There have been other experiments with telemedicine in China, and there are other telemedical services in operation.

In the spring of 1995, the case of a patient with heavy metal poisoning was sent from Beijing to the US. Respondents around the world sent suggestions over the Internet by e-mail for the patient's treatment.

In April 1997, the first real-time telemedical consultation between China and the US occurred. It was carried by satellite in the form of a video teleconference between physicians at Peking Union Medical College Hospital and physicians at Mass General and Partners Health Care in Boston.

The case of a boy with an undiagnosed immune deficiency disease was discussed, and senior officials from both countries attended, including Ambassador Sasser and the Minister of Health.

Many hospitals in China including Peking Union Medical College Hospital have acquired video-based teleconferencing systems and are delivering telemedical services. Such services are expensive because of the bandwidth and time they consume, and their costs are beyond the reach of the average citizen.

A group known as Medionet claims to have installed several hundred systems across China which permit physicians to consult by telephone-based teleconferencing. These services are more affordable, but still too costly for average citizens, and they are limited to one communications channel.

There is a mis-match between the level of technology of telemedicine in developed countries, and the capacities of telecommunications and computer installations in China. The 'high-end' systems that have proved effective in the US, UK, and Israel, for example, cannot be deployed widely in China, or be operated on a routine, day-to-day basis.

What are needed are 'low-end' systems that match the capacities of phone lines and computers, such as the Internet-based applications that will be demonstrated at Xi'an Medical University and UCSF/Stanford during the President's visit.

We believe that the future of telemedicine in China (and around the world) is more likely to be 'low-end'. That is, the greatest number of cases will be dealt with by store and forward e-mail, rather than by real-time teleconferencing.

We also believe that more research should be done and resources invested in practical applications, rather than in grand visions (low-orbit satellites linked around the world for transmission of high-resolution images from clinic to hospital, for example).

In China, in fact, in Beijing and Shanghai among other leading cities, there is an over-capacity of high-end medical equipment (including telemedical systems). In the countryside there is an under-capacity, and in most rural locations very little equipment of any sort at all.

The challenge is to deliver benefits of modern medicine to locations that are last in line to receive them, using applications that will work in the most difficult environments, work reliably and day-to-day.