Capital (New York)
Janauary 9, 2015
While New York City remains stalled in its efforts to
come up with a better way of regulating a controversial circumcision
ritual practiced by some Orthodox Jewish sects, Rockland County health
officials made a deal with a local community to create a protocol to
assess and mitigate risks associated with the practice.
The ritual, called metzitzah b'peh, involves a mohel—the
practitioner of the circumcision ritual—suctioning blood from a baby's
wounded penis with his mouth. The practice of placing mouth to open
wound has been linked by city health officials to the spread of Herpes
Simplex Virus-1 to babies.
The protocol worked out in a nonbinding agreement
between health officials and community leaders in Rockland County—home
to one of the state's largest concentrations of ultraorthodox Jews—is
as notable for what it doesn't attempt do to as what it does.
It doesn't alter the ritual, or require parents of boys
undergoing it to sign a waiver acknowledging the dangers of the
practice, as New York City currently requires. It also doesn't
immediately eliminate the risk of babies contracting herpes from
infected mohels.
But it does, by securing the cooperation of a deeply
religious community that is sometimes hostile to regulation by secular
authorities, allow for testing and data-gathering to identify and ban
mohels who infect circumcised babies with herpes.
Per the agreement between the county health department
and community leaders, if a mohel is found to be the direct source of a
baby contracting HSV-1, then that mohel would be permanently banned
from performing the ritual, according to Dr. Oscar Alleyne, the
county's director of epidimiology.
The Rockland health department has so far tested eight
babies who presented with herpes symptoms after circumcision, Alleyne
said. Of those, three had the virus. In two cases, the Rockland health
department concluded the mohel was not responsible. One case was
inconclusive.
“From Rockland County's perspective, the individuals who
did the metzitzah b'peh were not the ones who matched, and that tells
us we have to look at the bigger picture,” Alleyne said.
It's a very small sample, but the effort attempts to
address, however imperfectly, the health-based concerns about the
practice.
Of the cooperation with the Orthodox community, Alleyne
said, “That in and of itself was a major breakthrough."
Under the system set up in Rockland, if a state lab
determines a circumcised baby has HSV-1, county officials work to
identify all the potential point sources that come into contact with
the infant. Those individuals are then swabbed and tested to see if
they have HSV-1 and if their strain matches the infant's. Because the
virus is not always detectable, the county conducts 60 swabs over a
period of 30 to 60 days to try and ensure that nothing is missed.
The agreement also requires mohels not to perform the
ritual on other babies while testing is taking place, and Rockland
health officials are discussing additional measures that can make the
practice more hygienic.
The community has agreed, according to Alleyne, that if
a mohel is found to be the cause of infection then he will voluntarily
stop performing anywhere in the world for the rest of his life.
The agreement between Rockland and the Orthodox
communities there—the largest communities are in Monsey and New
Square—is similar to one that was discussed with the New York City
health department in 2006. That plan was rejected by the city,
according to court documents.
By only testing mohels after the fact of an infection,
the system can reduce but never actually eliminate the health risk. And
it leaves in place a ritual that is unhygienic and, according to New
York City health officials, among others, inherently dangerous.
But Alleyne says it is clearly the best option available
to the county.
“We are a health department," he said. "We can't
legislate the procedure. We don't have the ability to do so and there
is the question of how efficacious it would be anyway. But there are
ways for us to encourage practices to be safer.”
New York City's efforts to reckon with metzitzah b'peh
would seem to bear him out, in terms of the difficulty of imposing a
more aggressive system of regulation.
The issue has been a live controversy in New York City
since the Bloomberg health department first sought to regulate the
practice by requiring that parents sign a consent form acknowledging
that the city health department does not believe the ritual is safe.
The regulation was challenged in court. Attorneys
representing the Orthodox sects said the city's health department was
overestimating the dangers, and that there was insufficient evidence to
prove metzitzah b'peh is dangerous enough to warrant a public health
intervention.
Mayor Bill de Blasio promised to address the
consent-form arrangement—which the neither the city nor the Orthodox
sects affected by it were happy with—on his
first
day in office. But he has yet to address the topic in any
meaningful way.
Marti Adams, a spokeswoman for the mayor,
told
Capital the administration plans to unveil a policy "soon,"
but did not detail what that policy would be.
"The administration is working to develop a new, more
effective policy that protects children and protects religious rights
in a way that the community is comfortable with, and accepting of, and
will participate in," Adams said. "We expect to announce this new
policy soon.”
The city's efforts to regulate the ritual are
complicated politically by the resolute opposition of the Orthodox
sects who support unfettered metzitzah b'peh, but legally, by courts
rulings that have made it clear that the practice can't simply be
banned for being distasteful.
A
federal
appeals court ruled any city effort to infringe upon the
practice must pass the “strict scrutiny” test, meaning the government
must prove the law serves a compelling state interest and that it was
written in the least burdensome way possible. The case was
sent back to
the lower court and has not yet been heard.
The city's health department has for years warned the
practice can spread HSV-1, which is common in adults but can be
dangerous for newborns.
City health officials have linked 17 cases of neonatal
herpes to direct oral suction in the last 15 years. Of those, two have
died and two more suffered brain damage.
The city maintains the timing and placement of the
lesions is indicative of a virus that was caused by oral suction, and
produced several expert witnesses who supported the claim.
Dr. Anna Wald, who assisted in drafting guidelines on
the management of H.S.V. infection for the Centers for Disease Control
and Prevention, said the evidence linking direct oral suction with
neonatal infection is “strong, consistent, and more than biologically
plausible.”
The health department argues that there are multiple
lines of evidence supporting their assertion. Specifically, health
officials say that no other explanation makes sense.
"Any hypothesis to explain these infections needs to
explain why these infections are HSV-1, not HSV-2, occur on the
genitalia, occur in newborn baby males but not females from Jewish
families practicing direct orogenital suction, are clustered in a
single Brooklyn zip code where there are no female infant herpes
infections, have occurred in babies born to women who do not have HSV-1
infection, and occur within a time frame consistent with transmission
during circumcision," said Jean Weinberg, a spokeswoman with the health
department.
But without reaching an agreement with the mohels the
way Rockland did, the city can't do the tests necessary to prove beyond
a reasonable doubt that infected mohels cause the spread of the
disease.
That's why city officials use phrases such as “the
location … timing of signs and symptoms are consistent with” metzitzah
b'peh.
Between 2006 and 2011, the city reported 84 cases of
neonatal herpes. Among those, 30 boys had HSV-1 or untyped HSV
infection, and five of these boys had confirmed or probable direct
orogenital suction. (The disease can also be passed on to babies by
family members or other caregivers.)
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