Anne Vincent, M.P.H.'95, keeps on finding work in a war zone. A physician who earned her medical degree in her native France, Vincent worked for Médecins Sans Frontieres (MSF) in Sri Lanka and Rwandan refugee camps before studying at the School. After graduating, she signed up with UNICEF, partly because she was inspired by its mandate to promote children's rights. Vincent also wanted to get away from MSF's crisis-driven approach and to work on health projects with more staying power.

But when UNICEF assigned her to the small West African country of Sierra Leone, Vincent once again found herself in the midst of a bloody civil war. She has struggled to hang on to her belief that the most effective way to save lives is to take the long view.

"Sierra Leone gets more and more difficult," she wrote in an e-mail message in July. "Atrocities in the northern province and the taking over of Kabala town-three days after I visited the town and brought in supplies of medicines and vaccines-leave us helpless and hopeless, too. You save kids from measles and they get their hands chopped off by rebels three days later."

Vincent was hired by UNICEF to direct the organization's health and nutrition division in Sierra Leone. Even in the most tranquil of times, this job would have been an uphill battle. Sierra Leone has one of the worst health profiles in the world. Life expectancy at birth in the country is 37 years, the lowest in the world. The maternal mortality rate is the highest: 1,800 deaths for every 100,000 births. Working closely with local communities and what's left of the country's health bureaucracy, Vincent set about to revitalize Sierra Leone's network of primary health care clinics. Though they are rudimentary in such a war-torn place, these clinics are an essential part of the country's health care services, immunization programs, and food programs.

Vincent had been in Sierra Leone only a short time when the rebel forces that had been waging a brutal civil war in the bush for years completely took over the country in May 1997. All international health and relief workers were evacuated. Forced to coordinate her program from the neighboring country of Guinea, Vincent relied on her Sierra Leonese staff, directing and supporting them via e-mail and cellular phone. Although she is now back in Sierra Leone, in the capital city of Freetown, the continued bloodshed has greatly restricted her travel. Vincent still depends on her national staff in areas where it is unsafe for her to go.

Vincent delineated the striking contrast between her UNICEF experience and her days with MSF during a face-to-face interview this spring when she was in the Boston area to attend a course on health care financing and sustainability. Small and elegantly dressed, Vincent didn't look the part of an eight-year veteran of practicing public health amid murder and mayhem. She commented that at UNICEF she learned that "by working with national staff and depending on them, we actually empower them. I must say that has been one of the very positive aspects of this crisis; they did a great job."

Vincent used her time in Guinea to think through new strategies and programs for delivering health services even during an emergency as horrific as the civil war engulfing Sierra Leone. "It's not enough to drop kits of medicines here and there; that's not a program per se," she said.

One surprising aspect of her approach is a requirement that people pay for some health services. "We didn't know how long the crisis was going to last, and we wanted to create something that was sustainable," said Vincent. She and her colleagues let community leaders decide how much to charge and also gave them some discretion over how to spend the money collected. So far, none has refused to set fees, and all have agreed to use the money to pay their health workers. Vincent said, "It shows that somehow you can avoid this dependency syndrome of rushing in, bringing everything, and not asking anything from the community."

This experience has changed her view of people who are usually seen as worthy of help and pity but perhaps not much else. "In all the communities I met with, I was very impressed by the fact that those people were not weak victims. I felt that they were still strong. I think for me it was a fantastic lesson to learn. You can build on communities." Vincent said the idea of community was tossed around a lot during her year at the School. And she encountered it again at UNICEF meetings. "I've heard it so many times, but it was something very abstract. What does it really mean to empower a community? Now I know."

At about the same time as Vincent was in Boston, the cycle of violence started anew in Sierra Leone. Press reports said that rebel forces were mutilating people-gouging out people's eyes and cutting off women's breasts. When Vincent returned to Sierra Leone, friends rallied to Vincent's side via the Internet. "I know no one who has been more constantly immersed in the abominations which mankind can practice on its own," wrote one friend, Doug Carver. Vincent's optimistic mood and hopeful statements about community were being tested. Her July e-mail about saving kids with measles only to have their hands cut off days later concluded: "You really wonder what's the meaning of all this."

- Terri L. Rutter