A renewed focus on a controversial circumcision technique, which recently has been implicated in one infant’s death and five non-fatal cases of neonatal herpes since 2007, has exposed a rift in the haredi community over the ritual practice.

In a terse phone interview, Rabbi David Niederman, executive director and president of the United Jewish Organizations of Williamsburg, told The Jewish Week that the September death of an infant “had nothing to do with metzitzah b’peh,” or direct oral suction, despite the medical examiner’s ruling that the cause of death was “disseminated herpes simplex type 1, complicating ritual circumcision with oral suction.”

Rabbi Niederman, a prominent member of the Satmar chasidim, went on to say that “we are convinced that there is no connection” between neonatal herpes and metzitzah b’peh. And in response to a question about whether he believed that there has ever been a death or infection caused by the practice, he replied, “No, there has not.” He added, “We will continue to make metzitzah b’peh.”

Rabbi Niederman’s comments stand in stark contrast to statements made by Rabbi Shmuel Kamenetsky, the founder and dean of the Talmudical Yeshiva of Philadelphia and a senior member of Agudath Israel’s Council of Torah Sages, the prestigious haredi rabbinical policy-making body.

In a phone conversation with The Jewish Week, Rabbi Kamenetsky noted that in his community “as far as I know, they do metzitzah with a tube [a sterile pipette that prevents the mouth from directly touching the wound].”

When asked about rabbis who believe that using a tube is not valid under Jewish law, Rabbi Kamenetsky replied, “Nobody holds like that.” Told of those who make this claim, the apparently incredulous rabbi said only, “I don’t think there’s a response to them.”

The rabbi also expressed disbelief about those who would insist on the practice despite its links to the transmission of disease to infants.

“Chas v’shalom [God forbid], if [children are] getting sick [from oral suction], [you] wouldn’t do it,” under Jewish law, he said.

For its part, the Agudah, the haredi umbrella group, has never explicitly denied the risk of herpes transmission through metzitzah b’peh. But its spokesman, Rabbi Avi Shafran, recently told The Jewish Week that “to scientifically assess the risk … one would have to have more [information] than a number like the 20 [cases The Jewish Week counted in the literature],” namely the total number of metzitzah b'peh procedures done over the same time period.

Rabbi Kamenetsky also stated that because it is permissible to do the suctioning with a tube, which poses “no risk at all” to the infant, this should be the practice.

Meanwhile, a paper published in the Winter 2012 issue of the haredi periodical Dialogue — entitled “Is Metzitzah bePeh Dangerous?” — has apparently become a reference for those seeking to defend the practice.

The paper, by Dr. Daniel S. Berman, an infectious disease doctor, seeks to challenge those who argue that metzitzah b’peh carries serious helth risks and falls within a tradition of writings that defend against potential government interference for health reasons.

In the paper, Berman, who has a letter in this week’s Jewish Week, attempts to cast doubt on public health officials’ findings linking the herpes simplex virus to a particular mohel — presumably Yitzchok Fischer, who has been tied to at least four neonatal herpes infections, including one death. Berman argues that absent DNA “fingerprinting” that matches the baby’s virus to that of the mohel involved, one cannot claim that metzitzah b’peh was responsible for the baby’s infection.

Dr. Jonathan Zenilman, former president of the American STD Association and professor of medicine and chief of the Infectious Diseases Division at the Johns Hopkins Bayview Medical Center, rejects that argument. In insisting that DNA fingerprinting is the only way to conclusively demonstrate a link between MbP and a case of neonatal herpes infection, Zenilman says, Berman denies “the validity of standard epidemiological methods which are widely accepted by pretty much everyone else.”

In fact, while blood tests can determine if someone is infected with — and thus capable of transmitting — the herpes virus, it is not always possible to obtain the virus’ DNA, which is most likely to be obtained from fresh sores that have not yet scabbed over. “The lack of genetic sequencing to conclusively demonstrate that these are the exact same strains of herpes is not necessary, or even relevant, from a public health standpoint,” Zenilman emphasized.

Even when a mohel does not cooperate with testing — which has apparently happened in several reported cases — causal inferences can be made. “There is a whole paradigm of causal inference in epidemiology,” noted Zenilman, “which includes things like temporal association and biological plausibility,” a term that refers to a cause-and-effect relationship that is consistent with existing biological and medical knowledge.

Indeed, Berman himself seems to acknowledge that Fischer failed to cooperate with an investigation by the New York City department of health, refusing to undergo DNA testing because the city “offered the testing in a way that was extremely unfavorable to the Mohel with regard to his future.”

(Both the city and state departments of health have declined to comment on the investigation into Fischer, who was ordered to stop doing MbP in New York state in 2007; it appears, based on taped conversations obtained by The Jewish Week, he may have defied the order.)

Berman ultimately concludes, based on his summary of reported cases, that there is a “small risk” of herpes transmission through MbP.

However, experts like Zenilman caution that there is likely substantial underreporting of these infections because, for example, recognized cases are not always reported and other cases may not be recognized. “It’s the tip of the iceberg,” Zenilman believes, noting that once a child is infected with herpes, if he survives, he has the virus “for life.”

Without addressing the issue of underreporting, Berman asserts that it is reasonable to assume that any “small risk” of herpes transmission can be eliminated by the mohel rinsing his mouth with Peridex or Listerine, a claim Zenilman calls “nonsense.”

In the second half of the paper, Berman criticizes the New York City health department for declaring that there is “a definite risk of infection” from MbP, and seems to suggest that Jews in particular are being targeted because he “cannot find any recommendations from the Department of Health to members of the Jehovah’s Witnesses faith telling them of the dangers of refusing blood transfusions, which is part of their faith.”

However, there have been numerous cases in which the courts have ruled that the interests of the child and the interests of the state outweigh the parents’ rights to refuse medical treatment, and in some states parents who have declined to seek medical care for their children outside of their own religious treatment have been charged with involuntary manslaughter and endangering the welfare of a child.

In fact, according to Alex Luchenitser, associate legal director of Americans United for Separation of Church and State, though it has not attempted to do so, the government does have the power to ban metzitzah p’beh in the interest of protecting the public health.

“A practice that can cause infants to die or be infected with a sexually transmitted disease is certainly a practice that the government can constitutionally ban, even if the practice is a religious ritual of some sects,” Luchenitser told The Jewish Week.