Doctors Say Circumcision Ritual Still Not Safe

By Steven I. Weiss

Published December 15, 2006, issue of December 15, 2006.
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A long-simmering dispute over a controversial circumcision procedure with allegedly life-threatening risks will land like a hot potato on the desk of incoming New York state Governor Eliot Spitzer this January, after the administration of outgoing Republican Governor George Pataki reached an agreement with Hasidic leaders on precautions that medical experts say will do little to reduce the risks.

The circumcision procedure, known in Hebrew as metzitzah b’peh, is alleged by New York City health officials to have caused at least seven herpes infections in newborn infants in recent years, at least one of which resulted in death. Investigators linked the infections to a form of the circumcision ritual in which the mouth of the circumciser, or mohel, is applied directly to the infant’s circumcision wound to suck the blood away from the cut, as mandated by the Talmud. Most mohels today use a sterile tube to draw away the blood, but direct oral suction is common in Hasidic and other ultra-Orthodox communities.

The practice made headlines in early 2005, after three neonatal herpes cases, one of them fatal, were traced by investigators to a single mohel. New York City Health Commissioner Thomas Frieden spoke out against the practice and obtained a temporary injunction barring the mohel from practicing within city limits, sparking a dispute with ultra-Orthodox community leaders who insisted the ritual was safe.

The state Health Department issued its own ban on the mohel in February 2005, but withdrew it in April, after receiving a written assurance from a Hasidic businessman, Jacob Spitzer, that the community was instituting its own self-policing procedures, according to documents obtained by the Forward.

Frieden briefly considered relaxing his ban, but reversed himself in November, after an infant was hospitalized with a herpes infection that had spread to his spinal column according to sources in the city government and the Orthodox community. The state health commissioner, Antonia Novello, reached an agreement in separate negotiations with Hasidic leaders in June to continue under an agreed-upon safety protocol. However, an investigation by the Forward has found that the protocol adopted by Novello relied on measures that medical experts say would do little to reduce the risk of orally transmitting the herpes virus.

Novello, a Republican, served as surgeon general in the late 1980s, during the first Bush administration. She was appointed New York state health commissioner in 1999 by Pataki, who later touted her as a “strong candidate” to challenge Senator Hillary Clinton for re-election. Pataki has been known for his extremely strong ties to the Orthodox community since his days as a state senator, when he represented heavily Orthodox Rockland County.

State records show that at her January 18 meeting with Hasidic leaders, Novello proposed a protocol closely mirroring suggestions that had been circulating for months in the Hasidic world. Among other procedures, she proposed placing the anti-viral drug Valacyclovir on the circumcision wound. The drug is used to treat herpes symptoms in those carrying the virus, and experts say it has no impact on the transmission of the virus. The final protocol eventually announced in Albany last spring removed the Valacyclovir suggestion but included several other measures — including an antibiotic ointment — that experts consulted by the Forward insist do not significantly reduce the risk of herpes transmission.

Authors of the three medical papers cited in Novello’s protocol in support of its conclusions said they were not contacted by Novello’s office when it developed the protocol. Those authors and their associates emphasized in interviews with the Forward that the measures recommended by Novello would not make the ritual safe from neonatal herpes infection.

One paper, from the federal Centers for Disease Control, is cited as demanding that mohels wash their hands with antibiotic soap. Dr. Arjun Srinivisan, a CDC expert who commented on the paper, said that hand-washing does not “specifically address the issue of herpes transmission,” since “the primary risk for transmission during this procedure is from the mouth.”

In cases where an infection develops after circumcision but a viral DNA match does not conclusively show that the mohel is its source, the protocol requires the mohel to take Valacyclovir if he intends to continue performing the ritual. The author of the paper cited for this measure, Dr. Lawrence Corey, the head of virology at the University of Washington, said that Novello was making at best “an inference” from his work. “It’s probably not unreasonable to think that taking this antiviral will reduce transmission,” Corey said, “but acknowledging that, you’re only reducing it 50%.”

The protocol also cites the work of Dr. Timothy Meiller, an oral-surgery expert at the University of Maryland, to support the document’s major anti-herpes measure: rinsing the mohel’s mouth with Listerine prior to the ritual. Of the experts interviewed, Meiller was the most critical of the protocol and the most emphatic that his work was misapplied. He described the Novello protocol as “saying, ‘I’m going to use some superficial technique and say I’m now okay.’ You’re not.” Asked what he would have told Novello if she had called him before using his paper, he told the Forward: “I would have said that I didn’t think it was enough data to make a decision on anything.… It’s like having unprotected sex.”

Frieden, the city health commissioner, has voiced his own concerns. In a letter to Novello, obtained by the Forward, that was dated just a few days before she announced the protocol, Frieden stated four “fundamental concerns.” They included the lack of certain better-proven prevention methods; an investigation procedure that “implies that a community can stipulate how to conduct an investigation and may be justified in not cooperating”; an “approach to culture and molecular analysis [that] has many fundamental problems”; and “that the children of parents for whom metzitzah b’peh is not considered religiously necessary may undergo this procedure without the knowledge and/or request of both parents, and this is not addressed by your protocol.”

In an earlier letter, Frieden had written that “some parents whose infants had metzitzah b’peh say they did not know the mohel would perform it.” Jews outside of the Orthodox community often hire ultra-Orthodox mohels, but are believed to be largely unaware of the practice of direct oral suction.

Moreover, the bulk of the protocol’s requirements had already been in widespread use, according to Hasidic community spokesman Rabbi David Niederman. It thus appears possible that these or similar procedures would have been followed in the instances that Frieden’s office claims resulted in infections.

Novello’s office did not return calls requesting comment for this story. In an earlier interview, spokesman Robert Kenny told the Forward that the protocol had received the endorsement of the state department’s Public Health Council.

According to regulations committee member Dr. Jose Goris, the protocol received unanimous support in a May 12 vote that had been placed on that day’s agenda under the heading “For Emergency Adoption.”

Goris, asked by the Forward if the ritual presents a danger of neonatal herpes infection, responded, “Prospectively, yes.” Asked if there have been actual cases of infection, he said: “I believe so — otherwise we wouldn’t be talking about that.”

Goris said he could not recall being given any specific information about alleged infections or the relative risks of the ritual, including the level of risk if the protocol were followed. He said that the protocol was approved simply because “It doesn’t take a lot of science to determine that sterile techniques are important to avoid disease’s spread.” Goris said he did not know how or whether the protocol would reduce the specific risk of herpes transmission.

A fourth expert cited by Kenny as having been consulted in developing the protocol, Stephen Strauss of the National Institutes of Health, did not respond to repeated requests for an interview.

Niederman, the Hasidic leader who helped negotiate the agreement on the protocol, told the Forward that Novello’s protocol is “a victory for religious freedom.” Niederman, who heads the United Jewish Organizations of Williamsburg, said he is convinced that the ritual presents no danger of infection, an opinion he believes Novello shares.

Novello’s spokesman, Kenny, asked in an earlier interview how dangerous the ritual might be, replied: “I don’t think ‘dangerous’ is the right word.”

Although Niederman and other Hasidic leaders maintain that the ritual presents no risk of infection, they have repeatedly spoken in meetings with officials of self-regulatory measures they have instituted to limit risk. Following a reported case of infection in 1998, the administration of then-Mayor Rudolph Giuliani allowed the community to regulate a Hasidic mohel who continues to perform circumcisions but has someone else perform the suction ritual, according to Niederman and several government sources.

Asked how he could reconcile his view that the practice is not dangerous with the enforcement against that mohel, Niederman said he would not speak in detail about the mohel’s situation.

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