Countries located on the East African Rift System (EARS) are vulnerable to fluoride in their groundwater; a vulnerability for the developing country of Malawi at the southern rift periphery that is not well characterised. Groundwater fluoride occurrence in Malawi is documented here to better understand and manage fluoride risks posed. Available literature and Gov't of Malawi archive fluoride data spanning some fifty years have been collated and augmented by our own 2016-18 surveys of groundwater quality in Southern Malawi, targeting deep-sourced springs. In total, fluoride data for 1365 borehole, spring and hot spring samples were assembled. Statistically, 83% of samples were below the 1.5 mg/l WHO limit, concentrations in the 1.5-6 mg/l range between former (pre-1993) and current WHO guidelines at 14%, and those with fluoride above the current Malawi (former WHO) 6 mg/l guideline, at 3%. A lower occurrence than in other zones of the EARS, but indicative of a need for a Malawi Gov't management policy revision and associated management strategies endorsed by several documented incidences of dental fluorosis in proximity to high fluoride groundwater. Increased fluoride is related to increased groundwater temperatures signifying the importance of geothermal groundwater provenance. Temperature data may indeed be used as a proxy indicator of fluoride risk; samples with a temperature >32 °C, contained >6 mg/l fluoride. Structural geological controls appear to allow deep geothermal groundwaters to come to the near surface, as evidenced by increased fluoride in springs and boreholes close to faulted areas. Hydrochemical evaluation shows that fluoride concentrations are influenced by fluorite equilibration and sensitivity to calcium and pH. Recommendations are made to further document the occurrence of fluoride and enhance management of risks due to fluoride in drinking water in Malawi. With fluoride as a key indicator within Sustainable Development Goal number 6, the current Malawi standard and waters with concentration between 1.5 and 6 mg/l will come under increased scrutiny and pose a key challenge to assessment and management efforts.

Consumption of groundwater containing fluoride exceeding World Health Organization (WHO) 1.5 mg/L standard leaves people vulnerable to fluorosis: a vulnerability not well characterised in Malawi. To evaluate geogenic fluoride source and concentration, groundwater fluoride and geology was documented in central Malawi where groundwater supplies are mainly sourced from the weathered basement aquifer. Lithological composition was shown as the main control on fluoride occurrence. Augen gneiss of granitic composition posed the greatest geological fluoride risk. The weathered basement aquifer profile was the main factor controlling fluoride distributions. These results and fluoride-lithology statistical analysis allowed the development of a graded map of geological fluoride risk. A direct link to human health risk (dental fluorosis) from geological fluoride was quantified to support science-led policy change for fluoride in rural drinking water in Malawi. Hazard quotient (HQ) values were calculated and assigned to specific water points, depending on user age group; in this case, 74% of children under six were shown to be vulnerable to dental fluorosis. Results are contrary to current standard for fluoride in Malawi groundwater of 6 mg/L, highlighting the need for policy change. Detailed policy recommendations are presented based on the results of this study.

Meeting long-term rural community water supply needs requires diligent geohydrological conceptualisation. Study of Malawi’s Lake Chilwa Basin, including sampling of 330 water points in Phalombe District, enabled assessment of groundwater quality influence upon supply. The control of larger Lake Chilwa paleo-environments on current Basin groundwater quality is demonstrated. Lacustrine sediment deposition forming high-level deposits under open lake conditions and terrace deposits under open and closed lake conditions significantly control the groundwater major-ion quality and salinity now observed. Paleo-lake extent marks the transition between low-TDS (total dissolved solids) groundwater suitable for water supply at higher elevations and high-TDS brackish groundwater in areas overlain by lacustrine deposits closer to the current lake level. Low-TDS groundwater is limited to mid-to-low reach influent leakage of rivers incising terraces. Permeable fluvial deposits within the deeper paleo-river channel may possibly provide low-TDS water. The conceptual model, whereby paleo-lake controls groundwater salinity, provides science-based evidence to address policy to manage the significant water point functionality concerns quantified at the district and river basin scales. Targeting of the low-TDS groundwater alongside improved use of upland low-TDS stream/river sources with fewer, but larger capacity, and better maintained gravity-fed supply schemes are recommended. This study hence shows the value of paleo-geohydrology interpretation of the lake–groundwater system conceptualisation to inform Sustainable Development Goal 6 (SDG 6.5.1)—integrated water resources management policy for rural water supply.

Hidden hot springs likely impact rural water supplies in Malawi’s Rift Valley with excess dissolved fluoride leading to localised endemic severe dental fluorosis. Predicting their occurrence is a challenge; Malawi’s groundwater data archive is sporadic and incomplete which prevents the application of standard modelling techniques. A creative alternative method to predict hidden hot spring locations was developed using a synthesis of proxy indicators (geological, geochemical, dental) and is shown to be at least 75% effective. An exciting collaboration between geoscientists and dentists allowed corroboration of severe dental fluorosis with hydrogeological vulnerability. Thirteen hidden hot springs were identified based on synthesised proxy indicators. A vulnerability prediction map for the region was developed and is the first of its kind in Malawi. It allows improved groundwater fluoride prediction in Malawi’s rift basin which hosts the majority of hot springs. Moreover, it allows dentists to recognise geological control over community oral health. Collaborative efforts have proven mutually beneficial, allowing both disciplines to conduct targeted research to improve community wellbeing and health and inform policy development in their respective areas. This work contributes globally in developing nations where incomplete groundwater data and vulnerability to groundwater contamination from hydrothermal fluoride exist in tandem.

Fluoride concentrations in Malawi’s groundwater are primarily controlled by geogenic sources that are highly variable and may cause a heterogeneous fluoride occurrence and local-to-regional variations in fluorosis health risks posed. Our aim was to address the challenge of developing a national solution to predicting groundwater vulnerability to geogenic fluoride risk in the country of Malawi where incidences of fluorosis are reported and typical developing world problems of limited data and resources abound. Previously there have only been sporadic, local-scale studies linking fluoride occurrence with health risks in Malawi with no attempts to tackle the issue nationally. We hence develop a screening method for predicting groundwater vulnerability to geogenic fluoride in the form of detailed risk maps developed from statistical relationships shown between groundwater fluoride occurrence and known geogenic fluoride sources. The approach provides for dynamic update and informed acquisition of new data and hence on-going improving capacity to manage fluoride risks in Malawi. Our screening method provides a technical basis for redefining national fluoride policy to ensure commensurate management of health risks posed. Specifically, the approach provides a pathway for stepped progression from the current 6 mg/L Malawian standard for fluoride in drinking water to adoption of the World Health Organisation 1.5 mg/L guideline standard.