Representatives from the New York City's Department of Health and Mental Hygiene and representatives of ultra-Orthodox Jews are meeting this week to try to resolve a controversy over an ancient circumcision practice called metzitzah b'peh (“suction by mouth”).
The health department says the practice led to the death of one newborn boy from herpes simplex type 1 and caused brain damage in another. Seven cases of herpes have been linked to the practice since 1998. Three of the five recent cases were traced to one practitioner (called a mohel).
In metzitzah b'peh, the practitioner removes the baby's foreskin and then sucks blood from the wound to clean it. The practice is used only by a section of the ultra-Orthodox Jewish community. Doctors who favour and those who oppose the custom will meet with the health department and herpes experts.
New York's health commissioner, Dr Thomas Frieden, told the BMJ, “We're trying hard to protect the public's health without taking actions that would so alienate part of the community as to make future efforts to protect health in this community impossible.”
The furore arose when New York's current mayor, Michael Bloomberg, was running for re-election last year. The large Orthodox Jewish community usually votes as a bloc. Bloomberg is a public health advocate who donated millions to Johns Hopkins University, which named its school of public health after him. Both the mayor and the health commissioner are Jewish.
In November 2004 the health department was notified of the three newborns with herpes, one of whom died. All had been circumcised by a practitioner whom the department calls mohel B. He eventually agreed to blood testing (the results have not been released) and agreed not to perform metzitzah b'peh. Rabbinical authorities were to investigate and inform the health department, but they have not yet done so.
The ultra-Orthodox community lobbied the mayor, saying freedom to practise their religion was guaranteed by the US constitution. The community includes survivors of the holocaust and their descendants. “We chose America because of religious freedom,” Rabbi David Niederman told the New York Times (2006 Jan 6:A1). Many believe that if a metzitzah b'peh circumcision is not performed, the boy is not truly Jewish.
Because religious circumcisions are usually done eight days after the birth in the parents' home, it is not clear how often metzitzah b'peh is performed. Estimates range from 2000 to 4000 each year in New York City. A ban would be impossible to enforce.
The health department learned of two more babies infected with herpes, and last month Dr Frieden issued an open letter to the Jewish community recommending against metzitzah b'peh (www.nyc.gov/html/doh/html/std/std-bris.shtml) and alerted healthcare providers. The community persuaded one mohel to stop doing metzitzah b'peh but prevented the health department from learning the second mohel's identity.
Some in the community deny a link between metzitzah b'peh and herpes. But the health department says that the infants developed herpes eight to 10 days after circumcision, several mothers tested negative for herpes virus 1, the virus is found in the mouths of most adults, and the herpes sores on the infants' genitals and buttocks suggests the infection was introduced at the genitals.
According to Jewish Week, a New York publication, “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” (Jewish Week, 23 December). (See p 183.)