In Rajasthan’s Sambhar block, just 50 km from Jaipur, toddlers suffer from stunted growth, adolescents from deformed limbs and joint pains, and adults from depleted muscle strength and damage to tendons and kidneys, along with nervousness and depression. Sambhar’s disability rate as of 2023 is twice the national average. In Devpura, another rural Rajasthani village, 6 out of 30 children in the local school have disabilities, with no special-ed teachers trained to teach them (The New Indian Express, PTI, Jan 2023). And the residents of Shyamoli, a village in the Sawai Madhopur district of Rajasthan, are ailing with health issues like knee pain, throat pain, and kidney stones (Reddy et al., 2022). What is happening to Rajasthan’s rural communities?
Villagers are rapidly becoming dependent on groundwater as a freshwater source. But the same water that these communities are forced to drink is slowly poisoning them.
1.1 INTRODUCTION
Water is a precious commodity in Rajasthan, one of India’s driest regions, where the annual rainfall averages hardly 575mm (Patil & Lodhe, 2025). Every time I travel into the tribal villages where my host organization VAAGDHARA works, the families I meet graciously offer me and my coworkers water pulled straight from a handpump by their house. In fact, the hilly landscape is dotted with handpumps here and there, which I spot from the back of my coworker’s motorbike as we ascend the arid mountains. Households with better financial situations often also have borewells, dug deep into the earth.
I only learned what these structures were after a few field visits. A handpump is a manually operated pump (10-300 feet deep) used to draw groundwater from a high water table. A lever is pumped to create suction that pulls water up. Because handpumps don’t require electricity and are constructed at relatively shallow levels, they are cheaper to install than borewells. A borewell is a narrow well drilled into the earth (100-1000 feet deep), which uses an electric or diesel pump to draw water from a low water table. Borewells ensure a more consistent supply of water, though their installation is more expensive.
The metallic and hard quality of the water that tribal families consume is not just restricted to villages. In the town of Banswara, the Tier-4 city that lies 1-2 hours out from the tribal villages and is home to most of VAAGDHARA’s employees, the drinking water that my roommate and I fill in our matka (earthen pot) each morning is similarly heavy and even runs yellow sometimes.
WHERE IS THE FLUORIDE COMING FROM?
2.1 WATER SCARCITY
Groundwater in Rajasthan provides 90% of drinking water to the rural population and irrigates 65% of farmlands. While over forty percent of urban households use piped or surface water for drinking, the same percentage of rural households use groundwater from handpumps as their main source of drinking water (Choubisa, May 2023). But in rural India, the groundwater of 23 out of the country’s 37 states and union territories contains varying levels of fluoride (Choubisa, June 2023; Diundi, 2024). And out of the 7,746 reported fluoride-affected areas in India as of April 2025, Rajasthan accounted for well over half of them (Press Information Bureau).
The World Health Organization (WHO), the Indian Council of Medical Research, and the Bureau of Indian Standards all mandate that drinking water should not contain fluoride levels higher than 1-1.5 parts per million. Yet the groundwater in the Scheduled Areas of Rajasthan has fluoride at levels ranging from 1.0-21.6 parts per million (ppm) depending on the district–all well over the above institutions’ maximum permissible limit. For example, in a district like Banswara, the fluoride content in drinking water is 0.1-4.6ppm. And in districts like Sirohi, even the minimum fluoride content crosses permissible limits, with the range being 1.0-16.0 ppm. In addition to the water, fluoride enters the food chain, showing up in crops as well as the milk and meat of fluoridated animals (Choubisa, S.L. & Choubisa, Darshana, Dec 2023; Singh et al., 2001).
Why is fluoride so prevalent in rural Rajasthan? In the rural parts of several Indian states, including not just Rajasthan but also Gujarat, Andhra Pradesh, and Telangana, groundwater contains high fluoride levels due to the the natural presence of fluoride-bearing mineral deposits in the landscape, such as basalt, granites, gneiss, and phosphorite, especially in mountainous regions (Choubisa, Jan 2023).
2.2 PREVENTION OF GUINEA WORM DISEASE
Just forty-odd years ago, open water sources (e.g. lakes, rivers, dug open-wells) were rural communities’ main sources of drinking water. Aside from the fact that many such sources are rapidly drying up due to climate change, another reason behind the new ubiquity of handpumps and borewells was the discovery of guinea worm disease, endemic to rural India. The national government established the National Guinea Worm Eradication Programme (GWEP) in 1983-84 to tackle this issue. At the time of the program’s founding, Rajasthan had the highest number of cases of any Indian state. Thousands of handpumps and borewells were constructed in rural areas to ensure clean water for rural communities and livestock. (National Center for Disease Control, n.d.; Choubisa, Jan 2023; May 2023).
2.3 INDUSTRIAL EMISSIONS
Another way in which fluoride enters Rajasthan’s rural environs is through industrial activities, particularly those of the mining and minerals producer Hindustan Zinc Limited (HZL). HZL has lead and zinc smelters and refineries spread across Rajasthan, one each in the districts of Udaipur, Rajsamand, and Chittorgarh. In the smelting of zinc and lead, the ore often contains minerals like fluorite and apatite, which decompose and release gaseous fluoride when heated. Fluoride emissions, both as a gaseous and particulate (dust) form, contaminates the surrounding soil, air, and water. In doing so, it seeps into the food chain by contaminating agricultural crops and vegetation, which spreads across ecological webs (Choubisa, May 2023; Bhat et al., 2015; Torrisi, 2013).
THE CONSEQUENCE: FLUOROSIS
3.1 WHAT IS FLUOROSIS?
Fluoride is most dangerous for its causation of fluorosis, a disease in which fluoride is deposited in the place of calcium hydroxyapatite in bones and teeth, causing skeletal weakness and deformities (The New Indian Express, 2023). Fluorosis is endemic to over 25 countries, the top two being China and India (Choubisa, Dec 2023). According to the National Programme for Prevention and Control of Fluorosis (NPPCF), over 11.7 million people in India are at risk of hydrofluorosis (fluorosis specifically caused by drinking water)–though NGOs warn the real total maybe be around 60 million people (Choubisa, June 2023). Of this population, Rajasthan is one of the worst affected states (Singh et al., 2001).
Through exposure to fluoride levels higher than 1.0-1.5ppm, the first issue to arise is dental fluorosis, which manifests as yellow or brown mottling of the teeth. Other initial health issues are those that affect soft-tissue systems, like diarrhea, bloating, excessive thirst, and excessive urine production. As time goes on, teeth become weak and fall out early. Meanwhile, skeletal fluorosis sets in: bones become brittle and porous, while ligaments and tendons also calcify, leading to joint pain, stiffness in the neck and limbs, stunted growth, lameness, and bone lesions. Severe cases involve hunched backs, bow-leggedness, and scissor-legs, particularly in higher age groups due to prolonged exposure. At this point, other major bodily functions also become impaired. The reproductive and endocrine systems deteriorate, leading to miscarriages, stillbirths, and sterility, while related neurological impairments include reduced memory and diminished IQ (Choubisa, Dec 2023; May 2011).
3.2 OTHER FLUORIDE-RELATED ILLNESSES
Another long-term illness caused by fluorosis is nephrolithiasis or urinary stone disease, whose prevalence is nearly double in fluoride-endemic areas compared to fluoride non-endemic areas. This is in line with another study that found higher rates of nephrolithiasis among employees from marginalized demographics working in a Rajasthani mining site for zinc and phosphorite (Singh et al., 2001).
3.3 FLUORIDE IN THE ENVIRONS
Once fluoride enters the environment, wild animals, livestock, and crops are all harmed. Fodder irrigated with fluoride-rich water passes fluoride to livestock when eaten. That livestock in turn becomes a potential cause of fluorosis for its children as well as farmers who consume its meat and milk.
In the aforementioned Sambhar Lake, thousands of migratory birds ranging across ten different species were found dead around the area in 2019. Their deaths were attributed to water contamination (The New Indian Express, 2023). Similarly, in scheduled areas where the fluoride concentration in drinking water is above the permissible limit (ranging from 1.5-4.4ppm), dental fluorosis was found in bovine calves (82%), buffalo (70.2%), adult cattle (50.6%), goats (32.9%), and sheep (28.3%). Grass-eating livestock like cows and buffalo had higher rates of fluorosis than plant-eating livestock like sheep and goats, likely because smaller leaves, legumes, fruits, and shrubbery contain higher amounts of calcium and vitamin C, nutrients that mitigate fluoride toxicity and slow its metabolism in the body (Choubisa, June 2023).
3.4 FINANCIAL LOSSES
Aside from fluoride’s multivarious effects on health, high fluoride levels also lead to a range of financial losses for rural communities. First, an excess of fluoride damages the pipelines that connect to community tanks which store communal drinking water, forcing rural residents to expend money on repairs (Diundi, 2024).
Second, fluorotic animals become financial losses for a few reasons. As their dental lesions grow in severity, animals are unable to graze and chew grass and die younger than expected from hunger and cachexia. Animals with skeletal fluorosis are weak and unable to walk, so farmers can no longer utilize them in agricultural activities like plowing fields. If farmers do try to sell this livestock, they must do so at lower prices than the animals were purchased for. Similarly, fluorotic animals produce less milk and render lower-quality meat, so farmers are unable to sell their products at a regular market price (Choubisa, June 2023).
TRIBAL SUSCEPTIBILITY
Fluorosis disproportionately affects tribal areas throughout India, and Rajasthan is no exception. Eight out of Rajasthan’s 33 districts (Banswara, Chittorgarh, Dungarpur, Pali, Pratapgarh, Rajsamand, Sirohi, and Udaipur) are labelled as “Scheduled Areas,” meaning areas with predominantly Adivasi (tribal) populations. According to India’s most recent census (2011), 70% of the population in this area belongs to the Scheduled Tribe category, including tribes like the Bhils, Damors, Meenas, and Garasiyas.
4.1 OVERVIEW
In a 2023 survey study of 18,621 tribal members from the Dungarpur and Udaipur districts of Rajasthan, 69% suffered from dental fluorosis and 27% from skeletal fluorosis, compared to 57% and 21% for the scheduled caste (SC) participants and 39% and 9% for the general caste (GC) participants, respectively. This was despite the fact that the main sources of drinking water for all study participants were handpumps and borewells containing fluoride in the range of 0.1-21.6 ppm (Choubisa, Dec 2023).
A 2011 study by the same author produced even more alarming results. Out of 996 tribal members in 9 Rajasthani villages, where fluoride concentrations ranged from 1.5-4.4 ppm, 74% were afflicted with dental fluorosis and 30% with skeletal fluorosis (with some overlap between the groups). Again, the severity of the fluorosis was closely correlated with the intensity of the fluoride concentration: at 1.5 ppm, the lowest of all the villages surveyed, the prevalence of dental and skeletal fluorosis was 33.9% and 10.7 % respectively (Choubisa, May 2011).
As for nephrolithiasis (urinary stone disease), a 2001 study of 10,436 residents of both fluoride endemic and non-endemic areas found that the number of tribal people afflicted with urinary stones was 163 out of every 100,000 in non-endemic areas but 750 out of every 100,000 in endemic areas. In relation to fluorosis, the prevalence of urinary stones was 578/100,000 for non-fluorotic patients but around double that number for fluorotic patients. Finally, the recurrence rate of urinary stones was also double in endemic versus non-endemic areas (Singh et al., 2001). These numbers indicate a clear positive correlation between the presence of fluoride and the development of urinary stone disease.
4.2 NUTRITION
Tribal people seem to be more inherently susceptible to fluorosis overall, whether they live in fluoride-endemic or non-endemic areas. One reason behind this may be their nutritional status. Before the start of the Green Revolution in 1968, Adivasis largely cultivated indigenous fruits, vegetables and grains which held a variety of crucial nutrients. However, the Green Revolution pushed farmers to instead produce rice and wheat, high-yield crops whose production would reduce poverty in India (Nelson et al., 2019). Now, indigenous crop cultivation has been severely diminished in tribal areas, leading to nutritional difficulties including the dearth of essential vitamins like calcium and Vitamin C that would mitigate the deleterious effects of fluoride (Choubisa, May 2011).
4.3 GENETICS
Genetics may also play a key role, particularly through polymorphisms (variants of the same gene). Candidate genes such as COL1A2 (collagen type 1 alpha 2), CTR (Calcitonin receptor gene), ESR (Estrogen receptor gene), COMT (catechol-O’Methyltransferase), GSTP1 (Glutathione S-transferase pi1), MMP-2 (Matrix metallopeptidase 2), PRL (Prolactin), VDR (Vitamin D receptor) and MPO (Myeloperoxidase), whose variants may influence tribal individuals’ risk of fluorosis (Pramanik & Saha, 2017; Choubisa, Dec 2023). More research is needed on this front to determine the prevalence of these genes in Adivasi genetics.
OBTAINING CLEAN DRINKING WATER
There are many methods of removing fluoride from drinking water, including adsorption, ion exchange, precipitation, reverse osmosis (RO), electrocoagulation, and electrodialysis. Each method comes with its own drawbacks. For example, RO, electrocoagulation, and electrodialysis require electricity, a rare commodity in rural India. In adsorption, fluoride ions from the discarded adsorbent can leach back into groundwater. Similarly, coagulation produces a fluoride-heavy sludge whose disposal becomes a problem (Anjaneyulu et al., 2012).
6.1 NATURAL PURIFICATION METHODS
There are a few tried-and-tested methods of using naturally occurring stones or plants to minimize fluoride concentration in water. The most popular of these is the Nalgonda technique, first developed in 1975 by the National Environmental Engineering Research Institute in Nagpur and tested in the Nalgonda district of Telangana. In this method, alum (also called aluminum sulfate or aluminum salts, and locally called fitkari) is added to fluoride-contaminated water, along with lime and a small amount of bleaching powder. The alum is a coagulate that causes fluoride adsorption by forming aluminum hydroxide particles that agglomerate and settle in the water. The lime maintains the pH of the water, while the bleaching powder disinfects (Choubisa, July 2023; Engineers Without Borders Bristol & Frank Water, Sept 2013). This technique has been adopted in many other parts of the world, including East Africa and the Netherlands. It is budget-friendly and alum is readily found in rural marketplaces in India.
However, its efficacy is debatable. The technique is a temporary solution that does not remove fluoride from the actual water source, so rural residents would have to undertake this process for every matka they fill. After about 30 years since its inception, it became clear that the need for constant attention caused the Nalgonda technique to fail in many field applications (Anjaneyulu et al., 2012).
More important, there are concerns about residual aluminum and sulfate in the water, which also cause health issues, and the fluoride-heavy sludge byproduct, which can recontaminate the surrounding environment (EWB Bristol & Frank Water, Sept 2013). One study conducted in the Rift Valley of Ethiopia found that the Nalgonda technique only removes 18-33% of fluoride as a precipitate, while a much higher percentage (67-82%) is converted into soluble aluminum fluoride that again acts as a contaminant. However, by enhancing the Nalgonda technique with cow bone char powder and aluminum hydroxide, the researchers found that defluoridation rose to about 64% with 9.3 ppm of fluoride lowered to 2.5 ppm on average. The added elements also reduced the amount of sludge created, compared to Nalgonda. On the other hand, bone char introduces new risks of bacteria, and would also need to be replaced every 2-3 months for full efficacy. Further, it should be noted that even the reduced fluoride concentration in this study falls above the WHO-mandated maximum limit (Yami et al., 2018).
Traditionally, jamun (black plum) wood has long been utilized to keep water tanks clean because of its antibacterial and antifungal properties. In 2017, a research team from IIT Hyderabad also found a use for the jamun plant against fluoride-heavy water. By mixing jamun seed powder with potassium hydroxide and then heating it to 900 degree C for activation, the researchers were able to reduce the fluoride concentration in water from Nalgonda from 3.2 ppm to under 1.5 ppm (Prasad, 2017; Araga et al., 2017). Other natural coagulants include plant material, like lemon peel powder and the paste of stinking passionfruit (Gandhi & Sirisha, 2019). But all three of these natural materials work best at acidic pHs rather than neutral ones, reducing their efficacy in water with a normal pH of 7.
Another method of defluoridation is an inclined solar still containing sand and water. The solar still evaporates contaminated water, condenses the drops without the contaminants, and collects the distilled water into a separate container. In one 2012 study conducted in Bangalore, water samples with fluoride concentrations of 5-20 ppm were successfully distilled into water with under 1.5 ppm of fluoride. This option is affordable, costing 850 INR to install. However, a large surface area (2.5-25 m2) is needed to produce around 10L of water. And like the coagulates and sludge in the other purification techniques mentioned, disposal of the fluoride-heavy sand proved to be an unresolved issue (Sankannavar & Kaza, 2012).
6.2 RAINWATER HARVESTING
Year-round rainwater harvesting is likely the best option to help rural farmers and livestock become less dependent on groundwater, especially rainwater is much less likely to be contaminated (Patil & Lodhe, 2025; Choubisa, May 2023). Rainwater is usually harvested in one of two ways: either through surface runoff, where rainwater that flows over ground surfaces is collected and used for recharging aquifers; or rooftop rainwater harvesting, in which rainwater is channeled from the roof to a storage reservoir through downspouts or gutters. The latter is less expensive (10,000-13,000 INR), easy to implement in rural areas, and meets average household water needs (Verma et al., 2023; Khanna & Nag, 2019). If stored rainwater runs low, rural residents are often advised to mix rainwater with handpump water in a 60:40 ratio to reduce the overall concentration of fluoride.
AWARENESS & ACTION
7.1 NUTRITION
As with many issues affecting rural areas, awareness and education are two of the best tools to curb fluorosis in these communities. Particularly, rural residents (especially Adivasis) should be encouraged to consume foods with more calcium and vitamin C, including dairy products, leafy vegetables, and citruses. Certain fats like ghee and edible oils also reduce fluoride absorption in the body. While fluorosis is not reversible, these nutrients can alleviate its effects and slow further damage.
Meanwhile, livestock should be given more legumes, indigenous fruit, shrubs, and small leaves that similarly contain calcium and ascorbic acid (Choubisa, 2012). As these are the natural diets of camels and flock animals like goats and sheep, farmers in fluoride-contaminated areas can also be encouraged to raise these types of animals over bovine livestock.
7.2 INTERSECTIONAL RISKS
In educating rural communities about the dangers of fluoride, gender-specific susceptibilities must be addressed. Breastfeeding mothers and children are more susceptible to fluorosis given their lower levels of calcium (Choubisa, Dec 2023). Meanwhile, men are 11.5 times more likely than women to be affected by urinary stone disease (Singh et al., 2001).
New mothers should be encouraged to consume more calcium through dairy products like milk and dahi. Government anganwadis (rural childcare centers) can also offer calcium supplements to prepartum and postpartum mothers to decrease their and their children’s risk of fluorosis. Men in fluoride-endemic areas should be encouraged to limit their intakes of sodium, sugar, and alcohol, which contribute to dehydration and further increase the risk of urinary stones.
Finally, special attention should be given to tribal populations. Aside from their nutritional and genetic susceptibility, the 2019-21 National Family Health Survey (NFHS-5) found that STs and Other Backward Classes (OBCs) were significantly less likely to have household taps than SCs and GCs (Singh & Naik, 2024), forcing this demographic to instead be dependent on groundwater pulled from handpumps and borewells. Ensuring household taps in rural communities would also alleviate stress from women and female children in disadvantaged demographics, who are almost always responsible for collecting water from wells and handpumps. As per the NFHS-5, the national percentage of households in which adult women fetched water was about 76%, a number which is disproportionately skewed toward ST and SC households (Singh & Naik, 2024).
GOVERNMENT POLICIES
8.1 RAJASTHAN AUTHORITY GROUNDWATER BILL
Currently, there is little government oversight of borewell drilling in rural areas. Over-extraction through proliferous drilling depletes aquifers rapidly and forces rural residents to dig further into the ground for drinking water, which drastically increases the risk of fluoride contamination. The Groundwater Authority Bill was introduced in Rajasthan’s state assembly on March 19th, 2025, to propose permits for borewell drilling in areas where over-extraction is an issue, as well as penalties for unauthorized drilling and a tariff system based on volumetric consumption.
Although the tariff system seems an unnecessarily punitive measure for already-struggling families, such regulation is an urgent need for the state, where over 70% of its 302 administrative blocks were classified as over-exploited in 2023 and 2024 for withdrawing more groundwater than rainfall could replenish. The numbers found by a recent Central Ground Water Board report are staggering: in the current situation, Rajasthan is withdrawing almost 1.5 liters of groundwater for every 1 liter recharged in aquifers by rainfall (Khan, 2025). The bill was expected to pass but has stalled due to opposition arguments that it is overextending bureaucratic control on water.
8.2 JAL JIVAN MISSION
The Jal Jivan Mission (JJM), established in August 2019, aims to provide all rural households with potable tap water by 2024. According to government news sources, the percentage of rural households with drinking tap water connectivity skyrocketed from 16% in 2019 to almost 80% as of February 2025 (Ministry of Jal Shakti 2024-25 Annual Report; Water Digest, 2025). During the planning and implementation stages, state governments have been advised to install community water purification plants in fluoride-endemic areas so that affected households have at least 8-10L of clean drinking water daily in the interim.
The scheme also mandates that at least five people per village, ideally women, are trained on how to use field test kits (FTKs) to assess their villages’ water quality for not just fluoride but also particles like iron and nitrate. Handpumps are often painted red if found to carry contaminated water, a warning sign to locals not to drink from that pump. It is not always the case that nearby handpumps are also contaminated, as handpumps can each access different water channels despite being located close to each other. The government’s Press Information Bureau, which provides the public with updates on policies, attested in March 2023 that over 20 lakh women had been trained to use FTKs, with over 55.6 lakh samples tested in labs and 91 lakh samples tested in the field between 2022-23.
FTKs also serve as an example of how cooperation between state governments and corporate social responsibility groups (CSRs) can improve drinking water quality in rural India. Take the Piramal Foundation, the CSR arm of the Piramal Group, which worked on the Ministry of Drinking Water and Sanitation’s Swajal Scheme to provide FTKs to 112 districts in India (Reddy, 2023).
8.2 NATIONAL PROGRAM FOR PREVENTION & CONTROL OF FLUOROSIS
In 2008, the federal government also started the National Program for Prevention and Control of Fluorosis (NPPCF) in India’s 11th Five Year Plan. The program calls for increased surveillance of fluorosis in rural communities, capacity building and health education, the establishment of diagnosis facilities for fluorotic patients, and patient management including treatment, surgery, and rehabilitation (“Control of Fluorosis”). According to government webpages, 111 districts have been supported through this scheme as of 2015 (National Health Mission, Ministry of Health & Family Welfare), though it seems less well-known and widely administered than JJM.
CONCLUSION
All institutions working in rural, especially tribal, Rajasthan must take special efforts to educate residents about the risks of fluoride in groundwater. Of all the solutions mentioned above, only rainwater harvesting attacks the root of the issue by providing water that is completely disparate from the fluoride found underground. NGOs like VAAGDHARA must not simply ask rural communities to rely on the above purification methods, which lead to byproducts that again contaminate the environment, or conduct mitigation efforts like mixing rainwater with handpump water, which slows but does not stop fluorosis. Instead, we must emphasize the dire and immediate need for villagers to test their groundwater and must support their transition to other sources of drinking water. Jal Jivan Mission is a significant step in this direction, though future studies will be needed to assess the sustainability and quality of the drinking water pipelines installed through the scheme.
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