Dr. Barbara Starfield, a professor and health services researcher at the Johns Hopkins Bloomberg School of Public Health whose work in the field of primary care and health policy brought her international acclaim, died June 10 while swimming at her home in Menlo Park, Calif.
The longtime Mount Washington resident was 78.
"She was found floating in the pool and may have died of an apparent heart attack. We are waiting for the autopsy report from the coroner," said her husband of 56 years, Dr. Neil A. Holtzman, a pediatrician and a professor at the Johns Hopkins University School of Medicine.
"I was a student here in the 1980s, and she was already famous then. She was a petite woman but a giant in her field," said Dr. Michael J. Klag, who is dean of the Bloomberg School of Public Health. "She was indefatigable and a bundle of energy."
He said that Dr. Starfield's research concluded that a "strong primary care component resulted in a more efficient system, cost less money and lowered mortality. Her first studies were a tremendous contribution."
The daughter of educators, Dr. Starfield was born and raised in Brooklyn, N.Y., where she graduated in 1950 from Midwood High School.
She earned her bachelor's degree in 1954 from Swarthmore College and her medical degree in 1959 from the State University of New York at the Downstate Medical Center.
Dr. Starfield completed an internship and residency in pediatrics at Johns Hopkins Hospital, and earned a master's degree in epidemiology in 1963 from what was then the Johns Hopkins University School of Hygiene and Public Health.
Dr. Starfield, a pediatrician, began her career in 1963 as medical director of the community nursing project in the department of pediatrics at Hopkins Hospital, and was medical director of the pediatric care unit, also at the hospital.
From 1963 to 1966, she was also an instructor in the department of pediatrics at the Hopkins medical school.
She was assistant director of community health and comprehensive child care project at the hospital, where she was also a member of the Committee on Planning and Development from 1965 to 1967.
Dr. Starfield held pediatric teaching positions in the Hopkins School of Public Health and Hygiene until 1975, when she was appointed to lead the school's division of health policy in the department of health policy and management.
During her tenure, Dr. Starfield was the author of a significant study comparing the U.S. health system with those of other Western countries, and a study of doctors and clinics that cared for many Medicaid patients in Maryland.
Even though she stepped down in 1994, she remained an active member of the faculty and was the founding director of the Primary Care Policy Center.
In a 1993 interview with The Baltimore Sun, Dr. Starfield concluded that specialists ordered more tests, performed more procedures and hospitalized more patients than primary care physicians who were treating the same symptoms as their specialist colleagues.
"By their very nature, [specialists] will do more," she said. "They are looking for the unlikely, the rare. They think zebras, not horses."
Writing in The Sun in 2000, Dr. Starfield said that while many Americans complained about the high cost of health care, they rationalized that if it's expensive, then it must be the best in the world.
Not so, she concluded.
"How do the outcomes of our health-care system stack up against our Western, industrialized counterparts in Canada and Europe?" she wrote. "In a recent Johns Hopkins study that measured death rates and other indicators of health, the United States finished nearly last — 12th out of 13 countries studied."
One of the culprits, she wrote, was medicine's high-tech orientation.
"In the study, 'To Err is Human,' the Institute of Medicine estimates that between 44,000 and 98,000 Americans die each year as a direct result of medical errors," she wrote.
She also dispelled the notion that in countries such as England and Canada, which have subsidized health care, patients must wait months to see a doctor.
"That is true only for elective surgery," wrote Dr. Starfield.
Furthermore, she wrote, despite the legend of the family physician of old making house calls seven days a week in all kinds of weather and in the dead of night, "True primary care has never taken root in the United States.
"The leading medical schools, including Harvard and Johns Hopkins, do not have training for family physicians, who are the mainstay of primary-care practice in most of the other wealthy countries," she wrote.
"Her work led to important methodological tools for assessing diagnosed morbidity burden and had a worldwide impact," said Dr. Klag. "She was steadfast in her belief that a quality primary care system is critical to the future of health care in this country and worldwide, and received numerous accolades for her work in this important area."
Dr. Ellen J. McKenzie is chair of the Bloomberg School of Public Health's department of health policy and management.
"She was very passionate about the work she had done over the years and was also an incredible mentor and teacher," said Dr. McKenzie. "If she could encapsulate her life, it would be the establishment of the role of primary care in this country and other countries. She felt very strongly about this."
In 2005, Dr. Starfield received the John G. Walsh Award for Lifetime Contributions to Family Medicine from the American Academy of Family Physicians.
Dr. Starfield, who had homes in Menlo Park and Las Cruces, N.M., had not retired at her death.
Dr. Starfield was an outdoorswoman whose favorite activities, her husband said, were vacationing and hiking in the Adirondacks, biking on the Northern Central Railroad trail and swimming. She was also a world traveler.
Plans for a memorial service at Hopkins Hospital to be held in October were incomplete.
In addition to her husband of 56 years, Dr. Starfield is survived by three sons, Robert A. Holtzman of Orlando, Fla., Jon J. Holtzman of Las Cruces and Steve C. Holtzman of Berkeley, Calif.; a daughter, Deborah J. Holtzman Hart of Menlo Park; and eight grandchildren.