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Inclusive Policymaking Tools: A COVID-19 Pandemic Case Study

Ans Irfan1, Ankita Arora2, Christopher Jackson3, Celina Valencia4 1Environmental and Occupational Health Department, Milken Institute School of Public Health, George Washington University, Washington, D.C. 2Department of Biochemistry and Molecular Genetics, University of Colorado-Anschutz Medical Campus, Aurora, CO 3Department of Chemistry, University of California, Berkeley, Berkeley, CA 4Cancer Prevention and Control Program, The University of Arizona Cancer Center, Tucson, AZ http://doi.org/10.38126/JSPG170112 Corresponding author: ansirfan@gwu.edu


I. Introduction
The COVID-19 pandemic has exposed and exacerbated long-standing social inequities in the United States (U.S.), many of which can be directly tied to public policies that fail to consider the principles of diversity, equity, and inclusion (DEI). Sharing best practices and lessons learned can expedite sound policymaking and implementation processes. Evidence-based policies are based on relevant knowledge, research, and scientific evidence (de Marchi, Lucertini, and Tsoukiàs 2017). The benefits of the implementation of evidence-based policies have been captured across various sectors (Head 2015). The utility of a science-informed response to  has been demonstrated in several cases during the COVID-19 pandemic, including in Germany (Kirschbaum and King 2020) and New Zealand (Cousins 2020). In both of these cases, an evidence-based approach requiring strict public health measures, occasionally unpopular with the public, led to better population health outcomes such as a decreased number of cases, case fatalities, and community-based infections. In fact, New Zealand became one of the first nations to be virusfree, thanks to its evidence-based approach to the pandemic.
However, it is not enough to ground policies in evidence alone. To achieve transformative social change and eliminate social inequities, it is equally important to ensure that policies are inclusive and represent the communities' views, values, and needs in an equitable way. Existing evidence, especially from applied research fields such as implementation sciences, emphasizes the critical importance of engaging with and accounting for different stakeholders for effective interventions and policies (Chambers 2020). One of the key approaches to ensuring effective interventions and public policies is to ensure policies are inclusive in nature starting at the development phase. This paper builds on previous work on evidence-based, inclusive policymaking and asserts that to maximize positive policy outcomes across all populations and timescales, we must expand on the evidence-based underpinning of public policies and incorporate a DEI framework in the policymaking process.
We use the COVID-19 pandemic, and subsequent government responses, as a case study to identify meaningful opportunities for policymakers at all levels of government to influence positive changes grounded in DEI during the pandemic. However, we also believe that the DEI framework presented here can serve as a long-term guiding principle for policymakers beyond the pandemic.

II. Diversity, equity, and inclusion in policy
Diversity, equity, and inclusion are three distinct but interconnected pillars that public policies aiming to be holistic and fair should address. The absence of a concerted effort to integrate DEI into the policymaking process has historically resulted in structural barriers that impede the equitable distribution of the benefits intended by policies. These social and structural barriers to an equitable society in public policy have enduring, multigenerational consequences (Krieger et al. 2020;McClure et al. 2019). The integration of a DEI framework in policies provides an opportunity to mitigate long-lasting repercussions experienced by individuals who have been historically left out by the public policymaking process. We posit that if inequitable public policies can create these structural barriers, inclusive policies can help dismantle these structural barriers and achieve a more fair and just society.
We operationalize the following definitions of diversity, equity, and inclusion in this paper (Bolger 2020). Briefly, "diversity" refers to differences in identities, including but not limited to race, gender, ethnicity, religion, political ideology, migration status, age, physical ability, and sexual orientation. Diversity can only exist in relationship to others, and the meaning of diversity can vary widely based on the situational context. It is about the recognition and appreciation of unique individual differences. "Equity" addresses the inherent disadvantages and barriers created by historical systems of oppressions such as racism to ensure fair access to the same opportunities. Equity is akin to providing a level playing field. Unlike diversity and inclusion, equity is a process, not an outcome. Finally, "inclusion" builds upon a diverse foundation, ensuring that diverse perspectives are not only present but valued and acted upon in a meaningful way that goes beyond performative actions. It is making a conscientious effort to welcome, involve, engage, and empower individuals with diverse characteristics in a process, including the policymaking process. Taken together, the incorporation of DEI principles in the policymaking process can have significant positive impacts leading to inclusive policies that are equitable and effective. Policymaking entities can benefit from an increased diversity of perspectives which results in better decisions, policy outcomes, and a just society (OECD 2015).

III. Policy responses to COVID-19
The ongoing COVID-19 pandemic has yet again exposed many of the inequitable social structures and public policy infrastructure that underlie U.S. society. Here, we offer examples from the business, education, and healthcare sectors to highlight the disproportionate impacts of the disease, economic fallout, and corresponding policy responses on Black, Indigenous, and other communities of color, and the necessity of a DEI framework.

i. Business and employment
The CARES Act, a $2 trillion plus federal aid package passed in March of 2020 in response to the COVID-19 pandemic, highlights how well-meaning policies can be operationalized in ways that exacerbate social inequities. It also provides an opportunity to highlight the need for intentionally making an effort to formulate equitable policies. One subset of this package, the Paycheck Protection Program (PPP), exemplifies the disproportionate institutional burdens faced by minority-owned businesses. In PPP's early stages, the Small Business Administration (SBA) barred anyone with a criminal conviction in the past five years. This led to discrimination against members of the Black community who are often subjected to racially motivated higher rates of incarceration and convictions because of a racist legal system in the US (Donnan 2020). During the PPP program implementation, banks and lenders affiliated with the SBA also prioritized loans for their existing customers, which excluded many business owners of color (CRL 2020). This practice resulted in a projected 75-95% of Black, Latino, and Asian American/Pacific Islander (AAPI)-owned businesses having almost no chance of receiving a PPP loan (CRL 2020). By ensuring community voices are reflected at the early phases of policymaking, such unfortunate, structural injustices can be avoided.
At the individual level, while the COVID-19 driven recession is felt across the economy, the impact has not been equitably distributed (Cheng 2020;Badger and Parlapiano 2020). A study of San Francisco showed that the city's shelter-in-place ordinance caused COVID-19 cases to concentrate among lowincome Latinx communities, many of whom did not have the luxury, or proper occupational health protections, to work from home given the nature of their jobs as essential workers (Weiler 2020). At the same time, projections for a long-term shutdown in the U.S. estimate 42-54 million jobs that are vulnerable to reductions in hours or pay, temporary furloughs, or permanent layoffs. Of these, 42% are in service industries such as accommodation, food, and retail, highlighting disproportionate negative impacts among low-income workers and small businesses (Lund et al. 2020). Even as the economy recovers and jobs return, COVID-19 may further accelerate structural shifts in the economy towards an already increasing trend of gig economy -hiring independent workers for short-term commitments without benefits or many of the occupational health protections -or increased automation, changes that will require appropriate policy responses to ensure that historically marginalized communities are not left behind.

ii. Education
Other provisions of the CARES Act set aside $14 billion for higher education, with funds intended to support low-income students and community colleges, which serve the majority of these students. However, for-profit schools (serving 5.4% of students) received 9% of funding, while community colleges (serving 32% of students) received just 22% (Seville and Lehren 2020). These disparities were created by a distribution formula that emphasizes full-time students with Pell grants, who are more likely to attend for-profit schools. Moreover, the Department of Education's guidelines explicitly discriminated against undocumented, international, and the Deferred Action for Childhood Arrivals recipients on the basis of migration status by limiting the eligibility criteria (Nadworny, 2020). This is yet another example of inequitable social structures that create opportunity gaps and turn education from the great equalizer of social mobility to the great stratifier.
The necessary transition to remote instruction has also had disproportionate negative impacts on underserved communities due to a lack of infrastructure and access and affordability of amenities like technology and high-speed internet. Even before COVID-19, studies estimated that the opportunity gap between white students and Black and Hispanic students cost the U.S. economy between $310 to $525 billion, with similar results for the gap between high-and low-income students (Dorn et al. 2020). New studies estimate that this learning loss will continue and be exacerbated for low-income, Black, and Hispanic students due to lower access or affordability to high-quality remote learning environments. Nationally, 20% of students don't have access to the technology they need for a conducive remote learning experience (Hobbs and Hawkins 2020). Strikingly, while 38% of white K-12 students are likely to receive average or above-average remote instruction, this percentage drops to 21% for Hispanic students and14% for Black students (Dorn et al. 2020). These disparities result in months of lost learning, which leads to long-term socioeconomic implications. These short and long-term impacts can be avoided by having an inclusive approach. For instance, in response to the shortage of smart tablets, the Seoul Metropolitan Office of Education (SMOE) is operating a rental business that lends smart devices to students from low-income families to provide access to online education (Korea 2020). Policies like these, although still symptomatic treatment, ensure equal access to opportunities to learn for all, leading to an equitable education system. It is important to continue to challenge the systems such as poverty and racism that create such disparities in the first place.
iii. Healthcare The dysfunctional U.S. healthcare system is illequipped to address the inequities exacerbated by COVID-19, leading to disparities in hospitalization rates, mortality, and morbidity among both children and adults (Ford, Reber & Reeves, 2020;Kim et al. 2020). These disparities stem in part from lack of access or affordability to quality healthcare infrastructures. The mortality data from three dozen hospitals in New York revealed that patients at certain community hospitals were three times more likely to die than patients at private medical centers, a result of underfunding that led to lower staffing, worse equipment, and less access to treatment options (Rosennthal et al. 2020). Furthermore, when we consider healthcare workers who are being forced to risk their lives, due to a lack of occupational health protections, to care for patients, there remain significant systemic pay disparities across race, gender, and geography that must be addressed (Pifer 2020).
At the same time, a record number of layoffs has left millions of people without health insurance in the midst of a pandemic (Potter 2020). While the CARES Act requires all private plans to cover COVID-19 testing and future vaccines, it neglects those who are now unemployed or otherwise without access to insurance (Garfield, Claxton and Levitt 2020). In states where Medicaid has not been expanded, 3.1 million Americans still cannot afford health insurance; more than half of them are people of color, and 30% are Black (Yong 2020). Stopgap measures such as CARES act provisions are far from sufficient and only create an illusion of assistance. An inclusive approach to healthcare policy that goes beyond special interest and politicking is needed for a universal, equitable, and cost-effective healthcare system.
Policymakers must ensure that resource allocation priority is given to historically marginalized minority groups, particularly those who live in crowded conditions and have underlying medical conditions that increase their susceptibility to COVID-19 morbidity and mortality (Twohey 2020). For example, a CDC report recommended significant government action to tackle severe outbreaks among poultry plant workers, many of whom are Latinx and Marshallese, but failed to provide the necessary funds or an effort to collaborate with the Occupational Safety and Health Administration, the federal agency responsible for worker protections in the U.S. (Barrón-López and Ollstein, 2020). As treatment options and/or vaccines become available, it will require not only financial resources, but a sustained dialogue with all communities of color who have been historically overlooked or even harmed by the health care system to capture their unique needs and ensure equitable outcomes (Roubein and Owermohle, 2020).
These recent examples highlight both the importance and wide scope of impacts rooted in DEI considerations, as well as the negative consequences that can occur when DEI frameworks are not used in the policymaking process. Holistically, a DEI framework can lead to public policies with the potential for significant and equitable improvements in health, quality of life, and economic benefits to society.

IV. Inclusive policymaking recommendations
The core of an inclusive policymaking process is the principle of open government across various levelsfederal, state, county, city, local -which ensures meaningful citizen engagement, transparency, and accountability. Here, we synthesize literature on existing best practices concerning inclusive policymaking and provide some recommendations and specific tools to assist with an inclusive policymaking process. We offer some broader themes for better operationalization of a DEI framework and provide a list of specific actions that can be taken to ensure policies are inclusive in nature (Appendix: Table 1; Figure 1).

i. Positionality assessment
As a person involved with the policymaking process, the first step towards establishing best practices for inclusive policymaking should be introspection and recognition of one's privileges, including but not limited to race, education, socioeconomic status, linguistic ability, immigration status, sex, gender, and sexual orientation. Far too often, scientists and policymakers develop policies based on their own assessments without acknowledging their blind spots or incorporating community needs and perspectives. Self-reflection to confront our biases and tools such as Project Implicit, for all its limitations, can be a good starting point (Project Implicit 2020). At this critical moment in U.S. history as we reckon with the endemic structural racism and increased xenophobia within the COVID-19 pandemic, the critical importance of positionality assessment, especially for those in a decision-making capacity, cannot be overstated. It is important to acknowledge that the policymaking process is not objective. Policymakers and policy advisors' beliefs, value systems, and morality are inseparable from the decisions they make, often underestimating the power dynamics and power differentials over communities those decisions are being made for. Being grounded in self reflexivity and intentionally assessing our positions in a policymaking capacity can lead to more informed, inclusive, and equitable policies.
ii. Equity and impact assessment Experts developing policy must assess community needs and policy impacts that are grounded in the DEI framework. Moreover, policy proposals should make a concerted effort account for their impacts and unintended consequences on the populations who experience the most vulnerabilities. Impact assessments are an excellent tool for projecting the social, economic, environmental implications of a particular policy across the board. However, it is important to operationalize the impact assessments with a DEI approach that accounts for historical injustices towards certain historically marginalized populations and to ensure an equitable allocation of policy impacts. Similar to an impact assessment, an equity assessment will follow the same process with a focus on populations who experience the most vulnerabilities because of the interlocking systems of oppression and intentionally accounts for the exposure and impact differentials across vulnerable communities. In the case of COVID-19, these tools could have not only provided data on the consequences of the current response, but also generated evidence to inform similar emergency responses in the future.
iii. Mainstreaming policymaking The policy community, particularly the science policy community, must collaborate with other sectors such as the news media to mainstream the policymaking process. Currently, most of the public is often unaware of the details of public policies being proposed, passed, and implemented across different levels of government. Policymakers should work to open and mainstream this process through collaborations with news and mass media and other tools such as social media. This mainstreaming process should include the use of plain language, instead of jargon, that is accessible to a larger audience outside of the public policy circuits. By educating and informing the public about the policymaking process, scientists and policymakers will ensure broader participation in the process and eventual inclusive policy as a result of such participation.

iv. Community engagement
Meaningful community engagement is critical to an inclusive policymaking and development process. It is of paramount importance to ensure we engage local communities, particularly communities that experience vulnerabilities, in a tangible, meaningful way. For any given policy, it is crucial to identify stakeholders who may be either unable or unwilling to participate in the policymaking process. Policymakers should do the due diligence for aggressive outreach to these groups and incentivize participation to ensure their views, unique set of needs, and challenges are reflected in the final policy. A collaborative, community-centered approach towards public policy is the key towards positive social change and dismantling persistent challenges such as racism. Disparities in COVID-19 mortality and morbidity (Ford, Reber & Reeves, 2020) are reflective of a lack of community engagement in the policymaking process that leaves unmet needs and gaps in public policies, resulting in significant damage to communities. Engaging communities and getting their feedback can result in effective and inclusive policies that strengthen societies.

v. Citizen e-consultation
Building off the need for community engagement, it is critical to acknowledge that despite living in the digital era, policymaking process has largely lagged in taking full advantage of tools that can assist in community engagement and result in inclusive policies. 90% of the U.S. adult population uses the internet (Clement 2020). It is important to take advantage of this valuable resource and reach vulnerable communities through the internet in ways that are equitable and accessible. "E-consultation" is defined as using information and communication technologies (ICT) to support a collaboration in which citizens contribute their views and opinions to the government (Blumler and Coleman 2001). Various ICTs that could be used for community input in the policymaking process include the internet and email, smartphones, interactive digital television (DiTV), and video conferencing, and so on. COVID-19 pandemic and physical distancing requirements have further highlighted the utility of making econsultation a key component of policymaking feedback solicitation for inclusive policies. As an example, ICTs played a vital role in fighting COVID-19 in South Korea (Korea 2020). Free smartphone apps were used to support early detection, contact tracing, and to flag infection hotspots and an upsurge in local cases, providing critical data to combat the virus' spread (Korea 2020). vi. Big data Utilizing big data can provide rapid insights into community realities while also providing opportunity to bridge the gap between population level needs and public policies. An example of big data's potential for response is the COVID-19 High Performance Computing (HPC) Consortium with mass computing capacity to keep pace with the vast emerging data on the virus (Dabbar, 2020). While demographic data is currently only available for less than 50% of COVID-19 cases, better data collection and use could lead to more inclusive response legislation during a constantly evolving crisis (CDC 2020). The rapid, large-scale availability of relevant information can help protect the most excluded individuals against further regressions through equitable, early-stage Within the Twitterverse, notable groups such as Black Twitter could provide useful insights into public opinion trends and needs specific to the Black community, for instance. It is important to note that these insights may have some degree of bias as the users are self-selecting to engage in these platforms, have the technical capabilities, access, and affordability, hence, the insights may not be reflective of the entire community's views. Nonetheless, big data provides an opportunity for data points to be collected from populations and communities that are historically underrepresented in traditional datasets. Moreover, as big data diverges from other types of data as it is often collected passively and shifts the burden away from individuals. This allows for more encompassing data points that can then be used for informing public policies.

V. Conclusion
The COVID-19 pandemic has exacerbated many structural inequities, intended or unintended, and highlighted the urgent need to integrate DEI practices into the U.S. policymaking process. The pandemic's ripple effects have been felt broadly across multiple sectors, with disproportionately negative impacts on low-income and otherwise historically marginalized communities. Here, we present a broad range of DEI tools for inclusive policymaking ranging from selfassessment to community engagement to effective use of big data. Although we use COVID-19 as the case study, these tools will continue to assist policymakers and advisors in ensuring that future public policies are inclusive across the board and focused on not only alleviating the effects of structural issues such as racism but also actively dismantle such systems.

Citizen Panels
These standing panels are made up of a representative sample of the population (~500-5,000 people). The views of panel members on different issues are sought regularly using a variety of methods, such as surveys, interviews or focus groups.
Panels are cost effective once initial set up is done and can be used flexibly. However, attrition can be a problem, as it affects the representativene ss of the panel.

Mainstreaming Policymaking
Citizen E-Consultation

Consensus Conferences
A panel of 15-20 people representing all of the communities who will be impacted by the proposed policy are recruited through random selection techniques. The aim is to develop an understanding of a specific topic through briefing materials and dialogue with experts.
Opens policymaking to direct public scrutiny with access to experts in the respective fields. Initial setup is demanding but easily scalable.

Community Engagement
High High

Electronic Letterboxes
Email addresses on websites or documents which give citizens opportunities to give feedback to the government.
Low-cost, easy to implement and engage larger audiences.

Equity & Impact Assessment
Low Medium

Email Distribution Lists
Lists used to circulate consultation documents to interested parties. Citizens can register for these lists via a website. Their comments are forwarded to the government.
Higher participation, but requires efforts to skim through the comments.

Equity & Impact Assessment
Low Low Gives in-depth insight into a specific issue and the contextual and or situational factors that may not be captured by quantitative data such as surveys.

Community Engagement
Equity and Impact Assessment

Google Trends & Twitter
These tools can provide useful insights into public opinions, needs, and policy gaps in an efficient, rapid, and low-cost manner.
Extremely useful for emergency and rapid policy development needs.

Interactive Scenario Planning
This tool can be used to engage citizens in developing policy options or proposals.
Increases public interest in policy by making it more engaging.

Mainstreaming policymaking Community Engagement
Big Data Community Engagement

On-line Live Chat Events
Participants exchange views, within a fixed period of time (usually 2 hours), with government leaders. These can take place during the time period of an internet discussion forum or separately.
Dissemination of information and answering public queries.

Citizen Econsultation
Big Data Low Low

Op-Eds & Commentaries
These tools in local and/or national outlets represent strong, informed, and focused opinions of an independent writer on an issue of relevance to a targeted audience.
Disseminating the information to public on policy proposals in digestible chunks and help mainstream the policymaking process.

Mainstreaming Policymaking
Low Low

Planning for Real
Often initiated by local communities for planning issues, a three-dimensional model of a particular neighborhood is created. At a public event displaying this model, the public is invited to attach cards to identify problems, areas of concern, and possible solutions. These tools such as Twitter, Instagram, SnapChat, are also critical to mainstreaming the public policymaking process.

Mainstreaming Policymaking
Low Low

Visioning Exercises
This brings together a large group of stakeholders (~60), selected because they have decision-making authority, and understanding of, or are affected by, the topic under discussion. Participants take part in a structured meeting, lasting up to two and a half days, where they develop a shared vision for the future and commit to action towards the vision.
Good for helping to create consensus amongst a range of different stakeholders.

Positionality Assessment
Community Engagement

Working Groups
Working groups can likely be composed of the following groups in developing a specific policy: experts, citizens, representatives of civil society groups, and government officials. They might serve as a consultative forum or charged with engaging different groups and individuals in policymaking. These can also be convened online through Zoom or other similar technologies.
Good for drawing on the expertise of a range of people to help develop policy.

Workshops
These allow policymakers to engage in a dialogue with a group of citizens or stakeholders on a specific issue. The policymaking entity may introduce the issue for discussion and invite participants to debate in a mixture of small group and plenary sessions. They usually last between range in length from a half to -to-two full days.
Good for providing opportunities to assess an issue in some depth covering various aspects such as problems, policy priorities and solutions.

Community Engagement
Medium High

Written Consultation Exercises
The public participates in giving feedback and comments on policies laid out in a document.
Good for collating views from diverse parties on detailed and potentially complex proposals.

Community Engagement
Low Medium *Resource intensiveness is defined by the time required to implement the strategy and logistical feasibility with a qualitative rating of low, medium, and high.