Back in March, Stevie Neal’s doctors found a lesion on her shoulder bone during a routine scan. They weren’t sure, but they suspected it was cancerous, a tumor that had metastasized from the head and neck cancer she’d been treated for last year.

The 66 year old was set to get a biopsy done on March 31. But when the day came, Neal didn’t go to the hospital—instead, she hunkered down at her home in Rockville with her dog, increasingly afraid to venture outside.

“For me, the choice is very simple,” Neal says, explaining why she chose to cancel her biopsy despite feeling all but certain she has cancer again. “You know, the cancer might kill me. But the COVID definitely would if I were to catch it. So I’m more afraid of that right now than I am of the cancer.”

As hospitals and local jurisdictions around the country have braced for a surge in COVID-19 cases, many of them have cancelled elective surgeries and other non-emergency procedures, as recommended by the American College of Surgeons and the U.S. surgeon general. That means that people all over the country are being forced to delay medical procedures they need. Others, like Neal, are choosing on their own to delay medical attention and even urgent procedures, despite the fact that doctors are still willing to perform them.

“There are a few issues here. One is people who already had something scheduled, and it’s been cancelled,” says Dr. Ranit Mishori, a professor of family medicine at the Georgetown University School of Medicine. “And there’s also a group of people who are not showing up for care, or are foregoing care for acute issues they couldn’t anticipate” like heart attacks or strokes.

For people in the former category, Mishori says, it’s possible they’ll face minimal or no medical consequences from the delay—but it depends on how serious their conditions are to begin with. The chances of adverse effects increase the longer they have to postpone their care. Those in the latter category could be risking lifelong medical consequences and even death, particularly if they’re not seeking immediate emergency care for cardiac symptoms, where time is of the essence, she says.

Many locals are heartbroken by the cancellation of their surgeries, physical therapy, or diagnostic testing.

Dania Palanker, a 45-year-old research faculty member at Georgetown University, says she’s been left “gutted” by the cancellation of an out-of-state pain rehabilitation program she was supposed to begin on Thursday. Palanker suffers from an auto-immune condition called chronic inflammatory demyelinating polyneuropathy, which damages her nerves and causes severe chronic pain.

“I’ve just been living for pain for decades now, since I was a teenager,” Palanker says. “And I’ve basically come to a point where it’s overwhelming to be working, having pain, and having a family. I needed something to change.”

The plan was to attend a rehabilitation program that could teach her new ways to cope with and manage her pain, and then come home and spend time practicing the new habits. She took six months of unpaid medical leave from her job to do it, which is now largely going to waste.

“I actually feel like there’s a bit of mourning going on. I really lost something huge in my life,” says Palanker. “And I don’t blame anybody for it. The entity at fault is a virus … But it leaves me in a place of being gutted, because I sort of had a plan to maybe have a little less pain in my body, and it feels like it’s slipped away.”

The same thing is true for Madison Reyes, a 21-year-old classical pianist in Ellicott City whose left side was partially paralyzed by a mysterious bout of seizures in January. Reyes was supposed to get a comprehensive, five-to-seven day seizure study done at Johns Hopkins starting on April 4; doctors were hoping to understand why her brain keeps seizing, and what they might be able to do to help her gain full functioning back in her left side. The study has now been postponed to June.

“It’s really frustrating,” Reyes says. “We’re trying to figure out what’s wrong. It’s been four months. It’s just really hard.”

People with chronic conditions aren’t the only ones missing out on care, according to Mishori. Emergency rooms across the country are also seeing a reduction in visits, even for things like heart attacks and strokes. That reduction could point to a dangerous trend.

“It’s not that suddenly people don’t have heart attacks or suddenly people don’t have strokes,” Mishori says. “The question is, why are they not going to the emergency room, and where are they?” While there’s no hard data yet, Mishori says it’s possible that they’re waiting until the last possible minute to seek care (which is dangerous for cardiac events), or that more people are dying at home without seeking care at all.

Some local hospitals say they have seen a drop in non-coronavirus related medical visits. Jennifer Abele, the interim chief medical officer at Sibley Memorial Hospital, says emergency room visits are down about 40 percent this month alone.

“We are greatly concerned that this may mean people actually requiring emergency care for potentially serious medical conditions, such as heart attacks or stroke, may not be coming to the [emergency room] because they fear contagion with COVID-19,” she told DCist in an email.

Shelly McDonald-Pinkett, the chief medical officer at Howard University Hospital, says they have also seen a dip in emergency room visits and doctors’ appointments, though she could not provide exact numbers. Jamel Langley, a spokesperson for Children’s National Hospital, says the hospital saw the same trend initially, though they have made up some of that with telemedicine visits.

Like many hospitals across the country, all three have cancelled or postponed elective surgeries as they devote their resources to treating patients with COVID-19.

For Neal, whose body is weakened by intense medical interventions to treat her cancer, the idea of showing up in a hospital for the biopsy was unthinkable. Seven weeks of chemotherapy and radiation “just about did me in,” Neal says. Worst of all, the radiation destroyed her salivary glands and her taste buds, leaving her mostly unable to eat. In December, she ended up in the hospital again, severely weakened from malnutrition and dehydration. She’s still healing from the ordeal, and feels certain that she wouldn’t be able to survive the virus in her current state of health.

For now, she says, she’s at peace with her decision: “I am a little concerned, but I’m not anxious about [putting off the biopsy] yet.”

Smaller doctors’ offices have seen this pattern play out, too. Ken Zweig, an internal medicine physician with Northern Virginia Family Practice Associates in Alexandria, estimates that their office has seen a 75 percent drop in patient visits.

He says that in most cases routine care can be put off temporarily with little issue, and patients with emergency medical needs will likely know something is wrong and seek treatment. But he worries about the people in the middle of that spectrum.

“It’s those urgencies that are not emergencies, where it may be something bad but we don’t really know until you look,” he says. “Those are people that I think we’re missing mostly, where they could turn into something bad, but they’re not letting us [do] the evaluation that they should have. And that gray area is where it really gets tricky.”

Zweig says patients should not wait to contact their doctor if they think they might be sick, and his practice will address that very concern during a town hall meeting with patients over Zoom on Thursday, which he and his colleagues are holding weekly in an effort to stay connected with patients.

He says their absence has also been felt financially. While he couldn’t provide specific numbers, he says the crisis is “definitely taking a toll” on the business, which employs four doctors and one physician assistant. Northern Virginia Family Practice Associates is a concierge practice, and charges its patients an annual fee that Zweig says provides some padding, but the office manager has looked into getting financial assistance.

Doctors nationwide have felt a similar strain. According to a new survey, 20 percent of primary care practices believe they will have to close temporarily because of lost revenue, Business Insider reported this week, and while bailout money is sustaining them for now, some doctors will be forced to sell.

Larger hospital systems are feeling that pain, too. On Tuesday, Virginia’s Inova Health System announced plans to lay off more than 400 employees, most of whom were in non-clinical management roles. The same day, the Senate approved bipartisan legislation providing more emergency funds in response to the pandemic, including $75 billion for hospitals. A representative for Inova did not respond to DCist’s request for comment on the layoffs.

“It’s a very big financial and business reality for a lot of practices. We are seeing health team members being furloughed and we are seeing a general reduction in visits,” says Mishori. “I think we’re going to see a lot of practices, especially small practices, private practices, and primary care practices, who are going to be closing.”

The medical effects of the pandemic are going to ripple out far beyond those who ever get infected with the virus, Mishori says. People are foregoing mammograms and colonoscopies, blood tests for diabetes, and other serious preventive care that routinely saves lives. Surgeries are being put off, sometimes indefinitely, and people may end up without their primary care physicians when this is all over, if offices close down. The depth of the impact will largely depend on how long the stay-at-home orders have to last.

Neal says that’s something she worries about constantly. What if she still doesn’t feel safe going to a hospital in August? October?

“I think about it all the time. If this drags on to October, that’s very scary,” she says. “I’m hoping that things will have calmed down enough by June or July that I can get this biopsy done by then.”