Statins and cardiovascular conflicts of interest / HealthNewsReview.org

by Brian McFadden for Daily Kos

A compendium of comments on the new statin guidelines from Gary Schwitzer at Health News Review:

I’d like to see a public survey of comprehension of the recent splash of news about new guidelines for heart disease prevention and statin drug use.  Heads must be spinning.Here are some of the pieces that I found noteworthy:

• In the BMJ, Jeanne Lenzer writes, “Majority of panelists on controversial new cholesterol guidelines have current or recent ties to drug manufacturers.”

“The chairman and one of two additional co-chairs of the working panel that wrote the controversial cholesterol guidelines on reducing cardiovascular risk, released last week, had ties to the drug industry at the time they were asked to lead the panel. And, in all, eight of the 15 panelists had industry ties.”

• In an op-ed in the New York Times, Drs. John Abramson and Rita Redberg wrote, “Don’t Give More Patients Statins.”  Excerpt:

“The process by which these latest guidelines were developed gives rise to further skepticism. The group that wrote the recommendations was not sufficiently free of conflicts of interest; several of the experts on the panel have recent or current financial ties to drug makers. In addition, both the American Heart Association and the American College of Cardiology, while nonprofit entities, are heavily supported by drug companies.The American people deserve to have important medical guidelines developed by doctors and scientists on whom they can confidently rely to make judgments free from influence, conscious or unconscious, by the industries that stand to gain or lose.We believe that the new guidelines are not adequately supported by objective data, and that statins should not be recommended for this vastly expanded class of healthy Americans. Instead of converting millions of people into statin customers, we should be focusing on the real factors that undeniably reduce the risk of heart disease: healthy diets, exercise and avoiding smoking. Patients should be skeptical about the guidelines, and have a meaningful dialogue with their doctors about statins, including what the evidence does and does not show, before deciding what is best for them.”

• Medical ethicist Howard Brody wrote “New Cholesterol Guidelines – The Devil in the Details.” Excerpt:

“even if these guidelines were not written by people in the pay of the drug industry, they could just as well have been. And somehow, while important new evidence against the routine use of statins, and suggesting that we really don’t know much about the true mechanism by which these drugs work in the cases where they do, crept into the guidelines for the first time, the bottom line is largely unaffected by such enlightened thoughts. We’re back to putting statins in the water supply.”

UPDATE:  The NY Times informs us that if we are in the 20% having muscle pain from statins, it may be caused by a drug reaction. Perhaps another drug is slowing down metabolism of the statin.
Okay: but if you are having muscle pain, what other side effects might you be having that you didn't notice?  Liver inflammation? Cognitive decline? Do you really want to stay on the statin under these conditions?  Do you really want to get off other drugs?

JFK Assassination: Shot from in Front, Not from Texas School Book Depository/ Surgeon who treated JFK/ CBS News

The scoop on bullet wounds is very simple:  fired from a long distance, the bullet enters an object making a small entry wound, usually the size of the bullet, and leaves the object with an exit wound the same size or, usually, larger.  From the medical website "Explore Forensics":

Exit wounds - as we have already mentioned - are usually larger than the entrance wound and this is because as the round moves through the body of the victim it slows down and explodes within the tissue and surrounding muscle. This slowing down of the projectile means that as it reaches the end of its trajectory it has to force harder to push through. This equates to the exit wound normally looking larger and considerably more destructive than its pre-cursor - the entrance wound. Exit wounds will often bleed profusely as they are larger, but entrance wounds can sometimes look only like small holes...

JFK had the back of his head blown off, as seen in Abraham Zapruder's film (recall Jackie climbing behind the back seat in the heat of the moment to retrieve a large part of her husband's skull).  Now one of the surgeons, who held Kennedy's head in the Operating Room at Parkland Hospital, confirms that the back of the head was missing. That this was an exit wound.  Dr. Robert McClelland further says a colleague, who spoke to the press, was threatened at the time by the Secret Service and never spoke of the assassination again.

The President's vehicle was moving slowly before the shot, so momentum from the car would not propel the large skull fragment backwards with such force.  Two incontrovertible facts:  The fragment went backwards, and the posterior skull wound was much larger than the entrance wound, confirm that Kennedy was shot from the front, not the rear.  Not from behind, where the Texas School Book Depository was located.  Possibly from the grassy knoll.

There is controversy about the Xrays, autopsy, and about so much else.  But the laws of physics are inviolable.  The shot that blew off President Kennedy's posterior skull did not originate from the School Book Depository.

3 Senators Propose NDAA amendment: Congress to be Informed of FISA Rulings in which surveillance agencies were found to be in violation of law / UPI

From UPI and The Hill:

WASHINGTON, Nov. 20 (UPI) -- Three U.S. Senate Democrats are sponsoring a measure they say would require greater transparency regarding National Security Agency surveillance.

Ron Wyden of Oregon, Mark Udall of Colorado and Barbara Mikulski of Maryland introduced the measure as an amendment to the National Defense Authorization Act, which the Senate is debating this week, The Hill reported Wednesday.

The amendment would require the Department of Justice to release rulings by the Foreign Intelligence Surveillance Court in which government agencies were found to be in violation of the Constitution or the law, the report said.

It would require the director of national intelligence to report to Congress on NSA surveillance activities, and to produce a public report with certain sensitive information redacted.

"I'm continuing to fight for comprehensive surveillance reform, but these #NSA reform amdts to the NDAA are action we can take now," Wyden posted on Twitter.

Senate Armed Services Committee Chairman Carl Levin, D-Mich., has said the defense appropriations act is not a suitable vehicle for NSA issues, so it was not certain whether the amendment would get a Senate vote, The Hill said.

Off the Rack Surveillance Technology is Yours to Buy and Use/ Privacy International (UK)

Thanks to NGO Privacy International, we learn that over 300 companies can sell you your own surveillance package, incorporating 97 different technologies.  For example:

Over the last four years, Privacy International has been gathering information from various sources that details how the sector sells its technologies, what the technologies are capable of and in some cases, which governments a technology has been sold to. Through our collection of materials and brochures at surveillance trade shows around the world, and by incorporating certain information provided by Wikileaks and Omega Research Foundation, this collection of documents represents the largest single index on the private surveillance sector ever assembled. All told, there are 1,203 documents detailing 97 surveillance technologies contained within the database. The Index features 338 companies that develop these technologies in 36 countries around the world.

These companies include the following examples, which offer services that include location monitoring (accurate to one meter via your cellphone), intrusion technology, and monitoring centers.  If you pay, you can play.  Unlike the NSA, however, no secret court has issued a classified ruling approving private surveillance.  (At least none that we know of.) However, surveillance trade shows are proliferating here, here and here, selling both snooping and protection from snooping to nations and to private entities. 

Update:  Forbes covers this story today.

---

Featured Companies

Amesys is based in Aix-en-Provence, France and sells Monitoring Centres, Internet Monitoring, Audio Surveillance and Location Monitoring technology.

Gamma Group is based in Andover, United Kingdom and sells Monitoring Centres, Communications Monitoring, Technical Surveillance and Intrusion technology.

Utimaco is based in Aachen, Germany and sells Monitoring Centres and Communications Monitoring technology.

Nice Systems is based in Ra anana, Israel and sells Monitoring Centres, Communications Monitoring, Biometrics and Location Monitoring technology.

Cobham is based in Dorset, United Kingdom and sells Monitoring Centres, Phone Monitoring, Technical Surveillance and Location Monitoring technology.

Hacking Team is based in Milan, Italy and sells Intrusion technology.

DNI Clapper's Document Dump: Important, but Why Now?

About 1,000 pages of heavily redacted documents were released Monday night (yesterday) by the Director of National Intelligence.  Reporters are still sifting through them.  But it is striking that a major finding is that NSA repeatedly overstepped what was legally permissible in its collection of data, and then eventually authorization through FISA would "catch up" to what was being collected, and approve it.  The illegal collection was apparently troubling enough (to people like current FBI Director Comey, for example) that multiple Justice Department officials threatened to resign, because of the illegality.

Now why would DNI Clapper give out this morsel to the press now?  It was said the release was responsive to a lawsuit...  but those have been effectively stonewalled before.  Because of what the executive anticipates being released from the Snowden files?  Because the government intends to use this material to demonstrate its spying is now totally legal... that NSA went through  the right channels... and FISA judges gave all NSA's spying techniques the seal of approval, albeit retroactively. I await the answer to 'Why and why now?'

TheWaPo has a detailed piece on this subject; it concludes with information on the tracking of citizens using cell phone data, something the NSA has said it does not do. However, NSA claims it has the legal authority to do so, and is "considering" collecting local data in the near future:

The newly released memo, which was written in response to questions from the Senate Intelligence Committee, said however that the NSA was considering “acquiring such mobility data under this program in the near future under the authority currently granted by the [FISA] Court.”

Much of the document’s text was blacked out.

But only last month the NY Times reported on DNI Clapper's claims that NSA would not collect location data without further authority and Congressional notification--yet the new documents show NSA believed, unlike what Congress was told, that it already had the authority to routinely track American citizens.

The NY Times quoted ACLU senior attorney Jameel Jaffer, who succinctly pointed out that the FISA court is a "court" in name only:

“This is a reminder a lot of the most important and far-reaching decision of the past decade was issued by this court, which meets in secret and hears only from the government and doesn’t publish its decisions,” Mr. Jaffer said. 

Albania rejects request to destroy Syrian chemical weapons/ Fox

Albanians celebrate on a monument to the national hero Skanderbeg after Edi Rama rejected the US request to host the chemical weapons. Photo: Arben Celi/Reuters

The UN's Organization for the Prohibition of Chemical Weapons (OPCW) has completed its inspection work in Syria on time, and without any major hitch.  All production facilities for chemical weapons have been destroyed.  The US and its allies are satisfied that the chemical weapons Syria was believed to have possessed have been accounted for.

Now all that is left is to destroy the chemical weapons, which include filled munitions and bulk storage of agents.

Syria's government asked that this material be taken outside Syria and destroyed.  Norway agreed to use its ships to remove the items.  Albania was expected to perform the destruction, but major protests against the destruction ensued.  Today it reneged on the deal.

Albania!? Well, it did declare and destroy its own CW stockpile, years back. Thousands of Albanian protesters and Albania's new leader caving to them was a sudden, big surprise.

From Fox, AP and Reuters: 

... "We don't have the infrastructure here to deal with the chemical weapons. We can't deal with our own stuff, let alone Syrian weapons," said 19-year-old architecture student Maria Pesha, echoing the fears of many residents.  "We have no duty to obey anyone on this, NATO or the U.S."

Any destruction of Syria's weapons, wherever it happens, will be overseen by experts from the Hague-based OPCW, which won the Nobel Peace Prize this year for its efforts to eradicate poison gas and nerve agents around the world.

The risky disarmament operation in the midst of a raging civil war started more than a month ago with inspections. Then machinery used to mix chemicals and fill empty munitions was smashed, thereby ending the Syrian government's capability to make new weapons...

From BBC:

 A key meeting of the Organization for the Prohibition of Chemical Weapons (OPCW) - the international watchdog supervising the destruction - had adjourned for several hours in The Hague, awaiting Albania's decision.

From WaPo:

The mission to destroy Syria’s poison gas stockpile was dealt a serious blow Friday when Albania refused to host the destruction, but the global chemical weapons watchdog said it is still confident it can eradicate the arsenal outside Syria by the middle of next year.The surprise refusal by the small and impoverished Balkan country left open the question of where the Organization for the Prohibition of Chemical Weapons would send Syria’s estimated 1,300-ton arsenal, which includes mustard gas and sarin.

New Recs: Twice as many Americans should take statins! /AmerHeartAssn

New guidelines from the American Heart Association and the American College of Cardiology for the use of statin drugs came out on November 12.  This is a very big deal for big Pharma, for doctors and for patients. Health consumers beware!  

The guidelines may lead to tens of millions of healthy, low-risk people being transformed into patients--patients who need statins.  "The change could more than double the number of Americans who qualify for treatment with the cholesterol-cutting drugs known as statins," according to the guideline authors, as reported in the WSJ.

Statins: what exactly do they do?  Statins inhibit the production of mevalonate, a precursor of both cholesterol and coenzyme Q10, a compound believed to be crucial for mitochondrial function and the provision of energy for cellular processes. 

Statins definitely lower cholesterol, and they seem to lower the risk of heart disease in those people who have already had a cardiac event.  But they may also cause muscle pain and muscle weakness, liver inflammation, cognitive impairment, and increase the risk of diabetes.  Furthermore, while taking a statin, you are statistically much more likely to experience one of these side effects than you are to benefit by avoiding a heart attack or stroke.  That might suggest that patients need to be carefully selected for this treatment.

However, calculation of the risk-benefit equation requires adding a third element: pharmaceutical profits, and how they drive research, advertising, and the creation of guidelines.

[UPDATE Nov. 18, from NYT:  Adding insult to injury, it now turns out that the "risk calculator" designed to be used with the guidelines significantly overestimates risk--by 75 to 150%. Simply being an older adult, with no other risk factors, appears sufficient to put most healthy people into a category "who can benefit from therapy".  Last year, the Heart Lung and Blood Institute at NIH removed itself from development of the guidelines, soon after problems with the calculator surfaced.]

Eleven billion dollars was spent on just the two leading statin drugs in the USA in 2011, according to USAT.  Lipitor (atorvastatin) was the US' best-selling drug, and Crestor (rosuvastatin) was #4. [Subsequently Lipitor lost its patent exclusivity and cheaper generic versions became available.  Crestor remains on patent.]

However, Zocor (simvastatin) had been available as a generic for years; why were patients being given the much more costly, brand name drugs?  Another issue re statin prescribing has to do with choosing the optimal dose; experts have recommended pushing up the dose in higher-risk patients, but it is unclear whether evidence supports this.  What is the right dose? No study has shown that a particular target level of cholesterol provides protection from heart disease, which may be why specific target levels were removed from the guidelines just issued.  But instead, the new guidelines suggest most patients should get intensive (high dose) therapy.

Back in April 2011, the Harvard Health Letter provided the following statistics on the dramatic increase in use of statin drugs over two decades of availability.  By 2008, fully 50% of American men between 65 and 74 were being prescribed statins!  


If US doctors follow the new guidelines, a doubling of those on statins will add many $billions more to Pharma's coffers.  The rest of the world is befuddled by the US' addiction to prescription drugs; it will be interesting to see how doctors elsewhere react to these recommendations.

A NYT Op-Ed by doctors John Abramson and Rita Redberg lays out the serious questions surrounding the new recommendations.  Here is an excerpt:

Statins are effective for people with known heart disease. But for people who have less than a 20 percent risk of getting heart disease in the next 10 years, statins not only fail to reduce the risk of death, but also fail even to reduce the risk of serious illness — as shown in a recent BMJ article co-written by one of us. That article shows that, based on the same data the new guidelines rely on, 140 people in this risk group would need to be treated with statins in order to prevent a single heart attack or stroke, without any overall reduction in death or serious illness.

At the same time, 18 percent or more of this group would experience side effects, including muscle pain or weakness, decreased cognitive function, increased risk of diabetes(especially for women), cataracts or sexual dysfunction.

Perhaps more dangerous, statins provide false reassurances that may discourage patients from taking the steps that actually reduce cardiovascular disease. According to the World Health Organization, 80 percent of cardiovascular disease is caused by smoking, lack of exercise, an unhealthy diet, and other lifestyle factors. Statins give the illusion of protection to many people, who would be much better served, for example, by simply walking an extra 10 minutes per day.

Aside from these concerns, we have more reasons to be wary about the data behind this expansion of drug therapy.

When the last guidelines were issued by the National Heart, Lung, and Blood Institute in 2001, they nearly tripled the number of Americans for whom cholesterol-lowering drug therapy was recommended — from 13 million to 36 million. These guidelines were reportedly based strictly on results from clinical trials. But this was contradicted by the data described in the document itself...

Oral arguments next week in 2 cases could torpedo some NSA surveillance/ US News

The first legal cases (outside the secret FISA court and post Snowden) questioning the legality of NSA spying come to the forefront next week.  See the US News piece here.

The first case seeks a broad preliminary injection against "some NSA surveillance programs" and will be heard Monday, Nov 18.  It is a class action brought by Larry Klayman, formerly a Reagan prosecutor and later founder of "Judicial Watch."  He now heads "Freedom Watch".  Oral arguments will be heard by US District Court Judge Richard Leon in DC.

The second, narrower case was brought by the ACLU and seeks an injunction against the collection of phone metadata through Verizon.  Oral arguments will be heard by US District Court Judge William Pauley on November 22 in NYC.

In a November 1 column, Larry Klayman wrote:

Just this week, the Washington Post revealed yet another new outrage of NSA spying on the American people, coming on the heels of revelations that the government has even had the chutzpah to eavesdrop on the cellphone calls of foreign leaders like Germany’s Chancellor Angela Merkel. In an article written by Barton Gellman and Ashkan Soltani in the Post Oct. 30, entitled “NSA Infiltrates Links to Yahoo, Google Data Centers Worldwide, Snowden Documents Say,” they report:

“The National Security Agency has secretly broken into the main communications links that connect Yahoo and Google data centers around the world, according to documents obtained from former NSA contractor Edward Snowden and interviews with knowledgeable officials.

“By tapping those links, the agency has positioned itself to collect at will from hundreds of millions of user accounts, many of them belonging to Americans.

“According to a to a top-secret accounting dated Jan. 9, 2013, the NSA’s acquisitions directorate sends millions of records every day from internal Yahoo and Google networks to data warehouses at the agency’s headquarters at Fort Meade, Md. In the preceding 30 days, the report said, field collectors had processed and sent back 181,280,466 new records – including ‘metadata,’ which would indicate who sent or received emails and when, as well as content such as text, audio and video.

“The NSA’s principal tool to exploit the data links is a project called MUSCULAR. … From undisclosed interception points, the NSA … [is] copying entire data flows across fiber-optic cables that carry information among the data centers of the Silicon Valley giants.

“The infiltration is especially striking because the NSA, under a separate program known as PRISM, has front-door access to Google and Yahoo user accounts through a court approved process…

UPDATE Nov 18:  Without comment, the Supreme Court declined Monday to hear a case challenging the constitutionality of the National Security Agency's vast collection of telephone and electronic data.  The case had been brought by the Electronic Privacy Information Center (EPIC), which had contended that no other court was open to hear a challenge to orders of the FISA Court, so the Supreme Court should consider its case now. Unfortunately, the Supremes did not agree.

The jurisdictional issues of exactly what court, if any, has the right to access all information about NSA spying (which FISA lacks) and the jurisdiction to adjudicate the legality of such spying, should be fascinating... and may determine the survival of democratic traditions in the US.  Judge Leon heard arguments today and will rule later on the jurisdictional issues as he sees them.

Committee to Protect Journalists issues scathing report on Obama administration/ Guardian

Glenn Greenwald (who left the Guardian to start a new online news service Nov 1) has long had a unique ability to pile on the pithy quotes.  This time he outdid himself, simply by quoting from an amazing report written for the Committee to Protect Journalists (CPJ) by Leonard Downie Jr., former Washington Post executive editor.  Here is the CPJ's synopsis. Here are a few of the zingers:

*  James Goodale, the former general counsel of the New York Times during its epic fights with the Nixon administration, recently observed that "President Obama wants to criminalize the reporting of national security information" and added: "President Obama will surely pass President Richard Nixon as the worst president ever on issues of national security and press freedom."

*  Six government employees, plus two contractors including Edward Snowden, have been subjects of felony criminal prosecutions since 2009 under the 1917 Espionage Act, accused of leaking classified information to the press—compared with a total of three such prosecutions in all previous U.S. administrations. Still more criminal investigations into leaks are under way. Reporters' phone logs and e-mails were secretly subpoenaed and seized by the Justice Department in two of the investigations, and a Fox News reporter was accused in an affidavit for one of those subpoenas of being 'an aider, abettor and/or conspirator' of an indicted leak defendant, exposing him to possible prosecution for doing his job as a journalist. In another leak case, a New York Times reporter has been ordered to testify against a defendant or go to jail."

*  New York Times national security reporter Scott Shane was quoted by the Report on Press Freedoms as saying that sources are "scared to death."

*  New York Times reporter David Sanger said that "this is the most closed, control freak administration I've ever covered."

*  New York Times public editor Margaret Sullivan wrote that "it's turning out to be the administration of unprecedented secrecy and unprecedented attacks on a free press."

*  'I worry now about calling somebody because the contact can be found out through a check of phone records or e-mails,' said veteran national security journalist R. Jeffrey Smith of the Center for Public Integrity, an influential nonprofit government accountability news organization in Washington. 'It leaves a digital trail that makes it easier for the government to monitor those contacts,' he said."

The report prefaces its recommendations with the following statement:

CPJ is disturbed by the pattern of actions by the Obama administration that have chilled the flow of information on issues of great public interest, including matters of national security. The administration's war on leaks to the press through the use of secret subpoenas against news organizations, its assertion through prosecution that leaking classified documents to the press is espionage or aiding the enemy, and its increased limitations on access to information that is in the public interest -- all thwart a free and open discussion necessary to a democracy.

Seattle police can track the last 1,000 times your wifi-enabled device looked for a signal / RawStory

Yes, thanks to a tiny $2.6 million grant from the Department of Homeland Security, local Seattle police know everywhere your cell phone, ipad, and laptop have been for quite awhile.  There is likely video of you as well.  The "mesh network" that the police bought is capable of identifying and storing 

"the IP address, device type, downloaded applications, current location, and historical location of any device that searches for a Wi-Fi signal. The network is capable of storing that information for the previous 1,000 times a particular device attempted to access a Wi-Fi signal."

RawStory links to a video from local TV station KIRO7, which ran the same story on its website.  And here is what the City Council was told about the network, including a different cost of $4.875 and the installation of 169 access points and cameras, which might beam footage online.  A city councilman said it isn't "on" yet.  Hmmm.  The company that sold the system, Aruba networks, produced marketing material last year that claims the system, at least one stage, was "quickly deployed and configured in a few days."

Below is what the installations look like. 

 The system serves as both a communications system for police and a data tracking system.

The policy for how the system is to be used and monitored has not been shared with the ACLU (which asked some months back) or the public, yet.

The most detailed story (which also discusses the Seattle PD's two drones) is in the Seattle Stranger.

Long before you board, TSA "searches a wide array of government and private databases" on all passengers--and shares/sells its findings / NY Times

Buy a plane ticket, and TSA not only searches numerous databases about you, but then can share the information with state, local, foreign governments and may even sell the info to debt collection agencies or ???  Thanks to the NY Times for this important piece:

The Transportation Security Administration is expanding its screening of passengers before they arrive at the airport by searching a wide array of government and private databases that can include records like car registrations and employment information.

The prescreening, some of which is already taking place, is described in documents the T.S.A. released to comply with government regulations about the collection and use of individuals’ data, but the details of the program have not been publicly announced.

It is unclear precisely what information the agency is relying upon to make these risk assessments, given the extensive range of records it can access, including tax identification number, past travel itineraries, property records, physical characteristics, and law enforcement or intelligence information.

The measures go beyond the background check the government has conducted for years, called Secure Flight, in which a passenger’s name, gender and date of birth are compared with terrorist watch lists. Now, the search includes using a traveler’s passport number, which is already used to screen people at the border, and other identifiers to access a system of databases maintained by the Department of Homeland Security.

Privacy groups contacted by The New York Times expressed concern over the security agency’s widening reach.

... An agency official discussed some aspects of the initiative on the condition that she not be identified. (It is usually a sure sign you are being duped when paid public officials won't give their name--Nass)

... Civil liberties groups have questioned whether the agency has the legal authority to make these assessments, which the T.S.A. has claimed in Federal Register notices and privacy disclosures about the initiative. Privacy advocates have also disputed whether computer algorithms can accurately predict terrorist intent.

... Much of this personal data is widely shared within the Department of Homeland Security and with other government agencies. Privacy notices for these databases note that the information may be shared with federal, state and local authorities; foreign governments; law enforcement and intelligence agencies — and in some cases, private companies for purposes unrelated to security or travel.

For instance, an update about the T.S.A.’s Transportation Security Enforcement Record System, which contains information about travelers accused of “violations or potential violations” of security regulations, warns that the records may be shared with “a debt collection agency for the purpose of debt collection.”

... For travelers who feel they have been wrongly placed on some type of watch list or experienced security screening problems, the Department of Homeland Security has established a Traveler Redress Inquiry Program. According to a review by the department’s Privacy Office, there were at least 13,000 inquiries to the redress program in the nine months ending March 31, but civil liberties groups and some travelers described the redress process as a black hole.

“A lot of people I know have tried it,” Mr. Darrat said. “And it just doesn’t really make a difference.”

Euro-US Trade Accord Negotiations Now Involve Issue of Data Privacy/ Senator McCain says NSA head should resign or be fired / NY Times

Here is today's NY Times' update on negotiations between Germany and the US on spying; it appears we have not given Germany much besides a promise to leave Angela's phone alone...

Just as European and American negotiators resumed work on a groundbreaking trade accord meant to tie their two continents closer together, René Obermann, the chief executive of Deutsche Telekom, the German telecommunications giant, told a cybersecurity conference in Germany on Monday that his company was working to keep electronic message traffic from “unnecessarily” crossing the Atlantic, where it could fall into the hands of the National Security Agency.

Other German executives, and some politicians, are beginning to talk of segmenting the Internet, so that they are not reliant on large American firms that by contract or court order allow United States intelligence agencies to delve into their data about phone and Internet usage. Europeans are demanding that any new trade accord include data-privacy protections that the United States is eager to avoid. 

Almost never before has a spying scandal — in this case the revelation of the monitoring of the cellphone of Chancellor Angela Merkel of Germany — resulted in such a concrete, commercial backlash. Now it is also driving a debate inside the American government about whether the United States, which has long spied on allies even while nurturing them as partners, may have to change its approach.

“What’s more important?” Gen. Keith B. Alexander, the director of the N.S.A., asked during an interview last month, before the Merkel revelations. “Partnering with countries may be more important than collecting on them,” he said, especially when it comes to protecting against cyberthreats to the computer networks of the world’s largest economies. 

So far the Obama administration has refused to talk publicly about that choice, other than to provide Germany with assurances that now, and in the future, Ms. Merkel’s cellphone conversations will be safe. In the past two weeks, two pairs of senior German officials have visited Washington trying to negotiate a new accord on intelligence sharing that would set ground rules as their government faces its own choice between gently pushing back a protector that has patently played a double game for years, or asserting its power in ways unknown since 1945.

John C. Kornblum, a former American ambassador to Germany, said he “simply cannot imagine” how the United States could target Germans that way “and not end up with egg all over their face. It was unbelievably stupid, for no gain,” he said.

Over the weekend Senator John McCain, Republican of Arizona, told the German newsmagazine Der Spiegel that “there should be a wholesale housecleaning” of the American intelligence community, and, echoing Mr. Kornblum, said that General Alexander “should resign, or be fired.”

The White House has backed General Alexander, who is scheduled to retire early next year, but even some of President Obama’s advisers have begun questioning the judgment of the director of national intelligence, James R. Clapper Jr., who is supposed to review the costs and benefits of these operations, and some officials, saying they are speaking for themselves, have suggested he should leave around the time General Alexander does.

“The only way the president is going to get a fresh start with the allies,” one of his advisers said last week, “is to present them with a new team.”

Germany is now toughening its demands that the United States respect all domestic and international laws — code words for ceasing the surveillance on German soil amid rising anger at the United States. Veteran observers of relations between the two nations suspect that over time the anger will abate, as it has in past spy scandals. But that may not prove to be as easy as the officials hope. Richard N. Haass, the president of the Council on Foreign Relations, who worked on European security issues for Presidents George Bush and George W. Bush, noted recently “the broad drifting away” between Europe and the United States.

For its part, Germany has amassed a different kind of power as Europe’s foremost economy. And, as Berlin’s bridling at United States Treasury criticism of its economic policy showed last week, the country is resolute in defending its financial moves.

In addition to power shifts that require adjustments by both countries, each is experiencing a febrile moment politically and governmentally. The United States appears paralyzed in many ways, while in Germany, the conservative Ms. Merkel is negotiating a new government with the center-left Social Democrats.The attempt to rein in American activity is turning out to be harder than German officials hoped. The early talk that Germany would get the status accorded to Britain, Canada, Australia and New Zealand — just about full sharing of data, and no-spy agreements — has given way to a much more hardheaded discussion.

Even German officials concede that a full-fledged accord is unlikely — in part because it would require congressional approval — and that negotiations are more likely to yield a memorandum of understanding.

The United States has issued no public exemption from listening in on those in the German political, diplomatic or intelligence hierarchies other than Ms. Merkel.

“The reluctance is that you never know what you may need, in a month, or a year, or 10 years,” one American intelligence official said.