Saturday, December 17, 2005
New York City official Government web-site puts out Metzitza warning
The New York City official web-site, nyc.gov, put out a warning against Metzitza B'peh in their health section. The site warns parents of the dangers that can come from Metzitza B'peh being performed on their child and that not all Mohalim perform Metzitza B'peh.
http://www.nyc.gov/html/doh/html/std/std-bris.shtml
The New York City official web-site, nyc.gov, put out a warning against Metzitza B'peh in their health section. The site warns parents of the dangers that can come from Metzitza B'peh being performed on their child and that not all Mohalim perform Metzitza B'peh.
http://www.nyc.gov/html/doh/html/std/std-bris.shtml
Comments:
Its about time they put out this warning.
This is no different then the FDA puttting out a warning against Vioxxin or any medical item or procecudure that has even a remote possibility of a major health concern.
After all we are Mechallel Shabbes which is a deorysa to treat people .
Ask your friendly Hatzoloh neighbor if this is true even on a SOFEK Or not.
This is no different then the FDA puttting out a warning against Vioxxin or any medical item or procecudure that has even a remote possibility of a major health concern.
After all we are Mechallel Shabbes which is a deorysa to treat people .
Ask your friendly Hatzoloh neighbor if this is true even on a SOFEK Or not.
Comment Credit ---This article posted by 
: December 18, 2005 9:30 AM
: December 18, 2005 9:30 AM
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.”
Debra Nussbaum Cohen is a staff writer.
Larry Cohler-Esses is editor-at-large.
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.”
Debra Nussbaum Cohen is a staff writer.
Larry Cohler-Esses is editor-at-large.
Comment Credit ---This article posted by : December 18, 2005 11:25 AM
: December 18, 2005 11:25 AM
can some one give me the palce where halacha speaks about mezizah bepeh, someone asked me where it is found in the torah
Comment Credit ---This article posted by : December 19, 2005 12:39 PM
: December 19, 2005 12:39 PM
hare is An Open Letter to the New York City Health Commissioner from a member of the Jewish Community
Chanukah came early this year, with the gift of your Open Letter to the Jewish Community. How apt that, in the season of Chanukah, when we are asked to remember the Jewish revolt against the cultural tyranny of pan-Hellenist “enlightenment,” an officer of the City of New York has issued an all-points warning on the “dangers” of a Jewish religious practice which has been performed unfailingly – and safely – for over 3700 years.
In this widely distributed letter, your stated purpose is “to clear up misinformation, and to make clear that in the Department’s view there is no reasonable doubt that the practice of metzizah b’peh (suction by mouth) has infected several infants in New York City [with herpes simplex virus type 1].” Your message: “the Health Department recommends that infants being circumcised not undergo metzitzah b’peh.”
Simultaneously, you issued a not-so-open letter to all five-boroughs hospitals and pediatricians entitled “2005 Health Alert #46: Neonatal infection with herpes simplex virus type 1 following circumcision with oral suctioning.” Here you urge health professionals to broadcast to their colleagues a chilling new rule: all New York City medical providers “must maintain a high index of suspicion for herpes infection following circumcision which includes metzitzah b’peh . . . [and] report all suspected cases of herpes occurring in the weeks following circumcision to the Health Department.”
It stretches the bounds of reason that, notwithstanding the thousands of years and the hundreds of millions of infants which constitute the medical history of metzitzah b’peh, the New York City Department of Health has spearheaded a campaign to isolate it as a cause of a virus which is known to be carried by the vast majority of adults (i.e., potential caregivers of newborns).
The basis of your case: the appearance of the virus in 7 Jewish infants in the last 17 years!
With estimates for the prevalence of hsv-1 running from 70 to 90% worldwide, wouldn’t it seem medically prudent to inform the public about ALL possible sources of this infection, and to urge medical personnel to be vigilant in looking for the early signs of herpes simplex virus type 1 (hsv-1) infection in ALL newborns?
One has to ask why you have focused your hunt for the culprit of this universal bane on a millennia-old practice by a minority segment of the Jewish community.
In answer to this question, your letter catalogues 5 “reasons” for your office’s conclusion that “there is no reasonable doubt” that metzitzah b’peh (mbp) causes hsv-1.
The 5 “reasons”
● “All infants tested culture-positive” for hsv-1. This “reason” merely states the effect: neonatal hsv-1 did occur in certain infants. How does it indicate a cause of the infection? In fact, by your numbers (as stated in “2005 Health Alert #46”), “approximately 70% of persons age 40 and older are infected” with hsv-1. Thus, the source of the infection could be any person among 70% of the adult population who handled the infant. To use this as a basis to claim the sources are the mohels is nothing more than a guess.
● “The location of herpes sores (on infant genitals and buttocks) is very unusual and strongly suggests that infection was introduced at the genitals.” You state that the location of the sores is not limited to the genitals, but conclude that the infection was introduced there exclusively. Could the infection also have been introduced at the buttocks, such as at diapering or bathing, which have nothing to do with any part of the circumcision procedure?
● “Infection is consistent with acquisition of herpes at circumcision.” Since when does “consistency” with a hypothesis lead to its proof beyond any “reasonable doubt”? For hundreds of years, observable phenomena were “consistent” with the earth’s being flat and at the center of the universe. This isn’t a reason – it’s pure speculation. Indeed, given the prevalence of this virus in the adult population, almost anyone changing diapers, bathing the infants or otherwise coming into close contact with them could have been a source “consistent” with the infection. Yet, you didn’t warn parents about nurses, diapers or baths.
● “The medical circumstances are inconsistent with infection acquired at delivery, in the newborn nursery, or from caretakers.” Another guess, another attempt to substitute a form of “consistency” for proof. At least here you honestly describe this item only as “circumstances,” although you don’t even say what they could be. (If inconsistency is the sine qua non for proof, how do you explain cases of neonatal hsv-1 in the New York City area in the last 17 years involving girls, or involving non-mbp circumcisions, or where the mohels tested negative for the virus?)
● “Several mothers tested negative” for the virus, “making it impossible for them to have been the source of infection.” All you tell us here is who’s not the source in “several” cases. What about the other mothers? The fathers? Nurses? Older siblings? Grandparents? For that matter, what about the mohels? Not all of these people were tested. Why didn’t you mention them?
Mohel B
As if sensing the weakness of these “reasons,” you go on to make two other statements, which apparently don’t merit being listed as “reasons.” First, one mohel (the notorious “Mohel B”) was “associated” with 3 neonatal herpes cases, and the “odds [of this] . . . are infinitesimally small.”
There are problems here which you neglect to mention. First, as the case of this mohel has been widely reported in the press (and since you’ve been pursuing him relentlessly for over a year), you yourself must know very well that in one of these cases the mohel has strenuously denied having done mbp at all. It is noteworthy that this is the only case where this mohel, associated with 3 cases, denied having done mbp. There were, after all, a roomful of witnesses. Shrewdly, you state that this mohel “was associated with 3 cases of hsv-1,” but not necessarily associated with mbp.
Further, you left out another salient and widely reported fact: that the 2 remaining cases of this 3-case set were twins, making it highly likely that whoever was by the first twin was at the site of the other. Statistically, the location for both twins would almost always be treated as a single site.
Thus, since one of these infants was most likely circumcised without mbp, and the other two were twins and therefore a statistically single location, then the odds that the notorious Mohel B was the source of hsv-1 in this set of cases because of mbp is equal to any other cause associated with any other person present.
The “medical literature”
Finally, you state that the connection between mbp and hsv-1 “has been documented in the medical literature.” You go on to say that 3 studies describe 11 cases of hsv-1 “following metzitzah b’peh.” Again, Dr. Frieden, where’s the cause? These cases of hsv-1 undoubtedly “followed” many things – birth, for example, and car rides and exposure to the sun. This is post hoc reasoning - a logical fallacy! Temporal precedence does not establish causation.
In truth, Dr. Frieden, regarding these few studies you cite, is there any evidence proving neonatal hsv-1 was caused by mbp? Your medical literature contains no study designed to establish causation: they are little more than reports of individual cases of Jewish infants with hsv-1 whose bris procedure included mbp.
Risk Rates
According to your Open Letter, there were seven New York cases of neonatal hsv-1 occurring after mbp (although one of those cases arguably was mbp-less, as discussed above). These cases happened over a 17-year period. Estimates regarding the number of mbp circumcisions occurring in New York City range from 2,000 to 4,000 per year. Assuming the number most favorable to your argument (i.e., the lower number of 2,000 mbp’s per year), there were approximately 34,000 mbp’s in the 17-year period during which these cases occurred. Of the 7 cases, you state that one baby died and the other has evidence of brain damage – a total of two instances of what we’ll call “severe illness or worse,” out of 34,000 cases. Rounded to the nearest thousandth, that’s a risk rate for severe illness or worse of 0.0%. For death, it’s even lower – one in 34,000. Rounded, that’s 0.00%.
You state in your letter that the infection is spread “through breaks or cuts in the skin,” and that “newborns have immature immune systems.” If so, the 0.0% risk rate for mbp seems virtually miraculous. Wouldn’t you expect these rates to be higher than zero?
Given the inexplicably low incidence of adverse outcomes associated with mbp, the logical conclusion is that something else is at work in these cases, and that mbp is not the cause of hsv-1 at all. Certainly, it is safe according to medical standards. For example, the Executive Summary of an article published 5 years ago by The National Academy of Sciences (aptly titled “To Err is Human”) states that one study found that “adverse events” occurred in 3.7% of New York hospitalizations. Of these, 13.6% led to death, and more than half of these adverse events “resulted from medical errors and could have been prevented.” Some quick math shows that preventable deaths occurred in New York hospitals at a rate of over 2.5 per thousand, almost 100 times higher than deaths “associated” with mbp.
Of course, our hospitals are safe. But mbp is 100 times safer! Still, there has yet to be an open letter, Dr. Frieden, warning all New Yorkers not to use some – or any – New York hospitals! Further, some childhood immunizations with globally recognized serious risks are even mandated by the State of New York.
Instead of looking for what is wrong with mbp, Mr. Health Commissioner, you could be looking at what’s right with it.
The Not-So-Open Letter
Since my letter to you is truly open, I am attaching a copy of “2005 Health Alert #46,” issued by your Assistant Commissioner and “Director of Surveillance” (now there’s a title that makes us warm all over), and which, unlike the Open Letter, apparently was not issued to community leaders and the media.
There are two very disturbing things about this secret letter. First, it mandates reporting of all herpes infections following circumcisions – all herpes, not just hsv-1; all circumcisions, not just those with mbp. What could your Director of Surveillance be looking for by mandating reporting of neonatal hsv-2, which would only serve to increase the number of reported infections without being in any way related to mbp? And why expand the search to non-mbp circumcisions? Although you profess sensitivity to the religious needs of our community in your Open Letter, might your Secret Letter have a chilling effect on circumcision as a whole?
For that matter, why is your office targeting only hsv following circumcision? Why not just look for all cases of hsv-1? The department isn’t interested in neonatal herpes in girls? Is this a prelude to an “alert” about circumcision, or are you afraid that knowledge about the broad distribution of neonatal hsv in the general population would weaken your position on mbp?
Second, although you acknowledge that “severe illness associated with this practice may be rare” (!), you nevertheless mandate that “providers must maintain a high index of suspicion for herpes infection following circumcision which includes metzitzah b’peh.” Are you at all concerned that maintaining such a high index of “suspicion” might lead to false positives? Especially when you go on to say that such suspicion should apply to “any infant with fever . . . in the weeks following circumcision”?!
Instead of gaining the cooperation of the community you are supposedly serving, your actions are causing fear and suspicion. The Jewish Week recently reported (December 16th) that the families in the two recent mbp cases have been unwilling to identify who performed the circumcisions. And even more unsettling is your reported response: “We are continuing to try to gain their cooperation,” you said. How, one wonders? With your Director of Surveillance?
These new reporting requirements are overbroad (extending to all hsv and all circumcisions) and overreaching (extending into the heart of the doctor-patient relationship; coercing religious choice). They will overburden doctors and hospitals (reporting all fevers after circumcisions?) and may well force new parents away from a practice which is safer than the hospitals themselves.
You say in your Open Letter that you are resisting calls to ban mbp “at this time.” The truth is that the path you have chosen – public alerts and wide-ranging reporting requirements – has effected a de facto ban, if not one de jure.
Ultimately, Dr. Frieden, one needs to say clearly that the citizens of the observant Jewish community live by our own Director of Surveillance, with mandates that have guided and preserved our families for thousands of years. We will do all that is in our power, as we have always done, to preserve the health, safety and hygiene of our children. And we ask you to do what is in your power to take us out of this abusive line of fire. Desist from acting against us, our doctors and our mohels in this egregiously biased manner, and immediately end this wrongful infringement of a private religious practice which is both statistically and historically safe.
A member of the Jewish Community
First day of Chanukah, 5766
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Chanukah came early this year, with the gift of your Open Letter to the Jewish Community. How apt that, in the season of Chanukah, when we are asked to remember the Jewish revolt against the cultural tyranny of pan-Hellenist “enlightenment,” an officer of the City of New York has issued an all-points warning on the “dangers” of a Jewish religious practice which has been performed unfailingly – and safely – for over 3700 years.
In this widely distributed letter, your stated purpose is “to clear up misinformation, and to make clear that in the Department’s view there is no reasonable doubt that the practice of metzizah b’peh (suction by mouth) has infected several infants in New York City [with herpes simplex virus type 1].” Your message: “the Health Department recommends that infants being circumcised not undergo metzitzah b’peh.”
Simultaneously, you issued a not-so-open letter to all five-boroughs hospitals and pediatricians entitled “2005 Health Alert #46: Neonatal infection with herpes simplex virus type 1 following circumcision with oral suctioning.” Here you urge health professionals to broadcast to their colleagues a chilling new rule: all New York City medical providers “must maintain a high index of suspicion for herpes infection following circumcision which includes metzitzah b’peh . . . [and] report all suspected cases of herpes occurring in the weeks following circumcision to the Health Department.”
It stretches the bounds of reason that, notwithstanding the thousands of years and the hundreds of millions of infants which constitute the medical history of metzitzah b’peh, the New York City Department of Health has spearheaded a campaign to isolate it as a cause of a virus which is known to be carried by the vast majority of adults (i.e., potential caregivers of newborns).
The basis of your case: the appearance of the virus in 7 Jewish infants in the last 17 years!
With estimates for the prevalence of hsv-1 running from 70 to 90% worldwide, wouldn’t it seem medically prudent to inform the public about ALL possible sources of this infection, and to urge medical personnel to be vigilant in looking for the early signs of herpes simplex virus type 1 (hsv-1) infection in ALL newborns?
One has to ask why you have focused your hunt for the culprit of this universal bane on a millennia-old practice by a minority segment of the Jewish community.
In answer to this question, your letter catalogues 5 “reasons” for your office’s conclusion that “there is no reasonable doubt” that metzitzah b’peh (mbp) causes hsv-1.
The 5 “reasons”
● “All infants tested culture-positive” for hsv-1. This “reason” merely states the effect: neonatal hsv-1 did occur in certain infants. How does it indicate a cause of the infection? In fact, by your numbers (as stated in “2005 Health Alert #46”), “approximately 70% of persons age 40 and older are infected” with hsv-1. Thus, the source of the infection could be any person among 70% of the adult population who handled the infant. To use this as a basis to claim the sources are the mohels is nothing more than a guess.
● “The location of herpes sores (on infant genitals and buttocks) is very unusual and strongly suggests that infection was introduced at the genitals.” You state that the location of the sores is not limited to the genitals, but conclude that the infection was introduced there exclusively. Could the infection also have been introduced at the buttocks, such as at diapering or bathing, which have nothing to do with any part of the circumcision procedure?
● “Infection is consistent with acquisition of herpes at circumcision.” Since when does “consistency” with a hypothesis lead to its proof beyond any “reasonable doubt”? For hundreds of years, observable phenomena were “consistent” with the earth’s being flat and at the center of the universe. This isn’t a reason – it’s pure speculation. Indeed, given the prevalence of this virus in the adult population, almost anyone changing diapers, bathing the infants or otherwise coming into close contact with them could have been a source “consistent” with the infection. Yet, you didn’t warn parents about nurses, diapers or baths.
● “The medical circumstances are inconsistent with infection acquired at delivery, in the newborn nursery, or from caretakers.” Another guess, another attempt to substitute a form of “consistency” for proof. At least here you honestly describe this item only as “circumstances,” although you don’t even say what they could be. (If inconsistency is the sine qua non for proof, how do you explain cases of neonatal hsv-1 in the New York City area in the last 17 years involving girls, or involving non-mbp circumcisions, or where the mohels tested negative for the virus?)
● “Several mothers tested negative” for the virus, “making it impossible for them to have been the source of infection.” All you tell us here is who’s not the source in “several” cases. What about the other mothers? The fathers? Nurses? Older siblings? Grandparents? For that matter, what about the mohels? Not all of these people were tested. Why didn’t you mention them?
Mohel B
As if sensing the weakness of these “reasons,” you go on to make two other statements, which apparently don’t merit being listed as “reasons.” First, one mohel (the notorious “Mohel B”) was “associated” with 3 neonatal herpes cases, and the “odds [of this] . . . are infinitesimally small.”
There are problems here which you neglect to mention. First, as the case of this mohel has been widely reported in the press (and since you’ve been pursuing him relentlessly for over a year), you yourself must know very well that in one of these cases the mohel has strenuously denied having done mbp at all. It is noteworthy that this is the only case where this mohel, associated with 3 cases, denied having done mbp. There were, after all, a roomful of witnesses. Shrewdly, you state that this mohel “was associated with 3 cases of hsv-1,” but not necessarily associated with mbp.
Further, you left out another salient and widely reported fact: that the 2 remaining cases of this 3-case set were twins, making it highly likely that whoever was by the first twin was at the site of the other. Statistically, the location for both twins would almost always be treated as a single site.
Thus, since one of these infants was most likely circumcised without mbp, and the other two were twins and therefore a statistically single location, then the odds that the notorious Mohel B was the source of hsv-1 in this set of cases because of mbp is equal to any other cause associated with any other person present.
The “medical literature”
Finally, you state that the connection between mbp and hsv-1 “has been documented in the medical literature.” You go on to say that 3 studies describe 11 cases of hsv-1 “following metzitzah b’peh.” Again, Dr. Frieden, where’s the cause? These cases of hsv-1 undoubtedly “followed” many things – birth, for example, and car rides and exposure to the sun. This is post hoc reasoning - a logical fallacy! Temporal precedence does not establish causation.
In truth, Dr. Frieden, regarding these few studies you cite, is there any evidence proving neonatal hsv-1 was caused by mbp? Your medical literature contains no study designed to establish causation: they are little more than reports of individual cases of Jewish infants with hsv-1 whose bris procedure included mbp.
Risk Rates
According to your Open Letter, there were seven New York cases of neonatal hsv-1 occurring after mbp (although one of those cases arguably was mbp-less, as discussed above). These cases happened over a 17-year period. Estimates regarding the number of mbp circumcisions occurring in New York City range from 2,000 to 4,000 per year. Assuming the number most favorable to your argument (i.e., the lower number of 2,000 mbp’s per year), there were approximately 34,000 mbp’s in the 17-year period during which these cases occurred. Of the 7 cases, you state that one baby died and the other has evidence of brain damage – a total of two instances of what we’ll call “severe illness or worse,” out of 34,000 cases. Rounded to the nearest thousandth, that’s a risk rate for severe illness or worse of 0.0%. For death, it’s even lower – one in 34,000. Rounded, that’s 0.00%.
You state in your letter that the infection is spread “through breaks or cuts in the skin,” and that “newborns have immature immune systems.” If so, the 0.0% risk rate for mbp seems virtually miraculous. Wouldn’t you expect these rates to be higher than zero?
Given the inexplicably low incidence of adverse outcomes associated with mbp, the logical conclusion is that something else is at work in these cases, and that mbp is not the cause of hsv-1 at all. Certainly, it is safe according to medical standards. For example, the Executive Summary of an article published 5 years ago by The National Academy of Sciences (aptly titled “To Err is Human”) states that one study found that “adverse events” occurred in 3.7% of New York hospitalizations. Of these, 13.6% led to death, and more than half of these adverse events “resulted from medical errors and could have been prevented.” Some quick math shows that preventable deaths occurred in New York hospitals at a rate of over 2.5 per thousand, almost 100 times higher than deaths “associated” with mbp.
Of course, our hospitals are safe. But mbp is 100 times safer! Still, there has yet to be an open letter, Dr. Frieden, warning all New Yorkers not to use some – or any – New York hospitals! Further, some childhood immunizations with globally recognized serious risks are even mandated by the State of New York.
Instead of looking for what is wrong with mbp, Mr. Health Commissioner, you could be looking at what’s right with it.
The Not-So-Open Letter
Since my letter to you is truly open, I am attaching a copy of “2005 Health Alert #46,” issued by your Assistant Commissioner and “Director of Surveillance” (now there’s a title that makes us warm all over), and which, unlike the Open Letter, apparently was not issued to community leaders and the media.
There are two very disturbing things about this secret letter. First, it mandates reporting of all herpes infections following circumcisions – all herpes, not just hsv-1; all circumcisions, not just those with mbp. What could your Director of Surveillance be looking for by mandating reporting of neonatal hsv-2, which would only serve to increase the number of reported infections without being in any way related to mbp? And why expand the search to non-mbp circumcisions? Although you profess sensitivity to the religious needs of our community in your Open Letter, might your Secret Letter have a chilling effect on circumcision as a whole?
For that matter, why is your office targeting only hsv following circumcision? Why not just look for all cases of hsv-1? The department isn’t interested in neonatal herpes in girls? Is this a prelude to an “alert” about circumcision, or are you afraid that knowledge about the broad distribution of neonatal hsv in the general population would weaken your position on mbp?
Second, although you acknowledge that “severe illness associated with this practice may be rare” (!), you nevertheless mandate that “providers must maintain a high index of suspicion for herpes infection following circumcision which includes metzitzah b’peh.” Are you at all concerned that maintaining such a high index of “suspicion” might lead to false positives? Especially when you go on to say that such suspicion should apply to “any infant with fever . . . in the weeks following circumcision”?!
Instead of gaining the cooperation of the community you are supposedly serving, your actions are causing fear and suspicion. The Jewish Week recently reported (December 16th) that the families in the two recent mbp cases have been unwilling to identify who performed the circumcisions. And even more unsettling is your reported response: “We are continuing to try to gain their cooperation,” you said. How, one wonders? With your Director of Surveillance?
These new reporting requirements are overbroad (extending to all hsv and all circumcisions) and overreaching (extending into the heart of the doctor-patient relationship; coercing religious choice). They will overburden doctors and hospitals (reporting all fevers after circumcisions?) and may well force new parents away from a practice which is safer than the hospitals themselves.
You say in your Open Letter that you are resisting calls to ban mbp “at this time.” The truth is that the path you have chosen – public alerts and wide-ranging reporting requirements – has effected a de facto ban, if not one de jure.
Ultimately, Dr. Frieden, one needs to say clearly that the citizens of the observant Jewish community live by our own Director of Surveillance, with mandates that have guided and preserved our families for thousands of years. We will do all that is in our power, as we have always done, to preserve the health, safety and hygiene of our children. And we ask you to do what is in your power to take us out of this abusive line of fire. Desist from acting against us, our doctors and our mohels in this egregiously biased manner, and immediately end this wrongful infringement of a private religious practice which is both statistically and historically safe.
A member of the Jewish Community
First day of Chanukah, 5766
Comment Credit ---This article posted by : December 26, 2005 7:36 PM
: December 26, 2005 7:36 PM
