Lake Victoria, bordered by Kenya, Tanzania, and Uganda, provides one of the largest freshwater fisheries in the world and supports millions in small-scale fishing communities. Historical environmental change, including population growth, nutrient loading, introduced invasive species, and rising temperatures, has resulted in eutrophication and persistent cyanobacterial harmful algae blooms (cyanoHABs) over recent decades, particularly in the shallower gulfs, bays, and inlets. CyanoHABs impact fisheries and food web dynamics and compromise food and water security for nearshore fisher populations. In this study, we examine the socialecological impact of freshwater blooms on fisher health in one of these eutrophic regions, Winam Gulf in Lake Victoria. CyanoHABs persist for months and produce microcystins and hepatotoxins at levels unsafe for human health. We assessed potential risk and contribution of microcystin exposure through fish consumption, in addition to exposure through water source, and conducted 400 fisher and 400 household surveys. Average microcystin concentrations exceeded the World Health Organization (WHO) guideline for drinking water consistently during the long dry season, and cyanobacterial cell counts surpassed WHO standards for recreational risk in 84% of samples. Hazard quotients for fish consumed by young children were 5 to 10 times higher than permissible levels. In addition, fishers chronicled profound ecosystem changes with direct impact on livelihood, fisheries, and water quality with 77.4% reporting a decline in profit or catch, 83.1% reporting adverse impacts of cyanoHABs on fish in the lake, and 98.2% reporting indicators of declining water quality in the lake overall. Through the application of a social-ecological lens to a public health model, we identified spheres of influence that modify how fishers experience HABs related stressors and risks to provide a starting point at which to identify sustainable strategies to improve food and water security and livelihood for the millions in nearshore communities.