Who else might we list as victims of the great foot and mouth crisis of 2001, now said to be in its endgame? We probably should add the Ministry of Agriculture, Fisheries and Food, which seems set for a post-election cull of its own: the death sentence may even be declared in today's Labour manifesto. Along with Maff, place its hapless minister, Nick Brown. He, too, looks set for the chopping block - though that will not be announced by Tony Blair in Birmingham today.

The victims are many and we will hear their stories for years to come. More reluctant to come forward may be those who want to bury this episode along with the animal carcasses. They are the culprits.

For any examination of this extraordinary saga - which paralysed a nation and suspended democracy for the only time in our peacetime history - reveals a complete systemic failure. Not one group or institution involved emerges with any credit; they all failed in their most basic duty. Long after the last pyre has stopped burning, foot and mouth will stand as an indictment of British public life - and of the very way we govern ourselves.

Since no institution is immune, let's start with my own. The media failed from the outset, by never explaining the most basic facts of this disease. When I wrote in February that foot and mouth was not a killer, but amounted to flu for animals and, at worst, a cold-sore for human beings, I was inundated with shocked responses from readers who had watched TV, read the papers and listened to the radio - but had never once been told the symptoms of a condition instantly branded a national emergency. For weeks the media aired terrifying pictures and wore long faces but refused to perform its fundamental task: stating the facts.

Next we should target government, at every level. Maff did almost everything wrong. Civil servants succumbed to that perennial bureaucratic habit: instead of thinking, they reached for the files. They saw that the past response to foot and mouth had always been to shut down the countryside and impose a blanket policy of slaughter. That was how it had been in 1967, so that's how it would be in 2001. Even the "no entry" signs Maff produced were printed in retro, postwar type: emblems of a dumb obedience to the past script and a failure to think anew.

Ministers were no better. Nick Brown did not demand a strategic overview from his department; he simply went for crisis control. He obeyed his civil servants, followed precedent and ordered mass slaughter. But even that he did not do properly, failing to move quickly enough, allowing crucial time to elapse between spotting the disease and killing infected animals. If he had just talked to a few agricultural historians, he would have heard how a 1920s outbreak spread chiefly because of the delay from report to slaughter. But he never learned that lesson.

Still, the buck hardly stops with him. The biggest cock-ups occurred far above his pay grade. The army was called in too late; there was complete indecision on the countryside - first visitors were told to keep out, then urged to come back in - and constant vacillation on vaccination, with talks, consultations and delays but no resolution. All these failures belong not to Nick Brown, but Tony Blair.

As a prime minister who declared himself in personal charge of this crisis, it fell to him to enlist the MoD or to make a firm decision on vaccination. That he did neither dents his constant boasts of competence: on foot and mouth he dithered as badly as John Major ever did.

These are, however, minor charges on the PM's rap sheet. His greatest failure was one of leadership. He should have been able to do what Maff and Brown did not - to see the big picture. He should have asked why the policy of slaughter existed in the first place, rather than blindly following it. He would have been told the aim was to eradicate foot and mouth as quickly as possible so that Britain could soon regain its disease-free status.

If he'd wondered why that mattered, he would have been told it was essential for Britain's meat export industry. "How much is that worth?" he might have asked, only to be told, on Maff's own figures, that the total amounted to £592m. He could then have compared that sum to the £64bn generated by British tourism, and worked out whether it was worth jeopardising that - by showing the world TV pictures of Britain in flames - for the sake of selling lamb, pork and beef abroad.

In other words, a genuine act of leadership would have been to bin Maff's outdated files and think about the British economy that exists today. He could have stopped the slaughter, opting for limited vaccination instead - saving billions of pounds and millions of animals.

He did not, because that would have risked antagonising the farming lobby - next in line in the great foot and mouth rollcall of shame. Their weepy protests for their slaughtered herds, even as they refused a vaccination policy that might have saved animal lives, exposed the farming lobby for what it is: defenders of an economic interest. It was their short-sighted, profit-seeking pursuit of the export trade that drove the insane slaughter policy. As the veterinary historian Abigail Woods puts it: "The economic interest of a small section of the farming community seems to have governed the country."

The prosecution is not finished yet. The animal welfare movement was missing in action throughout the whole ordeal. Their only presence came in the form of RSPCA inspectors, cheerfully on hand during the mass culls. They did not raise their voices in protest; they did not attempt the blockades they once mounted to stop live exports of veal calves or the demos they stage outside laboratories involved in animal experimentation. They stayed silent, perhaps believing that such creatures were doomed through intensive farming anyway, and that a funeral pyre was no worse than an abattoir. Maybe, says Woods, "they would rather save a single fox than a couple of million cattle".

Their record is appalling, along with everyone else connected with this sorry story. We need a serious, probing public inquiry to lay bare what really happened. For a kind of collective madness descended on these islands - and we were all infected by it.