelli, chair of the Department of Population and Family Health at Columbia University’s Mailman School of Public Health, joined the criticism.

“Those kids are at very high risk of death and encephalitis,” he said, explaining, “If you cut the skin — as obviously you have to in a circumcision — it increases risk of transmission to the infant. Newborns just don’t have great immune systems, so the worst time to get a case of herpes is in the newborn.”

Metzitzah b’peh, which is practiced routinely by some fervently Orthodox mohels, has been at the center of a case involving Rabbi Yitzchok Fischer, a Monsey-based mohel suspected of having infected three babies with herpes. One of the baby boys died last October.

But the city Department of Health and Mental Hygiene, which began investigating the suspected link of the infections to Rabbi Fischer, agreed not to ban the practice after vigorous lobbying by New York’s fervently Orthodox community, including of Bloomberg. In his re-election campaign, Bloomberg’s TV commercials tout him as a champion of public health.

On Sept. 15 the city withdrew the lawsuit it had filed against Rabbi Fischer and the court order banning him from using the technique, and turned the case over to an Orthodox rabbinical court, or bet din, in Williamsburg, Brooklyn. Rabbi Fischer agreed to stop using the technique pending the bet din’s resolution of the case.

This appears to be the first time the city has turned the adjudication of a public health issue over to a religious body.

Zenilman and Santelli said the narrow focus on Rabbi Fischer is misplaced. They said because Herpes Simplex Virus Type 1 is a very common disease — studies cited by the Health Department in its legal briefs say that 65 percent of Americans have contracted it by age 12 — the potential impact on public health goes far beyond concern over one mohel.

“From a public health standpoint, at the least there should have been a consent decree that this practice would not continue in this community,” said Zenilman, who also heads the Johns Hopkins Center for Reproductive Tract Infections and is president of the American STD (Sexually Transmitted Diseases) Association. “It is within the scope of a public health authority to ban it, and I find it outrageous that it hasn’t been.”

Santelli, who is also a pediatrician, stressed, “This is a public health problem. It’s certainly a dangerous practice from a medical point of view.”

Indeed, legal documents filed in connection with the case by the director of the Health Department’s Bureau of Sexually Transmitted Diseases, state that Herpes Type 1, which generally causes just fever blisters and cold sores in healthy older children and adults, is fatal as much as 30 percent of the time in newborns.

Dr. Susan Blank, the bureau’s director, turned down an interview request from The Jewish Week. Requests for access to the results of the Health Department’s investigation of Rabbi Fischer have gone unanswered.

Rabbi David Zwiebel, executive vice president of Agudath Israel, an umbrella body of ultra-traditional Orthodox groups, has said metzitzah b’peh is probably performed more than 2,000 times a year in New York City.

The New York Times reported in August that Rabbi Fischer had done some 12,000 circumcisions.

Parts of the Orthodox community and Rabbi Fischer’s attorney frame the issue as one of religious practice that should be free from government interference. They question claims that it spreads herpes.

Mohels use antiseptic mouthwash before performing oral suction, they say, and the known incidence of herpes among infants who have undergone it is minuscule.

According to the Times, the city’s Health Department recorded cases in 1988 and 1998, though doctors in New York, as in most states, are not required to report neonatal herpes.

Prominent members of the large Satmar chasidic community, based in Brooklyn and Rockland County, including Rabbi David Niederman, a spokesman for the rabbinical court handling the case, have told The Jewish Week the community will continue the practice. A delegation of chasidic leaders lobbied Bloomberg on the issue in August. Their bloc vote is sought after by mayoral candidates.

“We’re going to do a study and make sure that everybody is safe, and at the same time it is not the government’s business to tell people how to practice their religion,” Bloomberg said on a radio program one day later.

Health Commissioner Thomas Frieden told the Times the city did not intend to ban or regulate the practice, partly because any such an attempt would be virtually unenforceable. Circumcision generally takes place in private homes.

Not all ultra-traditional groups mandate the practice, and the Modern Orthodox-oriented Rabbinical Council of America recommends using a sterile tube and gloves to avoid direct oral-genital contact.

The criticisms by Zenilman and Santelli come in the wake of a paper in the medical journal Pediatrics last year that studied eight cases of baby boys in Israel who developed herpes after their circumcision, “most probably as a consequence of transmission by the mohel’s saliva,” it stated.

“Oral metzitzah after ritual circumcision may be hazardous to the neonate” because it “carries a serious risk for transmission” of the herpes simplex virus, the paper concluded.

Asked its reaction to the experts’ warning this week, the Health Department reissued a statement it released last month:

“Our goal was for Rabbi Fischer to discontinue practicing metzitzah b’peh,” a spokesman said. “He has now agreed to do so. It has always been our preference for the religious community to regulate itself as long as the public’s health was protected.”

While cases of herpes transmission from mohel to baby are rare, they are documented going back as far as an 1811 medical book that detailed an outbreak in Krakow’s Jewish quarter.

Metzitzah b’peh was abandoned by all but fervently Orthodox mohels in the 1950s, when diseases including herpes, syphilis and gonorrhea were shown to be transmitted from mohel to baby.

As with Herpes Type 2 — the kind that results in genital blisters in adults — there is no cure for Type 1, only treatment for outbreaks. The virus can be passed from one person to another even when there are no symptoms, say medical experts.

“It’s often an asymptomatic disease,” Santelli said.

According to Zenilman, “People shed the virus occasionally even without the presence of lesions,” and any immune system suppression, including cancer and HIV-AIDS, can prompt shedding. Even taking inhaled steroids for asthma can prompt someone to unknowingly shed the Herpes 1 virus.

An actual outbreak of lesions can be prompted by trauma to the mouth, like having a dental cleaning, by having a fever for any reason, or being congested, or by exposure to the sun.

“It’s an everyday occurrence,” Zenilman said. “Although an individual can look absolutely healthy and have no illness, they can be shedding virus.”

Transmitting the virus, he said, requires genital-genital contact, oral-genital contact or other direct transmission across mucous membranes, like contact between a herpes blister on someone’s finger and someone else’s mouth.

Rabbi Fischer’s attorney, Mark Kurzmann, has said the infection of the three baby boys — including twins from Brooklyn — which became evident shortly after Rabbi Fischer circumcised them is “nothing more than a tragic coincidence.”

The twins were circumcised on Oct. 16, 2004, and admitted to Maimonides Medical Center eight days later with fever and lesions in the genital area, according to court documents. Two days after that, one of the twins died of liver failure as a result of Type 1 Herpes Simplex Virus.

At about that time, the Health Department became aware of another baby, on Staten Island, who developed signs of herpes infection a week and a half after Rabbi Fischer circumcised him using metzitzah b’peh. That baby was hospitalized for three weeks and recovered after antiviral treatment.

Kurzmann said he had no comment in response to the statements by Zenilman and Santelli.

In a September interview, Kurzmann said “it appears more likely than not that the babies contracted the herpes from someone prior to the bris, or a person other than Rabbi Fischer after the bris.”

That, said Zenilman, is nearly impossible because of when and where on the boys the herpes lesions appeared.

If it had passed from mother to baby during birth, he said, it would have required that the mothers in question had active herpes lesions in the birth canal. The newborns, in turn, would have had sores all over their bodies, not just in their genital areas.

Alternatively, Zenilman said, a mother-passed infection would have caused an encephalitis-like disease, and the baby also would have shown evidence of the disease in his first week of life, before the brit.

It is also highly unlikely another nurse in the hospital or caregiver caused the infection, he said, as that would have required the nurse to spit on the baby’s penis or have direct mouth-to-genital contact that could have infected all three babies.