BANGKOK, Mar 8 (Reuters) When June Flowers woke up in her small Ohio town one winter's morning, unable to move because of back pain, she never dreamt she would fly to the other side of the world to undergo surgery that she couldn't afford at home.

One of 40 million Americans with no health insurance, the part-time cashier who had never been outside the United States became a ''medical tourist'' to a hospital with a strange-sounding name in the Thai capital, Bangkok, a city she knew nothing about.

''When we think of Asia, we think of run-down huts, poverty and disease,'' said Flowers, 47.

Few places could dispel that image more forcefully than Bumrungrad International, a luxurious hospital with a Starbucks in the lobby and an Italian restaurant upstairs.

From the graceful receptionists in tailored silk suits to the plush carpets and spacious rooms -- everything is designed to give the hospital the look and feel of a five-star hotel.

Unable to pay the 30,000 dollars that US surgeons would charge to operate on her herniated disc, Flowers had spent more than three years trying to keep the pain at bay with chiropractic treatments and cortisone injections.

Watching the ''60 Minutes'' television show in 2005, she learned about Bumrungrad, where most of the doctors are Western trained but the cost of treatment is about one eighth of that in the United States. It was a daunting but tempting prospect.

''My son said to me 'Mom, don't you know that's a third world country?'. But the surgery there cost just 3,500 dollars. I knew right then I had to go.'' OUTSOURCING Thailand, famous for its beaches, temples and nightlife, is a leading destination for medical tourism.

Bumrungrad offers everything from heart bypass surgery to chemotherapy and breast enlargement procedures. It treated 450,000 foreign patients last year -- more than any other hospital in the world.

Competition is strong from the Apollo Hospitals group in India, which is also courting Americans looking for cost savings and Europeans unhappy with long waiting times at home.

Health care could soon follow the flight of manufacturing, services and software development to the developing world where a lower cost of living translates to cheaper treatment, said Ruben Toral, Bumrungrad's marketing director.

''We believe that medical tourism will eventually lead to medical outsourcing,'' Toral told Reuters. ''Your corporation, your insurer, your government could send you here for surgery and make significant savings.'' Meanwhile, individuals are already outsourcing their own health care and encouraging friends and family to do the same in a word-of-mouth market.

''This is where all my family will come now. If there is a problem, we will come here,'' said Mariam Taqi, a 62-year-old Kuwaiti woman receiving treatment for leukaemia at Bumrungrad.

Like most patients, Taqi said she was impressed by the service in a country known for its gentle hospitality. ''The nurses are so kind and sweet. Nothing is too much trouble.'' NEGATIVE REACTION Unsurprisingly, this potential revolution is not going down well with the medical establishment in the West.

''When I told my doctor we were thinking about going to Thailand, he said he had serious concerns about the cleanliness of the place and the dearth of expertise. He refused to give me handover notes,'' 61-year-old Sherry Pinckley said.

Pinckley, from an Alaskan fishing village, decided to go anyway, and had both her knees replaced at a cost of 10,000 dollars per knee in February -- less than one fifth of the price for the same surgery at home.

''The joke is that this is the cleanest hospital I've ever seen,'' said Pinckley, lying in bed in her spotless private room.

The Australian Society of Plastic Surgeons has expressed alarm about the phenomenon it calls ''scalpel tourism'', often driven by agents who offer a package of flights, hotel accommodation, surgery and sightseeing.

It says its members are seeing more and more patients after botched cosmetic surgery jobs in countries such as Thailand. They say patients are often not told about the risks and have no recourse if things go wrong.

''When I get involved it's usually been an absolute disaster,'' said Dr Anand Deva, a Sydney plastic surgeon.

WEEPING WOUNDS One of Deva's patients is a woman in her 50s who went to Bumrungrad for a breast lift and tummy tuck. Five days after the operation and already discharged from hospital, she developed an infection in her abdomen and left breast.

Doctors at Bumrungrad offered to readmit her but she had to foot the bill. Her confidence in the hospital lost, her budget already spent, ''She got on an international flight, very sick, with weeping wounds in the tummy and breast,'' Deva said.

The woman was admitted immediately to a Sydney public hospital to treat the potentially fatal infection. After several rounds of revisional surgery, she still has horrific scarring.

''If you operate on someone and things go wrong you need to deal with the consequences,'' said Deva, a senior lecturer in plastic surgery at the University of New South Wales.

''It's very convenient if there is a major complication to stick the patient on an aeroplane and send them somewhere else.'' But Bumrungrad, Asia's first internationally accredited hospital, denies that patients are ''trading down'' to a lower quality of care to save money.

''Highlighting an isolated case, like this, misses the point entirely and plays into a stereotype that foreign doctors or hospitals are inferior,'' Toral said.

June Flowers was so happy with her treatment that a year after her first operation she came back for a hysterectomy. She even made time for a little sightseeing with her sister.

''You don't realise it's a hospital. It's like you're there for vacation,'' Flowers said from her home in Huron, Ohio.

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