Two Jewish infants in New Jersey were recently infected with — but survived — a herpes virus attributed to their ritual circumcisers’ use of an oral suctioning technique that is said to have caused the death of an infant in New York in September.
Dr. Margaret Fisher, chair of pediatrics at Monmouth Medical Center, told the Forward that a newborn boy was admitted to the center within the past month, infected with the virus, known as HSV-1, within days of his circumcision. The other case “was in the last year or two,” said Fisher, a pediatric infectious disease specialist. Both boys had herpes lesions on their genitals but “extremely mild cases,” she said, and both were successfully treated for 10 days with intravenous anti-viral medication.
The two babies were admitted to a hospital close to Lakewood, N.J., which is home to a large ultra-Orthodox community.
News of the New Jersey infections comes amid renewed debate sparked by the report of the baby who died in September of HSV-1, acquired when his mohel orally suctioned his circumcision wound, according to New York City officials. The procedure, known in Hebrew as metzitzah b’peh, was last blamed for causing an infant death in New York in 2006.
The death last September occurred at Brooklyn’s Maimonides Medical Center, and the Brooklyn district attorney, Charles Hynes, said recently that he is conducting a criminal investigation into the matter. Metzitzah b’peh, which is practiced in particular by ultra-Orthodox mohelim, has never been illegal. Asked if Hynes’s investigation meant that the procedure might now be a crime, spokesman Jerry Schmetterer replied, “I don’t believe it is criminal, but I’m not a lawyer.” Pressed further on what law the D.A. believed could have been violated, Schmetterer said, “I’m not saying another word.”
The family of the infant who died in September has declined to disclose to authorities who performed their son’s circumcision, or brit mila.
In 2007, the mohel linked as an HSV-1 carrier to the death of a baby boy was prohibited under Section 16 of New York State’s Public Health Law by the state Department of Health from performing metzitzah b’peh “in and throughout the state of New York.” The mohel, Rabbi Yitzchok Fischer, was also prohibited from engaging in any other practice in which he “[allows his] mouth or oral fluids to come in direct contact with an infant’s genitals…”
But a story posted online by The Jewish Week of New York on March 13 reported that Fischer was taped in a phone conversation within the last two weeks saying it “was not a problem” for him to perform the procedure, in apparent violation of the ban.
Meanwhile, New York State Governor Andrew Cuomo convened a meeting March 12, bringing together state health department officials and ultra-Orthodox leaders. His liaison to the Jewish community, Emily Saltzman, referred questions about the meeting to his press office, which did not respond to multiple messages seeking further information.
The spate of recent cases marks a re-emergence of the metzitzah b’peh issue, which last erupted in 2005 and 2006, after twin boys and an unrelated baby were infected with HSV-1 by their mohel, resulting in the death of one of the infants. While most adults carry the HSV-1 virus, and do so with no serious danger to their health, and often without symptoms, the virus sometimes kills infants, whose immune systems are immature. Modern Orthodox and non-Orthodox religious practice endorses the use of a sterile pipette, rather than the mohel’s mouth, to suction blood from the baby’s circumcision wound. But ultra-Orthodox defenders of metzitzah b’peh say that a circumcision is not kosher absent the oral suctioning. Public health experts and New York City Mayor Michael Bloomberg have strongly criticized the practice on medical grounds.
In 2005 and 2006, Bloomberg and his public health aides tried, but failed, to convince ultra-Orthodox practitioners to desist from using metzitzah b’peh. At that time, city health officials identified Fischer as the mohel who had, unintentionally, infected the three babies with the virus. City authorities filed a civil lawsuit against him but dropped it after meeting with ultra-Orthodox community leaders. The city officials instead turned over the case to the Satmar Hasidic community’s Central Rabbinical Congress, located in the Williamsburg section of Brooklyn. More than a dozen calls over the course of a week to Rabbi David Niederman, a spokesman for that community and the CRC, seeking information about the outcome of that investigation, were not returned.
Following public disclosure of the most recent HSV-1 infant, the New York City Health Department’s spokesman, John Kelly, would say only that “the city and health department are working with members of the community to address this issue.” Asked for details about how they are doing so, Kelly stated in an email, “We don’t yet have further details to share.”
For areas with substantial ultra-Orthodox communities, addressing the issue can be sensitive both culturally and politically. Some health professionals are afraid to antagonize the community. Helene King, a spokeswoman for Sinai Hospital, which serves Baltimore’s large ultra-Orthodox population, declined to answer even a general question about babies with HSV-1 being admitted soon after their circumcisions. “With such a close-knit community as the Baltimore Orthodox one is, I would not want to chance that any family or families would realize they were in an article like this,” she said in an email.
Debate about the practice within the Orthodox community itself is heated.
“There is no requirement to make metzitzah b’peh. The Talmud says plainly it is not part of the ritual but belongs to the medical, post-surgical component,” said Rabbi Moshe Tendler, a medical ethicist and a dean of Yeshiva University’s rabbinical school, where he teaches fourth-year students about circumcision. Tendler, who has a doctorate in microbiology, said, “There is no doubt that insistence on metzitzah b’peh is wrong. I firmly believe that making metzitzah b’peh is a criminal act.”
The procedure’s defenders point to the extremely low number of affected children, considering the the high birth rate for Orthodox families and the number of ritual circumcisions that include metzitzah b’peh. Between 10 and 15 children have been admitted to hospitals in the United States, Israel and Canada with the disease in well over a decade.
The incidence of infection is “certainly a minuscule number,” said Fisher of Monmouth Medical Center. “However, you could make that number be zero by not using your mouth to suction the blood. I want to be culturally sensitive, but it’s hard to be in favor of that practice.”
In Israel, the state’s chief rabbinate recommends metzitzah b’peh, but does not require it. Most mohelim use a sterile pipette. In the past year in the Jewish state there have been three cases of HSV-1 reported in connection with infant circumcision, but all the babies made full recoveries.
A paper published in the Haredi journal “Dialog” shortly before the Brooklyn baby’s death was made public says that other possible sources of HSV-1 include parents and health care workers. The paper’s author, Dr. Daniel Berman, an infectioius disease specialist, challenges public health officials’ conclusion, identifying mohelim as the source of the infection.
Berman, along with other defenders of oral suctioning, argue that such an identification is invalid absent a genetic DNA analysis matching the baby’s HSV-1 virus to that of the mohel suspected of having given it to him. Short of such proof, they say, there is no reason to refrain from the practice.
Some defenders of the practice argue that the danger of infection can be reduced significantly through the use of antiseptic mouthwash. But Fisher said there is no practical way of preventing transmission of disease when oral suction is used. “Other than the mohels being on constant antiviral medication, there is nothing they can do except not do the practice,” she said.
No Jewish source interviewed for this article advocated government regulation of any aspect of brit milah. Several said that public health officials should work within Orthodox communities to contain the incidence of babies being infected by their mohels.
“The best thing would be to focus on an intra-community education effort. I know there are Haredi [ultra-Orthodox] physicians trying to re-educate the public to make them more aware” of the risk, said a medical doctor in Boro Park, who insisted on anonymity. “You need a critical mass of rabbis who will set off a chain reaction.”
Contact Debra Nussbaum Cohen at firstname.lastname@example.org. Nathan Jeffay and Larry Cohler-Esses contributed reporting.