The indictment, filed in March, revolves around the sale of several high caliber firearms to an undercover agent who posed as a gun runner for a Mexican drug cartel. The case is the first of its kind brought against a firearms dealer in the state and likely the first such action in the United States, according to an analysis of federal court records by the International Consortium of Investigative Journalists.

The Trump administration designated six Mexican drug cartels as terrorist organizations in February 2025, opening the door for law enforcement agencies to take a variety of actions against the groups and those who do business with them.

Criminal organizations in Mexico and elsewhere have long relied on the loosely regulated U.S. gun market to procure firearms, including powerful, military-style rifles they have used in shootouts with government forces and in civilian massacres.

In February, those arsenals were on full display as cartel gunmen unleashed violence across Mexico in response to the Mexican Army killing New Generation Jalisco Cartel leader Nemesio Rubén Oseguera Cervantes, known as El Mencho.

More than 60 people died during the violence.

Mexican soldiers watched over a funeral home in the city of Guadalajara, Jalisco state, Mexico, on March 1, 2026, where the body of drug trafficker Nemesio “El Mencho” Oseguera, who died on February 22 during a military operation, was being held for a wake.

In the wake of the attacks, Mexican defense secretary Ricardo Trevilla Trejo told reporters that 80 percent of the more than 23,000 firearms seized by the Mexican government since late 2024 originated in the United States

U.S. gun dealers have rarely been held accountable for their role in facilitating the movement of those weapons.

There are over 77,000 licensed firearms dealers across the country, compared to two in all of Mexico, according to the most recent government data. And there are few federal restrictions on what kinds of guns they can sell or who can buy them.

In theory, the federal government can bring criminal charges against dealers who facilitate trafficking or can take administrative action against them, such as revoking their license, but in practice that is often difficult, according to Marianna Mitchem, a former senior official at the ATF who worked on industry regulation and currently serves as the Senior Firearms Industry Advisor at Everytown for Gun Safety, a non-profit that advocates for stronger firearms regulation.

“Both avenues are available, but both require proving the dealer’s culpability, and for years that difficulty has been used as a reason not to try,” Mitchem said.

The terrorism-related charges unveiled in Arizona in March appear to be a “test case” for a new strategy to reign in illicit firearms sales, according to Jason Red, a former investigator at the Department of Homeland Security in Arizona, who worked on gun trafficking investigations.

Mark Oliva, managing director of public affairs for the National Shooting Sports Foundation, a firearms industry trade association, said that the group, “supports the Department of Justice’s efforts to keep firearms from being illegally trafficked, whether that is to criminal elements within the United States or narcoterrorists beyond our borders.”

https://www.icij.org/news/2026/02/nearly-half-of-powerful-50-caliber-ammo-seized-by-mexican-government-came-from-us-army-plant-defense-minister-says/

IMPACT Nearly half of powerful .50-caliber ammo seized by Mexican government came from US Army plant, defense minister says Feb 10, 2026

https://www.icij.org/news/2026/02/mexican-cartels-overpower-police-with-ammunition-made-for-the-us-military/

INVESTIGATION Mexican cartels overpower police with ammunition made for the US military Feb 07, 2026

https://www.icij.org/news/2026/03/human-rights-court-calls-on-governments-to-crack-down-on-weapons-trafficking/

IMPACT Human rights court calls on governments to crack down on weapons trafficking Mar 12, 2026

Recommended reading IMPACT Nearly half of powerful .50-caliber ammo seized by Mexican government came from US Army plant, defense minister says Feb 10, 2026 INVESTIGATION Mexican cartels overpower police with ammunition made for the US military Feb 07, 2026 IMPACT Human rights court calls on governments to crack down on weapons trafficking Mar 12, 2026

Idris is the executive director of the Center for Uyghur Studies, a U.S.-based research and advocacy nonprofit. Last month, he traveled to Malaysia to launch the Malay-language version of his book, which chronicles Beijing’s repression of Uyghurs, a primarily Muslim ethnic group from northwestern China. But his plans changed when immigration officers detained him upon arrival in Kuala Lumpur, seized his U.S. passport and left him languishing in a detention room for hours before eventually deporting him.

There was clearly pressure from Beijing, Idris told ICIJ. “I feared [for] my life.”

Center for Uyghur Studies Executive Director Abdulhakim Idris. Image: via Center for Uyghur Studies

Idris’ detention is the latest high-profile example of China’s campaign to quell dissent worldwide, a trend that ICIJ and a team of 104 journalists explored as part of last year’s China Targets investigation. Interviews with more than 100 people in 23 countries who were targeted by Chinese authorities revealed how Beijing uses other governments, as well as international institutions like the United Nations and Interpol, to silence critics.

In a statement to ICIJ, a spokesperson for the Chinese Embassy in Washington, D.C., said allegations of transnational repression were “fabricated by a handful of countries and organizations to slander China.”

But human rights advocates say Idris’ case is a clear example of China’s international reach.

“Beijing successfully weaponized a third country to detain and expel a U.S. citizen,” Rushan Abbas, founder and executive director of Campaign for Uyghurs, said in a press release following Idris’ deportation from Malaysia. “China is escalating its efforts to harass citizens of sovereign nations engaged in lawful advocacy.”

Beijing has consistently been one of the world’s leaders in transnational repression, according to the U.S.-based human rights group Freedom House, which began recording cases in 2014.

Since then, Uyghurs like Idris have been involved in more than 20% of incidents recorded by the nonprofit, but the Chinese government has also targeted political dissidents, Tibet and Taiwan independence advocates and Falun Gong practitioners.

In 2025, the total number of direct, physical incidents of Beijing’s repression rose to 319, according to Freedom House’s latest report. Incidents recorded last year included the detention and suspicious death of a Tibetan lama in Vietnam; the detention of a Thailand-based pro-democracy activist; and the mass deportation of 40 Uyghur men from Thailand who had fled repression in China more than a decade ago.

But those cases just scratch the surface.

“There’s a whole universe of digital or indirect transnational repression,” said Freedom House research director Yana Gorokhovskaia, who co-authored the report. In addition to direct threats, China carries out mass surveillance, online harassment, and coercion by proxy, including threats to friends and family. Those cases are harder to track and validate.

Freedom House also found that Beijing continues to leverage geopolitical and economic power to influence other governments. Thailand’s deputy foreign affairs minister said the country deported the group of Uyghurs last year to avoid “retaliation from China,” according to the report, which suggested that Thai authorities may have been concerned about compromising Chinese investments in Thailand’s agricultural industry and other sectors.

When Malaysian officers detained Idris, he saw them conferring with three people in civilian clothes. “They avoided eye contact with me. They were wearing a mask,” he said. “I’m sure they were Chinese.” Idris’ contact in Malaysia was able to confirm that Beijing had put pressure on the Malaysian government to detain him.

Gorokhovskaia said that transnational repression is “cheap and easy to do.”

“It relies on kind of the existing structures in the international system,” she said, emphasizing the abuse of Interpol red notices, alerts shared with police forces around the world. Freedom House recorded 11 incidents of wrongful detention or deportation last year spurred by red notices, though China was not among the perpetrators.

ICIJ’s China Targets investigation exposed how Beijing previously exploited the red notice system to pursue dissidents and powerful businesspeople in violation of Interpol’s rules. Targets of red notices interviewed by ICIJ included Uyghur rights advocates who said they had been falsely accused of terrorism; a small-town politician who said he was blacklisted after exposing corruption in the communist party; and followers of the Falun Gong spiritual movement.

https://www.icij.org/investigations/china-targets/fake-journalists-cyber-spies-china-targets-reporters/

TRANSNATIONAL REPRESSION Phony whistleblowers, fake journalists and cyber spies: ICIJ network targeted after China Targets probe  Apr 27, 2026

https://www.icij.org/investigations/china-targets/watch-inside-china-targets-a-live-panel-with-icij-reporters/

INSIDE ICIJ WATCH: Inside China Targets — a live panel with ICIJ reporters Jun 10, 2025

https://www.icij.org/investigations/china-targets/china-uses-dissidents-turned-spies-to-infiltrate-overseas-activist-groups-as-authorities-flounder/

CHINA TARGETS China uses dissidents-turned-spies to infiltrate overseas activist groups, as authorities flounder Jun 23, 2025

Recommended reading TRANSNATIONAL REPRESSION Phony whistleblowers, fake journalists and cyber spies: ICIJ network targeted after China Targets probe  Apr 27, 2026 INSIDE ICIJ WATCH: Inside China Targets — a live panel with ICIJ reporters Jun 10, 2025 CHINA TARGETS China uses dissidents-turned-spies to infiltrate overseas activist groups, as authorities flounder Jun 23, 2025

“Chen” claimed to be working for the International Consortium of Investigative Journalists and was requesting an interview with Hung on a range of topics: then pending impeachment proceedings against Taiwan’s president, the island’s divided government, and Watchout’s planned events with members of civil society groups.

Hung, whose media outlet monitors information manipulation, found the email unusual.

“The topic and questions in the invitation email [were] too entry-level for a senior journalist,” Hung told ICIJ. What’s more, Chen’s name was spelled in English, instead of the original Chinese, and the email address didn’t include ICIJ’s official domain.

Hung decided to find out more and started interacting with “Chen” on LINE, a popular messaging app in Taiwan.

The person, who used Chen’s name and photo in their handle, told Hung that an American journalist from ICIJ would meet him in Taipei for the interview and sent a link to what looked like an ICIJ webpage with the reporter’s photo. Hung noticed it wasn’t ICIJ’s real website. The fake Chen also sent Hung another link she said would direct him to a list of questions, adding: “For journalists, information security is truly very important,” a warning most journalists would find superfluous.

Hung didn’t click.

“I played stupid,” he said. “And then she gave up.”

Kuochun Hung, the chief operating officer of the Taiwanese media outlet Watchout. Image: Supplied / Kuochun Hung

Hung, who knows malicious links can be used to steal personal information, suspects that his interlocutor was a Chinese spy impersonating the real Yi-Shan Chen, a financial journalist and editor-in-chief of CommonWealth magazine — a trusted news source in Taiwan. As a member of ICIJ’s network, Chen has partnered with the Washington, D.C.-based news organization on many investigations, but is not an employee.

“They are spies with cyber capabilities,” Hung said. “Their goal is political.”

The real Chen told ICIJ in an interview that she shared Hung’s concerns. “Ironically, they are using the credibility of the investigative reporters to [collect] intelligence,” she said. Chen reported the impersonation attempt to Taiwanese authorities.

Now, an investigation by ICIJ, with the help of cybersecurity analysts at Toronto University’s Citizen Lab, has found that the incident was part of a sophisticated offensive strategy against ICIJ and its network following the 2025 publication of China Targets. The ICIJ-led exposé, in collaboration with 42 media outlets, revealed Beijing’s tactics to threaten, coerce and intimidate regime critics overseas.

Citizen Lab, which specializes in investigating digital threats, analyzed suspicious emails sent to this ICIJ reporter and other messages sent by ICIJ impersonators to targets in Asia, Europe and the United States. Detailing the findings in a report released today, one year after China Targets was published, the analysts said the attacks against the ICIJ network are part of “a wide-ranging campaign” aimed at stealing private information from entities of interest to the Chinese government. Those include Uyghur, Tibetan, Taiwanese, and Hong Kong diaspora activists, as well as journalists from ICIJ and elsewhere who report on activities related to these groups.

A fake website designed to look like an ICIJ landing page. The URL shows it is not an ICIJ webpage.

Rebekah Brown, who led the Citizen Lab investigation, said it indicated that so-called threat actors linked to the Chinese government had used surreptitious means to learn who ICIJ was talking to.

“We suspect that there was some sort of directive [saying] that it’s very important to know, especially after the China Targets report, who’s talking to you, what are you working on now? How can they intervene? How can they stop this narrative from growing?” Brown said. “That results in these targeted digital intrusions, both on [ICIJ] and on a lot of the communities who might possibly be telling you and other journalists things that the government doesn’t want.”

While the probe couldn’t identify which government agency may have given the orders, “we are highly confident that this is China,” said Brown, who in the past worked as a network warfare analyst for the U.S. government.

A Taiwanese national security official told CommonWealth magazine that the attacks are similar to others identified as part of a Chinese state-sponsored espionage operation.

In response to questions from ICIJ, a spokesperson for the Chinese Embassy in Washington, D.C., said that “China has always opposed and cracked down on any form of cyber attacks” and that transnational repression is “a completely fabricated narrative maliciously concocted by certain countries and organizations in an attempt to smear China.”

The Citizen Lab analysts found more than 100 domains targeting at least a dozen individuals with the aim of stealing credentials, most likely to enable further surveillance, device compromise and coordinated harassment campaigns.

ICIJ spoke to some of the targets, including a Taiwanese foreign ministry official, who was approached by someone impersonating an ICIJ reporter. The imposter told the official that his contact information was provided by “headquarters” — a term journalists generally don’t use.

Citizen Lab found several errors suggesting that the attackers may have been involved in a “high volume” of attacks and used artificial intelligence to automate them, identify targets and generate messages without much oversight.

“It’s yet again a confirmation that the Chinese state continues to be deeply concerned about controlling the narrative about itself overseas and repressing, surveilling or harassing individuals who are challenging their preferred narrative,” said Emile Dirks, a researcher of Chinese surveillance and contributor to the Citizen Lab report.

https://www.icij.org/investigations/china-targets/cyberattack-against-uyghur-rights-activists-shows-hallmarks-of-chinese-repression-tactics-researchers-say/

Digital repression Cyberattack against Uyghur rights activists shows hallmarks of Chinese repression tactics, researchers say Apr 28, 2025

https://www.icij.org/investigations/china-targets/china-transnational-repression-dissent-around-world/

OVERVIEW Inside China’s machinery of repression — and how it crushes dissent around the world Apr 28, 2025

https://www.icij.org/investigations/china-targets/interpol-red-notice-police-warrant-jack-ma/

INTERPOL Chinese authorities exploited Interpol and strong-armed one of the world’s richest men to pursue a target Apr 29, 2025

Recommended reading Digital repression Cyberattack against Uyghur rights activists shows hallmarks of Chinese repression tactics, researchers say Apr 28, 2025 OVERVIEW Inside China’s machinery of repression — and how it crushes dissent around the world Apr 28, 2025 INTERPOL Chinese authorities exploited Interpol and strong-armed one of the world’s richest men to pursue a target Apr 29, 2025

These limitations suggest the attackers were private contractors in China’s ever-growing commercial hacking industry working for a government agency, according to Brown and a Taiwanese security official interviewed by CommonWealth magazine.

The attack shared similarities with another type of campaign called spear phishing, which cybersecurity analysts previously attributed to Chinese state-sponsored actors who target people with personalized messages to trick them into divulging sensitive data.

“In the case of state-sponsored credential theft,” the Citizen Lab report said, “the attacker can gain insight into topics of state-interest, spread disinformation via the compromised account, or use the credentials in future attacks against the target or their contacts.”

According to Dirks, the Chinese surveillance researcher, even if the attack is unsuccessful, campaigns like these can have a “chilling effect.”

“It sends a message to people like yourself and your colleagues, to members of diaspora communities, to human rights organizations that they are being watched, they are being monitored and that they are in the crosshairs of Beijing.”

Digital transnational repression

Digital transnational repression — the use of online technologies for targeted intimidation, threats and surveillance — is a common weapon in the hands of autocratic regimes such as China and Russia, according to a recent European Parliament study. In China, hackers-for-hire compete to support the government’s cyber operations, from monitoring negative social media posts to selling spyware, phishing kits and other offensive cyber tools.

Last year, ICIJ and its media partners interviewed more than 100 targets of Beijing’s repression and found about half of them had been victims of online smear campaigns, hacking attempts, or phishing campaigns seeking to steal their information.

Among them was Jiang Shengda, a Paris-based artist and activist whose family in Beijing has often been visited and interrogated by Chinese security officials demanding that Jiang stop his activism.

Jiang Shengda, a Beijing-born activist now living in France. Image: Maxime Tellier / Radio France

After ICIJ exposed details of the officials’ intimidation tactics against Jiang’s family last year, the activist noticed an uptick in cyberattacks targeting his email account.

Jiang, who also collaborates with a Chinese dissident considered a “key individual” — or threat — by Beijing, said he receives about two to four phishing emails a day from accounts mimicking supermarket chains or postal services.

Jiang said he has informed European authorities about the “harassment” campaign against him and now helps other Chinese dissidents protect against cyber threats.

“This is not just a personal issue,” he said, “but a pressure shared across the entire community.”

For Brown and her team at Citizen Lab, the work isn’t over.

They will continue to collect evidence about attacks and perpetrators, hoping to inform the public as well as policymakers and government leaders, Brown said.

“By more people knowing that this is a coordinated effort and it’s not isolated, we’ll be able to connect more dots and identify what’s actually going on,” she said. “That will help us both to prevent and detect it better, but also it will give people in leadership maybe some way to hold accountability.”

Note: ICIJ staff email addresses include the domain icij.org. If you believe an ICIJ impersonator has approached you, please do not engage and notify us at contact@icij.org.

Cologne’s regional court sentenced Christoph Zollinger, a Swiss-Panamanian dual national, to one year and nine months’ probation, according to ICIJ’s German partner ZDF. A spokesperson for the court confirmed to ICIJ that the probation period will last for three years.

German prosecutors accused Zollinger and accomplices of establishing offshore companies based in Panama and other tax havens in exchange for payment, which the court determined was done “on a massive scale” and “in a factory-like manner.”

https://www.icij.org/investigations/panama-papers/swiss-lawyer-from-panama-papers-firm-to-face-court-on-tax-evasion-charges/

Offshore finance Swiss lawyer from Panama Papers firm to face court on tax evasion charges Nov 28, 2025

https://www.icij.org/investigations/panama-papers/ten-years-after-the-panama-papers-enablers-and-tax-cheats-are-still-being-brought-to-justice/

IMPACT Ten years after the Panama Papers, enablers and tax cheats are still being brought to justice Apr 02, 2026

https://www.icij.org/investigations/panama-papers/judge-orders-nazi-looted-modigliani-linked-to-panama-papers-be-returned-to-heirs/

IMPACT Judge orders Nazi-looted Modigliani linked to Panama Papers be returned to heirs Apr 06, 2026

Recommended reading Offshore finance Swiss lawyer from Panama Papers firm to face court on tax evasion charges Nov 28, 2025 IMPACT Ten years after the Panama Papers, enablers and tax cheats are still being brought to justice Apr 02, 2026 IMPACT Judge orders Nazi-looted Modigliani linked to Panama Papers be returned to heirs Apr 06, 2026

The investigation, led by ICIJ and 47 media partners, explores how Merck & Co. — known as MSD outside the United States and Canada — keeps huge revenues flowing while pricing out many patients and governments from its blockbuster cancer drug Keytruda.

ICIJ’s investigation revealed that Merck operates with a gross lack of transparency in pricing, even as the cost of Keytruda strains public health systems and counterfeiters reap massive windfalls from duping the expensive drug. The findings have so far elicited widespread reactions from politicians, government agencies, and health and financial accountability experts.

Merck’s tax maneuvers highlighted in the U.S.

The international collaboration found that Merck reduced its U.S. taxes by recording profits in lower-tax jurisdictions. In its 2025 annual report, Merck disclosed it paid around $1.6 billion in U.S. income taxes, compared to $4.5 billion in other countries.

At a U.S. congressional hearing on corporate taxation on Tuesday, Zorka Milin, head of the Financial Accountability and Corporate Transparency Coalition, confirmed those findings.

“Despite making more than half of its sales at outrageous prices to American customers, Merck paid more taxes to Switzerland than it did to the U.S.,” Milin said at the Democrat-led hearing. “For decades, major American pharma companies have been moving their profits and sometimes also their factories overseas. Their customers are mostly American, their intellectual property is developed here with support of American tax dollars, but somehow their profits are Irish, Swiss, Dutch.”

https://www.icij.org/investigations/cancer-calculus/merck-keytruda-cancer-drug-price/

OVERVIEW How Merck turned its wonder drug into a blockbuster — and priced out cancer patients worldwide Apr 13, 2026

https://www.icij.org/investigations/cancer-calculus/a-burgeoning-black-market-inflated-dosing-and-the-over-judicialization-of-health-care-reporters-around-the-world-tell-stories-about-keytruda/

PARTNER STORIES A ‘burgeoning black market’, inflated dosing and the over-judicialization of health care: reporters around the world tell stories about Keytruda Apr 21, 2026

https://www.icij.org/investigations/cancer-calculus/report-mercks-blockbuster-cancer-drug-topped-200000-a-year-under-trump/

KEYTRUDA Report: Merck’s blockbuster cancer drug topped $200,000 a year under Trump Apr 17, 2026

Recommended reading OVERVIEW How Merck turned its wonder drug into a blockbuster — and priced out cancer patients worldwide Apr 13, 2026 PARTNER STORIES A ‘burgeoning black market’, inflated dosing and the over-judicialization of health care: reporters around the world tell stories about Keytruda Apr 21, 2026 KEYTRUDA Report: Merck’s blockbuster cancer drug topped $200,000 a year under Trump Apr 17, 2026

Update April 27, 2026: This story was updated to clarify that Belgium’s reported spending on Keytruda reflects gross expenditure rather than the net price.

The reporting shed new light on the strategies pharmaceutical giant Merck & Co., known as MSD outside the U.S. and Canada, has used to widen the use of its blockbuster cancer drug, Keytruda, and protect its monopoly. Journalists found that the drug’s sky-high price has caused a ripple effect for health care systems around the world, exacerbating inequalities and driving patients to desperate measures.

The reporting team interviewed hundreds of people, including oncologists, cancer patients and their families, patent experts, regulators and pharmaceutical industry insiders, and gathered more than 1,000 public records requests in 27 countries. Here are some of the stories our partners told around the world.

Keytruda, known generically as pembrolizumab, is a type of immunotherapy that restores the body’s ability to fight cancer cells. Unlike chemotherapy, which targets rapidly dividing cancer cells, Keytruda disrupts a process that allows some cancers to circumvent the immune system. That process involves a protein called PD-1, which is found on the surface of some white blood cells. (White blood cells regulate the body’s immune response.) But some cancer cells express proteins called PD-L1 or PD-L2 that bind to PD-1 and block the body’s ability to recognize and kill cancer cells. Keytruda works by attaching to PD-1, preventing it from interacting with the cancerous cells’ proteins and allowing the immune system to detect and attack the cancer. Pembrolizumab was first invented in the early 2000s by Dutch scientists working for a company that was later acquired by Merck. The drug was approved for medical use in the U.S. in September 2014.

Higher dosing strains public health systems

If a toothpaste maker widens the tube opening, it empties faster.

That’s how oncologist Dr. Daniel Goldstein describes the likely reason behind Merck’s move to set a fixed 200 milligram dose of Keytruda for all patients, despite originally submitting studies to regulators that used a weight-based dosing system which could recommend lower doses for some patients.

In an interview with Der Spiegel, ZDF and Paper Trail Media, the Israel-based cancer specialist laid out his potentially game-changing research finding: Keytruda can work at 25% lower doses with identical efficacy. This would mean significant savings for insurers and public budgets around the world.

In Austria, Der Standard reported that Keytruda costs 6,800 euros (about $8,000) per dose without discounts, making it the country’s single largest medication expense.

Based on research by advocacy organization Public Eye, t

ICIJ’s partners’ work in both countries exposed the health system’s deeper dysfunctions beyond the strain that Keytruda purchases have on their budgets.

https://www.icij.org/investigations/cancer-calculus/report-mercks-blockbuster-cancer-drug-topped-200000-a-year-under-trump/

KEYTRUDA Report: Merck’s blockbuster cancer drug topped $200,000 a year under Trump Apr 17, 2026

https://www.icij.org/investigations/cancer-calculus/cancer-patients-legal-battle-keytruda-lifesaving-drug/

INSURERS ‘They deny the medication that is keeping you alive’: Patients wage grueling legal battles for lifesaving cancer drug Apr 13, 2026

https://www.icij.org/investigations/cancer-calculus/keytruda-evergreening-patents-merck/

INTERACTIVE How Merck uses patents to help maintain Keytruda’s exorbitant price Apr 13, 2026

Recommended reading KEYTRUDA Report: Merck’s blockbuster cancer drug topped $200,000 a year under Trump Apr 17, 2026 INSURERS ‘They deny the medication that is keeping you alive’: Patients wage grueling legal battles for lifesaving cancer drug Apr 13, 2026 INTERACTIVE How Merck uses patents to help maintain Keytruda’s exorbitant price Apr 13, 2026

Kinahan is a leader of the Kinahan cartel, which has been involved in cocaine and heroin trafficking and linked to at least 20 murders across Europe. His detention came after an Irish court issued an arrest warrant tied to his alleged role in an international organized crime network.

Kinahan was arrested on April 15 under the terms of an extradition agreement between Ireland and the United Arab Emirates. Irish police said in a statement that the arrest “is another extremely important demonstration of the need for international law enforcement co-operation in tackling transnational organised crime.”

Kinahan, who is in his 40s, moved to Dubai after he was the target of an infamous 2016 assassination attempt at Dublin’s Regency Hotel. His presence in Dubai had long allowed him to evade U.S. and European law enforcement. He and his wife, Caoimhe Robinson, built a multimillion-dollar property portfolio in the Gulf emirate, ICIJ reported in 2024. They maintained some of these properties, which included a sprawling villa, even after Kinahan was hit with U.S. sanctions in 2022 for drug smuggling and money laundering.

https://www.icij.org/inside-icij/2025/03/drug-kingpin-daniel-kinahan-was-paid-millions-of-dollars-under-the-table-to-be-top-promoters-exclusive-agent-court-complaint-alleges/

KINAHAN CARTEL Drug kingpin Daniel Kinahan was paid millions ‘under the table’ to be boxing promoter’s exclusive agent, court complaint alleges Mar 05, 2025

https://www.icij.org/news/2024/05/dubai-property-portfolio-calls-into-question-effectiveness-of-sanctions-on-kinahan-cartel-leader-experts-say/

CRIME CARTEL Dubai property portfolio calls into question effectiveness of sanctions on Kinahan cartel leader, experts say May 14, 2024

https://www.icij.org/inside-icij/2022/04/how-a-ruthless-irish-gang-found-a-home-away-from-home-in-dubai-and-an-enemy-in-the-white-house/

Dubai How a ruthless Irish gang found a home away from home in Dubai and an enemy in the White House Apr 23, 2022

Recommended reading KINAHAN CARTEL Drug kingpin Daniel Kinahan was paid millions ‘under the table’ to be boxing promoter’s exclusive agent, court complaint alleges Mar 05, 2025 CRIME CARTEL Dubai property portfolio calls into question effectiveness of sanctions on Kinahan cartel leader, experts say May 14, 2024 Dubai How a ruthless Irish gang found a home away from home in Dubai and an enemy in the White House Apr 23, 2022

The pharmaceutical giant is among more than a dozen companies that signed confidential deals with the Trump administration to lower the prices of some prescription drugs. However, Keytruda, an immunotherapy treatment that accounts for nearly half of Merck’s revenue, has only become more expensive.

In March, Merck’s CEO Robert M. Davis declined to answer questions from ICIJ about the deal, including whether it mentioned Keytruda or if the medicine had been excluded from consideration for lower prices in the United States.

“We cannot disclose the details of this confidential agreement,” Merck said in a statement to ICIJ sent by senior vice president Johanna Herrmann. “However, the agreement overall has a manageable impact in the short- and long-term on our business and is immaterial across the KEYTRUDA family.”

The Food and Drug Administration has approved Keytruda to treat 19 types of tumors in the U.S. But its cost can be ruinous.

The Cancer Calculus, an investigation by ICIJ and 47 media partners published this week, shows how Merck has kept the price of the lifesaving drug sky-high by building a fortress of patents to deter competition and through opaque pricing. An ICIJ analysis found that a standard 200 milligram dose of Keytruda ranged from $1,700 in Indonesia to $12,000 in the U.S., before negotiations and manufacturer rebates.

https://www.icij.org/investigations/cancer-calculus/merck-keytruda-cancer-drug-price/

OVERVIEW How Merck turned its wonder drug into a blockbuster — and priced out cancer patients worldwide Apr 13, 2026

https://www.icij.org/investigations/cancer-calculus/cancer-patients-legal-battle-keytruda-lifesaving-drug/

INSURERS ‘They deny the medication that is keeping you alive’: Patients wage grueling legal battles for lifesaving cancer drug Apr 13, 2026

https://www.icij.org/investigations/cancer-calculus/about-keytruda-cancer-calculus/

Behind the scenes About the Cancer Calculus investigation Apr 13, 2026

Recommended reading OVERVIEW How Merck turned its wonder drug into a blockbuster — and priced out cancer patients worldwide Apr 13, 2026 INSURERS ‘They deny the medication that is keeping you alive’: Patients wage grueling legal battles for lifesaving cancer drug Apr 13, 2026 Behind the scenes About the Cancer Calculus investigation Apr 13, 2026

Nearly 15 minutes passed before Trump entered the room, trailed by Health and Human Services Secretary Robert F. Kennedy Jr. and several senior officials. The president glanced at the executives.

“Wow, what a group of people,” Trump said. “They make a lot of money.”

Collectively, their annual compensation topped $100 million. But only one — the bespectacled corporate lawyer with a goatee — was at the helm of a $65 billion drug juggernaut with a lifesaving medicine that was unaffordable for much of the world: Robert M. Davis, CEO and chairman of Merck & Co., maker of the anti-cancer blockbuster pembrolizumab. Brand name: Keytruda.

Trump promised drug prices would plummet “fast and furious” because of the new deals. Before the ceremony ended each executive stepped to the lectern to say a few words. When it was Davis’ turn, he declared “100%” support for the president’s actions.

Merck CEO Robert M. Davis, wearing a blue suit, stands between the heads of other major pharmaceutical companies as President Donald Trump announces a deal to lower drug prices at the White House in December 2025. Image: Brendan Smialowski / AFP via Getty Images

“I reflect on your goal of driving affordability and access to Americans but equally of getting prices up outside the U.S.,” Davis said.

He vowed Merck would drop prices on a diabetes drug and a cardiovascular pill, but he didn’t say anything about cutting the cost of Keytruda, which accounted for $31.7 billion in sales in 2025 and for nearly half of Merck’s revenue. In fact, the New Jersey-based drug giant would be making life tougher for so many cancer patients worldwide.

An investigation by the International Consortium of Investigative Journalists reveals how one of the world’s largest drugmakers deployed tactics to both inflate the volume of prescriptions and keep the price high through lobbying and by seeking to delay cheaper versions of the drug from reaching hundreds of thousands of cancer patients in the coming years. This is playing out as governments around the world spend growing amounts on Keytruda, with steep prices straining government budgets, even in wealthy countries. List prices range from about $80,000 for a year’s treatment in Germany to $208,000 in the U.S., $93,000 in Lebanon to about $130,000 in Colombia, $65,000 in South Africa to $116,000 in Croatia.

Cancer is a growing public health threat, responsible for nearly 1 in 6 deaths worldwide. Projections show cancer rates rising particularly in lower-income countries where Keytruda remains largely unaffordable. The death toll is forecast to surge by 75% to 18.6 million in 2050, with the cost of some new therapies already exceeding $1 million per patient.

Living with or beyond a cancer diagnosis brings about profound costs — physical, emotional and financial. Some patients are so desperate for Keytruda that they turn to the black market to get the drug for less money, though they don’t know if it’s the drug or a counterfeit version. Other patients seeking Keytruda face harrowing bureaucratic obstacles and end up suing their governments for access to the drug; not all of them survive long enough to learn the court’s ruling.

Reporting by ICIJ’s media partners across five continents paints a picture of deep and dangerous inequity:

In India, families seeking Keytruda rely on a frayed safety net — poor insurance coverage, Merck’s patient assistance program and out-of-pocket funds. In Brazil, the world’s seventh most populous country, most cancer patients can’t afford Keytruda, and thousands turn to the courts to get it. In South Africa, where the vast majority of citizens are not able to afford private health care and the typical monthly income for a household is under $500, a single dose of Keytruda costs roughly 10 times as much: $4,904.

Cancer patients receiving treatment in the oncology unit at the public hospital in Quetzaltenango, Guatemala. Image: Laura Garcia / Plaza Pública

In the United Kingdom, research shows that Keytruda tops the list of drugs for which the cash-strapped National Health Service overpays. For some lung cancer patients, the NHS has been paying five times as much for Keytruda than it should, according to cost-effectiveness data from the University of York shared with the Bureau of Investigative Journalism, ICIJ’s U.K. partner. And in Guatemala, one doctor dealing with limited access had to choose two among his many patients to receive the drug.

“What’s left for me to do? To play God,” said Julio Ramirez, head of the oncology unit at the regional public hospital in Quetzaltenango, Guatemala’s second largest city. “The first patient who arrives, that’s who I’m going to give the treatment to because that’s all I can do.”

The Cancer Calculus, a yearlong investigation by ICIJ and 47 media partners in 37 countries, is based on hundreds of interviews with oncologists, cancer patients and their families, patent experts, regulators, pharmaceutical industry insiders and others, as well as exclusive pricing data and patent analyses and thousands of pages of company presentations, patent board documents, lawsuits and corporate and regulatory records. ICIJ’s media partners also unearthed public health records, meeting minutes, pricing and reimbursement data, and other documents through  1,018 public records requests in 27 countries.

The investigation explores how Merck, known as MSD outside the U.S. and Canada, employed aggressive but legal tactics to increase its Keytruda revenues and make the drug one of the bestselling ever — at the expense of some patients.

Among the project’s findings, we report:

exploited the patent system

Merck and other cancer research businesses exploited the patent system to build a fortress around Keytruda of at least 1,212 patent applications in 53 countries, regions and territories. This stream of follow-on patents could help Merck stifle competition and maintain high prices — and billions of dollars in revenue — for 14 years after its original patents expire in 2028. Merck has promoted a higher dosage of Keytruda than is necessary, some leading cancer researchers say. And that dosage could cost the world an estimated $5 billion just for lung cancer patients by 2040, according to researchers at the World Health Organization. The drug giant has taken advantage of industry regulatory shortcuts, helped orchestrate a costly global lobbying campaign and operated with a gross lack of transparency in pricing. It has distributed tens of millions of dollars in the U.S. in consulting fees, travel costs and other Keytruda-related payments to doctors and health-care professionals.

All of these strategies produce revenue for Merck, with about 60% of its Keytruda sales in the U.S.

An ICIJ analysis shows that Merck has generated about $163 billion in Keytruda sales since 2014, reaching more than 3 million people. The company funneled nearly $75 billion in dividends to shareholders and $43 billion into share buybacks while reducing its U.S. taxes by recording profits in lower-tax jurisdictions. In its 2025 annual report, Merck disclosed it paid around $1.6 billion in U.S. income taxes, compared with $4.5 billion in other countries.

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Davis declined to comment for this story, but Merck senior vice president Johanna Herrmann defended the company’s pricing practices, saying that Keytruda’s price “reflects its value to patients and health-care systems.”

“We have a long history of responsibly pricing our medicines to reflect their value to patients, payers and society,” she wrote in a letter to ICIJ.

Herrmann acknowledged in a separate letter that Merck faces “increasing political and business pressures” over access and pricing in emerging markets. But she said the company is working to ensure health care is “affordable, efficient, equitable and sustainable on a global scale.”

In our reporting, we found that Merck’s conduct was typical of the pharmaceutical industry — and that the company was not an outlier in terms of its overall business practices. But the incredible growth of and interest in Keytruda could be further pushing what is acceptable by industry standards.

Peter Maybarduk, director of the access to medicines group at Public Citizen, a nonprofit consumer advocacy organization based in Washington, D.C., said the pharmaceutical industry has created a system of global rules to protect drugmakers and ensure wealthy governments protect them. “There is a whole architecture underpinning Keytruda and every patented drug where the U.S. government and Europe go to bat for the industry and its rules,” he said.

That system is marked by big questions about how the practices of Merck and the other Big Pharma companies affect the future of our collective wellness. How that plays out is often the story of putting profits over patients. For the world’s haves and have-nots, it can also be the story of who lives and who dies.

Miracle beginnings

Rob Davis, 59, grew up in Franklin, Ind., a farming town 20 miles south of Indianapolis, in the shadow of Eli Lilly, one of the world’s largest drug companies. He would work at Lilly for 14 years while studying for his business and law degrees.

When his father, Morris, an auditor, was fighting cancer, Davis went for a job interview with Merck’s then-CEO Ken Frazier. At the end of their meeting, Frazier directed Davis toward an image by the door. He wanted to show him a PowerPoint slide taped to the wall, Davis said in a 2024 interview at Northwestern University’s law school. It displayed different tumor types and their responses to Keytruda.

“This is why you need to come to Merck,” Frazier told him. “Because we’re going to make a real difference.”

Robert Davis, chief executive officer of Merck, speaks during a Senate Health, Education, Labor, and Pensions Committee hearing on drug prices in Washington, D.C., in February 2024. Image: Tierney L. Cross/Bloomberg via Getty Images

Davis joined Merck as chief financial officer in the spring of 2014, a few months before his father died of lung cancer at age 82. “I wonder what would have happened if that drug would have been available 10 years ago when my father was going through his battle,” he said in the interview.

As Davis settled into the new job, Merck was getting ready to launch Keytruda to treat melanoma, the deadliest form of skin cancer. Projected U.S. sticker price: about $12,500 a month, or $150,000 a year.

When it emerged, it revolutionized cancer treatment. In a class of immunotherapy drugs called immune checkpoint inhibitors, Keytruda shifted the focus from directly attacking tumors to empowering the immune system to fight them. Now approved in the U.S. to treat 19 types of tumors, including of the skin, lung, breast and colon, it has become a lifeline for millions, turning previously terminal forms of advanced cancer into manageable diseases and increasing survival rates for others with cancers that are hard to treat — sometimes for months, sometimes for years.

Carolina García Corsini, right, with her daughter, Cristina in 2023. Carolina was pregnant with Cristina when she was diagnosed with cancer, but went into remission after successful treatment with Keytruda. Image: Supplied

“All these years later I haven’t stopped coming here to give thanks, for my life, for being alive,” Carolina García Corsini told an ICIJ reporter while at a Catholic shrine in Madrid. A former journalist and mother of three from the Spanish capital, García was 37 years old and four months pregnant when she was diagnosed with metastatic melanoma in February 2011. The tumors had spread to her left breast. After securing a coveted spot in Keytruda’s first clinical trial, she began traveling to Paris every few weeks to get treated. Fourteen years later, and in remission, she said, “I’m convinced it’s a miracle.”

Such experiences are just some of the reasons Merck is now ranked No. 65 on the Fortune 500, with its Keytruda revenues greater than McDonald’s or the entire National Football League.

Today, as Merck’s CEO and chairman and head of the powerful trade lobby PhRMA, Davis promotes key pillars of the industry agenda: that patent protection and high prices help drug companies recover the billions spent developing new medicines and getting them to patients safely on a mass scale. The process typically takes a decade or more, and a U.S. patent, which generally lasts 20 years from the application date, allows companies to enjoy a dominance in the market, charge higher prices, recover research and development costs and earn profits to fund future research. From 2011 to 2023, Davis said in 2024 congressional testimony, Merck invested $46 billion to research, develop and manufacture Keytruda. He cited more than 2,200 clinical trials — conducted by Merck and other researchers — to study Keytruda, and the company plans to invest another $18 billion in Keytruda clinical studies into the 2030s.

Keytruda, known generically as pembrolizumab, is a type of immunotherapy that restores the body’s ability to fight cancer cells. Unlike chemotherapy, which targets rapidly dividing cancer cells, Keytruda disrupts a process that allows some cancers to circumvent the immune system. That process involves a protein called PD-1, which is found on the surface of some white blood cells. (White blood cells regulate the body’s immune response.) But some cancer cells express proteins called PD-L1 or PD-L2 that bind to PD-1 and block the body’s ability to recognize and kill cancer cells. Keytruda works by attaching to PD-1, preventing it from interacting with the cancerous cells’ proteins and allowing the immune system to detect and attack the cancer. Pembrolizumab was first invented in the early 2000s by Dutch scientists working for a company that was later acquired by Merck. The drug was approved for medical use in the U.S. in September 2014.

But a new analysis by Public Eye, a Swiss-based nonprofit advocating for corporate accountability, estimates Keytruda’s R&D costs at $1.9 billion — 1% of the drug’s global revenue since its launch in 2014. Adding the cost of failed clinical trials, the R&D estimate is $4.8 billion, or 3% of the drug’s revenue. Patrick Durisch, Public Eye’s pharma specialist, said he based his numbers on a review of Keytruda clinical trials and their average costs, which are the largest share of R&D expenses.

Davis’ figures are “absolutely unverifiable,” Durisch told ICIJ. “Merck could throw any figure they want — as high as possible to justify the exorbitant price tag.”

“The share of R&D costs in relation to the price of a vial is very tiny and they have long been recouped,” he added. “The price is thus excessively high, not to cover the R&D costs or hedge risks but to make maximum profits.”

Nathan Cherny, an oncologist and director of cancer pain and palliative medicine at Shaare Zedek Medical Center in Israel, said a “perfect storm” led to the high cost of Keytruda. It began in 2003 when the U.S. Congress passed a “non-interference” clause as part of the Medicare law, requiring the government to go along with manufacturers’ list prices for new drugs without any price negotiations. Although the clause barred the federal government from negotiating prices, its supporters framed it as a reinforcement — not a suspension — of market forces by shifting negotiating power to private plans rather than the government.

“It was a suspension of market forces,” Cherny told ICIJ. And its impact was felt worldwide.

https://www.icij.org/investigations/cancer-calculus/cancer-drug-counterfeits-keytruda-immunotherapy/

COUNTERFEITS Counterfeiters cash in on the world’s bestselling cancer drug Apr 13, 2026

https://www.icij.org/investigations/cancer-calculus/keytruda-evergreening-patents-merck/

INTERACTIVE How Merck uses patents to help maintain Keytruda’s exorbitant price Apr 13, 2026

https://www.icij.org/investigations/cancer-calculus/cancer-patients-legal-battle-keytruda-lifesaving-drug/

INSURERS ‘They deny the medication that is keeping you alive’: Patients wage grueling legal battles for lifesaving cancer drug Apr 13, 2026

Recommended reading COUNTERFEITS Counterfeiters cash in on the world’s bestselling cancer drug Apr 13, 2026 INTERACTIVE How Merck uses patents to help maintain Keytruda’s exorbitant price Apr 13, 2026 INSURERS ‘They deny the medication that is keeping you alive’: Patients wage grueling legal battles for lifesaving cancer drug Apr 13, 2026

Immunotherapy, while offering life-changing and sometimes miraculous results for a small number of cancer patients, failed to help many others, and some complained that doctors downplayed risks.

Keytruda sales ballooned globally. From 2020 to 2024, according to exclusive sales data shared with ICIJ by IQVIA Institute for Human Data Science, there was a 232% increase in France to $2.8 billion; 265% in Brazil to $753.7 million; 491% in Mexico to $137.3 million; and 584% in Türkiye to nearly $100 million.

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The changed landscape raised new questions for oncologists and insurers: Which treatments work for which patients? What are the proper doses, frequency of treatment and duration of treatment? And how should they assess the value of all the new treatments?

Wolf-Dieter Ludwig, an oncologist who chaired the German Medical Association’s drug commission for 18 years, cited Keytruda as an example of “where too much money is being spent in our health care system.” The medicine has made a significant difference in some types of cancers, he told ICIJ’s partners at Paper Trail Media, but added that it rarely leads to a cure, and the high price is not justified. Pharmaceutical companies often use the term “game changer,” Ludwig said, but it is, above all, about one thing: good marketing.

But as the global crisis over skyrocketing drug prices intensified, Davis expressed concern about cancer patients’ financial hardships. And there had been plenty of hardship. Since Keytruda came to market in 2014, ICIJ found 632 cases in which patients in 51 countries turned to GoFundMe and other crowdfunding sites to raise money for Keytruda treatments.

“We need to focus efforts on reducing out-of-pocket cost,” the Merck chief executive told investors at a health care conference in 2021. “That is the focal point.”

ICIJ’s investigation found that Merck’s list prices, or the initial undiscounted prices, vary wildly across countries, ranging from about $850 for a single 100 mg vial in Indonesia to $6,015 for the same vial in the U.S.

Cancer patients in a clinic in Quetzaltenango, Guatemala, receiving treatment. Image: Laura Garcia / Plaza Pública

Extreme disparities stem from secret discounts and rebates applied to list prices in different countries as well as the different ways health care systems decide drug costs. There’s no price cap for most prescription drugs in the U.S., for example, where drug manufacturers set prices largely on their own. In many other countries, governments negotiate with drugmakers to set a price.

A common feature of drug-pricing systems worldwide: They thrive on secrecy. At least half a dozen authorities around the globe refused to disclose to ICIJ and its media partners public spending details about Keytruda or the number of patients receiving the medicine. They cited an array of explanations — for example, that they or Merck had deemed the information a “trade secret.”

Despite the extreme secrecy, ICIJ obtained and compared Keytruda list prices and the drug’s maximum sales prices in 31 countries. ICIJ found big differences in affordability, with Keytruda comparatively less affordable in poorer countries. In South Africa, for example, Keytruda’s list price (excluding taxes and fees) is about $3,800 for a 200 mg dose — a third of the U.S. list price. Still, Keytruda is far less affordable in South Africa, where a person earning the median income can’t even buy one dose in a year, while in the U.S. a patient earning the median income can afford fewer than five doses.

At the same time, according to ICIJ’s analysis, Americans with the median income can afford less Keytruda than those earning the median income in some wealthy European countries, such as France and Belgium. In poorer Eastern European countries like Bulgaria and Hungary, Keytruda tends to be less affordable than in more affluent Western Europe, ICIJ’s affordability comparison shows.

And in Mexico and several other Latin American countries, sticker prices for Keytruda tend to be higher — when adjusted for economic levels — than in wealthier countries, ICIJ’s investigation shows.

In Guatemala, Alberto Xum thought, like many cancer patients in Latin America, that he would have to forgo treatment altogether. A one-year supply of Keytruda vials costs $180,000 or more in the Central American country, and Xum, a 65-year-old uninsured artisan, sells leather souvenirs in a region where the average monthly household income is around $700. Diagnosed with metastatic kidney cancer in 2022, Xum told his oncologist, Julio Ramírez, that he was ready to give up treatment after being prescribed pills that cost $1,900 every three months. Xum was able to pay just one time.

Alberto Xum, 65, said he couldn’t afford treatment after he was diagnosed with cancer in 2022. But he got lucky — a government program paid for Keytruda for him. Image: Laura Garcia / Plaza Pública

“I told the doctor I couldn’t afford it,” he said. “I was putting my life in God’s hands.”

To Xum’s great fortune, though, Ramírez was about to receive authorization from the health ministry for one of the first Keytruda treatments at his hospital. Xum was the chosen one. Every three weeks for the next two years Xum rode a bus for 2½ hours from his rural town, Samayac, to the public hospital in Quetzaltenango to receive the $11,000 infusion, paid for by the government.

“Sometimes I ask, ‘Who am I to deserve all this luck?’ ” Xum told ICIJ. His tumors had shrunk, but he was not in remission.

Now a new study supports ICIJ’s findings and raises fresh concerns about Keytruda’s affordability and access. Treatment for six months of Keytruda for head and neck cancer costs nearly 80 times the average monthly income in India and 43 times the average in Pakistan. The cost remained catastrophically high in wealthy countries too — nearly six times the average monthly income in the U.S. and nine times the average in the U.K., according to the study, published in February in an oncology specialty journal. In short, six months of Keytruda ranges from $7,676 in Bangladesh to $38,254 in Australia, the researchers found, concluding, “Modern immunotherapies remain economically inaccessible across most settings.”

ICIJ found Keytruda treatment costs for patients are particularly chaotic in the U.S. Data compiled by Serif Health, a San Francisco firm that analyzes health care reimbursement information, shared data with ICIJ showing that patient and insurer costs vary dramatically. Across the U.S., estimated costs range from $5,858 to $43,800 for a typical 200 mg Keytruda treatment, depending on where the drug is given, which commercial insurance company and provider are involved and how it’s billed.

For Barbara Thornton, a 64-year-old home health aide from Cincinnati, Ohio, who recently overcame pancreatic cancer, Keytruda treatments at a nearby hospital’s outpatient center cost well above the list price.

Each treatment at the infusion center came with a bill of about $42,000, Thornton told ICIJ’s partners at USA Today. A combination of her husband’s insurance, financial assistance from her hospital system, and Medicaid covered the majority of her portion of the costs.

“I was lucky. I had insurance,” Thornton said. “We’re not living the high life — let me put it that way — so we qualified for financial assistance.”

Barbara Thornton received multiple Keytruda infusions to help treat her pancreatic cancer. Image: Phil Didion / The Cincinnati Enquirer

Thornton received Keytruda intravenously for 27 months. When her treatment ended, she rang the bell at her center last December, marking the milestone and her transition to cancer survivor.

The Health Care Cost Institute, a nonprofit group that analyzes employer-sponsored insurance claims in the U.S., also reviewed U.S. Keytruda treatment cost data for ICIJ, covering five years from 2018 to 2022. HCCI unearthed a startling fact: In 2022, employer-sponsored insurance plans paid $3.79 billion for Keytruda coverage for just 30,997 patients – or about $122,400 per patient. The institute also found that in the same year, the cost could nearly double when Keytruda was administered in a hospital outpatient department instead of a doctor’s office.

“Whether it is drug administration, lab testing, or imaging, the care provided is often identical, but as we saw with Keytruda, the price tag depends entirely on the building you’re treated in,” said John Hargraves, HCCI’s managing director of data strategy and analytics. He added that spending nearly $3.8 billion on fewer than 31,000 patients underscores how expensive these therapies have become and how much they can drive overall spending in employer-sponsored insurance. “While it’s not unusual for specialty drugs like Keytruda to carry very high per-patient costs, the scale of spending we’re seeing here is remarkable and raises important questions about affordability for employers and patients alike,” Hargraves said.

In a statement, Merck spokeswoman Julie Cunningham blamed high prices in the U.S. on pharmacy benefit managers and health insurers, middle players who extract rebates and fees, driving up costs for patients. “Narrowly focusing on prescription drugs fails to address the much bigger contributors to higher health care spending in the United States,” Cunningham said. “America is the only country in the world where entities that don’t make medicines take half of every dollar spent on brand medicines.”

Merck’s Herrmann said 59% of U.S. patients with private health insurance paid no out-of-pocket costs for Keytruda. For those patients with out-of-pocket costs, about 80% paid between 1 cent and $375 per infusion, after satisfying their deductible. “We routinely provide coupons and other co-pay assistance for our products, including Keytruda, to reduce out-of-pocket costs,” Herrmann said, adding that the value of this assistance totaled around $125 million last year. But even when insured, patients may struggle with thousands of dollars in upfront costs, including high deductibles before coverage kicks in.

Merck’s U.S. headquarters in Rahway, New Jersey. Image: Christopher Occhicone/Bloomberg via Getty Images

Although the company does not publicly break out how much it spends on patient assistance for Keytruda, Herrmann said Merck provided $1.7 billion in free medicines in the U.S. — covering all eligible Merck products — to uninsured or underinsured patients in 2024.

For Nasır Nesanır, chair of the public health branch of the Turkish Medical Association, these disparities are framed by larger questions that go beyond health care.

“Should medical innovation be regarded as a common gain of humanity?” Nesanır asked in an interview with ICIJ partner DW Türkçe in Türkiye. “Or should it remain a commercial asset under patent protection that deepens global inequality?”

Put another way: Is the system designed around saving lives first or making money — and who gets left out because of that choice? The answers aren’t just about health care but speak to larger debates about whether lifesaving discoveries belong to all of us.

“They are hand-to-mouth daily wage workers,” Akhade told ICIJ. “They are worried about where their next meal will come from.” The Indian government provides chemotherapy to these patients for free, however. Others receive help from Merck’s patient assistance programs. In India, the program is called Kiran, a Sanskrit-derived name meaning “ray of light,” which lets patients buy five vials and get up to 30 free, according to reporting from the Indian Express. Merck says Kiran has provided access to Keytruda to more than 68,000 patients across 11 Asia-Pacific markets and is committed to expanding that.

Patients waiting to be seen at Nair Hospital in Mumbai, India. Image: Nayonika Bose / The Indian Express

“The company is doing their bit to make the drug affordable,” Akhade said. “It is not like they’re doing nothing. But it’s still very difficult for most patients. They can do more. They can definitely do more.”

A top oncologist at Tata Memorial Hospital, less than three miles from Nair Hospital, agrees. “It is heartbreaking and disheartening for us,” Kumar Prabhash told ICIJ. “And now let us think from the patient point of view how devastating it is for them.”

Prabhash, a professor who leads the hospital’s oncology unit, and colleagues in Mumbai and Delhi are working on cost-effective ways to expand access. Although Merck recommends 200 mg of Keytruda every three weeks, doctors at Indian hospitals are testing low-dose immunotherapies. In one clinical trial, breast cancer patients received three doses of Keytruda at 50 mg every six weeks along with chemotherapy. In other studies, patients received low dosing or weight-based dosing of Keytruda — 2 mg per kilogram every three weeks or 1 mg per kilo every six weeks.

So far, results from the trials indicate that lower doses of Keytruda are effective for some types of treatments. Hospitals in Singapore, Malaysia and Taiwan have arrived at a similar conclusion from their own studies, and several countries — including the Netherlands, Canada and Israel — have started switching to weight-based dosing.

The health system just simply cannot afford all of these drugs. — oncologist Daniel Goldstein

The savings can be massive. After years of studying the costs and benefits of cancer drugs, Daniel Goldstein, a British-born oncologist with U.S. training now practicing in Israel, made that discovery in 2017: Fixed dosing of Keytruda costs the U.S. health care system an extra $825 million annually. “The health system just simply cannot afford all of these drugs,” Goldstein, director of the Center for Cancer Economics at Rabin Medical Center’s Davidoff Cancer Center, told ICIJ. “And in every single country in the world, there’s pressure.”

Researchers for the World Health Organization estimated in a separate, modeled projection that the world could save $5 billion over 15 years if lung cancer patients received Keytruda based on their weight vs. fixed-dosing amounts. And the weight-based dosing method would be more of a savings for all eligible cancer patients.

Merck said it bases its dosing formulas on clinical evidence detailed in the FDA-approved recommended dosage section of its Keytruda prescribing information. But Goldstein’s crusade gathered momentum and spilled beyond borders. Bishal Gyawali, an oncologist and drug policy researcher in Canada, told ICIJ’s partners at the Toronto Star of a key reason Merck likely gives the same dose to everyone: money. “They can sell more of the drug,” he said, and “they will make more money. … There is no scientific, medical, biological reason to do that. It’s just commercially motivated.”

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“Each patent application is a potential landmine” that could create a costly and lengthy legal challenge for Merck’s lower-cost competitors, Amin told ICIJ. “The goal is to carpet-bomb the competitor with as many patents as possible to either deter them, make the cost of entering [the market] as costly as possible or hope the more patents a competitor has to litigate their way through will result in a settlement” that could mean a delayed launch.

But Merck says its post-2014 patents are genuinely new discoveries. “We continue to evaluate Keytruda in the hopes of expanding its use to other forms of cancer and increasing access to the treatment,” Herrmann said in a letter. “This includes innovations around formulation, dosing and novel uses, including combinations with other agents. As you would expect, when appropriate, Merck protects its innovation through the filing of patent applications.”

Merck’s scramble to fortify its dominance includes filing for patents that are combinations of Keytruda and another medicine. For example, ICIJ identified 29 patent applications filed jointly worldwide by Merck and Japan-based Eisai relating to the combination therapy of Keytruda with the cancer drug Lenvima. But according to Amin, this type of combination is not new.

“Why is Merck not exploring new, unchartered therapeutic combination avenues?” Amin asked. “What is the point of dedicating time and money towards therapeutic combinations that already exist?”

Merck engineered another patent strategy commonly used by drugmakers. It filed new patents for a “product hop” — switching consumers to a similar, newer version of the same drug that resets the patent clock for more years of exclusivity. Merck hopes to move up to 40 percent of its customers to a Keytruda injection given under the skin instead of an intravenous infusion before lower-cost rivals gain a foothold. The product hop could help Merck generate billions of dollars and delay competition into the 2030s, according to three industry experts.

And Merck adopted a new pricing tactic in Latin America in 2024, when an Argentine firm tried to shake up the market with a local, cheaper version of Keytruda called PembroX. Merck had no patent in force in Argentina, where there is chronic economic turbulence and a hostile environment for foreign drug companies. The New Jersey firm was operating alone in the market, constantly raising prices, Gustavo Pelizzari, CEO of the rival drug company Elea, told ICIJ’s Argentine partners. PembroX went on sale in January 2025; the day before the launch Merck suddenly lowered its price for Keytruda by 50%, just marginally higher than the competitor’s price, Pelizzari said. And Keytruda’s price kept dropping.

The competition has led to wider access and affordability, Pelizzari said, with thousands more patients now being treated. That led him to consider Keytruda’s pricing and its financial impact in the U.S.

“I’m convinced that they’re selling much cheaper in Argentina than in the United States,” Pelizzari said. “They must be causing significant damage to the American government. I mean, they, Merck,” he said, “should be forced to sell at the Argentine price. That’s why they don’t make the prices public.”

Price explosions

Merck’s Rob Davis experienced a wave of online hate after he expressed condolences and sadness for Brian Thompson, the CEO of UnitedHealthcare who was fatally shot outside a Midtown Manhattan hotel in December 2024. In addition to the shock and condemnation, the early morning killing also unleashed widespread celebration and declarations of justice from patients all over the world who had experienced denied insurance claims.

“Saddened?” a cancer patient wrote on Davis’ LinkedIn account. “Does your sorrow extend to the patients and families who have lost their lives or livelihoods because of leadership and policies prioritizing profit in insurance over health?”

Given the disquieting endorsement of Thompson’s assasination in the days that followed, every CEO in the health care industry could be justified in feeling anxiety. But Davis was dealing with additional pressures: While Keytruda’s patent expiration was still four years off, investors were already bracing for the impact. With the new U.S. president touting lower drug prices on the campaign trail, what would that mean for Merck and Keytruda?

Protestors demonstrated against healthcare companies’ profiteering outside the trial of Luigi Mangione, who is accused of killing of UnitedHealthcare CEO Brian Thompson in New York in 2024. Image: John Lamparski/Getty Images

“So lots of concerns about Keytruda,” said Tim Anderson during an earnings conference call in April 2025. Anderson was a stock analyst at Bank of America at the time and was worried about Merck’s stock dropping. He added that he’d raised these concerns last quarter as well. Now, Anderson asked Davis, “I’m wondering where you are on that line of thinking as the stock continues to kind of drift lower.”

Merck was confident, Davis replied, about the future revenue stream. “We have over 20 new products that we see coming over the next few years,” he said, “almost all of which have blockbuster potential.”

Merck paid PhRMA $16 million in 2024 to lobby on its behalf, and Davis, following in the footsteps of his predecessor, became chairman of the trade group’s board in February. PhRMA explicitly asked U.S. officials to target European drug policy and take action against countries trying to control prices of Keytruda and other branded drugs. Among the nations singled out were Australia, Canada, Denmark, France, Germany, Greece, Italy, Japan, South Korea, Spain, Switzerland and the United Kingdom.

At a conference in Paris in February, Belgium’s deputy prime minister and health minister, Frank Vandenbroucke, detailed the “squeeze” to raise prices. “The Trump administration is prepared to use trade coercion to force European governments to change their pricing practices,” Vandenbroucke said. He cited Trump’s claim in January that he had pressured President Emmanuel Macron to raise French drug prices by threatening 100% tariffs on champagne.

After months of pressure from the White House, Davis joined executives from 15 pharmaceutical companies in endorsing deals with Trump to sell medications for less in the U.S. Davis and Trump shook hands, and the president vowed to lower prices to what’s paid in other wealthy countries.

Neither the Trump administration nor the manufacturers would disclose details of the agreements. Merck wouldn’t say whether Trump carved out an exemption for Keytruda, but health policy researchers and government sources said it’s not clear the price of Keytruda will go down in the U.S. anytime soon. Prices could climb elsewhere, though, as they already have in the United Kingdom, or as they could in Germany, where an industry source sees “price explosions.” And, said Peter Maybarduk, the consumer advocate, “In poor countries, all Trump’s plans may achieve is more suffering and death.”

U.S. President Donald Trump shakes hands with Merck CEO Robert Davis during the December White House announcement about lowering prescription drug costs. Image: Alex Wong/Getty Images

Promises and prescriptions

In February, Trump used his State of the Union address to give a pep talk about the slowing U.S. economy. “Our country is winning again,” he said. “In fact, we’re winning so much that we really don’t know what to do about it.”

“I took prescription drugs, a very big part of health care, from the highest price in the entire world to the lowest,” Trump said. “The result is price differences of 300, 400, 500, 600% and more” — claims the administration has provided no evidence for.

There was no mention of Keytruda. In fact, Trump spent just five minutes of the 1 hour 47 minutes — the longest State of the Union address in history — talking about health care costs. He spent more time celebrating the U.S. men’s hockey team.

Nearly 3,000 miles away in Guatemala, the contrast to Trump’s grand promises for affordable health care felt a world away. At sunrise on a cold Friday in February, Julio Ramírez, the oncologist who treated Alberto Xum, walked through the small waiting room at his public hospital’s oncology unit, greeting everyone on the way to his office, where he sees about 40 patients a week.

Oncologist Julio Ramírez works at the public hospital in Quetzaltenango, Guatemala, where access to Keytruda is limited. Image: Laura Garcia / Plaza Pública

Ramírez showed an ICIJ reporter handwritten lists of medications he needs for his patients. He knew he wasn’t likely to get them all because of budget constraints.

“Look, I’m not complaining,” he said. “I have the opportunity to give [Keytruda] at least to two or three patients here at the hospital” — an uptick in what he had previously been able to offer.

“My dream would be to be able to give all my patients the prescriptions they need without having to play Eeny, meeny, miny, moe to decide who gets it and who doesn’t,” he said.

It was time for the doctor to start seeing the day’s patients. A short, middle-aged man, wearing a face mask and ski cap, moved quietly toward the office, clutching his latest test results. Ramírez shook the man’s hand, and then he got down to the business of what he could — and couldn’t — do for him.

Editor’s note: Some ICIJ funders advocate for reform of the pharmaceutical industry to make it more transparent and its products more affordable and accessible for patients. Funders have no involvement in ICIJ’s editorial decisions.

Contributors: Andrés Bermúdez Liévano, Iván Ruiz (CLIP); Hala Nasreddine (DARAJ); Lars Bové (De Tijd); Zsuzsanna Wirth, Zita Szopko (direkt36); Pelin Ünker (DW Türkçe); Sergio Silva Numa (El Espectador); Carlos Carabaña, Daniele Grasso (El País); Gaby de Groot, Thieu Vaessen (Het Financieele Dagblad); Mariel Fitz Patrick (Infobae); Shauna Bowers (Irish Times); Jiyoon Kim (KCIJ-Newstapa); Kristof Clerix (Knack); Gloria Riva, Leo Sisti (L’Espresso); Francisca Skoknic (LaBot); Hugo Alconada Mon (La Nación); Natasha Cambronero (La Nación); Anne-Sophie Leurquin (Le Soir); Yiswaree Palansamy (Malaysiakini); Jacob Borg (Malta Times); Dejan Milovac (MANS); Maria Christoph, Sophia Stahl (Paper Trail Media); Jody García (Plaza Pública); Guilherme Waltenberg (Poder360); Stefan Melichar (profil); Despina Papageorgiou (Reporters United); Violeta Santiago (Quinto Elemento Lab); Fabiola Torres (Salud con Lupa); Fiona Walker, Andjela Milivojevic (The Bureau of Investigative Journalism); Nayonika Bose, Anonna Dutt, Kaunain Sheriff (The Indian Express); Amy Dempsey, Jesse McLean, Megan Ogilvie (Toronto Star); Jacob Borg (Times of Malta); Dirk Waterval, Martijn Roessingh (Trouw); Austin Fast (USA Today); Kirsi Karppinen, Minna Knus-Galán (Yle); Denise Ajiri, Agustin Armendariz, Kathleen Cahill, Jelena Cosic, Isabella Cota, Jesús Escudero, Miguel Fiandor Gutiérrez, Karrie Kehoe, Micah Reddy, Delphine Reuter, Joanna Robin, David Rowell, Richard H.P. Sia, Dean Starkman, Fergus Shiel, Annys Shin, Angie Wu (ICIJ)

“When our dad died, I was just crying so much. We didn’t do enough,” Piya told the International Consortium of Investigative Journalists. “But when my mom died, I really felt like we did all that we could.”

Piya had moved back to Nepal from Cleveland for six months while her husband, Dain Finke, an American physician, remained in the United States. There she cared for her 63-year-old mother, Sita Gurung, during the day and worked remotely as a project manager for a health care technology company at night, until she could no longer manage it all.

Piya quit her job. She paid thousands of dollars toward Gurung’s more than $40,000 treatment. She accompanied her to India for medical scans. She even watched dutifully as Gurung, increasingly frail and eventually unable to eat, spent hours in the kitchen teaching her how to cook her favorite recipes.

“She once told me that if it weren’t for me, she would have died a long time back,” Piya, now 36, said.

Bhinnata Piya, 36, moved from Cleveland to Nepal to care for her mother who was diagnosed with esophageal cancer. Image: Dustin Franz / ICIJ

At the end of 2022, as Gurung’s health worsened, her doctor prescribed an expensive immunotherapy treatment called Keytruda. Following the doctor’s recommendation, they bought the medication from a hospital worker in India who ran a medical tourism business.

Gurung was on the medication for two months, but it made no difference.

On Feb. 9, 2023, after enduring 2½ years of grueling chemotherapy, radiation and immunotherapy, she died at home with her elder daughter and Piya by her side.

“I took peace in knowing that we did everything,” Piya said.

But that feeling was short-lived.

One year after Gurung’s death, Piya’s sister learned shocking news while visiting her in Ohio and told her, “You need to sit down for this.” An Indian newspaper had reported that the man who sold them their mother’s cancer medication had been arrested. Police in New Delhi charged him and several others with selling adulterated drugs after allegedly finding they had filled vials labeled as Keytruda or other expensive oncology treatments with antifungal medicine, according to police records.

Piya never tested her mother’s medication, never suspected it could be fake. But the news planted a terrible fear in her mind: that she had possibly given her mother fake drugs.

“I just felt so numb,” Piya said.

Image: Dustin Franz / ICIJ

For people with certain cancers, Keytruda is a lifeline. It can extend some patients’ lives by years or even cure them entirely.

Produced by the pharmaceutical giant Merck & Co., the blockbuster drug is used to treat more than a dozen types of cancer, including types of lung and breast cancers. But the cost can be ruinous.

A 200 milligram dose of Keytruda ranges from $1,700 in Indonesia to $12,000 in the U.S., according to an ICIJ analysis of recent list prices. Typically administered via intravenous infusion every three weeks, treatment can last up to two years — amounting to a staggering $416,000 in the U.S. before discounts.

In 2025, Keytruda accounted for nearly half of Merck’s $65 billion revenue, making it the company’s biggest moneymaker. And Merck has worked tirelessly to keep it that way.

The Cancer Calculus, a new global investigation by ICIJ and 47 media partners, found that Merck has exploited the global patent system to ward off competitors. It has also promoted a higher dosage of Keytruda than is often necessary, driving up costs for patients and hospitals, in its aggressive campaign to boost revenue.

The resulting high prices have contributed to vast disparities in access depending on where patients live and how much they, their governments or their health insurers are willing or able to pay. This dynamic has created a dangerous opening: new opportunities for counterfeiters to cash in on demand for costly oncology medicines as cancer rates soar worldwide.

The cancer drug Keytruda accounted for nearly half of Merck & Co.’s $65 billion revenue in 2025. Image: Kena Betancur/Getty Images

ICIJ and its partners filed dozens of public records requests, interviewed investigators and experts, approached illegal sellers, and found that not only patients — but hospitals — have become unwitting customers of counterfeiters.

One patient in Mexico told broadcaster Univision that he was administered fake Keytruda in a public hospital. His account was among several alarming incidents that ICIJ identified in the country, where at least one person died after being “infused” with counterfeit Keytruda, according to Merck.

Anthony Zook, Merck’s associate vice president for global security, told ICIJ in an email that “criminal groups are now more commonly targeting life-saving medicines.”

“This shift is financially driven,” he said. Even so, in a statement to ICIJ, Merck defended its pricing.

“We have a long history of responsibly pricing our medicines to reflect their value to patients, payers and society,” said Johanna Herrmann, senior vice president and chief communications officer at Merck.

The World Health Organization (WHO) predicts that by 2050, cancer rates will surge to over 35 million cases, a 77% increase from 2022, disproportionately affecting patients in lower-income countries. These are the same people who already have the least access to basic health care, let alone expensive oncology treatments like Keytruda.

For counterfeiters, it’s all upside. “It probably cost them 10 bucks to make it when they’re selling it for $1,500, $2,000, $4,000,” said Kris Buckner, the founder of Investigative Consultants, a California-based private investigations firm that tracks down counterfeit products, including pharmaceuticals. Plus, if a cancer patient dies, it’s unlikely anyone will ever know whether they died from cancer or from taking a fake drug. “It’s the perfect crime.”

As long as Keytruda is priced like a luxury good, it will inevitably spawn cheap imitations and drive counterfeiters to exploit vulnerable people.

https://www.icij.org/investigations/cancer-calculus/merck-keytruda-cancer-drug-price/

OVERVIEW How Merck turned its wonder drug into a blockbuster — and priced out cancer patients worldwide Apr 13, 2026

https://www.icij.org/investigations/cancer-calculus/cancer-patients-legal-battle-keytruda-lifesaving-drug/

INSURERS ‘They deny the medication that is keeping you alive’: Patients wage grueling legal battles for lifesaving cancer drug Apr 13, 2026

https://www.icij.org/investigations/cancer-calculus/keytruda-evergreening-patents-merck/

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Image: Dustin Franz / ICIJ

In 2016, Mahendra Piya was diagnosed with esophageal cancer, and his health deteriorated rapidly. About a year into his illness, Bhinnata Piya’s sister called to tell her she needed to come home. Soon after Piya and her husband arrived in Nepal, they awoke in the middle of the night to find her father losing consciousness. They raced toward the hospital with Piya cradling her father in the back of the car, but he died in her arms before they arrived.

“For a year it was just like a repeat of that scene over and over again in my head,” Piya said.

Gurung mourned the death of her husband, but her life slowly began to open up in new directions. In her 60s, she decided to pursue a postgraduate degree in counseling psychology.

Around that time, Gurung, who had always been health-conscious, became fearful that she too would get esophageal cancer. Piya thought her mother was being paranoid, but one day “she just called me, maybe after three years, and was like, ‘I’m at the hospital and I have what your dad [had]. And they’re saying I’m going to die basically because of the cancer,’ ” Piya recalled. Gurung had already started chemotherapy. “It felt unreal.”

Piya’s favorite photo of her mom shows Gurung preparing to submit her thesis for her postgraduate degree. Image: Dustin Franz / ICIJ

Piya helped transfer her mother from the hospital where her father had been treated to a state-of-the-art facility about 10 miles south of Kathmandu, the nation’s capital. At first, she was impressed by Gurung’s new oncologist, Pankaj Barman, who seemed professional and respectful and actually listened — something her father’s doctors failed to do, Piya said. Barman put Gurung on a treatment plan that included chemotherapy and radiation, and after six months she went into remission.

To confirm Gurung’s clean bill of health, Barman recommended that she get a specialized scan at a hospital in southwest New Delhi. A man named Neeraj Chauhan, a longtime administrator across several hospitals’ oncology departments in India, would coordinate the visit, Barman told the family. Piya accompanied her mom to India, where Chauhan assisted them, and sure enough, the scan confirmed Gurung was in remission. But before they returned to Nepal, Piya said, Chauhan and Barman asked them for a favor: Could they carry some medications for other patients across the border?

Piya was suspicious. Her mom was adamant, though, that they follow her doctor’s request, worried that a refusal might affect how he treated her.

After they agreed to the plan, Chauhan delivered the medications to their hotel in a heavily taped Styrofoam box. Despite not knowing what the drugs were or who they were for, Gurung and Piya carried them back to Nepal. They were told there was no need to declare the package at the border. Even then, the arrangement wasn’t that unusual — India and Nepal share an open border, and it’s not illegal to take small quantities of medication across the border for personal use. When Piya and Gurung returned to Nepal, Barman told them via text to refrigerate the package and deliver it to the hospital the next day.

Barman continued to treat Gurung as before, prescribing nivolumab, an immunotherapy medication similar to Keytruda, to prevent the cancer from recurring. But after seven months the cancer returned. Piya said hearing this news was almost worse than learning Gurung’s initial diagnosis, that the remission had felt “too good to be true,” especially after her father’s death. Gurung began chemotherapy again, and then she and Piya returned to India for a second opinion.

Once more, Chauhan and Barman asked them to bring back medication for another patient. This time, Finke, Piya’s husband, sent Barman a stern message expressing his “significant concern” about the request. “To me that was a huge red flag,” said Finke, whose job as an internal medicine doctor at Case Western Reserve University in Ohio made him acutely aware of the power imbalance between doctors and patients in Nepal. “It’s a sense of coercion.”

Chauhan said he would find someone else to do the job or do it himself.

A few months later, Barman prescribed Keytruda, telling the family they had a choice: They could buy each 200 mg dose for 368,000 Nepali rupees, the equivalent of roughly $2,700 at the time, though he didn’t specify from where. Or they could buy it from Chauhan, who “might arrange for a discounted price,” according to WhatsApp messages Piya shared with ICIJ. At first Piya did her own research and found a similar medication that a Nepalese company could import from Bangladesh. She attempted to buy the drugs from that company several times but “customs would keep rejecting it and returning it” without explanation, she said. So instead they turned to Chauhan.

Other patients transported the Keytruda from India to Nepal, Piya said, just as she and her mother had done. The doses arrived sporadically, depending on when people were traveling to and from India. On one occasion, Gurung’s family picked up Keytruda from the Kathmandu airport after Chauhan sent it with a Nepal Airlines passenger. “We have no idea who this person was,” Piya told ICIJ. “When we met him at the airport, he said he was very worried when they asked him to carry [the medications], but as soon as he heard it could help a cancer patient, he was willing to do it.”

The family ultimately paid Chauhan more than $7,800 for what they were told was Keytruda, Piya said. Another doctor, who collected the payment on behalf of Chauhan, directed them to pay in cash.

“They were very shady about the whole thing,” Piya said, adding that the same doctor asked her to pay him in private, out of sight of anyone else. Chauhan’s lawyer, Ankit Verma, told ICIJ that Chauhan denied that such payments occurred.

Gurung received infusions for two months, but the cancer progressed until she could no longer eat or talk. “She went to sleep, and she was in that state for six or seven days,” Piya said, recalling the last week of her mother’s life. “One of the things I read was they breathe a certain way right before they die. And I saw that breath come, and I went and brought my sister from the other room and said, ‘It’s time.’ So we just stayed around her and just held her hand. And then she passed away.”

The family had Gurung cremated that same night, later spreading some of her ashes in the Bagmati River, a sacred waterway.

Image: Dustin Franz / ICIJ

Piya moved back to the U.S. and started working again. But her grief was reignited in 2024 when she learned that Chauhan and nearly a dozen others were arrested as part of an alleged cancer drug racket.

New Delhi police said they found 519 empty vials used for cancer drug injections and more than $120,000 in various currencies in Chauhan’s apartment. He later admitted to selling counterfeit drugs, police records show. Chauhan told police he had worked as a manager in the oncology departments of major hospitals in Delhi between 2006 and 2022, according to the records. In 2022, he said, he met the alleged ringleader of the operation, Viphil Jain. Chauhan said he was inspired by Jain, who had described refilling empty vials used in cancer treatments with anti-fungal medicine, which he sold “at half the market price.”

Chauhan and the other defendants are still awaiting trial. Chauhan’s lawyer told ICIJ that the allegations against his client are unfounded and that the police pressured him to make a false confession. He also said that the police fabricated the claims about seizing empty vials and cash from Chauhan’s apartment.

“He didn’t do anything wrong,” Verma said, adding that Chauhan “supplied” authentic medications to Jain, who then altered them without his knowledge. Chauhan also denied asking Gurung’s family to transport medication from India to Nepal, according to Verma.

Barman, the doctor who treated Gurung, told ICIJ in a WhatsApp message that he had “never heard or seen about spurious Keytruda being used anywhere.” He also said that because many drugs were not available in Nepal during the coronavirus pandemic, patients may have carried “medicine for one another during that tough period.” Authorities have not accused Barman of wrongdoing.

During Gurung’s treatment, Keytruda was not — and still isn’t — approved for sale in Nepal. Barman denied medical negligence and said that he “used to send patients to [Chauhan] on their request if something is not available in Nepal.”

“All this,” he said, “was done in good faith and intention to treat.”

A global problem

More than a year after Piya learned about the fake Keytruda from a newspaper article, a newscast in Mexico’s Yucatán Peninsula confirmed Francisco Chávez’s suspicions that his cancer treatment was tainted.

Chávez, an entertainment producer in his 50s, managed tours for musicians — including Ricky Martin and J Balvin — in the town of Mérida. But in late 2022, he lost 123 pounds and his skin began to look gray, he told ICIJ’s partner Univision. He was diagnosed with a cancerous kidney tumor, which was surgically removed, but the cancer had already spread to his lungs. His doctors at the Elvia Carrillo Puerto public hospital prescribed Keytruda, and on his fourth dose he experienced painful side effects: tremors, paralysis and what he described as an out-of-control spike in blood sugar. Chávez took photos of every box of Keytruda he was given.

Within days of his treatment, he filed complaints with three authorities, including the government agency that runs the hospital where he was treated. He demanded to know what was in the vials he was treated with, as well as to see the invoices related to the hospital’s Keytruda purchase. He also asked the hospital to disclose how many patients were affected, but received no response.

Francisco Chávez, 56, says he was administered falsified Keytruda at a public hospital in Mérida, Mexico. Image: Gerardo Reyes / Univision

Chávez then sent Merck the photos he had taken, along with copies of his complaints. Staff at MSD, as Merck is known outside the U.S. and Canada, traveled to the hospital to collect the suspect material — three product samples with two different batch numbers — and sent them to Merck’s Forensic Services Lab in West Point, Pa., the company told ICIJ. The samples were collected as part of an investigation of the hospital, not in response to Chávez’s photos, Merck said.

Following its analysis, MSD told Chávez in a letter that “certain irregularities were identified that do not correspond to the characteristics of the products manufactured or distributed by our Company.” The letter, signed by the associate director of product integrity for Latin America, said MSD had shared its findings with Mexico’s health regulator, known as Cofepris, and the Attorney General’s Office.

In September 2024, Cofepris issued a warning about counterfeit cancer drugs, including the batch of Keytruda Chávez had reported. It remains unclear how the medication ended up in the hospital.

As Chávez’s treatment continued, he kept recording batch numbers — which turned out to be wise. “I was calmly watching television at home when a nationwide health alert was issued on the news channel, warning about the drug pembrolizumab, known as Keytruda,” he told Univision. He was in disbelief.

The newscast highlighted several fake batch numbers. He went to his phone and checked the photos he had taken. “It turns out that when I see that batch number on television, it’s the one I got,” he said. Chávez realized he had unknowingly been treated with falsified Keytruda a second time but experienced no adverse effects, he said.

Chávez, now 56, said his cancer is “controlled” but his life changed forever after the first unknown substance coursed through his veins. He now suffers from chronic back pain and sudden, inexplicable episodes of paralysis, preventing him from working and undermining his financial security.

“I can no longer move as I used to,” he told Univision. “Before, I would go up and down the stage to put things in place or set up, carry things. All that is over for me now.”

Some of the photos Chávez took of Keytruda packaging. Image: Francisco Chávez

Chávez said he has been gathering information from people who work at the hospital where he was treated as he prepares to file a civil lawsuit. He now believes other patients received suspect medication that, in some cases, caused adverse reactions. When journalists from Univision visited the hospital and asked to speak to the director, staff closed the doors to block access.

While he plans to seek financial compensation, Chávez said he also wants transparency from the hospital and to force the government to investigate. Although he has the lawsuit drafted and ready to file, he said he can’t afford a lawyer to pursue his case. When asked about the high prices of Keytruda set by Merck, Chávez said, “Seeing how you’re wearing your family down financially and physically, that you’re no longer the same person in your daily life and above all, you’re spending a terrible amount of money, and on top of that, [Merck is] profiting off you, it hurts, it hurts a lot.”

In Mexico, counterfeit pharmaceuticals are pervasive because of underfunded public health systems, medication shortages and rampant organized crime. Last year, the U.S. government added Mexico to its priority watchlist of eight countries that have failed to crack down on those “stealing intellectual property.”

Chávez’s case is one of four identified by ICIJ and its media partners in which fake Keytruda was supplied to hospitals in Mexico. At least three of those occurred in state-run institutions. Zook, Merck’s associate vice president for global security, said that MSD has filed 20 criminal complaints related to counterfeit Keytruda with the Mexican Attorney General’s Office.

In December 2021, staff at the Naval Medical Center in Mexico City identified a suspicious-looking vial of Keytruda in a delivery from Top Pharma SA de CV, a company with a yearslong track record of supplying medications to public hospitals and pharmacies. The hospital reported the batch numbers to Cofepris, which sent the vials to MSD and inspected Top Pharma’s headquarters, according to an internal report obtained by ICIJ. Once MSD confirmed the contents were not its patented formula, the regulator issued the country’s first alert on falsified Keytruda in early 2022. Mexico has since issued five more alerts about Keytruda, most recently in March.

In a separate report about the inspection, the regulator said it could not confirm whether Top Pharma had bought the medication from Merck. Instead, the company’s documentation showed it had bought Keytruda from a man who was subsequently added to a public list of substandard distributors as a warning to buyers in the pharmaceutical industry.

ICIJ and its media partners made multiple attempts to contact Top Pharma, which is based in Mexico City. When phone calls, emails and WhatsApp messages went unanswered, a reporter visited the address listed on the company’s website and found only a small pharmacy without Top Pharma signage. A man inside the storefront, who said he was in charge and worked for Top Pharma, refused to answer questions.

The Top Pharma headquarters in Mexico City’s Arboledas del Sur neighborhood. Image: Isabella Cota / ICIJ

A different address, nearly two miles away, is listed as the company’s headquarters in the regulator’s inspection report. The windowless building is about a block from a shopping center in a residential neighborhood. It has no sign or logo, is surrounded by a high fence topped with barbed wire, and is monitored by surveillance cameras.

After the Naval Medical Center incident, Top Pharma was fined more than 240,000 pesos (about $12,800). Yet it has continued to win Mexican government contracts. Public records show Top Pharma has been awarded 91 contracts worth some 42.8 million pesos (about $2.2 million) between 2021 and 2025. In response to questions sent by ICIJ, the navy’s public affairs office said that Top Pharma paid the fine and is legally allowed to keep competing for contracts.

Fighting the fakes

Counterfeit drugs are bad business for pharmaceutical companies. These cheaper alternatives infringe on trademarks, siphon off business, create reputational damage and erode patient trust, all of which can affect a company’s bottom line. To reduce these risks, pharmaceutical companies work with internal and external investigators to hunt them down.

Kris Buckner, the California-based private investigator, has spent 30 years probing everything from knockoff handbags to fake airbag covers. Pharmaceuticals, he said, are the most “egregious” type of product to fake. His company, Investigative Consultants, has worked with Merck on several cases, including a high-profile 2025 investigation that resulted in two Indian brothers being sentenced to prison over a scheme to sell heartburn medication falsely labeled as Keytruda in the United States, according to the U.S. Department of Justice.

Buckner said that he couldn’t comment on the specifics of the investigation but that his company seeks to give law enforcement a “head start.”

Andres Díaz runs a private investigations firm, based in Washington, D.C. — AIT Enforcement — that has helped Merck track down counterfeiters in Latin America. Law enforcement consulted Díaz as part of a 2024 operation in Guadalajara that led to the arrest of “El Tacho,” a man accused of selling counterfeit Keytruda and other drugs. During the raid on El Tacho’s property, Mexico’s navy found 12,500 doses of counterfeit medications, including Keytruda, according to reporting by ICIJ partner El Sol de México. Officials estimated the drugs had a market value of more than 110 million pesos ($5.7 million). The investigation is ongoing, the navy’s public affairs office told ICIJ.

Members of Mexico’s navy during a 2021 narcotics operation in Mexico City. Image: Pedro Pardo / AFP via Getty Images

In addition to working with investigators, Merck operates four forensic laboratories to test suspicious products, according to Zook. There, the products are photographed, and their packaging and chemical profiles are compared to authentic Keytruda. Merck’s forensic labs tested more than 800 product samples in 2024, according to the company’s website. That included nine Keytruda samples from the New Delhi operation allegedly involving Chauhan. Eight did not contain the drug’s active ingredient, pembrolizumab, according to Merck’s analysis.

When falsified Keytruda is identified, “Merck works closely with the relevant law enforcement agencies and health authorities worldwide, sharing intelligence, forensic evidence and operational support to enable them to conduct criminal and administrative enforcement actions that will protect public health,” Zook said. “Where applicable, Merck will also pursue civil legal action against those involved in the manufacturing and distribution of falsified medicines.”

Merck also actively monitors suspicious online listings on social media sites and e-commerce platforms like Amazon, eBay, Mercado Libre and IndiaMART. The company reported that it helped remove around 30,000 listings in 2024.

Stamping out dangerous imitations has become increasingly challenging, however, not just for pharmaceutical companies, but also for law enforcement. Today’s criminal networks use encrypted messaging apps to reach customers, hide their identities and wealth through complex financial networks, and abuse the international mail system to misdeclare shipments, a spokesperson for the U.S. Food and Drug Administration said in a statement.

Saifuddin Ahmed, principal investigator for BESAFE, a Johns Hopkins University initiative targeting the spread of dubious medicines, said that publicly funding the research and development of drugs like Keytruda could bring down prices. “If the drug is developed by the public-funded projects, that drug possibly will be distributed at a mass transport, cheaper rate,” he said.

For now, inaccessibility continues to plague health care systems worldwide, leaving many patients to fend for themselves. “Patients need access to affordable, therapeutic drugs that are authentic, that are going to save their lives,” Buckner said. “That’s the bottom line.”

‘The worst thing’

To remember her mother each year, Bhinnata Piya donates to a food-related charity. But that tradition is far from bringing her closure.

“How do you even process something like this?” she said of possibly giving her mother fake drugs. “I think once maybe we know that this won’t happen to others and they’re held accountable, maybe I can close that process mentally and move on.”

Bhinnata Piya is taking legal action over her mother’s treatment. Image: Dustin Franz / ICIJ

In an effort to do that, she filed a medical negligence lawsuit in Nepal against Barman, Chauhan, the doctor who accepted her Keytruda payments and the hospital her mother was treated in. Because Chauhan is not a Nepalese citizen, the case is moving slowly.

Francisco Chávez, too, continues to feel haunted by his experience as he works to get his case off the ground.

“I think profiting from people’s health,” Chávez said, “is the worst thing that can happen in the world.”

Contributors: Angie Sandoval and Gerardo Reyes (Univision), Violeta Santiago (Quinto Elemento Lab), Aldo Canedo (El Sol de México), Carlos Carabaña (El País), Denise Ajiri, Kathleen Cahill, Jelena Cosic and Karrie Kehoe (ICIJ)