3.2.2. Adaptation Activities Influenced by the External Pressure Factors of the State Apparatus

The lack of **public interest** may reduce the pressure on health systems to address climate change-related health risks. An Eurobarometer survey [68] confirms that, in comparison with the rest of Europe, Estonia has the fewest numbers of people who consider climate change as a very serious problem. Analyses of the population-based survey focused on people with strong beliefs that state measures are necessary to reduce the health risks from climate change (respondents scores 4–5 on a five-point-scale, ranging from strong disagreement (1) to strong agreement (5), accounting for 30% (301) of respondents). There are significantly (*p* < 0.05) more women, ethnicities other than Estonians, and urban residents with high interest in adaptation measures (Appendix D). The level of interest does not differ significantly by age, educational group, or level of individual self-rated health.

We identified factors explaining high interest in measures for reducing the health risks of climate change using logistic regression. The base model predicting demand for measures included gender, age, education, home language, and self-rated health status. Table 2 shows that Estonian-speakers had a 0.61 (95% CI 0.43–0.86) lower odds of requesting measures than individuals speaking Russian or other languages. When adding the possible predictors of demand to the base model one-by-one, no effect was seen between the trust in institutional efficacy in taking care of the healthfulness of the environment and demand for measures. Compared to individuals with high worry, individuals with low worry had 0.57 (0.37–0.88), and individuals with medium worry had 0.58 (0.38–0.88) lower odds of demanding measures. The odds of demanding measures increased by 1.24 (1.06–1.45) when the perceived exposure to extreme weather events increased by one degree on a five-point-scale.


**Table 2.** Association between factors and the belief in need for measures to reduce the health risks from climate change in Estonia, odds ratios (95% CI).

\* Logistic regression was adjusted for gender, age, education, home language, and self-assessed health status.

The opinion that the health risks of climate change are a comparatively less important concern for Estonian society is also reflected in the (lack of) political debate and administrative prioritisation. This was brought out in key expert interviews. All the respondents started the interview with a recognition that they do not believe that climate in Estonia will start changing considerably, and that there is not enough evidence to confirm that climate change is occurring. For example, an official from the Ministry of the Interior (29 April 2015) said: "*The numbers do not show that the climate would change dramatically in Estonia; we have no facts to support that today*."

One of the most important factors that has kept public and political salience low is the insufficiency of corroborating scientific evidence that climate change affects health. Up to 2015, there were very few studies in Estonia on the interaction between climate change, environmental factors, and health indicators. Limited governmental resources have forced the state to set priorities; environmental health is not one of them. A public health specialist (8 May 2015) emphasised: "*Unfortunately, environmental health is not a priority and therefore there is no state funding available*." Paradoxically, the officials consider the role of scientific research important in making decisions. As a specialist in environmental health from the Ministry of Environment (4 May 2015) said: "*We do nothing just because of gut feeling. We will not contribute the resources if there are no prognoses or studies made. At least when a change has been initiated by us, there must always be a scientific explanation behind it*."

The shortage of expertise in this area is also suggested by the fact that Estonia does not train specialists in environmental health, and in medical school, the topic is covered in only one subject. A public health specialist (8 May 2015) stated: "*We have many specialists on environment in different universities in Estonia, but in none of them has a course on environmental health in which climate change and its actual health effects would be clarified for the future decision makers*." The National Health Plan 2009–2020 [38] includes measures for training of health effect assessment specialists and for collecting environmental health related knowledge. So far, there are no resources to support this.

The key experts do not see commercial interests as having an impact on the design or implementation of health adaptation policies. Increasing introductions of viruses could interest new product development in pharmaceutical companies. For example, tick-borne encephalitis can be prevented by vaccination. According to a family physician (7 May 2015), it is simply a matter of time until the pharmaceutical companies "*get wind of it*" and start gathering support for the national vaccination programme.
