Firearm violence is a significant public health problem affecting societies across the globe. According to the Global Burden of Disease data, more than 250,000 deaths per year worldwide are attributed to firearms, with the highest burden in low- and middle-income countries. The consequences of firearm-related injuries go beyond mortality and include lifelong disability, mental trauma, and considerable economic costs. In many settings, particularly in low-resource areas, the healthcare system is not fully equipped to deal with the high fatality rate and the burden of trauma caused by firearms. India, although having stricter gun laws than some Western nations, continues to report consistent cases of firearm-related violence, especially in northern states such as Punjab, Haryana, and Uttar Pradesh. These cases involve not only criminal activity but also suicides, accidental discharges, and celebratory gunfire. Despite increasing awareness, cultural practices and access to illegal or unlicensed weapons continue to contribute to preventable deaths.

Firearms are increasingly contributing to injury-related deaths globally. Alongside road traffic accidents, firearm injuries remain a major cause of trauma.1 In India, the easy availability of licensed firearms is notable, especially in Punjab which ranks second in the country with approximately 4.5 lakh civilian licenses. This increased availability correlates with a concerning pattern of firearm injuries and deaths. Globally, suicide and homicide by firearms remain leading public health challenges.2,3

A previous study from same region reported that the firearm-related assaults, though fewer in number, were associated with more severe injuries, particularly involving the head and neck region. This regional evidence underscores the lethal potential of firearms even in isolated assault incidents and highlights the importance of continuous surveillance and research on firearm-related violence in North India.4

The severity of firearm injuries depends on the site, type of weapon, and medical response time. Beyond clinical implications, such injuries deeply affect societal wellbeing, contributing to economic costs and mental health disorders.5,6

This retrospective observational study analysed firearm-related deaths from January 2016 to December 2017 at a tertiary healthcare facility in Northern India. The study focused on 13 firearm death cases out of 1639 medico-legal autopsies. Data were extracted from inquest forms and autopsy reports. Parameters included demographics, time and location of incident, nature of firearm, anatomical site of injury, and cause of death.

Among the 13 firearm-related deaths studied at a North Indian tertiary care hospital from January 2016 to December 2017, victims were predominantly male (92.3%, n=12), with a female-to-male ratio of 12:1, and ranged in age from 21 to 80 years, with the 21–30 age group being most affected (30.76%, n=4), followed by the 31–40 and 41–50 age groups (23.07% each, n=3). Suicides were the leading manner of death (61.53%, n=8), typically involving close-range headshots with rifled weapons, followed by homicides (30.76%, n=4) linked to interpersonal conflicts or criminal activity, and one accidental death (7.69%, n=1) due to celebratory firing. Head injuries were most common (61.5%, n=8), followed by chest and abdominal injuries (23.07%, n=3). Rifled weapons, such as pistols and revolvers, were used in 76.92% of cases (n=10), while smooth-bored firearms, like shotguns, accounted for 23.08% (n=3). Most incidents occurred between 4 AM and 12 Noon (61.53%, n=8) and slightly more in rural areas (53.84%, n=7) than urban areas (46.15%, n=6). Occupationally, private sector workers were most represented (30.76%, n=4), followed by government employees (23.07%, n=3), with single cases among students, farmers, homemakers, shopkeepers, thieves, and the unemployed.

Table 1: Distribution of cases according to various factors.

Table 2. Comparison with different studies regarding firearm-related deaths

This study reveals critical insights into firearm-related deaths at a tertiary care hospital in North India, highlighting geographic, demographic, and contextual patterns.

Geographic Distribution: Rural areas accounted for 53.84% of cases compared to 46.15% in urban areas, likely due to higher firearm ownership for agricultural or celebratory purposes, lax regulatory oversight, and limited access to mental health and trauma care facilities. Rural settings often lack infrastructure to address psychiatric issues, contributing to elevated suicide rates, while urban areas see more homicides linked to interpersonal or criminal violence. These findings suggest the need for targeted firearm safety education and mental health outreach programs tailored to rural and urban contexts. 

Firearm-Related Death Rates: The study reports firearm death rates of 0.38 per 100,000 for India, 0.55 for Punjab, and 0.71 for Patiala in 2022 (NCRB data), indicating higher regional risks, particularly in Patiala. Globally, the 2020 Small Arms Survey estimates a firearm mortality rate of 2.7 per 100,000, with the USA at 4.31 in 2021, far exceeding rates in Canada (0.57) or the UK (0.013). Punjab’s ranking as fourth in India for accidental firearm deaths (31 cases in 2021) underscores the need for enhanced surveillance and regional policies to address underreported firearm violence, especially given the prevalence of unlicensed arms.

Demographic Trends: A stark male predominance (male-to-female ratio >12:1) aligns with global trends, reflecting men’s greater access to firearms and exposure to violence or self-harm due to sociocultural factors. Males are disproportionately affected by firearm suicides, consistent with international studies, highlighting the need for gender-specific mental health interventions.

Manner of Death: Suicides dominated (61.53%), driven by impulsivity, psychiatric conditions, and firearm accessibility, followed by homicides (30.76%) tied to conflicts or crime, and accidents (7.69%) often linked to poor handling during celebratory firing. The high suicide rate mirrors national and global patterns, emphasizing the lethality of firearms, particularly in head-targeted shots, and the urgent need for mental health support and firearm restrictions.

Injury Patterns: Head injuries were most common (61.5%), reflecting high intent in suicides and homicides, followed by chest and abdominal injuries. The 92.30% instantaneous death rate underscores the critical need for rapid trauma response systems and neurosurgical expertise. These patterns align with studies from the USA and Finland, where firearm suicides predominate, but contrast with high-homicide regions like Latin America, where gang-related violence prevails.

Global and Regional Comparisons: India’s firearm mortality is lower than in high-income countries like the USA but varies regionally, with Northern states like Punjab showing elevated rates due to cultural and legal factors. Countries with strict regulations, such as Japan and the UK, report minimal firearm deaths, while developing nations with unrest, like El Salvador, face homicide rates exceeding 20 per 100,000. These contrasts highlight the role of sociopolitical and legal frameworks in shaping firearm mortality.

Public Health Implications: Addressing firearm violence requires a multi-pronged approach: strengthening mental health services, particularly for men at risk of suicide; implementing stricter gun control measures like safe storage and psychological screening; and enhancing trauma care infrastructure with trained personnel and neurosurgical capabilities. Public awareness campaigns and improved counselling access can further reduce suicides, while regional policies should address the unique challenges of rural and urban settings.

Limitations: This study's findings are based on a small number of cases from a single institution. The relatively dated data and limited geographical coverage may not represent broader national patterns. Additional research across multiple centers with recent data is recommended.

This study highlights the demographic, clinical, and circumstantial profile of firearm deaths in North India. Suicide, male gender, and head injuries dominate the pattern. Interventions aimed at mental health support, firearm regulation, and public education are vital to reduce such fatalities.

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