In this context, cancer patients in Lebanon are fighting a multi-front battle: against the disease itself; against the war, with its displacement and the difficulties it creates in accessing hospitals and medication; and against the cost of modern treatments, foremost among them Keytruda, one of the world’s leading immunotherapy drugs today. In a country that ranks among the highest globally in cancer incidence relative to its population, access to this drug has become a harsh test of the healthcare system’s ability to manage its scarce resources and distribute them equitably.
Updated data show that 16,226 new cancer cases were recorded in 2024, with incidence rates having doubled over the past two decades. This places Lebanon among the countries with the fastest-rising cancer incidence and mortality rates worldwide. According to a study published in The Lancet, the number of new cancer cases in Lebanon increased by a striking 162% between 1990 and 2023, while cancer-related deaths rose by 80% over the same period. In 2023, Lebanon recorded 233.5 new cancer cases per 100,000 people, according to the study “Global, regional, and national burden of cancer 1990-2023, with projections to 2050: a systematic analysis for the Global Burden of Disease Study 2023,” published in The Lancet.
However, Lebanon’s Minister of Health, Rakan Nasser El-Din, issued a statement responding to these findings, arguing that “the data presented in the article are based on assumptions and pre-prepared models rather than on available real figures,” and that “to date, there are no precise scientific data in Lebanon on cancer-related mortality.” At the same time, he warned that the study nonetheless “rings an alarm bell for all those concerned with health policies in Lebanon.”
This investigation is part of the “The Cancer Calculus” project, led by the International Consortium of Investigative Journalists (ICIJ), in collaboration with 47 media outlets, including Daraj. More than 120 journalists from 48 media organizations across 36 countries took part in the project, investigating the high cost and commercial practices behind a key cancer drug.
What is Keytruda and why is it used?
Keytruda is neither chemotherapy nor radiation therapy. It is a form of immunotherapy that works with the body’s immune system to help fight certain types of cancer. The drug prevents cancer cells from “hiding” by blocking the PD-1 pathway, making it easier for the immune system to recognize and attack them, according to the explanation published on the drug’s official website.
Keytruda is used to treat a range of cancers, including lung cancer, melanoma (skin cancer), and other advanced malignancies. It is produced by Merck & Co. (MSD (known as Merck & Co outsidein the United States and Canada), one of the world’s leading companies in oncology and immunotherapy drugs.
The cost of this scientific advancement is steep. According to figures from the Ministry of Health and physicians, a single dose is priced at around $2,700. Patients typically require two doses every three weeks (21 days), amounting to more than $5,000 per month, or roughly 13 treatment cycles per year, as explained by Fatima Makki, head of the Drug Tracking System at Lebanon’s Ministry of Health, in an interview with Daraj.
At this price, the drug is effectively out of reach for the vast majority of patients unless it is covered by an insurance provider or the Ministry of Health.
A Cancer Patient’s “Tragedy”
Rita Moawad, like many cancer patients in Lebanon, was not fighting a single battle. After being struck in the head by a stray bullet as a child, she lived with partial paralysis in her arm and difficulty walking. Then cancer came, adding another layer of pain and hardship.
Rita emerged victorious from her first battle with breast cancer in 2005. She underwent all the available treatment protocols at the time: chemotherapy, radiation therapy, and hormone therapy, and remained “cancer-free” for 17 years. But in 2022, she was diagnosed again with a new form of breast cancer, this time triple-negative, a type that is often resistant to conventional treatment protocols.
Rita was enrolled in Lebanon’s National Social Security Fund, which in principle should have covered her treatment. However, the financial and economic crisis left the system “unable to provide the full coverage that existed before the crisis.” Coverage was reduced to partial, limited amounts that “fall far short” of the high cost of cancer medications, according to her brother Danny, in an interview with Daraj and the International Consortium of Investigative Journalists.
In 2024, Rita was removed from the Ministry of Health’s Keytruda treatment protocols, and official coverage came to an end. Her family was left with a single option: to secure the medication at their own expense. Typically, the Ministry purchases Keytruda from the local agent once a patient’s request is approved, covers its cost, and distributes it free of charge.
In Rita’s case, however, the family had to buy the drug directly from the same agent “out of our own pocket,” as Danny put it. Keytruda was not the only medication she required; it was administered alongside other drugs, pushing the cost of each session at times to $6,000. Every three weeks, a new session meant paying between $5,500 and $6,000. Rita managed to complete four sessions, but with little to no response, she was eventually moved to a different treatment protocol.
It became clear that the cost of continuing Keytruda was unsustainable for a middle-income family, especially in a country that “doesn’t give you your money from the bank,” as her brother describes it, where frozen savings in the banking system have become an additional barrier to treatment. This is how the option of turning to the GoFundMe platform emerged. The family reached out to friends, close networks, and the wider public, sharing Rita’s story in the hope of raising enough to purchase the drug directly from the local agent.
Rita’s life was “something of a tragedy,” as Danny describes it, as their home became a shared space of pain and endurance, before she passed away on August 15, 2025, at the age of 59.
Digitizing Tracking: From Chaos to a “Single Public Buyer”
With the collapse of the Lebanese lira since 2019, the COVID-19 pandemic, and the disappearance of subsidized medicines, the healthcare system found itself facing real chaos in the pharmaceutical market, particularly for cancer drugs. Former Minister of Health Dr. Firas Abiad estimates, in an interview with Daraj, that the number of cancer patients in Lebanon ranges between 10,000 and 15,000, noting that “not all of them receive the same medication, as they undergo multiple treatment regimens.”
Abiad explains that the Ministry of Health faced two main challenges: “first, ensuring that the medication reaches the patients most likely to benefit from it; and second, making sure that drugs are not dispensed to fictitious patients or diverted to the black market.”
To address this, two digital applications were launched: “Meditrack,” which tracks medication “from the moment it arrives in Lebanon and is received, until it reaches the patient, including verification of the patient’s identity,” through a unified health number that links each package to a specific patient; and the “Aman” platform, which “allows physicians requesting medication to input patient data, after which the case is reviewed to ensure it falls within approved treatment protocols, and based on that, the drug is dispensed.”
According to Abiad, initially no more than about 20 percent of patients were receiving their medication, but “through these two platforms, we were able to raise the percentage of patients covered by the ‘Aman’ platform to over 90 percent.”
This digitization was also tied to a fundamental reform in procurement. The Ministry of Health took over the management of cancer drugs for all payers, “giving us the opportunity to do what we had long aimed for: unify the public buyer, so that the state becomes the single public purchaser instead of having multiple buyers,” Abiad explains. This shift made it possible to launch a unified tender.
More importantly, the design of the tender itself was changed. “If the tender is based on the active molecule, Keytruda faces no competition because there is no generic equivalent, so it remains the sole product. But if the tender is designed based on therapeutic indication, such as drugs used to treat lung cancer, then Keytruda finds itself in direct competition with other drugs that achieve the same therapeutic outcome, even if they are chemically different.”
When the Ministry decided to procure only one drug per therapeutic indication, companies were forced to compete on price. “Through this mechanism, we managed to reduce the cost of cancer drugs in Lebanon by around 45 to 50 percent,” Abiad says, noting that when he left office, he had secured “a stockpile of medicines worth $80 million,” whereas previous ministers had left their successors with debts of a similar amount.
Makki adds that this approach helped secure better offers and lower prices. “Although Keytruda remains a unique treatment and does not behave in pricing like drugs with multiple alternatives, the company offered the Ministry in 2026 a much better price compared to previous years.”
MSD’s Response
Daraj contacted the External Affairs Director at Merck & Co. (MSD), the manufacturer of the drug, for the Mashreq region. The following response was received: “At MSD, our goal is to help extend and improve the lives of people with cancer. We are extremely proud of our portfolio of medicines, anchored by KEYTRUDA, that have helped to transform the way we treat some of the deadliest forms of cancer. Today, KEYTRUDA is foundational in the treatment of many advanced cancers. In the United States, KEYTRUDA has received approval for 44 distinct indications and has demonstrated statistically significant overall survival benefit in 28 trials. Worldwide, KEYTRUDA is approved for use in 106 countries.
MSD has a long history of responsibly pricing our medicines and vaccines to reflect the benefit they provide to people and society – and the price of KEYTRUDA reflects its value to patients and healthcare systems.
MSD remains committed to working with payors in high-income settings and actively engaging in access programs in middle- and low-income settings. Still, access is not dependent upon MSD alone. The process may involve feasibility of introducing immunotherapies to a healthcare system; the system’s willingness to invest in cancer care; flexibility with access agreements; and more.
As a research-intensive biopharmaceutical company, expanding access to health is central to our purpose to save and improve lives.”
Keytruda: The Capitalism of Survival
Dr. Hazem Assi, Director of Specialized Clinics and Clinical Services at the Naef K. Basile Cancer Institute and Professor of Clinical Medicine at the American University of Beirut Medical Center, explains the impact of Keytruda in an interview with Daraj. Studies using the drug across multiple cancers, from melanoma to lung and kidney tumors, show that “when we add immunotherapy, especially Keytruda, outcomes improve significantly, not only in terms of cure rates but also in disease control.” He adds: “In some stage IV cancers, we may not be able to cure the patient, but we can prolong life and turn the disease from a fatal condition into a chronic one. This is how immunotherapy helps, and it has made a substantial difference in cancers such as melanoma and lung cancer.”
But this “substantial difference” is not accessible to all patients. According to Assi, “with patients we know are in difficult financial circumstances, we often avoid even mentioning immunotherapy. We know there is a better treatment than what we can offer, but we are faced with overwhelming economic barriers. Sometimes we do not tell them about the better option to avoid placing an additional psychological burden on them.”
Has the Black Market Been Curbed?
At the height of Lebanon’s economic crisis, which coincided with the COVID-19 pandemic, many patients and their families turned to the black market to secure medication.
Fatima Makki from Lebanon’s Ministry of Health explains in an interview with Daraj: “During the peak of the crisis, we faced major challenges in securing medications, and the black market spread. Our priority was first to ensure that drugs did not run out for patients, and second to track where the medication was going and prevent any manipulation in its distribution. That is why the MediTrack system was launched. This system allows us to follow the path of the drug and know exactly where it goes.”
She adds: “We created a system based on what is called the Unified Health ID (UHID), which enables us to link each package of medication to a specific patient. We would send the patient’s UHID to the company, and based on it, the medication would be delivered specifically for that patient, allowing us to track its journey from the company all the way to the patient. Since the implementation of the drug tracking program, patients no longer receive medication directly, except for oral drugs. Instead, medications are sent to hospitals to ensure they are not exposed to damage or improper storage.”
Here, Hani Nassar, founder and president of the Barbara Nassar Association for Supporting Cancer Patients, explains in an interview with Daraj and the International Consortium of Investigative Journalists that in 2021 Lebanon went through a period of about five months “without any imported medications.” During that time, “we lost a large number of cancer patients among those we were supporting, which is why we raised our voices in the media and organized numerous protests and actions,” Nassar says.
He adds that patients who could afford it turned to the black market to buy their medications, while those who could not were forced to stop treatment altogether: “Patients died because they were deprived of their medications.”
Nassar continues: “Many Lebanese traveled to Turkey, bought medications, and brought them back to Lebanon to resell them for profit. This led to large quantities of counterfeit drugs reaching us, particularly Keytruda, because it was the most expensive.”
He notes that the price of Keytruda in Lebanon today is around $5,400 per session (two 200 mg doses), and that the significant price gap between Turkey (around $1,000 per dose at the time) and Lebanon (between $2,400 and $2,700 per dose) helped fuel the black market.
Nassar explains that obtaining Keytruda free of charge through the Ministry of Health is conditional on prior approval under strict and restrictive protocols. Patients who fall outside these protocols “are left with only two options: either pay $5,400 out of pocket for each session, or purchase the drug from abroad, in Turkey or Egypt, while risking counterfeit medication.”
In this context, Fatima Makki adds that the spread of the black market “coincided with a period when the Ministry of Health did not have a sufficient budget… which required the adoption of more restrictive dispensing protocols in line with available resources. These protocols excluded some patients from coverage, pushing a number of them to seek medication in Turkey or through the black market.”
However, she notes that with improved funding, the protocols were later expanded. “For Keytruda, for example, approvals during the peak of the crisis were around 50 cases. The guidelines were then reopened and expanded twice, in March and June 2025, raising approvals to approximately 161 per month by June. When we say 161 approvals per month, this means 161 patients receiving treatment, noting that a patient typically requires two vials per month, administered once every 21 days, or about 13 treatment cycles per year.”
Makki adds that rejection rates today do not exceed “5 to 10 percent,” with most of these cases reconsidered through appeal requests.
Daraj also contacted several pharmacies to inquire about the availability of Keytruda. Most declined, but one large pharmacy gave a different response. In March 2025, it confirmed that it could source the drug from abroad “without requiring a prescription,” at a cost of $9,000 for two doses, with an upfront payment of $2,250 before placing the order. Eight months later, when contacted again, the response had changed: the pharmacy now required the patient’s unique identification number issued by the Ministry of Health to request the drug, while other pharmacies declined to provide it altogether.
Dr. Hazem Assi emphasizes that transporting drugs like Keytruda is highly complex: “Immunotherapy requires strict temperature control, and if these conditions are not met, the drug becomes ineffective.” Such medications “are not عادة sold in pharmacies but are administered in hospitals.” He adds that a significant portion of drugs that entered through informal channels “were later found to be counterfeit,” with falsification reaching the level of replicating serial numbers in an “unusually sophisticated” manner.
Assi places primary responsibility on the state: “It is the duty of the state, through the Ministry of Health, to monitor the situation and conduct large-scale awareness campaigns to warn people against purchasing medication from suspicious sources.” At the same time, he acknowledges the difficulty of blaming patients: “Sometimes a patient is in a desperate condition and is told the drug costs $5,000, then someone offers it for $2,000. You cannot blame the patient if there are networks exploiting this desperation.”
In this context, Makki recommends minimizing reliance on the black market as much as possible and guiding patients and physicians toward alternative treatments available within the Ministry’s protocols when Keytruda cannot be secured. She stresses that expanding official coverage to include as many patients as possible remains the most effective way to reduce and ultimately eliminate the role of the black market.
Why Did Keytruda Enter Beirut and Dubai Early?
Paradoxically, Keytruda, a costly and complex drug, did not follow the conventional pathway of pharmaceuticals, which typically move from the U.S. market to Europe and then to “peripheral” markets. Instead, it entered markets such as the UAE and Lebanon at an early stage.
Abiad links this to the absence of Health Technology Assessment (HTA) in Lebanon. HTA relies on scientific studies assessing a treatment’s effectiveness, alongside economic evaluations of its cost-effectiveness. In systems that apply HTA, cases are assessed within broader priorities, such as the societal need for medications for diabetes or hypertension. In countries like Lebanon, where this type of evaluation was not institutionalized, companies were often allowed to set prices freely, benefiting from a fragmented market divided among multiple payers.
All it took was for a company to convince one payer, which would then pressure others under the pretext of ensuring equal treatment for patients. This created a “soft” market that was easy to penetrate, allowing many drugs to enter without Managed Entry Agreements (MEAs), such as those applied in some countries with Herceptin, where governments required reimbursement for treatments that did not benefit patients.
Abiad believes that Lebanon’s current trajectory, amid limited resources and the “continued weakness of investment in prevention (such as smoking, pollution, and poor health awareness…), makes the scale of the cancer burden likely to exceed available funding capacities, unless reforms are completed and supported by sustainable long-term policies.”
This investigation was produced with contributions from Sydney Freedberg and Nicole Sadek of the International Consortium of Investigative Journalists (ICIJ)global network of investigative journalists and Jana Barakat of Daraj.
