was transmitted, did not appear until August, 2014. This is a long-standing problem. During the 2003 SARS outbreak, an estimated 22% of research studies relating to SARS were submitted to journals, and only 7% were published.27 As with intellectual property barriers, negative results, which are often as helpful as positive results, generally go unpublished because of these structures. 21 Where negative or inconclusive results may be useful, the publishing imperative results in similar delays. Detailed information on the patients’ reactions to the drug ZMapp was not released; the stated reason was the adverse effect on the study authors publishing the cases. 18 Physicians in the field employed treatments such as blood plasma, based on the positive results from a minitrial of just eight patients in 1999. Trials set up during the outbreak indicated that this treatment was ineffective, but their results were not immediately made public. “Negative results made public earlier may have diminished pursuit of this [plasma treatment] in a more timely way.”20 k. The lack of data sharing or governance agreements The structure of data sharing was mediated through entities employed by major funders: the Bill & Melinda Gates Foundation, CDC, CDC Foundation, DFID, the Paul Allen Foundation, the UK government, and USAID among the most significant. These entities operated under agreements that limited or prohibited data sharing, required open data sharing, specified avenues for data sharing, or left the matter of data sharing ambiguous and unpredictable. Entities hired to collect, analyse, or work with discrete forms of data generally did not share that data outside contractual obligations or financial incentives to do so. “Without agreement about the mutually beneficial roles, responsibilities, and legitimate contributions of clinicians, scientists, and public health authorities, parties end up either encroaching on one another or not communicating.”14 These practices are reflected in the retrospective reports entities drafted for donors and others, emphasizing number of geographic locations in which there was a presence, number of volunteers trained, and number of staff hired. One report listed 78 partners and 36 sub-grantees.69 Some funders like the Bill and Melinda Gates Foundation and UK DFID made data sharing and data accessibility explicit requirements, although the commitment is broadly to openness 15 after publication. One agreement between the CDC and a logistics support entity depended upon the program officer who had rotated into the field (every four weeks) with each program officer in turn making different decisions on data sharing. Entities or persons collecting and/or analyzing data would claim that specific agreements under which they worked prohibited data sharing except to specific persons or ministries. With respect to clinical trial data collected following WHO’s August 11, 2014 declaration on emergency uses of products not yet tested in humans, the coordination between WHO, NIAID, MSF, ministries of health in Guinea, Liberia, and Sierra Leone, the Norwegian Research Council, IRDC Canada, donors, and universities minimized data sharing barriers. This coordination was attributed to agreements that clearly defined roles, transparent and agreed-upon categories of data needed for the trials to show evidence of safety and efficacy, and adequate resources to enroll volunteers, conduct trials, and gather information. Despite the relatively smooth sharing of data during clinical trials, third parties have complained that the data supporting arguably the most important trial in Guinea have never been made completely available. Trials were also delayed because of disagreements over logistics and ethics. For example, after MSF and researchers at the University of Oxford organized trials of the drug brincidofovir that did not include placebo groups, the US Food and Drug Administration pushed for randomized trials that would include untreated controls. The brincidofovir trial eventually went forward without a control group. Requirements for gathering evidence sufficient for FDA approval contemplated paper-based records that, in Sierra Leone, were logistically difficult or impossible. l. Political pressures i. Geopolitical and International Organizational Pressures Political pressures created both bottlenecks for relevant data as well as incentives to hide or obfuscate data. Between March and July of 2014, the Governments of Guinea and Sierra Leone sought to decrease the perception that there was a crisis, resulting in artificial suppression of the spread of the disease.7 A retrospective study by Chatham House noted that “several interviewees stated that WHO was not playing an independent role, and that no one in authority wanted to admit to [Sierra Leone] President Koroma how bad the situation was.”65 The health minister played down the severity of the outbreak and the ministry’s ability to cope with it.65 British participants in the response said that by late July they had decided that information coming out of the Sierra Leone Ministry of Health and Sanitation had to be ignored. 65 This sentiment was confirmed by other logistics, humanitarian, and aid representatives. Separate retrospective studies have catalogued the accusations made between March and July 2014 against MSF, that it was stirring a panic in order to raise