Militant violence, anti-vaccination conspiracies, and religious hard-liners have long thwarted a drive to once-and-for-all eradicate the crippling polio disease in Pakistan.
But now, vaccination teams in the South Asian nation of some 220 million people face a new obstacle: fake marker pens.
Polio workers say parents who are suspicious of the government’s immunization campaigns have acquired special markers used by health workers to put a colored dot on the left pinky fingers of children after they have been vaccinated.
Health workers say parents opposed to the vaccinations are marking their children's pinkies to make it appear they have been vaccinated when, in fact, they weren't. The deception causes vaccination teams to skip over children who need to be vaccinated -- thereby preventing the disease from being eliminated in the country.
With the disappearance of wild polio cases in Nigeria in recent years, Pakistan and Afghanistan are currently the only countries in the world where new polio cases are found.
The issue with the fake markers in Pakistan highlights the varied obstacles that are keeping Pakistan from eliminating polio -- a childhood virus that leads to deformed limbs, paralysis, and even death.
Thorough vaccination campaigns in recent years have dramatically reduced the number of polio cases in Pakistan, with only a dozen cases recorded last year.
But that number has jumped to 45 cases this year. Of those, 35 were found in the northwestern province of Khyber Pakhtunkhwa, a poor and religiously conservative region that was once a stronghold of militant groups like Al-Qaeda and the Pakistani Taliban.
Many residents of the province, which lies along the porous border with Afghanistan, have been suspicious of the polio vaccine, with conservative Islamic clerics and militants claiming it is a Western conspiracy to harm or sterilize children.
Dr. Imtiaz Ali Shah, the head of the provincial government's Polio Monitoring Cell in Khyber Pakhtunkhwa, warns that fake polio markers are the newest threat to anti-polio efforts.
"Our immunization teams first ask the parents if their children are vaccinated,” says Shah. “To confirm this, we check if the children have marks on their fingers. If they do, then it means they were vaccinated. But then we realized that some parents had applied fake marks on their children before polio teams arrived to their areas.”
Shah says suspicions were raised when 17 of the 45 polio cases recorded this year came from the same town -- Bannu -- a city of 50,000 in the country’s northwest.
In the past, the town has been the scene of deadly attacks on polio workers and militants are known to be active in the area.
Shah brought a team of health officials to Bannu to recheck if the children who had marks on their fingers had actually been vaccinated.
“When we checked some children, we found out that they were not immunized,” he says.
Shah says the provincial government in Bannu is making plans to address the issue of the fake pinky marks. In the past, polio teams would report to police the parents who refused to immunize their children.
But polio workers have since stopped registering complaints with authorities. He also says the government has launched a media campaign targeting parents, clerics, and school teachers in a bid to dispel the myths about the vaccinations.
In April, a vaccination drive in the province was thwarted after a mass panic was created by rumors of children fainting or vomiting after they were immunized.
As the rumors spread, thousands of panicked parents rushed their children to hospitals in the provincial capital, Peshawar, forcing the health facilities to declare emergencies. The rumors turned out to be wildly exaggerated.
Public health studies in Pakistan have shown that maternal illiteracy and low parental knowledge about vaccines -- together with poverty and rural residency -- are the factors that most commonly influence whether parents vaccinate their children against the polio virus.
Anti-vaccination propaganda has also been fueled by a distrust of Western governments who fund vaccine programs -- including after the CIA reportedly staged a fake hepatitis-vaccination campaign in 2011 to confirm the location of Al-Qaeda leader Osama bin Laden, who lived in Abottabad, where he was killed by U.S. SEALs.
Since then, some clerics have even issued fatwas saying that children who become paralyzed or die from polio are "martyrs" because they refused to be tricked by a "Western conspiracy."
Pakistani militants have also propagandized that Western-made vaccines contain pig fat or alcohol, which are both forbidden in Islam.
Militants in Pakistan have kidnapped, beaten, and assassinated dozens of vaccinators or their armed police escorts in recent years in a bid to stop local anti-polio campaigns.