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. Many additional instances occur in other areas with substantial populations of ultra-traditional Jews, such as Rockland County.
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. n