Health policy in Europe is at a crossroads. Longstanding challenges, such as persisting social and geographical inequalities, ageing populations, and rising burdens of chronic diseases, are being compounded by new, global threats, such as pandemic influenza and crises in the world's financial markets. Significant improvement in the health of Europe's population has been driven by factors both inside and outside the health sector. Key obstacles to improving population health in Europe result from underlying failures to overcome political and economic issues, including those shaping healthcare financing and delivery systems. How can the public health community respond to these challenges? This paper discusses three examples of how power and politics have shaped the world in which public health works. The focus on individual risk factors diverts attention from underlying determinants, such as the dominance of the market in healthcare, and the political decision to favour a rapid transition from communism in the 1990s. Effective public health policy requires addressing these political forces, seeking to understand the dominant paradigms, how they have been defined and shaped, and how they might be changed. Their effects are often subtle but powerful, shaping the language that is used, the assumptions that are made, and the rules that are implied. We can formulate key policy options to help improve health outcomes by reshaping the critical forces that affect public health risk factors among those populations currently most burdened by significant disease in Europe today.