In our world, many human lives are lost to crime and violence in which asphyxial deaths are one of the major contributors.Asphyxial deaths are regularly encountered during forensic practices, therefore it is of utmost importance to determine manner of asphyxial deaths to understand underlying root causes.In India, population has increased very rapidly resulting in poverty. Also, our daily life has become more stressful. Because of these factors cases of suicides, homicides and accidents due to violent asphyxia have become more and more common. According to the NCRB, suicide is among top ten causes of overall deaths in India in all age gros while among top three in 15 to 45 years’ age gro. According to NCRB-2013 statistics, among the methods chosen for suicidal purposes, Hanging, is most common (39.8%), drowning being 4th (5.7%). For Homicidal purposes, Asphyxiation by Strangulation & Smothering is 3rd most commonly chosen method.1 In present study an attempt has been made to analyze various trends and factors associated with the violent asphyxial deaths in UP region so that further insight into the existing knowledge related to the subject can be gained with the view to assist the process of crime investigation and proper utilization of resources. The World Health Organization estimates that nearly 52% of deaths and 38% of total disease burden in the South-East Asian Region are related to non-communicable diseases (NCDs) underscoring the need for reliable country data in the region.2 However, the burden of NCDs in developing countries has received much less policy attention and development assistance than maternal mortality, human immunodeficiency virus and tuberculosis.3 This lack  of focus on NCDs has been due to lack of data and its ineffective utilization for program planning. Verbal autopsy (VA) methods have been utilized world-wide with an aim of splementing mortality information.4-6  this paper attempts to provide the reliable information on causes of death in adults by using VA methods. Massive use of pesticides in agriculture⁷, as it is being the major profession in the rural areas of India also exposes farmers with these compounds Introduction of a variety of newer drugs for treatment, exposure to hazardous chemical products due to rapid industrialization, unhealthy dietary habits and increases in alcohol consumption have led to a wide spectrum of toxic products to which people are exposed.⁸ The cases of poisoning by Corrosives, Sedatives & hypnotics, Alcohol, Dhatura, Oleanders, Snake bite etc. are also frequently reported in adults and poisoning by Kerosene and cleaning agents is more common in children.⁸ Profile of poisoning in an area depends on a variety of factors, ranging from access to and availability of poison, socio- economic status of the individual, cultural and religious influences, etc. Poisoning forms a major problem in developing countries. Easy availability and low cost of hazardous chemicals play a major role in suicidal homicidal and accidental poisoning in developing countries. ⁸ This study is being conducted in Moradabad, which is situated in Teerthanker Mahaveer Medical College, Moradabad, and Uttar Pradesh, India. It is an educational hub for professional students and very rich in agricultural land and both students and farmers are vulnerable for exposure that’s why profiling of poisoning cases is essential.

These 28 villages come under health and demographic surveillance site (HDSS), also known as comprehensive rural health services project. The demographic and health information resides in electronic databases as previously described.9 under the project, there exist two primary health centers (PHCs) and one secondary level hospital at Moradabad. Each PHC has 6 sub-centers (total 12 sub-centers) and together they include 28 villages. The health-care in these villages is provided by paramedical multi-purpose health workers (MPHWs). VA was introduced in the villages in 1999 for under-five deaths and in 2002 for adult deaths.10 

The structured questions include symptoms, duration, tobacco and alcohol use and treatment sought. The open narrative section related to illness and circumstances preceding death and was completed with the aid of systematic prompting by the MPHW. Any available adult in the family who was knowledgeable about the events at the time of death could be a respondent. Informed consent was obtained from each respondent by MPHW. The information collected by the MPHW by using VA tool was independently confirmed by a paramedical servisor for all deaths and 5% of these forms were verified by the qualified medical. A total of 3224 autopsies were carried out during this period. Out of them 391 cases of violent asphyxial deaths were included and reviewed in study. Each and every case examined as per predesigned and pretested proforma, the data is then scrutinized with the help of statistician and presented in different tables to highlight the facts from various aspects of study. In present study various types of asphyxial deaths, their age wise distribution, sex wise distribution, manner of death and contributing factors are studied. General information regarding demographic profile, socioeconomic status etc. of each case was confirmed from causality & hospital records. Brought dead cases were not included in this study. The collected data were statistically analyzed in form of ratio & frequencies and compared with other studies.

Proportion of violent asphyxia deaths was 12.3% (401 cases) of total 3234 autopsies in the present study. (Table 1)

Table 1: Proportion of violent asphyxial death cases

Hanging (63.8% - 256 cases) is the most commonly encountered violent asphyxia death followed by drowning (24.9% - 100 cases) and strangulation (4.9% - 20 cases).(Table 2)

Table 2: Case wise proportion of violent asphyxial deathcases

Mostcommonly involved age gro is 21-30 years (107 cases forming 27.4% of total) followed by 11-20 years’ age gro (75 cases forming 19.2% of total). (Table 3)

Table 3: Age wise distribution of violent asphyxial deathcases

From all the cases of hanging, majorities (97.6%) were suicidal and a few were accidental (1.7%) and Homicidal (1.7%). All 20 strangulation cases were of homicide. 65 outof 100(65%) cases of drowning were accidental and remaining 30 (30%) were suicidal and 5 (5%) were homicidal. (Figure 4)

Figure 4: Manner of death

In our population, nearly 40% deaths occurred in individuals aged younger than 60. Our study highlights that more than 50% deaths were due to NCDs and injuries and other external causes across all ages studied. Infectious diseases still accounted for one-fifth of deaths in economically productive age gro (15-59 years). About two-third of deaths in the age gro of 60 years or above occurred due to cause gros-cerebrovascular diseases, lower respiratory tract, tuberculosis, intestinal infectious diseases and due to non-ascertainable causes. These results are comparable with Indian Council of Medical Research study on causes of death by VA in five states Assam, Bihar, Maharashtra, Rajasthan and Tamil

Nadu, representing different regions of India.11

Studies performed in rural Andhra Pradesh and Tamil Nadu also have documented large proportion of deaths from NCDs.12,13 More than half of deaths were attributed to NCDs. Similar results of predominance of non-communicable cause of deaths (more than 50% among males and 43-54% among females) have been observed in other states such as Assam, Maharashtra and Tamil Nadu.11 According to Sample Registration System (SRS) estimates (2001-2003), NCDs were the leading causes of death in the country, constituting 42% of deaths.14   A recent study based on 18-year mortality surveillance using VA from rural Haryana, reported 47.6% of deaths attributable to NCDs.15 Their lower proportion of deaths due to NCDs may be because of prior reference period and also inclusion of deaths under 15 years of age. However, a study in urban slums of Kolkata, India reported 66% of deaths due to NCDs.16 In conjunction with other studies, our study shows that injuries and chronic diseases predominate in the older years of life in which most of the deaths occur now. The preponderance of deaths due to chronic diseases in these study villages is likely because of rapid economic and social development as well as effective basic health services such as immunization and maternal and child health programs. Among communicable diseases, tuberculosis and diarrhea were the common causes of deaths. Mortality due to tuberculosis may be overestimated in this study because some deaths due to other respiratory disorders might have been narrated as tuberculosis deaths by family members if the patient had taken treatment for tuberculosis anytime in his life time. Although conditions such as diabetes and hypertension did not contribute much in the individual causes of death, these conditions would have contributed to the number of deaths by ischemic heart disease and cerebrovascular disease. The strength of the study is 6 years of prospectively collected data, which provides stability. Since, there   is an existing surveillance system HDSS in place in  the study area and it is attached to a research institute, quality control can be assured. Physician coding of cause of deaths further adds strength to the study. In 19% of deaths, cause of death was not ascertained due to the insufficient information in the VA forms, which is a limitation of using VA tool.

Other studies in India which used VA methods for ascertaining the cause of deaths also reported 11-18% of deaths due to ill-defined causes, whereas the study from rural Haryana reported 6.9% of deaths where cause was not ascertainable.11,12,15,16 VA, for all its shortcomings, remains the feasible option for documenting specific causes of death in community settings. This study reports the causes of death for the reference period of 2002-2007 and early reporting of the findings would have been better. Personal reasons were most commonly attributed to suicide by hanging followed by family problems and borrowings. The reason for homicide was unknown in 12 cases of strangulation. In the remaining 6 cases cause was revenge. In drowning cases 64 cases are accidental and in 20 cases the reason for death was unknown. In drowning 13 victims commit suicide due to family problems. It was elicited from the history that personal reasons (136 out of 254 cases) like failure in the examinations, psychiatric problems, long time illness etc. were the most common reasons for suicide by hanging followed by family/domestic problems (41 cases), borrowings (23 cases) and extra- marital affairs (7 cases). In 44 cases the reasons for suicide with hanging were not known and 3 victims were hanged accidentally during play. These findings are consistent with findings of Patel Ankur P et al.17

The primary health-care system in India appears to be effective in dealing problems of communicable diseases and maternal and child health. Our study clearly shows an epidemiologic transition with an increasing share of NCDs and injuries in mortality. Reorientation of health systems to include promotive, preventive and curative strategies to effectively tackle these problems is thus the need of the hour.A comprehensive programme is needed to identify causative factors and prevention of suicidal behaviors. Prevention strategies for drowning should be comprehensive and include multiple aspects like removal of hazard by using modern engineering technologies, tough laws to enforce prevention and increase awareness among individuals to understand risk.

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