told us about.”
Jobs was pleased that Obama followed up, and they talked by telephone a few times after the meeting. He offered to help create Obama’s political ads for the 2012 campaign. (He had made the same offer in 2008, but he’d become annoyed when Obama’s strategist David Axelrod wasn’t totally deferential.) “I think political advertising is terrible. I’d love to get Lee Clow out of retirement, and we can come up with great commercials for him,” Jobs told me a few weeks after the dinner. Jobs had been fighting pain all week, but the talk of politics energized him. “Every once in a while, a real ad pro gets involved, the way Hal Riney did with ‘It’s morning in America’ for Reagan’s reelection in 1984. So that’s what I’d like to do for Obama.”
The cancer always sent signals as it reappeared. Jobs had learned that. He would lose his appetite and begin to feel pains throughout his body. His doctors would do tests, detect nothing, and reassure him that he still seemed clear. But he knew better. The cancer had its signaling pathways, and a few months after he felt the signs the doctors would discover that it was indeed no longer in remission.
Another such downturn began in early November 2010. He was in pain, stopped eating, and had to be fed intravenously by a nurse who came to the house. The doctors found no sign of more tumors, and they assumed that this was just another of his periodic cycles of fighting infections and digestive maladies. He had never been one to suffer pain stoically, so his doctors and family had become somewhat inured to his complaints.
He and his family went to Kona Village for Thanksgiving, but his eating did not improve. The dining there was in a communal room, and the other guests pretended not to notice as Jobs, looking emaciated, rocked and moaned at meals, not touching his food. It was a testament to the resort and its guests that his condition never leaked out. When he returned to Palo Alto, Jobs became increasingly emotional and morose. He thought he was going to die, he told his kids, and he would get choked up about the possibility that he would never celebrate any more of their birthdays.
By Christmas he was down to 115 pounds, which was more than fifty pounds below his normal weight. 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 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 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 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 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,
