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CHAPTER THIRTY-SEVEN ROUND TWO
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.”

Memphis

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 publi............
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