A yearlong international investigation led by the International Consortium of Investigative Journalists (ICIJ), Deutsche Welle and 46 media partners examined how Merck’s cancer immunotherapy Keytruda (pembrolizumab) became both a major medical breakthrough and a symbol of unequal access to treatment worldwide. The probe drew on hundreds of interviews, exclusive pricing and patent data, and more than 1,000 public records requests across 27 countries to document how pricing systems, patents and regulatory frameworks shape who receives life‑saving care.
A therapeutic milestone and a commercial giant
First approved in 2014, Keytruda — part of a class of drugs that enable the immune system to attack cancer — is now approved for at least 19 tumor types. It has extended survival for millions and, in some cases, transformed fatal diagnoses into chronic conditions.
Keytruda is also one of the best‑selling medicines ever. In 2025 it generated $31.7 billion in sales and about $163 billion since launch, with roughly 60% of sales from the United States. Merck returned nearly $75 billion in dividends and spent $43 billion on share buybacks. Between 2020 and 2024 sales surged in many markets: France (+232% to $2.8 billion), Brazil (+265% to $753.7 million), Mexico (+491% to $137.3 million) and Turkey (+584% to nearly $100 million), according to IQVIA data shared with ICIJ.
The drug’s cost puts heavy pressure on health systems. Annual treatment costs cited in the investigation range from roughly $80,000 in Germany to $208,000 in the United States, and similar high sums in Lebanon, Colombia, South Africa and Croatia. Studies in the UK found the NHS may have overpaid in some cases, with prices up to five times assessed value for certain lung cancer patients.
Patents, pricing and power
Reporters identified at least 1,212 patent applications related to Keytruda across 53 jurisdictions. While primary patents expire in 2028, follow‑on patents could extend exclusivity into the 2030s or 2040s, delaying cheaper alternatives. Critics call this a “patent fortress” designed to deter competition; Merck says filings reflect ongoing innovation — new uses, formulations and combinations.
Confidential discounts, national negotiations and middlemen produce wide price variation. List prices range from about $850 per 100 mg vial in Indonesia to more than $6,000 per vial in the United States. Yet affordability depends on income: a median‑income person in the US can afford fewer than five doses a year, while someone on the median income in South Africa cannot afford a single 200 mg dose annually.
Merck’s commercial strategies also extend to regulatory and market dynamics. The company made nearly $52 million in Keytruda‑related payments to US healthcare professionals between 2018 and 2024, according to records cited by the investigation. Merck says collaborations help inform the medical community and that support for patient organizations is independent of prescribing decisions.
Disputed development costs
Merck’s CEO testified that the company invested $46 billion from 2011–2023 in researching, developing and manufacturing Keytruda and planned further investment. Nonprofit analyses contest that scale: Swiss group Public Eye estimates core R&D costs around $1.9 billion, rising to $4.8 billion when costs of failed trials are included — small fractions of the drug’s global revenue. Merck does not publicly break down R&D costs by medicine.
Opaque systems and real‑world consequences
Secrecy around pricing and public spending is a common theme. Authorities in several countries refused to disclose payments or patient numbers, citing “trade secrets,” hindering cross‑country comparisons and assessments of fairness.
Where governments or insurers do not cover Keytruda, patients often resort to courts, crowdfunding or black markets. ICIJ found at least 632 crowdfunding campaigns for Keytruda in 51 countries. In Latin America, soaring drug costs have driven thousands of lawsuits seeking court‑ordered access. In some countries limited supply has forced clinicians to ration treatment; an oncologist in Guatemala described having to choose which patients received medicine, likening it to “playing God.” The investigation documented cases in which patients died while legal claims were pending.
Dosing debates
The standard dosing strategies for Keytruda have come under scrutiny. Some researchers and hospitals argue the drug is frequently given at higher doses than necessary. The World Health Organization estimates that switching to weight‑based dosing for lung cancer patients alone could save roughly $5 billion globally over 15 years in modeling scenarios. Hospitals in Singapore, Malaysia and Taiwan testing lower‑dose approaches report similar effectiveness; the Netherlands, Canada and Israel have begun switching to weight‑based dosing. Merck maintains its dosing recommendations are grounded in extensive clinical evidence and regulatory approvals.
Turkey: a case study of policy, litigation and access
Turkey illustrates how exchange‑rate‑based pricing, reimbursement rules and courts interact. Drug prices there are calculated using a government‑fixed euro reference rate, often below market levels. As of April 1, 2026 the reference rate was raised to 29.11 Turkish lira, producing a retail price of 88,783.52 lira (~€3,049) per vial. Keytruda is typically given in two doses every three weeks, making a treatment cycle cost roughly 177,567 lira (~€6,099) — about 6.5 times Turkey’s monthly net minimum wage of 28,075.50 lira.
For years Keytruda was not reimbursed by the Social Security Institution (SSI), prompting patients to seek access through the courts. It entered reimbursement in July 2025 for six indications, but restrictions and off‑label disputes persist. A DW Turkish analysis of 50 lawsuits showed that in 10 of 34 open labor court cases the patient died while proceedings were ongoing, highlighting how judicial delays can negate legal rights to life‑saving care.
Merck’s response
Merck defends Keytruda’s price as reflecting its value to patients and health systems and points to differential pricing, patient assistance programs and access efforts in low‑ and middle‑income countries. The company reported providing $1.7 billion in free medicines across its portfolio in 2024 and about $125 million in co‑pay assistance. Merck also argues that access is multifactorial, shaped by health systems, insurers and intermediaries as well as manufacturer pricing.
Broader implications
ICIJ’s investigation concludes that the dynamics surrounding Keytruda are not unique: patent protections, pricing strategies and regulatory frameworks often favor manufacturers, producing uneven global access to innovation. For patients, outcomes increasingly depend on geography, income and the ability to navigate complex legal and financial systems.
The debate crystallizes a deeper question about medical innovation: should breakthroughs be treated as common gains for humanity or as commercial assets protected by patents that can deepen global inequality? The Keytruda story shows how a single drug can save lives for some while remaining out of reach for many others, exposing a widening divide in global health.