Rebuking the city’s health commissioner, two pediatricians with longtime practices in fervently Orthodox neighborhoods this week said that Dr. Thomas Frieden has failed to convince them that a controversial circumcision procedure practiced in those communities is endangering the health of infants.
Drs. Robert Adler and Steven Styler said Frieden has not proven a link between metzitzah b’peh, in which the mohel sucks the blood orally during circumcision, and life-threatening herpes in newborns.
Frieden last week issued an unprecedented “open letter to the Jewish community” warning parents against allowing mohels to use metzitzah b’peh, linking the practice directly to seven cases of herpes among baby boys from the fervently Orthodox community.
One case was in 1988, another in 1998, and five cases occurred over the past two years, three of them traced to one mohel, Rabbi Yitzchak Fischer. One of the infected babies died and another has suffered brain damage.
“I’m aware of a couple of isolated cases, but am not aware that there have been sufficient cases for me to agree with [Frieden],” said Styler, whose office is in Borough Park, Brooklyn. “It’s too bad that the documented number of cases cannot be more firmly established. The question is whether it’s common enough to pose a real risk. The number that would be? I’m not prepared to offer an opinion.”
Health Department spokesman Andrew Tucker said this week that the number of cases, along with the timing of the first symptoms of blisters in the genital area within days of the boys’ brises, proves a link to metzitzah b’peh.
“Statistically, with an estimated 30 cases of neonatal herpes in New York City per year, even a single case resulting from metzitzah b’peh contributes significantly,” Tucker said. “Since approximately 10 percent of all neonatal herpes cases occur after delivery, in New York City this would be three cases per year. A single case due to metzitzah b’peh would be even more statistically significant.”
Herpes is most commonly spread to babies from their mothers during birth, when the newborns come into contact with ulcers in their mothers’ genital areas.
Herpes Type 1 is not the variety usually described as a sexually transmitted disease but rather in healthy adults causes nothing more than cold sores. In people with weak immune systems, as all newborns have, it can cause meningitis, liver damage and even death.
In legal papers it filed several months ago, the Health Department said newborns that contract the disease suffer a mortality rate of about 30 percent.
Most adults have contracted herpes Type 1 by the time they are 40, and some can pass on the virus even when they are showing no signs of mouth sores.
The Health Department, in an advisory to physicians last week, warned that as many as 20 percent of babies who contract herpes may not develop skin lesions, “so providers must maintain a high index of suspicion for herpes infection following circumcision which includes metzitzah b’peh.”
Styler and Adler are on the medical advisory committee of an organization of fervently Orthodox mohels called the American Board of Ritual Circumcision, and have long experience caring for children from haredi communities.
Adler, who has offices in Borough Park and Williamsburg, was asked by the family of one of the boys who contracted herpes this year whose case has been cited by the Health Department to examine the baby at Maimonides Medical Center about a month ago, “even though the infectious disease person there didn’t think that his lesions were consistent with herpes,” the doctor said.
If it was herpes, Adler said, it may have been caused by a member of the baby’s family who had a cold sore and unwittingly transmitted it to him while changing his diaper, if the adult had touched his or her mouth with their fingers and then touched the baby’s genital area.
Tucker said that in this and the other cases cited by the Health Department, “the medical circumstances are inconsistent with infection acquired at delivery, in the newborn nursery or from caretakers.”
These herpes cases, he said, “are consistent with acquisition at circumcision” because of their timing and the location of the herpes sores, among other things.
Another doctor on the medical advisory committee of the American Board of Ritual Circumcision said he takes the health commissioner’s warning against metzitzah b’peh very seriously.
“It’s not a healthy practice because of transmission of herpes,” said Dr. Edward Gindi, who serves a largely Sephardic clientele in the Midwood section of Brooklyn. When mothers come in with their baby boys for the first visit after giving birth, “I advise them to avoid it,” he said.
The metzitzah b’peh technique is used only in the fervently Orthodox community. Out of concern over the transmission of disease, mohels serving other segments of the Jewish community have for decades used sterile glass tubes or sterile gauze for suctioning instead.
Mohels who maintain the practice believe metzitzah b’peh has been mandated by God and used safely since the time of Moses.
They also believe that the city has not proven its case, said Romi Cohen, chairman of the American Board of Ritual Circumcision, which has certified three dozen mohels, most of whom employ the practice.
Cohen formed the organization about a year ago, he said in an interview, out of concern for the professional standards and skill among mohels. His members are required to submit blood tests twice a year proving that they have not contracted herpes, HIV or hepatitis B, he said.
David Zwiebel, executive vice president of Agudath Israel, an organization that represents the interests of the fervently Orthodox community, estimates that metzitzah b’peh is performed more than 2,000 times a year in New York City.
The group issued a statement this week criticizing the Health Department for “a highly objectionable use of Departmental authority” when it issued last week’s statement, an “unprecedented and highly selective use of its bully pulpit authority to publicly attack a millennia-old practice.”
About a year ago the city started investigating Rabbi Fischer. In another unprecedented move, earlier this year the Health Department turned that case over to a religious court in Williamsburg to adjudicate.
When the bet din did not issue a ruling by an agreed-upon deadline of Dec. 1, the Health Department issued its statement.
Department officials said last week they also felt compelled to issue the statement by the discovery of two new cases this year they believe were caused by a mohel using metzitzah b’peh.
One of those babies is thought to have suffered brain damage; the other is believed to be recovering.
Tucker said this week that the babies’ families are not cooperating with the investigation and the Health Department has been unable to learn which mohel or mohels may be responsible.
“We have made many attempts with multiple potential sources to obtain information” about the circumstances of the babies’ infections, he said.
In a statement issued late last week, the Central Rabbinical Congress of the U.S.A. and Canada, as the Williamsburg religious court is known, said it “is nearing a decision concerning a mohel mentioned in earlier reports and the broader safety questions raised by the Health Department.”
In the next paragraph, however, the court reiterated its long-held stance that “we believe that continuing the religious practice of metzitzah b’peh is highly safe.”
And while Frieden last week urged new parents to consult with their pediatricians about the practice, the rabbinical court tried to direct them back to religious authorities.
“We will work with expectant mothers and fathers in our community to urge them to consult with their rabbis as they approach the blessed event of celebrating a bris for a newborn boy,” the statement said. n