When should a public health emergency of international concern be declared? The case of the 2018-2020 Ebola outbreak in the Democratic Republic of the Congo.

Criticism over the lack of transparency in the decision-making process to determine a public health emergency of international concern (PHEIC) has accompanied the mechanism since the category was first activated. For the 2018-2020 Ebola epidemic in North Kivu and Ituri, Democratic Republic of the Congo, this criticism intensified: it took four emergency committee (EC) meetings and nearly a year for the World Health Organization (WHO) Director-General to declare a PHEIC. The North Kivu case is emblematic of the complexities surrounding such determinations, complexities that the opacity and inconsistent application of the International Health Regulations (IHR) criteria across PHEIC history have made difficult to examine. What shaped the EC's assessment, and what does this reveal about how PHEIC determinations are made? Drawing on documentary analysis and interviews with former EC members, this paper investigates why the declaration was delayed and what shaped the EC's assessment over time. It finds that the EC's deliberations were driven by considerations that lay outside the IHR text, especially the political and operational dynamics on the ground, the financial and reputational stakes for the WHO, and the perceived risks of triggering border restrictions and deepening community resistance. How these considerations were weighed was ideationally driven, structured by the global health security paradigm that has come to shape both response interventions and the construction of certain outbreaks as matters of 'international concern'. The case carries significant implications for the credibility of the PHEIC mechanism and for the recent IHR amendments, which introduced the 'pandemic emergency' category as the highest level of global alert. By examining the interplay between real-time response dynamics and high-level decision-making, this work sheds light on the material and ideational factors that shape the governance of health emergencies, contributing to scholarly and policy debates on emergency response and agenda setting in global health.