City Urges Halt To Ritual Practice

Unprecedented open letter says controversial circumcision technique is dangerous; haredim say they won’t heed warning.

In the face of a beis din’s failure to conclude its investigation of a mohel who health officials say transmitted herpes to three babies, New York City’s health commissioner issued an unprecedented public warning Tuesday that a controversial circumcision procedure is endangering the lives of Jewish infants.

“There exists no reasonable doubt that metzitzah b’peh can and has caused neonatal herpes infection,” Dr. Thomas Frieden wrote in “An Open Letter to the Jewish Community” about a procedure routinely practiced by mohels in some sectors of the Orthodox community. “The Health Department recommends that infants being circumcised not undergo metzitzah b’peh.”

But some community leaders in sectors of the Orthodox community where the practice is common indicated they would continue to insist on the procedure as a requirement of religious law.

The letter — the Health Department’s first official warning against the procedure — follows an apparent breakdown in an agreement the department had with a beis din in Williamsburg, Brooklyn.

In September, the city withdrew a lawsuit against a mohel the department concluded had transmitted the disease to three babies on whom he had performed the procedure, including one who died as a result and one who suffered brain damage. It also withdrew a court order barring him from continuing to use the technique.

In exchange, Rabbi Yitzchok Fischer voluntarily agreed temporarily to stop performing metzitzah b’peh. Rabbi Fischer and his attorney dispute that the rabbi was the source of the infection. And a beis din court took up the case for final resolution. But according to Frieden, the beis din, failed to meet the Dec. 1 deadline.

“They’ve since communicated to us that it’s a complicated situation and they’re not sure when they can come back,” Frieden told The Jewish Week. “So rather than let that continue indefinitely, we felt it was important to make clear to the public our own conclusion and position.”

Rabbi David Niederman, liaison for the Williamsburg beis din, said he was “shocked” at Frieden’s reaction to the delay.

“We have set the date, and it might be a little bit later,” he said. “However, I believe that the lines of communication are open, so it’s only a phone call to ask … when would the report be issued. We did not break down the agreement.”

The rabbinical court, he said, “is making a very thorough and broad investigation. They will not leave one stone unturned.”

But whatever the court’s ultimate conclusions about Rabbi Fischer, it will not impact the practice of metzitzah b’peh in the haredi community, said Rabbi Niederman.

“We are convinced that it’s not dangerous,” he said. “Had it been dangerous we would not be performing it, and you know that Hashem [God] would not give something to us that is dangerous.”

In metzitzah b’peh, a mohel orally sucks blood from the site of the genital cut he makes during the circumcision procedure. Not all haredi 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.

But several haredi sects insist Jewish religious law requires the practice. City officials said mohels from these sects may also apply the procedure outside their communities.

Rabbi David Zwiebel, executive vice president of Agudath Israel, an Orthodox umbrella group, estimates that metzitzah b’peh is performed more than 2,000 times a year in the New York City.

Two New Herpes Cases

In his Open Letter, Frieden reviews seven cases of herpes that have occurred locally, including two this year that the letter discloses publicly for the first time.

Health Department investigators have concluded all were transmitted by mohels performing metzitzah b’peh.

According to Frieden, in one of the two new cases, the infant shows evidence of severe brain damage. The case came to the Health Department’s attention in October.

Frieden said in neither case have the families been willing to identify the mohel who performed the circumcision.

“We are continuing to try to gain their cooperation,” he said.

In legal documents filed several months ago the department stated that herpes, which generally causes just blisters and cold sores in healthy older children and adults, is fatal as much as 30 percent of the time in newborns.

Frieden’s warning against the procedure comes more than a year after a cluster of three neonatal herpes cases were attributed to Rabbi Fischer.

Furthermore, The Jewish Week has learned, the warning comes a full five years after two senior pediatricians at Long Island Jewish Medical Center warned the city that metzitzah b’peh was putting the lives of Jewish infants at risk.

Dr. Philip Lanzkowsky, chief of staff of Schneider Children’s Hospital at Long Island Jewish hospital, said he and a colleague reached out to city health officials and members of Brooklyn’s haredi community about the danger in 2000. The physicians acted after determining that two cases of neonatal herpes brought to Schneider Hospital had been caused by metzitzah b’peh.

“I went to Brooklyn myself and met with rabbis and a representative of the Health Department,” said Lanzkowsky.

He said he acted without publicity at the time, explaining, “One of the things we didn’t want to happen was adverse publicity in the general media that might affect [ritual circumcision] in general. We wanted to deal with it in the local Jewish community.”

There is little doubt the city was aware of Lanzkowsky’s warning. In his open letter, Frieden cites Lanzkowsky’s investigation of the two cases, published in the March 2000 edition of the Pediatric Infectious Diseases Journal.

Asked why he thought the city was acting now, Lanzkowsky said, “Obviously they [the community] didn’t heed the first warning.” But after the death of a child last year, “I think the Department of Health, which carries a responsibility here, could not sit quiet.”

Last year the city began to investigate the suspected link to one local mohel of three herpes cases in 2003 and 2004. As it probed the link, some sectors of the Orthodox community lobbied city officials heavily not to interfere with the practice. That effort included a meeting in August between Mayor Michael Bloomberg and prominent members of the Satmar chasidic community based in Brooklyn and Rockland County as Bloomberg was gearing up for re-election.

“We’re going to do a study to 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 one day after the meeting.

‘They Haven’t Banned It’

Frieden issued his statement in two parts: the open letter and a flier titled “Before the Bris: How to Protect Your Infant Against Herpes Virus Infection Caused by Metzitzah B’peh.”

The latter is a one-page “fact sheet” the city intends to distribute directly to new parents at hospitals frequently used by Jewish mothers to give birth, circumventing religious authorities who maintain that metzitzah b’peh is an essential element of brit milah, or ritual circumcision.

The fact sheet introduces options that Jewish parents could have for the ritual circumcision of their new sons — information they might not receive from within sectors of the community insisting on metzitzah b’peh. The fact sheet and letter are also on the Health Department’s Web site, www.nyc.gov/html/doh/html/std/std-bris.shtml.

The flier begins with the statement “circumcision has health benefits,” but goes on to explain how herpes is contracted from mohels who employ metzitzah b’peh and encourages parents to “consider other options.”

It takes aim squarely at arguments offered by some fervently Orthodox community leaders in the last few months claiming the practice is safe.

“There is no proven way to reduce the risk of metzitzah b’peh,” the flier says. “Although a mohel may use oral rinses or sip wine before metzitzah b’peh, there is no evidence that these actions reduce the spread of herpes. A mohel who takes antiviral medication may reduce the risk of spreading herpes virus during metzitzah b’peh, but there is no evidence that taking medication eliminates this risk.”

Other members of the haredi community joined Rabbi Niederman in expressing concern over the Health Department’s action.

David Zwiebel, an attorney and executive vice president of Agudath Israel, an organization that represents haredi interests, said he would have preferred the statement not be issued.

But at least “they have been true to their commitment that they would not regulate the procedure,” he said of Health Department officials. “They haven’t banned it and haven’t required some sort of informed consent, which was an idea on the table at an earlier stage.”

Zwiebel was concerned that the department’s action could harm the haredi community’s public image and serve as a “foundation on which other jurisdictions might choose to regulate the practice, or even New York City might do that at some future date.”

Haredi communities often view government agencies as interlopers meddling dangerously with their internal religious affairs. In this case the Health Department’s statement may prompt some to ask questions of their rabbis, Zwiebel said.

“The most likely reaction is that there will be a general message from many of these rabbonim to their communities whether or not — and probably not — the statement from the commissioner could impact their halachic practice,” he said.

Rabbi Levi Heber is a mohel based in Crown Heights, from the Lubavitch community, where metzitzah b’peh is considered a spiritually integral part of the brit milah ritual.

“The concept of non-Jewish authorities trying to influence certain behaviors should not be accepted by anyone,” said Rabbi Heber. “You never know where it could lead.”

Since the potential health risks of metzitzah b’peh hit the headlines, many clients have brought up concerns about it, Rabbi Heber said. “It’s something that’s been brewing.”

But parents “are sincerely interested in finding out the facts, and with a little bit of explanation they agree to it,” he said.

Rabbi Heber said he has never refrained from metzitzah b’peh because of a parental objection, but has had parents say “ ‘do what you have to do, but I’m not going to be there’ ” to see it.

Rabbi Niederman stressed the huge number of metzitzah b’peh procedures performed with no apparent ill effects.

“There have been seven cases, allegedly over a span of 15 years,” he said. “In Williamsburg alone we have close to 57,000 people. The overwhelming majority is very young, so you’re talking about 120,000 brises of metzitzah b’peh. You tell me, is it safer to give a flu shot or to do metzitzah b’peh?’

But Rabbi Moshe Tendler, a dean at Yeshiva University’s rabbinic school and a professor of biology there, as well as an expert in Jewish medical ethics with a doctorate in microbiology, has long opposed metzitzah b’peh as halachically unnecessary and medically dangerous.

In an interview this week, he said that indications of brain damage in one of the boys whose case is being cited by the Health Department should make people aware of the dangers, besides death, of herpes contracted through metzitzah b’peh.

“I’m convinced that many children have been infected and not diagnosed, and years later they are in special education in the schools and no one knows why,” Rabbi Tendler said.

Dr. Jonathan Zenilman, chief of the infectious disease department at Johns Hopkins Bayview Medical Center in Baltimore, and an internationally renowned expert in sexually transmitted diseases, agrees.

“Because neonatal herpes has a large variety of presentations, it’s quite likely that cases prior to this recent increased awareness were undiagnosed,” he said. “And because neonatal herpes causes encephalitis, the long-term effects of that infection will be lifelong, including neurological impairment.”

Public health policy experts, including Zenilman, say Frieden’s statement is unusually pointed.

“As these things go this is pretty strong,” said Zenilman.

The only reason the city Health Department didn’t impose an outright ban on metzitzah b’peh, he said, is because it would be nearly impossible to enforce, with most ritual circumcisions taking place in private homes and in synagogues.

Dr. John Santelli, a pediatrician and chair of the department of population and family health at Columbia University’s Mailman School of Public Health, said “it’s difficult when there’s a potential clash between religious values and medical information, but it’s really important that parents know, and for the commissioner to take the position that this is a dangerous practice.”

Health departments have learned from dealing with HIV-AIDS that “in public health you have to start with education, with a community and its leaders,” Santelli said. While the health commissioner has broad latitude protecting public health, in some cases amounting to police authority, officials “rarely take draconian measures because it alienates the people you want to work with.”

“The commissioner is now throwing the ball back to the Orthodox community and saying ‘how are you going to respond to this?’ ” Santelli said. “I hope we don’t have another tragedy.”

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