As an emergency room physician, I am trained to treat critically ill patients. But I never thought I would see this.

In her late 50s, my patient complained of diffuse body pain. When I examined her, I found something that I had only seen in illustrations from medical history books - a fungating (having eaten through the skin) breast tumor the size of an orange. This poor woman, in the 21st century, had a condition that modern health care and technology could have treated much earlier. However, she lacked the key to all our medical advances - insurance.

She had seen a doctor two years before and was told that she might have early breast cancer. But without health coverage, she was unable to obtain timely follow-up and came to see me in the emergency department after her condition was terminal.

In Cincinnati, this newspaper has published articles on the diverting of ambulances from nearby hospitals because of overcrowding reaching record levels in the last few years. We who work in emergency rooms know that this is a top-down view of the problem. My patient is the more heartbreaking and tragic part of the story.

Without health insurance, emergency rooms are the only place that our fellow citizens can go for treatment. But for conditions such as cancer that require health screening and preventive care, we are ill-equipped to help until it is too late.

It would be easy to say that primary care physicians should be willing to take patients even without insurance. But as medical reimbursements have fallen, these gatekeepers to our health care system are often overburdened. And it would not solve the problems of increased costs of medical technology and prescriptions, often the key to early diagnosis and treatment. Only government has the means to provide remuneration for uninsured patients, and rising deficits often put such coverage at risk.

We in Hamilton County have shown ourselves to be a generous community through the levy for indigent medical care. If even here such tragedies occur, I wonder what it must be like in less giving localities.

A colleague once told me that the emergency room is like the canary in the mine - a warning of the state of the health care system. My patient with the tumor indicates that unless our society does something to provide medical coverage to all of our citizens, such tragedies will only become more common.

Dr. Arvind Venkat is an emergency room physician who lives in Hyde Park.

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