Keytruda is often presented as the ultimate success story of modern pharmaceutical innovation. And in one sense, that is true. Few medicines have transformed oncology as profoundly as pembrolizumab. It has extended survival in melanoma, lung cancer, and many other malignancies, and it has helped turn immune checkpoint inhibition from a scientific hypothesis into a clinical reality. For many patients, it has meant years of life that previously had few options at all.

But that is only one part of the story.

The other part is far less comfortable. Keytruda is not just a breakthrough drug. It is also a striking example of how the contemporary pharmaceutical system works: publicly funded science lays the foundation, private firms take control of the resulting assets, monopoly rights determine pricing, and health systems are then forced to pay extraordinary sums to access medicines they helped make possible in the first place.

This is what makes Keytruda so politically important. It is not merely a story about scientific success. It is a story about ownership, public subsidy, corporate strategy, and the growing gap between biomedical progress and equitable access. In that sense, Keytruda is not an exception. It is one of the clearest illustrations of the current system’s structural logic.

The science was public before the profits were private

The foundations of Keytruda were laid long before Merck turned it into a blockbuster. The crucial scientific breakthrough came with the discovery of PD-1 by Tasuku Honjo and colleagues at Kyoto University in the early 1990s. Over time, this work revealed that PD-1 was part of the immune checkpoint machinery that restrains T-cell activity. That insight fundamentally changed cancer immunology. It suggested that instead of attacking tumors directly, medicine could work by releasing the brakes on the immune system.

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This was not the product of isolated corporate brilliance. It resulted from decades of publicly funded research. Government support in Japan sustained Honjo’s work. In the United States, public funding helped establish the wider domain of immune checkpoint research. University laboratories, academic medical centers, and publicly funded research infrastructures made the field possible long before pharmaceutical firms recognized its full commercial value.

That matters because the myth of drug innovation frequently begins too late in the story. It starts at the clinical trial, the patent filing, or the approval announcement, rather than at where innovation usually begins: in publicly supported science, collective knowledge production, and institutions built for the public good.

Keytruda emerged from that ecosystem. Without it, there would have been nothing for the industry to commercialize.

The market did not automatically recognize Keytruda’s value

Another revealing aspect of the Keytruda story is that the drug was nearly lost not because the science failed, but because corporate priorities shifted.

The antibody that became pembrolizumab originated at Organon, initially in a program not even designed for oncology. Through mergers and acquisitions, it passed to Schering-Plough and then to Merck. During these periods, the program was deprioritized, sidelined, and reportedly nearly discarded altogether.

This should give pause to anyone who assumes that private ownership naturally distributes resources to the most socially valuable innovations. Under a system driven by portfolio logic, mergers and stockholder expectations, even a future life-saving therapy can be neglected if it doesn’t fit immediate strategic calculations.

Big Pharma greed keeps lifesaving drugs out of reach for millions in the Global South. Source: ITPC/Facebook

Pembrolizumab survived not because the market perfectly understood its promise, but because a handful of committed scientists persisted and external developments forced management to reconsider. Once competing checkpoint therapies began to show promise, Merck moved rapidly. What had been treated as marginal suddenly became central.

This is often celebrated as corporate agility. But it can just as easily be read as evidence of structural irrationality. A therapy that would go on to become the world’s top-selling drug was almost abandoned because the system is not designed to maximize public health. It is designed to manage financial risk and competitive advantage.

From breakthrough to blockbuster

Once Merck committed to pembrolizumab, it did so aggressively. The company rapidly expanded the clinical program, scaled up trials, employed biomarker strategies with considerable success, and leveraged regulatory mechanisms to accelerate approval. Scientifically and operationally, this phase proved impressive. It helped bring a major therapeutic advance to patients faster than would otherwise have been possible.

That achievement should not be dismissed. It shows that large-scale clinical development, regulatory coordination, and manufacturing capacity remain essential parts of turning promising science into real treatments. The question is not whether these capacities are needed. The question is who controls them, whose interests they serve, and who reaps the rewards.

Because once Keytruda succeeded, the rewards were immense.

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By 2024, it had become the world’s top-selling medicine, generating nearly 29.5 billion USD in annual sales. That figure is astonishing not only because of its scale, but because it reveals how enormous the extractive potential of pharmaceutical monopolies can be when attached to a clinically transformative product.

And yet, even this commercial success was built on a landscape formed by public input. The scientific foundations were public. Clinical trial ecosystems depended heavily on academic hospitals and publicly subsidized research environments. Regulatory acceleration came through public institutions. The risks were socialized at crucial stages, but the financial gains were overwhelmingly privatized.

A medicine can be revolutionary and still be exclusionary

The great paradox of Keytruda is that a drug capable of redefining cancer care can simultaneously remain not accessible to many of the people who need it.

In the United States, treatment costs have exceeded 150,000 USD per patient per year. In Europe, health systems have had to negotiate rebates, confidential agreements, and special reimbursement arrangements to contain budgetary impact. Even wealthy countries struggle to absorb the costs of widespread access.

For lower-income countries, the situation is far worse. There, access is often minimal, delayed, or effectively nonexistent.

This is not a side issue. It is central to how we should evaluate medical innovation.

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A therapy cannot be judged only by its efficacy in clinical trials or its scientific sophistication. We must also judge it by whether patients can actually receive it. A drug that exists in principle but remains unreachable in practice is not a complete public health success.

Keytruda’s inclusion on the WHO Essential Medicines List should have been a powerful recognition of its importance. But that recognition also exposed a deeper contradiction. What does it mean for a medicine to be considered essential if it remains priced beyond the reach of most of the world?

At that point, the designation risks becoming symbolic. A medicine can be clinically essential and commercially exclusionary at the same time. Under the present model, that contradiction is not accidental. It is built into the system.

The real question is not whether industry matters, but on what terms

Defenders of the status quo often respond with a familiar argument: without patents, high prices, and private investment, drugs like Keytruda would never have reached patients. The claim that large-scale development requires resources, coordination, and risk-bearing has some truth. But that does not settle the matter. It merely restates the rules of the current system as if they were laws of nature.

They are not.

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The issue is not whether clinical development and manufacturing require serious investment. Of course they do. The issue is whether public institutions must always play a subordinate role: finance early discovery, de-risk innovation, build research infrastructure, and then step aside once commercialization begins.

Why should taxpayers fund the science, support the research ecosystem, and absorb part of the development risk, only to lose all control over pricing, licensing, and access at the decisive moment?

Why should a medicine built on public knowledge become a private asset governed by monopoly logic?

And why should governments then pay again, at inflated prices, to buy back access for their own populations?

These are not radical questions. They are the basic questions that any serious public-interest pharmaceutical policy must confront.

Public Pharma is not a fantasy but a necessary direction

This is where the idea of Public Pharma becomes more than a slogan. It becomes a practical and moral challenge to the current order.

A Public Pharma approach would begin from a simple premise: if public institutions are central to the creation of breakthrough medicines, they should not relinquish stewardship when those medicines become commercially valuable. Public actors should have the capacity not only to fund discovery, but also to shape development, retain ownership stakes, set access conditions, and, where appropriate, support manufacturing and distribution.

That would not mean excluding scientific collaboration or denying the complexity of drug development. It would mean changing the terms of engagement.

Under such a model, the benefits of a drug like Keytruda could be organized differently. Public investment could come with enforceable conditions on affordability and licensing. Intellectual property could be structured to prevent extreme monopoly control over entire therapeutic pathways. Revenues could be reinvested into further research rather than extracted as shareholder value. Health systems could negotiate from a position of public stewardship rather than defensive purchasing.

Most importantly, access would no longer be treated as an afterthought.

A breakthrough for whom?

Keytruda demonstrates what biomedical science can achieve at its best. It shows that diseases once regarded as almost uniformly fatal can be confronted in entirely new ways. That should be acknowledged without hesitation.

But Keytruda also shows the limits of celebrating innovation while ignoring political economy. A medicine can be scientifically brilliant and socially unjust at the same time. It can save lives while still comprising a system that rations access through price. It can stand as proof of human inventiveness while also revealing how poorly that ingenuity is governed.

That is why Keytruda should be remembered not only as a triumph of immuno-oncology. It should also be understood as a case study in the contradictions of pharmaceutical capitalism.

The lesson is not that we need less innovation. The lesson is that we need a different system for governing it.

The real measure of a medical breakthrough is not only whether it can be invented, patented, and sold at scale. It is whether we can make it available, sustainably and fairly, to all who need it.

On that question, Keytruda remains not only a success story but an unfinished indictment.

David Franco is a scientist and public health activist based in Belgium. In the People’s Health Movement, he focuses on the Public Pharma for Europe (PPfE) initiative. David holds a PhD in Pharmaceutical Sciences from the Free University of Brussels.

People’s Health Dispatch is a monthly bulletin published by the People’s Health Movement and Peoples Dispatch*. For more articles and subscription to People’s Health Dispatch, click* here.

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