Everyone influences public policy, but not equally. Relative influence depends upon when issues are raised, where they are raised, who raises them, and what criteria are used to compare alternatives. James Q. Wilson suggests that important determinants of who shapes policy, and how, are whether benefits and costs are broadly or narrowly distributed. His typology is not a robust theory to predict outcomes. No theory is, because of complexities, and hence opportunities, of the policy process; if public policy could be fully predicted, the meaning of democracy would be limited indeed. Wilson's typology is used here to explore and speculate, in order to go beyond simplistic explanations, to see a range of approaches to influence policy. The typology is:
 
 

	Distributed Costs	Concentrated Costs
Distributed Benefits	Majoritarian politics	Entrepreneurial politics
Concentrated Benefits	Client politics	Interest-group politics

Majoritarian politics are fought out through broad public debate. They address basic ideological beliefs and occur in the visible institutions of governments, particularly elections and legislative debates. They engage the political parties and are addressed by presidents, governors, and mayors. Special interest groups use mass communication to appeal for support. These politics build upon, and build, basic public values and attitudes. Debate may end with a resolution marking a shift in community values, for example, to accept pollution control as a legitimate constraint on development.

Disease prevention and health promotion often involve benefits and costs which are broadly distributed, but they do not necessarily generate majoritarian politics. The public may be more aware of the costs than the benefits, so that health professionals must carry the burden to expand public appreciation of the benefits. If professionals have only limited success in sharing their convictions, for example in immunizations, the politics approach client politics, wherein the costs are widely shared but the benefits more narrowly distributed. These contests may be reshaped, however, by actual or perceived health disasters, such as Three Mile Island, in which public opinion is so strongly shifted that costs become secondary, broadly felt fears command the public's attention, and politics fit the entrepreneurial model.

Interest-group politics pit special interest against special interest. For example they may dominate the allocation of block grants for public health programs, in which interest groups contest with each other for shares of a fixed pool of funds.

Interest-group politics take place "behind the scenes," in executive agencies and legislative committees. They stimulate the organization of client groups to promote programs, and are characterized by changing alliances as issues and influence shift. Interests cut across party lines; involvement by political parties is the exception rather than the rule. Policy changes incrementally, rather than through major confrontations or basic shifts in community values. These politics may involve attempts, or threats, to move to the more public majoritarian and entrepreneurial politics.

Health programs face interest-group politics when they hurt or threaten to hurt special interests and when active support comes not so much from the public as from health interest groups. This situation seldom favors health promotion, as the public's interests in health are not pressed by well organized groups. Even so, because of the limited capacities to generate the active public support necessary for entrepreneurial politics, effort may be best spent in the less public processes of interest-group politics, compromising to gain the health benefits least costly to competing interests. Apparent opponents may cooperate so that each gains by shifting costs to the general public, thereby moving to client politics. Opportunities for such shifts are best when economic circumstances favor expansions of governmental programs.

Client politics pit special interests against the general public by distributing costs and concentrating benefits. They typically support health programs benefiting special groups and financed by general taxes. Initially, AIDS programs were seen as such. Another example is tax preferences (costs born by public treasuries) for pollution control.

Client politics, like special-interest politics, are behind the scenes, the stuff of pork barrels and log rolling. Iron triangles (legislative committees, administrative agencies, and interest groups) find consensus to pursue their respective interests without costly political battles. Success partly depends upon the legitimacy which public opinion attributes to the interests being benefited. Political parties play a minor public role, though they may be quietly active. These politics encourage government agencies to organize active clientele groups.

A crucial aspect of client politics is the extent to which the relevant executive branch agency is captured by the interest groups (as in some pollution control), which may squeeze out the health interests (as was the case in tobacco policy). Another important aspect is the extent to which interest groups become creatures of the executive branch agencies, as in some health promotion programs for mothers, children, and the poor. This provides valuable support but can subordinate the real health interests to the self interests of the agencies and professionals.

Entrepreneurial politics pit the general public against special interests by distributing benefits widely while more narrowly concentrating the costs. These politics occurred, for example, in the late Sixties and early Seventies as politicians won reputations and power by leaping to the front of public enthusiasm for environmental protection.

Entrepreneurial politics are the reverse of client politics: the many rather than the few win the benefits. Entrepreneurial politics can be reactions to irresponsible success of client politics. Entrepreneurial politics are occasional, short lived, facilitated by mass media, and involve political entrepreneurs who identify and exploit an opportunity. While courts limit the effects of such politics, by protecting minority rights, the politics can be revolutionary. They also may lose their effect over time: public interest wanes and special interests recapture the initiative and the agencies.

Health has special opportunities for entrepreneurial politics because of its emotional appeal. Opportunities are not automatic; they usually come with special events, a catastrophe, or from long and articulate leadership. Consider the extended efforts of environmentalists and then the rallying cry of Rachel Carson's Silent Spring that gave energy to the environmental politics of the Sixties and Seventies.

The contest over a particular policy may shift from one type of politics to another, as when AIDS is recognized as threatening the health and budget of the general public, thus moving the policy debate from client to majoritarian politics. It is useful to anticipate such shifts, and sometimes to promote or discourage them. The shifts mean changes in the arenas, actors, and methods of politics, which can aid or hinder particular policies.

Each type of politics favors particular interests, and with time is likely to bring about a reaction which shifts the politics. This mechanism of self correction played out when tobacco interests exploited client politics. They created opportunities for entrepreneurs to mobilize public indignation and revolutionize public policy. Reversals offer opportunities to substantially change policy. The possibilities warn lobbyists that excesses can prompt sharp reversals, and warn entrepreneurs that victory is fleeting.

Economic and political processes operate as markets in shaping public policy, and both undervalue externalities and public goods. Good health is undervalued because its benefits are not concentrated. To some extent the political market works to correct the undervaluing of externalities by the economic markets. Thus governments adopt regulation, taxes, and programs of compensation when the economic market ignores the costs of air pollution or the value of seat belts. But the correction is not full. Until benefits or costs become excessive, politics tilt toward special interests, with policy being shaped largely through the processes of client politics. When the balance is substantially distorted it offers opportunity for entrepreneurial politicians to mobilize broad public support by promising to redistribute benefits from the special interests to the general public.

The political market differs from the economic market in being more restricted in its capacity to broker acceptable transactions. Democratic processes require elaborate organizational overhead, in structure and time. Political institutions can carry the burden of only a few majoritarian or entrepreneurial issues at a given time, and seldom resolve such issues quickly. Time pressures result in incomplete solutions. Political burdens result in symbolic politics of more promise than change. Client and interest-group politics are more easily carried by the political system, but by moving from broad democratic debate toward special interest bargaining, decision-making shifts to an economic market, based upon exchange of favors.

Health promotion and disease prevention have specific characteristics which affect the type and nature of the politics to be faced and used:

The most continuing political question in health promotion and disease prevention has been about financing these efforts. This has not inspired the publicly visible majoritarian or entrepreneurial politics but instead the more controlled, hidden, and informed client politics (to increase total funding) and interest-group politics (to allocate available funding).

Some aspects of health promotion and disease prevention (e.g. controlling cigarette advertisement and promoting health screening), however, raise larger political issues of how benefits and burdens are distributed, in and out of government. They are driven by larger cost concerns: billions rather than millions of dollars. They also are more political and more public because they directly raise questions over privacy (e.g., AIDS), of who carries the blame and burden of health risks (e.g., health screens affecting employment or insurance), and about the comfortable but costly myth that society will not sacrifice life because of costs (e.g., controls of environmental risks). These are heady politics -- not the technical, incremental politics common for 50 years, but the public health politics of a century ago.

Majoritarian and entrepreneurial politics, which brought public health and sanitation, are efforts which the public can not long sustain. Thus it was natural that, after significant victories, proponents fell to implementation, leaving little energy to wage continuing public contest. Perhaps their time and past victories were best protected by avoiding the political fray. Additional progress came when technology and public education enabled it, but attention stayed upon established programs.

It also is natural that physicians and nurses play relatively limited roles in health promotion and disease prevention, given that reimbursement systems discourage spending time on patient education and that providers' training focuses on diagnosis and treatment of established disease. Public attitudes respect the miracles of cure more than the coaxing to avoid or change (commercially promoted) lifestyles. Providers can keep busy doing that for which they are most appreciated and best paid.

Thus half a century of relative stagnation in health promotion and disease prevention might be explained as the natural result of the incentives and circumstances of public health officials and health care providers. But is it also because of limited leadership? The shift in smoking policy showed leadership could use scientifically derived information to capitalize upon luck and thus to shape its own opportunities. Attention to health promotion and disease prevention has mushroomed over the last two decades. Do leaders now have even more opportunity? Can they use it?

Sources:

 James Q. Wilson, Political Organizations, N.Y.: Basic Books, 1973, chapter 16; James Q. Wilson, ed., The Politics of Regulation, N. Y.: Basic Books, 1980; and James Q. Wilson, American Government, 4th ed., Lexington, Mass.: D.C. Heath, 1989, chapters 15 and 22.  While the framework and much of the general description are Wilson's, the above speculations about the four politics are drawn from several sources and this author's own experience, and are not necessarily consistent with those of Wilson.  Alternative and classic frameworks include:
Harold D. Lasswell, Politics: Who Gets What, When, and How, N.Y.: McGraw-Hill, 1936, which focuses analysis upon who, what, when, and how.
Peter Bachrach and Morton S. Baratz, "Two Faces of Power," American Political Science Review, 59(1962):947-952., which contrasts two forms of influence: (a) deciding issues and (b) deciding what will be the issues.
David Braybrooke and Charles E. Lindblom, A Strategy of Decision, N. Y.: The Free Press, 1963, which suggests politics are (1) revolutionary and utopian when change is large and understanding is high, (2) administrative and technical when change is small and understanding is high, (3) incremental when change is small and understanding is low, and (4) crisis driven when change is large and understanding is low.
Theodore J. Lowi, The End of Liberalism, 2nd ed., N.Y.: Norton, 1979, which classifies policy issues as redistributive, regulatory, or distributive.
Graham T. Allison, Essence of Decision, Boston: Little, Brown, 1971, saying governmental behavior is shaped by three approaches to a problem: rational analysis, standard operating procedures, and organizational politics.
Charles O. Jones, An Introduction to the Study of Public Policy, 2nd ed., North Scituate, Mass: Duxbury, 1977, which identifies the public policy processes, each with its own politics, as: problem identification, proposal formulation, program legitimation, finance, implementation, evaluation, and resolution.