GLOBAL SOCIAL VULNERABILITY TO PANDEMICS: AN EXAMINATION OF SOCIAL DETERMINANTS OF H1N1 2009 By NJOKI MWARUMBA Bachelor of Arts Communication Daystar University Nairobi, Kenya 1994 Master of Science Hospitality Management Oklahoma State University Stillwater, Oklahoma 2002 Submitted to the Faculty of the Graduate College of the Oklahoma State University in partial fulfillment of the requirements for the Degree of DOCTOR OF PHILOSOPHY May, 2017 GLOBAL SOCIAL VULNERABILITY TO PANDEMICS: AN EXAMINATION OF SOCIAL DETERMINANTS OF H1N1 2009 MORTALITY Dissertation Approved: Dr. David Neal Dissertation Adviser Dr. Laura Vinson Dr. Duane Gill Dr. Tom Wikle ii DEDICATION Wema Macharia Nyanjui ‘Mi Papi’ _ Salome Karwah _ iii Acknowledgements reflect the views of the author and are not endorsed by committee members or Oklahoma State University. ACKNOWLEDGEMENTS To God for lighting a path one step at a time I’m forever grateful and indebted. Thankful for Mwarumba Mwavita, with whom I have journeyed through many a bright day and dark night. Tuzo Mwavita Mwarumba, and Tuli Macharia Mwarumba, you two light up my world and give me cause. My committee members, current and past, Dr. Brenda Phillips, Dr. Emmanuel Nikolas, Dr. Dave Neal, Dr. Duane Gill, Dr. Thomas Wikle, and Dr. Laura Vinson, you illuminate my path. Each of you inspired me uniquely and completely. I am thankful. To my extended family, friends, and colleagues, my every step was made possible by your choosing to share your support, love, and wisdom with me. For that I am forever grateful. iv Acknowledgements reflect the views of the author and are not endorsed by committee members or Oklahoma State University. Name: NJOKI MWARUMBA Date of Degree: May, 12 th 2017 Title of Study: GLOBAL SOCIAL VULNERABILITY TO PANDEMICS: AN EXAMINATION OF SOCIAL DETERMINANTS OF H1N1 2009 Major Field: FIRE AND EMERGENCY MANAGEMENT ADMINISTRATION Abstract: This research analyzes the relationship between global determinants of health and mortality from the H1N1 2009 pandemic. Grounded in social vulnerability and social determinants of paradigms, six variables were examined in relationship with H1N1 2009 mortality. These are; health, education, communication, population, air transport, and governance variables of 193 WHO member states. Health had three indicators (Health Expenditure per capita, International Health Regulations and Health Emergency Preparedness, and Adult mortality), Education had two (Education expenditure, and adult literacy, ), Communication three (Radio, and Television penetration, and cell phone subscription), Population had two (population living in urban areas and international migrant stock), a single indicator of air transport, and two indicators of governance (Corruption Perception Index and Human Development Index). I conducted a multiple regression analysis to examine the relationship between these indicators and H1N1 2009 mortality. Results indicated significant relationship between the indicators and H1N12009 mortality. In addition, for each of the group of indicators, regression identified statistically significant predictors of H1N12009 mortality. The findings suggest that social vulnerability and social determinants of health provide a robust conceptual framework by which to examine pandemic disaster mortality. v TABLE OF CONTENTS Chapter Page I. INTRODUCTION ......................................................................................................1 Contemporary Infectious Diseases ..........................................................................3 Influenza .........................................................................................................3 Influenza Pandemic Disasters ..................................................................................5 Influenza pandemic H1N1 2009 ..............................................................................9 Social Vulnerability perspective and pandemics ...................................................11 Problem Statement .................................................................................................14 Purpose of Study ....................................................................................................15 Research Questions ................................................................................................15 Theoretical Framework ..........................................................................................16 Significance of Study .............................................................................................15 Overview of upcoming chapters ............................................................................17 II. REVIEW OF LITERATURE..................................................................................20 Dependent Variable: Pandemic Mortality .............................................................23 Defining Influenza Pandemics .....................................................................24 Historical Background .................................................................................26 The H1N12009 Pandemic ......................................................................................29 Operationalization of Pandemics ...........................................................................32 The United Nations (UN)...................................................................32 World Health Organization (WHO) ..................................................33 From traditional health theory to ecological model .....................34 Whole of Society Pandemic Preparedness ....................................35 International Health Regulations ..................................................36 National Level Pandemic Governance ...................................................................37 Independent Variables ...........................................................................................39 Health ..............................................................................................................45 Education ........................................................................................................47 Communication ................................................................................................48 Population ........................................................................................................49 Air Transportation .............................................................................................50 Governance ........................................................................................................50 III. METHODOLOGY ................................................................................................53 Introduction ............................................................................................................53 vi Research Design...........................................................................................................53 Population and unit of analysis ..............................................................................54 Data Sources ..........................................................................................................54 Study Variables ............................................................................................................58 Dependent Variable ...............................................................................................61 Independent Variables ...........................................................................................62 Health .............................................................................................................62 Health Expenditure per capita .................................................................63 International Health Regulations and Health Emergency Preparedness 63 Adult Mortality .......................................................................................64 Education Variable.........................................................................................65 Education Expenditure ............................................................................65 Adult Literacy .........................................................................................65 Communication Variable ...............................................................................66 Radio ........................................................................................................66 Television ................................................................................................66 Cellphones................................................................................................67 Population Variable .......................................................................................67 Population living in urban areas ...............................................................68 International migrant stock ......................................................................68 Air Transportation Variable ............................................................................69 Civil air transportation ................................................................................69 Governance Variable ......................................................................................71 Corruption Perception Index .......................................................................71 Human Development Index .......................................................................72