The Literary Old Age at the Intersection of Medical Practice and Public Health—A Cross-Disciplinary Reading of Ane Riel’s Clockwork †

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Introduction
During the past several decades, research into ageing and longevity has seen the advent of cross-disciplinarity [1], expanding traditional disciplines, methods and data. Literary gerontology [2]-the study of age and ageing using literary fiction-is one such example. Generally, earlier representations of the aging experience have been marginal and often aligned older age with negative stereotypes [3,4]. More recently, however, literary gerontologists have been increasingly guided by the need for greater diversity and nuance in the representations of old age, capturing the importance of the individualized experience as exemplified by Oró-Piqueras [5] and Goldman [6]. The current study aligns with this development, assessing fictional, complex representations of older individuals as a potential source of novel insight within the field of gerontology [7].
The study describes and conveys the main findings of an experiment where researchers representing literature, anthropology, history, public health and medicine took part in a joint reading, analysis and discussion of Danish author Ane Riel's Clockwork [8], a novel depicting a protagonist's reconcilement with ageing and death. Although this novel does not provide a positivistic, or matter-of-fact, account of the 'real world', it may challenge us to reflect on hitherto less known or unknown aspects. Based on this, the imaginative aspect of literature may be potentially valuable in this regard, and the aim of the current study was therefore to assess whether, and how, a literary work of fiction may provide a productive contribution to gerontology. While the study represents an exploratory, qualitative approach to gerontological research, literary gerontology and interdisciplinary collaboration, the term 'qualitative' should not be interpreted as adhering to established methodological traditions. To our knowledge, the current study does not align with traditional research approaches within literary gerontology; it may, however, in part be viewed as inspired by arts-based, shared reading interventions [9,10], extrapolating these types of initiatives to include members of a collaborative, cross-disciplinary research team.

Materials and Methods
During 2022, ten members of a research team encompassing the fields of literature, anthropology, history, public health and medicine read the novel Clockwork [8] by Danish author Ane Riel. Subsequently, each member completed a document covering the following questions: (1) What did you find interesting in the novel; (2) How does the novel align with or deviate from your research?; (3) What is the potential 'utility' of the novel? Additionally, a member of the public, an 87-year-old woman, contributed to the study by providing her reflections on the novel. Subsequently, the documents and reflections laid the framework for joint discussions by the research team. The output from these efforts constitutes the basis for the current study.
Briefly, the novel Clockwork depicts the life of the female protagonist, Alma, set in a village during the 1980's in Denmark. Her life is characterized by common ailments of ageing individuals. Alma maintains only a scattered recollection of life events, as her dementia is gradually worsening. A daily routine, the rewinding of a grandfather clock, points to a remnant of joy for life, despite the otherwise challenging existence. Striking up a friendship after an unexpected encounter with a little boy, Alma's existence is revitalized and propels her to retrospectively revisit two monumental life events: the loss of her daughter and the suicide of her husband. Towards the end of the novel, Alma fails to rewind the clock and in fact dies. However, in a supernatural twist, the novel describes Alma entering a ghost-like state, from where she is now able to reach a 'finality'. She is able to obtain closure on the marring events of her life and is now able to enjoy fond memories of her deceased daughter. Ultimately, Alma reunites with her husband in the 'ghost world' which they now both occupy, thus concluding the novel with an unhappy, happy end of sorts.

Results
The documents completed by the researchers following their reading of the novel point to a collective recognition of familiar aspects of the novel's portrayal of Alma. However, substantial differences were seen in these familiar aspects. Two overall categories were observed during the discussion: gerontological realism, indicating a confirmation of the existing knowledge of ageing and wellbeing characterized by physical and cognitive challenges; and imaginary knowledge, a term meant to capture literary fiction's potential to imagine what is not directly apparent to us. These two categories are explored below before a third section presents the cross-disciplinary insights and gains of the experiment.

Gerontological Realism
Although Clockwork contains dramatic elements not based in 'reality', the novel does in fact provide aspects of ageing and wellbeing which were recognizable to the group of researchers, although there were substantial differences; the epidemiologist pointed out that the portrayal of Alma's level of functioning relates to the parameters most often used for assessing health and wellbeing among the oldest old. During her good spells, she would 'peak' according to the most often measured parameters (physical function, mood and cognition), and conversely, a low-point would be apparent during challenging times for Alma. A general practice researcher held that, "the description of cognitive dysfunction, ageing, lack of social network, disempowerment, existential challenges, micropsychoses etc. is not far from my experience as a general practitioner" The anthropologist recognized familiar aspects with regards to her usual research field work, in the way that " . . . Alma compensates for her decline in physical function, by supporting herself against the furniture when moving around the house." These compensation strategies are closely tied to the existential challenges in Alma's life, as the anthropologist recognized in the central image of the novel, i.e., the rewinding of the grandfather clock: "The rewinding of the clock touches upon an overarching theme, the need to feel that you are an actor in charge, with a certain level of control." This way, Alma can be seen as an individual who is able to 'pull through', although her life circumstances are somewhat chaotic. The form of the novel, where several timelines, places and moods are interwoven, can be seen to represent these fluctuations as concurrently present in Alma. The cause of these fluctuations is often surprising. For example, Alma is emotionally elevated following the 'disappearance' of her husband. The anthropologist recognized this pattern from her interviews with several elderly women, who, as homemakers, had to conform to the working husband. Therefore, the death of their spouse was not only associated with grief but was also associated with a sense of relief and liberation.
This was indeed the case for our citizen contributor, who, as a widow, recognized aspects of her own marriage via the novel's portrayal: "If I'd been like young girls today, I would have left. But I couldn't leave, I had no education and four kids" and on the loss of her spouse: "I have enjoyed that! I have gained a lot of freedom." The next section focuses on 'imaginary knowledge', a term meant to capture literary fiction's potential to imagine what is not directly apparent to us.

Imaginary Knowledge
Our term "imaginary knowledge" relates to aspects that challenge us to view Alma's world as she sees it, i.e., that the reader can be seen to part of an 'imagination task', as Clockwork invites us to imagine what we do not know or cannot see.
Our citizen contributor, the 87-year-old woman, expressed particular interest in how dementia is experienced, and the epidemiologist related: "I took note of the train of thought and world view that a person with a moderately confused mental state may experience. Particularly, I thought about how it would be to be asked more than 100 very specific questions-even though the questions are asked by our trained and empathetic interviewers-when you are experiencing that level of confusion." Similarly, a researcher from general practice takes note of Alma's general confusion with regards to time and events: "How do different perceptions of time (health care professional/patient) align-or do they collide? Is quality of life [in the view of the health care professional] conditioned on a specific perception or experience of 'time'-a 'horizontal' time as opposed to a 'vertical' perception of time in some patient groups?" These comments indicate a recurring subject in the researchers' discussion of Clockwork. Whether we as researchers and health care professionals can, or should, extrapolate our own ideas and visions of the 'the good life' among the oldest to an individual like Alma? Although she is portrayed as a somewhat tragic existence, the author insists, perhaps paradoxically, on Alma's moments of joy and wellbeing. This way, one aspect of the imaginary knowledge relates to the novel's ability to allow the reader a sense of what old age may be experienced as and how it feels. Additionally, an interesting point here is that this 'imagination task' involves an individual who may represent an 'unknown' in traditional gerontological research efforts.
Additionally, in contrast to the health science researchers in the team who emphasized the absence of the health care system, i.e., that the 'system' was at fault, so to speak, the historian sees it differently: "there is a striking decoupling from the care of welfare state. To some extent, this decoupling is of their own choosing-the husband's rejection of everything and everyone made social ties impossible, although it is apparent that Alma misses her network".
However, the views of the historian and health science researchers are in a way aligned; their views indicate that Alma represents the exception, an individual among the oldest old that we lack knowledge of, that they exist 'outside' the system. This way, the researchers' views may represent an attempt to comprehend Alma's situation more fully, how she perceives her own existence and how she arrived there. Therefore, this imaginary knowledge does not provide evidence in the traditional sense. Instead, it represents an attempt to observe the world from Alma's point of view and to 'fill in the gaps' so to speak with regards to her situation.

Cross-Disciplinary Insights and Gains
In addition to the two categories, 'gerontological realism' and 'imaginary knowledge', the present study argues that the joint reading of literary fiction offers several cross-disciplinary insights and gains. The reading of the novel can be utilized as a driver for cross-disciplinary project work as the novel represents a shared material, which may spotlight different ways of thinking, areas of focus and blind spots. Indeed, the epidemiologist points to this: " . . . the reading has made clear to me how entrenched I am in the health science way of thinking" Secondly, as indicated by the quote from the epidemiologist, one aspect of the positive contribution of literary fiction to ageing research is that the reading of Clockwork made him reflect on his own scientific tradition and practices and heightened his awareness of the inherent limitations in the methods most often used when assessing the wellbeing of the oldest old [11].
Additionally, the novel and the joint reading fostered new hypotheses and research ideas. One grew out of the participants' discussion of the novel's depiction of Alma's initial relief and sense of emancipation after her husband's suicide. The literary scholars recognized a well-known cultural trope (the merry widow), and the anthropologist had experienced it as a recurrent phenomenon in her fieldwork. This led to a new collaborative study, currently underway, where the phenomenon experienced by the anthropologist and literary scholars will be investigated in an epidemiological, quantitative setting [12].
Finally, the current study has led to additional ongoing efforts. The insights of the novel and the joint discussion of it have influenced the team members' respective subprojects, resulting in two book manuscripts, currently in preparation, investigating how the end-oflife is portrayed in current Danish literature as a well as a collection of intimate life portraits of women near the end-of-life [13,14].

Discussion and Conclusions
In a joint reading of the novel Clockwork, the novel's depiction of old age as a multifaceted reality provided us with an opportunity to explore how each of our professional aspects are related and how they interact. These efforts resulted in dual dimensions of insight gained from an artistic literary representation of old age and dying: a 'gerontological realism', a realistic dimension which may be interpreted as a confirmation of the existing knowledge of ageing and wellbeing characterized by physical and cognitive challenges; and 'imaginary knowledge', an imagined dimension, a type of knowledge distilled in the interaction between the reader and the literary work. The reader can be seen to be tasked with identifying with the protagonist, and this process provides us with a hitherto unknown perspective on how ageing is experienced, how it feels and what it means. This is particularly relevant due to the well-known participation bias owing to underrepresentation of ageing individuals challenged by comorbidity and social background [15]. These ideas align with the core concept of literary gerontology, i.e., that literary fiction has the potential to provide unique insights into an individual's perception of ageing and late life [2] and contribute to the understanding of older individuals as human beings with complex inner lives [16]. Indeed, there is a growing appreciation in the health sciences that the most commonly used measures of health and wellbeing should perhaps be expanded and nuanced in order to capture relevant dimensions of the aging experience [17].
It should be emphasized that we are not attempting to cast literary gerontology as a unique, privileged source of knowledge for novel gerontological insights. Rather, the present study serves to exemplify, using literature as a vehicle, the potential of crossdisciplinary gerontological efforts to supplement, challenge and develop the perspectives and ways of thinking among the respective contributors. With this in mind, we view the joint reading of literature as a suitable concept in this type of cross-disciplinary teamwork. A novel like Clockwork represents a shared material, which provides concrete aspects for discussion and help tease out differences in thinking, foci and blind spots among the participating researchers. Additionally, the project stimulated several efforts, inspiring the cross-disciplinary work process itself as well as specific further studies.
The study exemplifies an exploratory cross-disciplinary approach that reinforces the relevance of fiction in the gerontological field by highlighting the complex interplay between multiple aspects of old age. The ideas presented here on the uses of literary gerontology may be seen as an extension of the type of knowledge which is reflected in a recent trend in public health research, namely a growing interest in the experience of the individual patient, citizen, user etc. and their 'lived' experience. Indeed, there may not exist one single narrative but several smaller narratives. Clockwork may help to remind us of the need for pluralistic, inclusive and empathetic approaches to understand a story like Alma's.