“There is no doubt we are in a far better situation now than we were a year ago, when the Omicron wave was at its peak,” WHO Director General Tedros Adhanom Ghebreyesus said in a news release—three years to the day he announced the start of the emergency.

But weekly global COVID deaths have been rising since the beginning of December, and more than 170,000 people have died of COVID over the past two months, he added. “And that’s just the reported deaths. We know the actual number is much higher.”

The WHO’s COVID-19 emergency committee met Friday to consider whether to extend the emergency status, which must be reconsidered every three months. It recommended to Ghebreyesus, who makes the final decision, that the emergency state continue. He agreed.

The extension comes as China endures some of its darkest days of the pandemic, after ending long-standing “zero-COVID” restrictions in December. An estimated 900 million Chinese have been infected with COVID as of Jan. 11, according to a recent study. With rampant infection comes a greater chance of the virus evolving a more dangerous strain that could sweep the globe.

Japan, too, recently saw its darkest days of the pandemic, when back-to-back waves of Omicron strain BA.5 caused deaths there to skyrocket to an all-pandemic high.

A matter of public perception

Dr. Jay Varma, chief medical adviser at the New York–based think tank Kroll Institute, told Fortune last week that the WHO should extend the global public health emergency for two reasons: rapid mutation of the virus, which raises the risk of the evolution of a new concerning variant, and the outbreak in China, the worst the world has seen so far.

“One of the largest countries on earth, China, is in the middle of a large, disruptive, and lethal COVID-19 outbreak and remains at high risk of similarly disruptive surges in the future due to under-vaccination,” said Varma, whose 20-year career with the U.S. Centers for Disease Control and Prevention included postings in in the Eastern superpower.

Dr. Michael Osterholm, director of the University of Minnesota’s Center for Infectious Disease Research and Policy (CIDRAP), told Fortune on Friday he wasn’t sure if the committee’s decision made a difference from a practical standpoint, given that emergency status doesn’t offer much in the way of additional funds, power, or options to respond.

“The only thing that is important is the public perception,” he said. “Most of the world is over this pandemic, even though the virus is not done with us yet. If you say it’s no longer an emergency, most people are going to interpret that as the pandemic is done.”

At a Thursday press conference, Dr. Matshidiso Moeti, World Health Organization regional director for Africa, pointed to the “very severe outbreak in China” and surges in some Western countries as factors the committee would likely consider.

Africa, however, appears to be faring significantly better, with new cases reported during the first three weeks of January down 97% year over year, according to the WHO. While underreporting may contribute to the continent’s apparent success, crucial indicators like hospitalizations and deaths are hovering at low levels, officials say.

Last year Africa saw no major pandemic peaks, in contrast with the year prior, when it saw waves of more transmissible and lethal variants, according to Moeti.

“I think what’s very important is the local interpretation and ensuring that, based on local data, we’re able to ramp up response when it’s needed,” she told Fortune prior to the committee’s decision.

A degradation of optimism

At a press conference Tuesday prior to the committee’s meeting, Ghebreyesus said he would “not preempt” the group but was “very concerned by the situation in many countries and the rising number of deaths.”

“While clearly we’re in better shape than we were three years ago when the pandemic hit, the global collective response is once again under strain,” he said. “My message is clear: Do not underestimate this virus. It has, and will continue, to surprise us, and it will continue to kill unless we do more.”

In mid-December, Ghebreyesus had appeared hopeful that the emergency could wrap up in 2023. At the time, global weekly deaths sat at 10,000—a fifth of what they were during Omicron’s peak in January 2022.

“That’s still 10,000 too many, and there is still a lot countries can do to save lives, but we have come a long way,” he said at the time.

In September, Ghebreyesus seemed even more optimistic that the pandemic was drawing to a close, saying that the world had “never been in a better position to end the pandemic,” as daily global deaths from COVID sat at record lows.

“We are not there yet, but the end is in sight,” he said at the time. “We can see the finish line. We’re in a winning position.”

In his Monday statement, Ghebreyesus remained hopeful that this year “the world will transition to a new phrase in which we reduce hospitalizations and deaths to the lowest possible level, and health systems are able to manage COVID-19 in an integrated and sustained way.”

He stopped short of expressing hope that the pandemic could be wrapped up this year.

In its report, however, the committee concluded that the pandemic “may be approaching an inflexion point,” and that high levels of population immunity globally may limit the ability of COVID to cause severe illness and death. It asked the WHO to research the regulatory implications of terminating the emergency status “in the coming months.”

‘Serious, sudden, unusual’

A public health emergency of international concern is defined by international health regulations as “an extraordinary event which is determined to constitute a public health risk to [WHO member states] through the international spread of disease, and to potentially require a coordinated international response,” according to the WHO. It implies that the situation is “serious, sudden, unusual, or unexpected” and may require immediate international action.

Once a potential emergency is reported to the WHO by a member state, the organization convenes an emergency committee of international experts to make a recommendation to the WHO director general as to whether it constitutes an emergency.

WHO global public health emergencies currently exist for COVID, polio, and mpox, the new name for monkeypox recommended by the organization last fall to reduce stigma. In July, Ghebreyesus declared an international public health emergency for mpox when an emergency committee twice failed to meet a consensus. International health regulations compelled him to do so, he said.

Emergency committees have been called seven additional times in the past for diseases including Ebola (three times), H1N1, and MERS. They can also be called for chemical agents and radioactive materials, as well as bacterial diseases.

The purpose of declaring an international public health emergency is to facilitate international coordination on diagnostics, treatments, and/or vaccines. But critics say that such declarations can place economic burdens on affected countries, especially if they result in travel and trade restrictions.