Taking Political Determinants of Planetary Health Seriously: Expanding from P4 to P5 Medicine.

Predictive, Personalized, Preventive, and Participatory (P4) Medicine is embedded in the precision medicine conceptual framework to achieve the overarching goal of "the right drug, for the right patient, at the right dose, and at the right time." Science cultures and political determinants of health have normative and instrumental impacts on P4 medicine. Yet, since the age of Enlightenment in the 17th century, science and economics have been disarticulated from politics along the lines of classical liberalism, and with an ahistorical approach that continues into the 21st century. The consequence of this liberal disarticulation is that science is falsely and narrowly understood as an invariably technocratic and objective field. In the aftermath of the Covid-19 pandemic, it is clearer that political determinants of health are the causes-of-causes for disease and health. I propose that we need P5 medicine with a fifth P, political determinants of planetary health. The new "P" can engage not only with instrumental aspects of P4 medicine research and clinical implementation but also with the structural factors that are an integral part of the politics of the P4 medicine. For example, the living legacies of colonialism contribute to the unequal relationships in trade, labor, provision, and production of materials among nation-states and between the Global South and the Global North and shape the class struggles in contemporary society, science, and medicine. A decolonial politics of care in which the political determinants of planetary health are taken seriously is therefore crucial and relevant to building a robust, ethical, responsible, and just P5 medicine in the 21st century.