Dr. Christina Marea, PhD in Nursing | Assistant Professor at Georgetown University

In this episode, we discuss Christina’s fascinating journey from midwifery to Doctors Without Borders to pursuing her PhD in nursing, the ways she prioritized her physical and mental wellbeing while working on her doctorate, and her advice for setting boundaries and finding alignment with your work.

Hosted by  Lois Dankwa

To connect with Christina and to learn more about her story, visit her page on the PHutures #100AlumniVoices Project website.

Transcript

Lois Dankwa

Hi, I'm co-host Lois Dankwa and this is the #100 alumni voices podcast, stories that inspire, where we explore the personal and professional journeys of a diverse group of 100 doctoral alumni from Johns Hopkins University. Today, we're joined by Christina Marea, PhD in nursing and current Assistant Professor at Georgetown University. Hi Christina.

Christina Marea 

Hi Lois, thank you so much for having me here today. I'm excited to chat with you.

Lois Dankwa

Yeah, I'm excited to have you join us. So how are you doing today?

Christina Marea 

Oh, doing pretty well. I'm working from home on some of my research today, and I have 2 toddlers who have been sick all week.

Lois Dankwa

Oh!

Christina Marea 

So, managing some research, some clinical work, and 2 little monsters who are 2 and 4, but feeling feeling good.

Lois Dankwa

That's good. Well, sorry that your kiddos are sick, but I hope that with the weekend coming up they'll be able to re-up and be ready for all that free time. So, I first want to dive in to understand more about what made you interested in pursuing a PhD in nursing, and just hear more about your graduate work at Hopkins.

Christina Marea 

Yeah, absolutely. So, I had a long journey to becoming a midwife. So, I am a certified nurse midwife, and before that I was a certified professional midwife. So, I began my my midwifery journey at a at a clinic on the US-Mexico border, where I cared primarily for migrant patients. My family is from Central America, my mother is from Honduras, and so, being able to work as a bilingual midwife on the border was really important to me, and I and I loved it, but I also had this sense of like there's a lot of geopolitical things that are going on impacting like the clients, the people who I'm seeing and just what's happening at the border. So, I looked into and got a masters in conflict resolution. I ended up moving to the UK and studying the impact of conflict on sexual and reproductive health, and particularly looking at the post-conflict reconstruction of health care systems. And I did a case study in Sierra Leone, and I got a chance to spend some time in Free Town, and I loved that. But I also missed clinical care. So, I went back, and I and I got a masters as a nurse midwife at Yale, which was a lot it was a lot of fun. I got to be the director of a clinic for undocumented migrants living in Connecticut. I got some excellent training, worked at an amazing federally qualified Health Center and then move to Washington, DC, which is my long-term home, and began working at a large tertiary care hospital here in DC. So, I predominantly cared for pregnant teenagers, and I was responsible for the prenatal care for most of the incarcerated teens in Washington, DC for a few years. But the health care system, right, means that I need to do 15 min visits, and most of my patients were insured via Medicaid, which means the reimbursement rates are lower, which means I had to be booked with a higher number of patients a day to generate enough revenue to pay my salary, but I also had clients who were pregnant and incarcerated teenagers, who needed more than 15 min of my time, and there was just this massive disconnect between the care that I was trained to provide as a midwife, the needs that I was trained to assess for, which were not just physical health, like, yes, your baby's growing. Your blood pressure's okay. But do you have a safe place to sleep? You know, how are you doing in school? What's going on with your parents? Are you able to eat food multiple times a day, right? Cause even access to food, much less healthy food, was a challenge, and after a couple of years of working in that environment, it was sort of a major moral and social disconnect of not being able to provide the care that I wanted to provide because I was working in a system that didn't work for the clients I was taking care of, and so this feeling of being underwater on my impact, like I am trying to solve individual problems on a daily basis in a way that I feel like I can't be successful at. I feel like I'm giving good care to the extent that I can, but in a massively constrained environment. So, I went back and got my PhD because I wanted to reimagine what health care could look like. I wanted to focus on the most vulnerable people. I also, so when I left that job at Washington Hospital Center, I actually didn't go straight to a PhD. I joined doctors without borders, and I worked as a midwife in South Sudan in a refugee camp sort of moving back to my interest in, you know, migrants, humanitarian crises. And so I went from doctors without borders into the PhD. And I'm happy to talk more about that journey once I started. But you know those are some of the backgrounds of of how I ended up in a doctoral program.

Lois Dankwa

I love all of that, for a number of reasons, one of them being you're definitely speaking my language when it comes to wanting to revise and improve and enhance healthcare and how it works for people. And just the overall net impact of it. But then, also recognizing that people in underserved spaces, there's a number of things that are unserved, which is why, when you see them in a healthcare setting, it's not the one thing you're addressing, there are all of those factors that influence. That's something you and I could talk about for hours, I'm sure. 

Christina Marea 

Yeah.

Lois Dankwa

I think I also really love how you, your approach to your PhD really stems from the like in the field, in practice and clinical experience that you had. And I'm curious what parts of that then really guided how you approached your PhD, whether it was when you took classes, what were you thinking about, or when you were thinking about what you wanted to do after your PhD. How did that experience inform the experience of pursuing your PhD?

Christina Marea 

Yeah, absolutely. So, I wanna talk a little bit more about my time and in South Sudan, because it's it's sort of both my my experiences as as a clinician in the US, my experiences globally and humanitarian work that brought me to some of the questions that I wanted to face when I was in my PhD program. And so, when I was in South Sudan, I was the only midwife for a refugee camp of about 15,000 people. The only licensed midwife. There were 2 Kenya nurses who had both had some midwifery training, but about 6 weeks of training, and then an amazing crew of 5 traditional birth attendants, who were Sudanese who were incredible midwives, but had no formal training. And there was a similar and incredible set of dynamics that operate in that environment as well. I mean, talk about marginalized and underserved, right? These are people who have been forced out of their homes, who are living in tents, and who are being served by tent hospitals and patient-to-provider ratios that are just wildly, you know not not what we would consider adequate in terms of meeting meeting patient need. But, there was also a decent amount of hierarchy in terms of, you know, colonial dynamics right being an aid worker, being a white person from a different country, who can get up and leave this environment at any time, coming from a health care system where we very much feel that there is a right answer, like if this, then that, right, like we, we train our clinicians in algorithms. If you have, you know if you are dehydrated in labor, you need an IV, right? And there's good like biomedical reasons for that. Like hydration is incredibly important in labor, but the way communication was often happening across hierarchies of power and culture and language and access were often very damaging and very violent, and conversations around contraception around labor interventions. We also had a massive outbreak of hepatitis E, that for a pregnant person who has hepatitis E in the third trimester, the risk of maternal mortality, or the maternal mortality rate can be upwards of 20% between 20 and 30%, so just a huge number of maternal deaths that I had never seen in the US. So, for me it was, it was devastating to to know that number one hepatitis E is preventable. It's a waterborne disease. So, with improved sanitation, you can just prevent it. It doesn't have a treatment, but knowing that the reason clients were were sick and dying from this were structural, right. They had to do with refugee crisis, with access to water and sanitation, and I couldn't intervene at the clinical level. Again, it was a systems problem. And then thinking about like this was such an extreme hierarchy of like race power colonialism across communication, around intimate decisions like contraception, and you know, exams during labor and and how you even approach treatment for a hemorrhage. That was it was similar, but magnified to what I saw in Washington, DC. And so, coming into my PhD, the nexus that I was most interested in, and that I continue to be really passionate about is is that intersection of how patients and clinicians experience the clinical encounter. And how do we train health care providers to build an awareness of their own positionality and hierarchies of power, and how that impacts the people they're caring for. How do we teach clinicians to take a broader view of the individual in front of them, to to see, you know who are their important people? What's influencing their decisions? How do you be a better listener? How do you separate out like I want you to have your blood pressure under control versus a client who says, I want to minimize the number of medications I'm taking, right? And and how do you like reconcile those conversations? So, I started my PhD thinking I was gonna do something around contraception and an intersection with gender-based violence and humanitarian settings. And that's that's not where I ended up. But I'll I'll stop there for a moment to see.

Lois Dankwa

Well, well, no! My brain is going. Where? Where did you end up? I I love everything.

Christina Marea 

Alright. Well, I'm happy to talk more about it. So, right. So, I finished doctors without borders. I actually contracted hepatitis E. I was really sick. And you know I witnessed a lot of maternal deaths that I had never seen before. I was in a brand-new refugee camp where the threats of violence were pretty pretty proximal, you know. We could hear the front lines. We weren't that we were about 30 30 to 50 miles away, so not that close, but not that far, either. You know, we had a couple of lockdown events, and and I had spent some time working in in Jordan, in Syria, and and other places that had been affected by conflict. So, I started my program going in this direction. But my physical health wasn't very good, and I didn't have the, I hadn't fully processed or gone to really enough therapy honestly to process a lot of the trauma that I had witnessed in doctors without borders, a lot of the sort of moral injury of being a health care provider and figuring out this disconnect, and and I burned out in my PhD. I burned out really hard, and I had an amazing committee, amazing support people, and I had a proposal to do some research looking at survivors of sexual violence in Somalia, which you know, overlapped well with my my clinical experience and my background working with survivors of violence, and I hit a wall, and I and I couldn't do it. I was, I was tired, and I was burned out, and I needed to reevaluate. So, at thinking of of how old I was. This was 2015, so I would have been about 34, and I'd been pretty consistently working in and out of humanitarian settings since it was about 24, so, about 10 years. And something just flipped, and I had to I had to pause, and it was really hard to go to my advisor, who is just an incredible researcher, and who herself works in conflict settings and has done this research, and feelings of like being a failure and like I can't hack it and like why can't I do it? But I also knew for my own well-being I couldn't, and I had to call it. So, I talked with my advisor. I talked with my committee members. I talked with my PhD program director, who's Sarah Szanton, who's now the new dean at the School of Nursing. And I had the most compassionate responses. Like my committee members, my faculty said, your wellbeing is the most important thing. Like if you're not well like, you can't do the work that's important to you. If you're not well, you can't you know do work that's going to be meaningful and impactful. Take care of yourself first. That's what we teach you in nursing, right? So, if you're gonna have a meltdown in your doctoral program, I highly recommend doing it with your nursing faculty, because just the most kind and compassionate people. And there was a lot of imposter syndrome and shame and fear. But I promised I would come back, and everybody made me promise I would come back, and I did. I took a year off. I did a little bit of like EMDR therapy because I was having, I had some intermittent flashbacks of some of the deaths and and some of the things that I had witnessed. And I rested. I slept, I read books, I I went to the community center. I went for long walks, and I did. I re-enrolled exactly a year later, and I went in a slightly different direction. I was able to work and collaborate with a faculty member with my committee at Georgetown, and with the physician in Arizona who does research around female genital mutilation and cutting. So, the community that I cared for in South Sudan were Sudanese refugees and you know, nearly 100% had type 3 FGM, which is the most extensive and fibulation removal of the external genitalia and sewing it closed so that it only leaves a small like dinme or nickel size opening for for urine and menstrual fluid. So, I was able to collaborate with her and develop a framework and a curriculum to train health care providers for the care of women and girls affected by female genital mutilation and cutting. But it brought back in a lot of these things that brought me to my PhD in the first place, which is, how do you communicate and how do you care for people across some of these margins and hierarchies of power? Because in the US, caring for people who have experienced FGM, well, they're gonna typically be migrants, many of them are from the African diaspora or the Middle Eastern. A lot of them speak English as a second language, or are not yet English speakers. They overlap with a lot of the biases that the Black community in the US experience, even as you know, born in the US and fluent English speakers, so thinking about, how do we take something that’s a stigmatized practice like FGM with a community that it tends to experience stigma and discrimination and bias and racism at baseline and design a curriculum that can both teach you how to do the clinical care, right? How do you surgically open an infibulation scar? To how do you get people to reflect on where their biases are, where they're positionality is, and hierarchies of power? What types of communication build trust, and what types of verbal and nonverbal communication disintegrate it. And so, I also did a lot of statistics and learned about data collection and wrote 1,000 iterations of my paper and and overcame all of the mental blocks to finishing, all of the feelings that like this is never gonna be good enough and learning how to write in the team with my faculty and feeling like I was doing something that was meaningful, that was along similar trajectories, but moved in a different direction. And also just as a side note, during that year I I met my partner, and I ended up having 2 babies between when I returned to the PhD and when I graduated. So, also writing a dissertation while pregnant, postpartum, and breastfeeding is a whole other journey we could.

Lois Dankwa

Oh, my! I, you always you say so many wonderful things, and my brain's like oh, my goodness! Which of them should I respond to? I think that something I love that you highlighted was that it being in a PhD program really causes a lot of different things to rise to the top, whether it's experiences in your life where you were like oh, my gosh I I need to take a minute and just step away and refresh, because I need to take time on myself, so that I can show up more fully for my PhD program, or you mentioned imposter syndrome, or feeling like you couldn't do the things that you thought you could sign up for. And I love that you mentioned that you had the support of your advisor community and things like that, and they really helped you in that moment. But I think there's that's something that all of us experience in different ways. The PhD program definitely shows you if you didn't know already what you're not good at. If you were amazing at everything before the PhD program will quickly show you this what you're not good at though. And I would love to hear from you how so I guess, in addition to the support from your advisor community, how did you navigate that? And was there any really great advice that they gave you in that moment that really stuck out?

Christina Marea 

Yeah, I mean, I I think, obviously no one needs permission to take care of themselves. But I needed permission to take care of myself, and so I don't know, if anyone's listening, like you have permission to like, pause, and take care of yourself. And like your well-being is important to the work that you're doing. And so, hearing that from people who I thought were going to be like, no, you just have to buckle down and do it, like you just have to finish. What are you talking about? This isn’t that hard. But was no like, go, take care of yourself, and and and the simultaneous like, but promise you'll come back, right? And I feel like this is, this is just a bigger life lesson that like you can pause and you can come back, and for some people I'm sure that that a better decision is leaving a program or changing directions. But for a lot of people like a pause and a reassessment, I think, can be really good, and it doesn't necessarily have to be a year off, right? I had some like really significant, both physical health, you know I'd like from the hepatitis E lost 40 pounds. Like I just wasn't physically healthy. And sleeping, like I wasn't sleeping. All all sorts of things, but that that permission, and that, and that sense of welcome welcoming to come back like like we'll we'll be here. We're not mad. Go, go, but come back, like come back, cause what you're doing is important. Come back because your voice is important, come back because we believe that the work that you want to do and the impact that you can have is important.

Lois Dankwa

Yeah, and that's that's such a a great thing to continue to state, just that the work that all of us are pursuing in our PhD is important. I think that it's about remembering that we ourselves have to be be at a strong version of ourselves, to be able to do that work well. Otherwise—and also, it's it shouldn't be so important that it prevents you from being able to live the life and the peace that you need for yourself, right? And I'm curious how that mindset then influences how you show up now in your current role at Georgetown as an assistant professor?

Christina Marea 

Yeah, oh, it's it's so much fun to be in in the faculty role at Georgetown. I'm in the midwifery and women's health nurse practitioner program is where I teach predominantly. Also for the first time, I'm teaching an undergraduate course, looking at reproductive rights in the law, teaching it in partnership with a lawyer. So, we have, like a lawyer and a clinician teaching about what it's like to deliver reproductive healthcare in a post-Dobbs world which can do another podcast on that later. But you know one of the things that I tell my clinical students right, my midwifery students, is that you know we have to be in integrity with our care of ourselves in order to give care to our clients, right? Like when there is that disconnect between our own ability to be well and the wellness we're trying to promote for others, right, we're really compromising our work, because we're not gonna have the longevity. Like we're not gonna have the staying power to commit to this if we don't set the boundaries. We also work in a healthcare system that is not shy about accepting our labor, and so like. And that was one of the other lessons from leaving the PhD program was that no one was gonna do it for me. No one—I was sort of waiting for someone to look at me and be like, you're not okay, you know, like what you're down year. You know, I wanted someone else to tell me it was okay to take a break. And so one of the things that I try to tell my clinical students is like, it's okay to set a boundary. Like your well-being is important. Your well-being is important to the care that you're gonna provide. And you maintaining your well-being, is an important boundary to set in a health care system that will absorb all of the labor you give it, because the way we currently have it set up there is always more need, right? And so you can give and give but the system isn't gonna change until the people well in the system starts saying like, no, you know what I can't take 72 hour call on the weekend, which I did for 3 years. I took 72 hours worth of call on the weekends. Say like that doesn't work, because you know what the patients who I saw in hour 65 were not getting the same level of care and compassion and attention from me, as the patients I saw an hour for, because I was tired, and I think that that goes for a a lot of our careers that that we can work in a way that is an alignment with the outcomes we want to see at the system level, right? I want to set the boundaries. I want to write all the papers. I'm doing research right now looking at an expanded model of postpartum care that provides home visits and peer support and care coordination and really holds people in this bear hug that says your recovery in this postpartum period deserves rest and attention and care and proactive communication, so that you don't have to make 1,000 choices about how to be well in your physical recovery and in your transition to a parent and a new family dynamic. But if I'm not seeing my kids and sleeping, then how am I supposed to promote that? So, finding ways to live in integrity with the outcomes that I want to see at the systems level I think have improved my my writing and my workflow, my sense of satisfaction. I think the the teaching that I can do with my students and and it makes me feel more optimistic in terms of the changes that we can make at larger levels, because if we can make them small, we can make them big.

Lois Dankwa

Oh, I love that. If we can make them small, we can make them big. So, I have one more question for you, and it is what inspires you right now?

Christina Marea 

Oh! My! My midwifery team. So, I am I am not at all the important clinician. So, I I work with a federally qualified Health Center in Washington, DC called Community of Hope, and our midwifery director, Ebony Marcel, who is an incredible midwife, and has led, created this like predominantly Black midwifery team, serving predominantly Black clients here in DC. In this model of care that is building out the social support components with an amazing like maternal child health system and department and supports and the midwives in this group, like Tracy and Cassandra and Katie and and I know I'm not saying everyone's names because now I'm panicked about it, but Sherish and Showla, like everybody, provide the most incredible care and are amazing humans and working in a community health center that is innovative, and that is trying to serve people in the way that really meets their needs instead of the way the system says we should is is an inspiring place to work, and it gives me hope for reimagining what healthcare delivery can look like.

Lois Dankwa

I love that, drawing inspiration from our environment and what we do daily. I love that. Christina, I wanna thank you, thank you, thank you for just taking time to chat with us and share a bit of your experience. And it's been wonderful to chat today.

Christina Marea 

Yeah, it was great to talk to you, too. Thanks, Lois. And hopefully we’ll chat more someday offline.