COVID-19 could be devastating for Amrita Nichols.

Nichols, a 47-year-old asthmatic, has had pneumonia three times, a medical history that puts her at high risk for complications from the virus. So when her home state of Massachusetts shut down in March, she avoided any activities that could endanger her. Even now, that means no outdoor exercise, no neighborhood bike rides for her kids, no babysitters. And, crucially, no doctors’ visits. 

It’s not an easy decision. Nichols is due for her physical, which includes a mammogram. Both her parents had diabetes, which emerged when they were around her age. The disease also ultimately blinded her grandmother. Nichols’ cousin was recently diagnosed with breast cancer, and in 2015, Nichols’ own breast tissue density triggered further screening. Ever since, she’s been religious about preventive care. Until now. 

“Does it concern me? Yes,” Nichols said. “But it’s a risk I’m willing to take. If cancer gets me — I’ve had kids, I’ll have a double mastectomy. But if I have COVID, I won’t survive.”

The pandemic has put “non-urgent” health care on the back burner for people across the country. Some, like Nichols, fear contracting the virus. For others, local shutdowns or the pandemic’s devastating economic fallout has put care out of reach. But when it comes to precisely whose care is being delayed, the impact isn’t equal: Women have faced an outsized burden, and the outcomes could be profound.

If cancer gets me — I’ve had kids, I’ll have a double mastectomy. But if I have COVID, I won’t survive.

June polling from the Kaiser Family Foundation (KFF), a health policy research group, found that 49 percent of women reported postponing some type of medical care because of the virus, compared to 33 percent of men (down from 52 percent of women in May, compared to 42 percent of men). Per the June polling, almost 60 percent of those who delayed care across genders reported putting off check-ups and physicals, while 23 percent said they skipped preventive screenings — categories of care that often include pap smears, mammograms and screenings for sexually transmitted infections. 

The poll question doesn’t ask about economic barriers to care or postponing doctors’ visits because of lost jobs or access to health insurance, but other research shows women have been disproportionately affected in this way too. Between February and May, 11.5 million women lost jobs compared to 9 million men. Meanwhile, June polling from the Commonwealth Fund, a New York-based health care foundation and research organization, found that a fifth of adults who lost a job that gave them health insurance or were furloughed because of the pandemic were now uninsured.

Postponing a health screening by a few months isn’t necessarily cause for concern. But women’s health experts worry that with no end to the pandemic in sight, indefinite health care delays will ultimately yield real, long-term problems for women. 

A small problem gets bigger

Even before the pandemic, limited access to child care and transportation meant women — especially lower-income women — were more likely to put off medical care, said Alina Salganicoff, a senior vice president and director of women’s health policy at KFF. Now, though, the obstacles are greater. Public transportation can be risky, and child care is harder to come by.

Initial data shows that provision of women’s health services declined dramatically during initial lockdowns. Strata Decision Technology, a hospital information company, examined 240 hospitals in late March and early April, when COVID-19 cases were surging and many states had started imposing lockdowns, and found drops as high as 86 percent in women getting services like women’s wellness visits, which are often where older women get mammograms and younger ones might get screened for STIs. Non-urgent procedures for ovarian cancer dropped by a third. A second study by IQVIA, another hospital data company, found that between February and April, pap smears — which detect cervical cancer — fell by 83 percent.  

“Delaying care, even preventive care, has impact and negative risk,” said Jennifer Ittner, senior director of data science at Strata. “Across the board, we are going to see the ramifications.”

Since April, Strata has found an uptick in breast health care and gynecological services, as well as wellness check-ups. But the numbers are still down by close to 50 percent compared to 2019. And if the recent uptick in COVID cases continues, Ittner added, it’s likely that fear of infection and local shutdowns mean women will once again scale back their medical care. 

Even when physicians’ offices reopen, they are seeing far fewer patients in an effort to maintain social distancing. That, many women are finding, means preventive screenings are almost impossible to schedule, even for those in high-risk categories. 

For Tahesia Bryant, a 49-year-old project manager in Riverside County, Calif., further delaying her mammogram and pap smear — which she’s already postponed because of the pandemic — doesn’t feel safe. She’s started displaying other symptoms that she believes might indicate perimenopause, and she wants to make sure it’s nothing more. When she tried to book an appointment, nothing was available for months.

“I can’t afford to prolong an appointment when my body is changing,” she said. “It’s a fight to get anything right now.”

Some physicians pointed to online medical care as a potential stopgap, at least until medical facilities can fully open up. A virtual visit can suffice for something like counseling someone about birth control pills, or helping diagnose an illness or infection based on medical history or symptoms, but many health services need to be done in person: cancer screenings, blood tests, and provision of intrauterine devices, which are considered among the most effective forms of birth control. And telemedicine may not be an option for women with limited internet access.

Even if in-person appointments are available, a doctor’s visit that might once have fit within the budget may no longer seem feasible. Women have been particularly hard hit by the pandemic’s subsequent economic recession, reporting greater job loss and higher unemployment rates. 

“A lot of people are losing their insurance, or have coverage where a copay, when they had a job, wasn’t a concern,” Salganicoff said. “Now it is causing them to pause and think twice.”

Altogether, the consequences could be staggering. A June analysis from the National Cancer Institute (NCI), for instance, projected more than 5,000 excess breast cancer deaths over the next decade, largely because of how the pandemic has curtailed access to medical care. That estimate, NCI director Ned Sharpless wrote in the analysis, is “moderate,” assuming, among other things, that the disruption in medical care only lasts six months.

And mitigating that fallout will take concerted outreach, especially for women who aren’t consistently able to access medical care, said Dr. Laurie Zephryin, a vice president at The Commonwealth Fund. 

“How do you ensure people with breast cancer that may fall through the system — what’s the process for making sure they’re being reached out to and brought back into the health care system?” she said. 

Uneven access

Medical experts pointed out that existing racial disparities in women’s health outcomes could deepen. In particular, Black women and Latinas — who are already disproportionately vulnerable to the coronavirus — are also more likely to suffer the implications of indefinitely delayed care. 

“It’s the coalescing of two crises,” Zephryin said. “There are striking inequities and disparities that have been laid bare.”

Breast cancer, for instance, is equally common in Black and White women. But more consistent and early access to preventive screenings means doctors typically detect it earlier in White women, which makes it easier to address. Already, breast cancer mortality is 42 percent higher for Black women than for White women, according to the Centers for Disease Control and Prevention. Meanwhile, cervical cancer is 40 percent more common among Latinas, who are 20 percent more likely to die from it. 

Polling suggests that White women are more likely to have voluntarily put off care, said Ashley Kirzinger, KFF’s associate director for public opinion and survey research. Black women and Latinas, however, have been hit harder by other pandemic-inflicted upheaval. They are more likely to live in areas deeply impacted by coronavirus, and where access to other kinds of medical care is harder to find. Even before the pandemic, they were more likely to run into the obstacles that force women to delay care: transportation, child care and cost.

“We worry about that all the time — regardless of a pandemic —  but especially right now with so much job insecurity,” said Dr. Meera Shah, the chief medical officer for Planned Parenthood Hudson Peconic, in New York. “Women of color are more likely to be the primary caregivers of children and other family members, as well as working one or maybe two jobs.”

Iris Reyes, a Texas-based organizer with the National Latina Institute for Reproductive Justice, is seeing those barriers play out in real time. Reyes works in South Texas’ Rio Grande Valley, a hotspot for the virus. Most of the people she works with are Latinx, and about a third are uninsured. 

Most women Reyes advocates for get medical care through community-based clinics — which are currently closed because of the pandemic — or are in theory eligible to visit a doctor online. But limited internet access means that those women are going without care. 

Already, she added, preventive care is hard to come by. The pandemic adds another layer. “It’s a domino effect,” she said.

Many of the people Reyes serves are in jobs without health benefits. The recession has put many of them out of work, meaning preventive health care simply isn’t affordable. Diabetes is prevalent and birth control hard to come by. She worries about women using remains from relatives’ unfinished prescriptions because money is tight or they can’t get to a pharmacy. The economic relief from Washington has done little, she said.

For 53-year-old Maria Reyes, who lives in Hidalgo County, a mammogram or pap smear is out of the question and has been for years due to financial barriers. Her doctors’ offices are closed. Beyond the screenings, she needs contraception, which she takes for heavy menstrual bleeding. Without it, Reyes (no relation to Iris) develops anemia. But that medication requires a prescription, which she hasn’t been able to get renewed in the shutdown.

Even if doctors’ offices reopen, the $20 copay for a visit — or more for some exams — is a financial strain she simply can’t afford right now.

Because Texas hasn’t expanded Medicaid eligibility, an optional component of the Affordable Care Act that extends insurance to lower-income people, Reyes recently purchased her own health insurance. It costs more than $100 a month. She works cleaning houses, and her clients have disappeared because of the pandemic. 

Best-case scenario, as things reopen, she can hope to earn $50 a day, working maybe three days a week. It isn’t enough. She has six children, and two live with her. Money goes toward taking care of her family, and paying existing bills. But she’s worried about the consequences.

“It’s super scary,” she said. “Some problems — it’s harder to detect them if there isn’t a doctor.” 

Traditionally, the University of Texas sponsors an outdoor free health fair in July. Hundreds of people come for mammograms, cancer screenings and diabetes checks. But this year, the risk of crowds means the fair was canceled.

“These are the types of things our community expects,” Iris Reyes said. “There’s just barriers and barriers.” 

Doctors and policy-makers could take deliberate action to bridge these gaps, suggested Usha Ranji, KFF’s associate director for women’s health. That could include extending health coverage to women who are uninsured or under-insured, and taking other steps to eliminate barriers to medical care. 

But for women, it will take time for the effects of these delays to become clear. And by then, it could be too late.