Mona Simpson came to Palo Alto for the holiday, along with her ex-husband, the television comedy writer Richard Appel, and their children. The mood picked up a bit. The families played parlor games such as Novel, in which participants try to fool each other by seeing who can write the most convincing fake opening sentence to a book, and things seemed to be looking up for a while. He was even able to go out to dinner at a restaurant with Powell a few days after Christmas. The kids went off on a ski vacation for New Year’s, with Powell and Mona Simpson taking turns staying at home with Jobs in Palo Alto.
By the beginning of 2011, however, it was clear that this was not merely one of his bad patches. His doctors detected evidence of new tumors, and the cancer-related signaling further exacerbated his loss of appetite. They were struggling to determine how much drug therapy his body, in its emaciated condition, would be able to take. Every inch of his body felt like it had been punched, he told friends, as he moaned and sometimes doubled over in pain.
It was a vicious cycle. The first signs of cancer caused pain. The morphine and other painkillers he took suppressed his appetite. His pancreas had been partly removed and his liver had been replaced, so his digestive system was faulty and had trouble absorbing protein. Losing weight made it harder to embark on aggressive drug therapies. His emaciated condition also made him more susceptible to infections, as did the immunosuppressants he sometimes took to keep his body from rejecting his liver transplant. The weight loss reduced the lipid layers around his pain receptors, causing him to suffer more. And he was prone to extreme mood swings, marked by prolonged bouts of anger and depression, which further suppressed his
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appetite.
Jobs’s eating problems were exacerbated over the years by his psychological attitude toward food. When he was young, he learned that he could induce euphoria and ecstasy by fasting. So even though he knew that he should eat—his doctors were begging him to consume high-quality protein—lingering in the back of his subconscious, he admitted, was his instinct for fasting and for diets like Arnold Ehret’s fruit regimen that he had embraced as a teenager. Powell kept telling him that it was crazy, even pointing out that Ehret had died at fifty-six when he stumbled and knocked his head, and she would get angry when he came to the table and just stared silently at his lap. “I wanted him to force himself to eat,” she said, “and it was incredibly tense at home.” Bryar Brown, their part-time cook, would still come in the afternoon and make an array of healthy dishes, but Jobs would touch his tongue to one or two dishes and then dismiss them all as inedible. One evening he announced, “I could probably eat a little pumpkin pie,” and the even-tempered Brown created a beautiful pie from scratch in an hour. Jobs ate only one bite, but Brown was thrilled.
Powell talked to eating disorder specialists and psychiatrists, but her husband tended to shun them. He refused to take any medications, or be treated in any way, for his depression. “When you have feelings,” he said, “like sadness or anger about your cancer or your plight, to mask them is to lead an artificial life.” In fact he swung to the other extreme. He became morose, tearful, and dramatic as he lamented to all around him that he was about to die. The depression became part of the vicious cycle by making him even less likely to eat.
Pictures and videos of Jobs looking emaciated began to appear online, and soon rumors were swirling
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about how sick he was. The problem, Powell realized, was that the rumors were true, and they were not going to go away. Jobs had agreed only reluctantly to go on medical leave two years earlier, when his liver was failing, and this time he also resisted the idea. It would be like leaving his homeland, unsure that he would ever return. When he finally bowed to the inevitable, in January 2011, the board members were expecting it; the telephone meeting in which he told them that he wanted another leave took only three minutes. He had often discussed with the board, in executive session, his thoughts about who could take over if anything happened to him, presenting both short-term and longer-term combinations of options. But there was no doubt that, in this current situation, Tim Cook would again take charge of day-to-day operations.
The following Saturday afternoon, Jobs allowed his wife to convene a meeting of his doctors. He realized that he was facing the type of problem that he never permitted at Apple. His treatment was fragmented rather than integrated. Each of his myriad maladies was being treated by different specialists—oncologists, pain specialists, nutritionists, hepatologists, and hematologists—but they were not being co-ordinated in a cohesive approach, the way James Eason had done in Memphis. “One of the big issues in the health care industry is the lack of caseworkers or advocates that are the quarterback of each team,” Powell said. This was particularly true at Stanford, where nobody seemed in charge of figuring out how nutrition was related to pain care and to oncology. So Powell asked the various Stanford specialists to come to their house for a meeting that also included some outside doctors with a more aggressive and integrated approach, such as David Agus of USC. They agreed on a new regimen for dealing with the pain and for coordinating the other
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treatments.
Thanks to some pioneering science, the team of doctors had been able to keep Jobs one step ahead of the cancer. He had become one of the first twenty people in the world to have all of the genes of his cancer tumor as well as of his normal DNA sequenced.
It was a process that, at the time, cost more than $100,000.
The gene sequencing and analysis were done collaboratively by teams at Stanford, Johns Hopkins, and the Broad Institute of MIT and Harvard. By knowing the unique genetic and molecular signature of Jobs’s tumors, his doctors had been able to pick specific drugs that directly targeted the defective molecular pathways that caused his cancer cells to grow in an abnormal manner. This approach, known as molecular targeted therapy, was more effective than traditional chemotherapy, which attacks the process of division of all the body’s cells, cancerous or not. This targeted therapy was not a silver bullet, but at times it seemed close to one: It allowed his doctors to look at a large number of drugs—common and uncommon, already available or only in development—to see which three or four might work best. Whenever his cancer mutated and repaved around one of these drugs, the doctors had another drug lined up to go next.
Although Powell was diligent in overseeing her husband’s care, he was the one who made the final decision on each new treatment regimen. A typical example occurred in May 2011, when he held a meeting with George Fisher and other doctors from Stanford, the gene-sequencing analysts from the Broad Institute, and his outside consultant David Agus. They all gathered around a table at a suite in the Four Seasons hotel in Palo Alto. Powell did not come, but their son, Reed, did. For three hours there were
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presentations from the Stanford and Broad researchers on the new information they had learned about the genetic signatures of his cancer. Jobs was his usual feisty self. At one point he stopped a Broad Institute analyst who had made the mistake of using PowerPoint slides. Jobs chided him and explained why Apple’s Keynote presentation software was better; he even offered to teach him how to use it. By the end of the meeting, Jobs and his team had gone through all of the molecular data, assessed the rationales for each of the potential therapies, and come up with a list of tests to help them better prioritize these.
One of his doctors told him that there was hope that his cancer, and others like it, would soon be considered a manageable chronic disease, which could be kept at bay until the patient died of something else. “I’m either going to be one of the first to be able to outrun a cancer like this, or I’m going to be one of the last to die from it,” Jobs told me right after one of the meetings with his doctors. “Either among the first to make it to shore, or the last to get dumped.”
Visitors
When his 2011 medical leave was announced, the situation seemed so dire that Lisa Brennan-Jobs got back in touch after more than a year and arranged to fly from New York the following week. Her relationship with her father had been built on layers of resentment. She was understandably scarred by having been pretty much abandoned by him for her first ten years. Making matters worse, she had inherited some of his prickliness and, he felt, some of her mother’s sense of grievance. “I told her many times that I wished I’d been a better dad when she was five, but now she should let things go rather than be angry the rest of her life,” he recalled just before Lisa arrived.
The visit went well. Jobs was beginning to feel a
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little better, and he was in a mood to mend fences and express his affection for those around him. At age thirty-two, Lisa was in a serious relationship for one of the first times in her life. Her boyfriend was a struggling young filmmaker from California, and Jobs went so far as to suggest she move back to Palo Alto if they got married.
“Look, I don’t know how long I am for this world,” he told her. “The doctors can’t really tell me. If you want to see more of me, you’re going to have to move out here. Why don’t you consider it?” Even though Lisa did not move west, Jobs was pleased at how the reconciliation had worked out. “I hadn’t been sure I wanted her to visit, because I was sick and didn’t want other complications.
But I’m very glad she came. It helped settle a lot of things in me.”
Jobs had another visit that month from someone who wanted to repair fences. Google’s cofounder Larry Page, who lived less than three blocks away, had just announced plans to retake the reins of the company from Eric Schmidt. He knew how to flatter Jobs: He asked if he could come by and get tips on how to be a good CEO. Jobs was still furious at Google. “My first thought was, ‘Fuck you,’” he recounted. “But then I thought about it and realized that everybody helped me when I was young, from Bill Hewlett to the guy down the block who worked for HP. So I called him back and said sure.” Page came over, sat in Jobs’s living room, and listened to his ideas on building great products and durable companies. Jobs recalled: We talked a lot about focus. And choosing people.
How to know who to trust, and how to build a team of lieutenants he can count on. I described the blocking and tackling he would have to do to keep the company from getting flabby or being larded with B players. The main thing I stressed was focus. Figure out what Google wants to be when it grows up. It’s now all over the map.
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What are the five products you want to focus on? Get rid of the rest, because they’re dragging you down. They’re turning you into Microsoft. They’re causing you to turn out products that are adequate but not great. I tried to be as helpful as I could. I will continue to do that with people like Mark Zuckerberg too. That’s how I’m going to spend part of the time I have left. I can help the next generation remember the lineage of great companies here and how to continue the tradition. The Valley has been very supportive of me. I should do my best to repay.
The announcement of Jobs’s 2011 medical leave prompted others to make a pilgrimage to the house in Palo Alto. Bill Clinton, for example, came by and talked about everything from the Middle East to American politics. But the most poignant visit was from the other tech prodigy born in 1955, the guy who, for more than three decades, had been Jobs’s rival and partner in defining the age of personal computers.
Bill Gates had never lost his fascination with Jobs.
In the spring of 2011 I was at a dinner with him in Washington, where he had come to discuss his foundation’s global health endeavors. He expressed amazement at the success of the iPad and how Jobs, even while sick, was focusing on ways to improve it.
“Here I am, merely saving the world from malaria and that sort of thing, and Steve is still coming up with amazing new products,” he said wistfully. “Maybe I should have stayed in that game.” He smiled to make sure that I knew he was joking, or at least half joking.
Through their mutual friend Mike Slade, Gates made arrangements to visit Jobs in May. The day before it was supposed to happen, Jobs’s assistant called to say he wasn’t feeling well enough. But it was rescheduled, and early one afternoon Gates drove to Jobs’s house, walked through the back gate to the open
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kitchen door, and saw Eve studying at the table. “Is Steve around?” he asked. Eve pointed him to the living room.
They spent more than three hours together, just the two of them, reminiscing. “We were like the old guys in the industry looking back,” Jobs recalled. “He was happier than I’ve ever seen him, and I kept thinking how healthy he looked.” Gates was similarly struck by how Jobs, though scarily gaunt, had more energy than he expected. He was open about his health problems and, at least that day, feeling optimistic. His sequential regimens of targeted drug treatments, he told Gates, were like “jumping from one lily pad to another,” trying to stay a step ahead of the cancer.
Jobs asked some questions about education, and Gates sketched out his vision of what schools in the future would be like, with students watching lectures and video lessons on their own while using the classroom time for discussions and problem solving.
