The Cancer Recurs
The Battles of 2008
By the beginning of 2008 it was clear to Jobs and his doctors that his cancer was spreading. When they had taken out his pancreatic tumors in 2004, he had the cancer genome partially sequenced. That helped his doctors determine which pathways were broken, and they were treating him with targeted therapies that they thought were most likely to work.
He was also being treated for pain, usually with morphine-based analgesics. One day in February 2008 when Powell’s close friend Kathryn Smith was staying with them in Palo Alto, she and Jobs took a walk. “He told me that when he feels really bad, he just concentrates on the pain, goes into the pain, and that seems to dissipate it,” she recalled. That wasn’t exactly true, however. When Jobs was in pain, he let everyone around him know it.
There was another health issue that became increasingly problematic, one that medical researchers didn’t focus on as rigorously as they did cancer or pain. He was having eating problems and losing weight. Partly this was because he had lost much of his pancreas, which produces the enzymes needed to digest protein and other nutrients. It was also because both the cancer and the morphine reduced his appetite. And then there was the psychological component, which the doctors barely knew how to address: Since his early teens, he had indulged his weird obsession with extremely restrictive diets and fasts.
Even after he married and had children, he retained his dubious eating habits. He would spend weeks eating the same thing—carrot salad with lemon, or just apples—and then suddenly spurn that food and declare that he had stopped eating it. He would go on fasts, just as he did as a teenager, and he became sanctimonious as he lectured others at the table on the virtues of whatever eating regimen he was following. Powell had been a vegan when they were first married, but after her husband’s operation she began to diversify their family meals with fish and other proteins. Their son, Reed, who had been a vegetarian, became a “hearty omnivore.” They knew it was important for his father to get diverse sources of protein.
The family hired a gentle and versatile cook, Bryar Brown, who once worked for Alice Waters at Chez Panisse. He came each afternoon and made a panoply of healthy offerings for dinner, which used the herbs and vegetables that Powell grew in their garden. When Jobs expressed any whim—carrot salad, pasta with basil, lemongrass soup—Brown would quietly and patiently find a way to make it. Jobs had always been an extremely opinionated eater, with a tendency to instantly judge any food as either fantastic or terrible. He could taste two avocados that most mortals would find indistinguishable, and declare that one was the best avocado ever grown and the other inedible.
Beginning in early 2008 Jobs’s eating disorders got worse. On some nights he would stare at the floor and ignore all of the dishes set out on the long kitchen table. When others were halfway through their meal, he would abruptly get up and leave, saying nothing. It was stressful for his family. They watched him lose forty pounds during the spring of 2008.
His health problems became public again in March 2008, when Fortune published a piece called “The Trouble with Steve Jobs.” It revealed that he had tried to treat his cancer with diets for nine months and also investigated his involvement in the backdating of Apple stock options. As the story was being prepared, Jobs invited—summoned—Fortune’s managing editor Andy Serwer to Cupertino to pressure him to spike it. He leaned into Serwer’s face and asked, “So, you’ve uncovered the fact that I’m an asshole. Why is that news?” Jobs made the same rather self-aware argument when he called Serwer’s boss at Time Inc., John Huey, from a satellite phone he brought to Hawaii’s Kona Village. He offered to convene a panel of fellow CEOs and be part of a discussion about what health issues are proper to disclose, but only if Fortune killed its piece. The magazine didn’t.
When Jobs introduced the iPhone 3G in June 2008, he was so thin that it overshadowed the product announcement. In Esquire Tom Junod described the “withered” figure onstage as being “gaunt as a pirate, dressed in what had heretofore been the vestments of his invulnerability.” Apple released a statement saying, untruthfully, that his weight loss was the result of “a common bug.” The following month, as questions persisted, the company released another statement saying that Jobs’s health was “a private matter.”
Joe Nocera of the New York Times wrote a column denouncing the handling of Jobs’s health issues. “Apple simply can’t be trusted to tell the truth about its chief executive,” he wrote in late July. “Under Mr. Jobs, Apple has created a culture of secrecy that has served it well in many ways—the speculation over which products Apple will unveil at the annual Macworld conference has been one of the company’s best marketing tools. But that same culture poisons its corporate governance.” As he was writing the column and getting the standard “a private matter” comment from all at Apple, he got an unexpected call from Jobs himself. “This is Steve Jobs,” he began. “You think I’m an arrogant asshole who thinks he’s above the law, and I think you’re a slime bucket who gets most of his facts wrong.” After that rather arresting opening, Jobs offered up some information about his health, but only if Nocera would keep it off the record. Nocera honored the request, but he was able to report that, while Jobs’s health problems amounted to more than a common bug, “they weren’t life-threatening and he doesn’t have a recurrence of cancer.” Jobs had given Nocera more information than he was willing to give his own board and shareholders, but it was not the full truth.
Partly due to concern about Jobs’s weight loss, Apple’s stock price drifted from $188 at the beginning of June 2008 down to $156 at the end of July. Matters were not helped in late August when Bloomberg News mistakenly released its prepackaged obituary of Jobs, which ended up on Gawker. Jobs was able to roll out Mark Twain’s famous quip a few days later at his annual music event. “Reports of my death are greatly exaggerated,” he said, as he launched a line of new iPods. But his gaunt appearance was not reassuring. By early October the stock price had sunk to $97.
That month Doug Morris of Universal Music was scheduled to meet with Jobs at Apple. Instead Jobs invited him to his house. Morris was surprised to see him so ill and in pain. Morris was about to be honored at a gala in Los Angeles for City of Hope, which raised money to fight cancer, and he wanted Jobs to be there. Charitable events were something Jobs avoided, but he decided to do it, both for Morris and for the cause. At the event, held in a big tent on Santa Monica beach, Morris told the two thousand guests that Jobs was giving the music industry a new lease on life. The performances—by Stevie Nicks, Lionel Richie, Erykah Badu, and Akon—went on past midnight, and Jobs had severe chills. Jimmy Iovine gave him a hooded sweatshirt to wear, and he kept the hood over his head all evening. “He was so sick, so cold, so thin,” Morris recalled.
Fortune’s veteran technology writer Brent Schlender was leaving the magazine that December, and his swan song was to be a joint interview with Jobs, Bill Gates, Andy Grove, and Michael Dell. It had been hard to organize, and just a few days before it was to happen, Jobs called to back out. “If they ask why, just tell them I’m an asshole,” he said. Gates was annoyed, then discovered what the health situation was. “Of course, he had a very, very good reason,” said Gates. “He just didn’t want to say.” That became more apparent when Apple announced on December 16 that Jobs was canceling his scheduled appearance at the January Macworld, the forum he had used for big product launches for the past eleven years.
The blogosphere erupted with speculation about his health, much of which had the odious smell of truth. Jobs was furious and felt violated. He was also annoyed that Apple wasn’t being more active in pushing back. So on January 5, 2009, he wrote and released a misleading open letter. He claimed that he was skipping Macworld because he wanted to spend more time with his family. “As many of you know, I have been losing weight throughout 2008,” he added. “My doctors think they have found the cause—a hormone imbalance that has been robbing me of the proteins my body needs to be healthy. Sophisticated blood tests have confirmed this diagnosis. The remedy for this nutritional problem is relatively simple.”
There was a kernel of truth to this, albeit a small one. One of the hormones created by the pancreas is glucagon, which is the flip side of insulin. Glucagon causes your liver to release blood sugar. Jobs’s tumor had metastasized into his liver and was wreaking havoc. In effect, his body was devouring itself, so his doctors gave him drugs to try to lower the glucagon level. He did have a hormone imbalance, but it was because his cancer had spread into his liver. He was in personal denial about this, and he also wanted to be in public denial. Unfortunately that was legally problematic, because he ran a publicly traded company. But Jobs was furious about the way the blogosphere was treating him, and he wanted to strike back.
He was very sick at this point, despite his upbeat statement, and also in excruciating pain. He had undertaken another round of cancer drug therapy, and it had grueling side effects. His skin started drying out and cracking. In his quest for alternative approaches, he flew to Basel, Switzerland, to try an experimental hormone-delivered radiotherapy. He also underwent an experimental treatment developed in Rotterdam known as peptide receptor radionuclide therapy.
After a week filled with increasingly insistent legal advice, Jobs finally agreed to go on medical leave. He made the announcement on January 14, 2009, in another open letter to the Apple staff. At first he blamed the decision on the prying of bloggers and the press. “Unfortunately, the curiosity over my personal health continues to be a distraction not only for me and my family, but everyone else at Apple,” he said. But then he admitted that the remedy for his “hormone imbalance” was not as simple as he had claimed. “During the past week I have learned that my health-related issues are more complex than I originally thought.” Tim Cook would again take over daily operations, but Jobs said that he would remain CEO, continue to be involved in major decisions, and be back by June.
Jobs had been consulting with Bill Campbell and Art Levinson, who were juggling the dual roles of being his personal health advisors and also the co-lead directors of the company. But the rest of the board had not been as fully informed, and the shareholders had initially been misinformed. That raised some legal issues, and the SEC opened an investigation into whether the company had withheld “material information” from shareholders. It would constitute security fraud, a felony, if the company had allowed the dissemination of false information or withheld true information that was relevant to the company’s financial prospects. Because Jobs and his magic were so closely identified with Apple’s comeback, his health seemed to meet this standard. But it was a murky area of the law; the privacy rights of the CEO had to be weighed. This balance was particularly difficult in the case of Jobs, who both valued his privacy and embodied his company more than most CEOs. He did not make the task easier. He became very emotional, both ranting and crying at times, when railing against anyone who suggested that he should be less secretive.
Campbell treasured his friendship with Jobs, and he didn’t want to have any fiduciary duty to violate his privacy, so he offered to step down as a director. “The privacy side is so important to me,” he later said. “He’s been my friend for about a million years.” The lawyers eventually determined that Campbell didn’t need to resign from the board but that he should step aside as co-lead director. He was replaced in that role by Andrea Jung of Avon. The SEC investigation ended up going nowhere, and the board circled the wagons to protect Jobs from calls that he release more information. “The press wanted us to blurt out more personal details,” recalled Al Gore. “It was really up to Steve to go beyond what the law requires, but he was adamant that he didn’t want his privacy invaded. His wishes should be respected.” When I asked Gore whether the board should have been more forthcoming at the beginning of 2009, when Jobs’s health issues were far worse than shareholders were led to believe, he replied, “We hired outside counsel to do a review of what the law required and what the best practices were, and we handled it all by the book. I sound defensive, but the criticism really pissed me off.”
One board member disagreed. Jerry York, the former CFO at Chrysler and IBM, did not say anything publicly, but he confided to a reporter at the Wall Street Journal, off the record, that he was “disgusted” when he learned that the company had concealed Jobs’s health problems in late 2008. “Frankly, I wish I had resigned then.” When York died in 2010, the Journal put his comments on the record. York had also provided off-the-record information to Fortune, which the magazine used when Jobs went on his third health leave, in 2011.
Some at Apple didn’t believe the quotes attributed to York were accurate, since he had not officially raised objections at the time. But Bill Campbell knew that the reports rang true; York had complained to him in early 2009. “Jerry had a little more white wine than he should have late at night, and he would call at two or three in the morning and say, ‘What the fuck, I’m not buying that shit about his health, we’ve got to make sure.’ And then I’d call him the next morning and he’d say, ‘Oh fine, no problem.’ So on some of those evenings, I’m sure he got raggy and talked to reporters.”
The head of Jobs’s oncology team was Stanford University’s George Fisher, a leading researcher on gastrointestinal and colorectal cancers. He had been warning Jobs for months that he might have to consider a liver transplant, but that was the type of information that Jobs resisted processing. Powell was glad that Fisher kept raising the possibility, because she knew it would take repeated proddings to get her husband to consider the idea.
He finally became convinced in January 2009, just after he claimed his “hormonal imbalance” could be treated easily. But there was a problem. He was put on the wait list for a liver transplant in California, but it became clear he would never get one there in time. The number of available donors with his blood type was small. Also, the metrics used by the United Network for Organ Sharing, which establishes policies in the United States, favored those suffering from cirrhosis and hepatitis over cancer patients.
There is no legal way for a patient, even one as wealthy as Jobs, to jump the queue, and he didn’t. Recipients are chosen based on their MELD score (Model for End-Stage Liver Disease), which uses lab tests of hormone levels to determine how urgently a transplant is needed, and on the length of time they have been waiting. Every donation is closely audited, data are available on public websites (optn.transplant.hrsa.gov/), and you can monitor your status on the wait list at any time.
Powell became the troller of the organ-donation websites, checking in every night to see how many were on the wait lists, what their MELD scores were, and how long they had been on. “You can do the math, which I did, and it would have been way past June before he got a liver in California, and the doctors felt that his liver would give out in about April,” she recalled. So she started asking questions and discovered that it was permissible to be on the list in two different states at the same time, which is something that about 3% of potential recipients do. Such multiple listing is not discouraged by policy, even though critics say it favors the rich, but it is difficult. There were two major requirements: The potential recipient had to be able to get to the chosen hospital within eight hours, which Jobs could do thanks to his plane, and the doctors from that hospital had to evaluate the patient in person before adding him or her to the list.
George Riley, the San Francisco lawyer who often served as Apple’s outside counsel, was a caring Tennessee gentleman, and he had become close to Jobs. His parents had both been doctors at Methodist University Hospital in Memphis, he was born there, and he was a friend of James Eason, who ran the transplant institute there. Eason’s unit was one of the best and busiest in the nation; in 2008 he and his team did 121 liver transplants. He had no problem allowing people from elsewhere to multiple-list in Memphis. “It’s not gaming the system,” he said. “It’s people choosing where they want their health care. Some people would leave Tennessee to go to California or somewhere else to seek treatment. Now we have people coming from California to Tennessee.” Riley arranged for Eason to fly to Palo Alto and conduct the required evaluation there.
By late February 2009 Jobs had secured a place on the Tennessee list (as well as the one in California), and the nervous waiting began. He was declining rapidly by the first week in March, and the waiting time was projected to be twenty-one days. “It was dreadful,” Powell recalled. “It didn’t look like we would make it in time.” Every day became more excruciating. He moved up to third on the list by mid-March, then second, and finally first. But then days went by. The awful reality was that upcoming events like St. Patrick’s Day and March Madness (Memphis was in the 2009 tournament and was a regional site) offered a greater likelihood of getting a donor because the drinking causes a spike in car accidents.
Indeed, on the weekend of March 21, 2009, a young man in his midtwenties was killed in a car crash, and his organs were made available. Jobs and his wife flew to Memphis, where they landed just before 4 a.m. and were met by Eason. A car was waiting on the tarmac, and everything was staged so that the admitting paperwork was done as they rushed to the hospital.
The transplant was a success, but not reassuring. When the doctors took out his liver, they found spots on the peritoneum, the thin membrane that surrounds internal organs. In addition, there were tumors throughout the liver, which meant it was likely that the cancer had migrated elsewhere as well. It had apparently mutated and grown quickly. They took samples and did more genetic mapping.
A few days later they needed to perform another procedure. Jobs insisted against all advice they not pump out his stomach, and when they sedated him, he aspirated some of the contents into his lungs and developed pneumonia. At that point they thought he might die. As he described it later:
I almost died because in this routine procedure they blew it. Laurene was there and they flew my children in, because they did not think I would make it through the night. Reed was looking at colleges with one of Laurene’s brothers. We had a private plane pick him up near Dartmouth and tell them what was going on. A plane also picked up the girls. They thought it might be the last chance they had to see me conscious. But I made it.
Powell took charge of overseeing the treatment, staying in the hospital room all day and watching each of the monitors vigilantly. “Laurene was a beautiful tiger protecting him,” recalled Jony Ive, who came as soon as Jobs could receive visitors. Her mother and three brothers came down at various times to keep her company. Jobs’s sister Mona Simpson also hovered protectively. She and George Riley were the only people Jobs would allow to fill in for Powell at his bedside. “Laurene’s family helped us take care of the kids—her mom and brothers were great,” Jobs later said. “I was very fragile and not cooperative. But an experience like that binds you together in a deep way.”
Powell came every day at 7 a.m. and gathered the relevant data, which she put on a spreadsheet. “It was very complicated because there were a lot of different things going on,” she recalled. When James Eason and his team of doctors arrived at 9 a.m., she would have a meeting with them to coordinate all aspects of Jobs’s treatment. At 9 p.m., before she left, she would prepare a report on how each of the vital signs and other measurements were trending, along with a set of questions she wanted answered the next day. “It allowed me to engage my brain and stay focused,” she recalled.
Eason did what no one at Stanford had fully done: take charge of all aspects of the medical care. Since he ran the facility, he could coordinate the transplant recovery, cancer tests, pain treatments, nutrition, rehabilitation, and nursing. He would even stop at the convenience store to get the energy drinks Jobs liked.
Two of the nurses were from tiny towns in Mississippi, and they became Jobs’s favorites. They were solid family women and not intimidated by him. Eason arranged for them to be assigned only to Jobs. “To manage Steve, you have to be persistent,” recalled Tim Cook. “Eason managed Steve and forced him to do things that no one else could, things that were good for him that may not have been pleasant.”
Despite all the coddling, Jobs at times almost went crazy. He chafed at not being in control, and he sometimes hallucinated or became angry. Even when he was barely conscious, his strong personality came through. At one point the pulmonologist tried to put a mask over his face when he was deeply sedated. Jobs ripped it off and mumbled that he hated the design and refused to wear it. Though barely able to speak, he ordered them to bring five different options for the mask and he would pick a design he liked. The doctors looked at Powell, puzzled. She was finally able to distract him so they could put on the mask. He also hated the oxygen monitor they put on his finger. He told them it was ugly and too complex. He suggested ways it could be designed more simply. “He was very attuned to every nuance of the environment and objects around him, and that drained him,” Powell recalled.
One day, when he was still floating in and out of consciousness, Powell’s close friend Kathryn Smith came to visit. Her relationship with Jobs had not always been the best, but Powell insisted that she come by the bedside. He motioned her over, signaled for a pad and pen, and wrote, “I want my iPhone.” Smith took it off the dresser and brought it to him. Taking her hand, he showed her the “swipe to open” function and made her play with the menus.
Jobs’s relationship with Lisa Brennan-Jobs, his daughter with Chrisann, had frayed. She had graduated from Harvard, moved to New York City, and rarely communicated with her father. But she flew down to Memphis twice, and he appreciated it. “It meant a lot to me that she would do that,” he recalled. Unfortunately he didn’t tell her at the time. Many of the people around Jobs found Lisa could be as demanding as her father, but Powell welcomed her and tried to get her involved. It was a relationship she wanted to restore.
As Jobs got better, much of his feisty personality returned. He still had his bile ducts. “When he started to recover, he passed quickly through the phase of gratitude, and went right back into the mode of being grumpy and in charge,” Kat Smith recalled. “We were all wondering if he was going to come out of this with a kinder perspective, but he didn’t.”
He also remained a finicky eater, which was more of a problem than ever. He would eat only fruit smoothies, and he would demand that seven or eight of them be lined up so he could find an option that might satisfy him. He would touch the spoon to his mouth for a tiny taste and pronounce, “That’s no good. That one’s no good either.” Finally Eason pushed back. “You know, this isn’t a matter of taste,” he lectured. “Stop thinking of this as food. Start thinking of it as medicine.”
Jobs’s mood buoyed when he was able to have visitors from Apple. Tim Cook came down regularly and filled him in on the progress of new products. “You could see him brighten every time the talk turned to Apple,” Cook said. “It was like the light turned on.” He loved the company deeply, and he seemed to live for the prospect of returning. Details would energize him. When Cook described a new model of the iPhone, Jobs spent the next hour discussing not only what to call it—they agreed on iPhone 3GS—but also the size and font of the “GS,” including whether the letters should be capitalized (yes) and italicized (no).
One day Riley arranged a surprise after-hours visit to Sun Studio, the redbrick shrine where Elvis, Johnny Cash, B.B. King, and many other rock-and-roll pioneers recorded. They were given a private tour and a history lecture by one of the young staffers, who sat with Jobs on the cigarette-scarred bench that Jerry Lee Lewis used. Jobs was arguably the most influential person in the music industry at the time, but the kid didn’t recognize him in his emaciated state. As they were leaving, Jobs told Riley, “That kid was really smart. We should hire him for iTunes.” So Riley called Eddy Cue, who flew the boy out to California for an interview and ended up hiring him to help build the early R&B and rock-and-roll sections of iTunes. When Riley went back to see his friends at Sun Studio later, they said that it proved, as their slogan said, that your dreams can still come true at Sun Studio.
At the end of May 2009 Jobs flew back from Memphis on his jet with his wife and sister. They were met at the San Jose airfield by Tim Cook and Jony Ive, who came aboard as soon as the plane landed. “You could see in his eyes his excitement at being back,” Cook recalled. “He had fight in him and was raring to go.” Powell pulled out a bottle of sparkling apple cider and toasted her husband, and everyone embraced.
Ive was emotionally drained. He drove to Jobs’s house from the airport and told him how hard it had been to keep things going while he was away. He also complained about the stories saying that Apple’s innovation depended on Jobs and would disappear if he didn’t return. “I’m really hurt,” Ive told him. He felt “devastated,” he said, and underappreciated.
Jobs was likewise in a dark mental state after his return to Palo Alto. He was coming to grips with the thought that he might not be indispensable to the company. Apple stock had fared well while he was away, going from $82 when he announced his leave in January 2009 to $140 when he returned at the end of May. On one conference call with analysts shortly after Jobs went on leave, Cook departed from his unemotional style to give a rousing declaration of why Apple would continue to soar even with Jobs absent:
We believe that we are on the face of the earth to make great products, and that’s not changing. We are constantly focusing on innovating. We believe in the simple not the complex. We believe that we need to own and control the primary technologies behind the products that we make, and participate only in markets where we can make a significant contribution. We believe in saying no to thousands of projects, so that we can really focus on the few that are truly important and meaningful to us. We believe in deep collaboration and cross-pollination of our groups, which allow us to innovate in a way that others cannot. And frankly, we don’t settle for anything less than excellence in every group in the company, and we have the self-honesty to admit when we’re wrong and the courage to change. And I think, regardless of who is in what job, those values are so embedded in this company that Apple will do extremely well.
It sounded like something Jobs would say (and had said), but the press dubbed it “the Cook doctrine.” Jobs was rankled and deeply depressed, especially about the last line. He didn’t know whether to be proud or hurt that it might be true. There was talk that he might step aside and become chairman rather than CEO. That made him all the more motivated to get out of his bed, overcome the pain, and start taking his restorative long walks again.
A board meeting was scheduled a few days after he returned, and Jobs surprised everyone by making an appearance. He ambled in and was able to stay for most of the meeting. By early June he was holding daily meetings at his house, and by the end of the month he was back at work.
Would he now, after facing death, be more mellow? His colleagues quickly got an answer. On his first day back, he startled his top team by throwing a series of tantrums. He ripped apart people he had not seen for six months, tore up some marketing plans, and chewed out a couple of people whose work he found shoddy. But what was truly telling was the pronouncement he made to a couple of friends late that afternoon. “I had the greatest time being back today,” he said. “I can’t believe how creative I’m feeling, and how the whole team is.” Tim Cook took it in stride. “I’ve never seen Steve hold back from expressing his view or passion,” he later said. “But that was good.”
Friends noted that Jobs had retained his feistiness. During his recuperation he signed up for Comcast’s high-definition cable service, and one day he called Brian Roberts, who ran the company. “I thought he was calling to say something nice about it,” Roberts recalled. “Instead, he told me ‘It sucks.’” But Andy Hertzfeld noticed that, beneath the gruffness, Jobs had become more honest. “Before, if you asked Steve for a favor, he might do the exact opposite,” Hertzfeld said. “That was the perversity in his nature. Now he actually tries to be helpful.”
His public return came on September 9, when he took the stage at the company’s regular fall music event. He got a standing ovation that lasted almost a minute, then he opened on an unusually personal note by mentioning that he was the recipient of a liver donation. “I wouldn’t be here without such generosity,” he said, “so I hope all of us can be as generous and elect to become organ donors.” After a moment of exultation—“I’m vertical, I’m back at Apple, and I’m loving every day of it”—he unveiled the new line of iPod Nanos, with video cameras, in nine different colors of anodized aluminum.
By the beginning of 2010 he had recovered most of his strength, and he threw himself back into work for what would be one of his, and Apple’s, most productive years. He had hit two consecutive home runs since launching Apple’s digital hub strategy: the iPod and the iPhone. Now he was going to swing for another.