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As detailed in the Lancet Countdown on health and climate change,1 the risks of climate change for human health are profound, and internationally coordinated efforts (eg, the UN Framework Convention on Climate Change [UNFCCC]) are essential to the response. The most noteworthy outcome of the 27th session of the Conference of the Parties of the UNFCCC (COP27), held in November, 2022, was the commitment to addressing loss and damage associated with climate change. Specifically, direction was given to address disproportionate losses and damages incurred to “the most vulnerable populations and the ecosystems on which they depend”.2 This work will commence in 2023, by identifying “priority gaps for which solutions should be explored”2 and the funding mechanisms to support those solutions.2, 3 In this framework, the concept of loss and damage involves the economic and non-economic impacts of climate change (extreme weather events, gradual change processes, and their corollaries), which exceed a population's ability to adapt. Vulnerability is broadly ascribed to populations that are particularly exposed to the effects of climate change, with an emphasis on poverty or scenarios to which there is no feasible response.

hange (extreme weather events, gradual change processes, and their corollaries), which exceed a population's ability to adapt. Vulnerability is broadly ascribed to populations that are particularly exposed to the effects of climate change, with an emphasis on poverty or scenarios to which there is no feasible response. In complex systems wherein some populations face disproportionate health risks as a function of climate change, the identification of points of leverage will be essential. One of these points is adequate shelter, which represents a nexus at which climate change and human health intersect. Vulnerable populations displaced due to the effects of climate change (often referred to as climate refugees) face disenfranchisement, threats to security and culture, and a loss of shelter. In turn, populations without adequate shelter are highly exposed to an array of risks ranging from the direct effects of extreme weather events to disease and air pollution exposure. Health is central to these effects, with pronounced implications for morbidity and mortality.4

curity and culture, and a loss of shelter. In turn, populations without adequate shelter are highly exposed to an array of risks ranging from the direct effects of extreme weather events to disease and air pollution exposure. Health is central to these effects, with pronounced implications for morbidity and mortality.4 We argue that shelter should be a key factor in the articulation of vulnerability in the loss and damage response. Access to adequate shelter is a variable that will be useful in identifying vulnerable populations at the country level and vulnerable subpopulations within countries; it is also a metric that can help assess the effects of interventions and can be tangible in efforts to account for the use of funds. Furthermore, prevention-oriented interventions that centre on housing can greatly reduce the impacts of climate change on health.5 Examples include improved housing and infrastructure for exposed communities, which can lead to staying in place, and education or planned migration, in a way that minimises risks in health, social, and cultural domains. Outreach models in the form of needed supplies and education also exist.

climate change on health.5 Examples include improved housing and infrastructure for exposed communities, which can lead to staying in place, and education or planned migration, in a way that minimises risks in health, social, and cultural domains. Outreach models in the form of needed supplies and education also exist. Cultural relevance and co-design are essential in developing and implementing these interventions, bringing a focus to intersecting forms of discrimination. For example, girls and women who are exposed to extreme weather events face particular risks because of discrimination and biological considerations, such as the risk of hyperthermia for pregnant women and fetal development complications.6 For Indigenous populations, exposure due to inadequate shelter and a depleted sense of home in the spiritual and cultural frames of destroyed natural environments have particularly damaging effects on health and wellbeing.7

tions, such as the risk of hyperthermia for pregnant women and fetal development complications.6 For Indigenous populations, exposure due to inadequate shelter and a depleted sense of home in the spiritual and cultural frames of destroyed natural environments have particularly damaging effects on health and wellbeing.7 Proposals for large-scale loss and damage funding schemes have been put forward since the early 1990s. Concerns regarding the commitments made at COP27 include a track record of being unable to deliver on similar pledges and the lack of headway on the major drivers of climate change.8 Setting aside the questions of funding promises and their implementation, the secretariat faces a formidable task in actioning the loss and damage commitment. Funding mechanisms and accountability standards need to be devised, and priority populations, intervention targets, and the interventions themselves need to be established. This work must be done in complex systems for which reliable data are lacking—particularly for the most vulnerable populations. Adequate shelter, as a fundamental determinant of health, could help in the development of strategies when the ambiguity of terms, such as vulnerable populations, could readily lead to responses that are poorly targeted and difficult to assess.