Small island states are often seen as the cause célèbre of climate change, although the total population at risk in small island states is substantially less than the dense populations at risk in low lying coastal areas globally. Nonetheless, Islands remain particularly vulnerable to climate change and climate variability. Viewing only the vulnerability of islands, however, limits the scope of island adaptation and denies island peoples agency. Human security, the relationship between environmental degradation, resource scarcity and conflict, and the use of the concept “climate refugees” are briefly discussed. The relationship between climate change and health is small islands is then explored using examples from the extreme ENSO event of 1997–1998. An argument is made for robust, multisectoral, stakeholder based approaches to climate change adaptation in islands. New paradigms including transdisciplinary climate change science must be embraced.