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

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

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

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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

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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

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

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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/

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

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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)

On the wall behind the table hang photos of seven deceased relatives. Four died of cancer.

“The one at the top is my grandma, my mother’s mom; she died of stomach cancer,” Chuc recently told a reporter from the International Consortium of Investigative Journalists. She pointed at the frames as she spoke. “My mom’s cousin also died of uterine [cancer]. And this is my mom’s sister; she died of colon cancer. She was only 23.”

The photo in the center of the gallery is the most recent addition: Chuc’s mother, Francisca Violeta Sam Colop, who died in July 2025 after a long journey with skin cancer. In the photo, Sam Colop, an Indigenous Maya K’iche’ educator from the Guatemalan highlands, is smiling widely, sitting with crossed arms, wearing a traditional handwoven blouse, or huipil, with blue, green and purple embroidery.

“There is always the fear that [cancer] might strike me, strike one of us next,” Chuc said. “There is so much you can’t control.”

Image: Laura Garcia / Plaza Pública

One night in 2012, Chuc said, Sam Colop noticed a stubborn dark spot on her right foot. She shrugged it off, telling her daughter it was a mole. But a dermatologist diagnosed her with melanoma. For the next nine years, Sam Colop was in and out of hospitals, undergoing surgeries and enduring round after round of chemotherapy. Still, the tumors kept spreading.

In 2021, she visited one of the country’s top oncologists, who prescribed what he considered to be the most effective treatment: pembrolizumab, an intravenous immunotherapy drug known as Keytruda. After its approval by the U.S. Food and Drug Administration in 2014, Keytruda began selling in the United States, Europe and Japan but was less available in developing countries like Guatemala.

Sam Colop would need regular infusions, and each cost nearly $11,000. “The whole treatment costs millions of quetzals [hundreds of thousands of U.S. dollars]. It would be impossible to afford,” Sam Colop’s husband, Juan Chuc Xum, recalled one doctor saying.

Sam Colop had to fight to get the medication, eventually taking her country’s publicly run health insurance system to court. By then, she’d been living with cancer for over a decade.

“Could [Keytruda] have saved my mother’s life?” Chuc wonders. “I think it would have. I also believe it was too late when she got it.”

Juan Chuc Xum (center) with his daughters Marina Chuc Sam (left) and Violeta Chuc Sam (right). Image: Laura Garcia / Plaza Pública

Sam Colop’s case is similar to that of thousands of patients around the world — particularly those in developing countries — who have taken on draining bureaucratic battles with public and private insurers to access Keytruda, which can cost anywhere from about $29,000 in Indonesia to $130,000 in Colombia, to $208,000 in the United States for a year of treatment. In developing countries, the drug is rarely included on the national lists of essential medicines, which governments rely on to decide what public and private insurers must cover. As a consequence, insurers in some low- and middle-income countries largely avoid covering the drug unless a court or regulator forces them to. Some cancer patients have died while waiting for health systems to comply with court decisions. Others have paid thousands of dollars out of pocket before their insurers complied with courts’ or regulators’ orders.

In South Africa, one of the only countries in sub-Saharan Africa where Keytruda is readily available, a small-business owner who has lung cancer can’t get her private insurer to fully comply with a landmark ruling by the national regulator to cover Keytruda. In Guatemala and elsewhere in Latin America, patients like Sam Colop have taken to courts to force their insurers or public health systems to provide the drug. Patients in wealthier countries struggle for access, too: In the United States, a CEO of a medical consulting firm went without treatment for many weeks while fighting a denial of coverage of the drug.

Many high-cost drugs trigger court battles. But Keytruda — which has made around $163 billion in revenue for Merck & Co. since its launch more than a decade ago — is one of the starkest symbols of a dysfunctional global system that disproportionately hurts poorer countries with limited health care budgets and little negotiating power with Big Pharma.

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

These findings are part of the Cancer Calculus, an investigation by ICIJ and 47 media partners that examines the reasons for Keytruda’s exorbitant prices — and exposes the global consequences.

Speaking in part to those consequences, Merck told ICIJ: “We operate in compliance with the applicable laws, and regulations, and do not support, promote, or engage in any activities intended to encourage legal claims. While legal claims are a lawful administrative pathway for some patients to access medicines, we believe they are not a sustainable approach, since it may be an inefficient use of government budgets, and do not consistently enable timely, predictable, and broad patient access.”

The company said that the development of Keytruda “is now one of the largest and costliest pharmaceutical

[research and development]

Merck also said: “We have a long history of responsibly pricing our medicines to reflect their value to patients, payers and society. To ensure our products reach as many patients as possible, we price them differentially across markets, and sometimes within markets, according to numerous factors. These factors include the value a therapy brings to patients and the healthcare system, countries’ pricing and reimbursement systems and the ability of governments to finance healthcare.”

But, as Daniel W.L. Wang, a law professor at the Fundação Getúlio Vargas in Sao Paulo whose research focuses on health-related litigation in Latin America, explained to ICIJ: “Many of these countries are middle- or low-middle-income countries, and they struggle to universalize even the most basic health services. So the claims for pembrolizumab put a lot of pressure on their health budget.”

“Even if we improve the funding for our health system, even if we improve our policies, this is still a cost challenge,” he added, “because the cost of the treatments grows at a pace that the health systems budgets cannot keep up.”

As a result, a sky-high price of a potentially lifesaving cancer drug puts it out of reach for many health systems, forcing patients who have the resources — and stamina — to fight for the right to treat their disease. When this happens, access to pricey drugs can become less about medical need and scientific evidence and more about whose lives are worth saving.

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-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

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

Researchers

“The courts in Central and South America treat the right to health as an absolute individual right,” Wang said. “So as long as you can show that you need the treatment, no matter the impact on the health system, no matter the impact on the other users of the health system, you have the right to receive it.”

Data analyzed by ICIJ shows that health and legal systems are increasingly intertwined in some Latin American countries, where Keytruda is often accessed through a court order. In Guatemala, from December 2022 to February 2026, the Constitutional Court — Guatemala’s highest court for constitutional matters — examined 96 amparo petitions for Keytruda coverage; all but one were granted.

In Brazil, federal and state courts have examined around 4,300 judicial requests for pembrolizumab since 2019; the majority ruled in favor of patients. In Mexico, ICIJ partner Quinto Elemento Lab found 55 amparos filed from October 2017 to February 2026. Thirty-six of those granted access to Keytruda, and eight were dismissed because the drug was provided to the patients before the courts had to decide. And in Chile, courts sided with patients in 10 of a dozen cases.

Nearly all of the amparo petitions in Guatemala were filed by IGSS beneficiaries. The IGSS has provided Keytruda to patients since at least 2018 — but generally after being forced by courts, public records show.

The Instituto Guatemalteco de Seguridad Social (the Social Security Institute), known locally as IGSS. Image: Wikimedia Commons

In a statement to ICIJ, IGSS said that high-cost medications “are administered under technical and medical protocols designed to balance timely access, available scientific evidence, and the sustainability of the system.”

“In this context, the IGSS has allocated significant resources to provide these types of treatments, amounting to approximately 1,703 million quetzals [more than $218 million] — a figure that reflects the growing demand and the progressive incorporation of specialized therapies,” the statement said. “The institution implements evaluation processes for the inclusion of new treatments, prioritizing patient safety, therapeutic efficacy, and the rational use of public resources.”

Sam Colop’s amparo petition argued that her IGSS-sanctioned treatments — chemo and targeted therapies — hadn’t stopped her disease’s progression. In May 2021, a court ruled in her favor, and she began receiving Keytruda. IGSS appealed the decision, arguing that it hadn’t denied Sam Colop comprehensive medical care and raising concerns about more than 30 possible side effects of Keytruda.

Chuc Sam in her mother’s office, where Sam Colop’s things are displayed: a Maya calendar, the flag of the national academy of Mayan languages, and her sun hats. Image: Laura Garcia / Plaza Pública

In court records reviewed by ICIJ, the public insurer said in its appeal that it had “no legal obligation” to buy specific commercial brands. According to IGSS’ arguments, the judges were overreaching by making decisions that should be left to “medical professionals within the scientific sphere of medicine.”

The case reached the Constitutional Court, which sided with Sam Colop in September 2021, four months after the original court decision in her favor. The ruling ordered IGSS to continue to provide the medication as prescribed and ensure there is no shortage of the drug.

For two years, Sam Colop received Keytruda when it was available. Medical supply shortages are common in Guatemala and other Central American countries due to underfunding of health systems and a high reliance on imported medication. Chuc recalled several times when Sam Colop traveled to the capital to receive her infusions, only to find out there was no medication. During these shortages, she’d go back to chemotherapy or miss treatment altogether.

Chuc Xum playing with his granddaughter on the rooftop. Image: Laura Garcia / Plaza Pública

The IGSS said in its statement that it “operates under principles of equity, legality, and transparency, utilizing internal procedures that allow for the review of clinical cases and the processing of requests in accordance with medical and administrative criteria.” Regarding judicial rulings, IGSS said, “in cases where a final judicial ruling mandates the provision of a specific medication or treatment, the institution is required to comply faithfully and strictly with said mandate.”

A childhood photo of Sam Colop with her parents and siblings in the 1960s. Image: Laura Garcia / Plaza Pública

By 2024, Sam Colop was in a wheelchair. The cancerous tumor on her right foot had become a deep, open sore, and her cartilage was nearly exposed. That April, though, she received good news and texted her family’s WhatsApp group: “the medication is back! I’m going back to my immunotherapy.” But by then, the off-and-on schedule had seemingly taken its toll; after two infusions with a different immunotherapy combination, her health began to rapidly decline.

In anticipation of her death, Sam Colop reminded her daughters to follow her detailed instructions for a burial according to Mayan faith: They were to dress her in the green huipil she wore to celebrate her 60th birthday and include incense, her comb, and her mirror in her coffin. On a warm afternoon last July, Sam Colop’s daughters and the oldest of her seven grandchildren were sitting around her bed when she died. “She opened her eyes widely,” Chuc said, “as if she wanted to look at us one last time.”

‘A choice between survival and solvency’

Thousands of miles across the Atlantic Ocean, in the port city of Durban, South Africa, Adri Jeffers, a 57-year-old owner of a small clothing label and mother of three, is embroiled in her own battle over Keytruda. Jeffers — stylish and businesslike with jet-black hair and thick-framed spectacles that accentuate her angular features — has top-tier private health coverage. Her fight led to a draining legal process, too, this time before a regulatory body for health insurance.

Like Sam Colop, cancer runs in Jeffers’ family. Her mother lived with breast cancer for many years before she died, and her father died of lung cancer. Still, when Jeffers was first diagnosed with Stage 3 breast cancer in 2005, at age 36, it came as a “massive shock,” she told ICIJ at her two-story Victorian home.

The diagnosis, she said, was “a life-altering moment — not something you consider in your 30s whatsoever.” She tried to stay positive around her then-9-year-old twins and 3-year-old son, but the strain was constant: “They’d look at you very bravely, but then you would walk past their room later and hear them crying. … Internally you’re basically crumbling, but you [act tough] so as not to upset the kids and your husband.”

Adri Jeffers, 57, runs a small clothing label and has three children. Image: Micah Reddy / ICIJ

After chemotherapy, remission, then a resurgence in 2007, Jeffers kept the cancer in check with vigilant monitoring and carefully managed treatment. But in 2015, she was overtaken by a strange fatigue and weakness. One night at a restaurant, she turned to her husband and said, “I think it’s back.” She was right. Scans showed that the disease was spreading again.

She started what she calls a standard treatment plan, involving rounds of chemotherapy. At times the treatment felt worse than the disease. “She would deflate like a balloon in front of your eyes” and be bedridden for days, said her husband, Wayne. Jeffers tried to schedule her chemo sessions on Fridays so she could recover over the weekend.

Over time, her oncologist tailored her treatment, and for the next several years, Jeffers would “knock back the cancer a little bit, rest a little bit, and repeat,” she said.

But in 2023, a scan picked up a nodule in her right lung. She soon had a new diagnosis: primary lung cancer. It was spreading aggressively, and the usual therapies were no longer working.

The news took a heavy toll on her children, by then 26 and 21. Her youngest son “was unable to cope with the diagnosis,” she said, and left an internship in Cape Town early to be with his mother.

Jeffers’ oncologist suggested she was a strong candidate for Keytruda. Jeffers was aware of the drug; she’d seen the news of former U.S. president Jimmy Carter’s remarkable response to it.

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.

In May 2023, Jeffers’ oncologist wrote to her medical aid scheme, Medshield, requesting coverage for a combination of chemotherapy and Keytruda. In South Africa, those able to afford private health care — a minority of the population — are typically covered through what are called medical aid schemes. These are regulated, not-for-profit medical funds, often administered by for-profit companies, that pay out claims from a pooled system of member contributions.

After Medshield declined her request, stating that Keytruda was not covered by her insurance plan, Jeffers — now familiar with the bureaucracy of insurance and with the help of her oncologist — appealed twice. Rejected, she lodged a special request for ex gratia coverage, meaning she appealed to Medshield to provide coverage out of a sense of moral obligation or goodwill. Before the year was out, Medshield had declined that request, too. Keytruda was not on South Africa’s essential medicines list, Medshield argued, and had not met the eligibility requirements for coverage of Jeffers’ cancer. Medshield also asserted that the mutations of Jeffers’ cancer made Keytruda clinically unsuitable — a claim that her oncologist strongly contested in a letter to the medical scheme.

Jeffers spent over four hours a week sending emails and following up with unresponsive Medshield staff, she told ICIJ. “The order of business [for insurers] is not to honor claims unless you [the patient] object, especially with oncology,” she said. “So once I figured that out, I understood you have to object and question.”

Jeffers in her home office, where she spent hours advocating for her insurer to cover the cost of Keytruda. Image: Micah Reddy / ICIJ

Her meticulous organization skills, honed by years of running her business, came in handy. Over the years, she has kept every record of her medical history: invoices, emails, letters, medical test results. Each item is archived, ready to be quickly summoned in her next dispute. “Not everyone has the tenacity and the circumstances to be able to do this,” she said.

As Jeffers’ fight dragged on, her health deteriorated. She’d been in the hospital five times in 2023.

She found a lawyer online who specialized in medical aid claims. On his advice, in the summer of 2024, Jeffers turned to South Africa’s statutory regulatory body for private health insurance plans, the Council for Medical Schemes. “I’d done what I needed to do: [had surgery to remove] the tumor, went onto chemo, and it failed,” she told ICIJ. “So I should be entitled to use immunotherapy.”

Keytruda is not on South Africa’s list of essential medicines largely because of its prohibitive cost, so it is not available in overstretched public health facilities that serve the majority of the population. (The price tag is nearly $5,000 for a typical 200 mg dose in a country where the median household annual income is only about $5,200.)

My struggle became not only against cancer, but against the very system meant to safeguard me.

— Adri Jeffers, small business owner and mother of three

Andy Gray, a senior lecturer in pharmacology at the University of KwaZulu-Natal in Durban, who is involved in medicines selection and regulation, said that “the essential medicines list is based on some sort of estimate of affordability as well as public health priorities.” Although this includes cancer drugs, these are “predominantly older, off-patent items where there’s either been a decision by the company to market a clone to the state at a different price or [it’s possible to] take advantage of new generic entrants. But in general, the number of monoclonal antibodies [like Keytruda] is severely limited, and that’s based mainly on their cost.”

South African courts have established the precedent of “progressive realisation” of the right to health, meaning that the government is obligated to take steps to improve access to health care and ensure the realization of the right, but within reason — resource constraints must be taken into account. While patients increasingly sue the state for access to medicines in some other developing countries, like Guatemala, the courts in South Africa rarely grant orders on constitutional grounds to provide high-cost treatments. There is little hope of uninsured cancer patients gaining access to Keytruda unless they can enroll in a clinical trial.

For the more than 9 million South Africans with private health coverage, disputes with insurers typically end up before the Council for Medical Schemes, a statutory body that regulates private health insurance schemes. The CMS’ rulings are binding and can only be overturned by a court. (When disputes between patients and insurers do go to court, they normally focus on contractual obligations and the law governing medical insurance, not the constitutional right to universal health care.)

Jeffers couldn’t afford to wait while her complaint ground through the official channels. She and her family decided to raise their own funds for Keytruda. The family could have set up an online fundraiser, but “I didn’t feel comfortable with it,” Jeffers said.

They had already successfully applied to a cancer support fund called the Access to Innovative Care Foundation, or AICF. The foundation helps patients in South Africa fund gaps in their coverage — when there are hefty co-pays for expensive cancer therapies, for example. But the AICF is supported by various Big Pharma companies — including Roche and Novartis — ostensibly to mitigate high prices, so it is “in some ways controversial,” said Paul Ruff, a medical oncologist and professor at the University of the Witwatersrand in Johannesburg. In South Africa, a statutory “single exit price” ensures that manufacturers and importers sell a product at a standard price to all private sector buyers and are prohibited from offering rebates, discounts and other such incentives. Ruff sees the AICF as a way around this regulation, effectively making drugs more affordable to some without having to lower prices.

Jeffers with her husband, Wayne. Image: Micah Reddy / ICIJ

The AICF declined to say which Big Pharma companies fund it but told ICIJ in a statement that it “assists in ensuring access to healthcare, where such access is hampered by reimbursement and financial challenges,” and that it “operates at an arms’ length basis from donors, guided by a Board comprising seasoned independent directors in the NGO sector, and renowned healthcare professionals, including oncologists.”

Merck told ICIJ in a written statement that it is “dedicated to making our medicines available to patients who may benefit from them as soon as possible — which is why Merck … provides many support programs and services to help ensure that people prescribed KEYTRUDA have access to our medicine.” Merck in South Africa, where the company is known as MSD, did not respond to questions about whether it funds the AICF.

In Jeffers’ case, the AICF agreed to cover half the cost of Keytruda, leaving her family to pay hundreds of thousands of rands out of pocket (about $85,000 currently) — and at a time when their income was drying up, as their business was still recovering from the shock of the COVID-19 pandemic and government restrictions. They were looking at having to spend roughly $2,450 at today’s price every six weeks for an infusion of Keytruda. They downsized their factory and sold off “scooters, sewing machines, fabrics, machines, computers, racking and shelving,” Jeffers’ husband told ICIJ.

Jeffers’ cancer battle took an emotional and financial toll on her family. Image: Micah Reddy / ICIJ

Jeffers and her family scraped together the money by early 2024. Within months of starting Keytruda, Jeffers noticed dramatic improvements. The side effects were tolerable; she was regaining her strength. Her scans showed that her tumor was shrinking. “For the first time I thought I might actually survive this,” Jeffers said.

Still, the financial strain was crippling. Each month, Jeffers said, was “a choice between survival and solvency.” They anticipated 35 infusions of Keytruda prescribed by the oncologist — with half the cost covered by the AICF — and hoped for a favorable CMS ruling. After depleting their savings, Wayne Jeffers told ICIJ, “the plan was then to use her retirement annuity.”

In July 2024, Adri Jeffers finally received good news: The CMS ruled in her favor, laying out a detailed clinical assessment showing “well demonstrated” improvements in survival rates for people with her type of cancer and ordering Medshield to fund Jeffers’ Keytruda in full. The CMS went even further, stating that the ruling also applied to “all other members who are in a similar position.”

Jeffers was “blown away” by what she saw as “a groundbreaking proclamation” that was a victory for herself and other cancer patients. But after the ruling, Jeffers said, Medshield stalled, failing to meet its payment obligations despite her constant emails reminding them. “The stress in between [treatment and approvals] is enormous,” she told ICIJ, “because you know your clock is ticking, you know what the studies say, and you know you’ve got to keep up the treatment.”

A month after the CMS ruling, on Aug. 21, Jeffers received an email from a staff member at Medshield. She soon realized that, while it was about her, it was not intended for her. The staff member, she figured, must have accidentally copied her on internal correspondence. The communication, with Medshield discussing its decision to deny coverage due to Keytruda’s “exceptionally high cost and limited overall survival benefit,” was startling to read. “They were discussing how they weren’t sure about my survival — that they couldn’t guarantee survival because I had been on so many treatments,” Jeffers said.

Her husband said he was shocked “to see the value of her life being worked out on a page.”

Jeffers immediately sent the correspondence to her lawyer, deciding not to disclose to Medshield what she had seen for fear of some sort of legal consequence. In September, Medshield wrote to Jeffers to say that they would only reimburse her for what she had paid; they would not fund any further treatment. “But I had a ruling” from the CMS, she said. “For us it was trauma and disbelief.”

After Jeffers’ lawyer contacted Medshield, it agreed to continue funding Keytruda. But every victory felt temporary. In July last year, Medshield notified her that it would only cover further Keytruda treatments until November 2025 — at which point Jeffers would have had 16 sessions — far fewer than her full complement of 35. Jeffers said that the medical aid scheme backed down again, this time because she publicly criticized Medshield on social media.

Every day she braces for another hurdle. “My struggle became not only against cancer,” Jeffers told ICIJ, “but against the very system meant to safeguard me.”

Jeffers in the garden of her home in Durban, South Africa. Image: Micah Reddy / ICIJ

In response to written questions from ICIJ, Medshield said: “Following careful consideration, including the evidence presented at the CMS hearing indicating, in contrast to available clinical studies, that the treatment has shown positive results, Medshield elected not to pursue an appeal and proceeded with compliance.”

Medshield said that it “acknowledges that intermittent delays occurred in the member receiving treatment due to previous technical errors in the claiming process, but this did not constitute a decline for the requested treatment or a withdrawal of the approved treatment regime.”

Medshield also highlighted the cost burden of expensive cancer therapies and the risk this poses to the sustainability of medical aid schemes that “are governed by legislation requiring them to accept all applicants regardless of prior health history and operate as not-for-profit entities that cannot access external capital.”

The rising costs of treatment and “open-ended funding” for that treatment, Medshield said, would have to be passed on to members. “Claims paid each year must be covered in full by premiums collected meaning there is no buffer against catastrophic oncology expenditure beyond premium increases.”

After her first four treatments with Keytruda, she was in complete metabolic remission, the technical way to say there is no active cancer. “I remember sitting at the doctor’s office, looking at the clean scans [and thinking], I wish I had gone on [Keytruda] sooner,” she said.

Then one afternoon in July 2024, as she was sitting in the infusion chair, ready for her next dose, a staff member walked in and told her her insurance had denied further coverage. Ferguson knew that if she went ahead either she or the cancer center would be stuck with the $12,000 Keytruda bill, on top of other costs. “I was already poked, but I elected to stop and reschedule,” she said.

The insurance denial was the beginning of a bureaucratic process that set her treatment back eight weeks while Ferguson, her husband and her medical team exhausted nearly every option to fight the denial.

In the United States, it’s nearly impossible to know how many of the more than 220 million people with private health insurance are denied coverage for specific treatments. But an analysis of 2023 data by the health policy organization KFF found that 20% of claims to insurance plans sold through the government marketplace were denied, with fewer than 1% of denied claims appealed. And 56% of those denials are upheld.

Regarding Keytruda prices in the U.S., Merck said in a statement that what patients paid depends largely on their insurer. Slightly more than half of patients paid nothing per infusion, and those who paid were charged “between 1 cent and $375 per infusion, after satisfying their deductible” the statement said. It also said it provided about $125 million in co-pay assistance in 2025 and supported a charitable program that delivered more than $1.7 billion in free medicines to patients in the U.S. in 2024.

But when patients are denied coverage, their options are limited. If appeals to the insurer fail, filing a complaint with the state insurance regulator may be the last recourse. Depending on state laws, complaints to regulators may become public records. In October, ICIJ requested complaints filed for denials of Keytruda since January 2014 from regulators in nine states. Two of those states provided information. ICIJ reviewed documents from Texas, which provided six final complaint resolutions, and in three of those the denial was reversed once it was reviewed by regulators. In California, an ICIJ examination of patient requests for independent medical reviews shows 17 cases upheld and 10 cases overturned.

Ferguson with her son.

Ferguson knows this system all too well. She is a medical social worker and the CEO of a small health care consulting firm that advises and trains hospital staff to handle case management, including insurance paperwork. “This situation blurred my personal life and my professional life,” she said. “Here I’m on the receiving end of this issue.”

In its denial letter dated July 17, 2024, CVS Caremark, the pharmacy benefits manager for Ferguson’s insurer, CareFirst BlueCross BlueShield, said it only covered the drug for 24 months for her “health condition.”

For Ferguson, the insurer’s argument “made absolutely no sense.” Keytruda has been the only treatment that has kept her in remission long-term, she said. Ferguson and her medical team found a recent study that they said showed the drug worked beyond the two-year period. “How could [the insurer] not be aware of this?” she wondered.

CareFirst BlueCross BlueShield did not respond to ICIJ’s requests for comment for this story.

Ferguson’s care team submitted documentation of the recent study. A doctor from a third-party advocate, PayerWatch, which was then her husband’s employer, helped file the appeal.

Ferguson and O’Hara spent countless hours on the phone and in front of the computer dealing with the insurer’s staff. Ultimately the insurer upheld the denial, rejecting both her appeals.

Ferguson was willing to go to court if necessary, she told ICIJ. But she and her husband felt the ultimate decision should be between Ferguson and her doctor, and so they tried another tactic, tagging the insurer publicly on social media. Ferguson, an occasional contributor to health care blogs and newsletters, wrote about her situation and talked about it on the podcast “Talk Ten Tuesday,” popular among health care professionals.

O’Hara wrote a long post on LinkedIn airing his frustrations with the process, without mentioning his wife’s name. “This isn’t how I like to use social media, but sometimes, as consumers, it is what we are left with. I do this for a living, and I would do this for anyone, but this one is also personal, as many of you know,” O’Hara wrote. “And, there are too many people out there not getting the care they need because insurance companies, not Doctors, dictate the delivery of care.”

Ferguson reposted it, writing: “Obviously this is very personal to me and I’m still trying to formulate my words. We are people that know the convoluted system. … Many people do not have access to such resources to understand work arounds for such a messed up system. Even with all the advantages, I am denied care — care that has kept my cancer in check and able to live a pretty ‘normal’ life.”

“I felt a bit exposed,” she told ICIJ about making her plight public. “I have shared my story before, but I have never made it my platform.”

After the post, she went about her day. “Life goes on, you have kids, dinner, homework,” said Ferguson.

Ferguson said her insurer’s argument for denying her coverage “made absolutely no sense.” Image: Supplied

A few hours later she checked her LinkedIn account. Their posts had been shared by dozens of people, with many sympathetic comments from strangers. Crucially, Ferguson could see that employees of CareFirst BlueCross BlueShield had seen it.

In early August, she received a surprising call from the insurer. “Good news!” the caller said. “We are going to approve your Keytruda.”

Ferguson said she wanted to scream: “What do you mean, good news?! For what?! For putting my life at risk by denying me the coverage that I need?! I’m in this situation because of you!” Instead, she thanked the caller, hung up and immediately scheduled her next infusion.

In December 2025, not long before Christmas, Ferguson received a new denial letter. She was now ready to give up. “I’m tired,” she thought at the time. But the reasons for the denial were so vague, she said — the insurance company sent a letter citing the 24-month limit and attached more than 15 pages of information about approved uses of Keytruda — that her health care provider said they would appeal. The denial was soon reversed, and she is back on Keytruda.

“I understand why some patients would give up,” she said. “You have to fight so hard because they deny you the medication that is keeping you alive. And for what? Just to save some money?”

Contributors: Violeta Santiago (Quinto Elemento Lab), Francisca Skoknic (LaBot), Guilherme Waltenberg (Poder360), Kathleen Cahill, Isabella Cota, Jesús Escudero, Sydney P. Freedberg, Karrie Kehoe and Nicole Sadek (ICIJ)

Timeline of Merck’s active U.S. Keytruda patents

Merck’s original patents for Keytruda are set to expire in 2028. But Merck, using a strategy known as “evergreening,” has filed hundreds of additional patents that could protect Keytruda’s dominance well beyond that year.

ICIJ analyzed 180 U.S. patent applications related to Keytruda, provided by the Initiative for Medicines, Access & Knowledge (I-MAK), a nonprofit that examines inequities in the patent system. These were linked to 1,032 additional patent filings around the world tied to the drug. From this universe, ICIJ identified active U.S. patents that illustrate Merck’s strategy of maintaining market exclusivity.

Patents can have different status, including active, pending, abandoned, expired, or others. Explore Merck’s active U.S. Keytruda patents below.

ICIJ identified 50 active U.S. patents held by Merck, either filed alone or jointly with partners. Active patents are central to evergreening because they carry defined expiration dates that can extend market exclusivity. Our analysis shows that these active U.S. patents could protect aspects of Keytruda’s dominance through at least 2042, about 14 years beyond the expiration of its core patents. v" id="tt-exp">— Patent type —

These patents can be grouped into two categories: primary and secondary patents. Primary patents are product patents. They protect the active ingredient, covering the antibody and main mechanism of action that creates the immune response. Once approved, these patents give the inventor exclusive rights to produce, use and sell the molecule, typically for 20 years from the application filing date, preventing competitors from launching biosimilars, which are close to the original and offer the same results. Keytruda’s U.S. patents include the core patents set to expire in 2028, which should open the door to biosimilars, unless additional secondary patents delay competition. Secondary patents are follow-on patents that protect aspects of an existing drug beyond the primary patent protection of the original active ingredient. They can cover new dosing amounts, different treatment schedules, manufacturing processes, or combinations with other drugs. A large volume of secondary patents can dissuade competitors from entering a market by increasing the risk of costly legal battles over patent infringement.

Data visualization: Antonio Cucho Gamboa

Text: Denise Ajiri

Contributors: Miguel Fiandor-Gutiérrez, Delphine Reuter, Joanna Robin, Hamish Boland-Rudder, Annys Shin

Source of the data: I-MAK, Espacenet and Google Patents.

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-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/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 OVERVIEW How Merck turned its wonder drug into a blockbuster — and priced out cancer patients worldwide Apr 13, 2026 COUNTERFEITS Counterfeiters cash in on the world’s bestselling cancer drug 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

The Cancer Calculus is a yearlong investigation by the International Consortium of Investigative Journalists that reveals how Merck & Co. keeps the price of its blockbuster cancer drug Keytruda extraordinarily high while stifling competition.

The investigation, led by ICIJ in collaboration with 47 media partners, shows how the pharmaceutical giant has exploited the global patent system and pushed to widen Keytruda’s use, even in cases with limited benefits, driving up costs for patients and hospitals. The Cancer Calculus draws on hundreds of interviews with oncologists, cancer patients and their families, patent experts, regulators, pharmaceutical industry insiders and others to tell the story of a breakthrough medicine whose transformative power has been constrained by its manufacturer’s quest for profits.

ICIJ and its partners filed 1,018 public record requests in 27 countries to unearth public health records, meeting minutes, pricing and reimbursement data, and other documents in order to pull back the curtain on how Merck maintains Keytruda’s dominance, even as countless patients struggle to access the lifesaving treatment.

What is Keytruda?

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.

The U.S. Food and Drug Administration approved it in 2014 to treat advanced melanoma, the most aggressive form of skin cancer. The FDA has since approved it for 19 types of tumors.

What are some of the key findings of the Cancer Calculus investigation?

The Cancer Calculus found that 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.

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Merck has promoted a higher dosage of Keytruda than is necessary, according to some leading cancer researchers. The World Health Organization estimates that switching patients with lung cancer to weight-based dosing could save $5 billion globally by 2040.

The drug giant has taken advantage of industry regulatory shortcuts, orchestrated 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.

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, including $2.1 billion in Switzerland.

Meanwhile, Keytruda’s steep prices are straining government budgets, even in wealthy countries. List prices for a typical treatment range from about $80,000 a year in Germany to $208,000 in the U.S., $93,000 in Lebanon to about $130,000 in Colombia, and $65,000 in South Africa to $116,000 in Croatia. According to ICIJ’s analysis, Keytruda is more expensive for median income earners in the U.S. and poorer Eastern European countries, like Bulgaria and Hungary, than in some wealthy Western European countries.

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How did Merck & Co. respond to ICIJ’s findings?

The CEO and chairman of Merck & Co., Robert M. Davis, declined to comment. But Merck senior vice president Johanna Herrmann defended the company’s pricing practices.

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

What data was used in the Cancer Calculus investigation?

ICIJ and its partners obtained data from a wide range of public and exclusive sources. For pricing information, the Austrian National Public Health Institute (GÖG) gathered and calculated the price data in national currency units (unweighted raw data) from national databases as part of its PPI (Pharma Price Information) service. ICIJ also gathered pricing information from Merck’s website, government sources, and Knowledge Ecology International’s drugdatabase.info.

To analyze patents, ICIJ first identified U.S. Keytruda patents and cross-checked them against the Initiative for Medicines, Access & Knowledge (I-MAK)’s research, then built patent families using Espacenet and Google Patents.

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Merck’s Keytruda-related payments to U.S. doctors and health care professionals are tracked in the U.S. government’s Open Payments database. The company discloses payments to U.S.-based patient groups through grants. ICIJ cross-checked that data with KFF’s list of advocacy organizations. In Belgium, De Tijd gathered data from betransparent.be that was used to identify payments made by MSD Belgium to patient and health care organizations. ICIJ cross-checked that information with LobbyFacts.

Swiss advocacy organization Public Eye analyzed Keytruda’s research and development costs for ICIJ and its partners, relying on clinicaltrials.gov data. And the Healthcare Cost Institute and Serif Health shared data about treatment costs in the U.S.

ICIJ reviewed 163 judicial requests from patients requesting access to Keytruda from government health systems in Guatemala, Mexico and Chile. For Brazil, judicial requests were gathered from a public dashboard. ICIJ also analyzed 27 decisions related to Keytruda access from the California Department of Managed Healthcare’s public search engine.

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-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/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 OVERVIEW How Merck turned its wonder drug into a blockbuster — and priced out cancer patients worldwide Apr 13, 2026 COUNTERFEITS Counterfeiters cash in on the world’s bestselling cancer drug 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

The Cancer Calculus, an investigation by ICIJ and 47 media partners in 37 countries, also sheds new light on the strategies that have allowed Merck to widen Keytruda’s use — even in cases where its benefits are more limited and lower dosages may be just as effective.

A game changer in cancer treatment, Keytruda, known generically as pembrolizumab, weaponizes a patient’s immune system against cancer cells. The U.S. Food and Drug Administration approved it in 2014 to treat advanced melanoma, the most aggressive form of skin cancer. The FDA has since approved it for 19 types of tumors.

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

Usually administered via intravenous infusion in 200 mg doses every three weeks or 400 mg doses every six weeks, treatment can last up to two years — amounting to a staggering $416,000 according to the drug’s list price in the U.S. — and sometimes longer, though insurance companies often stop covering the drug after the initial two years.

With the cost of prescription drugs continually soaring, President Donald Trump convened top executives from major drug companies at the White House this past December and promised to lower U.S. drug prices. Among the executives was Robert M. Davis, head of Merck. All the companies pledged price cuts, but Merck made no such commitment with Keytruda, which generated $31.7 billion in 2025 — nearly half the company’s revenue. And 60% of the drug’s sales were in the U.S.

U.S. President Donald Trump shakes hands with Merck CEO Robert Davis during the White House event announcing lower drug prices in December. Image: Alex Wong/Getty Images

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, together with thousands of pages of company presentations, patent board documents, lawsuits and corporate and regulatory records, and more than 1,000 public records requests in 27 countries, the Cancer Calculus investigation pulls the curtain back on precisely how Merck maintains its dominance.

A patent fortress: An ICIJ analysis of Keytruda patents based on patent databases and data shared by I-MAK, a nonprofit that examines inequities in the patent system, shows that there are at least 1,212 patent applications that form part of the Keytruda patent families in 53 countries, regions and territories. The drug’s primary patents are set to expire in 2028, but ICIJ found that Merck has continued to file and obtain secondary patents beyond Keytruda’s main pharmaceutical component, potentially extending the drug’s commercial exclusivity until at least 2042 in the U.S. These additional patents, which can overwhelm and deter competitors, could deny hundreds of thousands of patients cheaper alternatives over the next 15 years.

Merck told ICIJ that it’s a common myth that pharmaceutical companies “game the patent system” by filing multiple overlapping patents to delay the entry of generic or biosimilar alternatives to the market. Instead, the company said, it had been repeatedly shown that patent counts do not predict when generics are introduced.

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Calculated dosing: Researchers report that Keytruda is often prescribed at higher doses or for longer periods than needed. The World Health Organization estimates that switching just patients with lung cancer to weight-based dosing could save $5 billion globally by 2040. Hospitals in Singapore, Malaysia and Taiwan have arrived at the same conclusion, and several nations, including the Netherlands, Canada and Israel, have started to switch to weight-based dosing — in which a patient’s body weight determines how much medication to use — with promising results.

Merck told ICIJ that while strategies to save health care costs were vital, it was more vital to provide appropriate care to patients, especially for potentially life-changing drugs such as pembrolizumab. “The two FDA-approved dosing regimens for KEYTRUDA for the treatment of cancer are based upon wide-ranging preclinical data and extensive clinical evidence,” the company said in its statement to ICIJ, adding that guidance on dosing varied depending on the type of cancer and whether Keytruda was used alone or in combination with other treatments.

Prescribing influence: Merck has invested financially — and heavily — in relationships with doctors and patient groups and in the distribution of research grants. Studies show such payments increase prescriptions, sometimes without improving survival rates. In the U.S. alone, records show, Merck made nearly $52 million in Keytruda-related consulting and other payments to health care professionals from 2018 to 2024, with five doctors receiving more than $1 million each.

Blockbuster profits: Merck’s targeted medical influence practices, combined with aggressive marketing, have helped Keytruda reach about $163 billion in sales since 2014, making it one of the bestselling drugs of all time. Meanwhile, the company has funneled nearly $75 billion in dividends to shareholders and $43 billion into share buybacks.

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Sky-high pricing: Prices for Keytruda vary widely but remain high everywhere. ICIJ found Keytruda treatment costs for patients are particularly uneven in the U.S. Data compiled by Serif Health, a San Francisco firm that analyzes health care reimbursement information and shared with ICIJ, show 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.

Merck told ICIJ it had a long history of “responsibly pricing our medicines to reflect their value to patients, payers and society.” It also said that to ensure its products reached as many patients as possible, it priced them “differentially across markets, and sometimes within markets, according to numerous factors.”

Those factors, the company said, included the value a therapy brings to patients and the health care system, countries’ pricing and reimbursement systems, and the ability of governments to finance health care.

R&D rodeo: Merck claims to spend tens of billions of dollars in development of Keytruda, but a new analysis by Public Eye, a Swiss-based nonprofit advocating for corporate accountability, estimates Keytruda’s research and development 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 — the largest share of R&D expenses. Critics argue that Merck’s prices are driven more by profit-seeking than innovation costs.

The investigation also shows how the market maneuvers can lead to desperate measures: Patients often turn to crowdfunding or even black markets in search of cheaper prices. Since Keytruda came to market in 2014, ICIJ found 632 cases in which patients in 51 countries used GoFundMe and other crowdfunding sites to raise money for Keytruda treatments. Some patients turn to the court systems for access to Keytruda, only to die waiting for a verdict.

Doctors in poorer countries can be forced to ration treatment, deciding who lives and who goes without. The high price of Keytruda has also helped fuel a trade in counterfeit versions of the drug. In Mexico, for example, ICIJ and partners identified four cases in which fake Keytruda was supplied to hospitals.

The Cancer Calculus highlights how a system that protects pharmaceutical pricing monopolies prioritizes profit over access. The project also shows that Merck used regulatory shortcuts such as accelerated approvals and orphan drug designations (for any rare disease that the FDA says affects fewer than 200,000 people in the U.S.) to maintain its dominance and protect its profit margin even as patients wage desperate struggles to stay alive.

Keytruda has undeniably transformed cancer care by extending survival for patients with melanoma and lung cancers, as well as other hard-to-treat tumors. It even helped former president Jimmy Carter live years longer after he developed advanced skin cancer. But the Cancer Calculus reveals that Merck’s secret pricing negotiations with governments around the globe have reinforced a world of inequity where burdened health care systems foot the bill — sometimes at the expense of other drugs they can no longer afford to pay for — and doctors are forced to choose which patients they can treat.

Ultimately, the Cancer Calculus is a case study of a broken global system for drug pricing and distribution. These stories highlight the urgent need to rethink how the world balances innovation, cost and access. For hundreds of thousands of patients, that balance will determine their survival.

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/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

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

What they uncovered became the Panama Papers, a sweeping investigation that broke open the secretive world of finance and exposed how the rich and powerful use offshore structures to protect wealth and dodge scrutiny.

This is the final part in a series that explores how it all came together, drawing on the recollections of the journalists whose reporting sparked a global reckoning over financial secrecy and its consequences. Read parts one and two, or revisit the Panama Papers investigation in its entirety.

The high view

Marina Walker Guevara (United States)
Then: Deputy director, ICIJ | Now: Executive editor, Pulitzer Center

At 2 p.m. on April 3, 2016, when the first Panama Papers stories started publishing, Marina Walker Guevara was somewhere over the United States, suspended between time zones and cut off from the political tremors that had already begun.

She was traveling home from a family wedding in San Francisco, wondering how the stories would land and whether anyone would care.

The answers came quickly.

The plane had barely touched down in Washington when Walker Guevara turned on her phone. Messages surged in faster than she could open them.

“I had to catch my breath,” recalled Walker Guevara, an Argentine journalist who is now executive editor of the Pulitzer Center.

The world was absorbing the secrets she’d guarded for more than a year — details that were about to spark protests, topple world leaders and ignite criminal investigations.

Within the first hours and days, angry crowds gathered in Reykjavík and London, governments from Panama to Pakistan scrambled to issue denials, and all the while presses were still running, printing story after story about the global mix of politicians, financiers and celebrities whose financial dealings spanned jurisdictions.

Watching it all unfold, Walker Guevara began to understand the gravity of what this global team had achieved.

“This is much bigger than anything we thought,” she recalled. “This is truly a story about systemic inequity.”

Naming the untouchable

Moussa Aksar (Niger)
Founder and editor, L’Evenement

When L’Evenement published the Panama Papers, the paper’s founder and editor Moussa Aksar knew there would be consequences. The coverage named a powerful financier closely tied to the country’s ruling elite — “un intouchable,” Aksar said recently in his native French. An untouchable.

The reaction came quickly. L’Evenement sold out within hours. Another print run was needed. Aksar felt satisfaction — until he thought of his three children and unease took over.

Aksar had just told the world that a major political donor had used an offshore company to move revenue from his bus company into tax havens.

The calls began the morning of publication. First, a warning from a friend who admired his courage and urged him to be careful.

Then came calls from people he did not know. Threats. Each time the phone rang, the risk felt less abstract. In Niger, reprisals rarely stop with the journalist alone.

Journalist Moussa Aksar stands at the entrance to his newspaper, L’Evenement, in Niger. Image: L'Evenement

Aksar’s work was attacked in other newspapers. His motives were questioned. He was accused of serving Western interests — a dangerous charge in a fragile democracy.

His children — two teenagers and a 9-year-old — wondered if it was worth it. Aksar remembers them struggling to understand why he was, as he put it, sacrificing himself for an ungrateful society.

A decade later, Aksar says, they no longer ask why he took the risk. They’re proud of his reputation as a journalist who ensures that even les intouchables aren’t beyond the reach of scrutiny.

Defending the documents

Minna Knus-Galán (Finland)
Investigative reporter, Yle

As the Panama Papers shook governments around the world, one of the fiercest fights played out not in an authoritarian state, but in a country that routinely tops global press freedom rankings: Finland.

ICIJ member Minna Knus-Galán and her colleagues at the Finnish public broadcaster Yle found themselves fighting their own government’s tax authority’s threats of raids on their homes and newsroom unless they surrendered leaked documents.

Knus-Galán had just produced some of Finland’s most explosive findings from the leak: that Mossack Fonseca, the law firm at the center of the Panama Papers, had worked with Nordea, the Nordic region’s biggest bank, to establish hundreds of offshore companies, backdate documents and register deceased individuals as company directors to conceal the true owners.

The government argued it needed access to the Panama Papers material to investigate tax evasion by Finns named in the files.

I don’t know what the Finnish tax authorities thought — that we would have the Panama Papers in a [pile] on our desks?

Compliance, Yle countered, would violate source protection and shatter the trust that made cross-border collaboration possible. If one newsroom could be forced to surrender leaked material, whistleblowers might stay silent and future investigations could be jeopardized, Knus-Galán said.

“I don’t think we could do more ICIJ projects after that if there’s this risk,” she said.

The standoff spilled into reporters’ personal lives, too.  When a demand from Finland’s tax authority arrived at Knus-Galán’s home, it felt intimidating — an official threat breaking into her private space. Over dinner, she told her teenagers there was a small but real chance police might burst in and seize their computers. Her son, a budding tech whiz, worried: would they take his machine, too?

For all the pressure, there were no documents in her house or her newsroom for authorities to seize. The files were safe on ICIJ’s secure platform.

“I don’t know what the Finnish tax authorities thought — that we would have the Panama Papers in a [pile] on our desks?” Knus Galán said.

Finnish journalist Minna Knus-Galan speaks at a September 2016 meeting of European Parliament’s PANA Committee, which was convened in the wake of the Panama Papers. Image: Jan van de Vel / European Parliament

Partner journalists never possessed the data themselves. It was stored in the cloud. Reporters could log in to search the files, and ICIJ could cut off access at any time. By design, no single newsroom controlled the files — a safeguard that protected both the material and the investigation.

Still, the demand alone was a threat to press freedom. If authorities could compel journalists to hand over confidential material, it would compromise the independence that protects sources and hamstring future investigations.

Knus-Galán said the letter was “very, very stressful and super strange” — the kind of threat she expected colleagues in Russia might face, not reporters in Helsinki, which was, at the time, preparing to host World Press Freedom Day. “I was sort of thinking, this can’t be happening in Finland.”

https://www.icij.org/investigations/panama-papers/watch-the-panama-papers-at-10-live-panel-event/

VIDEO WATCH: The Panama Papers at 10 live panel event Apr 02, 2026

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 VIDEO WATCH: The Panama Papers at 10 live panel event Apr 02, 2026 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

“It fueled the demand for more transparency in financial markets,” Stiglitz said, “but the issues, sadly, have not be solved. They are still before us — and in some ways, even more so.”